FSN429.SoapNote1 - requirement Pt has a BMI in the...

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SOAP note September 26, 2011/10 am S. Pt states that she was referred by her primary care physician after her physical exam. She has gained weight (20# in 2 years since she has been working long hours) and this concerns her. Since she has been working long hours she doesn’t have time for physical activity and frequently has to eat out . She has a positive family history for heart disease and now has a slightly raised blood pressure . O. 30 YOWF Ht:66’ Wt: 160# BMI: 25.9 kg/m2 IBW: 130# (123% IBW) UBW: 140# (114%UBW) 14% weight gain in 2 years. MAC: 29 cm TSF:26 mm (50-75%tile) MAMA: 34.55 cm2 (50-75%tile) Labs: N/A EER (1.3 activity factor) 1900-2000 kcal/day Estimated protein requirement: 58-73 gm/day (0.8-1 gm pro/kg) Meds: none. 24 hour recall results: 2533 kcals, 71 gm pro, 215 gm CHO, 110 g fat. A . (PES) Involuntary weight gain related to lack of physical activity as evidenced by weight gain of 20# within in 2 years and reported consumption of 28% more than estimated energy
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Unformatted text preview: requirement. Pt has a BMI in the overweight range. Her 14% weight gain in 2 years is understood as being non-significant, since it is in a larger span of time. Her MAMA and TSF percentile is in the normal range indicating average fat stores. Pt’s diet assessment indicates pt’s diet is poorly balanced with inadequate fruit and vegetable consumption (her only consumption was lettuce and tomatoes). Pt’s diet is low in the majority of vitamins and minerals due to eating fast food for convenience. Pt seems interested in improving her diet and is interested in losing weight. P. Decrease energy intake by ~550 kcals/day through: 3 smaller-portioned meals and 2 snacks. Encourage 3-4 servings/day of fruit and vegetables. Cut out fast food and prepare food from home. Handouts discussed and provided: 3 day food menu of healthy, easy and quick recipes. Follow-up in 2 weeks for weight check and diet assessment. Kim Chin, RD...
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