FolicAcid
Deficiency:
MoreWine,
Anyone?
Pharmacotherapy Casebook, 11th Ed
Leslie Dawson
Kathaleen Osterritter
Suphanith Simthong
Chung Siu

ChiefComplaint “My stomach hurts
and I have been
throwing up today.”

History of
Present Illness
 Laura Jones is a 43-year-old woman with a 1-day
history of vomiting and mild abdominal pain.The
pain radiates down to the lower abdominal
quadrants bilaterally. She presents to the ED after
experiencing some chest discomfort late in the
day. She denies any fevers, chills, or similar pains
in the past. She also complains of loose stools and
chronic fatigue for the past 2–3 months.

Past Medical History
Fibromyalgia
Celiac disease
Hypothyroidism
Osteopenia
History of endometriosis
Placenta previa—s/pTAH–
BSO

Family
History
 Mother positive for lupus
 sister with Crohn disease
 negative for DM, CAD, CVA, CA

 Married; (+) alcohol—three to four glasses of wine per day,
increased recently from one to two glasses after her
mother-in-law moved in
 (+) smoking tobacco 0.5 ppd × 25 years
 (–) recreational drug use
 unemployed
Social History

Meds
 Levothyroxine 100 mcg PO daily
 OrthoTri-Cyclen Lo 1 tab PO daily

 Doxycycline—rash Allergies

Review of
Systems
 (+) Generalized weakness
 (–) dizziness; (–) weight gain or loss; (–) fever; (–) vision or
hearing changes; (–) cough, chest pain, palpitations; (–)
shortness of breath
 (+) nausea/vomiting, abdominal pain, loose stools
 (–) rectal bleeding; (–) nocturia or dysuria
 (+) bilateral lower extremity weakness
 (–) edema, rashes, or petechiae; (–) symptoms of depression or
anxiety; (–) history of bleeding problems orVTE

Gen
 Caucasian female who appears generally ill, but nontoxic
VS
 BP 135/90 mm Hg, P 82 bpm, RR 40,T 35.5°C; Ht 64′′,Wt 52 kg
Skin
 No petechiae, rashes, ecchymoses, or active lesions; decreased skin turgor
HEENT
 Atraumatic/normocephalic; PERRLA, EOMI; conjunctivae pink, sclera white;
TMs intact and reactive; nares patent; tongue is large and erythematous;
dry mucous membranes.
Neck/Lymph Nodes
 Normal ROM; no JVD, adenopathy, thyromegaly, or bruits
Lung/Thorax
 Lungs CTA bilaterally
CV
 RRR; no murmurs, gallops, or rubs
Abd
 Soft, nondistended, with midepigastric and right flank and right lower
quadrant tenderness; (+) bowel sounds
Genit/Rect
 Deferred
MS/Ext
 Lower extremities warm with 2+ bipedal pulses; no clubbing, cyanosis, or
edema
Neuro
 CN II–XII grossly intact; decreased muscle strength 3/5 bilaterally in upper
and lower extremities; DTRs 2+ throughout
Physical
Examination

Labs
Na 138 mEq/L Hgb 12.6 g/dL AST 128 IU/L Folate 2.8 ng/mL
K 4.2 mEq/L Hct 37.2% ALT 52 IU/L B12 242 pg/mL
Cl 102 mEq/L RBC 3.78 ×
106/mm3
Alk phos 142 IU/L
CO2 21 mEq/L Plt 217 × 103/mm3 GGT 288 IU/L
BUN 7 mg/dL WBC 6.3 × 103/mm3 T. bili 2.1 mg/dL
SCr 0.52 mg/dL MCV 120.4 µm3 Alb 3.4 g/dL
Glu 89 mg/dL MCH 40.5 pg TSH 2.06 mIU/L
Amylase 404 IU/L MCHC 33.6 g/dL T4, free 1.2 ng/dL
Lipase 679 IU/L RDW 12.1%

Assessment
Acute pancreatitis secondary
to alcohol use
Dehydration
Macrocytic anemia secondary to
folate deficiency