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The case was straightforward, exactly what we needed on a busy morning. A 40-year-old construction worker had given me a history that sounded as if he had reviewed the signs of acute appendicitis just before walking into the clinic. He’d had two days of central abdominal pain that had now migrated into his right lower quadrant, mild nausea, no appetite, no vomiting, and no diarrhea. “A slam dunk,” I thought. “Appendicitis until proven otherwise.” I asked him to lie down on the exam table, but my mind had already begun to move to the next question: Where could I send him for surgery?
My wife and I were volunteering in New Orleans East, just north of the devastated lower Ninth Ward. Nine months earlier, Hurricane Katrina had tried to wash away the Big Easy, and almost everything, including the health-care system, was still broken. In a parking lot across from a flooded-out high school, a charitable group had set up a cluster of trailers to serve as a clinic. A hundred people were being treated daily, many lining up in the predawn hours hoping to be seen.
At the city’s few functioning emergency rooms, the waiting time was up to two hours. And that was just to get a patient out of the ambulance. Once inside the ER, it was another 6 to 12 hours to get seen. “Unless you are bleeding or having chest pain, it’s a long wait wherever you go in this city,” the paramedics told me.
I continued with the exam. Placing my hands on the patient’s belly, I began exploring for the tenderness that I knew I would find on the lower right side. I pressed down gently and looked for any sign of pain. His face, however, remained impassive. When I asked him if it hurt, he said no. I pushed systematically all over his abdomen. No tenderness anywhere.
“Does this hurt?” I asked again, pressing once more on the right lower quadrant. His answer was unchanged: “No.”
I almost asked him, “Are you sure?” but refrained. Twenty years of practice had taught me to recognize when I had stumbled down the wrong diagnostic path. My slam-dunk case had just gotten interesting.
What could cause these symptoms yet produce no abdominal tenderness? My number one guess was a kidney stone, a mass that can form from minerals such as calcium in the urine. When stones migrate down the ureter—the channel linking the kidney to the bladder—they can cause trivial pain or induce sheer agony. But in either case, unless there are complications, there should be no abdominal tenderness.
The clincher would be blood in my patient’s urine. Stones in transit scratch the ureter as they travel and thus almost always cause microscopic amounts of blood to appear. We had a rudimentary lab at the clinic, so I had the patient give me a urine specimen. I dipped a plastic strip loaded with 10 different chemical spot tests into the urine, laid the strip on a paper towel, and then watched. Over the next 60 seconds I observed each of the spots for a color change. Sure enough, the one for blood turned blue-green—positive. “Yes, indeed,” I smiled to myself, “you almost fooled me.” But then I stopped short. My eye had just caught the spot for glucose. It was rapidly turning orange-brown—strongly positive for sugar.
