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

13.
1.a.What
subjective and
objective
information
indicates the
presence of
anemia
secondary to
folate
deficiency?
 Subjective information:
 chronic fatigue for the past 2–3 months, generalized
weakness, bilateral lower extremity weakness [objective as
well], chest discomfort late in the day, vomiting, abdominal
pain radiating bilaterally, loose stools
 Objective information:
 tongue is large and erythematous, decreased muscle
strength 3/5 bilaterally in upper and lower extremities,
midepigastric and right flank and right lower quadrant
tenderness. Folate 2.8 ng/mL, RBC 3.78 × 106/mm3, MCV
120.4 µm3, MCH 40.5 pg, BP 135/90 mm Hg, P 82 bpm, RR 40,
T 35.5°C; Ht 64′′,Wt 52 kg

14.
1.b.What
additional
information is
needed to fully
assess this
patient’s
anemia?
 More information about this patient’s dietary habits, MMA level to
rule out B12 deficiency, homocysteine testing may also help
confirm the diagnosis, as could erythrocyte folate levels. I’d like
additional information on this patient’s stooling habits, including
the presence or absence of steatorrhea.

15.
2.a.Assess the
severity of the
anemia based
on the
subjective and
objective
information
available.
 Anemia is defined as an abnormally low hemoglobin
concentration in the blood.This can be related to bleeding,
although when no source of bleeding is uncovered, insufficient
dietary intake of vegetables and increased amount of alcohol
intake for instance and GI malabsorption may be the cause (Kline
& Chiplinski, 2020). Celiac disease can be an example of a GI
malabsorption occuring in our patient. Given our 43YO patients'
systems of fatigue, generalized weakness, dry mucous
membranes, I would say her symptoms are mild. Anemias are
going to have classic symptoms of fatigue, weakness and
shortness of breath related to decreased oxygen carrying capacity
(Kline & Chiplinski, 2020). Her vital signs are stable BP 135/90 mm
Hg, P 82 bpm, RR 40,T 35.5°C; Ht 64′′,Wt 52 kg, her folate level is
2.8ng/mL which is low. Majority of her symptoms relate back to
her primary diagnosis of acute pancreatitis.To note, Mrs. Jones
there are psychosocial and economic factors to access. Mrs. Jones'
mother-in-law just moved in which made her want to drink one-
two more glasses of wine nightly. She is also unemployed.This can
be putting a strain on her and her family.

16.
2 . b .Create a list of
the patient’s drug
therapy problems
and prioritize them.
Include assessment
of medication
appropriateness,
effectiveness,
safety, and patient
adherence.
 Mrs. Jones is currently taking Levothyroxine 100mcg PO daily andOrthoTricyclen LO 1 tablet
PO Daily.
 Levothyroxine is a drug of a choice for hypothyroidism, which is appropriate for Mrs. Jones
since she has pmhx of hypothyroidism.This is the drug of choice for thyroid replacement
because it is chemically stable and relatively inexpensive (Cook & Greer, 2020).There are a few
adverse effects to consider when taking Levothyroxine. These are under-replacement, over-
replacement, and potentially causing heart failure, atrial fibrillation, angina pectoris, and
myocardial infarction.The patient should take this medication daily, the half-life is seven days
(Cook & Greer, 2020).
 OrthoTri Cyclen LO is an oral contraceptive, which is not appropriate for Mrs. Jones related to
her hysterectomy. Given this information it is important to include that some females take oral
contraceptives to decrease menopausal symptoms.These symptoms include irregular periods,
night sweats, and hot flashes. Although, if taking this medication is a must, the patient should
take this medication after eating dinner or at bedtime to help with an upset stomach or
nausea. It is important to take this medication at the same time each day, 24 hours apart (Cook
& Greer, 2020).
 We will be adding some medications to Mrs. Jones medication list for this admission to treat
her acute pancreatitis and anemia.
 Given Mrs. Jones’ dry mucous membranes I would assess whether she needs IV fluids related to
her acute pancreatitis.This helps reduce the risk of SIRS and organ failure (Cook & Greer, 2020).
I would also assess her electrolytes, although those are within normal range.
 We will relieve her abdominal pain with NSAIDS [Diclofenac].
 If there is a source of bacterial contamination antimicrobials or antibiotics will need to be
ordered. For instance, meropenem or metronidazole [Flagyl] (Cook & Greer, 2020).
 For her anemia, folate deficiency she should receive a supplement.Alcohol interferes with folic
acid absorption. Mrs. Jones should supplement 1 to 5mg daily of folic acid to replace stores. As
her nurse we can educate her on foods to intake that are high in folate. For instance, beef life,
green leafy vegetables, orange juice, and rice (Cook & Greer, 2020).
 Mrs. Jones should continue to take all her medications.These medications do not pose a risk
for interactions.They are appropriate for her diagnosis and safe for use.

