1. cognitive domain- knowledge 

2. pyschomotor domain- skill 

3. Affective domain- attitude

~patient

~intern

~supervisor 

~certain ppl approved by the px(parent etc)

~possibly the clinic director

~specific px must not be named or identified in anyway

~causal discussion of px info is inappropriate

~Interns must wear an approved clinic coat (some exceptions), clinic coats should be clean and not creased.

~interns must wear a UW intern name tag 

~Men should wear a tie, dress pants and dress shirt 

~Women must wear a dress, or a dress shirt/top (that is not low cut) and a dress pant/skirt

~interns must wear clean dress shoes 

~

~When there is excessive heating in an examination room 

~In paediatric and special needs clinic to ease patient anxiety 

~body piercings must not be visible

~Visible piercings must be limited to 3 ear piercings per ear and one small nose stud 

~head dress/coverings are allowed for religious observances ONLY 

~minimum, perfumes, fragrances, colognes and lotions can be worn 

**(some px and staff have allergies, also prohibited for the TLC rotation due to laser sensitivity)

1. age 

2. monocular cross cyl

3. Sheard's add determination

~medication use

~Geographic locations (closer to the equator earlier presbyopia 

~preferred working distance

~systemic disease 

38-45

~this group can present with blur in the distance due to slow relaxation of accomodation in the distance 

~concentrate on prism balance and fog the fellow eye if there are any symptoms of distance blur

~X cyl works well in this group (make sure that illumination is reduced or you will get a lower than expected add)

~add by amplitude (Sheard's) but can be more difficult

~ fogging is NOT required BUT binocular refraction is still needed since there is some accommodation present 

~use X cyl, Sheards or age

False- these px have no accommodation left and you should NOT fog or prism balance them

~also VA is not usually equal so prism balance would not be done 

NOTE:nuclear sclerosis may invalidate R/G balance

Age 

~X cyl may not give reliable results(distortions, cataracts)

~Sheards may not give reliable results (measuring depth of focus)

(Near VA/ Required VA) X WD  = ADD

~must educate the px that the working distance must be a specific distance 

(0.1/0.5)X2.50= +5.00D 

TF working distance is 20 cm

~Amplitude of accommodation

push up amplitudes 

~add determination is a sufficient accommodative assessment 

Increased Exophoria (no accommodation ie no accommodative convergence)  

6-10 exophoria

~ AC/A can not be measured and are NOT useful

~accommodative facility is not measured and is NOT useful 

NOTE: also there are NO blur pts on the fusional reserve with an ABSOLUTE PRESBYOPE

1. Cover test

2. Maddox Rod

3. Refraction 

1. AC/A ration 

2. Amplitude of accommodative(push up amplitudes)

1. Binocular vision system  

2. Refractive system 

3. Sensory system 

4. Ocular health section 

1. algorithmic 

2. pattern recognition (intuitive)

3. Hypothetico - Deductive reasoning (analytical)

~older patient 

~blur vision 

~mild anterior subcapsular opacification (located on the anterior surface of the lens) 

~located in the cortex of the lens, spoke like opacities towards the visual axis 

~Older patient 

~Increased glare

~Gradual decreased VA

~better VA in bright light

~found in the nucleus of the lens, delineated yellowed lens. 

~causes myopic shift 

~ older patient 

~near VA better at increased WD

~Gradual loss of VA

~near VA better than distance VA 

~posterior surface of lens, black opacity on retroillumination, 

~pin hole decreases VA

~Younger adults 

~rapid VA loss 

~steroid use, radiation or inflammation 

~RP, myopia or hereditary conditions 

1. Problem Identification and clarification 

2.Hypothesis Generation

3. Hypothesis Testing

4. Hypothesis review: dx made?

5. Developing a px management plan  

1. Chief complaint 

2. Mentally list diagnostic possibilities 

3. consider px considerations( age- young possible myopia or young possible cataracts)

4. prioritize by order of probablity and revise list 

5. Additional probing questions

6. problem specific testing 

7. Additional probing questions 

8. Database testing 

9. diagnosis and plan 

~age

~sex

~race 

~occupation/ environment 

~impacts how likely it is for a px to have a certain disease/condition 

~ when a px experiences floaters and flashes of light 

~onset of change in the number or size of floaters

~when a px has a sudden unexplained vision change or loss, Or experiences metamorphopsia 

~when a px has a systemic condition or is taking a medication that may affect ocular tissues 

~history of ocular trauma or ocular surgery that increased risk to posterior segment

~increased risk of peripheral retinal disease exits 

~Hx of moderate to high axial myopia

~a better appreciation of the nature of a fundus anomaly is required

~ocular fundus is not clearly visible through an undilated pupil 

~the size of a fundus anomaly necessitates the need for an increased view of the view for its interpretation 

~disease of the ciliary body is suspected and or disorders of the vitreous

~

1.A daily appointment record that sets out the name of each patient that the optometrist examines or treats or to whom the optometrist provides any service.   

