Week 4 i-Human Case Study: Comprehensive
Assessment of a Patient Presenting With an Eye
Disorder
, Patient Information
• Name: Michael Thompson (Simulated Patient)
• Age: 42 years
• Gender: Male
• Chief Complaint: “My right eye is painful, red, and sensitive to light.”
• Care Setting: Outpatient / Primary Care Clinic
History of Present Illness (HPI)
Michael Thompson is a 42-year-old male who presents with 3 days of progressively worsening
right eye pain, redness, tearing, and marked photophobia. Pain is described as deep, aching,
rated 6/10, worsened by light exposure and eye movement. He reports blurred vision in the right
eye but denies sudden vision loss, halos around lights, or colored rings. There is no purulent
discharge, only excessive tearing.
He denies trauma, foreign body sensation, chemical exposure, or contact lens use. He reports a
mild viral upper respiratory infection one week ago. Artificial tears provided no relief. No prior
history of similar symptoms.
Past Medical History
• Hypertension (well controlled)
• Seasonal allergic rhinitis
Medications
• Lisinopril 10 mg PO daily
• Loratadine 10 mg PO PRN
Allergies
Assessment of a Patient Presenting With an Eye
Disorder
, Patient Information
• Name: Michael Thompson (Simulated Patient)
• Age: 42 years
• Gender: Male
• Chief Complaint: “My right eye is painful, red, and sensitive to light.”
• Care Setting: Outpatient / Primary Care Clinic
History of Present Illness (HPI)
Michael Thompson is a 42-year-old male who presents with 3 days of progressively worsening
right eye pain, redness, tearing, and marked photophobia. Pain is described as deep, aching,
rated 6/10, worsened by light exposure and eye movement. He reports blurred vision in the right
eye but denies sudden vision loss, halos around lights, or colored rings. There is no purulent
discharge, only excessive tearing.
He denies trauma, foreign body sensation, chemical exposure, or contact lens use. He reports a
mild viral upper respiratory infection one week ago. Artificial tears provided no relief. No prior
history of similar symptoms.
Past Medical History
• Hypertension (well controlled)
• Seasonal allergic rhinitis
Medications
• Lisinopril 10 mg PO daily
• Loratadine 10 mg PO PRN
Allergies
