,Patient Information
Name: Jessica Lee
Age: 26 years
Gender: Female
Ethnicity: Asian American
Setting: Outpatient primary care clinic with access to laboratory
and imaging capabilities
Date of Encounter: July 16, 2025
Informant: Patient
II. Chief Complaint (CC)
"I’ve been having more frequent and severe headaches over the
past two months, and they’re interfering with my work."
,III. History of Present Illness (HPI)Jessica Lee, a 26-year-old Asian
American female, presents to the clinic with a chief complaint of
increasingly frequent and severe headaches for the past two months.
She describes the headaches as unilateral, pulsating, and located in the
right temporal region, rating them as 8/10 in severity. Each episode
lasts 6-12 hours and occurs 2-3 times per week, up from 1-2 times per
month previously. The headaches are associated with nausea,
photophobia, and phonophobia, and are aggravated by physical
activity. Jessica reports occasional visual disturbances (flashing lights)
preceding the headaches by 20-30 minutes. She denies vomiting, fever,
neck stiffness, or focal neurological symptoms (e.g., weakness,
numbness). Over-the-counter ibuprofen (400 mg) provides partial
relief, reducing pain to 4/10, but does not fully resolve symptoms.
Jessica associates the increased frequency with recent work stress as a
graphic designer, often working long hours at a computer. She denies
recent trauma, changes in vision, or new medications. Her last
, menstrual period was two weeks ago, and she notes headaches
sometimes worsen around menstruation.
IV. Past Medical History (PMH)
Medical Conditions: History of occasional headaches since age 18,
diagnosed as migraines by a previous provider.
Surgeries: None.
Hospitalizations: None.
Allergies: No known drug, food, or environmental allergies.
Medications: Ibuprofen 400 mg PRN for headaches; oral
contraceptive pills (ethinyl estradiol/levonorgestrel) for 3 years.
Immunizations: Up to date for age (per CDC guidelines).
Family History: Mother has a history of migraines; no family
history of stroke, brain tumors, or seizures.
Social History:
Name: Jessica Lee
Age: 26 years
Gender: Female
Ethnicity: Asian American
Setting: Outpatient primary care clinic with access to laboratory
and imaging capabilities
Date of Encounter: July 16, 2025
Informant: Patient
II. Chief Complaint (CC)
"I’ve been having more frequent and severe headaches over the
past two months, and they’re interfering with my work."
,III. History of Present Illness (HPI)Jessica Lee, a 26-year-old Asian
American female, presents to the clinic with a chief complaint of
increasingly frequent and severe headaches for the past two months.
She describes the headaches as unilateral, pulsating, and located in the
right temporal region, rating them as 8/10 in severity. Each episode
lasts 6-12 hours and occurs 2-3 times per week, up from 1-2 times per
month previously. The headaches are associated with nausea,
photophobia, and phonophobia, and are aggravated by physical
activity. Jessica reports occasional visual disturbances (flashing lights)
preceding the headaches by 20-30 minutes. She denies vomiting, fever,
neck stiffness, or focal neurological symptoms (e.g., weakness,
numbness). Over-the-counter ibuprofen (400 mg) provides partial
relief, reducing pain to 4/10, but does not fully resolve symptoms.
Jessica associates the increased frequency with recent work stress as a
graphic designer, often working long hours at a computer. She denies
recent trauma, changes in vision, or new medications. Her last
, menstrual period was two weeks ago, and she notes headaches
sometimes worsen around menstruation.
IV. Past Medical History (PMH)
Medical Conditions: History of occasional headaches since age 18,
diagnosed as migraines by a previous provider.
Surgeries: None.
Hospitalizations: None.
Allergies: No known drug, food, or environmental allergies.
Medications: Ibuprofen 400 mg PRN for headaches; oral
contraceptive pills (ethinyl estradiol/levonorgestrel) for 3 years.
Immunizations: Up to date for age (per CDC guidelines).
Family History: Mother has a history of migraines; no family
history of stroke, brain tumors, or seizures.
Social History:
