SOAP Note – Heather Stanton, 48-year-old Female
2025 _2026
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S – Subjective
Chief Complaint (CC):
“I’ve been feeling tired, irritable, and can’t sleep well. I wake up in the night sweating and hot.”
History of Present Illness (HPI):
Heather Stanton is a 48-year-old G2P2002 female who presents with fatigue, irritability, and
disrupted sleep for over a year. She reports no difficulty falling asleep but frequently awakens
3–4 times nightly due to hot flashes and night sweats. She notes vaginal dryness, itching,
redness, decreased libido, brittle nails, and an 8 lb weight gain over the past year. She has not
had a menstrual period for more than 12 months. No history of fever, chills, chest pain,
shortness of breath, palpitations, headaches, or mood swings beyond irritability. She denies
depression or anxiety. No recent medication changes. Over-the-counter multivitamin only.
Associated Symptoms:
Positive: Night sweats, hot flashes, vaginal dryness, decreased libido, brittle nails, weight gain.
Negative: Fevers, chills, dysuria, urinary urgency/frequency, abnormal vaginal bleeding, mood
instability beyond irritability, dizziness, palpitations.
, Past Medical History (PMH):
None significant.
Past Surgical History (PSH):
None.
Medications:
OTC multivitamin daily.
Allergies:
NKDA.
Family History (FH):
Mother: Menopause at 50, hypertension.
Father: Hypertension.
2025 _2026
---
S – Subjective
Chief Complaint (CC):
“I’ve been feeling tired, irritable, and can’t sleep well. I wake up in the night sweating and hot.”
History of Present Illness (HPI):
Heather Stanton is a 48-year-old G2P2002 female who presents with fatigue, irritability, and
disrupted sleep for over a year. She reports no difficulty falling asleep but frequently awakens
3–4 times nightly due to hot flashes and night sweats. She notes vaginal dryness, itching,
redness, decreased libido, brittle nails, and an 8 lb weight gain over the past year. She has not
had a menstrual period for more than 12 months. No history of fever, chills, chest pain,
shortness of breath, palpitations, headaches, or mood swings beyond irritability. She denies
depression or anxiety. No recent medication changes. Over-the-counter multivitamin only.
Associated Symptoms:
Positive: Night sweats, hot flashes, vaginal dryness, decreased libido, brittle nails, weight gain.
Negative: Fevers, chills, dysuria, urinary urgency/frequency, abnormal vaginal bleeding, mood
instability beyond irritability, dizziness, palpitations.
, Past Medical History (PMH):
None significant.
Past Surgical History (PSH):
None.
Medications:
OTC multivitamin daily.
Allergies:
NKDA.
Family History (FH):
Mother: Menopause at 50, hypertension.
Father: Hypertension.
