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LEARNING OBJECTIVES

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After completing this case study, the reader should be able to:

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  • Recognize the signs, symptoms, and laboratory abnormalities associated with folic acid deficiency.

  • Identify the confounding factors that may contribute to the development of folic acid deficiency (eg, medications, concurrent disease states, and dietary habits).

  • Recommend an appropriate treatment regimen to correct anemia resulting from folic acid deficiency.

  • Educate patients with folic acid deficiency regarding pharmacologic and nonpharmacologic interventions used to correct folic acid deficiency.

  • Describe appropriate monitoring parameters for initial and subsequent monitoring of folic acid deficiency.

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PATIENT PRESENTATION

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Chief Complaint

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

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HPI

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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.

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PMH

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  • Fibromyalgia

  • Celiac disease

  • Hypothyroidism

  • Osteopenia

  • History of endometriosis

  • Placenta previa—s/p TAH–BSO

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FH

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Mother positive for lupus; sister with Crohn disease; negative for DM, CAD, CVA, CA

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SH

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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

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Meds

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  • Levothyroxine 100 mcg PO daily

  • Estradiol 0.05 mg/24 hour transdermal patch (Estraderm); replace twice weekly

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All

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Doxycycline—rash

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ROS

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(+) 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 or VTE

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Physical Examination

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Gen
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Caucasian female who appears generally ill, but nontoxic

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VS
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BP 135/90 mm Hg, P 82 bpm, RR 40, T 35.5°C

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Skin
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No petechiae, rashes, ecchymoses, or active lesions; decreased skin turgor

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HEENT
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Atraumatic/normocephalic; PERRLA, EOMI; conjunctivae pink, sclera white; TMs intact and reactive; nose is patent; tongue is large and erythematous; dry mucous membranes

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Neck/Lymph Nodes
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Normal ROM; no JVD, adenopathy, thyromegaly, or bruits

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Lung/Thorax
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Lungs CTA bilaterally

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