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Neurological examination SOAP
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: norm cephalic and atraumatic
Objective – Physical exam
Head: Pain in both sides of head, dull aching head pain
Assessment: – Differential diagnosis [GIVEN]
- Tension headache
- Explanation:
- Sinusitis
- Explanation:
- Migraine headache
- 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 Headachesand 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.
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