Here is a sample SOAP note that is incomplete. You will need to provide at least 3 bullet points FOR the ASSESSMENT AND

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Here is a sample SOAP note that is incomplete. You will need to provide at least 3 bullet points FOR the ASSESSMENT AND TREATMENT PLAN
SOAP NOTE
[subjective/objective/assessment/plan]
Patient Name: Jennifer Markus MR#: 45879
Attending Physician: Katrina McKenzie, M.D.
Consulting Physician: Erik Anderson, M.D. Date:12/4/15
Subjective: Mrs. Markus is a 33-year-old woman with a PMH [past medical history] significant for depression, asthma, hiatal hernia, and migraine headaches. She presents complaining of waking with a pulsing headache on the left side of her head, with 1 day of prior increased sensitivity to light and to noises, as well as nausea, no emesis. The patient notes that work has been increasingly stressful over the past couple weeks and she’s had trouble sleeping. She took two tablets of ibuprofen last night in the hopes of avoiding a migraine, with minimal relief. She is currently taking sertraline for her depression.
She denies any history of seizure, cluster headaches, or tension headaches. She does smoke approximately half a pack of cigarettes daily. She notes that she’s been getting these headaches more frequently, as in two to three times per month. She would like something to decrease the duration of the headache, as well as some suggestions for prevention of future headaches.
Objective: VS: BP 134/80, HR 76, Temp 98.4, wt 155. Physical Exam. General: The patient is sitting with her eyes partially covered by her hands, otherwise, no acute distress. HEENT: Normocephalic/atraumatic, conjunctivae noninjected, pupils equal and round, reactive to light and accommodation (PERRLA), ears with normal cone of light reflex, nose with clear discharge, throat nonerythematous. Neck: No lymphadenopathy, thyroid smooth and symmetric, no nodularity palpated. Lungs: Clear to auscultation bilaterally. Heart: Regular rate and rhythm, no murmurs, grunts, or rubs. Abdomen: Soft, nontender, nondistended, no abdominal bruits. Extremities: Warm and well perfused at distal extremities, no edema bilaterally. Musculoskeletal (MSK): Strength of upper and lower extremities equal and 5/5, no loss of sensation at extremities, normal patellar reflexes bilaterally.
Use the information in the subjective and objective measures listed to guide you.