The troublesome eye exam

During medical school we were admonished never to take short cuts. High on the list of forbidden behaviors was to fail to do a complete physical exam, regardless of how focal the presenting problem seemed. For one thing, our diagnostic skills were in their infancy, and narrowing the focus too early was a way to miss important things. For another, there is a wide range of normal and multiple exams would help us recognize an outlier. The relationship with the patient was felt to be enhanced by the process of a methodical and attentive exam with laying on of hands. Finally, practice was deemed essential to improving our physical exam skill and efficiency. (There was also the possibility of gaining credit for recognizing and demonstrating an unusual finding on morning rounds, and the ever-present fear that the attending would ask us about some obscure aspect of the exam.)

During my first year of family practice residency the habit of full exams on every patient had not yet fallen victim to time pressure. Usually worth while, it occasionally led to unexpected results.

I was seeing a middle aged man in the Emergency Department about a swollen and exquisitely tender knee that he felt was related to gout. His reason for thinking this was that he had had numerous previous identical episodes, most often - as in this instance - several weeks after he stopped taking his allopurinol, a medication used to lower uric acid levels and prevent gout. He patiently tolerated my taking a detailed medical and social history and review of systems, once replying to my explanation for seemingly off-topic questions with a comment about having plenty of time.

When it came time for the exam, after putting both his knees through their paces (and convincing myself that he did, indeed, have gout), I asked if he would mind if I did a full physical, using my usual excuse, that I wanted ‘to make sure we weren’t missing anything important.’ He said he was happy to help me learn to be a good doctor.

There is a system to the physical exam. One starts at the top and on the right side of the patient, and descends, following the protocol passed on through generations of physicians. His head was symmetric and atraumatic, with normal hair distribution and scalp. Both external ears were appropriately placed and without skin lesions. (The top of the ears get lots of sun and rare sunscreen and are a place we are taught to look for pre-cancerous lesions.) The canals were clear and they tympanic membranes, easy to visualize, were translucent with normal landmarks and light reflex. His right eye was normal, with no icterus (jaundice shows up first in the whites of the eyes) or conjunctival injection, arcus senilis (deposit of lipids in the iris, a marker for hypercholesterolemia), or Kayser-Fleishcer ring (copper in the iris, a sign of Wilson’s Disease). The fundoscopic exam  showed a no evidence of cataracts, a nice sharp disc where the optic nerve left the back of the eye, and normal caliber vessels. The left eye was also anicteric and had no injection, arcus senilis or Kayser-Fleischer ring. Fundoscopic exam, however, presented difficulties - I was unable to clearly visualize the interior of the eye. I shook my opthalmoscope, checked that the light worked, and worked my way methodically through all the lenses - but was still unable to get a clear view of his fundus. I turned the room light off and tried again, with no greater success. 

Flummoxed by my increasingly obvious incompetence, I stopped trying and walked across the room to turn the light on.  When I turned around, he said: “Here, doc, maybe this will help” and he held out his hand with a glass eye in the palm - and a huge - though lopsided - smile on his face. 

“I prolly shoulda said sumpin doc, but it jes dint seem imporant. It’s my knee what hurts, y’ know. I loss the eye inna service. The marble dey gave me weren’t crap, so I spent more’n I shoulda, gettin the best fake un I could find.” He was clearly proud. And he had stories to tell.

“Don’t feel bad, doc. You ain’t the first. Lotta of ‘em get fooled. Even da old docs. Dat’s special fun, da big mucky docs wid white coats and baby docs wid em. You know, da ones what don ‘member howta laugh.”

He liked that the eye made him special and gave him something to talk about, with people who otherwise wouldn’t listen. And he liked how often the eye meant he knew something the experts didn’t, like the time they made him take it out for his eye test for his license, so he ‘couldn’t cheat.’ 

His favorite, though, was the time he was making a trip cross country, camping out in fields to save money, and got a bug bite on the left upper lid. It got red and swollen and he thought it was infected, so he stopped in at the next small town ED where he was diagnosed with ‘celly-litis’and treated with antibiotics and instructions for warm soaks, and instructions not to put the glass eye back in for a couple days, until the swelling had decreased. As he was preparing to leave, he said, the ED doc asked him if he was traveling,  and told him he couldn’t drive for a few days, because it was not safe to drive without both eyes!



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