I-HUMAN CASE ANALYSIS — 20-YEAR-OLD MALE
PRESENTING WITH AN EYE PROBLEM WEEK #4
(CLASS 6512) — OUTPATIENT CLINIC WITH
LABORATORY CAPABILITIES WALDEN UNIVERSITY
LATEST UPDATE
,1. General Case Information
Case title & summary:
Contact-lens associated acute keratitis in a 20-year-old male — urgent outpatient
evaluation, microbiologic sampling, empiric topical antimicrobial therapy, close
follow-up and ophthalmology referral.
Reason for encounter:
“Right eye is very red and painful and I can’t see well with it.”
Patient demographics:
Name: (anonymous for exam)
Age: 20 years
Sex: Male
Height: 178 cm (5′10″) — optional
Weight: 74 kg (163 lb) — optional
BMI: 23.4 (normal range)
Case mode: Learning / exam submission
Case location: Outpatient primary care clinic with slit lamp, tonometer,
microbiology lab access (Gram stain, culture), and ability to refer emergently to
ophthalmology.
Attempts allowed: Unlimited (learning mode)
2. Chief Complaint (CC)
, “My right eye started hurting two days ago and is getting worse.”
Main problems: increasing ocular pain, redness, light sensitivity, blurred vision in
the right eye.
3. History of Present Illness (HPI)
Onset & course: Symptoms began 48 hours ago with mild irritation and redness.
Over 2 days symptoms progressed to moderate–severe throbbing eye pain,
photophobia, and cloudy/blurry vision. Symptoms worse since waking today.
Symptoms detail:
Pain: Constant, throbbing, aggravated by blinking and light. Rated 7/10 at
worst.
Vision: Subjective blurring centrally in the right eye; left eye unaffected.
Discharge: Small amount of purulent/serous eyelid crusting in morning; not
profuse watery discharge.
Photophobia: Marked — cannot tolerate bright lights.
Tearing: Moderate lacrimation.
Systemic: Denies fever, malaise, nausea, headache. No recent sinus
infection.
Trauma: Denies recent blunt trauma or foreign body except prior rubbing.
Contact lenses: Wears daily disposable soft contact lenses; reports sleeping
while wearing lenses ~3 nights ago and occasionally “napping” in lenses.
Last wore right lens 3 days ago. Last cleaning solution: multipurpose
solution; admits to occasionally topping off solution rather than replacing
case.
PRESENTING WITH AN EYE PROBLEM WEEK #4
(CLASS 6512) — OUTPATIENT CLINIC WITH
LABORATORY CAPABILITIES WALDEN UNIVERSITY
LATEST UPDATE
,1. General Case Information
Case title & summary:
Contact-lens associated acute keratitis in a 20-year-old male — urgent outpatient
evaluation, microbiologic sampling, empiric topical antimicrobial therapy, close
follow-up and ophthalmology referral.
Reason for encounter:
“Right eye is very red and painful and I can’t see well with it.”
Patient demographics:
Name: (anonymous for exam)
Age: 20 years
Sex: Male
Height: 178 cm (5′10″) — optional
Weight: 74 kg (163 lb) — optional
BMI: 23.4 (normal range)
Case mode: Learning / exam submission
Case location: Outpatient primary care clinic with slit lamp, tonometer,
microbiology lab access (Gram stain, culture), and ability to refer emergently to
ophthalmology.
Attempts allowed: Unlimited (learning mode)
2. Chief Complaint (CC)
, “My right eye started hurting two days ago and is getting worse.”
Main problems: increasing ocular pain, redness, light sensitivity, blurred vision in
the right eye.
3. History of Present Illness (HPI)
Onset & course: Symptoms began 48 hours ago with mild irritation and redness.
Over 2 days symptoms progressed to moderate–severe throbbing eye pain,
photophobia, and cloudy/blurry vision. Symptoms worse since waking today.
Symptoms detail:
Pain: Constant, throbbing, aggravated by blinking and light. Rated 7/10 at
worst.
Vision: Subjective blurring centrally in the right eye; left eye unaffected.
Discharge: Small amount of purulent/serous eyelid crusting in morning; not
profuse watery discharge.
Photophobia: Marked — cannot tolerate bright lights.
Tearing: Moderate lacrimation.
Systemic: Denies fever, malaise, nausea, headache. No recent sinus
infection.
Trauma: Denies recent blunt trauma or foreign body except prior rubbing.
Contact lenses: Wears daily disposable soft contact lenses; reports sleeping
while wearing lenses ~3 nights ago and occasionally “napping” in lenses.
Last wore right lens 3 days ago. Last cleaning solution: multipurpose
solution; admits to occasionally topping off solution rather than replacing
case.
