SOAP noteOctober 4, 2011/10 amS.Pt states that she was referred by her doctor. She has lost weight(6-8# in the past month since she has lost appetite and a drop of energy level) and this concerns her. She has persistentlethargy, diarrheaand coldness at her extremities. She plays tennis 2-3 times weekly categorizing her in normal physical activity. O.28 YOWFHt:66’ Wt: 115# BMI: 18.6 kg/m2IBW: 130# (88% IBW) UBW: 122# (94%UBW)6% weight loss in the past month.MAC: 22 cm TSF: 11 mm (5-10%tile) MAMA: 12.55 cm2(<5%tile)Labs:Gluc 120 mg/dL high Serum Fe 150 ug/dL normal HCT 35% lowMCH 37 pg/cell high Alb 2.9 g/dL low Hgb 11 g/dL lowRBC 3.1 x 1012/L low MCV 115 fL macrocytic MCHC 31.43 g/dL normochromicEER (1.6 activity factor) 2100-2200 kcal/dayEstimated protein requirement: 42-52 gm/day (0.8-1 gm pro/kg)Fluid Requirement: 1820-2080 mlMeds: none.24hour recall results: 1677 kcals, 41.5 gm pro, 175 gm CHO, 83 g fat.A.(PES) Inadequate energy intake related to lack of appetite and persistent lethargy as evidenced
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