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For the BMJ authors, the clinical picture is the most important factor in determining whether someone has B12 deficiency

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

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