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Neuro Case Studies
Neuro Case Study 1
CC: 36 y/o Caucasian female with complaints of headaches.
HPI: Reports having 7-10 headaches per month. Rates the pain 4-6/10. The pain usually begins
in the afternoon or evening & starts slowly feeling like a vice squeezing her head. Denies
associated nausea, vomiting, or visual disturbance. The headaches usually last all evening but
sometimes they can last a few days. The headaches first began 3 years ago. Denies association
with her menstrual cycle. Denies head trauma.
Medications: Tylenol PRN, Excedrin Migraine PRN, Naprosyn PRN
Allergies: Morphine, Demerol, Prednisone, Propranolol
Immunizations: Up to date
PMH: Reports history of anxiety and depression. Tonsillectomy as a child. LMP 2 weeks ago.
G1P1. Pap smear 4 years ago- “normal”
FH: Mother age (55yrs), alive, osteoarthritis, hypothyroidism.
Father (57yrs), alive, hypertension, hyperlipidemia
Brother (28yrs), alive and well
Paternal Grandfather (88yrs), alive, hypertension, MI, Stroke, arthritis, dementia
Paternal Grandmother (86yrs), alive, hypothyroidism, depression, arthritis, glaucoma
Maternal Grandfather (89yrs), alive, arthritis, gout, hypertension
Maternal grandmother (83yrs), alive, macular degeneration, DMT2, depression, arthritis
SH: Lives with significant other and 2-year-old son. Works as a retail clerk. Habits: Denies
smoking or illicit drug use; occasional ETOH; enjoys reading and playing computer games.
Enjoys frequent meals out. Drinks 6 cups of coffee per day. Minimal exercise. Sleeps for 7 hours
per night.
ROS: Denies history of polyuria, polydipsia, nocturia, nasal congestion, cough, sore throat, ear
pain, brittle hair, constipation, dry skin, weight gain, palpitations, SOB, dyspnea or chest pain.
Has seen chiropractor in the past for neck and shoulder aching and tightness. Chiropractor
reported a “curvature of the spine.” Denies history of seizures, muscle weakness, or syncope.
PHYSICAL ASSESSMENT: HR 70; BP 122/78; RR 16; T 97F; Ht: 5’5; Wt: 152lbs.
General: Alert & orientated x 3. No acute distress. Clothing appropriate for season, clean and
neat
HEENT: Head normocephalic/atraumatic. Face symmetric. Denies pain with palpation of scalp.
Denies tenderness with palpation of maxillary or frontal sinuses. TMJ ROM full without
crepitus. Temporal artery pulses 2+ bilateral. No bruits noted. PERRLA 3mm OU. Vision 20/20
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uncorrected.TM non-erythematous. Nasal mucosa pink with edema. Pharynx pink without
edema.
Neck: No adenopathy noted. Thyroid without masses. No carotid bruit noted. -JVD. No nuchal
rigidity
CV: RRR, S1S2 present, no S3S4
Resp: Clear throughout to anterior and posterior auscultation
M/S: Cervical spine ROM full in all directions, denies pain on palpation of spine, expresses pain
with palpation of prevertebral muscles. Lumbar lordosis adequate. No scoliosis or spinal
deformity with inspection and palpation of the spine. ROM of lumbar spine adequate. Muscle
strength power grade 5/5 in bilateral upper and lower extremities.
Neuro: Fundoscopic exam reveals no papilledema, hemorrhage, or exudates. Extraocular
movement full in all directions. Reflexes +2 bilateral upper and lower extremities. Negative
Romberg. Rapid alternating movements and coordination symmetric and appropriate. Gait
steady. Heel shin intact. Finger to nose intact
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Neuro Case Study 2
CC: 25 y/o Indian female with complaints of a headache.
