| Course | NR 576 Differential Diagnosis in Adult-Gerontology Primary Care |
|---|---|
| Week | 7 |
| Paper type | Atypical presentation write-up |
| Length | About 1,110 words, 5 pages |
| Format | APA 7 student paper |
| School | Chamberlain University |
| Program | MSN, Adult-Gerontology Primary Care NP (AGPCNP) |
| Updated | October 2026 |
Free sample paper for NR 576 Week 7
Atypical Presentation Write-Up: Vitamin B12 Deficiency in a 78-Year-Old Without Glossitis, With Only Mild Anemia and With Memory Change Attributed to Age, and Three Reasons Each Feature Was Missing
Student Name
College of Nursing, Chamberlain University
NR 576: Differential Diagnosis in Adult-Gerontology Primary Care
Instructor Name
Month Day, Year
Atypical Presentation Write-Up: Vitamin B12 Deficiency in a 78-Year-Old Without Glossitis, With Only Mild Anemia and With Memory Change Attributed to Age, and Three Reasons Each Feature Was Missing
The Comparison: What the Illness Ordinarily Produces
Vitamin B12 deficiency is ordinarily described as producing a set of findings across several systems. In the blood, a macrocytic anemia, often marked, with oval macrocytes and hypersegmented neutrophils on the smear. In the mouth, a smooth, sore, red tongue. In the nervous system, a peripheral neuropathy, posterior column loss with impaired position and vibration sense and a positive Romberg, and sometimes corticospinal signs. In the mind, memory loss, depression or, rarely, psychosis. The hematologic and neurologic features do not always appear together, and neurologic damage can occur with little or no anemia (Stabler, 2013).
Against that list, this patient showed: posterior column loss, a positive Romberg, mixed reflexes and a mild macrocytic anemia with a hemoglobin of 11.2 and a mean volume of 102. The patient did not show a sore red tongue, a marked anemia or clear psychiatric change, and memory change had been recorded since 2023 and attributed to age.
Why Features Were Absent: Three Separate Reasons
A feature can be absent for three different reasons, and the reasons call for different responses.
The body may no longer generate it. Older adults may mount less dramatic signs; a less marked anemia in an older person may also reflect the slower pace of a deficiency developing over years.
An agent the patient takes may be suppressing it. This is the reason most often missed in older adults, and it applies here. The patient had been taking an over-the-counter multivitamin each day for roughly two years, containing 400 micrograms of folic acid. Folic acid can partly correct the anemia of B12 deficiency while doing nothing for the nerves and spinal cord, which allows neurologic damage to progress with a blood count that looks only mildly abnormal (Stabler, 2013). The mild anemia in this patient is therefore not evidence of a mild deficiency.
Nobody may have looked, or nobody may have recorded it. The tongue was described in my episodic note as "smooth at the edges, not sore." I examined it because I was looking for B12 deficiency; nobody else had, and there is no earlier record of the tongue at all. So "no glossitis" is partly a finding and partly an absence of earlier observation. The memory change is the clearest example: it was recorded in 2023 as memory complaints with a Mini-Cog of 3 of 5 and attributed to age, but no one measured B12 then, and B12 deficiency can contribute to cognitive change.
Applying the Three Reasons to Each Missing Feature
Table 1
Expected Features of B12 Deficiency, Their Presence and the Likely Reason for Any Absence
| Feature expected | Present in this patient? | Most likely reason if missing |
|---|---|---|
| Marked macrocytic anemia | Mild only | Suppressed by folic acid in a multivitamin |
| Sore red tongue | Not present at examination | Possibly never generated; no earlier observation |
| Posterior column loss | Present | Not missing |
| Peripheral neuropathy | Present, overlapping with diabetic neuropathy | Not missing; attributed to diabetes on the record |
| Cognitive change | Present, attributed to age | Not missing; not looked at as part of this illness |
How the Absences Were Checked
For each missing feature I asked whether it had been looked for. The tongue had not been described in any note before mine. The smear had never been reviewed, because no smear had been ordered; I requested one, and it showed oval macrocytes and a few hypersegmented neutrophils, which is a present feature that had simply never been looked for until now, three years after the anemia was first recorded. Cognition had been screened in 2023 with a brief tool and not repeated until this visit. Mood had not been screened. A feature that was never looked for cannot count as absent, so two of the expected features were reclassified from absent to not previously examined.
What a Typical Presentation Would Have Looked Like Here
If this patient had not taken folic acid, the hemoglobin might well have been lower and the cells larger, and the anemia might have prompted a B12 level years earlier, as anemia often does. If the patient had not carried a label of diabetic neuropathy, the posterior column signs might have been examined as a new finding rather than as progression. The typical presentation was available in principle; two features of this patient's history, a supplement and an existing label, turned it into an atypical one.
Why the Presentation Was Read as Something Else
The presentation was read as worsening diabetic neuropathy because the neurologic features overlapped with a label already on the record, the anemia was mild and had its own label, and the memory change had been attributed to age. None of the features alone was atypical; what made the presentation atypical was that the anemia, which most clinicians think of as the main sign, was muted by a supplement, and the neurologic features were absorbed by an existing diagnosis.
Drugs That Caused the Deficiency Itself
Separate from the folic acid that masked the anemia, two drugs probably contributed to the deficiency itself. Metformin was associated with lower B12 levels than placebo in a randomized trial over about four years (de Jager et al., 2010), and long-term proton pump inhibitor use has been associated with deficiency (Lam et al., 2013). These are not reasons a feature was absent; they are reasons the illness occurred.