2. Financial record for each patient this record must include the optometrists fees for services or any commercial laboratory costs charged to the member

3. A patient health record for each px that must include:

~Name, Address of the patient 

~name of the optometrist that provided the service 

~the date of each visit of the patient 

~ the date of every entry in the record 

~Name and Address of any referring health professional 

~patients oculohealth and vision history 

~clinical procedures used 

~clinical findings obtained

~diagnosis when possible

~every order made by the optometrist for examinations, tests,  consulations, or treaments to be preformed by another person 

~particulars of every referral to and from another health professional 

~information about every delegation of a controlled ACT within the meaning of subsection 27(2) of the Regulated Health Professionals ACT delegated by the optometrist 

~information about a procedure that was commenced by but completed, including reasons for non completion and a copy of every written consent to treatment. 

1. Are problem specific and aid in a diagnosis (including grading severity)

2.Provide information useful for monitoring therapy over time

3.Provide information to cross the treatment threshold

4. They help to establish a database of information 

1. Fee Generation 

2. Medico-legal reasons

~ validity: accuracy

~reliability:reproducibility

~Range: Measurement range within what is needed

The portion of patients with the disease taht have a positive test result

When a test with a high sensitivity is negative it effectively rules out the diagnosis of the disease.

The portion of people with out the disease that have a negative test result

~when a test has high specificity a positive result can rule IN the diagnosis 

Post Test Odds= Likelihood Ratio X Pre Test Odds  

Pre Test odds = prevalence / (1-prevalence)

~inferior rectus 

(Then the medial rectus)

Ask:identify type of question and put it in PICO format 

Acquire: Identify the appropriate study design, identify a source for the information then research that source and take the best and most relevant evidence

Appraise:look at susceptibility to bias, and look at the results that are impt for the evaluation of impt px outcome 

Apply: evaluate the applicability of the study for your px.  Evaluate the issues of applicability with the relational construct

Meta analysis 

summaries 

Randomized controlled trial 

cohort studies

case control studies

case/series case report studies

Animal Research/ laboratory studies

~knowledge base (continuing education)

~analytical and diagnostic reasoning skills 

~clinical experience

~professional style (ability to relate to the px)

type 1 intuitive: fast pattern recognition, used by experts and takes time to develop

Type 2: differential diagnosis. Used for difficult problems and used by novices

They are general rules or strageties that usually support and assist good decision making. They are "Rules of Thumb"

~representative heuristics (miss a dx bc signs ans sxs do not coincide with your knowledge about a condition)

~available heuristics (make a dx bc it is similar to a recent px of yours)

~anchoring heuristics (there is a sign/sxs that anchors and dx in your mind and you do not change the dx even if other tests prove that dx is not the best)

1. obtain information from the patient

2. Establish a rapport with the patient  

~support 

~empathy 

~reassurance 

True or false 

REFRACTION= PRESCRIPTION

~people over 65 

~people in long term care facilities 

~people in special care facilities 

~people receiving special services under the Home care progam 

~trilium Drug program recipients

~social assistance

If there is no ophthalmologist on call the patients are sent to?

True

~The referral has to be in the system in the right way or they may fall through the cracks 

1. supervisor/patient determines which doctor the referral will go to

2. intern informs the patient on the procedure

3. intern writes the referral/form and saves it to a disc they get from Rose

4. The doctor approves the letter with corrections

5. Rose faxes the letter/form and a records it in a log book

6. when the appointment is received the px is notified by Rose

7. Can take up to 2-3 weeks for non urgent referrals

8. the appointment will likely to months after the notification  

A-accuracy

B- brevity

C- clarity

~Name, age, sex, race (if relevant), vocation, avocation of patient 

~chief compliant (all details)

~ Relevant ocular and health history 

~relevant anomalies and abnormalities in the test results

~diagnosis of each identified problem 

~management plan for each problem 

~if should be attempted even if there is uncertainity of the dx or the plan 

1. educate

2. Support

3. Administration

~1. ensuring the safety of the patient/care

THEN 

2. educating the trainee

3. promoting high Standards  

4. identifying trainee problems 

5. supporting trainee

6. monitoring trainee progress

room lights off over the distance chart and ceiling lights should be set at half maximum

~the stand light should be OFF for X cyl test BUT then must be turned on for reading card demonstration of add

402- partial exam of unisured ages no limits

404- exam for 19 yrs and younger 

406- 65 yrs or older 

408- partial exam for ppl of 409

409- exam for ppl who have other diseases(DM, glaucoma)

410- visual fields for covered px 

Privately Billed:

full exam no coverage $80.00

partial (emergency) $55.00

new px partial (emergency) 65.00

other $45

roughly 2,3,4 months 

85 -127 days