Publish 4 August 2022
Kevin RR Williams
Compounding Misdiagnosis
In my daily active life, I noticed a gradual back immobility. Stretching to reach my toes or bending side to side would relieve pressure. Months later I began curtailing activities.
Repetitive lifting of lightweight boxes or perhaps a single heavy one increased pain, mainly in my right flank. Simple tasks like rising out of bed or putting on socks became a test of endurance.
Over-the-counter pain relievers help productivity but are not a longterm solution. I scheduled a doctor visit for answers. This led to more questions:
Doctor Visit Consultation
“On a scale of 1 to 10, what is your level of pain?”
“It varies from 3 to 11. Right now it’s about 6.”
“Were you in an accident recently?”
“No”
“What type of trauma could cause this?”
“I don’t know?
“You should try taking Tylenol.”
“I’ve been taking them without significant relief for over 4 months.”
“I will refer you to an osteopath.”
Backache
An osteopath handles pain with non-invasive methods. Recommendations include vitamin supplements, topical ointments, and exercise. When these prove unsuccessful, he experiments with prolotherapy.
An ultrasound of my liver and gallbladder is unremarkable. An MRI focuses on the relatively healthy L-4 and L-5 lumbar region exhibiting incipit arthritis and minor protrusion without stenosis. This led to a pain management referral. Suspecting facet joint syndrome, spinal epidurals relieved most pain sensation for 18 months.
When the pain resumes, the osteopath issued temporary disabled placards and suggests more epidurals. Immobility results in weight gain so I receive a referral to 6 weeks of weight management classes. Weight loss does not eliminate the pain.
Within the HMO, I schedule appointments with my primary to request an audience with a rheumatologist. She runs tests and discovers vitamin D deficiency. Then she referred me back the same osteopath.
Abdominal Pain
Abdominal pain became another seemingly unrelated symptom. This led to a gastroenterologist referral. His desire was to perform upper and lower endoscopy. However, the pandemic hit and postponed elective medical procedures and surgeries.
Two years later, with daily NSAIDs the norm, I break the cycle of referrals by changing health plans—or so I think. During the first visit, a new symptom shines light on a diagnosis—hematuria. A 3D CT scan of the digestive system reveals an oblong kidney stone measuring between 7 and 10.3 millimeters (0.4 inches). This explains the backache, abdominal pain, nausea, and blood in the urine.
A urology referral is 3 months away. As a new patient, I receive the next available urologist—new to the practice. Unprepared for the visit, he has none of the imaging records but begins examining blood and urine results during the visit. He then orders an X-ray and makes a referral to a nephrologist 2 months away.
Emergency
Symptoms multiply with abdominal discomfort, nausea, constipation, and waves of sharp pain. Two courses of magnesium citrate relieves constipation, but not all abdominal discomfort. During an emergency room visit, 4-month-old imaging is repeated. Followup consultation recommends stone removal.
Detection of the stone causing years of discomfort was spurred hopefulness, but the delays continue. With X-ray on disc, a followup appointment is scheduled 3 days prior to nephrology.
On that visit, I discover that the urologist unilaterally cancelled my appointment. The nurse offers to work me in. This turns out to mean wait 2 hours for medical group founder to consult during lunch hour.
Procedure
After a brief mea culpa for his colleague, the conversation focuses on scheduling a visit to break up the stone. The most effective method involves transurethral laser vaporization of the stone(s) with image guidance. On the way, to the kidney, the surgeon takes photos of the bladder (cystoscopy) and inserts a temporary stent to hasten exiting of debris.
An alternate method does so through high-energy shockwaves. This can result in external bruising and possible kidney damage. It does not negate the need for cystoscopy and stent.
Since neither eliminate the need for transurethral investigation, I choose the recommended, more expensive, procedure. After meeting the insurance deductible, cost will balance out.
Under general anesthesia, there is no discomfort during this surgery absent of incisions. Upon awakening 90 minutes post-op, I experienced sharp abdominal pains. Five courses of pain relievers lasted a maximum of 20 minutes each.
Post-Operation
Discharge would necessitate urination. However, the first attempt was unsuccessful. Drinking several cups of water and apple juice with an additional pain reliever and muscle relaxer extended my post-op recovery to 5 hours.
Finally, a painful combination of blood and debris was excreted. This reduced the abdominal pain from level 7–8 down to level 2. Discharge with 4 prescriptions was then possible.
Painful urination continued throughout the night. But the absence of right-flank pain on the prior location of the stone was welcomed.
Temporary stent extends from kidney to bladder.
Within a few days the flexible stent is removed during a followup urology office visit. Even with local anesthetic, the brief process is uncomfortable. Urine color migrates from red, to pink, to yellow, and mostly clear. A nephrologist can evaluate urinalysis months later.
Welcome Change
Years of misdiagnosis was the result of reliance upon antiquated equipment and narrow ares of specialization. The assumption of radicuelopathy resulting from chronic L5 back pain prevented kidney exploration. MRI equipment was aimed at the spine. In-house ultrasound focused on the liver and gallbladder.
A new health plan with modern abdominal CT scans detected the kidney stone. It was not, however, initially regarded as urgent. In time, when it severely impaired daily function, the urologist took action. Ideally, patients should not need to wait months or years for proper diagnosis and treatment. If you are unsatisfied with your care, don’t recoil from voicing your displeasure or changing health plans.
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