B12 Bianca — Pernicious Anemia: The Beefy Red Tongue and the Wobbly Walk
Big cells, smooth red tongue, tingling feet — iron anemia never touches the nerves
Bianca's tongue is smooth and red, her feet are tingling, and no amount of steak will fix it — the vitamin must go straight into the muscle.
Bianca cannot absorb her B12. Pernicious anemia is a B12 deficiency caused by missing intrinsic factor — the stomach protein needed to absorb B12 — often from autoimmune gastritis or gastric surgery. The result is a macrocytic anemia: very large, fragile red blood cells with a high MCV. What separates it from iron-deficiency anemia is the nervous system: without B12, nerves lose their insulation, causing tingling and numbness in the hands and feet, poor balance, a wobbly unsteady gait and confusion. The tongue turns smooth, beefy and red. Because the gut cannot absorb it, B12 is given by injection — monthly, for life. Check the gait and the tongue, not just the pallor.
Read B12 Bianca's full story →The story arc
The setup
An older adult reports fatigue, and her blood count shows unusually large red blood cells.
The turn
Her tongue is smooth, shiny and beefy red, and she mentions her feet tingle.
The crisis
Her walk has become unsteady and she seems increasingly confused.
The save
Monthly B12 injections begin, and Bianca learns this is lifelong, not a short course.
NCLEX study section — Pernicious Anemia: The Beefy Red Tongue and the Wobbly Walk
What this chapter is testing: the recognition cues, the numbers and the priority action.
Study section: Health Assessment
Take this chapter into practice questions on the same topic.