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  1. FolicAcid Deficiency: MoreWine, Anyone? Pharmacotherapy Casebook, 11th Ed Leslie Dawson Kathaleen Osterritter Suphanith Simthong Chung Siu
  2. ChiefComplaint “My stomach hurts and I have been throwing up today.”
  3. 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.
  4. Past Medical History Fibromyalgia Celiac disease Hypothyroidism Osteopenia History of endometriosis Placenta previa—s/pTAH– BSO
  5. Family History  Mother positive for lupus  sister with Crohn disease  negative for DM, CAD, CVA, CA
  6.  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
  7. Meds  Levothyroxine 100 mcg PO daily  OrthoTri-Cyclen Lo 1 tab PO daily
  8.  Doxycycline—rash Allergies
  9. 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
  10. 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
  11. 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%
  12. Assessment Acute pancreatitis secondary to alcohol use Dehydration Macrocytic anemia secondary to folate deficiency