What is the diagnosis and recommended treatment for a 58-year-old male presenting with dizziness, numbness in hands and feet, frequent belching, nausea, sour taste, difficulty defecating, and pallor, with pending CBC and FBS results?

Diagnosis at Pagtatasa

Ang pasyenteng ito ay may clinical presentation na consistent sa Vitamin B12 deficiency anemia na may gastrointestinal symptoms (functional dyspepsia/gastritis), at kailangan ng immediate workup gamit ang CBC at FBS para ma-confirm ang diagnosis bago magsimula ng treatment.

Sintomas at Kahulugan

Ang kombinasyon ng mga sintomas ay nagpapakita ng dalawang overlapping conditions:

Neurological at Hematologic Features

• Peripheral neuropathy (namanhid, parang may tumutusok sa kamay at paa) - classic sign ng B12 deficiency 1
• Pallor (namumutla) - nagpapahiwatig ng anemia 2
• Dizziness (nahihilo) - maaaring dulot ng anemia o peripheral vestibular disorder 3, 4

Gastrointestinal Symptoms

• Frequent belching (laging sinisikmura) - gastric belching na nakikita sa 50% ng patients na may GERD o gastritis 1, 5
• Nausea with sour taste (nasusuka, maasim) - functional dyspepsia o gastritis 1, 6
• Constipation (hindi makadumi) - common sa functional GI disorders 6

Diagnostic Workup Priority

Immediate Laboratory Tests (Already Requested - Correct Approach)

• CBC - para ma-assess ang anemia, MCV (macrocytic sa B12 deficiency), at hemoglobin levels 2
• FBS - para i-rule out diabetes bilang cause ng peripheral neuropathy 2

Additional Considerations After Initial Results

• Kung ang CBC ay nagpapakita ng macrocytic anemia, kailangan ng Vitamin B12 at folate levels 1
• Upper endoscopy ay HINDI kailangan unless may alarm features (weight loss >10%, GI bleeding) 2, 6

Provisional Diagnosis Para sa PhilHealth Encoding

"Anemia, unspecified with peripheral neuropathy, R/O Vitamin B12 deficiency; Functional dyspepsia"

Treatment Plan (Within 300 Pesos Budget)

Pending CBC/FBS Results - Symptomatic Management

Para sa Gastrointestinal Symptoms:

• Omeprazole 20mg - 1 capsule once daily, 30 minutes before breakfast
  • Dispense: 14 capsules (2 weeks supply)
  • Para sa gastritis at acid-related symptoms 1

Para sa Nausea:

• Metoclopramide 10mg - 1 tablet three times daily, 30 minutes before meals
  • Dispense: 21 tablets (1 week supply)
  • Para sa nausea at gastric motility 2

Para sa Constipation:

• Bisacodyl 5mg - 1-2 tablets at bedtime as needed
  • Dispense: 10 tablets
  • Para sa constipation 6

Important Caveats

• HUWAG magbigay ng Vitamin B12 supplements bago makuha ang CBC results - dahil ito ay mag-alter ng diagnostic accuracy 1
• Ang dizziness ay dapat ma-reassess after correction ng anemia kung proven 3, 4
• Kung ang symptoms ay persistent after 2 weeks o may worsening, kailangan ng upper endoscopy 2, 6

Medical Certificate

Diagnosis: Anemia, unspecified with peripheral neuropathy, R/O Vitamin B12 deficiency; Functional dyspepsia

Recommendation: Patient advised for laboratory workup (CBC, FBS). Symptomatic treatment initiated. Follow-up after laboratory results for definitive management. May return to work with light duties, avoid heavy lifting or prolonged standing until anemia is corrected.

Purpose: For sick leave/return to work clearance as requested by patient

Follow-up Plan

• Return after 3-5 days with CBC and FBS results 2
• Kung confirmed ang B12 deficiency: Vitamin B12 supplementation (oral 1000-2000 mcg daily o IM injection) 1
• Reassess neurologic symptoms after 2-4 weeks ng treatment 1
• Dietary counseling para sa B12-rich foods (meat, dairy, fortified cereals) 1