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THIRD YEAR ROUNDS / CASE DISCUSSION
OPTO 7120 (13232)
SPRING 2015
SYLLABUS AND CLASS SCHEDULE
ROOM 267 WEST HBSB
MEETING TIME: THURSDAYS FROM 11:00am - Noon
Course Description
This course strengthens the student’s case analysis skills through a series of
primary care encounters presenting with a variety of problems spanning the
full scope of optometric practice. The student’s integrative skills are
sharpened through written analysis of the cases and through group
discussion.
Course Objectives
Upon completion of this course, the student will be able to:
1. Critically evaluate a case based on the information furnished and provide
an assessment with a tentative diagnosis and a list of likely differentials.
2. Determine additional information needed and the diagnostic tests
required in order to finalize the diagnosis of the case.
3. Develop a management plan based on the tentative diagnosis.
Coursemaster
Danica J. Marrelli, O.D.
Office 2166
Phone (713) 743-1945
Email: [email protected]
Requirements
1. All case analyses must be typed. The student’s name & assigned
number must be typed in the upper right hand corner of the analysis.
2. Case analyses must be turned in by 9:00 a.m. on the Monday of the
week the case will be discussed. For example, the case discussed
Thursday, January 15, is due by 9:00 a.m. on Monday, January 12.
3. Case analyses must be turned in to the library. The student MUST sign
the sheet when the case is turned in to receive credit for the case. Cases
may not be emailed or placed in faculty mailbox. Failure to sign the
sheet may result in not receiving credit for the case.
CLASS EXPECTIONS & GRADING
1. Required attendance at all classes. Failure to sign the attendance sheet
will result in the student not getting credit for attendance. Tardiness will
not be accepted.
2. ALL case analyses must be turned in on time to the library, and the
student must sign the sheet. Late cases are not accepted.
3. The analysis must be the student’s own work and must be completed in
an acceptable fashion following the guidelines and example in the
syllabus. If a case analysis is determined to be substandard, the student
will not be given credit for it. If a case analysis is thought to be copied
or shared work, or if it is plagiarized, charges may be brought before the
Academic Committee for unethical behavior, and the student will not
receive credit for the suspicious case analysis.
4. The student must be an ACTIVE participant in class.
TO EARN AN "A":
The student may miss one class period OR may miss one case analysis and
still receive an "A", provided that all other expectations are met.
TO EARN A "B":
The student may miss TWO items: e.g. may miss one class period and one
case analysis, OR may miss two class periods but turn in all case analyses,
etc (provided that all other expectations are met)
TO EARN A "C":
The student may miss THREE items: e.g. may miss two class periods and
one case analysis, OR may miss 2 analyses and one class period; however,
the student may NOT miss 3 classes or 3 case analyses (provided that all
other expectations are met)
How To Fail The Course: Fail to meet the requirements for an A, B, or C.
NOTE: A grade of B or C may be raised one letter grade by turning in an
additional case analysis. This extra case must be a patient that the student
has seen in clinic at the University Eye Institute; the UEI patient number
must be provided. The student will write up two parts: the data (as
typically given to the student in class) and the case analysis (as typically
turned in by the student). Only one additional case may be turned in per
student (i.e. the student may not raise his grade two letters by turning in two
additional cases). A grade of F may not be raised to a grade of C under any
circumstance. The extra case is due to Dr. Marrelli NO LATER THAN
CLASS TIME ON Thursday, April 16.
Textbooks
Books that were required of previous courses, as well as journals and books
from the UHCO library, will provide valuable references. All references
should be cited in the case analyses. Failure to cite references will
result in no credit for the given case analysis.
Note: Many students find the Wills Eye Manual, Ocular Therapeutics
Handbook, and/or the Massachusetts Eye and Ear book to be helpful texts
for this course; I agree. However, if one of these is utilized, there must be at
least one additional reference (other than these 3).
CASES will be posted online. Exact details will be provided once
determined.
