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Class notes

Health Assessment

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Looking for the best study guides, study notes and summaries about comprehensive health assessment. Advanced Practice Care of Adults? This document will take you through the template of conducting health assessment and writing SOAP Notes.

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  • March 29, 2023
  • 7
  • 2022/2023
  • Class notes
  • Bharidiwa
  • All classes
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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.

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