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In the outpatient facility setting, there is a hierarchy to determine the initial service: 1

Patients frequently experience: Fatigue and generalised weakness that persists despite adequate rest Breathlessness on exertion due to anaemia Palpitations and reduced exercise tolerance Pallor of the skin and mucous membranes These symptoms result from megaloblastic anaemia, where impaired DNA synthesis leads to the production of abnormally large, dysfunctional red blood cells with reduced oxygen-carrying capacity

Case description A 47-year-old, north-african, male patient, has recently been diagnosed with pernicious anemia, treated with weekly intramuscular hydroxocobalamin 5000 g

L.Van der HoevenR