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Folic Acid Deficiency
Folic Acid Deficiency
Wine, Anyone? ……… Level I
Learning Objectives
After completing this case study, the reader should be able to:
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 (e.g., 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.
Patient Presentation
Chief Complaint
“My stomach hurts and I have been throwing up today.”
HPI
Laura Jones is a 43yearold woman with a 1day 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 motherinlaw 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 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 throughout
Labs
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Assessment
Acute pancreatitis secondary to alcohol use
Dehydration
Macrocytic anemia secondary to folate deficiency
Clinical Pearl
Unlike dietary folate, supplemented folic acid (pteroylglutamic acid) is absorbed even with abnormal function of GI mucosal cells. Likewise, persistent
alcohol ingestion or the use of drugs affecting folic acid absorption, folate transport, or dihydrofolate reductase will not prevent a sufficient therapeutic
response to oral supplementation.
References
1. Arafah BM. Increased need for thyroxine in women with hypothyroidism during estrogen therapy. N Engl J Med 2001;344:1743–1749.
CrossRef [PubMed: 11396440]
2. Malouf R, Grimley Evans J. Folic acid with or without vitamin B12 for the prevention and treatment of healthy elderly and demented people.
Cochrane Database Syst Rev 2008;(4):CD004514. doi: 10.1002/14651858.CD004514.pub2.
3. Snow CF. Laboratory diagnosis of vitamin B12 and folate deficiency: a guide for the primary care physician. Arch Intern Med 1999;159:1289–1298.
CrossRef [PubMed: 10386505