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Clin ical
Proced ures
for Ocular
Exam ination
 NOTICE
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new in ormation becomes available, changes in treatment and in the use o drugs
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in ormation material included in the package insert o each drug or therapeu-
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disclaims any liability, loss, injury or damage incurred as a consequence, directly or
indirectly, o the use and application o the contents o the volume.
Clin ical
Proced ures
for Ocular
Exam ination
Fo u rth Ed itio n

NANCY B. CARLSON, OD, FAAO

Pro essor Emeritus
New England College o Optometry
Boston, Massachusetts

DANIEL KURTZ, OD, PhD, FAAO

Associate Dean o Academic A airs
Pro essor o Optometry
Western University o Health Sciences
College o Optometry
Pomona, Cali ornia

New York Chicago San Francisco Athens London Madrid Mexico City
Milan New Delhi Singapore Sydney oronto
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 S
Contributors xi

T
Preface xiii
Introduction xv
Acknowledgments xix

N
1 Patient Communication 1
Introduction to Patient Communication 2

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Case History 5
Presenting Examination Results to a Patient 11

T
Verbal Presentation o Your Patient to a Colleague,
Preceptor, or Attending Supervisor 15
How to Write a Consultancy or Re erral Letter 19

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Reporting Abuse 23
How to Write a Prescription or Medication 25

2 Entrance Tests 29

O
Introduction to the Entrance Tests 30
External Observation 34
Visual Acuity (VA): Minimum Legible 36

C
Visual Acuity (VA): Minimum Legible Using
a LogMAR Chart 43
Visual Acuity (VA): Minimum Legible Using the
Massachusetts Visual Acuity Test With Lea Symbols 51
Pinhole Visual Acuity 58
Amplitude o Accommodation: Push-Up Method and
Pull-Away Method 60
Color Vision 63
Cover Test 67
Stereopsis 75
Screening Stereopsis Using the Random
Dot E and PASS 78
Worth 4 Dot 82
Near Point o Convergence (NPC) 86
Hirschberg Test and Krimsky Test 89
Brückner Test 92
vi Contents

Extraocular Motilities (EOM) 95

Pupils 98
Screening Visual Fields 101
Finger Counting Visual Fields 104
Interpupillary Distance (PD) 107
Summary o Expected Findings 110

3 Refraction 111
Introduction to Re raction 113
Lensometry 116
Keratometry 121
Introduction to the Phoropter 127
Static Retinoscopy 130
Routine Distance Subjective Re raction with
the Phoropter 136
Step-by-Step Procedure or the Routine Distance
Subjective Re raction with the Phoropter 137
I. Monocular Distance Subjective Re raction 138
Initial MPMVA (Maximum Plus to Maximum Visual Acuity) 138
Initial Duochrome (Bichrome, Red-Green Test) 139
The Jackson Cross Cylinder (JCC) Test 142
Second Monocular MPMVA 147
II. Binocular Balance 149
Binocular MPMVA 152
Use o the Trial Frame to Modi y a Prescription 156
III. Side Trips rom the Routine Distance Subjective Re raction 159
Clock Chart (Sunburst Dial) 159
Jackson Cross Cylinder (JCC) Check Test or Uncorrected
Astigmatism 161
Prism-Dissociated Duochrome Test 162
Sighting-Dominance Check 164
Trial Frame Re raction 165
Stenopaic Slit Re raction 171
 Contents vii

Cycloplegic Re raction 174

Delayed Subjective Re raction 177
Convergence Controlled Re raction 179
Binocular Re raction with the Vectographic Slide 181
Humphriss Immediate Contrast Method 185
In nity Balance 188
Mohindra’s Near Retinoscopy 190
Determining the Add or the Presbyope 192
Septum Near Balance 197
Near Re nement o Cylinder Axis and Power Using
the Borish Binocular Nearpoint Card 202
Modi ed Humphriss or Near Re nement o Cylinder
Axis and Power 204

4 Functional Tests 207

Introduction to Functional Tests 208
Distance Lateral Phoria by von Grae e Technique 210
Distance Vertical Phoria by von Grae e Technique 213
Horizontal Vergences at Distance 216
Vertical Vergences at Distance 220
Near Lateral Phoria by von Grae e Technique 223
Near Vertical Phoria by von Grae e Technique 227
Horizontal Vergences at Near 230
Vertical Vergences at Near 233
Fusional Vergence Facility at Near 235
Fused Cross Cylinder 236
Negative Relative Accommodation/Positive Relative
Accommodation (NRA/PRA) 239
Accommodative Facility 241
Dynamic Retinoscopy: Monocular Estimation
Method (MEM) 245
Dynamic Retinoscopy: Bell Retinoscopy 248
Amplitude o Accommodation: Minus Lens to Blur 251
viii Contents

Associated Phoria 253

Maddox Rod Phoria 257
Modi ed Thorington Phoria 261
4Δ Base Out Test 266

5 Ocular Health Assessment 271

Introduction to Ocular Health Assessment 273
Biomicroscopy (Slit Lamp) 278
Special Slit Lamp Procedures 289
Examination o the Anterior Chamber 290
Eversion o the Upper Lid 292
Corneal or Conjunctival Staining 294
Specular Ref ection Technique 297
Sclerotic Scatter Technique 299
Instillation o Drops 301
Gonioscopy 304
Tear Breakup Time 313
Schirmer Tests: Schirmer #1 Test and Basic Lacrimation Test 315
Cotton Thread Test 318
Fluorescein Clearance Test (or “Dye Disappearance Test”) 320
Jones #1 (Primary Dye) Test 323
Direct Ophthalmoscopy 325
Binocular Indirect Ophthalmoscopy 328
Scleral Depression 335
Fundus Biomicroscopy 338
Nerve Fiber Layer Evaluation 341
Retinal Evaluation With the Goldmann 3-Mirror Lens 343
Goldmann Applanation Tonometry 348
Pachymetry 355
Noncontact Tonometry 357
Amsler Grid 363
Tangent Screen 366
D-15 Color Test 370
 Contents ix

Brightness Comparison Test 372

Photostress Recovery Time Test 374
Red Desaturation Test 377
Exophthalmometry 380

6 Contact Lenses 385

Introduction to the Contact Lens Examination 387
Contact Lens Case History 390
Contact Lens External Examination 392
Inspection and Veri cation o Gas Permeable Contact Lenses 396
Base Curve Radius: Radiuscope or Radiusgauge 397
Base Curve Radius: Lensco-Meter 401
Back Vertex Power and Optical Quality 403
Lens Diameter and Optic Zone Diameter 405
Center Thickness 408
Sur ace Quality 410
Sur ace Wettability 413
Insertion, Removal, and Recentering o Gas Permeable
Contact Lenses 415
Fit Assessment o Gas Permeable Contact Lenses 420
Inspection and Veri cation o So t Contact Lenses 426
Back Vertex Power 427
Sur ace Inspection: Films and Spots 429
Sur ace Inspection: Tears, Nicks, and Scratches 432
Insertion and Removal o So t Contact Lenses 434
Fit Assessment o So t Contact Lenses 439
Insertion and Removal o Scleral Contact Lenses 445
Fit Assessment o Scleral Contact Lenses 449
Over-Re raction: Phoropter 451
Over-Re raction: Spectacle Trial Lenses 453
Evaluation o the Multi ocal Contact Lens Patient 456
Distance Over-Re raction 458
Evaluation o the Monovision Patient 460
x Contents

7 Systemic Health Screening 465

Introduction to Systemic Health Screening 466
Blood Pressure Evaluation (Sphygmomanometry) 467
Carotid Artery Evaluation 473
Orbital Auscultation 478
Lymph Node Evaluation 482
Paranasal Sinus Evaluation 487
Glucometry 493

