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Comprehensive i-Human Case
Analysis Week 4 (2025) | 20-Year-
Old Male With Acute Eye Problem
(Bacter
Comprehensive i-Human Case Analysis – Week 4 (2025)
Course: NRNP / NR (i-Human)
Setting: Outpatient Clinic
Patient: 20-Year-Old Male
Chief Complaint: “My eye is red and has discharge.”
,FULL PATIENT INTRODUCTION
A 20-year-old male presents to an outpatient clinic with a 2-day history of unilateral eye redness,
irritation, and purulent discharge. He reports waking up with his eyelids “stuck together” and notes
worsening redness and discomfort. He denies trauma or vision loss. The patient appears mildly
uncomfortable but in no acute distress.
HISTORY OF PRESENT ILLNESS (HPI)
• Onset: 2 days ago
• Location: Right eye
• Duration: Continuous
• Characteristics: Redness, gritty sensation, thick yellow discharge
• Aggravating factors: Touching the eye, blinking
• Relieving factors: Wiping discharge (temporary)
• Severity: Mild to moderate discomfort
• Associated symptoms: Tearing, eyelid crusting
• Denies: Severe pain, photophobia, blurred vision, eye trauma, contact lens use, fever
PAST MEDICAL HISTORY
• No chronic medical conditions
• No prior eye disease
Surgical History
• None
Medications
• None
Allergies
• No known drug allergies (NKDA)
FAMILY HISTORY
• No family history of eye disease, autoimmune disorders, or diabetes
, SOCIAL HISTORY
• College student
• Denies tobacco or illicit drug use
• Occasional alcohol use
• No recent travel
• No known sick contacts but attends crowded classes
REVIEW OF SYSTEMS (ROS)
General: Denies fever, chills, fatigue
Eyes: Redness, discharge, tearing (right eye); denies vision loss or photophobia
ENT: No nasal congestion or sore throat
Respiratory: Denies cough or shortness of breath
Cardiovascular: Denies chest pain or palpitations
Neurologic: Denies headache or dizziness
Skin: No rash
All other systems reviewed and negative.
PHYSICAL EXAMINATION / OBJECTIVE FINDINGS
Vital Signs
• BP: 118/72 mmHg
• HR: 76 bpm
• RR: 16/min
• Temp: 98.4°F (36.9°C)
• SpO₂: 99% RA
General
• Alert, oriented ×3, well-appearing
Eyes
• Right eye:
o Conjunctival injection
o Thick yellow-green purulent discharge
Comprehensive i-Human Case
Analysis Week 4 (2025) | 20-Year-
Old Male With Acute Eye Problem
(Bacter
Comprehensive i-Human Case Analysis – Week 4 (2025)
Course: NRNP / NR (i-Human)
Setting: Outpatient Clinic
Patient: 20-Year-Old Male
Chief Complaint: “My eye is red and has discharge.”
,FULL PATIENT INTRODUCTION
A 20-year-old male presents to an outpatient clinic with a 2-day history of unilateral eye redness,
irritation, and purulent discharge. He reports waking up with his eyelids “stuck together” and notes
worsening redness and discomfort. He denies trauma or vision loss. The patient appears mildly
uncomfortable but in no acute distress.
HISTORY OF PRESENT ILLNESS (HPI)
• Onset: 2 days ago
• Location: Right eye
• Duration: Continuous
• Characteristics: Redness, gritty sensation, thick yellow discharge
• Aggravating factors: Touching the eye, blinking
• Relieving factors: Wiping discharge (temporary)
• Severity: Mild to moderate discomfort
• Associated symptoms: Tearing, eyelid crusting
• Denies: Severe pain, photophobia, blurred vision, eye trauma, contact lens use, fever
PAST MEDICAL HISTORY
• No chronic medical conditions
• No prior eye disease
Surgical History
• None
Medications
• None
Allergies
• No known drug allergies (NKDA)
FAMILY HISTORY
• No family history of eye disease, autoimmune disorders, or diabetes
, SOCIAL HISTORY
• College student
• Denies tobacco or illicit drug use
• Occasional alcohol use
• No recent travel
• No known sick contacts but attends crowded classes
REVIEW OF SYSTEMS (ROS)
General: Denies fever, chills, fatigue
Eyes: Redness, discharge, tearing (right eye); denies vision loss or photophobia
ENT: No nasal congestion or sore throat
Respiratory: Denies cough or shortness of breath
Cardiovascular: Denies chest pain or palpitations
Neurologic: Denies headache or dizziness
Skin: No rash
All other systems reviewed and negative.
PHYSICAL EXAMINATION / OBJECTIVE FINDINGS
Vital Signs
• BP: 118/72 mmHg
• HR: 76 bpm
• RR: 16/min
• Temp: 98.4°F (36.9°C)
• SpO₂: 99% RA
General
• Alert, oriented ×3, well-appearing
Eyes
• Right eye:
o Conjunctival injection
o Thick yellow-green purulent discharge
