“Hi, Bob, what’s going on?” Melissa asked the fifty-nine-year-old when she entered the exam room.
Bob paced back and forth. “Something bad, Doc. My insides feel like Dana Higgins’s mule trampled them.”
“When did the pain start?”
“I hurt a little last night, but this morning the pain done gone and got bad on me.”
“Have you seen any blood in your urine?”
“Ain’t paid no attention to that, Doc.”
“Any diarrhea or constipation?”
“I’m like clockwork after dinner.”
Melissa asked a few more questions, made notes in the chart. “Have a seat,” she told the still pacing man, “and I’ll check you.”
Having him take off his shirt first, which he did with several grunts and moans, she listened to Bob’s heart and lungs. Nothing abnormal. She motioned for him to lie back on the table, and for a moment she didn’t think he was going to comply, but, grimacing, he slowly lowered himself.
“Show me where you hurt,” she ordered. He pointed to his right lower quadrant, close to the midline. “That’s an appendectomy scar, isn’t it?”
“Had my appendix out when I was fourteen,” he confirmed.
“Have you ever had a kidney stone?” From the amount of pain he was in, she suspected that might be the culprit.
“A few years ago. You think this is another one?” He winced. “I hurt up higher with the last one. More in my back.”
Melissa listened to his abdomen, but everything sounded normal. She went to lightly palpate it, but Bob’s hand covered hers.
“I don’t think I can let you do that.”
“I have to check you. I’ll be as gentle as I can.”
Swallowing, Bob nodded, closed his eyes and visibly braced himself for expected pain. Melissa’s sense of unease grew.
She gently checked him, but his guarding prevented her from feeling confident in her exam.
“Bob, I’m going to do an X-ray of your abdomen as I can run that here at the office. Depending on that and what the tests Debbie ran show, I will likely send you to Dekalb General for a CT scan of your abdomen and pelvis.”
Melissa stepped out of the room and went into the small lab where Debbie and the lab technician stood.
“He’s got four plus blood in his urine. Think it’s a kidney stone?” Debbie asked.
“His blood count is normal,” Stacey, the lab technician, who was also certified as an X-ray technician, said. “And everything else on his urinalysis is normal.”
Which would make one think Bob had a kidney stone.
“I’d like an abdominal and pelvic X-ray. Maybe the stone will show. Come get me when it’s done.”
Melissa went back to her desk to do some paperwork while she waited.
A few minutes later Debbie stuck her head in the doorway. “X-ray’s ready. He has a stone on the right.”
Relief washed over Melissa. She would order some strong pain medication for Bob, have him drink plenty of fluids, and send him for a CT scan this afternoon.
But when she looked at the X-ray, she frowned. The stone was too high. Other than a lot of gas in the intestines, probably from his pain, she didn’t see anything else abnormal.
“I’m finished with my last patient for the morning.” James walked up behind her to look over her shoulder at the X-ray light box. “Debbie said you needed help.”