Clinical Procedures For Ocular Examination 4Th Edition Nancy B Carlson Full Chapter

Clinical Procedures for Ocular
Examination 4th Edition Nancy B.

Carlson
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Clin ical
Proced ures
for Ocular
Exam ination
NOTICE
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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
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Preface xiii
Introduction xv
Acknowledgments xix
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1 Patient Communication 1
Introduction to Patient Communication 2
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Case History 5
Presenting Examination Results to a Patient 11
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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
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Introduction to the Entrance Tests 30
External Observation 34
Visual Acuity (VA): Minimum Legible 36
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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
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Sta Optometrist
East Boston Neighborhood Health Center
O
East Boston, Massachusetts
Marion M.W. Hau, OD, FAAO

Adjunct Clinical Faculty
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Sta Optometrist
U
East Boston Neighborhood Health Center
East Boston, Massachusetts
Ronald K. Watanabe, OD, FAAO

Associate Pro essor o Optometry
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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.
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.
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Patient
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Communication
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Nancy B. Carlson, OD, FAAO, and
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Daniel Kurtz, OD, PhD, FAAO
H
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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.
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?
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?”
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.
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.
“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.
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
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.
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
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.
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
h ve t h nd.
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.
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
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.
(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 .
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CHAPTER XXXIII
ARGENTINA: AREA, HISTORY, GOVERNMENT, POPULATION, ETC.
Argentina, from the south the first country on the Atlantic coast, the second largest
in South America, has been called not only the most progressive on that continent
but the richest per capita on the globe.
Area, Population, Boundary
Area. Occupying the greater part of the southern extremity of the continent,
Argentina is nearly 2300 miles long, with an extreme width just south of Paraguay of
930 miles. Nearly as broad in the centre, the country below the Province of Buenos
Aires narrows rapidly towards the south. Extending from 22° to 56° S. Lat., it has an
area of 1,154,000 square miles, equal to about one-third of Europe and more than
one-third of the United States: approximately that of the part east of the Mississippi
River with Texas in addition.
Population. In 1919 the inhabitants were reckoned as over 8,000,000. In 1921
there may be 9,000,000, at least 8,500,000; more than seven to a square mile.
Ninety per cent of the population is found in 40 per cent of the territory, although the
rest may be the richest.
Boundary. While boundary disputes have occurred with her neighbors as in the
case of the other South American countries, all of Argentina’s have been amicably
settled by arbitration or agreement. Bolivia and Paraguay, a trifle of Brazil and of
Uruguay are on her northern border, the last three are on the east; a long stretch of
the Atlantic Ocean is at the southeast; at the south is a bit of Chile, which country
extends along the entire western boundary.
History
While a few settlements were made in Argentina (the country was discovered in
1508) from a half to a whole century earlier than those of our own coast cities, the
country was so hampered by restrictions of immigration and commerce, exceeding
those placed on the West Coast, that its growth was stifled. After proclaiming
independence it suffered for years from internal disorders, but during the last half
century its development has been phenomenal. In 1535, the same year that Pizarro
founded Lima, Pedro de Mendoza landed on the south shore of La Plata River and
made at Buenos Aires the first settlement on this part of the continent. But the
Indians of the East Coast were more savage than most of those on the West, and a
few years later, after many colonists had been killed, the little town was abandoned.
In 1580 it was re-established by Juan de Garay, after a number of settlements had
been made in other districts, as at Mendoza, Santiago, Tucumán, and Córdoba.
Previously attached to the great dominion ruled from Peru, in 1776 a Viceroyalty was
established at Buenos Aires.
In 1806-07, during a European war, the city was attacked by British forces which
were ultimately obliged to retreat. By reason of this success the colonists became
more self reliant, and May 25th, 1810, they formed a junta of citizens who took from
the Viceroy the control of the Government. While this was done in the name of
Ferdinand VII, the date is regarded as the birth of their independence. July 9th, the
date of the Proclamation of Independence by an Argentine Congress in 1816, is
alike celebrated. Not being at first obliged to fight a Spanish army in Argentina, some
of the colonists under General San Martín kindly assisted in liberating Chile and later
Peru from the Spanish yoke. Meanwhile Congress having declared independence
had made Buenos Aires the seat of government. Yet during civil strife which for
many years continued, the Province of Buenos Aires was at one time an
independent State, separated from the Argentine Federation. In 1861 matters were
finally settled and reunion was established. In the latter part of that decade occurred
the Paraguayan War, which was followed by some internal difficulties; but with many
able leaders, growth and prosperity for the most part have since prevailed.
Government
The Government of Argentina is that of a Federal rather than a Centralized