Communication with Instructor: Email communication is an official
form of communication for the University of Houston. ALL email
correspondence must be generated from the university-issued (i.e.
“alumni”) email account. Emails generated from gmail, yahoo,
comcast, etc., are not accepted.
The Case Analysis Summary
(General Guidelines)
A case will be presented for discussion each week. The week before the
case is discussed, it will be uploaded onto the UHCO intranet.
* No late analysis will be accepted.
* The analysis must be typed according to the enclosed format, unless
otherwise specified. The student’s name and assigned number must be
written on the upper right hand corner of the first sheet.
* The analysis must be acceptable. Habitually unacceptable case analyses
(i.e., those demonstrating little preparation or thought) will be grounds
for failure.
* All references must be cited on the case analysis. If The Will’s Eye
Manual. Ocular Therapeutics Handbook, or the Massachusetts Eye and
Ear book is a reference, there must be at least one additional reference
(other than these 3).
* The student must work individually on the case analyses. The student
should consider that (s)he is in practice alone. There are no partners to
rely on. The student, and the student alone, must “make the call”.
The Case Analysis
(Template)
1. Assessment of the patient and his/her problem
Write an assessment of the patient and his/her problem. It should
include:
A. The tentative diagnosis
B. A list of LIKELY differentials, if appropriate (not “remote” things)
C. Special considerations, if any (there may not be any)
ex: prognostic factors
special concerns (occupational or otherwise)
general health issues
2. How will we rule out differentials/confirm diagnosis
A. For each differential:
If you can rule out differentials base on info given, explain.
If additional information is needed to rule out differentials or confirm
diagnosis, explain: (ex: additional diagnostic tests or history) *****
Note: There may be tests that could be done in a case, but are not
mandatory. IF you put these tests down, the assumption is that you would
do them. (You must decide what you WILL do, not what you might
consider doing)
B. Additional Information required
3. The Treatment or Management Plan based on your tentative
diagnosis
In this section, an outline of the treatment or management plan must be
provided. While emphasis should be directed toward solving the
presenting problem, other aspects of the case that require attention
should not be overlooked. This should include ALL aspects of plan
(patient education, in-office treatments, home treatments, referrals, etc.)
If more than one option is reasonable, you may want to include options
and discuss why you would/would not do that particular thing
***If medications will be used, the student MUST write a prescription
4. Follow-up
In this section, the follow-up required to appropriately manage the patient
should be outlined. Specific time frame for follow-up is necessary (not
generalized time frames), as well as testing to be performed that day.
5. References
Note References here. NO MATTER WHAT TYPE OF CASE,
REFERENCES MUST BE INCLUDED TO RECEIVE CREDIT.
If you use Will’s Eye Hospital, Ocular Therapeutics Handbook, or Mass
Eye and Ear, you must cite an additional reference (other than “the big
3”).
