I-HUMAN CASE ANALYSIS – WEEK #4 FOR A 20-YEAR-OLD MALE PRESENTING WITH AN EYE PROBLEM CLASS 6512 – ADVANCED HEALTH ASSESSMENT OUTPATIENT CLINIC WITH LABORATORY CAPABILITIES LATEST UPDATE

I-HUMAN CASE ANALYSIS – WEEK #4 FOR A 20-YEAR-OLD
MALE PRESENTING WITH AN EYE PROBLEM CLASS 6512 –
ADVANCED HEALTH ASSESSMENT OUTPATIENT CLINIC
WITH LABORATORY CAPABILITIES LATEST UPDATE




Reason for Encounter:
Evaluation of eye pain and redness.

Patient Demographics:

 Age: 20 years
 Sex: Male
 Height: 5’9” (175 cm)
 Weight: 165 lbs (75 kg)
 BMI: 24.4 kg/m²

,Case Mode: Learning mode

Case Location: Outpatient primary care clinic with laboratory and ophthalmic
exam capabilities

Attempts Allowed: Unlimited




2. Chief Complaint (CC)

“My right eye is red and painful, and my vision is blurry.”




3. History of Present Illness (HPI)

The patient is a 20-year-old male presenting with a 2-day history of right eye
redness, pain, and blurred vision. Symptoms began abruptly and have
progressively worsened.

Eye symptom characteristics:

 Location: Right eye
 Onset: Sudden, 48 hours ago
 Duration: Continuous
 Quality: Sharp, gritty sensation with deep aching pain
 Severity: 6/10
 Radiation: Localized to the eye and periorbital area
 Vision changes: Mild blurred vision and photophobia
 Discharge: Watery discharge, no purulence

,  Laterality: Unilateral

Associated symptoms:

 Sensitivity to light
 Excessive tearing
 Mild headache

Negative symptoms:

 No fever
 No nausea or vomiting
 No diplopia
 No trauma
 No foreign body sensation

Risk factors:

 Contact lens use (daily soft lenses)
 Admits to sleeping in contacts occasionally
 Poor lens hygiene reported

Aggravating factors:

 Bright light
 Eye movement

Relieving factors:

 Keeping eye closed
 Avoiding light