Review Question - QID 108786

A 65-year-old gentleman presents to his primary care physician for a 3-month history of fatigue and difficulty with gait. The patient works in a health food store, follows a strict vegan diet, and takes an array of supplements. He noticed that his symptoms have progressed over the past year and decided to see a physician when he found himself feeling abnormally weak on a daily basis in conjunction with his trouble walking. The patient has a past medical history of Crohn disease that was diagnosed in his early 20s as well as celiac disease. He states that he has infrequent exacerbations of his Crohn disease. Recently, the patient has been having worsening bouts of diarrhea that the patient claims is non-bloody. The patient is not currently taking any medications other than traditional Chinese medicine supplements. A physical exam is notable for 3/5 strength in the upper and lower extremities, absent upper and lower extremity reflexes, and a staggering, unbalanced gait. Laboratory values reveal the following:

Serum:
Na+: 135 mEq/L
Cl-: 100 mEq/L
K+: 5.6 mEq/L
HCO3-: 22 mEq/L
BUN: 27 mg/dL
Glucose: 79 mg/dL
Creatinine: 1.1 mg/dL
Ca2+: 8.4 mg/dL
Mg2+: 1.5 mEq/L

Leukocyte count and differential:
Leukocyte count: 4,522/mm^3
Hemoglobin: 9.2 g/dL
Hematocrit: 29%
Platelet count: 169,000/mm^3
Reticulocyte count: 2.5%
Lactate dehydrogenase: 340 U/L
Mean corpuscular volume: 97 fL

Which of the following is most likely deficient in this patient?