CASE STUDY A 20-Year-Old Male Complains of Experiencing Intermittent Headaches

A 20-year-old male complains of experiencing intermittent headaches. The headaches diffuse all over the head, but the greatest intensity and pressure occurs above the eyes and spreads through the nose, cheekbones, and jaw.

You will be focused on Neurological Symptoms. Group 1 has Case study 1 and Group 2 Numbness and Pain. You have 2 required assignments for this Week.

Assignment 1: Case Study Assignment: Assessing Neurological Symptoms

To Prepare for

  • By Day 1 of this week, you will be assigned to a specific case study for this Case Study Assignment. Please see the “Course Announcements” section of the classroom for your assignment from your Instructor CASE STUDY: A 20-year-old male complains of experiencing intermittent headaches.
  • Also, your Case Study Assignment should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP notes have specific data included in every patient case.

With Regard to The Case Study, You Were Assigned:

  • Review this week’s Learning Resources, and consider the insights they provide about the case study.
  • Consider what history would be necessary to collect from the patient in the case study you were assigned.
  • Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
  • Identify at least three possible conditions that may be considered in a differential diagnosis for the patient.

The Case Study Assignment

  • Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources.
  • Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.

By Day 6 Of Week 9

Sample Approach

A 20-year-old male complains of experiencing intermittent headaches. The headaches diffuse all over the head, but the greatest intensity and pressure occurs above the eyes and spreads through the nose, cheekbones, and jaw.

Consider What History Would Be Necessary to Collect From The Patient In The Case Study You Were Assigned.

During history taking, the patient should have been asked more about the headache.

The examiner should have utilized SOCRATES to assess the headache more. According to Gregory (2019), SOCRATES mnemonic is a pain assessment tool that is widely utilized by healthcare providers to help them remember key questions about the pain.

The onset, character, associated symptoms, severity, or the aggravating or relieving factors. The patient should have also been asked about any history of head injury, visual disturbances, dizziness, nausea, vomiting, photophobia, fever, sleep disturbances, neurological deficits, neck stiffness, temporal region tenderness, rash, or weight loss.

Consider What Physical Exams and Diagnostic Tests Would Be Appropriate To Gather More Information About The Patient’s Condition. How Would the Results Be Used to Make a Diagnosis?

According to Lee et al. (2018), physical examination is very crucial for patients with headaches to assist in ruling out secondary headaches. Physical examination of a patient presenting with headache will include monitoring of the vital signs of the patient, general appearance, general examination, and a full neurological examination.

The scalp is examined for any swelling and tenderness, the ipsilateral temporal artery should be palpated, and temporomandibular joints should be palpated for tenderness and crepitus as the patient opens and closes the mouth.

Inspection of the periorbital area for any conjunctival injection, lacrimation, or flushing. The pupils are examined for size, response to light, extraocular movements, and the visual fields are also assessed.

The fundi should be examined for spontaneous retinal venous pulsations and papilledema. The oropharynx should be inspected for any swelling, and the teeth are pricked for any tenderness. The neck is flexed to detect any stiffness or discomfort and the cervical spine is palpated for any tenderness.

According to Filler et al. (2019, February), diagnostic imaging workup for headache is very important in ruling out brain abnormalities or bleeding. Most patients presenting with headache do not require laboratory tests, but tests are important in diagnosing some conditions which present with headache and also those that are emergent.

A head CT scan and an MRI are neuroimaging studies which are utilized in patients with headache. Other important tests include a lumbar puncture and CSF analysis, ESR, and a full blood count test. These tests can be utilized to make an accurate diagnosis of a primary headache or a secondary headache type and the cause of the secondary headache.

  • Identify At Least Five Possible Conditions That May Be Considered in A Differential Diagnosis for The Patient.
  • Sinus headache– According to Hutchinson (2016), sinus headache feels pressure around the eyes, cheek, and forehead.
  • Migraine headache– this is a condition where the patient experiences severe headaches which are on and off.
  • Cluster headache– this is the most prevalent headache disorder among trigeminal autonomic cephalgia and is common among young men.
  • Tension headache– it is described as a featureless headache since due to lack of associated symptoms, it is episodic but it rarely impacts daily life activities.
  • Idiopathic stabbing headache– this is a headache that is characterized by sharp, brief but severe jabbing pain and it can occur anywhere in the head.


