, SOAP NOTE: 25-Year-Old Female with
Loose Stool
Patient Name: [Not provided in screenshot - will refer to as Patient]
Age: 25 years old
Gender: Female
Encounter Date: [Current Date]
Setting: Primary Care Clinic / Urgent Care
Chief Complaint: "I've been having loose stool for the past several days."
SUBJECTIVE (S)
History of Present Illness (HPI):
The patient is a 25-year-old female who presents to the clinic with a chief
complaint of loose, watery stools for the past 4-5 days. She reports having
approximately 4-6 episodes of diarrhea per day. She describes the stool as
loose to watery, brown in color, without visible blood or mucus. She
endorses associated abdominal discomfort, described as cramping pain
located in the lower quadrants, which temporarily improves after bowel
movements.
She denies nausea, vomiting, fever, chills, or night sweats. She reports
some subjective feeling of bloating and gas. She denies any recent travel
outside the country. She lives with her roommate who has not been ill. She
denies any known sick contacts. She reports eating out at a local
restaurant 2 days prior to symptom onset but cannot identify a specific
food item. She has tried over-the-counter loperamide (Imodium) which
provided minimal relief.
Loose Stool
Patient Name: [Not provided in screenshot - will refer to as Patient]
Age: 25 years old
Gender: Female
Encounter Date: [Current Date]
Setting: Primary Care Clinic / Urgent Care
Chief Complaint: "I've been having loose stool for the past several days."
SUBJECTIVE (S)
History of Present Illness (HPI):
The patient is a 25-year-old female who presents to the clinic with a chief
complaint of loose, watery stools for the past 4-5 days. She reports having
approximately 4-6 episodes of diarrhea per day. She describes the stool as
loose to watery, brown in color, without visible blood or mucus. She
endorses associated abdominal discomfort, described as cramping pain
located in the lower quadrants, which temporarily improves after bowel
movements.
She denies nausea, vomiting, fever, chills, or night sweats. She reports
some subjective feeling of bloating and gas. She denies any recent travel
outside the country. She lives with her roommate who has not been ill. She
denies any known sick contacts. She reports eating out at a local
restaurant 2 days prior to symptom onset but cannot identify a specific
food item. She has tried over-the-counter loperamide (Imodium) which
provided minimal relief.
