Soap Note Gastroenteritis -

Clear to auscultation bilaterally, no wheezes or crackles.

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.

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.

NKDA.

None. No chronic GI disorders.

Generalized abdominal cramping, diffuse without radiation.

Warm, dry overall but with reduced turgor on sternum. soap note gastroenteritis

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

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

Mucous membranes dry, no thrush, oropharynx clear. Clear to auscultation bilaterally, no wheezes or crackles

~24 hours.

None. No recent antibiotics.

Cranial nerves II–XII intact. No focal deficits. Assessment (A) Diagnosis: Acute viral gastroenteritis with mild-to-moderate dehydration. Low-grade fever (100