What I Did Not Put in the Chart

What I Did Not Put in the Chart

Jessica Neutz

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Chief Complaint: _______________

floaters / onset: one week

She said: floaters. She meant: I haven't told my husband yet.

I typed floaters. I typed onset: one week. I did not type the way she looked at me when I handed back her glasses, both of us knowing that floaters are sometimes nothing and sometimes the beginning of the kind of news that restructures a life. I did not type the specific quality of her pause before she answered each question. The way a pause can be its own diagnosis.

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History of Present Illness: _______________

glaucoma suspect, borderline IOP, disc cupping stable, returns Q6 months

There is a man who comes every six months. He brings his wife. Every time. She sits in the waiting room with a magazine she never opens. He tells me she drives now because the peripheral loss makes him nervous at night. He says: the wife makes me come. He says: you know how they are. I smile the smile that clinical settings require of women who are not doctors. I write: accompanied by spouse. I do not write that I think he is afraid and she is the only one who knows and neither of them will say it.

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Visual Acuity: OD _____ OS _____

20/20 / 20/20

Perfect vision. I have typed this about people who were crying. The human eye sees fine while the human being is falling apart. Vision and sight are not the same thing, and the chart has no field for what the patient is actually looking at.

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Slit Lamp Examination: _______________

mild blepharitis / trace SPK / anterior segment unremarkable

The slit lamp is an intimacy. Your chin here. Your forehead here. Don't blink. The machine brings me close enough to see the trabecular meshwork, the crystalline lens, the fine vessels in the iris, the exact topography of someone's cornea. My chin an inch from a stranger's chin. The room is dark. Sometimes people cry in the slit lamp and they don't know I can see it happening in real time, the tear film destabilizing, flooding the meniscus.

I write: anterior segment unremarkable. I do not write: she was crying in the dark and I pretended not to notice because there was no field for it and because noticing felt like trespass.

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Intraocular Pressure: OD _____ OS _____

OD 14 / OS 16

The tonometer touches the cornea for less than a second. Most people flinch. One man did not flinch and told me his mother had died that morning. He said: I couldn't cancel. She always reminded me about my appointments. I said: I'm sorry. I pressed the tonometer to his cornea again.

I wrote: OD 14 OS 16. I did not write what he told me. It was not medical information. It was the kind of thing you put somewhere else. I have never figured out where.

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Dilated Fundus Exam: _______________

dilation achieved / fundus exam deferred to physician

The dilation takes forty-five minutes. Patients sit in a dim room with their pupils forced open and nothing to do. Sometimes they talk. A woman told me about her affair. An elderly man cried about his dead dog for twenty minutes and then apologized for crying about a dog. A teenager told me she hadn't eaten in four days and then said: please don't write that down.

I didn't write it down. I knocked on the doctor's door afterward and said we had a patient with some concerns, and I watched the doctor go in, and I never knew what happened next because the chart only follows the eye.

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Assessment: _______________

The body has more information than medicine can hold. I learned this in the dark, in small rooms, with instruments designed to see past the surface of things. The chart is a vessel and it has a shape and the shape determines what pours in. Most of what I witnessed did not have the right shape. Most of what I witnessed landed nowhere.

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Plan: _______________

I don't know what I thought I would do with any of it. I was twenty-two. I was trained to refract, to measure, to document in the approved fields with the approved language. I was not trained for what to do when someone's body is fine and their life is not. I was not trained for the asymmetry of being trusted by people who have nowhere else to put things, in the dark, in a room that smells like eye drops, with your chin here, your forehead here, don't blink.

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Follow-Up: _______________

What I did not put in the chart: the woman whose husband stood in the doorway during the whole exam and never stopped watching her. The way the visual field looks when someone is losing it, the small missed points at the edges, the shape of the absence. The specific sound of a doctor delivering bad news through a wall I was standing next to. The way I drove home. The things I thought about. The way none of it went anywhere because I was not the patient, and the chart was not for me, and professionalism means you hold what you hold and then you let it go, except you don't, except it doesn't go.

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Signature: _______________