Lessons for the Record
The record now lists the multivitamin with its folic acid content, so that a future reader can interpret a blood count with that in mind. The anemia entry has been changed to macrocytic anemia due to B12 deficiency. And the 2023 memory entry carries a note that it should be reassessed after three months of replacement, with the same screening tool so the results can be compared.
What the Write-Up Supports
In this patient, an absent or mild feature was evidence about the patient's other medicines and about what had been examined, not about the severity of the deficiency. The practical point for primary care is that a mild macrocytosis in an older adult taking metformin, a proton pump inhibitor or a folic acid supplement deserves a B12 and methylmalonic acid measurement, whatever the hemoglobin.
References
de Jager, J., Kooy, A., Lehert, P., Wulffele, M. G., van der Kolk, J., Bets, D., Verburg, J., Donker, A. J. M., & Stehouwer, C. D. A. (2010). Long term treatment with metformin in patients with type 2 diabetes and risk of vitamin B-12 deficiency: Randomised placebo controlled trial. BMJ, 340, Article c2181. https://doi.org/10.1136/bmj.c2181
Lam, J. R., Schneider, J. L., Zhao, W., & Corley, D. A. (2013). Proton pump inhibitor and histamine 2 receptor antagonist use and vitamin B12 deficiency. JAMA, 310(22), 2435-2442. https://doi.org/10.1001/jama.2013.280490
Stabler, S. P. (2013). Vitamin B12 deficiency. New England Journal of Medicine, 368(2), 149-160. https://doi.org/10.1056/NEJMcp1113996
The Chamberlain NR 576 Week 7 instructions
For Week 7 the task is a presentation that departed from the usual picture, examined closely. Expect two halves of roughly equal weight. The first establishes the comparison: what the illness ordinarily produces, cited to a current description, with features listed individually so the missing ones can be pointed at. The second is about absence, and separates three reasons a feature might not appear: the body no longer generates it, an agent the patient takes suppresses it, or nobody looked or recorded it. Most prompts warn against explaining every absence by aging alone. Expect to say which features were actually examined and which were simply never recorded.
How this NR 576 Week 7 example is built
The sample lists the usual features of B12 deficiency across the blood, mouth, nerves, spinal cord and mind, citing a clinical review, and sets the patient's findings against them. Three reasons for absence are explained, and the folic acid in an over-the-counter multivitamin is identified as the agent that muted the anemia. A table applies the reasons to five expected features. A section on how absences were checked reclassifies two features as never examined and records a smear that turned out abnormal. Sections explain what a typical presentation would have looked like and why the case was read as neuropathy. Drugs that caused the deficiency are separated from the one that masked it. The table makes each absence easy to check.
Where the points sit in the NR 576 Week 7 rubric
The top loss is a paper calling a presentation atypical without stating the description it is measured against; this sample lists the expected features with a source. Next, particular to this course, is absence explained by physiology alone, such as aging, for a sign that a drug the patient takes is known to suppress; the folic acid explanation addresses that. Features called absent without noting whether they were looked for cost a row, so the sample checks each. Separating drugs that caused the illness from one that masked it earns the analysis marks. A table applying the three reasons makes the argument easy to follow. Separating what masked the illness from what caused it is the sharpest point here.
NR 576 Week 7 help: mistakes that cost points
Weak NR 576 Week 7 papers say a presentation was atypical without describing the typical one. Others blame aging for every missing sign. Many count a sign as absent when it was never examined. Supplements and over-the-counter products are often left out of the analysis. Some papers confuse the drug that caused the illness with the one that hid it. If your patient's presentation differs, send the findings and the full medicine and supplement list; a write-up can set the usual picture beside the patient's and explain each absence. List the expected features first, then check each against what was actually examined before calling it absent.
Get a NR 576 Week 7 example written to your instructions
Send the case or vignette your section published, the rubric, and any headings your classroom requires. A custom NR 576 Week 7 atypical presentation write-up is written to those requirements and comes back inside 24-48h, at no cost the first time, with the comparison stated openly and every missing feature accounted for.
More NR 576 papers and AGPCNP samples
- NR 576 Week 1: Old Label Versus New Complaint Post
- NR 576 Week 2: Problem List Review
- NR 576 Week 3: Episodic Visit Note
- NR 576 Week 4: Clinical Reasoning Write-Up
- NR 576 Week 5: Diagnostic Work-Up Plan
- NR 576 Week 6: Case Presentation Script
- NR 576 Week 8: Diagnostic Synthesis Paper
- NR 568 Week 7: Polypharmacy Case Study
NR 576 Week 7 questions, answered
Is atypical the same as rare?
No, and the write-up separates them early. A presentation can be the usual one in this population and still be atypical against a description drawn from younger patients, which is the situation the week is generally built around. The example keeps the two ideas apart, since treating an ordinary geriatric presentation as a curiosity leads a reader to expect it less often than they should.
How much physiology should the paper carry?
Only what a specific missing feature requires, and placed beside that feature. The example explains one mechanism, where a sign is genuinely not being produced, and cites it there. A separate background section on physiological change tends to sit unused, and rubrics in many sections mark the join between mechanism and finding rather than the mechanism by itself.
What if nothing about the presentation looks unusual?
Then argue that, which is a legitimate result and needs the same comparison to support it. The method works either way: the usual description is set out, the features are marked off one by one, and the conclusion follows from that pass. Material supplied by a section commonly contains at least one feature that does not sit right, so a paper finding none is worth re-reading before it goes in.
Where can I find a free NR 576 Week 7 sample paper?
The full atypical presentation write-up on B12 deficiency, with the three reasons for absence applied feature by feature, is published here.
Why was the anemia mild in the NR 576 Week 7 case?
The patient took a multivitamin with 400 micrograms of folic acid, which can partly correct the blood findings of B12 deficiency while the nerve damage continues.