Soap — Note Gastroenteritis

Generalized abdominal cramping, diffuse without radiation.

Cranial nerves II–XII intact. No focal deficits. Assessment (A) Diagnosis: Acute viral gastroenteritis with mild-to-moderate dehydration.

Lives alone. No recent travel. No sick contacts known. Eats out frequently. Denies alcohol or illicit drug use. soap note gastroenteritis

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

~24 hours.

Warm, dry overall but with reduced turgor on sternum.

Mucous membranes dry, no thrush, oropharynx clear. Generalized abdominal cramping, diffuse without radiation

None. No chronic GI disorders.