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The patient is male. He is thirty-four years old. The patient wears contact lenses due to having myopia. However, there is no known history of him having any other diseases connected to eyesight problems. The main complaints of the patient include redness and itchiness of the conjunctiva of the right eye, increased tear production and presence of liquid discharge in the eye. Moreover, he reports to having problems with wearing his contact lenses. The right eye started to itch and burn three days ago. The patient tried to clean the eye with water and searched for any foreign objects that might have caused the irritation. Then, the patient applied Visine eye drops, which temporarily soothed the irritation. However, the redness did not go away. The left eye seems to look healthy. The patient reports to having good hygiene and says that he washes hands regularly.
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The patient was diagnosed with myopia when he was twelve years old. He usually wore glasses. However, he decided to switch to contact lenses a month ago.
The patient has no history of other diseases connected to eyesight. No previous history of eye infections is recorded.
The patient denies having any family history relevant to his condition. The father has a history of regulated hypertension. He takes medications and performs regularly check-ups at the hospital. The mother has a history of a generalized anxiety disorder, which is being treated with therapy. She was diagnosed with GAD a year ago. No medical history related to eye diseases can be found.
The patient has no history of major surgeries.
The patient admits to smoking and drinking on rare occasions. He denies illicit drug use. The patient lives with his wife and daughter. He works as a professor at a university. He denies having stressful experiences at work. He does not exercise regularly due to a busy schedule. His safety level is average. However, the history of hypertension and mental illness in his family should be considered in the future.
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The patient denies taking any medications.
General: The patient denies having any recent body problems or weight fluctuation. He has a normal appetite and sleeps as usual. The levels of energy are regular as well.
Cardiovascular: The patient denies any chest pains, palpitations, edema, or dyspnea.
Respiratory: The patient reports having no problems with breathing. He denies asthma or coughing.
Dermatology: The patient denies having any skin problems. However, he reports to having redness and irritation around the right eye, admitting to touching and rubbing it before and after the appearance of symptoms. Overall, he denies any scaling, lumps, or blisters.
Mouth, throat, nose, ears: The patient denies having a sore throat, oral or dental problems, nasal congestion, or hearing loss.
Eyes: The patient admits to having myopia, which he did not attempt to fix with any surgeries or medications. According to the patient, the left eye is not dry or irritated. The right eye is red and itchy. The patient also reports to having blurred vision in his right eye due to excessive tear production and discharge. The difficulty focusing is explained by myopia, the quality of sight is not significantly different.
Genitourinary: The patient denies any changes in urgency. There is no pain during urination.
Gastrointestinal: The patient denies having nausea or loss of appetite. He denies having any abdominal pains.
Musculoskeletal: The patient denies joint pain, muscle pain, cramping, stiffness, or swelling.
Hematologic: The patient denies anemia or unusual bleeding.
Neurologic: The patient denies headaches, tiredness, dizziness, memory loss, weakness, seizures, or numbness.
Allergic: The patient denies having seasonal allergies, food allergies, or animal allergies. There is no family history of allergies as well.
+1 (206) 350-4565
support@nursingstudyhub.com