17.
2.c.Could the
patient’s folate
deficiency
have been
caused by drug
therapy or
comorbidity?
 Mrs. Jones folate deficiency could have been caused by her celiac
disease and increased amount of alcohol intake, but I do not think
Levothyroxine or OrthoTri Cyclen could have caused her to have
decreased levels of folic acid. Celiac disease is a GI disorder leading
to malabsorption in the gut (Cook & Greer, 2020). Unfortunately,
for Mrs. Jones folic acid is absorbed in the GI tract which probably
was not occurring in her case due to her previous diagnosis.

18.
2. d .Why is it
important to
differentiate
folate deficiency
from vitaminB12
deficiency, and
how is this
accomplished?
 It is important to quickly differentiate folate deficiency from
Vitamin B12 deficiency becauseVitamin B12 deficiency can cause
neurologic and hematologic complications (Cook & Greer, 2020).
The patient typically presents with bilateral paresthesia, as well as
your typical anemia symptoms. If this is not treated, it can
progress to ataxia, dementia-like symptoms, psychosis, and vision
loss (Cook & Greer, 2020). Individuals withVit B12 deficiency you
will see laboratory findings of MCV elevated, a peripheral blood
smear showing macrocytosis accompanied by hyper segmented
polymorphonuclear leukocytes.This is one of the earliest
indications of the disease.This patient's bilirubin levels may be
elevated, low reticulocyte count, low B12 level, and low HCT (Cook
& Greer, 2020).

19.
3.a.What are
the goals of
pharmacother
apy for this
patient’s
anemia?
 Pharmacotherapy is based on initiating appropriate drug
replacement therapy treatment based on etiology and pertinent
drug interactions.
 The patient will adhere to the treatment plan for the one month
with success by taking a 1mg folic acid tablet daily, and recording
daily intake on a note pad to keep a record.
 The patient will display a normal in folate levels, 4.0 to 17.0
nanograms per milliliter (ng/mL) in one week (“Folic acid - test,”
n.d.).
 The patient is able to achieve a dietary goal of having three foods
high in folic acid with each meal daily.
 The patient will recognize three signs and symptoms of anemia by
the end of one week.
 The patient will be able to walk approximately 50 feet without
verbalizing complaints of fatigue or exhibiting signs of fatigue in
one week.

20.
3.b.What
nondrug
therapies may
be used to
correct this
patient’s folic
acid
deficiency?
 Folic acid deficiency treatment consists of replacement therapy
and dietary changes, even for patients with absorption problems.
Because humans cannot synthesize sufficient folate to meet total
daily requirements, they depend on nutritional sources. Dietary
sources rich in folate include fresh green leafy vegetables, dairy
products, legumes, whole grains, citrus fruits, and animal organs
such as the liver and kidney. Limiting alcohol interferes with folic
acid absorption and utilization at the cellular level and decreases
hepatic stores of folic acid (DiPiro et al, 2020).

