Week 7 SOAP Note - Heather Martin 2026/2027
1
Week 7 SOAP Note
Heather Martin
NURS 6551N-19: Primary Care of Women
Walden University
July 15, 2018
, Week 7 SOAP Note - Heather Martin 2026/2027
2
SOAP Note Template
SUBJECTIVE DATA:
Patient Initials: AT Age: 17 Gender: Female
Chief Complaint (CC): Frequent headache, weight gain, and frequent infections since
intrauterine device insertion
History of Present Illness (HPI): AT is a 17-year-old Caucasian female who presents
today with complaints of frequent headache, weight gain, and frequent infections since
insertion of her intrauterine device (IUD) last year. She reports a 20-pound weight gain
over the last year. AT reports that she gets plenty of exercise as she is exercising daily on
an elliptical at home for 30 minutes and runs laps for 20 minutes every other day for band
practice at school. The patient states that she has eaten sushi, chicken and stuffing
casserole, celery, nuts, cantaloupe, and pineapple over the last 24 hours and has drank 2
cans of Dr. Pepper and 6 glasses of water. AT also reports frequent headaches that occur
4-5 times per week, are a 5 out of 10 on a scale of 0-10 and feels like “pressure” on both
sides of her head. The headaches are not associated with any other symptoms and
generally last for a few hours. Nothing seems to make the headaches worse and she has
taken over the counter ibuprofen which has helped to decrease the pain to a 1 out of 10.
AT also reports copious, thick, yellow vaginal discharge that has been present for about 1
month. She reports that she has also experienced some urinary frequency and an odor
that smells “like a rotten egg” since this discharge has been present. Nothing seems to
make the discharge better or worse and she has not tried anything over the counter to treat
the odor.
Medications:
1
Week 7 SOAP Note
Heather Martin
NURS 6551N-19: Primary Care of Women
Walden University
July 15, 2018
, Week 7 SOAP Note - Heather Martin 2026/2027
2
SOAP Note Template
SUBJECTIVE DATA:
Patient Initials: AT Age: 17 Gender: Female
Chief Complaint (CC): Frequent headache, weight gain, and frequent infections since
intrauterine device insertion
History of Present Illness (HPI): AT is a 17-year-old Caucasian female who presents
today with complaints of frequent headache, weight gain, and frequent infections since
insertion of her intrauterine device (IUD) last year. She reports a 20-pound weight gain
over the last year. AT reports that she gets plenty of exercise as she is exercising daily on
an elliptical at home for 30 minutes and runs laps for 20 minutes every other day for band
practice at school. The patient states that she has eaten sushi, chicken and stuffing
casserole, celery, nuts, cantaloupe, and pineapple over the last 24 hours and has drank 2
cans of Dr. Pepper and 6 glasses of water. AT also reports frequent headaches that occur
4-5 times per week, are a 5 out of 10 on a scale of 0-10 and feels like “pressure” on both
sides of her head. The headaches are not associated with any other symptoms and
generally last for a few hours. Nothing seems to make the headaches worse and she has
taken over the counter ibuprofen which has helped to decrease the pain to a 1 out of 10.
AT also reports copious, thick, yellow vaginal discharge that has been present for about 1
month. She reports that she has also experienced some urinary frequency and an odor
that smells “like a rotten egg” since this discharge has been present. Nothing seems to
make the discharge better or worse and she has not tried anything over the counter to treat
the odor.
Medications:
