Soap Note Gastroenteritis Apr 2026

Clear to auscultation bilaterally, no wheezes or crackles.

~24 hours.

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

Generalized abdominal cramping, diffuse without radiation.

Warm, dry overall but with reduced turgor on sternum. Clear to auscultation bilaterally, no wheezes or crackles

NKDA.

Cranial nerves II–XII intact. No focal deficits. Assessment (A) Diagnosis: Acute viral gastroenteritis with mild-to-moderate dehydration. Generalized abdominal cramping, diffuse without radiation

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 recent antibiotics.

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

None. No chronic GI disorders.