A 47-year-old woman is brought to the emergency department with complaints of malaise,nausea, vomiting, andfatigue. The patient reveals a long history of alcohol abuse for the last 10 years and requires drinks daily, especially in the morning as an"eyeopener." She has been to rehabilitation on several occasions for alcoholism but has not been able to stop drinking. She is currently homeless and jobless. She denies cough, fever, chills, upper respiratory symptoms, sickcontacts , recent travel, hematemesis, or abdominal pain. She reports feeling hungry and has not eaten very well in a long time . On physical examination , she appears malnour ished but in no distress. Other findings on physical exam are normal. Her blood count reveals a normal white blood cell count but does show an anemia with large red blood cells. Her amylase, lipase, and liver function tests were normal.