Presenting With an Eye Problem in an Outpatient
Clinic With Laboratory Capabilities||Real 2025 i-
Human Case Study| FREE PDF
I-human Case Study: 20-year-old Male With Eye Problem
Patient Profile
• Age/Sex: 20-year-old male
• Setting: Outpatient clinic with laboratory capabilities
, • Source of History: Patient (reliable)
Reason for Encounter (Chief Complaint)
"My right eye is red and painful, and my vision is blurry."
History of Present Illness (HPI)
The patient is a 20-year-old male presenting with a 3-day history of right eye
redness, pain, tearing, and photophobia. Symptoms began gradually after
sleeping in contact lenses overnight. He reports foreign body sensation and
blurred vision in the affected eye. Denies trauma, chemical exposure, or similar
symptoms in the left eye. No purulent discharge, but notes watery tearing. Pain
worsens with light exposure. He denies fever, headache, nausea, or vomiting.
• Onset: 3 days ago
• Location: Right eye
• Duration: Constant
• Characteristics: Redness, pain, photophobia, tearing, blurry vision
• Aggravating factors: Light exposure, blinking
• Relieving factors: Eye closure, darkness
• Severity: Pain 6/10
Review of Systems (ROS)
• General: Denies fever, chills, fatigue
• HEENT: Right eye redness, pain, photophobia, blurred vision; denies
diplopia, left eye symptoms, ear pain, nasal discharge, sore throat
• Neurologic: Denies headache, weakness, dizziness
• Skin: No rash or lesions