Meghan blinked drowsily as she reached for her phone, the alarm going off to let her know it was now 8 am. She sighed and snuggled under the covers, wishing she could go back to sleep, but she knew she needed to shower and wash her hair prior to heading to see Mitch. She pushed back the covers and swung her legs to sit on the edge of the bed… then remembered the injury she’d sustained the evening before as her leg started to throb.

She limped her way into the bathroom and dug in her cupboard for some leftover pain meds. She found a bottle that matched the prescription form from the evening before and took a dose as prescribed. Well, a shower’s out, she thought, looking down at the bandaging covering the new sutures. Guess it’s back to the bed bath routine for a few days.

Meghan cleaned herself up and washed her hair in the sink before brushing out the tangles. She made sure to shave her underarms and her legs as best as she could, considering the large bandage covering half of her right calf. She brushed her teeth, put her hair up into its usual pony tail, and headed for the bedroom.

She pulled on her usual undergarments, a pair of loose pants, a Guns vs. Hoses t-shirt, and shoved socked feet into casual tennis shoes. She knew everything would be coming off later, so she wanted casual, comfortable attire.

She left the house after longing glances at her coffee maker and headed for the pharmacy. She waited in a long line to get the scripts checked in and was warned of a longer than usual wait for them to get filled. Looking at her watch, she pulled out her phone and called her sister.

Meghan! How are you this morning?

“Aside from hungry and jonesing for coffee? Hey, could you pass along to Mitch that I’ll be a bit later than 9? I’m waiting for the pharmacy to fill my prescriptions, and I think everyone decided to get theirs this morning. It’s going to be a bit of a wait.” Meghan looked at the long line still waiting to speak to the pharmacy tech.

Do you need to get them now, or could you go back to pick up your meds? Kelsey asked.

“Well, normally I’d just come back for them, but since one is an antibiotic…” Meghan replied.

Gotcha. Well, hopefully it won’t take you too long. We’ll see you when you get here.

Meghan hung up the phone and started walking around, browsing the shelves in an attempt to make the time pass by. She was perusing the nail polish when her name was called on the speakers. She made a selection and returned to the pharmacy counter. She paid for the polish and her prescriptions and headed back to her car and her in-law’s home.

Kelsey greeted Meghan when she arrived. “Hey, there, sis! Only about 15 minutes later.”

Meghan nodded. “I think everyone and their cousin were there to get prescriptions this morning.” She sniffed the air appreciatively and sighed. “Okay, where’s that husband of yours? I want coffee!”

Mitch laughed, having overheard her comment. “Did you get your meds? Kelsey said that you got stuck at the pharmacy.”

Meghan held up her bag of purchases. “Right here. I’ll take them when you let me have something to drink.”

“Well, let’s get your labwork drawn, then.” He gestured towards the medical suite, and Meghan headed towards the exam suite. Mitch had a chair sitting next to the exam chair already, and gestured for Meghan to sit there. He brought over supplies, arranging them on the chair, and Meghan placed her right arm up on the chair. “I’m going to have labs run on both your blood and urine. But let’s get the blood drawn first.” He secured a tourniquet around her arm and inserted a butterfly needle into a vein. He filled a complete set of tubes – 5 in all – before removing the needle and applying a bandage. He picked up a specimen cup and handed it to her.

Meghan took the cup and retreated to the bathroom, returning within a few minutes with it half-full of urine. She set this carefully on the paper towels on the cabinet that Mitch indicated as he put label stickers on the test tubes.

“Meghan, you can head for the coffee pot,” Mitch chuckled. “I’ll be in soon for some myself.”

Meghan was happy to head down the hall and accept a steaming cup from Kelsey. Meghan sipped the coffee and sighed in contentment.

Mitch rounded the corner and chuckled. “You’re an addict, you know that?”

“Yeah, I know, but it’s about the best thing out there to be addicted to,” Meghan countered.

Kelsey shook her head in amusement. “That’s the pot calling the kettle black, Mitch.”

“True.”

They drank their coffee while chatting amicably. Meghan stood up and retrieved a glass from the cabinet and made her way over to the refrigerator to get ice and water from the door dispensers. She returned to the bar stool she had been sitting on and pulled over her pharmacy bag. She skipped the pain meds but opened the antibiotic bottle and took her first dose, washing it down with the water. She put it in the bag and saw her other purchase.

“Sis, I got this for you. I think I remember Mitch liked the color,” she said, winking at him.

Kelsey accepted the polish and winked. “Yes, he did! I might have to put some on this evening.”

Mitch cleared his throat. “If you’ve had enough coffee to last you for a little bit, let’s get you checked out, Meghan.”

Meghan finished off her coffee. “Okay, let’s get it done.” She followed Mitch to the exam room again. He handed her a gown and a drape for her lap. “You know the drill: everything off. You can keep your socks on for now. I’ll be here when you’re ready, and you might want to void your bladder again.”

