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Fsn429.SOAPnote7

Fsn429.SOAPnote7 - SOAP note/10:00 S Pt was referred by...

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SOAP note November 16, 2011/10:00 S. Pt was referred by doctor and was newly diagnosed with Type 2 DM. She isn’t very active physically, but likes gardening. She has been gaining a fair amount of weight in the past 4-5 months and is still gaining. She wants to make some changes , but is unsure how to do so. Doctor has ordered 1000 kcal diet. O. 65 YOWF Dx: Type II diabetes Ht: 61” Wt: 158# BMI: 29.9 kg/m 2 overweight IBW: 105# (105% IBW) WC: 37” WHR: 1.03 Labs: Blood sugars: before breakfast: 190 mg/dL high Before dinner: 206 mg/dL high Before lunch: 225 mg/dL high Before bed: 190 mg/dL high All WNL except: HDL: 20 mg/dL low TG: 400 mg/dL high LDL: 230 mg/dL high FBG: 160 mg/dL high Hgb A1c : 9.2% high 24 hour recall: ~2430 kcal, 335.5 g CHO g (55%), 64 PRO g (11%), 66 g fat (24%). Energy distribution: 90% Estimated energy requirement (20 kcals/kg): ~1430 kcals Estimated Protein Requirement (15%): 54 g/day Estimated CHO intake: 28 CHO servings/day A. (PES) Excessive energy intake related to knowledge deficit and lack of physical activity as evidenced by her 24 hour recall and excessive weight gain.
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