Soap Note Gastroenteritis -

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.

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

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. Clear to auscultation bilaterally, no wheezes or crackles

Generalized abdominal cramping, diffuse without radiation.

~24 hours.

NKDA.

Mucous membranes dry, no thrush, oropharynx clear. No sick contacts known

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

Warm, dry overall but with reduced turgor on sternum.