Neurological examination SOAP – Pt is a female 21 year old
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.
Explanation & Answer
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