21.
3.c.What
feasible
pharmacother
apeutic
alternatives
are available
for treating
this patient’s
anemia?
 Folic acid:Taking a daily folic acid tablet will help you increase your
folate levels.The synthetic version of the B vitamin folate is called
folic acid. By active and passive transport mechanisms, folate is
transported across the intestinal wall and absorbed in the jejunum
(Khan & Jialal, n.d.).The villi are harmed by celiac disease, making it
impossible for your body to absorb the nutrients it needs for growth
and wellness.Therefore, celiac disease can prevent folate absorption,
leading to a shortage. One of the frequent side effects of celiac
disease is anemia brought on by folic acid malabsorption.
 Ascorbic acid (Vitamin C) tablet multivitamin:The pancreatitis Mrs.
Jones has makes it more challenging for the body to absorb folic acid.
Consequently, vitamin and mineral supplements are needed as
replacements depending on the type of anemia, the presence of low
oral intake, and any diagnosed deficiencies.Vitamins are essential for
maintaining health because they serve as the body's building blocks.
For the body to grow and operate properly, vitamin C is required. In
addition, it is crucial to immune system operation. Anemia can result
from a vitamin C deficiency because vitaminC is necessary for the
production of red blood cells and maintaining healthy red blood cells.

22.
3 . d .Createan individualized,
patientcentered,teambasedcare
planto optimizemedication
therapyforthis patient.Include
specificdrugs,dosageforms,
doses,schedules,anddurationsof
therapy.

23.
Folic acid
 Once a day, take a 1 mg folic acid tablet by mouth. After four
months, once the clinical symptoms have subsided and the test
values have returned to normal, reduce the dose to 0.4 mg once a
day (Skidmore-Roth, 2020, p. 1717).
 The synthetic version of the B vitamin folate is called folic acid.
The patient's folic acid deficiency-related anemia is replaced with
vitamin and mineral supplements. Mrs. Jones consumes three to
four glasses of wine daily, lowering folic acid absorption, cellular
use, and hepatic folic acid storage. Please avoid taking your folic
acid within two hours of consuming antacids with aluminum or
magnesium, which could prevent the folic acid from absorbing
correctly (Skidmore-Roth, 2020, p. 1717).

24.
Ascorbic acid
 Take one 500 mg oral multivitamin tablet of ascorbic acid (vitamin
C) by mouth daily (Skidmore-Roth, 2020, p. 1719).
 Mrs. Jones's current pancreatitis and past Celiac disease make it
more challenging for the body to absorb folic acid. However, for
the body to grow and operate properly, vitamin C is required. It
also has a significant impact on immune system performance.

25.
Lactated
Ringer's
 Administer IV lactated ringer's bolus of 20 ml/kg followed by 150-
300ml/hr for the first 24 hours. If she reponses to this therapy as
assessed by BUN, the rate should be reduced to 2ml/kg/hr for 48
hours.
 Goals for fluid therapy when manging acute pancreatitis focus on
a heart rate less than 120/min, mean arterial pressure 65-85mmhg,
urinary output greater than 0.5 to 1ml/kg/hr, invasive measures of
stroke volume or intrathoracic blood volume (Cook & Greer, 2020).
All patients with acute pancreatitst should receive supportive care
to prevent sepsis (Cook & Greer, 2020).

26.
Ondansetron
 Administer IV ondansetron (Zofran) 2mg /ml as needed [PRN]
every 4 hours-8 hours as needed for a week.
 Ondansetron works by inhibiting the activities of serotonin, a
chemical your body naturally produces that may result in nausea
and vomiting (Skidmore-Roth, 2020, pp. 1147-1149).Therefore,
you should give treatment based on a specific pathophysiologic
cause of nausea and vomiting. It would be best to prevent nausea
for the predicted durations by providing the necessary antiemetics
using the most efficient route, considering the medication's side
effects.

