Order Description

Folic Acid Deficiency Case Study

PATIENT PRESENTATION
Chief Complaint
“My stomach hurts and I have been throwing up today.”
HPI
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.
PMH
Fibromyalgia
Celiac disease
Hypothyroidism
Osteopenia
History of endometriosis
Placenta previa—s/p TAH–BSO
FH
Mother positive for lupus; sister with Crohn’s disease; negative for DM, CAD, CVA, CA
SH
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
Meds
Levothyroxine 100 mcg po daily; Estradiol 0.05 mg/24 h transdermal patch (Estraderm); replace twice weekly
All
Doxycycline—rash
ROS
(+) 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
Physical Examination
Gen – Caucasian female who appears generally ill, but nontoxic
VS – BP 135/90 mm Hg, P 82 bpm, RR 40, T 35.5°C
Skin – No petechiae, rashes, ecchymoses, or active lesions; decreased skin turgor
HEENT – Atraumatic/normocephalic; PERRLA, EOMI; conjunctivae pink, sclera white; TMs intact and reactive; nose is 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 ?ank 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 throughout
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 27.2%
ALT 52 IU/L
B12 242 pg/mL
Cl 102 mEq/L
RBC 3.78 × 10 6 /mm 3
Alk phos 142 IU/L

CO 2 21 mEq/L
Plt 217 × 10 3 /mm 3
GGT 288 IU/L

BUN 7 mg/dL
WBC 6.3 × 10 3 /mm 3
T. bili 2,1 mg/dL

SCr 0.52 mg/dL
MCV 120.4 ?m 3
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
T 4 , 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 de?ciency
Please respond to the following questions:
1. Create a drug therapy problem list for this patient.
2. What signs, symptoms, and laboratory values indicate that this patient has anemia secondary to folate de?ciency?
3. Could the patient’s folate de?ciency have been caused by drug therapy or comorbidity?
4. What additional information can be used to assess this patient’s folate de?ciency?
5. Why is it important to differentiate folate de?ciency from vitamin B 12 de?ciency, and how is this accomplished?
6. What are the goals of pharmacotherapy for this patient’s anemia?
7. What nondrug therapies may be used to correct this patient’s folic acid de?ciency?
8. What pharmacotherapeutic alternatives are available for treating this patient’s anemia?
9. What are the most appropriate drug, dosage form, dose, schedule, and duration of therapy for resolving this patient’s anemia?
10. What parameters should be used to evaluate the ef?cacy and adverse effects of folic acid replacement therapy in this patient?
11. What information would you provide to this patient about her folic acid replacement therapy?