Republic, although in fact the President has a preponderating influence, with certain
rights of intervention in the affairs of any Province. The constitution following quite
closely that of the United States, there are the three usual branches. The President
of the Republic, elected for a term of six years, is not immediately eligible for
reëlection. Congress has a Senate of 30 members and a Chamber of Deputies of
158.
The Provinces have each a Governor and a Legislative Assembly of its own
choosing. The Governors of Territories are appointed by the President. A Territory
has the privilege of becoming a Province when it has 50,000 inhabitants, but for
some reason this right has not been exercised. The Federal District, the City of
Buenos Aires, is governed by a Mayor and a Council elected by tax paying
residents.
Male citizens have the right of suffrage at the age of 18. The passage of a law, at
the initiative of President Dr. Roque Saenz Peña, made the exercise of the franchise
obligatory upon all native born citizens, and on foreigners after two years of
residence, thus inaugurating a great change. At the first election under the new law
in 1916, Dr. Hipolito Irigoyen of the Radical Party was chosen President by the
Electoral College, the first person outside of the previously governing class to be
elected.
There are 14 Provinces corresponding to our States, and 10 Territories, besides
the Federal District, Buenos Aires. The best obtainable figures of the area and
population of the Provinces and Territories with those of the population and altitude
of their capitals follow. The Provinces are named in order from the north across from
west to east in four rows, thus beginning at the northwest:
Provinces Area, Population Capitals Population Altitudes, Distance
in in feet from
square Buenos
miles Aires, in
miles
Jujuy 15,800 78,000 Jujuy 25,000 3,675 937
Salta 62,160 160,000 Salta 40,000 5,200 925
Catamarca 37,000 110,000 Catamarca 15,000 1,663 833
Tucumán 10,400 350,000 Tucumán 100,000 1,522 718
Santiago 75,000 265,000 Santiago 35,000 593 630
del Estero
San Juan 38,000 130,000 San Juan 20,000 2,077 750
La Rioja 38,000 85,000 La Rioja 13,000 1,650 506
Córdoba 67,000 750,000 Córdoba 135,000 1,428 432
Santa Fé 50,000 1,000,000 Santa Fé 80,000 52 298
Corrientes 33,000 400,000 Corrientes 40,000 .... 838
Entre Rios 30,000 450,000 Paraná 80,000 .... 356
Mendoza 55,370 300,000 Mendoza 65,000 2,470 651
San Luis 30,000 127,000 San Luis 25,000 2,513 488
Buenos 117,800 2,200,000 La Plata 135,000 34
Aires
Federal 72 1,800,000 Buenos 1,800,000
District Aires
Territories
Los Andes 35,000 2,600 San 1,000 11,000 1,056
Antonio
Formosa 44,000 52,000 Formosa 4,200 208
Chaco 386,000 65,000 Resistencia 12,000 144 840
Misiones 11,880 52,000 Posadas 10,000 407 700
Pampa 58,000 110,000 Sta. Rosa 5,400 .... 376
Central de Toay
Neuquen 42,470 31,500 Neuquen 4,500 870 740
Rio Negro 77,220 42,000 Viedma 7,500 .... 577
Chubut 946,000 23,000 Rawson 8,000
Santa Cruz 111,000 10,000 Puerto 3,000
Gallegos
Tierra del 8,300 2,500 Ushuaiá 1,600 .... 1,600
Fuego
The Territories are four at the extreme north, and the remaining six south of a line
from Mendoza to the City of Buenos Aires.
Population
With an estimated population of at least 8,600,000, Argentina suffered a large

decrease in its previously great immigration, as well as a considerable emigration,
during the Great War, which in other ways at first gravely interrupted its prosperity. In
the 50 years preceding 1912, over 4,000,000 immigrants had entered the country,
more than 3,000,000 remaining. Of those entering, the Italians numbered over
2,000,000, Spanish over 1,000,000; those of any other nationality except 200,000
French were each fewer than 100,000. The Negroes and the Indians of earlier days,
except perhaps 100,000 of the latter in remote sections, have become assimilated or
killed. The Chaco Indians, it is said, are not difficult to domesticate, especially the
Tobas living near the Bermejo River. The people are generally considered the most
homogeneous of any of the South American countries except Uruguay, as nearly all
are of European descent. Here as in Chile we observe the effect of location in the
temperate zone, all of the country being so situated except a small section at the
north.
A great preponderance of population is in the cities, one fifth of the whole in the
city of Buenos Aires. While the people are proud of its greatness they have begun to
realize that this concentration is not for the general welfare. Forty-three per cent of
the urban and 25 per cent of the entire population is said to be foreign born. Aside
from the Capital of the Republic, there are in the Province of Buenos Aires five cities
with a population above 50,000 and a dozen more with over 30,000. In Buenos Aires
there is a large social circle of wealth and culture, as well as a laboring class with
strong radical elements.
Education
Education receives much attention and $25,000,000 are annually devoted to this
purpose. Primary education is free and called compulsory. There are primary and
secondary schools, Universities, Normal Schools, Technical Colleges, Schools
Agrarian and Veterinary, of Viticulture, Mines, Arts, and Music. The Universities are
at Buenos Aires, La Plata, Córdoba, Tucumán, and Santa Fé; there are three
Schools of Commerce at Buenos Aires, and one each at Rosario and Concordia. In
various towns are private schools, some English and American. The schools
generally are of high grade, and it was said by a former Argentine Ambassador,
corroborated by other persons familiar with Buenos Aires, that their school children
knew more about the United States than most of our business men and Members of
Congress knew about Argentina. Many of their school buildings, though usually
smaller than ours, are superior in architectural beauty.
Press, Religion, etc.
Press. As to the Press, Buenos Aires can boast of two of the wealthiest and best
newspapers in the world, the Prensa and the Nación. Not many years ago, the
Prensa contained as many pages of telegraphic and cable dispatches as any New
York paper had columns, and articles superior in literary and intellectual ability. It was
pronounced by some Europeans the best newspaper in the world. Buenos Aires has
other papers of almost equal merit, besides several in English and in other foreign
languages.
Religion. In Religion there is entire freedom, but the President must be of the
Roman Catholic Church. One in Buenos Aires no longer sees women with manta or
lace veil over their heads for church going as on the West Coast.
Telegraph. Argentina has about 45,000 miles of telegraph lines, ample cable
connections, and a dozen or more wireless stations. Telephones are in general use
in all the large cities and in many smaller places.
Money current in Argentina is paper, with coins for small change. A paper peso is
equal to .44 of a gold peso, which is a little less than an American dollar, 96.48
cents; but for practical purposes except in large transactions a paper peso may be
reckoned as 44 cents.
CHAPTER XXXIV
ARGENTINA: PHYSICAL CHARACTERISTICS
Argentina is oftenest thought of as a country of broad plains, but