27.
Promethazine
 For the initial dose of Promethazine (Phenergan), take 25 mg
orally.Then, take 12.5 to 25 mg every four to six hours
as necessary (Skidmore-Roth, 2020, p. 1288) for nausea or
vomiting.
 Motion sickness, nausea, vomiting, and vertigo are other side
effects that Promethazine can treat or avoid.The patient can take
Promethazine with food, water, or milk to lessen stomach upset.
Due to this medication, individuals may experience
lightheadedness, drowsiness, or decreased alertness.Therefore,
do not forget to alert the patient to any activities that call for
awareness.

28.
Nonsterioidal
Anti-
inflammatory/
Ibuprofen
• For Mild to Moderate Paid [1-5] Ibuprofen given orally initial dose
400mg. Follow-up dosing are 200mg to 400mg every 4 hours as
needed. Maximum doses of 4 in a 24-hour period.
• For Moderate to Severe Paid [6-10] Morphine given IV Initial dose
0.5mg/ml. Follow up dosing 0.5mg/ml-1mg/ml every 2-3hours as
needed. Maximum doses of 4 in 24 hours. Notify the provider if
the patient is requiring more pain medication.
• Morphine causes biliary pressure, but there is no evidence
to indicate that it is contraindicated (Cook & Greer, 2020).

29.
Meropenem
 Meropenem IV administration of 1g every 8 hours run over 1 hour.
Total duration of therapy [which may include oral step-down
therapy] is 4-7days following infection control.
 Treatment depends on the severity of illness and microbiology
data. Patients treated for intra-abdominal infections should be
assessed for occurrence of drug-related adverse effects (Cook &
Greer, 2020).

30.
Metronidazole
 Metronidazole (Flagyl) take one 500mg tablet every 8 hours by
mouth for 5 days (after discharge) following adequate source
control.
 Oral regimens are appropriate for individuals with mild to
moderate infections (Cook & Greer, 2020).

31.
Famotidine
 Take one 20 mg oral tablet of famotidine (Pepcid) orally in the
morning at least one hour prior to your first meal for six weeks.
 By inhibiting the histamine receptors in your stomach that cause
acid production, H2 blockers are designed to cure sudden
heartburn and reduce the quantity of acid your stomach produces.
H2 blockers decrease acid for up to 12 hours and begin reducing
heartburn symptoms in only 15 to 30 minutes (Skidmore-Roth,
2020, pp. 623). H2 blockers are therefore recommended over
proton pump inhibitors.

32.
Loperamide
 The recommended starting dose of loperamide (Imodium) is four
4 mg capsules by mouth, followed by one 2 mg capsule for each
unformed stool as needed.The maximum recommended daily
dose is 16 mg, or eight capsules (Skidmore-Roth, 2020, p. 1679).
 Usually, within 48 hours, clinical improvement is visible.
Antidiarrheal medications allow your body to absorb more liquid
and slow food passage through your intestines, which lessens
diarrhea.

33.
Nicotine
transdermal
patch
 Long-acting (Nicoderm CQ): Since Mrs. Jones smoked 0.5 packs
daily, she needs to start with 21 mg patches (Skidmore-Roth,
2020, p. 1092).The patient will put on the 21 mg/day patches for
six weeks before switching to the 14 mg/day patches for two
weeks (Skidmore-Roth, 2020, p. 1092).The patient will finish using
the third stage (7 mg per day) patches for an additional two
weeks.Ten weeks will be spent on treatment in total.
 To prevent skin irritation, instruct the patient to apply one patch
each morning to any area of the body without hair and rotate the
spot daily.At bedtime, the patch needs to be taken off and
replaced.The patient can take off the patch if they experience
insomnia or have vivid dreams.