8 Cranial Nerve Screening 499

Introduction to Cranial Nerve Screening 500
Muscle Field with Red Lens, Ductions, and Saccades 501
Test or a Paretic Horizontal Muscle 504
Park’s 3-Step Method or a Paretic Vertical Muscle 506
Dim–Bright Pupillary Test 508
Near (Accommodative) Response o the Pupil 511
Pupil Cycle Time 513
Pharmacological Tests o the Pupil 515
Trigeminal Nerve Function Test 518
Facial Nerve Function Test 522
Screening Tests or Cranial Nerves I, VIII, XI, and XII 525

References 531
Index 561
 S
Robert C. Capone, OD, FAAO
Adjunct Clinical Faculty

R
New England College o Optometry
Boston, Massachusetts
Sta Optometrist
East Boston Neighborhood Health Center

O
East Boston, Massachusetts

Marion M.W. Hau, OD, FAAO

Adjunct Clinical Faculty

T
New England College o Optometry
Boston, Massachusetts
Sta Optometrist

U
East Boston Neighborhood Health Center
East Boston, Massachusetts

Ronald K. Watanabe, OD, FAAO

Associate Pro essor o Optometry

B
New England College o Optometry
Boston, Massachusetts

I
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 E
It has been 25 years since the publication o the rst edi-

C
tion o Clinical Procedures for Ocular Examination and
11 years since the publication o the third edition. During that
period, health care has undergone numerous changes related

A
to improved technology or testing, changes in insurance
coverage that in uence tests chosen and time spent with the
patient, the addition o electronic health record keeping, and
improved privacy or patients. T e movement to standard-

F
ize optometry on a national level continues. T e intellectual
oundations o optometric practice have been strengthened
by an ever-growing body o scienti c literature. Consequently,

E
we have updated the re erence sections with recent cita-
tions and added or modi ed procedures in accordance with
contemporary concepts and knowledge.

R
One o the key motivations or the 1990 edition o this
book was the lack o standardization or many clinical proce-
dures. Books such as this one attempt to alleviate the problem
to some degree. Nevertheless, it remains true now as it did at

P
the time o the rst, second, and third editions: there is still
more than one acceptable way to per orm many o the proce-
dures. In some o these instances we have added variations in
the step-by-step procedures, clearly indicating that there is a
valid, alternate way to per orm that step or procedure.
T is edition continues the practice o earlier editions
o not including highly technical or equipment-speci c
techniques. o learn to operate these tools, one must re er to
the manual that comes with the instrument. We remain true
to our primary mission: to describe how to per orm a wide
variety o use ul tests without a large body o theory.
This page intentionally left blank
 N
T e purpose o Clinical Procedure for Ocular Exam
ination is to provide students and practitioners with detailed

O
step-by-step procedures or a comprehensive battery o
techniques used in the examination o the eye. T ese pro-
cedures include tests or assessing the re ractive error, the
accommodative unction, the binocular coordination, and

I
the health o the eyes, monitoring the t and condition o
contact lenses, and screening tests or neurological and sys-

T
temic health conditions. T e book contains detailed, step-
by-step instructions on how to per orm each technique. For
each procedure, the reader is provided with comprehensive

C
in ormation on the purpose o the test, what equipment is
needed, how to set up the equipment and the patient prop-
erly, and how to record the ndings. Expected ndings are

U
listed or most tests. T e text includes diagrams and photo-
graphs to rein orce the descriptions o the techniques.
T e emphasis in this book is technical. It provides little in
the way o the theory or the background o the tests. Removal

D
o the theoretical discussion leaves a pure, concise descrip-
tion o the techniques and allows the reader to concentrate
on the psychomotor mechanics o the procedures. Readers
who are un amiliar with the techniques can use the descrip-

O
tions in this manual to learn the test procedures with little
or no supervision. Readers who are already amiliar with the
techniques can use this manual to review a test procedure

R
to ensure that they or someone under their supervision is
per orming it correctly. Mastery o the techniques and inter-
pretation o the ndings, however, cannot be obtained solely
through the use o this book, but requires supervised clinical
T
practice as well as a thorough understanding o the theoreti-
cal basis or each technique. Included in the Re erences sec-
tion at the end o the book are sources that will provide the
N
reader with the necessary theory and background or each o
the procedures.
T e rst chapter o the book deals with patient commu-
nication, clearly the most important aspect o patient care.
I
Good communication improves patient outcomes and makes
the encounter more enjoyable or both the patient and the
doctor. T e rst time the patient and doctor meet is usually
during the case history, a critical phase o the examination. In
addition to establishing rapport with the patient and setting
xvi Introduction

the tone or the exam, the history marks the beginning o the doctor’s
diagnostic thought process. Knowing the patient’s concerns, the examiner
can now begin to develop his examination strategy. Based on the patient’s
chie complaints and routine background in ormation gathered in the
case history, the examiner can decide which phases o the examination to
concentrate on and which problem-speci c testing should be done.
T e second chapter describes the entrance tests. T ese techniques
are the rst procedures per ormed ollowing the case history. T ey are
relatively simple procedures that use minimal, primarily handheld equip-
ment. T ey screen or problems in each o the three major problem areas:
re raction, visual unction, and health. Most o the entrance tests screen
or problems in more than one o these three areas. T ought ul interpre-
tation o the results o the entrance tests can greatly increase the ef ciency
o the examination. Augmented by the in ormation gathered in the case
history, entrance tests data aid the examiner in pinpointing the patient’s
problem areas and appropriately directing the examination strategy.
Chapters 3 through 5 correspond to the problem areas o re raction,
visual unction, and ocular health. raditionally, a complete ocular exami-
nation consisted o comprehensive testing in each o these three areas. T e
in ormation thus obtained was re erred to as the “minimum de ned data
base.” I a problem was discovered through these procedures, additional
problem-speci c tests were per ormed to enhance urther evaluation. In
this age o managed health care, providers no longer have the luxury o
per orming a battery o procedures on every patient simply to collect data.
It is important to detect problems quickly, with a minimum number o
tests, allowing time to probe each problem with more speci c testing.
In Chapters 3 through 5 we have de ned tests that can be consid-
ered “core” tests. Core tests can be viewed as providing the center or
nucleus o the exam. T ey supply the examiner with enough in ormation
to detect but not to diagnose the vast majority o ocular, binocular, neu-
rological, or visual anomalies, even in the absence o patient symptoms.
T e examiner’s philosophy and the demographic characteristics o the
patient will in uence what tests will be included in the core tests. T e
traditional minimum de ned data base o the past included more tests
than those currently de ned as core tests. T is reduction in the number
o procedures included in a complete examination is reasonable, since
the minimum de ned data base already contained some redundancy. For
this reason, excluding certain tests will not a ect the quality o in or-
mation obtained. However, examiners must be aware o the increased
importance o screening or unexpected problems, and diligently ollow
up with problem-speci c testing in the case o any abnormal test results.
 Introduction xvii

Each o these three chapters also describes a wide variety o prob-

lem-speci c tests, by which the examiner explores a speci c area o con-
cern in detail. T ese tests are not done on a routine basis, but are selected
on the basis o the patient’s case history and the results o other test-
ing. Problem-speci c tests are not placed in a separate chapter. T ey are
included in the chapter corresponding to their problem area.
Included within these chapters are owcharts that illustrate how
tests might be grouped or sequenced in order to promote examination
ef ciency. T ese charts do not represent the only appropriate sequenc-
ing o the techniques, but they do illustrate one sequence or ef ciently
combining the procedures.
Separate owcharts are presented or the most commonly applied
core entrance tests, re ractive tests, and ocular health assessment tests.
Since unctional testing and problem-speci c testing are almost always
customized to the patient and depend strongly on the individual patient’s
problem or complaint, there is no standard owchart or these parts o
the ocular examination.
Individual owcharts could not possibly work or all patients. Rather,
they are intended to provide a standard sequence o testing or the major-
ity o patients seen in most examiners’ practices. T is standard test order
can be compared to the itinerary o a trip. T e traveler plans the trip rom
start to nish along a standard pathway, or “main route.” Similarly, the
owcharts depict a standard itinerary o ocular tests that lead rom
the beginning to the end o the routine exam.
However, many patients need problem-speci c tests, which can be
compared to points o interest along the main route. When indicated,
the examiner takes a “side trip.” T at is, he per orms certain tests that are
supplemental to the main route. T e owcharts and text show when side
trips are indicated. Once the necessary side trip is completed, the exam-
iner should usually return to the main route and continue the examina-
tion rom there. For the sake o examination ef ciency, however, some
side trips may be postponed.
Chapter 6 concentrates on the procedures necessary or basic t-
ting and monitoring o contact lenses. T ese procedures are considered
problem-speci c since they are use ul only or contact lens patients. It
is possible to quickly and ef ciently incorporate these procedures into
a comprehensive ocular examination as shown in the ow chart at the
beginning o Chapter 6.
Chapter 7 deals with procedures used to screen a patient’s systemic
health. T e eye care pro essional is o ten the patient’s entry point into
the health care system. T ere ore, they have the responsibility to evaluate
xviii Introduction

the overall health o the patient. T e examiner may select to per orm
certain procedures based on the patient’s age, medical history, or pre-
senting symptoms or as the result o in ormation gathered during the
comprehensive examination. Alternately, the examiner may pre er to
per orm these screening procedures routinely on all patients. Patients
with abnormal results should be re erred to the appropriate health care
provider or more thorough evaluation and diagnosis.
Chapter 8 concentrates on procedures used to assess the cranial
nerves when screening or neurological disorders. T ese techniques are
rarely used or routine screening, but they are particularly help ul when
a problem is suspected on the basis o the patient’s case history or ocu-
lar examination ndings. Many o these screening procedures should be
per ormed as side trips rom corresponding entrance tests.
T roughout the text, the masculine orm o the third person singular
pronoun is used. T is orm is used or the sake o simplicity, and applies
equally to men and women without prejudice.
 S
T
We wish to thank our students who have used the numerous
outlines, owcharts, PowerPoint presentations, and hand-
outs that are the oundation o this book. T rough their ques-

N
tions they helped us determine the appropriate level o detail
needed to describe each procedure. We owe a special debt

E
to Dr David Heath and Dr Catherine Hines, who invested
countless hours and dra ted much o the text or the rst
three editions. We also wish to thank Mr Mirza Hasane endic,

M
Dr Robert Gordon, Dr i enie Harris, Mr Ed MacKinnon,
and Dr errence Knisely or their excellent photography;
Dr Susan Baylus or her work on many o the computer graph-

G
ics; Dr Patti Augeri, Dr Bina Patel, and Dr Maureen Hanley,
who were involved in developing the laboratory manual that
was the oundation or Chapter 5, Rudol Mireles, PharmD,

D
or help with preparation o the section on “How to Write
a Prescription or Medication,” and Ms Monique essier,
Ms Lori Rees, and Dr Ida Chung o the Western University

E
o Health Sciences College o Optometry or countless
hours xing last-minute emergencies during the preparation

L
o the manuscript or the ourth edition.
We would also like to acknowledge the sacri ces, sup-

W
port, and contributions o our amilies: om Corwin, Brian
Carlson, Adam, Esther, and Nathan Kurtz, and Kyra and
Lynne Silvers.

O
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K
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A
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 1
R
E
Patient

T
Communication

P
Nancy B. Carlson, OD, FAAO, and

A
Daniel Kurtz, OD, PhD, FAAO

H
C
Introduction to Patient Communication
Case History
Presenting Examination Results to a Patient
Verbal Presentation o Your Patient to a Colleague,
Preceptor, or Attending Supervisor
How to Write a Consultancy or Re erral Letter
Reporting Abuse
How to Write a Prescription or Medication
2 Chapter 1

INTRO DUCTIO N TO PATIENT

CO MMUNICATIO N
Co unic ting with tients is the ost i ort nt s ect o tient
c re. Good tient co unic tion cilit tes the ex in tion ro-
cess, i roves the ccur cy o di gnosis, i roves tient co li-
nce, decre ses tient co l ints nd l r ctice cl i s, nd kes
every tient encounter ore enjoy ble or the clinici n s well s or
the tient. Co unic tion is skill th t c n be le rned nd i roved
over ti e.
Fro the ti e th t the tient c lls or n oint ent until the
tient le ves the o ce, ll st need to know th t the tient is the ost
i ort nt erson in the roo nd they ust be tre ted with dignity nd
res ect.
T ere re ny o ortunities to de onstr te good tient co u-
nic tion in the c re rocess st rting with the c se history. Other co u-
nic tion o ortunities resented in this ch ter include resenting the
ndings to the tient t the end o the ex in tion, resenting the c se
to colle gues or to n ttending doctor, writing consult tion nd/or re er-
r l letters, re orting buse, nd writing rescri tion or edic tion.
C se history is the ost i ort nt rocedure in the entire re ertoire
o ex in tion rocedures, nd it is one o the ost di cult to le rn.
History t king c n be stered only ter the cquisition o bro d b se
o knowledge nd ter ye rs o clinic l ex erience. An ex erienced nd
knowledge ble clinici n o ten c n deter ine the di gnosis ro the
history lone. Conversely, the novice is requently overwhel ed by the
in or tion g thered in the c se history nd is r rely ble to e ectively
g ther nd use the relev nt in or tion in the di gnostic rocess. It is
beyond the sco e o this book to rovide su cient in or tion or
novice clinici n to conduct ro cient, co rehensive c se history.
R ther, the co onents o the c se history re resented to illustr te the
in rts o history or ty ic l ri ry c re ex in tion nd or
ty ic l ollow-u ex in tion.
T e c se history is usu lly conducted t the beginning o the
ex in tion, nd is the ti e or the clinici n nd tient to beco e
cqu inted. T e clinici n ust resent hi sel to the tient s c ring
nd e thetic individu l i he ex ects the tient to be orthco ing
bout his roble s nd to co ly with dvice given. At the s e ti e,
the clinici n begins the di gnostic thought rocess by sking the tient
ro ri te questions to deter ine the otenti l c uses or e ch o the
tient’s sy to s. T e in or tion is then used in deciding which
 Patient Communication 3

rocedures the clinici n will use to con r or rule out e ch otenti l

di gnosis. During the c se history the clinici n lso h s n o ortunity
to begin educ ting the tient bout his visu l unction nd bout his
ocul r nd gener l he lth.
T e c se history or ty ic l ri ry c re ex in tion is divided into
sever l rts: the Chie Co l int or History o the Present Illness (HPI),
P st Medic l nd Ocul r History including edic tions nd llergies,
Review o Syste s, F ily History, Soci l History, nd the Su ry. In
the beginning o the history, the clinici n sks o en-ended questions to
ssess the tient’s re son or seeking c re (the history o the resent
illness/chie co l int) nd to scert in the visu l needs o the tient’s
d ily li e. I the tient does not initi lly volunteer co l int, it is wise
to sk key, robing questions bout his vision nd visu l unction nd
visu l e ciency.
T e P st Medic l nd Ocul r History ortion o the history consists
o series o questions to deter ine i the tient is t risk or ny o
v riety o ocul r, syste ic, or neurologic l disorders. T e clinici n sks
bout the tient’s revious ocul r history, his edic l history, nd his
ily’s ocul r nd edic l history. T e clinici n lso gives the tient
list o sy to s o co on eye roble s to nd out i the tient h s
ever ex erienced ny o the . So e clinici ns g ther this in or tion
in written questionn ire th t the tient lls out rior to the ex i-
n tion. Although this is n e cient ethod o d t collection, it ust
be ollowed by convers tion between the clinici n nd the tient to
est blish doctor- tient rel tionshi nd to be cert in th t ll relev nt
in or tion w s g thered.
Fin lly, the c se history concludes with brie rec itul tion, or
su ry, o the tient’s chie co l int or co l ints, but this ti e in
the clinici n’s words. T is su ry ensures both the clinici n nd the
tient th t the clinici n underst nds the tient’s concerns, nd gives
the tient n o ortunity to dd nything th t y h ve been issed.
It lso gives the clinici n n o ortunity to st rt the rocess o tient
educ tion th t will be concluded t the end o the ex in tion.
T e c se history c n be odi ed or roble - ocused ex in -
tion or reviously seen tient by o itting the in or tion th t h s
been g thered in the revious ri ry c re ex in tion nd by sking
only the questions th t re relev nt to the tient’s re son or the visit.
A roble - ocused c se history should include the tient’s re son or
visit, questions bout the sy to s th t will hel the clinici n in the di -
erenti l di gnosis rocess, nd su ry o the tient’s co l ints in
the clinici n’s words.
4 Chapter 1

A ter the ex in tion is co leted, the clinici n ust su rize

the ndings o the ex in tion or the tient long with reco end -
tions or ro ri te c re, re err ls, nd ollow-u c re. It is i ort nt
to rel te the ex in tion ndings b ck to the tient’s re son or visit or
chie co l int.
 Patient Communication 5

CASE HISTO RY
Purpose
• o est blish c ring rel tionshi with the tient, showing co s-
sion, e thy, nd res ect or the tient.
• o g ther in or tion bout the tient’s chie co l int, visu l unc-
tion, ocul r nd syste ic he lth, risk ctors, nd li estyle.
• o begin the rocess o di erenti l di gnosis.
• o begin the rocess o tient educ tion.

Setup
Prior to st rting the or l c se history, the doctor should welco e the
tient, show the tient where to ut his co t nd belongings during
the ex in tion, introduce hi sel to the tient, nd exch nge ew
le s ntries with the tient (eg, How bout the P triots/Bruins/Celtics/
Red Sox? Wh t do you think bout the we ther we’ve been h ving?).
Be sure th t the tient is co ort ble where he is se ted nd th t the
overhe d light is not shining in the tient’s eyes. T e doctor should be
se ted t the s e height s the tient, in osition th t kes it e sy
to int in eye cont ct with the tient nd to cilit te convers tion.
When using electronic health records, t blet co uter will cilit te
good co unic tion, s shown in Figure 1-1. Although the c se history
is usu lly done t the beginning o the ex in tion, d t y be dded
to it s in or tion is g thered during testing. P tients so eti es reve l
ore in or tion s they beco e ore co ort ble with the doctor.

Case History Components for an Adult

Primary Care Examination
• History of the Present Illness (HPI)
1. Chie co l int.
a. Initi tion: Ask the tient bout the re son or his visit with
question such s:
Wh t brought you in tod y?”
Wh t roble s re you h ving with your eyes?
How c n I hel you tod y?
Wh t is the in re son or tod y’s eye ex in tion?
6 Chapter 1

FIGURE 1 -1. The doctor takes the case history and records it on a tablet computer, enhanc-
ing his ability to maintain eye contact with the patient.

b. El bor tion o the chie co l int (FOLDARQ).

For e ch co l int the tient resents, sk or ddition l in or-
tion using ny o the ollowing qu li ers th t will hel you in
your di erenti l di gnosis o e ch co l int:
Frequency: How o ten does this occur? H ve you h d nything
si il r in the st or is this the rst ti e?
Onset: When did the roble begin?
Loc tion: Where is the roble loc ted? (eg, OD, OS? At dis-
t nce, t ne r?)
Dur tion: How long do your sy to s l st?
Associ ted ctors: Wh t other sy to s do you ex erience
with this roble ? Does the sy to occur with your gl sses
or only when you do not we r the ? Does this h en only
when you we r your cont ct lenses or lso when you re not
we ring your cont ct lenses?
 Patient Communication 7

Relie : Wh t see s to ke your sy to s go w y?

Qu lity: On sc le o 1 to 10, how would you r te the severity
o your sy to s?
2. Visu l e ciency, i not lre dy covered in the chie co l int.
“C n you see cle rly nd co ort bly both r w y nd close
u or ll your visu l ctivities?”
A ter he ring the tient’s descri tion o his co l int(s),
su rize or hi wh t you h ve he rd.

• Past Medical History (including past eye history)

1. P tient’s ocul r history.
a. “When w s your l st eye ex in tion? By who ? Wh t w s the
outco e o th t ex in tion?”
b. Corrective lenses history.
I the tient we rs gl sses, sk:
How long h ve you been we ring gl sses? Are they or
dist nce, ne r, or both? C n you see cle rly nd co ort-
bly with the ?
When were your gl sses l st ch nged?
I the tient does not currently we r gl sses, sk,
“H ve you ever worn gl sses? Wh t were they or? When
did you we r the ? When nd why did you sto we ring
the ?”
Do you we r cont ct lenses? (For urther cont ct lens
history, see Ch ter 6.)
2. P tient’s edic l history.
H ve you ever h d ny edic l ttention to your eyes? Any
surgery, injuries, or serious in ections?
H ve you ever worn n eye tch?
H ve you ever used ny edic tion or your eyes?
H ve you ever been told th t you h ve n eye turn or
l zy eye?
H ve you ever been told th t you h ve c t r cts, gl u-
co , or ny other eye dise se?
8 Chapter 1

How is your gener l he lth?

When w s your l st hysic l ex in tion? By who ?
Are you currently under the c re o hysici n or ny
he lth condition?
H ve you ever been told th t you h ve di betes, high
blood ressure, thyroid dise se, he rt dise se, or ny in ec-
tious dise se?
Are you t king ny edic tions? I yes, wh t edic tion,
how long h ve you been t king the edic tion, wh t is it or,
nd wh t is the dos ge?
Do you h ve ny llergies? I yes, to wh t, wh t re your
sy to s, nd how re your llergies tre ted?
3. Review o Syste s (ROS).
T e Review o Syste s is list o org n syste s th t c n hel the cli-
nici n deter ine the st te o the tient’s gener l he lth. Included
in this list re:
Constitution l
Eyes
E rs, nose, nd thro t
Res ir tory
C rdiov scul r
G strointestin l
Genitourin ry
Neurologic l
Psychologic l
Musculoskelet l
Skin
Allergic/i unologic l/ly h tic/endocrine
4. Sy to s o co on eye roble s.
H ve you ex erienced ny o the ollowing: f shes o light, f o t-
ers, h los round lights, double vision, requent or severe he d-
ches, eye in, redness, te ring, or s ndy, gritty eeling in your
eyes?

• Family History
H s nyone in your ily h d c t r cts, gl uco , or blindness? H s
nyone h d n eye turn or l zy eye? I yes, who, when, or how long,
nd wh t w s the tre t ent?”
 Patient Communication 9

H s nyone in your ily h d di betes, high blood ressure, thyroid

dise se, he rt dise se, or ny in ectious dise se? I yes, who, when, or
how long, nd wh t w s the tre t ent?

• Social History
Wh t kind o work do you do?
Wh t re your hobbies? Wh t do you like to do in your s re ti e?
Do you drive?
Do you s oke? Drink lcohol? Use street drugs?

• Summary
T e re son or your visit tod y is nd you h ve concerns bout?
Wh t other concerns bout your eyes, your gener l he lth, or your
ily’s eyes or he lth would you like to tell e bout?
Wh t questions do you h ve or e t this oint in the ex in tion?

