1
Soap note on Gastroenteritis
Student’s Name
Institutional Affiliation
, 2
Soap note on Gastroenteritis
Name: Date: Time:
Age: 20 Years Sex: Female
SUBJECTIVE DATA
CC:
“I have diarrhea.”
HPI:
A 20 years old Hispanic female visits the office with complaints of diarrhea. She also adds that
she has been having nausea, cramps and vomiting since yesterday. She says that she has never
experienced such symptoms before. She also adds that her symptoms have been aggravating with
time. Patient states that she has not done anything to alleviate her symptoms She states that she
takes her super at home and eats out during lunch time. She also states that she likes eating take
ways from restaurants. Patients states that she is currently under no medication and that she has
never been diagnosed with gastrointestinal conditions. She denies heartburn and swelling of the
stomach. She also says that she has no fever and no chills. Patient states that since she is
currently at home, she has been taking all of her meals from home and that she has not eaten out
recently. She also states that none of her family members has complained of the symptoms she
has presented with.
Medication:
Patient is currently under no medication.
PMH:
Allergies: Patient states that she gets lumps on her hands and legs when she takes a lot of
proteins.
Soap note on Gastroenteritis
Student’s Name
Institutional Affiliation
, 2
Soap note on Gastroenteritis
Name: Date: Time:
Age: 20 Years Sex: Female
SUBJECTIVE DATA
CC:
“I have diarrhea.”
HPI:
A 20 years old Hispanic female visits the office with complaints of diarrhea. She also adds that
she has been having nausea, cramps and vomiting since yesterday. She says that she has never
experienced such symptoms before. She also adds that her symptoms have been aggravating with
time. Patient states that she has not done anything to alleviate her symptoms She states that she
takes her super at home and eats out during lunch time. She also states that she likes eating take
ways from restaurants. Patients states that she is currently under no medication and that she has
never been diagnosed with gastrointestinal conditions. She denies heartburn and swelling of the
stomach. She also says that she has no fever and no chills. Patient states that since she is
currently at home, she has been taking all of her meals from home and that she has not eaten out
recently. She also states that none of her family members has complained of the symptoms she
has presented with.
Medication:
Patient is currently under no medication.
PMH:
Allergies: Patient states that she gets lumps on her hands and legs when she takes a lot of
proteins.
