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FSN429.SoapNote2 - SOAP note October 4 2011/10 am S Pt...

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SOAP note October 4, 2011/10 am S. 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 persistent lethargy , diarrhea and coldness at her extremities . She plays tennis 2-3 times weekly categorizing her in normal physical activity. O. 28 YOWF Ht:66’ Wt: 115# BMI: 18.6 kg/m2 IBW: 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 cm 2 (<5%tile) Labs: Gluc 120 mg/dL high Serum Fe 150 ug/dL normal HCT 35% low MCH 37 pg/cell high Alb 2.9 g/dL low Hgb 11 g/dL low RBC 3.1 x 10 12 /L low MCV 115 fL macrocytic MCHC 31.43 g/dL normochromic EER (1.6 activity factor) 2100-2200 kcal/day Estimated protein requirement: 42-52 gm/day (0.8-1 gm pro/kg) Fluid Requirement: 1820-2080 ml Meds: none. 24 hour 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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