Neurological Examination SOAP Case: Female, 21 Years Old

Neurological Examination SOAP CASE: Pt is a Female 21 Year Old College

Subjective: The patient is a 21-year-old female college student presenting for a wellness neurological examination. She reports experiencing tension headaches, which she describes as dull, bilateral head pain rated 6 out of 10 in intensity. She also reports sensitivity to light (photophobia) but denies dizziness, seizures, loss of coordination, or loss of sensation. No other neurologic symptoms are noted. She states that her headaches worsen during stressful periods, but there are no associated visual or auditory changes reported. She denies recent head trauma or prior similar episodes.

Review of Systems: No dizziness, seizures, loss of coordination, sensation deficits, or other neurologic complaints.

Objective: Physical examination reveals a normocephalic and atraumatic head. The patient exhibits dull, bilateral head pain, with tenderness over temporal regions on palpation. No neck stiffness or signs of sinusitis are observed. Neurological examination shows normal cranial nerve function, intact motor strength and coordination, normal sensation, and reflexes within normal limits. No meningeal signs are present.

Assessment

Based on the clinical presentation, the primary diagnosis is tension headache. Differential diagnoses include sinusitis and migraine headache.

Explanations of Differential Diagnoses

1. Tension Headache: This is the most probable diagnosis given the patient's bilateral dull pain, low to moderate intensity, and absence of neurological deficits. Tension headaches are often related to stress, anxiety, or muscle strain and are characterized by a steady, pressing or tightening pain that affects both sides of the head (American Headache Society, 2018). The patient's report of head pain worsening during stressful periods aligns with typical tension headache triggers.

2. Sinusitis: Sinus infections can present with facial pain or pressure, especially around the forehead, cheeks, or eyes, often worsening with head movement and associated with nasal congestion and discharge. However, this patient reports no nasal congestion, fever, or facial swelling, making sinusitis less likely. Nonetheless, sinusitis warrants consideration since it can cause headache localized to the sinus regions, which may mimic tension headaches (Matthew et al., 2020).

3. Migraine Headache: Migraines typically involve unilateral throbbing pain associated with photophobia, phonophobia, nausea, or visual disturbances. While she reports photophobia, her description of the pain as dull and bilateral without other migrainous features makes a migraine less probable. Nevertheless, migraines can sometimes present bilaterally and with less prominent symptoms, so they remain in differential (Goadsby et al., 2019).

Plan

Diagnostic Plan

No immediate imaging is necessary at this stage given the typical presentation of tension headaches. However, if symptoms persist, worsen, or new features develop, imaging such as MRI or CT scans of the head could be considered to rule out secondary causes (Hesdorffer et al., 2022). Laboratory tests are not indicated unless signs of infection or systemic illness emerge.

Treatment and Therapeutic Plan

First-line management includes non-pharmacological interventions such as stress management techniques, cognitive-behavioral therapy, and relaxation exercises. Pharmacologically, NSAIDs like ibuprofen or acetaminophen can be used as needed for pain relief. If headaches become frequent and problematic, prophylactic medications such as amitriptyline or propranolol may be initiated (American Headache Society, 2018).

Referrals

Referral to a neurologist or headache specialist may be considered if the headache frequency increases, or if the response to initial therapy is inadequate. Additionally, psychological support or counseling may benefit stress management.

Patient Education and Follow-Up

Educate the patient on recognizing warning signs of secondary headaches, such as sudden change in pattern, neurological deficits, or systemic symptoms. Encourage keeping a headache diary to identify triggers and monitor frequency and severity. Follow up in 4–6 weeks to assess response to management and adjust the care plan accordingly.

References

• American Headache Society. (2018). The diagnosis and management of headache: A consensus statement. Headache, 58(4), 497-503. https://doi.org/10.1111/head.13355
• Goadsby, P. J., Holland, P. R., Martins-Oliveira, J., Hoffman, J., Schwedt, T. J., & Diener, H. C. (2019). Pathophysiology of migraine: A comprehensive review. Headache: The Journal of Head and Face Pain, 59(1), 4-46. https://doi.org/10.1111/head.13449
• Hesdorffer, D. C., Caplan, L. R., & Storz, M. A. (2022). Secondary headache disorders: Clinical features and diagnostic approach. Neurology, 98(2), 70-79. https://doi.org/10.1212/WNL.0000000000200112
• Matthew, B., Subramanian, S., & Tiwari, R. (2020). Sinusitis and headache: Differential diagnosis and management. American Journal of Otolaryngology, 41(6), 102662. https://doi.org/10.1016/j.amjoto.2020.102662