Date:
Patient:
MRN:
Clinician: (Primary Care Physician, Hematologist)
Reason for Visit:
Follow-up for folate deficiency
Evaluation of symptoms and response to treatment
Monitoring of blood counts
History of Present Illness:
Briefly describe the patient’s current status:
Duration of symptoms suggestive of folate deficiency (fatigue, weakness, headache, glossitis – inflamed tongue)
Dietary habits (low intake of folate-rich foods)
Severity of symptoms
Response to folate supplementation and any side effects
Past Medical History:
Underlying conditions that may contribute to folate deficiency (malabsorption syndromes, inflammatory bowel disease, chronic alcoholism)
History of medications that can interfere with folate absorption (anti-seizure medications, methotrexate)
Previous surgeries (gastric bypass surgery can decrease folate absorption)
Pregnancy (increased folate needs)
Family History:
Family history of anemia (not directly related to folate deficiency but may be present)
Social History:
Alcohol consumption (heavy alcohol intake can decrease folate absorption and stores)
Physical Exam:
Vital Signs: (may be normal)
General: Pallor (pale skin) in severe cases
Oral exam: Glossitis (red, inflamed tongue)
Neurological: Peripheral neuropathy symptoms (numbness, tingling) in severe cases
Labs:
Complete Blood Count (CBC):
Macrocytosis (red blood cells larger than normal) is a characteristic finding in folate deficiency anemia.
May also show anemia (low red blood cell count, hemoglobin, and hematocrit).
Serum folate level: Low serum folate level confirms the diagnosis.
Consider mentioning other labs ordered based on suspicion:
Vitamin B12 level (deficiency can cause similar symptoms, differentiation needed)
Iron studies (iron deficiency anemia can also cause macrocytosis)
Assessment:
Confirm the diagnosis of folate deficiency based on clinical presentation, macrocytosis on CBC, and low serum folate level.
Identify the underlying cause of folate deficiency if possible (dietary, malabsorption, medications).
Evaluate the severity of anemia and other symptoms.
Plan:
Outline the treatment plan to replenish folate stores and improve symptoms:
Folate supplementation: High-dose oral folic acid supplements to correct the deficiency.
Dietary modifications: Encourage consumption of folate-rich foods (leafy green vegetables, fruits, legumes).
Treatment of underlying cause: If identified, address the underlying condition contributing to the deficiency (e.g., gluten-free diet for celiac disease).
Prognosis:
Briefly discuss the prognosis. Folate deficiency is usually reversible with appropriate treatment.
Recovery time depends on the severity of the deficiency and adherence to treatment.
Education:
Document any education provided to the patient regarding:
The importance of folate for overall health and red blood cell production
The benefits of a healthy diet rich in folate-containing foods
The importance of taking folic acid supplements as prescribed
The potential need for ongoing monitoring of blood counts
Notes:
Include any additional relevant information not covered above, such as the patient’s understanding of the diagnosis and treatment plan, and any concerns they may have.
Consider mentioning the importance of maintaining a healthy lifestyle and avoiding factors that contribute to folate deficiency.
Disclaimer: This is a template and should be adapted to the specific needs of each patient. It is important to consult with a healthcare professional for diagnosis and treatment recommendations.