1st October 2008
It’s 5:30 Friday evening. The office closed half an hour ago, but you’re sitting down to see the last emergency add on. One look through the slit lamp and your heart sinks.
- The conjunctiva is red, but not too red.
- There is a white area on the cornea. An ulcer? Infectious? Sterile? Herpetic?
- No hypopyon. That’s a good sign.
- Hmm, the patient did wear their contact lenses without break for the past 3 months…
Your mind flits between diagnoses. You’re fairly sure what needs to be done. But at the end of a hectic week, you’d almost be willing to trade that refracting system for a colleague to take a look and discuss treatment options with you. It’s not the first time you’ve wished you worked in a multi-doctor practice—if only to have another pair of eyes to look at worrisome cases.
In situations like this, optometric physicians at PCLI are happy to help.
Feel Free to Call
There is no need to feel like you are on your own. We are always happy to review challenging cases and assist you with treatment plan details—even if we never see the patient. We can help sort out the options while you maintain control and keep the patient within your practice. Success is based on solid phone consultations.
Organize Your Thoughts
Before working at PCLI, my phone consultation skills were weak at best. I would call a colleague or specialist and find myself stumbling over details. I would omit important information and repeat myself. At PCLI I learned to organize information into a logical sequence before discussing things with others. A benefit of this process is that it has often helped me discover answers to questions, without further input.
Prior to calling, organize the case and your thoughts into the SOAP format.
Have a concise list of the patient’s presenting information such as age, gender, location, timing, duration, severity and associated symptoms. For example:
I have a 27-year-old female, extended-wear soft contact lens wearer, who presented to my office today with a 2-week history of a red, irritated, photophobic, watery right eye.
She removed her contact lens this morning and has been using Visine QID x 1 week without relief of symptoms. She takes no medications and has no pertinent health history.
Next, summarize your pertinent exam findings, omitting non-essential information.
My exam showed mild lid edema and mild blepharitis, grade 1+ conjunctival injection (mostly superior-nasally), and a 1.5x3 mm focal infiltrate in the mid-periphery at 2 o’clock. There is clear cornea between the infiltrate and the limbus. There is staining over the infiltrate. No associated stromal edema. Central cornea is clear. AC shows a rare cell, no hypopyon. Lid eversion shows mild injection on the palpebral conjunctiva, no follicles or papillae. All other findings are normal. The left eye shows mild blepharitis, and is otherwise unremarkable.
Assessment and Plan
Provide your own assessment and treatment plan:
I think she most likely has marginal keratitis, but her history of EWSCLs and the fact that the infiltrate stains does concern me. My differential diagnoses are bacterial keratitis and possibly Acanthamoeba or fungal infection. I doubt it’s herpetic. I was planning on starting her on Vigamox q2h and seeing her again tomorrow, but if it’s truly a marginal infiltrate, shouldn’t I be putting her on a steroid? If I put her on a steroid and it turns out she has Acanthamoeba or a fungal infection, could she go blind? Does this patient need to be seen at PCLI?
With the above case presentation, my response and recommendation would be:
Great job! I agree with your diagnosis. You’ve done everything right and have thought about the case from all angles. Your treatment plan seems appropriate. If the patient needs it, consider adding a mild steroid once the epithelium is intact. They absolutely do not need to battle rush hour traffic to get to PCLI to receive the same diagnosis and treatment plan.
This is very typical of the phone consults we are happy to provide. The practitioner thought through all the angles and devised an appropriate treatment plan. They had legitimate concerns about their patient’s long-term prognosis and potential loss of visual function, and needed reassurance that they were on the right track. And, if things headed south, they were confident a back-up system was in place.
We are here to support you, your patients and your practice. Whether you feel like you are in over your head, or just need a little reassurance, our entire team of optometric physicians is happy to help. This type of comanaged care is an important part of our service at PCLI.
Whether you cover after hour emergencies via cell phone, pager or a local call group, PCLI technicians and doctors are available 24/7 to back you up. If you have an urgent case after office hours, dial any of our offices and a recording will give you the on-call tech’s cell phone number. They can connect you with an optometric physician.