I-HUMAN CASE WEEK #4 | 20 Y/O
MALE 180CM AND WEIGHT 79.5 KG |
REASON FOR ENCOUNTER ACUTE EYE
PROBLEM | LATEST EXAM
PATIENT INFORMATION
Attribute Value
Age 20 years
Sex Male
Height 180 cm (5'11")
Weight 79.5 kg (175 lb)
BMI ~24.4 kg/m² (normal range)
Setting Outpatient clinic with laboratory capabilities
Reason for Encounter Eye problem
CHIEF COMPLAINT (CC)
, "My eye is red and blurry."
HISTORY OF PRESENT ILLNESS (HPI)
The patient is a 20-year-old male presenting with a 2-day history of right eye redness,
irritation, and blurred vision that has progressively worsened .
Symptom Characterization:
Characteristic Details
Location Right eye (unilateral)
Onset Gradual, began approximately 2 days ago
Duration Continuous, worsening over time
Quality Gritty sensation, mild burning, irritation
Discharge Thick, yellow-green purulent discharge present; eyelids stick together upon waking
Vision Mildly blurred; no significant vision loss
Photophobia Mild, present
Pain Mild discomfort, 3/10
Trauma Denies eye trauma, chemical exposure, foreign body sensation
Associated Symptoms:
No severe pain
No vision loss
, No fever or systemic symptoms
No upper respiratory symptoms
Exposures:
Contact lens use: Denies contact lens use (or specifies if present in case)
Recent exposures: Denies recent swimming or chemical exposure
Sick contacts: Unknown at this time
Self-treatment: Has not attempted any over-the-counter treatments
PAST MEDICAL HISTORY (PMH)
No chronic medical conditions
No history of asthma, diabetes, or autoimmune disease
No prior ocular disease or eye infections
Denies prior surgeries
MEDICATIONS & ALLERGIES
Category Details
Current Medications None
Allergies No known drug allergies (NKDA)
FAMILY HISTORY (FH)
Non-contributory for eye disease
MALE 180CM AND WEIGHT 79.5 KG |
REASON FOR ENCOUNTER ACUTE EYE
PROBLEM | LATEST EXAM
PATIENT INFORMATION
Attribute Value
Age 20 years
Sex Male
Height 180 cm (5'11")
Weight 79.5 kg (175 lb)
BMI ~24.4 kg/m² (normal range)
Setting Outpatient clinic with laboratory capabilities
Reason for Encounter Eye problem
CHIEF COMPLAINT (CC)
, "My eye is red and blurry."
HISTORY OF PRESENT ILLNESS (HPI)
The patient is a 20-year-old male presenting with a 2-day history of right eye redness,
irritation, and blurred vision that has progressively worsened .
Symptom Characterization:
Characteristic Details
Location Right eye (unilateral)
Onset Gradual, began approximately 2 days ago
Duration Continuous, worsening over time
Quality Gritty sensation, mild burning, irritation
Discharge Thick, yellow-green purulent discharge present; eyelids stick together upon waking
Vision Mildly blurred; no significant vision loss
Photophobia Mild, present
Pain Mild discomfort, 3/10
Trauma Denies eye trauma, chemical exposure, foreign body sensation
Associated Symptoms:
No severe pain
No vision loss
, No fever or systemic symptoms
No upper respiratory symptoms
Exposures:
Contact lens use: Denies contact lens use (or specifies if present in case)
Recent exposures: Denies recent swimming or chemical exposure
Sick contacts: Unknown at this time
Self-treatment: Has not attempted any over-the-counter treatments
PAST MEDICAL HISTORY (PMH)
No chronic medical conditions
No history of asthma, diabetes, or autoimmune disease
No prior ocular disease or eye infections
Denies prior surgeries
MEDICATIONS & ALLERGIES
Category Details
Current Medications None
Allergies No known drug allergies (NKDA)
FAMILY HISTORY (FH)
Non-contributory for eye disease