34.
Problem # 1
chronic fatigue
for the past 2–
3 months
 You should evaluate the client's capacity to carry out activities of
daily living as a provider.The client's ability to engage in self-care
and fulfill social and familial obligations, such as working outside
the home, may be limited by anemia-related fatigue.Take note of
the client's pulse rate, blood pressure, breathing pattern, dyspnea,
usage of accessory muscles, and skin tone before, during, and
after the activity to gauge how much the client can endure. Assist
the client in setting up a log of activities to track exercise
tolerance. Exercise might be challenging while anemic.Too much
will make your symptoms worse and make you more easily
exhausted. If you get too little, you'll miss advantages like more
energy, less stress, and overall higher quality of life.As a provider,
you should advise the patient by starting with 10- to 15-minute
exercise and working your way up to sessions lasting 30- to 60
minutes three or four times a week. Of course, the health
advantages increase as you exercise more.

35.
Problem #2
Loose stools
 Anti-diarrheal drugs are administered to lessen the frequency of
loose stools. Loperamide allows your body to absorb more liquid
by slowing the passage of food through your intestines.There
have been complaints about loose stools; therefore, you want to
teach patients to track how often they pass feces.Tell the patient
to avoid gluten since she has celiac disease; if she does eat it, she
will get diarrhea.

36.
Problem #3
Nausea
 A precise pathophysiologic cause of nausea and vomiting should
be the basis for treatment.You should pay attention to the time
frames that the sickness is predicted. Additionally, when the
patient has vomited, give dental care. By removing the taste and
smell of the vomit, oral care helps to lessen the stimulus for
another vomiting episode. Every patient's nausea and vomiting
and the results of any therapies should be documented. Consider
the onset, duration, timing, amount of emesis, pattern frequency,
setting, connected circumstances, aggravating actors, and
previous medical and social histories when evaluating and
documenting the client's episodes of nausea and vomiting. As
necessary, implement suitable dietary measures, such as low-fat,
frequent, small, and nothing-by-mouth status. Avoiding fatty,
spicy, or salty foods may be helpful.

37.
Problem #4
Pancreatitis,
untreated
 To treat her pancreatitis, Mrs. Jones must learn about diet and
reduce alcohol usage. Mild abdominal pain that spreads to both
lower abdominal quadrants is the primary symptom of Mrs. Jones'
pancreatitis.The patient consumes more wine than is typical for
women—three to four glasses daily.The amount of alcohol the
patient drinks aggravate pancreatic discomfort.Teach the patient
to follow a low-fat diet, to consume whole grain bread and cereals,
lean cuts of meat, to eat five to six little meals daily rather than
three large ones, to eat a variety of fruits and vegetables, and to
drink a lot of water to avoid being dehydrated. Use calorie counts
three days in a row with each meal to determine the client's total
nutritional intake and identify a deficit or excess intake.

38.
Problem # 5
Dehydration
 Health issues and even potential death can result from dehydration.
Due to her decreased fluid intake from vomiting, the patient is
dehydrated. Dehydration can be avoided by instructing the patient to
drink water to replenish lost fluids. Instruct the patient to drink eight
glasses of water per day or 2 quarts/0.5 gallons, but not more than 1.5
quarts per hour. Consuming more than 1.5 quarts per hour can result
in a medical emergency by dangerously lowering the blood's salt
concentration ("How much water should I drink?: Urgent care
treatment for dehydration," n.d.). Mild dehydration can typically be
reversed by drinking liquids. However, you should visit the emergency
room if the dehydration is severe and does not improve after 48 hours
of oral replenishment.The provider will typically put the patient on
nothing by mouth diet to rest the pancreas and reduce
gastrointestinal secretions.Thus appropriate intravenous hydration is
required.Weight increase is a sensitive and reliable indicator of fluid
volume balance and a nutritional assessment, so weigh yourself as
soon as you wake up in the morning, before breakfast.Weight is
measured every day at the same time with minimal clothing on and
the same quantity of clothing using a reliable scale.

39.
Problem #6
Mild
abdominal
pain
 For one week, take one acetaminophen (Tylenol) 650 mg tablet
orally every 6 hours as needed for temporary relief.The maximum
daily dose of acetaminophen for a healthy adult weighing at least
150 pounds is 4,000 milligrams in 24 hours (Skidmore-Roth, 2020,
pp. 66-68).Acetaminophen is typically advised for mild to
moderate pain as a first-line treatment because it can lower
fevers. In addition, because it doesn't have any negative side
effects like stomach pain and bleeding, acetaminophen is typically
considered safer than other non-opioid painkillers.