while a large portion of the country is of this character there are three
distinct sections: the Mountains, the Plateau, and the Plains, with
several subdivisions.
Mountains
We know that the Andes form the western boundary of the country
for the entire distance from north to south, and that some of the
loftiest summits including the highest, Aconcagua, are in Argentine
territory; but east of the great Cordillera, which as already noted is
less steep on this than on the Chilian side, are other ranges of the
same and other systems. Two or three extend from the Bolivian
plateau, and farther down spurs run out from the main chain. In
Córdoba are three ranges separate from the Andes, with one peak
above 9000 feet; a peak in San Luis is over 7000. Near the sea in
the Province of Buenos Aires, are low mountains, mere hills in
comparison, one reaching a height of 4000 feet; and in Misiones are
spurs from the Brazilian Coast Range, the highest a hill about 1300
feet.
Plateaus
There are plateaus in the north among the mountains, but the
distinctive Plateau Region is in what used to be called Patagonia, a
name not so much employed in Argentina as formerly. This section is
arranged in terraces, falling from the Andes to the east, the western
part called the Plateau, having an altitude of 2000-500 feet; near the
sea it goes from the latter figure to sea level. The Plateau has many
sterile plains, some strewn with boulders, others with dunes of sand;
also good grazing and forest land, and some suitable for farming.
Lakes. The Andine lakes in the Patagonia section are of glacial
origin, with much scenic beauty. One of these, Nahuel-Huapi, 40
miles long, is said to be 1000 feet deep. Lake Buenos Aires, partly in
Chile, is 75 miles long. The lakes number more than 400; at the
north are many swampy lagoons.
Plains
The plains, once under the sea, and now for the most part less
than 500 feet above it with a very gradual rise from the ocean to the
Andes, extend from the Pilcomayo River, the boundary line with
Western Paraguay, on the north, to the Rio Negro on the south. The
northern part belongs to the Gran Chaco, swampy and partly
wooded, with so slight a southeastward slope that large spaces are
regularly flooded in the rainy season. South of the Bermejo River
which is parallel with the Pilcomayo, the land is higher, some of it
800 feet above the sea, and the forests are heavier; but there are
still marshy lagoons. Then come open grassy plains with occasional
salt pans. The section between the Paraná and Uruguay Rivers,
called the Argentine Mesopotamia, in Corrientes at the north is of
somewhat similar character, but has higher land in Entre Rios at the
south. The remainder of the plain is the real Pampa, the part west of
the Paraná River and below that extending to the ocean, mainly,
treeless and grassy. It includes the Provinces of Buenos Aires, Santa
Fé, Córdoba, San Luis, Mendoza, and the Territory Pampa Central.
In the far west is a depressed region containing some lakes and
swamps with no outlet, but with too little rain.
Rivers
The rivers of Argentina are of great importance, being navigable

for immense distances. Chief among them are those of the System
of La Plata, this river being formed by the union of the Paraná and
the Uruguay: a great river indeed, the outflow of water being 80 per
cent more than that of the Mississippi, and the drainage basin
covering 1,500,000 square miles. The Paraguay, Pilcomayo,
Bermejo, Salado del Norte, Iguassú, and many others belong to this
basin. The Iguassú, though not navigable except for a mile from the
Paraná, is world famed for its magnificent waterfall, surpassing
Niagara in height, width, and most of the year in volume of water;
while it is rendered altogether incomparable by the extraordinary
beauty of its setting.
The Plata River, 250 miles long, is much like a gulf, having a
width of over 100 miles at its mouth between Capes Santa Maria in
Uruguay and San Antonio in the Province of Buenos Aires. The
Paraná River with many tributaries has two principal sources well up
in Brazil and a total length of 2600 miles, about one half in or on the
border of Argentine territory. At first flowing south it turns west
between Argentina and Paraguay, and after receiving the Paraguay
River again flows south in Argentina. From January to September,
nine months, it is open to trans-Atlantic steamers to Rosario; for
6000 ton vessels, 12 foot draft, to Paraná or Colastiné, the port of
Santa Fé; for smaller steamers up the Alto Paraná nearly to the Falls
of La Guayra, a little above the northeast extremity of Argentina.
Steamers of 7 foot draft go up the Paraguay to Asunción and smaller
steamers to Corumbá in Matto Grosso, Brazil, 2000 miles from
Buenos Aires, and beyond to Cuyabá. Forty-two miles up stream
from Buenos Aires is Ibicuy, a port where a steam ferry operates,
carrying trains to and from Zarate on the Buenos Aires side.
A few small streams flow into lagoons with no outlet; a number in
the Buenos Aires Province flow into the Atlantic. Farther south are
rivers of more importance, among these the Rio Negro and the
Colorado, the only ones of this section easily and regularly
navigable.
Climate
The climate of Argentina naturally varies on account of its wide

range of latitude, as well as from increasing altitude in the
mountainous section. The prevailing winds, the mountain barriers,
and the sea also modify the climate in restricted locations. The
conditions of temperature and rainfall are different from those in the
northern hemisphere. Thus Tierra del Fuego and the south main land
are more habitable than corresponding latitudes in Labrador, partly
by reason of a southern equatorial current; it is an excellent region
for sheep raising. At the same time it is colder than at similar
latitudes of Western Europe, as the prevailing west winds are chilled
by the mountains.
In the Provinces of Buenos Aires, Mesopotamia, and Santa Fé the
average temperature in January is 72°, the maximum 97°-107°; the
annual at the Capital city is 62.6°, farther south 42°. In Buenos Aires
it may rain at any time, but the greatest precipitation is in the
summer and fall. In summer there is a land breeze by day and a sea
breeze at night. The north winds are hot and unhealthful, ending in
violent storms. Southwest winds, the pamperos, which are gales,
sometimes hurricanes, are invigorating. The central region has
greater extremes of daily heat and of annual temperature, the widest
at Córdoba; Santiago is the warmest of the Provinces. In the city of
Buenos Aires the mercury in summer may reach 107°; in winter it
goes below freezing only a few times, but there is a peculiar chill in
the atmosphere which causes strong men, who never did so in New
York or Boston, to wear heavy woolen underwear. The country has
200 meteorological stations.
CHAPTER XXXV
ARGENTINA: THE CAPITAL, INDIVIDUAL PROVINCES AND TERRITORIES
The Capital
Buenos Aires, the metropolis of South America, the largest city

on that continent, and fourth in all America, has also a wide
reputation as the second Latin city in the world. Its population is well
towards 2,000,000, its area is more than double that of Paris. All its
splendors may not here be rehearsed. The attractions of its 74
beautiful parks and plazas, its fine avenues, its magnificent Capitol
and other public buildings, its beautiful opera house, almost the
finest in the world, the many artistic and sumptuous residences, the
excellent hotels, with many other admirable features make it a city
delightsome to tourist and resident. The city is spoken of as a very
expensive place to live, but in ordinary times, some things were
cheaper than in New York while others were much dearer. Rents
were high, the prices of fruit and vegetables, etc. In general, in other
places in Argentina prices were higher for poor accommodations
than in Europe before the War for far better. As a business centre,
Buenos Aires naturally is of prime importance for the southern part of
the continent. From here it is easy to visit Uruguay, Paraguay, and
since the opening of the Trans-Continental, Chile also; while in every
direction railways radiate to the chief cities of Argentina, even to
those that are accessible by boat.
Provinces and Territories
We may perhaps get the geography of the Republic most

accurately if we begin near the countries with which we are familiar
at the northwest, and come from the outskirts to the commercial and
political centre of the Republic.
Jujuy in the northwest corner naturally has on the north Bolivia,
which comes down a little on the west, where it is followed by a bit of
Chile, then by the Argentine Territory of Los Andes. The last is also
on the south with a longer stretch of the Province of Salta, which
extends along the entire east border as well. Here in Jujuy we are
again among the mountains, for three ranges come from Bolivia,
passing on through Salta at the south. The puna at the northwest is
nearly 12,000 feet high; on this arid plateau are two salt lakes. The
mountains reach an altitude of 15,000-20,000 feet. There are low
valleys too, where there is mixed farming, not many cattle. Above
are the wild vicuñas, guanacos, and chinchillas, as in Bolivia, and
various minerals including gold, silver, petroleum, etc., not much
worked. Sugar refining and wine making are important.
The capital, Jujuy, is in a rich and picturesque valley as low as
3675 feet, from which the railway climbs rapidly to La Quiaca, on the
border of Bolivia.
Salta extends along the southern border of Bolivia from Jujuy to
Formosa and Gran Chaco on the east; on the south are Santiago,
Tucumán, and Catamarca; on the west Los Andes with Jujuy. The
north and west sections are mountainous and cold, with high table-
lands and fertile valleys; in the east the terrain comes down to the
tropical country, where in places there are forests though some
sections are hot and dry. Temperate and tropical products are found
here; in the mountains are many varieties of minerals. Cattle are
raised, some being driven over the mountains into Chile; hence the
proposed railway to Antofagasta.
Salta, the capital, with an agreeable climate, is a considerable
town, important as a railway centre and with trade of various kinds.
Los Andes, a Territory at the west, is a bleak mountain region,
once belonging to Chile, and a part of the Puna de Atacama. It is but
slightly explored, dry and sandy, with salt marshes; it appears to be
rich in minerals.
San Antonio, the capital, is a place of small importance not on a
railway.
Formosa and Gran Chaco, Territories east of Salta, are precisely
opposite to Los Andes in character. Formosa has Bolivia on the
northwest; on the long northeast boundary the Pilcomayo River
separates it from Paraguay, which is also at the southeast, there
separated by the Paraguay River. On the southwest the Bermejo
divides it from the Chaco, while Salta is west.
The Chaco of similar shape has at the southeast a bit of the
Paraguay River and country, and below a little of Corrientes across
the Paraná. Santa Fé and Santiago del Estero are on the south, the
latter with Salta west. These two Territories are truly semi-tropical,
flat or undulating, sloping to the southeast, partly covered with dense
forests, not thoroughly explored; partly with open plains, lakes and
marshes, many rivers, much very fertile land suited to tropical
products, some of which are grown, and excellent pasturage where
herds of cattle are bred, horses, sheep, and goats. The quebracho
industry for tannin, and the production of sugar are important, with
some cotton plantations and castor oil factories.
Formosa, capital of that Territory, is important as a port, shipping a
variety of products down the river, and as the terminus of a railway to
go to Embarcación, opening up this rich Territory.
Resistencia, capital of the Chaco, on the Paraná River, is of equal
and growing importance. It has railway connection with Santa Fé.
Misiones, at the extreme northeast of Argentina, is a Territory of
some similarity to the two just mentioned, but with greater attractions
and merit. Long and narrow, it extends up between Paraguay and
Brazil, separated from the former country by the Paraná River on the
west, from the latter by the Iguassú on the north and by the Uruguay
on the southeast, Brazil enclosing it on the north, east, and south.
Misiones joins the rest of Argentina only by a small strip along the
Province Corrientes on the southwest. Misiones is a subtropical
garden largely covered with beautiful forests where the picking of
mate leaves is a leading industry; there is some timber extraction,
and saw mills. It is an undulating plain with ranges of low mountains
and hills. There are various minerals, and in open spaces some
cattle.
Posadas, the capital, is a pleasant town, important as a railway
and steamboat junction.
Catamarca, a Province again at the west, we find bordering on
Chile, south of Los Andes and Salta, with Tucumán and Santiago
east, and Córdoba and La Rioja south. The Province is largely
mountainous, one peak in the eastern range, Aconquija, being over
15,000 feet. Some short torrential streams, formerly disappearing in
salt marshes, are now utilized for irrigation. Cereals and other
agricultural products, also cattle are raised. The Province is rich in
minerals, with workings in gold, silver, copper, iron, lead, and salt.
Catamarca, the capital, on the Catamarca River, is of some
importance as the centre of a rich agricultural district.
Tucumán, east of Catamarca, south of Salta, with Santiago east
and south, is the smallest of the Provinces, but more varied in
character than most. It has snow-capped mountains, and well
watered valleys and plains, some quite tropical; with agriculture, or
with dense forests of quebracho, oak, pine, etc. There is activity in
sugar refining and tanning, with steam saw mills, and with cereals
and fruit.
Tucumán, the capital, is a large city, especially important, as the
center of the sugar industry, and with many varied interests.
Santiago del Estero, more than seven times the size of Tucumán,
is south of Salta and the Chaco, with Chaco and Santa Fé east,
Córdoba south, and Catamarca and Tucumán west. Mostly in the
lowlands, it is in places covered with forest; in other parts is a salt,
clayey, partial desert which is now being crossed by railways. Here
woodmen cut out quebracho trees, though in this section it does not
rain for 11 months in the year, nor can wells, they say, be dug to get
water unless they are over 3000 feet deep, as water obtained higher
is salt. The summer temperature by day runs nearly to 120° F., while
in winter it falls to 50°, with cool nights always. Water difficulties are
obviously great, worse than formerly at Iquique. To cross these partly
forested deserts by rail is a 40-hour journey. Between the two rivers,
the Salado and Dulce, both used for irrigation, the soil is fertile,
producing sugar cane, vines, wheat, alfalfa, for which the soil is
favorable, coffee, and tobacco. Some quarrying of marble and
gypsum goes on; but timber is the main industry.
The capital is a small town of the same name on the Rio Dulce.
La Rioja is a long, irregularly shaped Province south of
Catamarca, with that and Córdoba east, San Luis and San Juan
south, the latter running nearly all the way up on the west, leaving a
small space of Rioja bordering on Chile. Among high mountains at
the west are fertile irrigated valleys with varied agriculture; there are
forests with quebracho, carob, and acacia; but much of the eastern
part is low, sandy, and barren. Great mineral wealth of many
varieties exists, but silver and copper are chiefly exploited.
La Rioja, the capital, is the centre of a rich fruit growing district,
with some mining.
San Juan, with an extended border on Chile, has Rioja north and
east, San Luis and Mendoza on the south, on the west are lofty
mountains and well watered valleys; in the east barren sand hills and
marshes. Wine making is the most important industry; varied
minerals give promise for the future. The Province has been called
rather slow, but it is now said to be waking up; irrigation is beginning
and other improvements will follow.
Córdoba, an important Province, much larger, is the fourth in
population and the second in wheat production. It has Santiago
north, Santa Fé east, Buenos Aires and La Pampa south, and San
Luis, La Rioja, and Catamarca west. Although mostly rather flat,
there are mountains in the northwest of an altitude of 8000-9000 feet
among which are deep broad valleys. The country is chiefly
agricultural and pastoral.
Córdoba, the old capital, founded in 1573, in a charming location
among the hills, preserves some rather mediaeval characteristics, its
university dating from 1613. A wonderful reservoir is near, the Dique
San Roque, called one of the largest semi-natural reservoirs in the
world. A wall of masonry was built across a gorge among the
mountains forming a lake which holds 825,000,000 cubic feet of
water. Fifteen miles lower is a basin from which lead two primary
canals carrying water for irrigation, which extends over 300,000
acres.
