Soap Note Gastroenteritis • Trending

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

Warm, dry overall but with reduced turgor on sternum.

None. No chronic GI disorders.

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

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. soap note gastroenteritis

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.

Lives alone. No recent travel. No sick contacts known. Eats out frequently. Denies alcohol or illicit drug use. Tachycardic, regular rhythm, no murmurs, rubs, or gallops

NKDA.

~24 hours.

Clear to auscultation bilaterally, no wheezes or crackles.