ENCOUNTER MORE FREQUENT SEVERE HEADACHES
LATEST !! latest !!! 2025
History of Present Illness (HPI):
The patient is a female who is 26 years old with a complaint of more severe and more frequent
headaches over the past [insert duration]. The patient reports that the headaches have increased from
[insert baseline frequency] to [insert current frequency], and the headaches are worse now. The
headache is [throbbing, pulsating, dull, sharp, etc.], typically [unilateral/bilateral/frontal/occipital/etc.],
and [duration].
She reports associated symptoms like [nausea, vomiting, photophobia, phonophobia, visual aura, etc.].
She has tried [OTC medications, rest, hydration, etc.], which alleviate [partial/complete/no] relief.
, She denies any known history of head trauma, recent illness, or neurologic symptoms like weakness,
numbness, or trouble with speech. She does/not have a family history of migraine or similar symptoms.
She identifies possible triggers like [stress, menstruation, lack of sleep, etc.].
Physical Exam
General:
Well-developed, well-nourished 26-year-old female in no acute distress. Alert and oriented ×3.
Vital Signs:
Temperature: [Insert if available]
Heart Rate: [Insert bpm]
Respiratory Rate: [Insert]
Blood Pressure: [Insert]
Oxygen Saturation: [Insert]
Head:
Normocephalic, atraumatic. No scalp tenderness or deformities.
Eyes:
PERRLA (pupils equal, round, reactive to light and accommodation). EOMI (extraocular movements
intact).
No papilledema or visual field defects observed. Fundoscopic exam WNL.
Ears/Nose/Throat: