If Ophthalmology Ran Medicine

Sometimes I wonder what it would be like if all the members of the internal medicine team were replaced by ophthalmologists. It would probably look a lot like this...



(Ophthalmology attending, 2nd year resident, Intern, and two med students gather in the hospital at 9:45am on a Tuesday. They are all wearing glasses and look well rested)

ATTENDING: Alright let's get going.

(Everybody finds a seat)

LIZ (INTERN): We'll start with Mr.--

ATTENDING: Whoa whoa hold on, Dan hasn't found a seat yet. We should all be seated for rounds. Conserve our strength.

(Dan, 2nd year resident, enters a patient's room, muffled apologies are heard. He then returns carrying a chair, one of the patient's family members is seen standing in the room, looking bewildered)

ATTENDING: Sorry Liz, please continue...

LIZ: We'll start with Mr. Thomson, 80 year old who presents with chest pain. The pain has been there for some time and does not seem to affect his vision. His past ocular history is significant for cataract surgery in the right eye only and mild primary open angle glaucom--

ATTENDING: Wait, right eye only? Highly unusual, ok I trust you will be addressing that in your assessment. Nice job on the history. Go on to the review of systems.

LIZ: There is no eye pain, no change in vision, no diplopia, no blurriness, and no episodes of sudden vision loss.

ATTENDING: What about the other organ systems?

LIZ: Negative unless previously addressed in the HPI

ATTENDING: Perfect. Tell me about the exam.

LIZ: Normocephalic atraumatic, mucous membranes moist, visual acuity 20/20 OD, 20/70 OS with myopic correction using near card, intraocular pressure 13/15 with bedside Perkins applanation tonometer, extraocular movements normal, confrontation visual fields full, there was 1mm of physiologic anisocoria with no relative afferent pupillary defect. Eyelids had moderate meibomitis with concretions along the palpebral conjunctiva. There was 1+ conjunctival injection with sectoral dilation of episcleral vessels. The cornea was clear with trace guttae OU. The anterior chambers were deep without cell or flare and the iris was round with a few peripupillary TIDs. He has a posterior chamber intraocular lens in the right eye and 2+ nuclear sclerosis with scattered anterior cortical vacuoles and a dense PSC in the left eye. On dilated exam, the vitreous was clear and vessels were mildly tortuous. The optic nerves had sharp margins without pallor or edema with a cup to disc ratio of 0.2 OU. The maculae were normal and aside from reticular pigmentation, the peripheral retina was healthy. The heart was present, emitting S's 1 through 2. The lungs filled up the remainder of the thorax. The abdomen and pelvis were well supported by two legs.

ATTENDING: Hmm ok, how about the 24 hour Eyes and Ohs?

LIZ: Two eyes, four Ohs, and that's stable compared to yesterday.

ATTENDING: Very good.

MED STUDENT #1 (whispering to Dan): What are the Ohs?

DAN: The number of times the patient said, "Oh now where did I put my reading glasses?"

(med student #1 nods, med student #2 nods as well even though it's obvious he didn't hear anything that was said)

ATTENDING: So what's your assessment and plan?

LIZ: This is an 80 year old with a cataract and moderate blepharitis in the setting of pneumonia. I would start artificial tears QID and hot compresses BID. I would also sign him up for cataract surgery as an outpatient.

ATTENDING: That sounds good. I like it.

(Liz puts orders in incorrectly and doesn't communicate with the nursing staff)

ATTENDING: What about the pneumonia?

LIZ: Surgical co-management?

ATTENDING: Make it happen. Alright, let's get lunch.

(Entire team takes elevator down one floor)