Comprehensive iHuman Case: Corneal
Abrasion in a 20-Year-Old Male
Presenting with Acute Eye Problem
(2025-WK #4)
FULL PATIENT INTRODUCTION
• Patient Name: [Redacted]
, • Age: 20 years
• Gender: Male
• Date: 2025
• Location: Outpatient Clinic
• Chief Complaint: “My right eye hurts and feels like something is in it.”
• Presenting Problem: Acute onset eye pain in the right eye, associated with tearing and
photophobia.
HISTORY OF PRESENT ILLNESS (HPI)
• Onset: Acute, began approximately 6 hours prior to presentation.
• Location: Right eye.
• Duration: Constant since onset.
• Character: Sharp, foreign-body sensation, mild throbbing.
• Aggravating Factors: Blinking, bright light.
• Relieving Factors: None identified.
• Associated Symptoms: Tearing, redness, photophobia, mild blurred vision. No discharge, no
floaters, no loss of vision.
• History of Trauma: Patient reports a minor injury while cutting wood; may have had a small
wood splinter in the eye.
• Past Ocular History: No prior eye injuries, no history of contact lens use.
• Past Medical History: Unremarkable.
• Medications: None.
• Allergies: NKDA.
• Social History: College student, no tobacco or illicit drug use, occasional alcohol.
• Family History: Non-contributory.
REVIEW OF SYSTEMS (ROS)
• General: No fever, no malaise.
• Eyes: Pain, redness, tearing, photophobia (positive); vision loss, floaters, discharge (negative).
• ENT: No sore throat, no nasal congestion.
, • Cardiovascular: Denies chest pain, palpitations.
• Respiratory: No cough or dyspnea.
• Gastrointestinal: No nausea, vomiting, abdominal pain.
• Musculoskeletal: No joint pain or swelling.
• Neurologic: No headache, weakness, numbness.
PHYSICAL EXAMINATION / OBJECTIVE FINDINGS
• Vital Signs:
o BP: 118/70 mmHg
o HR: 76 bpm
o RR: 16/min
o Temp: 36.8°C
o SpO₂: 98%
• General: Alert, in mild distress due to eye pain.
• Eye Examination (Right Eye):
o Visual Acuity: 20/25 OD, 20/20 OS
o External Eye: Mild erythema, no swelling.
o Conjunctiva: Injection present.
o Cornea: Fluorescein staining shows linear superficial abrasion; no foreign body
detected.
o Pupils: Equal, round, reactive to light.
o Anterior Chamber: Clear
o Extraocular Movements: Intact, no pain on movement.
o Intraocular Pressure: Within normal limits
• Left Eye: Normal.
• Other Systems: Within normal limits.
DIFFERENTIAL DIAGNOSIS TABLE
Abrasion in a 20-Year-Old Male
Presenting with Acute Eye Problem
(2025-WK #4)
FULL PATIENT INTRODUCTION
• Patient Name: [Redacted]
, • Age: 20 years
• Gender: Male
• Date: 2025
• Location: Outpatient Clinic
• Chief Complaint: “My right eye hurts and feels like something is in it.”
• Presenting Problem: Acute onset eye pain in the right eye, associated with tearing and
photophobia.
HISTORY OF PRESENT ILLNESS (HPI)
• Onset: Acute, began approximately 6 hours prior to presentation.
• Location: Right eye.
• Duration: Constant since onset.
• Character: Sharp, foreign-body sensation, mild throbbing.
• Aggravating Factors: Blinking, bright light.
• Relieving Factors: None identified.
• Associated Symptoms: Tearing, redness, photophobia, mild blurred vision. No discharge, no
floaters, no loss of vision.
• History of Trauma: Patient reports a minor injury while cutting wood; may have had a small
wood splinter in the eye.
• Past Ocular History: No prior eye injuries, no history of contact lens use.
• Past Medical History: Unremarkable.
• Medications: None.
• Allergies: NKDA.
• Social History: College student, no tobacco or illicit drug use, occasional alcohol.
• Family History: Non-contributory.
REVIEW OF SYSTEMS (ROS)
• General: No fever, no malaise.
• Eyes: Pain, redness, tearing, photophobia (positive); vision loss, floaters, discharge (negative).
• ENT: No sore throat, no nasal congestion.
, • Cardiovascular: Denies chest pain, palpitations.
• Respiratory: No cough or dyspnea.
• Gastrointestinal: No nausea, vomiting, abdominal pain.
• Musculoskeletal: No joint pain or swelling.
• Neurologic: No headache, weakness, numbness.
PHYSICAL EXAMINATION / OBJECTIVE FINDINGS
• Vital Signs:
o BP: 118/70 mmHg
o HR: 76 bpm
o RR: 16/min
o Temp: 36.8°C
o SpO₂: 98%
• General: Alert, in mild distress due to eye pain.
• Eye Examination (Right Eye):
o Visual Acuity: 20/25 OD, 20/20 OS
o External Eye: Mild erythema, no swelling.
o Conjunctiva: Injection present.
o Cornea: Fluorescein staining shows linear superficial abrasion; no foreign body
detected.
o Pupils: Equal, round, reactive to light.
o Anterior Chamber: Clear
o Extraocular Movements: Intact, no pain on movement.
o Intraocular Pressure: Within normal limits
• Left Eye: Normal.
• Other Systems: Within normal limits.
DIFFERENTIAL DIAGNOSIS TABLE
