, 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.
