Neurological examination SOAP|Course hero helper

Posted: March 9th, 2023

Neurological examination SOAP

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CASE: Pt is a female 21 year old college student who came to the clinic for wellness examination of the Neurological examination. She suffers from Tension Headaches (Final DX).

Subjective – Review of Systems

Neurologic: no dizziness, seizures, no loss of coordination, or sensation. She reports headaches, rated: 6 out of 10. Sensitivity to light.

Head: normocephalic and atraumatic

Objective – Physical exam

Head: Pain in both sides of head, dull aching head pain

Assessment: – Differential diagnosis [GIVEN]

1- Tension headache

a. Explanation:

2- Sinusitis

a. Explanation:

3- Migraine headache

a. Explanation:

Final DX: Tension headache. EXPLANATION

Plan:

Diagnostic plan (x-rays, labs, PFTs, etc.):

Treatment/Therapeutic Plan (meds):

Referrals:

Education and Follow up plan:

——Please follow the format. Add information in sections that are empty, and expand with additional information to subjective and objective if needed to support the diagnosis Tension Headaches and plug in-text citations with references and APA format as usual.

· Add information to the Plan section

· Write Explanations to the assessment as to why each of these could be a possible diagnosis: Sinusitis OR Migraine headache

Please format to support and expand the information I have written, with in citations.

Everything in APA format with intext citations

References: 2 high-level scholarly references within the last 5 years in APA format.

Plagiarism free.

Turnitin receipt.

SOLUTION

General: The patient appears well-nourished and well-hydrated. She is alert and oriented to person, place, and time. She is cooperative and attentive during the examination. Vital Signs: Blood pressure, heart rate, respiratory rate, and temperature are within normal limits. Cranial Nerves:I (Olfactory): Not tested as there are no complaints of anosmia. II (Optic): Visual acuity is 20/20 bilaterally with correction. Visual fields are intact by confrontation. Funduscopic exam reveals clear optic discs and sharp foveal reflex.