Comprehensive i-Human Case Analysis Week
4 (2025) Class 6512 | 20-Year-Old Male With
Acute Eye Problem (Bacterial
Conjunctivitis )| Outpatient Clinic | 100%
Complete & Exam-Ready (Walden University)
,Comprehensive i-Human Case Analysis: Week 4
Patient: 20-year-old male
Reason for Visit: Red, irritated, and purulent left eye
Setting: Outpatient Clinic
Date: Week 4, 2025
Course: Class 6512
1. Patient Introduction
• Age/Sex: 20-year-old male
• Height/Weight: 5’10” (178 cm), 165 lbs (75 kg)
• Occupation: College student
• Medical History: No chronic illnesses reported
• Surgical History: None
• Allergies: No known drug allergies
• Medications: None
• Family History: Non-contributory
• Social History: Non-smoker, occasional alcohol, no recreational drug use
• Immunization Status: Up to date, including tetanus
2. History of Present Illness (HPI)
Patient presents with redness, irritation, and purulent discharge in the left eye for 2 days. Symptoms
began suddenly, initially with mild itching and foreign-body sensation. He reports thick yellow
discharge, especially in the morning, causing eyelids to stick together. There is no pain with eye
movement, no blurred vision, and no photophobia. Patient denies systemic symptoms such as fever or
malaise. No recent trauma or contact lens use. No history of similar episodes. No sick contacts reported.
Key HPI Points:
Symptom Onset Duration Severity Aggravating/Relieving Factors
Redness 2 days Continuous Moderate Worsens in morning, relieved by warm compress
Discharge 2 days Continuous Thick, yellow Improves after wiping eye
Itching/burning 2 days Intermittent Mild Relieved by artificial tears
, Symptom Onset Duration Severity Aggravating/Relieving Factors
Pain N/A N/A None N/A
Vision changes N/A N/A None N/A
3. Review of Systems (ROS)
System Findings
General No fever, fatigue, or malaise
HEENT Red left eye, purulent discharge, mild itching, no vision loss, no trauma
Respiratory Denies cough, shortness of breath
Cardiovascular Denies chest pain or palpitations
GI Denies nausea, vomiting, diarrhea
GU Denies dysuria or hematuria
MSK Denies joint pain
Neuro Denies headache, dizziness, or photophobia
Skin No rashes
4. Physical Examination / Objective Findings
Vital Signs:
• Temperature: 98.6°F (37°C)
• Blood Pressure: 118/72 mmHg
• Heart Rate: 78 bpm
• Respiratory Rate: 16 bpm
• SpO₂: 98% on room air
General: Alert, well-nourished, in no acute distress
Eyes:
• Left eye: Conjunctival injection, purulent yellow discharge, mild eyelid edema
• Right eye: Normal
4 (2025) Class 6512 | 20-Year-Old Male With
Acute Eye Problem (Bacterial
Conjunctivitis )| Outpatient Clinic | 100%
Complete & Exam-Ready (Walden University)
,Comprehensive i-Human Case Analysis: Week 4
Patient: 20-year-old male
Reason for Visit: Red, irritated, and purulent left eye
Setting: Outpatient Clinic
Date: Week 4, 2025
Course: Class 6512
1. Patient Introduction
• Age/Sex: 20-year-old male
• Height/Weight: 5’10” (178 cm), 165 lbs (75 kg)
• Occupation: College student
• Medical History: No chronic illnesses reported
• Surgical History: None
• Allergies: No known drug allergies
• Medications: None
• Family History: Non-contributory
• Social History: Non-smoker, occasional alcohol, no recreational drug use
• Immunization Status: Up to date, including tetanus
2. History of Present Illness (HPI)
Patient presents with redness, irritation, and purulent discharge in the left eye for 2 days. Symptoms
began suddenly, initially with mild itching and foreign-body sensation. He reports thick yellow
discharge, especially in the morning, causing eyelids to stick together. There is no pain with eye
movement, no blurred vision, and no photophobia. Patient denies systemic symptoms such as fever or
malaise. No recent trauma or contact lens use. No history of similar episodes. No sick contacts reported.
Key HPI Points:
Symptom Onset Duration Severity Aggravating/Relieving Factors
Redness 2 days Continuous Moderate Worsens in morning, relieved by warm compress
Discharge 2 days Continuous Thick, yellow Improves after wiping eye
Itching/burning 2 days Intermittent Mild Relieved by artificial tears
, Symptom Onset Duration Severity Aggravating/Relieving Factors
Pain N/A N/A None N/A
Vision changes N/A N/A None N/A
3. Review of Systems (ROS)
System Findings
General No fever, fatigue, or malaise
HEENT Red left eye, purulent discharge, mild itching, no vision loss, no trauma
Respiratory Denies cough, shortness of breath
Cardiovascular Denies chest pain or palpitations
GI Denies nausea, vomiting, diarrhea
GU Denies dysuria or hematuria
MSK Denies joint pain
Neuro Denies headache, dizziness, or photophobia
Skin No rashes
4. Physical Examination / Objective Findings
Vital Signs:
• Temperature: 98.6°F (37°C)
• Blood Pressure: 118/72 mmHg
• Heart Rate: 78 bpm
• Respiratory Rate: 16 bpm
• SpO₂: 98% on room air
General: Alert, well-nourished, in no acute distress
Eyes:
• Left eye: Conjunctival injection, purulent yellow discharge, mild eyelid edema
• Right eye: Normal