Case History Components for a

Problem-Focused Examination
• Establish the reason for the patient’s visit.
Ask, “Wh t is the re son or your visit tod y?” I you sked the tient
to return, use decl r tive st te ent bout wh t you know is the re son
or the tient’s visit such s, “I see th t you re here or dil ted ex .”
Conclude by sking, “Are there ny other roble s you re h ving th t
I c n t ke c re o or you tod y?”

• Probe the patient’s symptoms.

1. Use the questions ro the History o the Present Illness, section 1b
bove, to el bor te on the tient’s re son or this visit.
2. Ask the tient bout his edic l history, the edic tions he is cur-
rently t king, nd ny llergies he h s, rticul rly to edic tions.
• Summary
Su rize wh t the tient h s told you by s ying, “T e re son or
your visit tod y is nd you h ve concerns bout...?”
10 Chapter 1

CASEHISTORYat a glance

COMPONENTS TECHNIQUES

Introduction Introduce yoursel , make the patient com ortable

History o the Establish reason or patient’s visit and elaborate on his com-
Present Illness/Chie plaints to ully understand them and to begin the process
Complaint (HPI/CC) o di erential diagnosis

Past Medical History Ask about ocular history, general health, symptoms o com-
(PMH) and Review mon eye problems, medications, allergies, review systems
o Systems (ROS) to f nd out about the patient’s health

Family History (FH) Ask about problems that run in the amily to determine
patient’s risks

Summary Summarize in your own words why the patient is here and
ask i the patient wants to add anything

Recording
Record ll in or tion, including the neg tives.
 Patient Communication 11

P RESENTING EXAMINATIO N
RESULTS TO A PATIENT

Purpose
o rovide concise verb l su ry to the tient o ll ertinent in or-
tion ro the ex in tion.

Indications
Every tient should be given su ry o results ter every
ex in tion.

Equipment
No s eci c equi ent is required.

Setup
A co y o the tient record or other notes y be hel ul re erences to
h ve t h nd. However, you should be su ciently ili r with the ex -
in tion ndings th t you need to consult the record only in requently.

St e p b y St e p Pro ce d u re
1. Begin by st ting the di gnosis to the tient in l ngu ge he c n
underst nd. Alw ys rel te the di gnosis to the tient’s chie co -
l int or re son or visit.
2. Su rize the testing th t w s done to con r the di gnosis nd to
rule out other di gnoses.
3. Describe the etiology, rognosis, nd ex ected course o the
roble .
4. In or the tient o your reco ended tre t ent nd n ge-
ent o the di gnosis. When there is ore th n one o tion or
n ge ent, in or the tient o the v rious o tions with your
reco end tion or the best o tion. Include the risks nd bene ts
o e ch o tion.
5. I the l n involves re err l to nother clinici n, in or the tient
who you would like hi to see nd how urgent it is or the tient
12 Chapter 1

to see nother r ctitioner. I the re err l is urgent, ke the oint-

ent or the tient be ore he le ves your o ce.
6. In or the tient o your reco ended ollow-u interv l or the
next ex in tion. Let the tient know wh t nd when he should
ex ect in ter s o ch nges in his sy to s.
7. Give the tient written teri ls describing his di gnosis nd n-
ge ent when teri ls re v il ble.
8. Conclude by s ying to the tient, “Wh t questions do you h ve
or e?”

Recording
Present tions re given verb lly to the tient. Det ils o the di gnoses,
n ge ent l n, tient educ tion given, re err ls, nd when you w nt
to see the tient g in should be recorded in the tient’s record.

Example #1
Presentation to the Patient
(B ckground, not s id to the tient: Mr XY is 43-ye r-old ccount nt
whose chie co l int is di culty re ding, es eci lly t the end o the d y
or in di light. He re orts th t things re e sier to see i he holds the
urther w y, but his r s h ve beco e too short. Mr XY’s gener l he lth
is good nd urther erson l nd ily histories re unre rk ble.)
S y to the tient, “Mr XY, you h ve resbyo i , roble th t
everyone ex eriences t so e ti e between the ges o 38 nd 45.
Presbyo i is c used by the decre se in f exibility o the lens inside your
eye th t ocuses or close u nd is nor l ex ected ch nge with ge.
T e lens h s been losing f exibility since ge 15 but c tches u to ost o
us in our e rly 40s.
“Presbyo i c n be corrected with re ding gl sses. Since you we r
gl sses ll the ti e, I reco end rogressive ddition lenses. T ese
lenses llow you to see t ll dist nce without h ving to ch nge to di -
erent ir o gl sses.
“I you would like to consider cont ct lenses, I c n discuss sever l
cont ct lens o tions with you.
“As the lens inside your eye continues to lose f exibility u to ge 60,
resbyo i will rogress over ti e whether or not it is corrected with
gl sses. You will notice th t the gl sses I rescribe or you tod y will not
work s well in ew ye rs s they do now.
 Patient Communication 13

“I going to give you this hlet bout resbyo i th t will give

su rize the things th t I h ve told you tod y.
“I would like to see you g in in 1 ye r or nother co rehensive
ex . I you h ve ny questions or roble s be ore th t, le se c ll e.
Wh t questions do you h ve or e?”

Recording for Patient #1

Assess ent:
Presbyo i
Pl n:
Rx PALs
P tient educ tion re resbyo i : nor l ge ch nge th t will continue
to worsen over ti e but c n be corrected with gl sses or cont ct lenses.
G ve tient AOA hlet on resbyo i .
old the tient to c ll with questions or concerns.
Reco end co rehensive ex in tion in 1 ye r.

Example #2
Presentation to the Patient
(B ckground, not s id to the tient: Ms BC is 19-ye r college so h-
o ore who h s noticed inter ittent vision loss in eriorly in her right
eye or the st 3 d ys since she w s hit in the he d by te te’s
elbow during b sketb ll r ctice. BC h s lso noticed little bl ck s ecks
f o ting in ront o her right eye nd occ sion l f shes o light. She h s
worn cont ct lenses since ge 12 or oder te yo i nd h s h d ye rly
ex in tions since ge 10. Ms BC t kes no edic tions nd h s no ller-
gies. Her gener l he lth is good nd urther erson l or ily history is
unre rk ble. Check the tient’s he lth insur nce, c ll the ro ri te
retin l s eci list, nd ke n oint ent or Ms BC.)
S y to the tient, “BC, you h ve retin l det ch ent in your right
eye. T is ost likely occurred when you were hit during b sketb ll r c-
tice. Pro t tre t ent o retin l det ch ent is necess ry to revent er-
nent vision loss. I would like you to see retin l s eci list s soon s
ossible.
“I h ve c lled Dr H nd he c n see you this ternoon. I de n
oint ent or you with Dr H t 2:45 pm tod y nd I will send co y o
your record ro tod y to hi . He will ex ine you nd decide on the
14 Chapter 1

ro ri te tre t ent or the det ch ent. Dr H will let e know when

he w nts e to see you g in.
Wh t questions do you h ve?”

Recording for Patient #2

Assess ent:
Rheg togenous retin l det ch ent su eriorly, OD, second ry to
blunt tr u
Pl n:
Re er to retin l s eci list Dr H, ASAP.
Discussed the i ort nce o ro t ollow-u or best visu l outco e
with the tient.
C lled Dr H nd de oint ent or tient or tod y t 2:45 pm.
Sent co y o tod y’s record to Dr H. G ve tient co y o record to
give to Dr H s well.
Will c ll the tient when I h ve received re ort ro Dr H nd
schedule ro ri te ollow-u here t th t ti e.
 Patient Communication 15

VERBAL P RESENTATIO N O F
YO UR PATIENT TO A CO LLEAGUE,
P RECEPTO R, O R ATTENDING
SUP ERVISO R

Purpose
o rovide concise verb l su ry o ll ertinent in or tion bout
tient to en ble your rece tor or su ervisor to rrive t n e cient
underst nding o the c se in order to rovide e cient, in or ed c re
o the tient without w sting his ti e. T is rocedure is si il r to the
rocedure or writing consult ncy or re err l letter.

