Soap Note Gastroenteritis May 2026

NKDA.

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.

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

Mucous membranes dry, no thrush, oropharynx clear.

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. Tachycardic, regular rhythm, no murmurs, rubs, or gallops

None. No chronic GI disorders.

Clear to auscultation bilaterally, no wheezes or crackles. diffuse without radiation.

Generalized abdominal cramping, diffuse without radiation.