SAMPLE CASE
Demographics: DM, 34 year old white female
CC/RFR: Sudden onset of sharp pain in the right eye after her 10 year old accidently
poked her in the eye
HPI: Daughter poked her in the right eye with her finger approximately 14 hours
earlier; immediately patient experienced pain, watering, and light sensitivity; feels
somewhat better this morning but still hurting & light sensitive
POH: LEE –never; “perfect vision” before now
PMH: (-) DM, HTN, Heart Dz, Renal Dz, Respiratory Dz, other chronic dz
(+) Hospitalizations
1996, 1999, 2002 - childbirth
1998 - back surgery
FMH/FOH:
(+) HTN - mat. & pat. grandmothers
(+) Heart Dz - mat. grandfather (CHF)
Meds: prenatal vitamins
ALL: Penicillin
EXAMINATION RESULTS
Habitual RX:
None
Unaided VA:
Distance:
20/40 - 2
20/15
20/15
Near:
20/50
20/20
20/20
Pupils: 4mm OD/OS; 4+ D/C OD, OS; (-) RAPD OD, OS
EOMS: Full OU CVF: FTFC OD,OS
Slit Lamp Exam:
All structures unremarkable OS
OD
Lids/Lashes: Normal
Conj:
2 + diffuse injection
Cornea:
4 mm central epithelial defect with
+NaFl staining/pooling; no loose edges
AC:
Trace cells; no flare
Iris:
Normal
Lens:
Clear
Danica Marrelli
#42
THE CASE ANALYSIS (FOR SAMPLE CASE)
DJM, 32 YEAR OLD WF
1. Assessment of patient and her problem
A. Tentative Diagnosis
1. Traumatic Corneal Abrasion OD
B. List of Most Likely Differentials
1. Recurrent Corneal Erosion
2. Infectious Corneal Infiltrate (unlikely, but must consider)
C. Special Considerations
1. Prognostic Factors
- Good prognosis for rapid recovery and alleviation of
symptoms
- Guarded prognosis log term with regard to recurrent corneal
erosion given nature of injury
2. Special Concerns (occupation or otherwise)
- Patient is in considerable pain; need to address pain relief
- Why is patient taking prenatal vitamins (is she pregnant or
nursing - possible medication implications)
- Proper education regarding recurrent erosion prevention
2. How will we rule out differentials/confirm diagnosis
A. To rule out differentials:
1. Recurrent Corneal Erosion: Ruled out by case history (would
occur on wakening, no history of trauma, possibly episode in past)
2. Infectious Corneal Infiltrate: Need to know if infiltrate is present
(little information given on cornea other than size of epithelial
defect); very unlikely given history
B. Additional Information needed
1. Info needed for data base:
Best Visual Acuity (BVA): Required for management of all
cases; must pinhole or refract (not done or recorded in this case)
Past Ocular History: Does patient wear contact lenses (Note: in
this case, the patient MUST not wear contact lenses, because she’s
never had an eye exam before; however, in any corneal abrasion,
contact lens information must be obtained)
Gross Examination: With any history of trauma, and with ANY
red eye, a gross external examination should be performed to rule
out any adnexal problems
2. Info needed for management decisions:
Is patient a contact lens wearer
Why is patient on prenatal vitamins
3. The Treatment or Management Plan based on the tentative diagnosis
-
Cycloplegic agent in office (homatropine 5% OD x 1)
Antibiotic prophylaxis: Polytrim ophth sol qid OD
Bland ophthalmic ointment at night: Refresh pm
Voltaren ophth sol in office OD for pain management
Date: January 18,2015
Patient Name: No Name
Rx
Polytrim ophthalmic solution
Disp: 5cc
Sig: I gtt qid OD
___________________
Substitution Permitted
____________________
Dispense As Written
Other options:
1) pressure patching to control pain - Under NO circumstances
would this patient be pressure patched if she were a contact lens
wearer.
2) bandage contact lens for pain control. Not chosen because…
3) other antibiotic choices: 4th generation fluoroquinolone, topical
azithromycin (not chosen because they are expensive and this is not
an infection, just prophylaxis)
4) prescribe voltaren for home use: not done because the cycloplegic
should significantly improve pain once it begins to work; pain will be
short lived, no need to purchase expensive bottle of voltaren
4. Follow Up
a. Follow up in 24 hours; re-asses symptoms, BVA, slit lamp findings; if abrasion
is resolved, patient to return only if symptoms worsen or reappear; if not resolved,
RTC every 2 days until resolved
b. Continue Polytrim qid OD x 5-7 days
c. Continue with ointment in this fashion: continue ointment for several weeks to
reduce risk of recurrent corneal erosion
e. Careful counseling regarding recurrent corneal erosion
REFERENCES
Will’s Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye
Disease
Class Notes (Dr. Piccolo’s notes) Spring 2014
DATES TO REMEMBER
 Jan 20: The case for class date January 22 will be due by 9:00 am
 Mar 19: No case due. However, class will meet and attendance is
mandatory
 Apr 16: Extra case due if needed