HPI: Presents to clinic for evaluation of headaches that have been occurring over the course of
the last six months. Seven months ago, moved to the US from India to pursue a master’s degree,
and noted the headaches started shortly after this time. Describes the headaches as a dull, tight
pain around the whole head “like a rubber band”. The headaches start gradually and last for
approximately 6-12 hours. Denies any vision changes, aura, neck pain, nausea or vomiting, and
the light does not bother her when she has these. Denies dizziness, feeling weak, or having chills.
Denies previous cold symptoms or sinus congestion. Denies prior history of similar symptoms.
Medications: None
Allergies: None
Immunizations: Has not received Gardasil; other immunizations are up to date
PMH: Has been treated for depression in the past, but medication was suspended by her
physician when depression resolved 2 years ago. Repots last PAP was normal 7 months ago.
LMP 2 weeks ago.
FH: Mother (52yrs), alive, history of “breast surgery” at age 48 yrs
Father (52yrs), alive and well
Sister (29yrs), alive and well
Sister (22yrs), alive and well
SH: Lives with husband while both attend graduate school; G0P0. Denies smoking, ETOH, or
illicit drug use. Follows a vegetarian diet. Usually drinks coffee x 4 cups a day, denies pop soda.
Denies abuse in her relationship. Sleeps for 6 hours per night.
ROS: Denies history of severe HA, unilateral weakness, paralysis, palpations, chest pain, SOB,
orthopnea, chronic constipation, weight gain, dry skin, brittle hair, seizures, muscle weakness, or
syncope.
Exam: T 97.5F; BP 120/75; HR 77; RR15; Ht: 5’2”; Wt: 126lbs.
General: Alert & oriented x 3, no acute distress. Appears stated age.
HEENT: PERRLA 3mm OU. Extraocular movements symmetric, vision fields within normal
limits. Denies tenderness with palpation of maxillary or frontal sinuses Ophthalmoscope exam
shows no papilledema, hemorrhage or exudates.
Neck: No nuchal rigidity, thyroid non-palpable, trachea midline, no cervical lymphadenopathy.
Cervical spine ROM showed no limitations
CV: RRR, S1S2 present, no S3S4 noted
Resp: Clear throughout lung fields anterior and posterior
Neuro Case Studies
Neuro Case Study 1
CC: 36 y/o Caucasian female with complaints of headaches.
HPI: Reports having 7-10 headaches per month. Rates the pain 4-6/10. The pain usually begins
in the afternoon or evening & starts slowly feeling like a vice squeezing her head. Denies
associated nausea, vomiting, or visual disturbance. The headaches usually last all evening but
sometimes they can last a few days. The headaches first began 3 years ago. Denies association
with her menstrual cycle. Denies head trauma.
Medications: Tylenol PRN, Excedrin Migraine PRN, Naprosyn PRN
Allergies: Morphine, Demerol, Prednisone, Propranolol
Immunizations: Up to date
PMH: Reports history of anxiety and depression. Tonsillectomy as a child. LMP 2 weeks ago.
G1P1. Pap smear 4 years ago- “normal”
FH: Mother age (55yrs), alive, osteoarthritis, hypothyroidism.
Father (57yrs), alive, hypertension, hyperlipidemia
Brother (28yrs), alive and well
Paternal Grandfather (88yrs), alive, hypertension, MI, Stroke, arthritis, dementia
Paternal Grandmother (86yrs), alive, hypothyroidism, depression, arthritis, glaucoma
Maternal Grandfather (89yrs), alive, arthritis, gout, hypertension
Maternal grandmother (83yrs), alive, macular degeneration, DMT2, depression, arthritis
SH: Lives with significant other and 2-year-old son. Works as a retail clerk. Habits: Denies
smoking or illicit drug use; occasional ETOH; enjoys reading and playing computer games.
Enjoys frequent meals out. Drinks 6 cups of coffee per day. Minimal exercise. Sleeps for 7 hours
per night.
ROS: Denies history of polyuria, polydipsia, nocturia, nasal congestion, cough, sore throat, ear
pain, brittle hair, constipation, dry skin, weight gain, palpitations, SOB, dyspnea or chest pain.