40.
Problem #7
Nicotine
dependence
 Given that the patient smoked 0.5 packs per day for 25 years,
combined nicotine replacement therapy (NRT) is a feasible option
for treating this patient's nicotine dependence.This approach may
be more successful than utilizing only one kind of NRT.You can use
a smoking cessation method like nicotine replacement therapy
(NRT) or the drug bupropion, which lessens cigarette cravings.
According to studies, smokers often have greater homocysteine
concentrations than non-smokers, and low folate levels have been
linked to higher mortality rates from all causes and cardiovascular
disease (Zhou,Yu et al., 2018). Education on quitting smoking will
help those who are folic acid deficient and be good for their
health. Most smokers want to quit but worry they won't be able
to. Inquire about the patient's desire to stop smoking.A significant
motivation could be a provider's guidance and encouragement.

41.
Problem #8
Alcohol
dependence
 After her mother-in-law moved in, Mrs. Jones raised her daily wine
consumption from one to two glasses to three to four. Even if
alcohol was not the cause of her acute pancreatitis, she should
abstain from alcohol entirely for at least six months to give her
pancreas time to heal.The provider should recommend that the
patient refrains from drinking alcohol after that, but if you do
decide to do so, remember that you must adhere to the low-risk
drinking recommendations.Alcohol should still only be drunk in
moderation, the CDC advises, with women restricting intake to
one drink or less per day on days when alcohol is consumed
(Centers for Disease Control and Prevention, 2022).

42.
Team – BasedCare

43.
PrimaryCare
Doctor
 Depending on the etiology and any relevant drug interactions, the
primary care doctor will start the right drug replacement therapy
treatment.The patient's current medications, medical history, and
social background will all be discussed with the patient in order to
determine whether they may be causing or exacerbating anemia.
It's crucial to keep all of your visits when receiving therapy for
anemia and to adhere to the recommended course of action,
particularly if your symptoms are altering or developing.Avoid
making any major lifestyle adjustments without first consulting a
doctor, especially when starting or discontinuing any medications
or supplements.The patient can be instructed by the primary care
physician to eat naturally high folate foods and take supplements;
it should be noted, however, that excessive folate
supplementation may increase the risk of cancer.

44.
Dietician
 A dietician offers dietary recommendations to high-risk patients
and supplements their meals with folic acid to avoid the
development of deficiencies.The dietician can also examine the
patient's typical diet for their pancreatitis. By recording the foods
the patient often eats and any possible food allergies, the dietitian
can look for nutritional gaps in their diet. Consider asking a
nutritionist to evaluate your dietary requirements and provide you
with the recommended nutrition.Then, the patient can create a
diet plan tailored to the nutritional needs with the dietitian's help.

45.
Therapist
 Mrs. Jones has increased her intake of alcohol daily ever since her
mother-in-law moved in, and it seems like this is stressful for her.
When your mental well-being deteriorates, a therapist is
recommended. It makes it easier to deal with your challenging
emotions if you talk them out.You can have weekly sessions with a
therapist for a while. Instead of acting on angry feelings, a therapist
encourages you to take a moment.The more you share what's going
well for you and how you feel, the more positive feelings you
generate.Therapists help you to understand the interrelationships
between your emotions, thoughts, decisions, and behaviors.You'll
acquire coping mechanisms, improve your mood, and find assistance
for your issue.The client and family members may benefit from the
resources, support networks, and counseling offered by the therapist
to maintain connections and day-to-day functioning and manage the
client's needs in the future. Mrs. Jones can get stress relief from a
therapist, who can also assist the patient in self-help groups like
Alcoholics Anonymous (AA). Alcoholics Anonymous offers peer-based
support to those who are struggling with alcohol addiction.
Participants use the program's 12 traditions in AA as they progress
through the program's 12 steps.

