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Ben Case ADIME and SOAP Examples

Ben is a 55-year-old man who has a stressful job that requires long hours and travel, causing him to eat only one meal per day and smoke more. A physical exam found Ben to be overweight with high blood pressure, cholesterol, and triglycerides. Tests also showed low food intake, physical inactivity, and weight loss over the past 6 months despite always believing his high metabolism prevented health issues.

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narsola
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115 views

Ben Case ADIME and SOAP Examples

Ben is a 55-year-old man who has a stressful job that requires long hours and travel, causing him to eat only one meal per day and smoke more. A physical exam found Ben to be overweight with high blood pressure, cholesterol, and triglycerides. Tests also showed low food intake, physical inactivity, and weight loss over the past 6 months despite always believing his high metabolism prevented health issues.

Uploaded by

narsola
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Ben is 55 and has always been lucky to have a high metabolism and has never had to worry

about his weight. He figured that he didn’t have to exercise, and he really doesn’t have time with
the long stressful hours at work and lots of out of town travel. Due to the stress of his job, he has
started smoking more than normal.

Lost around 2 Kg during the last 6 months.

When he went in for his yearly physical, his blood pressure was 140/90. When his labs came
back, his cholesterol was 250 and his triglycerides level was 320. His weight is 165 lbs (74.8 Kg)
with a height of 5 ft 7’’ (170-170.5 cm). He has a wrist circumference of 18 cm with a body fat
of 28.3 %. Ben has always felt that keeping his weight down would prevent him from having
heart disease. He really doesn’t eat much, usually just one meal a day at a restaurant or on the go.

Ben has done no surgeries in the past. He just suffers from allergy and muscle spasms. He only
takes multivitamins and Otrivin nasal spray occasionally.

1- Write the A & D part of an ADIME note for Ben.


2- Write a SOAP note for Ben.
ADIME Note:

Reason for consult: 55-y.o boy with hyperlipidemia and anemia

Assessment:

36- y.o boy, admitted for dyslipidemia and hypertension

Client History:

 PMH: Dyslipidemia, HTN, allergy


 PSH: none
 Social Hx :stressful hours of work , sedentary life style, have lunch out at various
restaurants, smoker

Food and Nutrition-Related History:

Medications: Otrivin- multivitamins

Food & Nutrient Intake:

 Patient doesn’t eat much, usually just one meal a day at a restaurant or on the go.

Anthropometric Data:

 Ht: 5 ft 7’’=170-170.5 cm
 Act Wt: 165 lbs =74.8 Kg
 UBW : 76.8 (before 6 months)
 BMI: 25.8 kg/m2  overweight
 Frame size= ht/wrist circ = 9.4< 9.9  small
 ABW (obese M)= (Act wt- IBW)*0.38 +IBW= 66.3 kg
 % wt loss in 6 months: (UBW –Act Wt)/ UBW x 100 = 2.6 % (acceptable- no
Significant weight loss)
 % body fat: 28.3 % > 25%  unhealthy (high)

Biochemical Data:

 TG = 320 mg/dl (H)


 LDL = 250 mg/dl (H)
 Bp = 140/90 mmHg (HTN stage 1)

Nutrition focused physical findings:

 Allergy
Comparative Standards:

 Energy needs : 2470 kcal/ day – 500 kcal (since he is overweight)= 2000 kcal ( based
on ABW and WHO formula with activity factor 1.12 (very light)
 Protein: 60g/ d (0.8g/ CBW)
 Fluids : 2625ml = 2.6 L ( 35ml/kg ABW)

Current diet order: 1 Meal/day at restaurants

Diagnosis:

Overweight (NC-3.3) RT sedentary lifestyle AE by BMI: 25.8 kg/m2

Altered nutrition-related laboratory values (HTN) (NC-2.2) RT to excessive smoking AE by Bp=


140/90 mmHg

Inadequate Oral Intake (NI-2.1) RT loss of appetite AE by patient’s interview ( just one meal a
day at restaurant)

Physical inactivity (NB-2.1) RT long stressful hours of work AE by patient’s interview (and he
really doesn’t have time)
SOAP Note:

Subjective

Patient state that he is 55 years old

Patient reports very low food intake because he claims that he has a high metabolism

Pt reports an increase in smoking more than normal.

Pt also says that he didn’t have to exercise, and he really doesn’t have time with the long
stressful hours at work and lots of out of town travel.

Pt doesn’t eat much, usually just one meal a day at a restaurant or on the go.

Lost around 2 Kg during the last 6 months

Objective

 Ht: 5 ft 7’’=170-170.5 cm
 Act Wt: 165 lbs =74.8 Kg
 UBW : 76.8 (before 6 months)
 BMI: 25.8 kg/m2  overweight
 Frame size= ht/wrist circ = 9.4< 9.9  small
 ABW (obese M)= (Act wt- IBW)*0.38 +IBW= 66.3 kg
 % wt loss in 6 months: (UBW –Act Wt)/ UBW x 100 = 2.6 % (acceptable- no
Significant weight loss)
 TG = 320 mg/dl (H)
 LDL = 250 mg/dl (H)
 Bp = 140/90 mmHg (HTN stage 1)
 Medications: Otrivin, multivitamins
 Energy needs : 2470 kcal/ day – 500 kcal (since he is overweight)= 2000 kcal ( based
on ABW and WHO formula with activity factor 1.12 (very light)
 Protein: 60g/ d (0.8g/ CBW)
 Fluids : 2625ml = 2.6 L ( 35ml/kg ABW)
Assessment

 Allergies and muscle spams


 HTN
 Dyslipidemia
 Overweight: BMI: 25.8 kg/m2
 Hypertension: Bp= 140/90 mmHg
 % body fat: 28.3 % > 25%  unhealthy (high)

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