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Background: Neck pain has an annual incidence of 10.4 to 21.3% affected in the United States. Clinical practice guidelines developed by the American Physical Therapy Association have classified neck pain into four categories that guide treatment: neck pain with mobility deficits, neck pain with movement coordination impairments, neck pain with headaches, or neck pain with radicular symptoms. Case Description: A patient presented to an outpatient physical therapy clinic with severe chronic neck pain, dropped head syndrome, and neurological symptoms including bowel incontinence and split hand sign. His chief complaint was neck pain. The patient transported Agent Orange during the Vietnam War and had comorbidities linked to his military history. Differential Diagnosis: Several diagnoses were considered for this patient due to the risk factors and signs and symptoms identified during the evaluation. Agent Orange exposure has been linked to a number of disease states. Dropped head syndrome can be a sign of certain neurological and autoimmune conditions. Epidemiological studies identified a 60% greater risk of ALS in military men during the last 100 years compared to the general population. The purpose of this case report is to describe the clinical decision-making process for the differential diagnosis of a patient with complex neurological signs and symptoms. Discussion: Physical therapists are direct access providers in many states, so it is imperative to screen for underlying conditions that would not be appropriately treated with physical therapy alone. This patient is an example of someone who did not realize the potential implications of his additional neurological signs and symptoms. Several physical therapy interventions were used with this patient including manual therapy, dry needling, and movement coordination training.