SOAP Diarrhea

By Jose Dixon,2014-05-09 22:28
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SOAP Diarrhea

SOAP: Diarrhea

Problem List:

Medication List:



    HPI or chief complaint:


    ; Onset, duration, frequency, timeline of symptoms

    ; Size of stools, mucus or blood in stool, color

    ; Consistency and number of stools, volume

    ; Odor, greasy, floating ; Previous episodes

    ; Food associations

    ; Fever, abdominal pain, vomiting, weight loss, appetite

    ; Urgency, tenesmus

    ; Incontinence

Past medical history:


    Inflammatory bowel disease Antibiotic use



    Thyroid disease

Medication history

Family history:

    ; Inflammatory bowel disease ; Irritable bowel syndrome ; Cystic fibrosis

    ; Celiac sprue

    ; Liver disease


    ; Travel history

    ; Ill contacts

    ; Stressors if situation determines

    ; Diet history

Pertinent review of system: urinary symptoms, respiratory symptoms

Physical Exam:

Vital signs

    ; General appearance

    ; HEENT: Eyes-sclera, oral-hydration status, if infant-fontanelles (sunken or raised)

    ; Neck: lymph nodes, thyroid

    ; Cardiac: rate, murmurs, gallops

    ; Lung: breathing pattern, breath sounds

    ; Abdomen: distention, masses, tenderness, organomegaly ; Rectal exam: if indicated

    ; Skin: rashes

    ; Extremities: pedal edema

    ; Neuro: alertness, nuchal rigidity, reflexes

Labs/ Tests: (consider)

    Electrolytes: ( if dehydration suspected)

    CBC (if blood in diarrhea)

    Stool specimen: (WBCs, blood)

    ESR (if chronic inflammatory etiology is suspected)

    Stool culture

    Stool for ova and parasites

    Other radiological testing if indicated by history and physical


    1. Diarrhea most likely secondary to (list your differential here)


    1. Oral rehydration therapy

    2. BRAT diet

    3. Further workup if indicated

    4. Follow up

    5. Referral to gastroenterologist if indicated

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