Soap Note Gastroenteritis Online

None. No recent antibiotics.

None. No chronic GI disorders.

Here’s a well-structured for a patient with gastroenteritis , with a strong emphasis on the Subjective and Objective features. SOAP Note: Acute Gastroenteritis Patient: 34-year-old male Chief Complaint: “Nausea, vomiting, and diarrhea for the past 24 hours.” Subjective (S) Onset: Symptoms began suddenly yesterday evening, approximately 6 hours after eating leftover takeout food. soap note gastroenteritis

Lives alone. No recent travel. No sick contacts known. Eats out frequently. Denies alcohol or illicit drug use.

NKDA.

~24 hours.

Mucous membranes dry, no thrush, oropharynx clear. No chronic GI disorders

Generalized abdominal cramping, diffuse without radiation.

Low-grade fever (100.8°F subjective at home), mild generalized weakness, dry mouth, decreased urine output (only once in past 12 hours, dark yellow). Denies hematemesis, hematochezia, jaundice, dysuria, headache, or stiff neck. Lives alone

Cranial nerves II–XII intact. No focal deficits. Assessment (A) Diagnosis: Acute viral gastroenteritis with mild-to-moderate dehydration.