1|Page
I-HUMAN CASE STUDY FOR A 20 YEARS OLD MALE
WITH AN EYE PROBLEM WEEK #4 CLASS 6512
LOCATION – OUTPATIENT CLINIC WITH LAB
CAPABILITIES WALDEN UNIVERSITY LATEST
UPDATE
Reason for Encounter:
Evaluation of eye redness, irritation, and discharge.
Patient Demographics:
Age: 20 years
Sex: Male
Height: 5’9” (175 cm)
Weight: 160 lbs (72.6 kg)
BMI: 23.6 kg/m²
,2|Page
Case Mode: Learning mode
Case Location: Outpatient primary care clinic with laboratory and basic
ophthalmic testing capabilities
Attempts Allowed: Unlimited
2. Chief Complaint (CC)
“My right eye is red and irritated, and it has some discharge.”
3. History of Present Illness (HPI)
The patient is a 20-year-old male who presents with a 3-day history of right eye
redness and irritation. Symptoms began gradually and have progressively
worsened.
Symptom characteristics:
Location: Right eye only
Onset: 3 days ago
Duration: Constant
Course: Gradually worsening
Quality: Gritty, burning sensation
Severity: Mild to moderate
Discharge: Thick, yellowish discharge noted upon waking
Vision changes: Denies blurred or decreased vision
, 3|Page
Pain: Mild discomfort; denies severe eye pain
Associated symptoms:
Mild photophobia
Eyelids stuck together in the morning
Mild itching
Negative symptoms:
No eye trauma
No foreign body sensation
No halos around lights
No headache, nausea, or vomiting
No fever
Risk factors/exposures:
Wears soft contact lenses (daily use)
Admits to occasionally sleeping in contacts
Recent upper respiratory infection
Lives in a college dorm
Aggravating factors:
Contact lens use
Rubbing the eye
Relieving factors:
Removing contact lenses
I-HUMAN CASE STUDY FOR A 20 YEARS OLD MALE
WITH AN EYE PROBLEM WEEK #4 CLASS 6512
LOCATION – OUTPATIENT CLINIC WITH LAB
CAPABILITIES WALDEN UNIVERSITY LATEST
UPDATE
Reason for Encounter:
Evaluation of eye redness, irritation, and discharge.
Patient Demographics:
Age: 20 years
Sex: Male
Height: 5’9” (175 cm)
Weight: 160 lbs (72.6 kg)
BMI: 23.6 kg/m²
,2|Page
Case Mode: Learning mode
Case Location: Outpatient primary care clinic with laboratory and basic
ophthalmic testing capabilities
Attempts Allowed: Unlimited
2. Chief Complaint (CC)
“My right eye is red and irritated, and it has some discharge.”
3. History of Present Illness (HPI)
The patient is a 20-year-old male who presents with a 3-day history of right eye
redness and irritation. Symptoms began gradually and have progressively
worsened.
Symptom characteristics:
Location: Right eye only
Onset: 3 days ago
Duration: Constant
Course: Gradually worsening
Quality: Gritty, burning sensation
Severity: Mild to moderate
Discharge: Thick, yellowish discharge noted upon waking
Vision changes: Denies blurred or decreased vision
, 3|Page
Pain: Mild discomfort; denies severe eye pain
Associated symptoms:
Mild photophobia
Eyelids stuck together in the morning
Mild itching
Negative symptoms:
No eye trauma
No foreign body sensation
No halos around lights
No headache, nausea, or vomiting
No fever
Risk factors/exposures:
Wears soft contact lenses (daily use)
Admits to occasionally sleeping in contacts
Recent upper respiratory infection
Lives in a college dorm
Aggravating factors:
Contact lens use
Rubbing the eye
Relieving factors:
Removing contact lenses
