Fsn429.SoapNote5

Fsn429.SoapNote5 - SOAP note November 3 2011/10:00 S Pt has...

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SOAP note November 3, 2011/10:00 S. Pt has been losing weight (10# in the past 3 months). She was diagnosed with lupus 5 years ago , and both her mother and aunt have lupus. She has been experiencing malaise, fatigue, chest pain when taking a deep breath, hair loss, stiff joints in her hands, and a skin rash. She c/o difficulty eating and a loss of appetite. She has said that she doesn’t feel well and is starting to feel depressed about her situation but she wants to feel better and get back to her normal routine. She feels like she’s getting sick more often which doesn’t help with her food intake. She’s willing to drink an Ensure a day . O. 35 YOAF Ht: 64’ Wt: 105# BMI: 18 kg/m 2 underweight IBW: 120# (87.5% IBW) mild deficit UBW: 115# (91%UBW) mild deficit 8.7% severe weight loss in the past 3 months. TSF=12 mm (5-10%tile) below average MAC=19 cm (<5%tile) muscle deficit Labs: Alb: 2.0 g/dl, CRP: 135 mg/L, RBC: 3.6 x 10 12 /L, Hgb: 12 g/dl, Hct: 35%, MCH: 27 pg/cell EER (40 kcal/kg): 1800-1900 kcal/day Estimated Protein Requirement (1.2 g/kg): 57.2 g/day
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