Low B12 and Folate On Blood Tests — Free SCA Practice Case

Character Overview: You are Hannah, a 34-year-old graphic designer. You are health-conscious and thoughtful, and you follow a vegan diet (about three years). You have been exhausted for months and are relieved something has shown up on the blood tests. You want to understand the cause and get it fixed. You are cooperative and will engage with dietary and treatment advice.

Opening Sentence: "Hi Doctor. The nurse rang to say my B12 and folate were low and that I needed to speak to a doctor. I've been so tired for months — no energy, foggy, run down. What does it mean, and how do we fix it?"

History if Asked (Data Gathering Phase)

• ●The fatigue: "Exhausted all the time, for months. Low energy, a bit of brain fog, and I've been more forgetful and irritable."
• ●Diet (only volunteered if asked): "I've been vegan for about three years. I eat well — lots of veg, pulses, tofu — but I'll admit I don't really take a B12 supplement or check for fortified foods."
• ●Neurological symptoms (only if asked): "Now you mention it, I've had some tingling in my fingers and toes on and off. I hadn't connected it."
• ●Other symptoms: "My tongue's felt a bit sore lately. No weight loss. No tummy problems."
• ●Periods: "Normal, regular, not heavy."

ICE — Ideas, Concerns, Expectations

The patient does not volunteer this information unprompted. These responses surface only when the candidate directly explores her perspective.

• ●Ideas: Hannah suspects her vegan diet might be behind the B12, though she is not certain and had not thought it through. "I've wondered if being vegan is the reason for the B12 — but I eat really healthily otherwise, so I'm not sure."
• ●Concerns: She is worried about why she is so tired and whether it is something serious, and — when the tingling is explored — a little alarmed that it might mean nerve damage. "Mostly I want the exhaustion sorted. And now you've asked about the tingling, I'm a bit worried — is my diet damaging my nerves?"
• ●Expectations: She expects to be told the cause and given treatment — possibly supplements. "I want to know the cause and get treatment. I assumed I'd be put on some vitamins."

If Asked — Medical History and Medications

The patient confirms these details only when directly asked.

• ●Diet detail: "Strict vegan three years. No meat, fish, eggs, or dairy. I don't take B12 and don't specifically buy fortified products."
• ●GI/malabsorption symptoms: "No diarrhoea, no weight loss, no tummy trouble. No previous gut surgery."
• ●Medications: "Nothing regular — no metformin, no stomach tablets."
• ●Pregnancy/planning: "Not pregnant, but my partner and I are thinking about trying for a baby in the next year or so."
• ●Family history: "No family history of pernicious anaemia or thyroid problems that I know of."
• ●Alcohol: "The odd glass of wine, nothing much."

Social History and Lifestyle Impact

Hannah is a graphic designer. She lives with her partner.

• ●Diet and lifestyle: "Vegan, health-conscious, exercise when I can — though the tiredness has stopped a lot of that."
• ●Work: "Design work, deadlines. The brain fog and forgetfulness are affecting my work."
• ●Impact: "I feel like a shadow of myself — no energy, foggy, snappy. It's getting me down."
• ●Support: "My partner's supportive."

If Asked — Neurological and Systemic Screen

The patient answers these only when directly asked.

• ●If asked about paraesthesia (tingling/numbness in hands/feet): "Yes — intermittent tingling in my fingers and toes for a few weeks." (B12 neurological feature.)
• ●If asked about balance, walking, or coordination problems: "No, my balance and walking are fine."
• ●If asked about cognitive symptoms/mood: "Foggy, forgetful, and irritable — yes."
• ●If asked about sore tongue (glossitis): "Yes, my tongue's been a bit sore and smooth."
• ●If asked about weight loss, appetite: "No weight loss, appetite's fine."
• ●If asked about bowel symptoms suggesting coeliac/malabsorption: "No diarrhoea, no bloating, no weight loss."
• ●If asked about breathlessness/palpitations (anaemia): "A little breathless on the stairs, occasionally."

Responses to Management (The Negotiation Phase)

• ●If the Doctor explains the vegan diet is the likely cause of the B12 deficiency: "So it is the diet? Does that mean I have to stop being vegan?" (The tested point is explaining dietary B12 deficiency and that it can be managed with supplementation and fortified foods, without requiring her to abandon veganism, while still excluding other causes.)
• ●If the Doctor explains they need to check for pernicious anaemia and coeliac disease: "But if it's my diet, why do I need more tests?" (The tested point is explaining that dietary and malabsorptive causes can coexist and that excluding pernicious anaemia/coeliac matters.)
• ●If the Doctor explains B12 must be treated before folate: "Why does the order matter? Can't I just take both?" (The tested point is explaining that treating folate before B12 can worsen the neurological problem.)
• ●If the Doctor discusses replacement route (oral vs injections): "Do I need injections, or will tablets do?"
• ●If the Doctor raises the tingling: "Will the tingling get better with treatment? Is the nerve damage permanent?"