Gastroenteritis - Soap Note

Clear to auscultation bilaterally, no wheezes or crackles.

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

Cranial nerves II–XII intact. No focal deficits. Assessment (A) Diagnosis: Acute viral gastroenteritis with mild-to-moderate dehydration. Clear to auscultation bilaterally, no wheezes or crackles

Mucous membranes dry, no thrush, oropharynx clear. Clear to auscultation bilaterally