Indications
When it is necess ry to rovide su ry o tient’s ex in tion
ndings to nother ro ession l who will beco e involved in the c re o
th t tient.

Equipment
No s eci c equi ent is required.

Setup
A co y o the tient record or other notes y be hel ul re erences to
h ve t h nd. However, you should be su ciently ili r with the ex -
in tion ndings th t you need to consult the record only in requently.

St e p b y St e p Pro ce d u re
1. Begin with n introduction to the tient, giving n e, ge, gender, nd
ethnicity, i ertinent to the c se, nd wh t ty e o ex in tion you
h ve done (eg, co rehensive routine ex in tion, roble -s eci c
ex in tion, ollow-u ex in tion, cont ct lens tting, or ollow-u ).
2. In one sentence, su rize the tient’s resenting co l int or
re son or his seeking c re t the resent ti e. Follow this by giv-
ing ertinent det ils bout the tient’s descri tion o the roble ,
including things he believes cco nied it. Also rovide enough
in or tion to l ce the co l int in ti e.
16 Chapter 1

3. T is should be ollowed by recit tion o ll ex in tion d t rel-

ev nt to the tient’s resenting co l int. Include the roxi te
d te o the tient’s l st ull eye ex in tion. Avoid roviding in or-
tion th t is not relev nt to the tient’s resenting co l int.
4. T e next sentence should rovide other in or tion, including neg-
tive ndings th t re relev nt.
5. Conclude with concise st te ent o your resu ed di gnosis nd
your ro osed initi l tre t ent or n ge ent str tegy. Include
the roble s th t were rt o your di erenti l di gnosis th t you
h ve ruled out nd how you h ve ruled the out. In this rt o the
resent tion, lw ys include rec ll interv l nd s eci c lly wh t
you ro ose to ssess t the tient’s return visit.

Notes:
• Best-corrected VA is relev nt so o ten in eye c re th t you should
include it even i you re not sure it is relev nt. Un ided VA is r rely
relev nt.
• P tient’s edic l history: syste ic illness(es), edic tions, recent
ch nges in ctivities: only i relev nt to the resent tion.
• F ily ocul r nd edic l history only i relev nt.

PRESENTINGACASETOACOLLEAGUEORATTENDINGat a glance

COMPONENTS DETAILS

Introduce patient State name, age, gender, ethnicity, and type o examination

Chie complaint(s) Give patient’s description o his complaint(s) or reason

or visit

Examination data Summarize only the examination data relevant to your

assessment or diagnosis o the patient’s problem(s)

Di erential diagnosis Summarize the other possible diagnoses and the examina-
tion data that ruled out other possible diagnoses

Treatment and Summarize your recommended treatment or management

management o the patient’s problem

Give recommended time or the next visit and what should

be done at the next visit
 Patient Communication 17

Recording
Present tions re given verb lly. While they re not recorded, everything
th t is re orted should be rt o the tient’s o ci l ex in tion record.

Notes:
• T e key to good resent tion is to concisely re ort everything th t is
relev nt, but to re ort nothing th t is irrelev nt so s not to ob usc te
the ur ose o the ex in tion or to w ste ti e.
• Knowing wh t is relev nt nd wh t is irrelev nt is the di cult rt, but
th t is the key to resenting c se e ectively nd concisely.

Example #1
1. My tient is 66-ye r-old white le.
2. He is here bec use his brother w s recently di gnosed with gl uco ,
nd our tient w s told th t he needed ull eye ex in tion bec use
gl uco runs in ilies. He h s no other eye or visu l co l ints.
He is not w re o ny other ily e bers with gl uco .
3. His best-corrected vision is 20/20 t dist nce in e ch eye with od-
er te yo ic correction. I ound his IOP to be 23 in the right eye nd
27 in the le t eye. Cu to disc r tios re .5 horizont l nd .5 vertic l
right eye, ollowing the ISN rule, nd .6 horizont l by .75 vertic l le t
eye, not ollowing the ISN rule. His ch ber ngles re o en to the
cili ry body with lightly ig ented tr becul r eshwork in both
eyes. His visu l elds re ull to con ront tion in e ch eye. His l st ull
eye ex in tion w s bout 2 ye rs go. I h ve not dil ted hi yet.
4. He is neg tive or seudoex oli tion or KPs in either eye nd neg tive
or high blood ressure or di betes. His l st hysic l w s 3 onths go.
5. I believe he h s ri ry o en- ngle gl uco with elev ted IOP in
his le t eye nd we should begin tre t ent with bi to rost dro s
0.03% once d ily. He should return 2 weeks ter he begins ther y
to recheck his IOP.

Example #2
1. My tient is 26-ye r-old L tin e le.
2. She is here bec use she h s noticed th t light e rs brighter in
her le t eye th n in her right eye or the st week. She h s no other
co l ints.
18 Chapter 1

3. Her best-corrected vision is 20/20 t dist nce in e ch eye with low

hy ero ic correction. I ound th t her le t u il w s l rger th n the
right u il initi lly nd res onded slowly to light both directly nd
consensu lly, but it did constrict ter bout 5 inutes o testing.
T e right u il res onded briskly to light both direct nd consen-
su l. T ere w s no tosis o either eye. Her visu l elds re ull to
con ront tion in e ch eye. On slit l her eyes were white nd
quiet; I looked or uneven contr ction or iris stre ing, but I did
not see ny. Her l st ull eye ex in tion w s bout 2 ye rs go here
t the he lth center. No roble s were ound t th t ti e.
4. She denies ever seeing double or h ving eye in, exce t her le t eye
w s so ewh t light sensitive when she rst e erged ro seeing
ovie this weekend. She h s never ex erienced nything like this
reviously. She re orts th t her syste ic he lth is good; she is not
t king ny edic tions other th n birth control ills. She w s l st
seen by hysici n 2 onths go to renew her BCP rescri tion.
5. I believe she h s recent onset o tonic u il OS. We should re ssure
her th t she h s no serious thology or dise se nd see her g in in
5 weeks. At th t ti e we c n recheck ll her eye ndings, nd we c n
ex ect to see the ddition o iris signs o Adie’s, such s ver i or
contr ctions nd stro l stre ing.
 Patient Communication 19

HO W TO WRITE A CO NSULTANCY
O R REFERRAL LETTER

Purpose
o rovide written su ry o ll ertinent in or tion bout tient
to en ble nother r ctitioner to rovide e cient, in or ed consult tion
nd/or c re o the tient without w sting the ti e o the reci ient o
the letter.

Indications
When it is necess ry to rovide written su ry o tient’s ex i-
n tion ndings to nother ro ession l who will beco e involved in the
c re o the tient.

Equipment
• Word rocessor.
• St tionery with the letterhe d o the re erring r ctice or clinic.

Setup
A co y o the tient record or other notes y be hel ul re erences to
h ve t h nd.

