I HUMAN CASE STUDY WEEK 4:20 YEARS OLD
REASON FOR ENCOUNTER EYE PROBLEM- [eye
discomfort and visual changes] WITH FULL
SOAP NOTE REAL EXAM 2025!!! LATEST
Reason for Encounter
The patient presents today with eye discomfort and visual changes, including redness, irritation, and
blurred vision.
,History of Present Illness (HPI)
The patient is a [age]-year-old [male/female] who presents with [right/left/bilateral] eye symptoms
that began [time frame, e.g., 2–3 days ago]. The patient reports redness, itching, tearing, and a gritty
sensation in the affected eye. There is [presence/absence] of eye pain, described as
[mild/moderate/severe], and [presence/absence] of photophobia.
The patient notes [clear/purulent] discharge, especially [in the morning/throughout the day], causing
[crusting of the eyelids/no crusting]. Vision is described as [unchanged/slightly blurred/significantly
blurred]. The patient denies double vision, halos around lights, or sudden vision loss.
Symptoms are [worsened/improved] by [bright light, rubbing the eye, contact lens use] and
[relieved/not relieved] by [rest, artificial tears, OTC eye drops]. The patient [does/does not] wear
contact lenses and reports [appropriate/improper] lens hygiene.
The patient denies recent eye trauma, foreign body exposure, chemical exposure, fever, headache, or
upper respiratory symptoms. There is [no/history of] recent sick contacts. No prior history of similar
eye problems is reported.
Physical Examination
General
The patient is alert, oriented, and in no acute distress. Appears well-nourished and appropriately
groomed.
Vital Signs
Vital signs reviewed and within normal limits.
Head
Normocephalic and atraumatic. No scalp tenderness or lesions.
Eyes
• Inspection:
o [Right/Left/Bilateral] conjunctival injection noted
o Mild eyelid erythema without edema
o No ptosis or proptosis
• Visual Acuity:
o [Normal / mildly decreased] in affected eye
, • Pupils:
o Pupils equal, round, and reactive to light and accommodation (PERRLA)
• Extraocular Movements:
o Intact without pain or restriction
• Discharge:
o [Clear / mucopurulent] discharge present
• Cornea:
o Clear, no visible abrasions or ulcers
• Sclera:
o No icterus
• Fundoscopic Exam:
o Red reflex present
o No hemorrhages or exudates
Ears, Nose, Throat (ENT)
• Ears: Tympanic membranes intact bilaterally
• Nose: Nasal mucosa moist without congestion
• Throat: Oropharynx clear, no erythema or exudates
Neck
Supple with full range of motion. No cervical lymphadenopathy.
Skin
Warm and dry. No rashes or lesions.
Neurologic
Cranial nerves II–XII intact. No focal neurologic deficits.
Assessment
Primary Diagnosis
REASON FOR ENCOUNTER EYE PROBLEM- [eye
discomfort and visual changes] WITH FULL
SOAP NOTE REAL EXAM 2025!!! LATEST
Reason for Encounter
The patient presents today with eye discomfort and visual changes, including redness, irritation, and
blurred vision.
,History of Present Illness (HPI)
The patient is a [age]-year-old [male/female] who presents with [right/left/bilateral] eye symptoms
that began [time frame, e.g., 2–3 days ago]. The patient reports redness, itching, tearing, and a gritty
sensation in the affected eye. There is [presence/absence] of eye pain, described as
[mild/moderate/severe], and [presence/absence] of photophobia.
The patient notes [clear/purulent] discharge, especially [in the morning/throughout the day], causing
[crusting of the eyelids/no crusting]. Vision is described as [unchanged/slightly blurred/significantly
blurred]. The patient denies double vision, halos around lights, or sudden vision loss.
Symptoms are [worsened/improved] by [bright light, rubbing the eye, contact lens use] and
[relieved/not relieved] by [rest, artificial tears, OTC eye drops]. The patient [does/does not] wear
contact lenses and reports [appropriate/improper] lens hygiene.
The patient denies recent eye trauma, foreign body exposure, chemical exposure, fever, headache, or
upper respiratory symptoms. There is [no/history of] recent sick contacts. No prior history of similar
eye problems is reported.
Physical Examination
General
The patient is alert, oriented, and in no acute distress. Appears well-nourished and appropriately
groomed.
Vital Signs
Vital signs reviewed and within normal limits.
Head
Normocephalic and atraumatic. No scalp tenderness or lesions.
Eyes
• Inspection:
o [Right/Left/Bilateral] conjunctival injection noted
o Mild eyelid erythema without edema
o No ptosis or proptosis
• Visual Acuity:
o [Normal / mildly decreased] in affected eye
, • Pupils:
o Pupils equal, round, and reactive to light and accommodation (PERRLA)
• Extraocular Movements:
o Intact without pain or restriction
• Discharge:
o [Clear / mucopurulent] discharge present
• Cornea:
o Clear, no visible abrasions or ulcers
• Sclera:
o No icterus
• Fundoscopic Exam:
o Red reflex present
o No hemorrhages or exudates
Ears, Nose, Throat (ENT)
• Ears: Tympanic membranes intact bilaterally
• Nose: Nasal mucosa moist without congestion
• Throat: Oropharynx clear, no erythema or exudates
Neck
Supple with full range of motion. No cervical lymphadenopathy.
Skin
Warm and dry. No rashes or lesions.
Neurologic
Cranial nerves II–XII intact. No focal neurologic deficits.
Assessment
Primary Diagnosis