Mendoza, the third largest Province and the most southern of the
Andean, with a long border on Chile, is just below San Juan; has
San Luis on the east, and on the south the Territories of La Pampa
Central and Neuquen. The surface is much diversified, containing
the highest peaks of the Andes including Aconcagua at the west, and
eight passes across the Andes, among them, the famous Uspallata,
at the summit of which is the celebrated statue, the Christ of the
Andes, at a height of 12,796 feet above the sea. More than 2000 feet
below, the Trans-Andine tunnel pierces the range. The Province has
many rivers from which there is extensive irrigation; for the climate
and the soil are dry, though the latter is fertile when irrigated. It is a
great section for grapes.
Mendoza, the capital, is headquarters for the wine industry.
Grapes are brought thither from the regions north and south. Raisins
and alcohol are also produced. Excellent livestock, cattle, horses,
mules, donkeys, sheep, goats, and pigs are raised; in the San Rafael
section, Durhams and Herefords, many of which are sent over to
Chile.
San Luis, east both of Mendoza and San Juan, lies south of La
Rioja and Córdoba, has the latter and La Pampa east, and La
Pampa south. The Province has mountains of the Córdoba system,
some rising to a height of 7000 feet, with fertile well watered valleys;
at the west are swamps, while the south is flat and arid. There are a
number of rivers and much attention is paid to agriculture, to cattle
raising, and horse breeding. The minerals, of great variety, are
hardly noticed.
Santa Fé, the last of the Provinces west of the Paraná River,
extends along its right bank from the Chaco on the north a distance
of nearly 500 miles to the Province of Buenos Aires on the south,
with Corrientes and Entre Rios on the other side of the river, and
Córdoba and Santiago on the west. This State, second in population
to Buenos Aires, though fifth in area, is a great plain with slight
elevations, having dense forests at the north, at the south the fertile
prairie, and along the great river many islands, covered with luxuriant
vegetation. It is an agricultural, cattle raising country, with mills and
factories also; and with extensive commerce in cereals, meat, hides,
quebracho extract, and timber, from the many fluvial ports. The chief
of these, Rosario, is the second largest city of the Republic with a
population of 317,000. The Province contains 3000 miles of railway.
Corrientes, east and south of the Paraná River, therefore south of
Paraguay, has Misiones at the northeast, Brazil east, across the
Uruguay River, Entre Rios south, and Santa Fé and the Gran Chaco
west across the Paraná. The Province has temperate uplands and
warmer lowlands, and is well watered by rivers and some lakes and
marshes. Corrientes is prominent as a cattle-raising State and has
also large flocks of sheep.
The capital, Corrientes, is an important river-port visited during
most of the year by vessels drawing 12 or 13 feet. Goya, farther
south, is famed for its excellent cheese.
Entre Rios, south of Corrientes, has Uruguay east beyond the
Uruguay River, Buenos Aires south across the Paraná, and Santa Fé
beyond the same river on the west. It is in general a fertile, well-
watered plain, with a forest region at the northwest running over into
Corrientes, containing much valuable timber. It is a stock-raising and
an agricultural region, largely devoted to cereals, with grain of the
finest quality. It has also many industrial establishments.
Paraná, the capital, is a growing centre with some fine buildings,
electric lights, and other facilities. Concordia, on the Uruguay River,
is an important commercial town.
Buenos Aires, the last, largest, and most important of the
Provinces, with the greatest population, is the only one with an
ocean front. Buenos Aires has on the north Córdoba and Santa Fé;
northeast, on the other side of the Paraná and La Plata, Entre Rios
and Uruguay; the Atlantic is on the east and south with a bit of Rio
Negro, which with La Pampa is on the west, with a little also of
Córdoba. The land is flat, but with two ranges of hills; the highest in
one range is 1200, in the other about 3000 feet. Several useful,
some navigable rivers flow towards the ocean. The country is
agricultural and pastoral, especially devoted to cattle and wheat, but
in the numerous towns, industries and manufactories are developing.
Many great railway systems converge at the Federal Capital. There
are good roads near most of the towns, which is not the case in the
other Provinces, and good auto roads lead from Buenos Aires to
Tigre and to La Plata.
South of the Provinces, at least below Buenos Aires, is what was
once called Patagonia, now divided into Territories.
La Pampa Central, a Territory which extends farther north, is
already from its population entitled to be a Province. Lying south of
Mendoza, San Luis, and Córdoba, it has Buenos Aires on the east,
Rio Negro Territory south, with the Colorado River as the dividing
line; and west, Neuquen and Mendoza. The Territory is undulating,
with hills, valleys, prairie, and lakes; the soil is generally fertile,
yielding fine crops; wheat, corn, barley, linseed, alfalfa, vines, fruits.
Large herds of cattle roam over the pastures but are usually sent out
for fattening.
Neuquen, south of Mendoza, borders on Chile, has Rio Negro
south, and also with La Pampa, east. The north and east parts are
arid, but the west mountain section has fine fertile valleys and
forests, with many rivers and lakes. A railway now making this
section accessible, it will be more attractive to settlers.
Rio Negro, first of the divisions of Argentina to stretch across the
country, has Neuquen and La Pampa on the north, Buenos Aires
and the Atlantic east, Chubut south, and Chile and Neuquen west.
The section between the Negro and Colorado Rivers is fertile, also
patches near other streams; wherever irrigated, good crops of
wheat, corn, oats, and alfalfa are certain. Fruits and vines do well in
the Negro Valley. Excellent timber is exported in beams and planks.
There are some towns and many agricultural colonies; trade goes on
with Chile in cattle and sheep. Several rivers are navigable and a
railway has been constructed from the port San Antonio to Lake
Nahuel-Huapi.
Chubut, south of Rio Negro, also extends across from the Atlantic
to Chile, with Santa Cruz on the south. The central part has little
vegetation but in the west are fertile valleys, and good grazing for
cattle and sheep. There are millions of each, and many horses.
Cereals and alfalfa are also raised in the east, with temperate zone
fruits and berries. Near the oil fields of Comodoro Rivadavia is
excellent farming land under cultivation. In this section there is now
great activity on account of the petroleum development; some
railways have been constructed and one is expected soon to cross
the country. There is trade in wool and hides; gold, copper, and salt
exist.
Santa Cruz, the largest division next to Buenos Aires, south of
Chubut, has the Atlantic on the east and Chile on the south and
west. The northwest is rather barren and rocky, with dense forests
farther south; but near the coast and south of the Santa Cruz River
are fine pastures supporting great flocks of sheep. There are many
rivers and lakes, several, like the Buenos Aires, on or near the
Chilian boundary. Wool, frozen mutton, and timber are exported.
Tierra del Fuego has the Atlantic Ocean on the north, east, and
south, with the Chilian part of the island on the west. This triangular
part of the island is mountainous, but has sheltered valleys, good
pasturage, and vast forests with excellent timber, to some extent
exploited. There are large flocks of sheep; the gold and copper
deposits are unworked except for washing the sands. The capital,
Ushuaiá, on the Beagle Channel, is a small penal colony.
CHAPTER XXXVI
ARGENTINA: SEAPORTS AND INTERIOR TRANSPORTATION
Argentina has a long sea coast, about 1300 miles, with a number
of gulfs and good harbors. The ports of Buenos Aires and Ensenada,
both constructed at great expense, on the wide La Plata River, may
be regarded as seaports. The best natural harbor is 500 miles by
sea south of Buenos Aires, Bahia Blanca, where the Government
has built a port and naval station, and the harbor is accessible to
large ocean vessels. Farther south are other ports, not greatly
frequented on account of lack of population, but of growing
importance. North of Buenos Aires are river ports, some of these
visited by ocean steamers, others by river boats only, a few of the
latter 1000 miles from the sea. The river ports above Buenos Aires
with facilities for ocean liners besides Rosario, are Campana, Zarate,
Ibicuy, San Nicolas, and Santa Fé (Colastiné).
Seaports
Buenos Aires has port facilities of the first order, though

insufficient for its great commerce. These are in two divisions: one,
the natural port, is on the Riachuelo, a small river south of the city,
which probably determined the precise location of its site. The river
admits vessels of 18-foot draft. Capable of an annual traffic of
1,200,000 tons, it is of great value in national commerce. There are
wooden quays on the north side of the river, now to be rebuilt at a
cost of $400,000, and on the south, concrete docks and quays
constructed by the Southern Railway. On that side are some of the
noted frigorificos and the famous Mercado de Frutos, the Central
Produce Market, with 180,000 square yards of floor space.
The main port, receiving the ocean steamers, is on the city front,
extending two miles directly along the Plata River. Constructed at
great expense, and expected to supply the needs of the city for
years, it was completed in 1897; but the growth of the city soon
outran its capacity, so that in 1911 provision was made for its
enlargement, which, however, has not yet been accomplished. About
$35,000,000 have been spent altogether. The port consists of two
basins, darsenas, the north and south, with four docks between
having a depth of 23 feet and a total area of 164 acres. The length of
the quays which may be used for loading and discharging freight is
about ten miles. Along the docks are 33 warehouses with
30,000,000 tons capacity, and four sheds. Grain elevators have a
total capacity of 300,000 tons of cereals, and granaries of 55,000
tons in sacks. Loading under cover, the work goes on in bad
weather, each elevator loading 20,000 tons a day. Two dry docks
accommodate ships 400 feet long; 874 electric lights, 100 feet apart,
serve the harbor entrance. Sixty-four thousand ships with
22,000,000 tonnage have entered the harbor in a year, bringing 85
per cent of the imports and carrying out 50 per cent of the exports of
the country.
Ensenada, the port of the made-to-order city of La Plata, more
noteworthy for its university and museum than for its commercial
affairs, has been constructed for the relief of Buenos Aires, and
because, 35 miles lower down, the water naturally has greater depth.
The port has 8000 feet of quays, warehouses, and other necessary
appliances. Two American packing houses are here located.
Mar del Plata, the Newport of South America, 250 miles by rail
south of Buenos Aires, is being developed also as a commercial
port, with quays, warehouses, etc.
Bahia Blanca, with a population of 80,000 in the city and its
several ports, is about 700 miles south of Buenos Aires. It is of such
importance that the Southern Railway has four different routes for
the journey. The city also has direct connection with Mendoza and
with other parts of the country. Being situated on a large well
protected bay of the ocean, it has a naturally better harbor than
Buenos Aires and may be compared to Liverpool as Buenos Aires to
London. Since 1882 its development has been rapid. With more than
ordinary advantages for business for a city of its size, including
factories, warehouses, and good hotels, it is a railway centre for lines
spreading over the agricultural and stock-raising districts of southern

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Clinical Procedures For Ocular Examination 4Th Edition Nancy B Carlson Full Chapter

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Clinical Procedures for Ocular

Examination 4th Edition Nancy B.

NANCY B. CARLSON, OD, FAAO

DANIEL KURTZ, OD, PhD, FAAO

eBook conversion by codeMantra

Extraocular Motilities (EOM) 95

Cycloplegic Re raction 174

4 Functional Tests 207

Associated Phoria 253

5 Ocular Health Assessment 271

Brightness Comparison Test 372

6 Contact Lenses 385

7 Systemic Health Screening 465

8 Cranial Nerve Screening 499

Marion M.W. Hau, OD, FAAO

Ronald K. Watanabe, OD, FAAO

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

INTRO DUCTIO N TO PATIENT

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

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

Case History Components for an Adult

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

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

• Past Medical History (including past eye history)

How is your gener l he lth?

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

Case History Components for a

• Probe the patient’s symptoms.

Introduction Introduce yoursel , make the patient com ortable

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

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

Recording for Patient #1

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

Recording for Patient #2

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

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

Examination data Summarize only the examination data relevant to your

Treatment and Summarize your recommended treatment or management

Give recommended time or the next visit and what should

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

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

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

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

REP O RTING ABUSE

Area, Population, Boundary

The Government of Argentina is that of a Federal rather than a Centralized

With an estimated population of at least 8,600,000, Argentina suffered a large

Press, Religion, etc.

Argentina is oftenest thought of as a country of broad plains, but

The rivers of Argentina are of great importance, being navigable

The climate of Argentina naturally varies on account of its wide

Buenos Aires, the metropolis of South America, the largest city

Provinces and Territories

We may perhaps get the geography of the Republic most

Buenos Aires has port facilities of the first order, though

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