Gastroenteritis — Soap Note

None. No chronic GI disorders.

None. No recent antibiotics.

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.

Clear to auscultation bilaterally, no wheezes or crackles. soap note gastroenteritis

NKDA.

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

Mucous membranes dry, no thrush, oropharynx clear. No recent antibiotics

~24 hours.

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.

Tachycardic, regular rhythm, no murmurs, rubs, or gallops. Capillary refill ~2–3 seconds. Clear to auscultation bilaterally, no wheezes or crackles

Generalized abdominal cramping, diffuse without radiation.

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

Warm, dry overall but with reduced turgor on sternum.