Soap Note Gastroenteritis Page

Tachycardic, regular rhythm, no murmurs, rubs, or gallops. Capillary refill ~2–3 seconds.

Clear to auscultation bilaterally, no wheezes or crackles.

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

NKDA.

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

None. No recent antibiotics.

Mucous membranes dry, no thrush, oropharynx clear. soap note gastroenteritis

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.

Warm, dry overall but with reduced turgor on sternum. Tachycardic, regular rhythm, no murmurs, rubs, or gallops

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.

None. No chronic GI disorders.

~24 hours.