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A 67-year-old lady presents to the emergency department at 4 am having fallen over while walking to the bathroom.
She often falls in the night, but this time she badly hurt her left hip, necessitating a hospital visit.
After assessment, a diagnosis of soft tissue injury is made. However, examination of the lower limbs reveals loss of light touch, vibration and joint position sense in a stocking distribution. Romberg’s sign is positive. There are no ankle jerks, the plantar reflexes are extensor and the knee jerks are brisk.
Her haemoglobin is 7.2g/dl with a megaloblastic blood film.
On further questioning, she reports progressive symmetrical numbness in her fingers and toes, increasing tiredness, dyspnoea, and a sore red tongue.
She also says her family have suggested that she is becoming increasingly confused.
Which of the following is least likely to be part of this lady’s clinical picture?
Which of the following is least likely to be a cause of B12 deficiency?