46.
Occupational
Therapist
 An occupational therapist is recommended since the patient has
had chronic fatigue for the past 2-3 months.The occupational
therapist can do an evaluation and teach the client about using
assistive devices.The occupational therapist can also assist the
client and family determine whether extra energy-saving
measures in the home are necessary.

47.
Implement theCare
Plan

48.
4.a.What
information
should be
provided to the
patient to
enhance
compliance,
ensure
successful
therapy, and
minimize
adverse effects?
 Provide information on signs and symptoms of anemia for the
patient to better recognize them when she is at home.
 Provide patient with accessible and easy to understand
information on dietary intake of folate and folic acid. Refer patient
to the U.S. Food & Drug Administration guidelines on the
nutritional and supplement facts of folate and folic acid.
 Stress the importance of adherence to taking once a day Folic acid
tablets. Providing the patient with the common side effects of
upset stomach, nausea, diarrhea, irritability, confusion, skin
reactions, behavior changes, and seizures.
 Provide smoking cessation information to the patient and stress
the importance of quitting smoking for the patient’s overall health
to improve.
 Coordinate a plan with the patient to lower the amount of
alcoholic drinks per week. In order to enhance compliance,
suggest to the patient to lower the amount of alcoholic drinks
down to 2 glasses of wine per day and ultimately down to one
glass of wine per day.

49.
Foods that Provide Folate:
Foods Fortified with FolicAcid:
https://www.fda.gov/food/new-nutrition-facts-
label/folate-and-folic-acid-nutrition-and-
supplement-facts-labels

50.
4.b. Describe
how care
should be
coordinated
with other
healthcare
providers.
 Ensure that the patient’s primary care physician is aware of any
addition or cessation of medications.
 Update and chart any intervention that was completed onto the
patient’s virtual chart for easy access not only for the patient to
view and other healthcare providers the patient may be seeing
now or in the future.
 Consult an occupational therapy session for patient evaluation to
see if the patient needs any further therapy sessions or assistive
devices to improve her physical activity. Communicate with
occupational therapist for updates and any continuation of
therapy sessions moving forward.
 Recommend a therapist for the patient to address her recent life
stressors and communicate with the therapist for updates and any
continuation therapy sessions moving forward.

51.
Followup: Monitor and
Evaluate

52.
5 . a .What clinical
and laboratory
parameters should
be used to evaluate
the folic acid
replacement
therapy for
achievement of the
desired therapeutic
outcome and to
detect or prevent
adverse effects?
 Serum folic acid tests ordered with vitamin B12 levels should be
part of the patient’s assessment of desired therapeutic outcome.
The normal range of folic acid we are looking for is 2.7 to 17.0
ng/mL and the normal range of vitamin B12 is 160 to 950 pg/mL
(Ashraf et al, 2008).
 Clinical parameters to be utilized will be assessment of the
patient’s existing symptoms of abdominal pain, loose stools, and
chronic fatigue.The goal is the cessation of these symptoms post
treatment of folic acid deficiency.

53.
5 . b . Develop a
plan for follow-
up that includes
appropriate time
frames to assess
progress toward
achievement of
the goals of
therapy.
 Schedule folic acid andVitamin B12 lab levels to be drawn within 4
weeks after treatment initiation.
 Continue to conduct lab tests of folic acid andVitamin B12 levels
every four weeks until and after achievement of the goals of
therapy.
 At the patient’s four week follow up appointment, assessment of
the patient’s abdominal pain, loose stools, and chronic fatigue will
show that these symptoms have resolved or improved.

54.
References

55.
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Khan, K. M., & Jialal, I. (n.d.). Folic acid deficiency. NationalCenter for Biotechnology Information. Retrieved January 23, 2023, from https://pubmed.ncbi.nlm.nih.gov/30570998/
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