St e p b y St e p Pro ce d u re
1. Begin with st nd rd business-letter or t nd s lut tions (eg, d te
o the letter, ddress o the reci ient o the letter).
2. Begin the body o the letter with st nd rd business s lut tion, such
s “De r Dr Xyz”).
3. List the tient’s n e, d te o birth, chie co l int, re son or
re err l, d te o oint ent with the consult nt.
4. T is should be ollowed by n rr tive, such s “(Ms, Mr, or Mrs)
( tient’s ull n e), ( ge)-ye r-old ( le, e le), resented to
( y o ce, the * * He lth Clinic, etc) on (d te) with in co l int
o (concise st te ent o the tient’s chie co l int or which the
consult tion is being requested).”
20 Chapter 1

5. T e next sentence should then st te the ur ose o the consult -

tion or re err l, “We re re erring hi /her to you to st te the ur-
ose o the re err l (eg, or consult tion concerning his... to rule
out..., or tre t ent o ..., or urther di gnostic worku ..., or urther
ev lu tion o ...,” nd so on ). Be s eci c, be concise, identi y s eci c
di gnoses bout which you re concerned, nd st te s eci c tests
you wish to h ve er or ed (eg, “ or electroretinogr hy”).
6. I the tient lre dy h s n oint ent to see the consulting doc-
tor, the next sentence should s y, “M- h s n oint ent to see you
t (indic te the ti e nd d te).”
7. A li y the tient’s chie co l int by su lying the ollowing
d t :
• i e o onset (eg, it beg n 2 d ys go in the evening)
• Dur tion (eg, it h s l sted 2 d ys)
• Descri tion o ti e-course (eg, co es nd goes, getting ste dily
worse, etc)
• Acco nying sy to s or signs observed by tient or by you
(eg, qu lity o the disch rge, in)
8. Provide ddition l relevant in or tion, including relev nt neg -
tives, ro the ex in tion nd c se history, such s:
• Best-corrected VA. T is is relev nt so o ten in eye c re th t you
should include it even i you re not sure it is relev nt. I re er-
ring to nother eye-c re rovider, include your best re r ction
long with the VA. O it the re r ctive rescri tion i re erring to
so eone who is not n eye-c re s eci list.
• Note: Un ided VA is r rely relev nt.
• In or tion obt ined ro extern l observ tion, slit l , etc.
• P tient’s edic l history: syste ic illness(es), edic tions,
recent ch nges in ctivities: only i relev nt to the resent tion
(eg, tient h s se son l llergies).
• F ily ocul r nd edic l history only i relev nt.
9. Finish with n ex ression o your reci tion or the consult nt’s
willingness to rtici te in the c re o your tient nd request
eedb ck bout the results o the urther testing or tre t ent.
10. Sign your n e to the letter.

Recording
Ret in co y o the letter in the tient’s clinic record or le.
 Patient Communication 21

Notes:
• Do include other pertinent in or tion.
• Do include relev nt neg tives.
• Do not include in or tion th t is irrelevant to this resent tion

• So e r ctices re er to receive co ies o FAX versions o your let-

ter nd/or ctu l tient record or notes. I you re sending co ies o
your notes, ention this in the re err l letter. It is lso ro ri te to
e- il your consult ncy or re err l letter rovided you c n con dently
co ly with HIPAA.
• T e key to good re err l letter is to concisely re ort everything th t is
relev nt so the consult nt cquires quick nd in-de th underst nd-
ing o the tient’s roble , but to re ort nothing th t is irrelev nt
so s not to ob usc te the ur ose o the re err l or to w ste the con-
sult nt’s ti e trying to nd the i ort nt in or tion in the idst o
irrelev ncies.
• Knowing wh t is relev nt nd wh t is irrelev nt is the di cult rt, but
th t is the key to writing n e ective nd concise re err l letter.

Example #1
Se te ber 6, 2015
LP, OD
XXX YYY Co unity He lth Center
Street ddress
City, st te, zi code
Re Ms SS
dob A ril 15, 1925
Chie Co l int: reduced ne r visu l cuity with her gl sses
Re: ev lu tion or low vision services
A oint ent: October 3, 2015, 9:30 a m

De r Dr P:
I re erring Ms SS, 90-ye r-old e le, to you or low vision ev lu-
tion. During our ex in tion o Ms SS on Se te ber 5, 2015, we ound
severe cul r degener tion in both eyes nd gr de 2 erent u ill ry
de ect with disc llor in the right eye. Her best-corrected dist nce visu l
cuity w s OD light erce tion nd OS 20/400, with no i rove ent
with inhole. We g ve Ms SS ne r vision rescri tion o “b l nce” OD
(LP) nd + 4.50 s h OS (20/200 @ 16”).
22 Chapter 1

She is currently being ev lu ted by her ri ry c re hysici n ol-

lowing high r ndo seru glucose test result but does not h ve di g-
nosis o di betes t this ti e.
Ms SS will be cco nied by her d ughter when she co es to
see you.
T nk you or seeing this tient nd ev lu ting her suit bility or
low vision ids. Ple se tell us your ssess ent nd gener l l ns or her.

T nk you.
Sincerely,
D niel Kurtz, OD, PhD

Example #2
Se te ber 6, 2015
JH, MD
XXX YYY Co unity He lth Center
Street Address
City, st te, zi code

De r Dr JH:
Ms BC, 19-ye r-old C uc si n e le college student, resented to y
o ce or ex in tion t the O to etry Service t XXX YYY Co unity
He lth Center on Se te ber 5, 2015, with chie co l int o inter it-
tent vision loss nd f shes o light in her right eye since she w s hit in
the he d during b sketb ll r ctice 3 d ys go. She h s n oint ent
to see you tod y t 2:45 pm.
Our dil ted ex in tion reve led rheg togenous su erior te -
or l retin l det ch ent three disc di eters ro the o tic nerve he d
nd two disc di eters in size. Ms BC’s best-corrected visu l cuity t
dist nce tod y w s 20/20 in her right eye nd 20/20 in her le t eye we r-
ing her gl sses o OD − 6.00 nd OS − 6.50.
Ms BC will be cco nied to your o ce by her boy riend. Ple se
tell us your ssess ent nd tre t ent l ns or her nd how you would
like to coordin te with e or her ollow-u c re.
T nk you or seeing this tient on n e ergency b sis. I look or-
w rd to he ring ro you.

Sincerely,
N ncy B. C rlson, OD
 Patient Communication 23

REP O RTING ABUSE

Purpose
o rotect tients ro h r inf icted by others.

Indications
In the United St te, l ws nd te the re orting o buse or neglect o
vulner ble o ul tions such s children nd the elderly. In gener l, it is
required to re ort even the sus icion o buse. T e o to etrist h s to be
knowledge ble o loc l nd st te l ws to deter ine or who nd under
wh t circu st nces he is nd ted re orter.

Equipment
T e s eci c or s used to re ort buse re usu lly nd ted by the rel-
ev nt jurisdiction. T e r ctitioner should h ve su ly o such or s
re dily v il ble in the o ce. T ese or s v ry ro st te to st te.

Setup
T e r ctitioner is ex ected to h ve knowledge o the signs nd sy -
to s o buse.

St e p b y St e p Pro ce d u re
(Ma ssa ch u se t t s)
1. H ve v il ble ll necess ry re orting in or tion: the tient’s ull
n e, d te o birth, ddress, hone nu ber, s well s the ty e o
buse you sus ect nd wh t you observed in the tient to ke you
sus icious.
2. C ll the relev nt hotline or the tient nd jurisdiction.
3. Answer ll questions.
4. Obt in nd record the n e o the erson to who you g ve the
verb l re ort.
5. Within 48 hours, le written version o the re ort to the ro ri-
te rty.
24 Chapter 1

Recording
• Your ex in tion record should include ll the relev nt ndings th t
de you sus ect buse.
• A co y o the ctu l re ort does not go into the tient’s clinic l record,
but ust be ke t in se r te, con denti l le.

Example
S e king to the Abuse Hotline in your jurisdiction: “My tient is
9-ye r-old le. He c e or n eye ex in tion this ternoon t
1 o’clock. He w s cco nied by his ther. He resented with round
lesion on his le t u er eyelid. It w s bout the di eter o cig rette.
I did not observe other signs o tr u to his ce or eyes, but the child
w s very reticent. I could not gure w y to t lk to hi se r ted ro
his ther.”