Has seen chiropractor in the past for neck and shoulder aching and tightness. Chiropractor
reported a “curvature of the spine.” Denies history of seizures, muscle weakness, or syncope.
PHYSICAL ASSESSMENT: HR 70; BP 122/78; RR 16; T 97F; Ht: 5’5; Wt: 152lbs.
General: Alert & orientated x 3. No acute distress. Clothing appropriate for season, clean and
neat
HEENT: Head normocephalic/atraumatic. Face symmetric. Denies pain with palpation of scalp.
Denies tenderness with palpation of maxillary or frontal sinuses. TMJ ROM full without
crepitus. Temporal artery pulses 2+ bilateral. No bruits noted. PERRLA 3mm OU. Vision 20/20
, 2
uncorrected.TM non-erythematous. Nasal mucosa pink with edema. Pharynx pink without
edema.
Neck: No adenopathy noted. Thyroid without masses. No carotid bruit noted. -JVD. No nuchal
rigidity
CV: RRR, S1S2 present, no S3S4
Resp: Clear throughout to anterior and posterior auscultation
M/S: Cervical spine ROM full in all directions, denies pain on palpation of spine, expresses pain
with palpation of prevertebral muscles. Lumbar lordosis adequate. No scoliosis or spinal
deformity with inspection and palpation of the spine. ROM of lumbar spine adequate. Muscle
strength power grade 5/5 in bilateral upper and lower extremities.
Neuro: Fundoscopic exam reveals no papilledema, hemorrhage, or exudates. Extraocular
movement full in all directions. Reflexes +2 bilateral upper and lower extremities. Negative
Romberg. Rapid alternating movements and coordination symmetric and appropriate. Gait
steady. Heel shin intact. Finger to nose intact
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Neuro Case Study 2
CC: 25 y/o Indian female with complaints of a headache.
HPI: Presents to clinic for evaluation of headaches that have been occurring over the course of
the last six months. Seven months ago, moved to the US from India to pursue a master’s degree,
and noted the headaches started shortly after this time. Describes the headaches as a dull, tight
pain around the whole head “like a rubber band”. The headaches start gradually and last for
approximately 6-12 hours. Denies any vision changes, aura, neck pain, nausea or vomiting, and
the light does not bother her when she has these. Denies dizziness, feeling weak, or having chills.
Denies previous cold symptoms or sinus congestion. Denies prior history of similar symptoms.
Medications: None
Allergies: None
Immunizations: Has not received Gardasil; other immunizations are up to date
PMH: Has been treated for depression in the past, but medication was suspended by her
physician when depression resolved 2 years ago. Repots last PAP was normal 7 months ago.
LMP 2 weeks ago.
FH: Mother (52yrs), alive, history of “breast surgery” at age 48 yrs
Father (52yrs), alive and well
Sister (29yrs), alive and well
Sister (22yrs), alive and well
SH: Lives with husband while both attend graduate school; G0P0. Denies smoking, ETOH, or
illicit drug use. Follows a vegetarian diet. Usually drinks coffee x 4 cups a day, denies pop soda.
Denies abuse in her relationship. Sleeps for 6 hours per night.
ROS: Denies history of severe HA, unilateral weakness, paralysis, palpations, chest pain, SOB,
orthopnea, chronic constipation, weight gain, dry skin, brittle hair, seizures, muscle weakness, or
syncope.
Exam: T 97.5F; BP 120/75; HR 77; RR15; Ht: 5’2”; Wt: 126lbs.
General: Alert & oriented x 3, no acute distress. Appears stated age.
HEENT: PERRLA 3mm OU. Extraocular movements symmetric, vision fields within normal
limits. Denies tenderness with palpation of maxillary or frontal sinuses Ophthalmoscope exam
shows no papilledema, hemorrhage or exudates.
Neck: No nuchal rigidity, thyroid non-palpable, trachea midline, no cervical lymphadenopathy.
Cervical spine ROM showed no limitations
CV: RRR, S1S2 present, no S3S4 noted
Resp: Clear throughout lung fields anterior and posterior
