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WEEK 4 I-HUMAN CASE STUDY FOR A 20-YEAR-
OLD MALE PRESENTING WITH AN EYE
PROBLEM — WEEK #4 CLASS 6512 LOCATION:
OUTPATIENT CLINIC WITH LAB CAPABILITY
WALDEN UNIVERSITY LATEST UPDATE WITH
SOAP NOTE
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1. General Case Information
Case Title & Summary
Contact-lens user with acute unilateral painful red eye and decreased visual acuity
— urgent evaluation for corneal infection (contact-lens associated microbial
keratitis) vs other causes (corneal abrasion, viral keratitis, conjunctivitis, foreign
body, uveitis).
Summary: 20-year-old male presents to outpatient clinic with 24–48 hours of right
eye pain, redness, photophobia and blurred vision. He wears soft contact lenses,
sometimes overnight.
Reason for Encounter
Acute onset right eye pain and visual disturbance.
Patient Demographics
Name / ID: (Redacted for exam)
Age: 20 years
Sex: Male
Height / Weight: Not clinically important for ocular diagnosis (documented
if required)
Contact lens status: Daily-wear soft contact lenses; reports occasional
extended/overnight wear.
Case Mode
Learning / Exam mode (Walden University Class 6512)
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Case Location
Outpatient primary care clinic with slit-lamp, fluorescein strips, tonometer, and
microbiology lab access (corneal scraping & culture).
Attempts Allowed
Unlimited (learning mode)
2. Chief Complaint (CC)
“My right eye is very red and painful and things look blurry — it hurts in
bright light.”
Primary problem: Right eye pain, redness, blurred vision, photophobia.
Onset: 36 hours ago (patient estimates “yesterday evening started, worse
today”).
Course: Progressive (increasing pain, worsening vision).
Severity: Severe (rates 8/10); interfering with reading and screen use.
Pertinent positives: Contact lens use, slept once with lenses a week ago;
saline rinses only, no recent swimming while wearing lenses.
Pertinent negatives: No trauma, no foreign body sensation after initial
episode, no discharge described as thick purulent (initially watery then more
mucopurulent), no systemic viral prodrome.
3. History of Present Illness (HPI)
WEEK 4 I-HUMAN CASE STUDY FOR A 20-YEAR-
OLD MALE PRESENTING WITH AN EYE
PROBLEM — WEEK #4 CLASS 6512 LOCATION:
OUTPATIENT CLINIC WITH LAB CAPABILITY
WALDEN UNIVERSITY LATEST UPDATE WITH
SOAP NOTE
,2|Page
1. General Case Information
Case Title & Summary
Contact-lens user with acute unilateral painful red eye and decreased visual acuity
— urgent evaluation for corneal infection (contact-lens associated microbial
keratitis) vs other causes (corneal abrasion, viral keratitis, conjunctivitis, foreign
body, uveitis).
Summary: 20-year-old male presents to outpatient clinic with 24–48 hours of right
eye pain, redness, photophobia and blurred vision. He wears soft contact lenses,
sometimes overnight.
Reason for Encounter
Acute onset right eye pain and visual disturbance.
Patient Demographics
Name / ID: (Redacted for exam)
Age: 20 years
Sex: Male
Height / Weight: Not clinically important for ocular diagnosis (documented
if required)
Contact lens status: Daily-wear soft contact lenses; reports occasional
extended/overnight wear.
Case Mode
Learning / Exam mode (Walden University Class 6512)
, 3|Page
Case Location
Outpatient primary care clinic with slit-lamp, fluorescein strips, tonometer, and
microbiology lab access (corneal scraping & culture).
Attempts Allowed
Unlimited (learning mode)
2. Chief Complaint (CC)
“My right eye is very red and painful and things look blurry — it hurts in
bright light.”
Primary problem: Right eye pain, redness, blurred vision, photophobia.
Onset: 36 hours ago (patient estimates “yesterday evening started, worse
today”).
Course: Progressive (increasing pain, worsening vision).
Severity: Severe (rates 8/10); interfering with reading and screen use.
Pertinent positives: Contact lens use, slept once with lenses a week ago;
saline rinses only, no recent swimming while wearing lenses.
Pertinent negatives: No trauma, no foreign body sensation after initial
episode, no discharge described as thick purulent (initially watery then more
mucopurulent), no systemic viral prodrome.
3. History of Present Illness (HPI)
