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.
Mucous membranes dry, no thrush, oropharynx clear. soap note gastroenteritis
Generalized abdominal cramping, diffuse without radiation. Generalized abdominal cramping, diffuse without radiation
Lives alone. No recent travel. No sick contacts known. Eats out frequently. Denies alcohol or illicit drug use. No sick contacts known
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.