COMPLETE I HUMAN LATEST
CASE WEEK #4 20Y/O
MALE REASON FOR
ENCOUNTER; EYE
PROBLEM
HPI STATEMENT
The patient is a 20-year-old male who presents today with a primary
complaint of an eye problem that began 3 days ago. He reports the onset
was acute and initially mild but has progressively worsened. The
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PAGE
1
,COMPLETE I HUMAN LATEST
CASE WEEK #4 20Y/O
MALE REASON FOR
ENCOUNTER; EYE
PROBLEM
symptoms involve the right eye and include redness, irritation, tearing,
and a gritty foreign-body sensation. He describes the discomfort as
burning and scratchy, rated 5/10 in severity, and states that it is constant
throughout the day.
The patient reports associated symptoms of mild photophobia and clear
watery discharge. He denies purulent discharge, eye trauma, blurred
vision, double vision, vision loss, halos around lights, eye pain with
movement, headache, fever, nausea, or vomiting. He reports no recent
contact lens use and states he wears glasses occasionally. There is no
history of recent eye injury, chemical exposure, swimming in pools, or
foreign body entry.
The patient notes that symptoms are worsened by bright light and
prolonged screen use and are partially relieved by resting the eye and
blinking frequently. He has not used any prescription eye medications
but tried over-the-counter artificial tears, which provided minimal relief.
He denies recent upper respiratory infection but reports recent close
contact with a roommate who had red eyes. He denies any history of eye
disease, glaucoma, cataracts, or previous similar episodes. There is no
history of autoimmune disease. The patient denies recent travel, sexually
transmitted infections, or systemic symptoms.
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PAGE
2
, COMPLETE I HUMAN LATEST
CASE WEEK #4 20Y/O
MALE REASON FOR
ENCOUNTER; EYE
PROBLEM
HISTORY OF PRESENT ILLNESS
Approach Question Patient Response
Chief What brings you in “I’m having a problem with
Complaint today? my eye.”
When did the eye “It started about three days
Onset
problem start? ago.”
Did it begin suddenly or “It started suddenly and has
Onset Pattern
gradually? gotten worse.”
Location Which eye is affected? “My right eye.”
Laterality Is the other eye affected? “No, only the right eye.”
Is the problem constant “It’s been constant since it
Duration
or intermittent? started.”
How severe is the
Severity discomfort on a scale of “About a 5 out of 10.”
0–10?
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3
CASE WEEK #4 20Y/O
MALE REASON FOR
ENCOUNTER; EYE
PROBLEM
HPI STATEMENT
The patient is a 20-year-old male who presents today with a primary
complaint of an eye problem that began 3 days ago. He reports the onset
was acute and initially mild but has progressively worsened. The
END OF
PAGE
1
,COMPLETE I HUMAN LATEST
CASE WEEK #4 20Y/O
MALE REASON FOR
ENCOUNTER; EYE
PROBLEM
symptoms involve the right eye and include redness, irritation, tearing,
and a gritty foreign-body sensation. He describes the discomfort as
burning and scratchy, rated 5/10 in severity, and states that it is constant
throughout the day.
The patient reports associated symptoms of mild photophobia and clear
watery discharge. He denies purulent discharge, eye trauma, blurred
vision, double vision, vision loss, halos around lights, eye pain with
movement, headache, fever, nausea, or vomiting. He reports no recent
contact lens use and states he wears glasses occasionally. There is no
history of recent eye injury, chemical exposure, swimming in pools, or
foreign body entry.
The patient notes that symptoms are worsened by bright light and
prolonged screen use and are partially relieved by resting the eye and
blinking frequently. He has not used any prescription eye medications
but tried over-the-counter artificial tears, which provided minimal relief.
He denies recent upper respiratory infection but reports recent close
contact with a roommate who had red eyes. He denies any history of eye
disease, glaucoma, cataracts, or previous similar episodes. There is no
history of autoimmune disease. The patient denies recent travel, sexually
transmitted infections, or systemic symptoms.
END OF
PAGE
2
, COMPLETE I HUMAN LATEST
CASE WEEK #4 20Y/O
MALE REASON FOR
ENCOUNTER; EYE
PROBLEM
HISTORY OF PRESENT ILLNESS
Approach Question Patient Response
Chief What brings you in “I’m having a problem with
Complaint today? my eye.”
When did the eye “It started about three days
Onset
problem start? ago.”
Did it begin suddenly or “It started suddenly and has
Onset Pattern
gradually? gotten worse.”
Location Which eye is affected? “My right eye.”
Laterality Is the other eye affected? “No, only the right eye.”
Is the problem constant “It’s been constant since it
Duration
or intermittent? started.”
How severe is the
Severity discomfort on a scale of “About a 5 out of 10.”
0–10?
END OF
PAGE
3