Notes:
In gener l, the go l o re orting is to revent urther h r to the tient
nd to ini ize ddition l risk to the tient.
Whether or not nd how you in or the tient nd ily e bers
th t you h ve led re ort de ends on the circu st nces. Above ll else,
do no h r .
Another random document with
no related content on Scribd:
The Project Gutenberg eBook of Christmas
carols
 This ebook is for the use of anyone anywhere in the United
States and most other parts of the world at no cost and with
almost no restrictions whatsoever. You may copy it, give it away
or re-use it under the terms of the Project Gutenberg License
included with this ebook or online at www.gutenberg.org. If you
are not located in the United States, you will have to check the
laws of the country where you are located before using this
eBook.

Title: Christmas carols

Old English carols for Christmas and other festivals

Contributor: Lucy Etheldred Broadwood

Editor: L. Edna Walter

Illustrator: J. H. Hartley

Release date: December 23, 2023 [eBook #72492]

Language: English

Original publication: New York: The MacMillian Company, 1922

Credits: Robin Monks, Linda Cantoni, and the Online Distributed

Proofreading Team at https://www.pgdp.net (This file
was produced from images generously made available
by The Internet Archive)

*** START OF THE PROJECT GUTENBERG EBOOK CHRISTMAS

CAROLS ***
Transcriber’s Note: In the HTML version of this e-book, you can click on the [Listen] link to
hear an mp3 audio file of the carol. Click on the [MusicXML] link to download the notation
in MusicXML format. These music files are the music transcriber’s interpretation of the
printed notation and are placed in the public domain.
CHRISTMAS CAROLS
CONTENTS

IN THE SAME SERIES.

ENGLISH NURSERY
RHYMES.

Selected and Edited by L. EDNA

WALTER. B.Sc.
Harmonized by LUCY E.
BROADWOOD.
Illustrated by DOROTHY M.
WHEELER.
Containing 32 full-page
illustrations in colour, decorative
borders, and about 60
decorative headings and tail-
pieces. Demy 4to (11½ × 8¾
inches).

SONGS FROM
ALICE IN
WONDERLAND
AND
 THROUGH THE
LOOKING-GLASS.
Words by LEWIS CARROLL.
Music by LUCY E. BROADWOOD.
Illustrations by CHARLES
FOLKARD.
Containing 12 full-page
illustrations in colour, decorative
borders, and many small
illustrations. Demy 4to, cloth.

Published by A. & C. BLACK, Ltd., 4, 5, & 6, Soho

Square, London, W.1.
 CHRISTMAS
CAROLS
Old English Carols for
Christmas and other
Festivals.
SELECTED AND EDITED BY
L. EDNA WALTER M.B.E., B.Sc.,
A.C.G.I.

HARMONISED BY
LUCY E. BROADWOOD
ILLUSTRATED BY
J.H. HARTLEY

NEW YORK: THE MACMILLAN COMPANY,

FIFTH AVENUE.
LONDON: A. & C. BLACK, LIMITED, 4, 5, & 6,
SOHO SQUARE.

This book is dedicated to

 ELIZABETH
because she rather liked it.

Published, Autumn, 1922.

 FOREWORD

Special times or events have been celebrated from time immemorial

by feasting, dancing, and singing. Often the dancers formed a ring
and sang as they danced, first the dance and later the song being
called a carol. The carol was not always strictly religious, although in
the old times both the singing and dancing often took place in
cathedrals and churches. Some of the carols that we still know are
connected with times before the Christian era. They have now lost
their dance and the melody has changed, but the ideas are very
ancient. The Holly and the Ivy suggest the old Druids, and we still
put up Holly and Ivy in our houses just as people did before the time
of Christ. We put them up at Christmas, and we sing the carol at
Christmas—but the idea at the back of it is older than Christmas, for
the Church accepted all that was found to be of value in the old
customs, and adapted them to set forth the newer faith. The carrying
in of the Boar’s Head is an old ceremony, too. It was considered a
Royal Dish, and Henry II. ordered it to appear at a special feast
which he gave in honour of his son.
In the old days people thought of the New Year as the time when the
trees and flowers began to come out—that is about May Day—so
the May Day Carols celebrate the New Year’s Day of ever so long
ago. Gradually, however, carols have centred more and more round
events in the life of Christ, and especially round the wonderful story
of His Birth. Many of them have just been handed on from one
person to another through hundreds of years, some have only been
written down at all during the last century. For example, the version
given here of the “Black Decree” was sung into my phonograph by
an old man of seventy-five. All the carols chosen for this book are
those which have been sung through many, many years at times of
festival and mirth (note how often food and drink are referred to), so
don’t expect them to be pious in the modern way or to be at all like
our present-day hymns.
The Publishers desire to acknowledge their indebtedness to Miss
Lucy E. Broadwood for kindly permitting them to reproduce in this
collection the following carols from her ENGLISH TRADITIONAL
SONGS AND CAROLS: “King Pharaoh,” “The Moon Shines Bright,”
“The Sussex Mummers’ Carol,” and “I’ve been Rambling all the
Night.” Also to Miss A.G. Gilchrist for the “Pace Egging Song” and
“The Seven Joys of Mary,” and to the Rev. S. Baring-Gould and his
publishers (Messrs. Methuen & Co., Ltd.) for the “Somersetshire
Wassail” from A GARLAND OF COUNTRY SONG.

CONTENTS
PAGE
GOOD KING WENCESLAS 12
AS JOSEPH WAS A-WALKING 14
CHRISTMAS DAY IN THE MORNING 15
GOD REST YOU MERRY, GENTLEMEN 16
THE HOLY WELL 18
THE FIRST NOWELL 20
THE CHERRY TREE CAROL 23
DIVES AND LAZARUS 24
THE HOLLY AND THE IVY 25
A VIRGIN MOST PURE 26
THE WASSAIL SONG. Part I. 28
THE WASSAIL SONG. Part II. 29
THE BOAR’S HEAD CAROL 30
ALL THAT ARE TO MIRTH INCLINED 33
KING PHARAOH: Part I. The Miracle of the Cock 34
KING PHARAOH: Part II. The Miraculous Harvest 37
THE BLACK DECREE 38
SOMERSETSHIRE WASSAIL 40
A CHILD THIS DAY IS BORN 43
THE MOON SHINES BRIGHT 44
A CAROL FOR TWELFTH DAY 47
THE LORD AT FIRST DID ADAM MAKE 48
THE SEVEN JOYS OF MARY 50
THE SUSSEX MUMMERS’ CAROL 52
AS I SAT ON A SUNNY BANK 53
PACE-EGGING SONG 54
I’VE BEEN RAMBLING ALL THE NIGHT 57
GOOD CHRISTIAN MEN, REJOICE 58
 ILLUSTRATIONS IN COLOUR
BY

J.H. HARTLEY

Page and Monarch forth they went Frontispiece

PAGE

In fields where they lay keeping their sheep 21

Mary said to cherry tree, “Bow down to my
22
knee”
The Boar’s head in hand bear I 31
Let all your songs and praises be unto His
32
Heavenly Majesty
“Say, where did you come from, good man?” 35
“Come, husbandman,” cried Jesus, “cast all your
36
seed away”
O maid, fair maid, in holland smock 41
Glad tidings to all men 42
Awake, Awake, good people all! 45
For I perforce must take my leave of all my
46
dainty cheer
Oh, here come we jolly boys, all of one mind 55
A branch of May, my dear, I say, before your
56
door I stand
Now to the Lord sing praises, all you within this On the
place Cover
Good King Wenceslas