Year-Old Male Presenting With an Eye
Problem in an Outpatient Clinic With
Laboratory Capabilities
1. Patient Biodata
• Age: 20 years
, • Gender: Male
• Ethnicity: African
• Marital Status: Single
• Occupation: College student
• Setting: Outpatient clinic with laboratory capabilities
• Date of Encounter: 2025
• Source of History: Patient (reliable)
2. Past Medical History
• No known chronic medical conditions
• No history of eye trauma or eye surgery
• No history of diabetes, hypertension, or autoimmune disease
Past Surgical History
• None
Medications
• None
Allergies
• No known drug allergies (NKDA)
Family History
• No family history of glaucoma or other eye disorders
• Parents alive and healthy
Social History
• Non-smoker
• Denies alcohol and illicit drug use
• Uses contact lenses occasionally
• Lives in student housing
3. History of Present Illness (HPI)