  • Gregory, J. (2019). Use of pain scales and observational pain assessment tools in hospital settings. Nursing Standard. doi, 10.
  • Lee, V. M. E., Ang, L. L., Soon, D. T. L., Ong, J. J. Y., & Loh, V. W. K. (2018). The adult patient with headache. Singapore medical journal, 59(8), 399.
  • Hutchinson, S. (2016). Sinus headaches.
  • Filler, L., Akhter, M., & Nimlos, P. (2019, February). Evaluation and management of the emergency department headache. In Seminars in neurology (Vol. 39, No. 01, pp. 020-026).Thieme Medical Publishers.

Episodic/Focused SOAP Note Template

Patient Information:

Initials, Age, Sex, Race

CC (Chief Complaint)

A BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”.


This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI.

You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:

Location: head

Onset: 3 days ago

Character: pounding, pressure around the eyes and temples

Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia

Timing: after being on the computer all day at work

Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better Severity: 7/10 pain scale

Current Medications:

Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.


Include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).


Include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed.

Soc Hx:

Include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.

Fam Hx

Illnesses with possible genetic predisposition, contagious or chronic illnesses. Reasons for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent


Cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL: No weight loss, fever, chills, weakness or fatigue.

HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclera. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose or sore throat.

SKIN: No rash or itching.

CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY: No shortness of breath, cough or sputum.

GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.

GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness.

HEMATOLOGIC: No anemia, bleeding or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

PSYCHIATRIC: No history of depression or anxiety.

ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES: No history of asthma, hives, eczema or rhinitis.

Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head-to-toe format i.e., General: Head: EENT: etc.

Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidence and guidelines) A.

Differential Diagnoses (list a minimum of 3 differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence-based guidelines.

This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.


You are required to include at least three evidence-based peer-reviewed journal articles or evidenced based guidelines which relate to this case to support your diagnostics and differentials diagnosis. Be sure to use correct APA 6th edition formatting.

Learning Resources

Required Readings

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

  • Chapter 7, “Mental Status” This chapter revolves around the mental status evaluation of an individual’s overall cognitive state. The chapter includes a list of mental abnormalities and their symptoms.
  • Chapter 23, “neurologic system” The authors of this chapter explore the anatomy and physiology of the neurologic system. The authors also describe neurological examinations and potential findings.
  • Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.
  • Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.

Chapter 4, “Affective Changes”

This chapter outlines how to identify the potential cause of affective changes in a patient. The authors provide a suggested approach to the evaluation of this type of change, and they include specific tools that can be used as part of the diagnosis.

Chapter 9, “Confusion in Older Adults”

This chapter focuses on causes of confusion in older adults, with an emphasis on dementia. The authors include suggested questions for taking a focused history as well as what to look for in a physical examination.

Chapter 13, “Dizziness”

Dizziness can be a symptom of many underlying conditions. This chapter outlines the questions to ask a patient in taking a focused history and different tests to use in a physical examination.

Chapter 19, “Headache”

The focus of this chapter is the identification of the causes of headaches. The first step is to ensure that the headache is not a life-threatening condition. The authors give suggestions for taking a thorough history and performing a physical exam.

Chapter 31, “Sleep Problems”

In this chapter, the authors highlight the main causes of sleep problems. They also provide possible questions to use in taking the patient’s history, things to look for when performing a physical exam, and possible laboratory and diagnostic studies that might be useful in making the diagnosis.

Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.

Chapter 2, “The Comprehensive History and Physical Exam” (“Cranial Nerves and Their Function” and “Grading Reflexes”) (Previously read in Weeks 1, 2, 3, and 5)

Note: Download the Physical Examination Objective Data Checklist to use as you complete the Comprehensive (Head-to-Toe) Physical Assessment assignment.