, Patient Information
Name: Kathleen Parks
Age: 26 years old
Gender: Female
Setting: Outpatient Primary Care Clinic
Chief Complaint: “My headaches are getting worse and happening
more often.”
Reason for Encounter: More frequent severe headaches
History of Present Illness (HPI)Narrative: Kathleen Parks, a 26-
year-old Caucasian female, presents to the outpatient primary care
clinic reporting an increase in the frequency and severity of headaches
over the past 2 months. She describes the headaches as a throbbing
pain, primarily frontal and bilateral, rated 7–8/10 in severity, lasting 4–
,6 hours, and occurring 3–4 times per week. Previously, Kathleen
experienced headaches 1–2 times per month, managed with over-the-
counter (OTC) ibuprofen, but recent episodes are less responsive to
ibuprofen 400 mg (requiring 800 mg for partial relief). She reports
associated symptoms of nausea, photophobia, and phonophobia during
severe episodes, but denies vomiting, visual disturbances (e.g., aura,
blurry vision), or neurological deficits (e.g., weakness, numbness). The
headaches are triggered by stress, lack of sleep, and caffeine
withdrawal, and are alleviated slightly by lying in a dark, quiet room.
Kathleen notes increased stress from her job as a graphic designer,
working 50–60 hours per week with tight deadlines, and reports
sleeping 5–6 hours per night due to work demands.Kathleen denies
recent trauma, fever, neck stiffness, seizures, or changes in speech or
coordination. She reports no recent infections, travel, or exposure to
environmental toxins. Her medical history includes occasional tension
headaches since college, managed with ibuprofen, and seasonal
allergies treated with cetirizine PRN. She denies prior migraines,
, neurological disorders, or head injuries. Kathleen takes oral
contraceptives (ethinyl estradiol/norethindrone) daily and ibuprofen
PRN. She is up to date on vaccinations, including the 2024–2025
influenza vaccine and COVID-19 booster. Kathleen is concerned that her
headaches are interfering with her work performance and social life, as
she often cancels plans due to pain and fatigue. She worries the
headaches could indicate a serious condition, such as a brain tumor,
due to a coworker’s recent diagnosis.Explanation: The HPI is critical for
evaluating headaches, as it helps differentiate primary (e.g., migraine,
tension headache) from secondary (e.g., tumor, meningitis) causes.
Kathleen’s throbbing, severe headaches with nausea, photophobia, and
phonophobia, worsened by stress and sleep deprivation, strongly
suggest migraines, especially given their increased frequency. The
absence of red flags (e.g., sudden onset, fever, neurological deficits)
reduces suspicion for secondary causes like tumors or intracranial
hemorrhage. Her occupational stress and irregular sleep are likely
triggers, common in migraines, while her fear of a brain tumor
Name: Kathleen Parks
Age: 26 years old
Gender: Female
Setting: Outpatient Primary Care Clinic
Chief Complaint: “My headaches are getting worse and happening
more often.”
Reason for Encounter: More frequent severe headaches
History of Present Illness (HPI)Narrative: Kathleen Parks, a 26-
year-old Caucasian female, presents to the outpatient primary care
clinic reporting an increase in the frequency and severity of headaches
over the past 2 months. She describes the headaches as a throbbing
pain, primarily frontal and bilateral, rated 7–8/10 in severity, lasting 4–
,6 hours, and occurring 3–4 times per week. Previously, Kathleen
experienced headaches 1–2 times per month, managed with over-the-
counter (OTC) ibuprofen, but recent episodes are less responsive to
ibuprofen 400 mg (requiring 800 mg for partial relief). She reports
associated symptoms of nausea, photophobia, and phonophobia during
severe episodes, but denies vomiting, visual disturbances (e.g., aura,
blurry vision), or neurological deficits (e.g., weakness, numbness). The
headaches are triggered by stress, lack of sleep, and caffeine
withdrawal, and are alleviated slightly by lying in a dark, quiet room.
Kathleen notes increased stress from her job as a graphic designer,
working 50–60 hours per week with tight deadlines, and reports
sleeping 5–6 hours per night due to work demands.Kathleen denies
recent trauma, fever, neck stiffness, seizures, or changes in speech or
coordination. She reports no recent infections, travel, or exposure to
environmental toxins. Her medical history includes occasional tension
headaches since college, managed with ibuprofen, and seasonal
allergies treated with cetirizine PRN. She denies prior migraines,
, neurological disorders, or head injuries. Kathleen takes oral
contraceptives (ethinyl estradiol/norethindrone) daily and ibuprofen
PRN. She is up to date on vaccinations, including the 2024–2025
influenza vaccine and COVID-19 booster. Kathleen is concerned that her
headaches are interfering with her work performance and social life, as
she often cancels plans due to pain and fatigue. She worries the
headaches could indicate a serious condition, such as a brain tumor,
due to a coworker’s recent diagnosis.Explanation: The HPI is critical for
evaluating headaches, as it helps differentiate primary (e.g., migraine,
tension headache) from secondary (e.g., tumor, meningitis) causes.
Kathleen’s throbbing, severe headaches with nausea, photophobia, and
phonophobia, worsened by stress and sleep deprivation, strongly
suggest migraines, especially given their increased frequency. The
absence of red flags (e.g., sudden onset, fever, neurological deficits)
reduces suspicion for secondary causes like tumors or intracranial
hemorrhage. Her occupational stress and irregular sleep are likely
triggers, common in migraines, while her fear of a brain tumor