Meghan accepted the pieces of cloth and headed for the bathroom to change, leaving her clothes in the bathroom piled on the vanity. She put the gown on so that it opened to the back and wrapped the drape around her before exiting the bathroom and stepping back into the exam room.

Mitch indicated the exam chair, and Meghan sat down on it from the side. Mitch picked up his stethoscope and approached her. “Okay, Meghan, I’m going to do a full physical exam. I want to be thorough, so that we don’t miss anything, okay?”

“Sure, Dr. Mitch. I want to get this figured out.”

Mitch smiled as he pulled his stethoscope from around his neck and placed it in his ears. He approached her back and placed the bell on her bare skin. “Deep breaths for me, Meghan.” He listened carefully to her lungs, thankful that they sounded clear. He moved around in front of her and placed the bell on her chest. “Breathe normally. I’m going to listen to your heart.”

He listened carefully to her heart, making sure there were no murmurs present. Satisfied, he removed the stethoscope from his ears and lay the instrument on the counter. He pulled the otoscope from the wall unit and looked in her eyes, ears, up her nose, and then removed a tongue depressor from his pocket. He unwrapped it and put it in Meghan’s mouth. “Say aaah.”

“Aaahhhh.”

“Throat looks good,” he said, removing the depressor and throwing it away. He replaced the otoscope on the wall unit and stood behind her. Confident hands felt along her jawline, palpating her lymph nodes. Then he made his way down to her larynx. “Swallow for me.”

Meghan swallowed. Mitch came around in front of her. “Meghan, if you don’t mind, lie down for me. I want to look at your stoma scar for a moment.”

Meghan lay back on the exam chair, and Mitch made sure the extension was pulled out for her legs. Mitch moved the neckline of her gown down a bit to see the stoma better and gently palpated it and the surrounding tissue. “It looks fine, Meghan. Healed nicely. Does it ever cause any issues?”

“No, and thankfully it didn’t affect my voice. I’ve heard that some people have voice changes with a trach.”

Mitch helped Meghan sit back up, sliding in the table extension for the moment. “Okay, Meghan. Let’s do a breast exam. I want you to go ahead and drop your gown to your waist.”

Meghan did as requested, pulling her arms out of the sleeves of the gown and letting it fall to her waist. Mitch put her through several positions so he could observe how the breast tissue moved and looking for any abnormal lumps or bumps. He finally had her put both arms above her head and keep them there. He spent a good couple of minutes palpating the lymph nodes in her axillae and looking at the skin there before examining each breast. He then helped Meghan to lie back down, pulling out the table extension again.

Mitch looked closely at Meghan’s skin before repeating the breast exam in this position. “Meghan, have you ever noticed that you have a darker patch of skin running between and slightly under your breasts?”

She nodded. “I’ve seen it, but just figured it was maybe a buildup of skin or pigmentation or something. Is it a bad thing?”

“Not necessarily,” he assured her. “I’m just looking for anything and everything right at the moment.” He smiled and reached for her right arm, guiding it above her head and proceeding to repeat his thorough breast exam. He guided that arm down and had her raise her left arm so he could examine the left breast carefully.

He then took time to again look at the darkened skin on her chest, raising each breast a bit to better visualize the skin changes. He also took time to palpate over her ribcage and her sternum. Finished with this part of his assessment, he helped Meghan put the gown back on.

Mitch then lifted the hem of the gown to just below her breasts and lowered the drape to just above her pubic mound. He started with listening to her abdomen carefully, reaching below the drape to listen to her femoral arteries. Setting his stethoscope aside, he started palpating her abdomen, first superficially before going deeper with his palpation. “Sorry if this gets a little uncomfortable, but I want to be sure to palpate your liver and your spleen.” Meghan nodded, although it was a touch uncomfortable at times.

Mitch then moved his hands so that one was under her back and the other on her abdomen and palpated deeply, feeling her kidney on one side before moving to do the same on the other side. He noticed a dark patch around the surgical scar from her cyst removal less than a year ago and gently palpated along the scar line. “Does this hurt?”

Meghan shook her head no. Mitch pulled down the hemline of the gown and raised the drape up some. He then drew up the bottom of the drape to mid-thigh. He tugged off her socks before starting to inspect her feet. Meghan giggled as he ran his hand along her arches. He checked pedal pulses and did a Babinski reflex test before helping her snug her socks back on again. He checked the range of motion for her ankles, her knees, and her hips. Aside from tight ankles, he found nothing wrong.

“Okay Meghan. I’m going to do a pelvic exam now. Let’s get the table set up and get you into position.” Mitch attached the knee supports to the chair and helped guide Meghan’s legs into the supports as she scooted down to the end of the table. Mitch pulled over his rolling stool as he moved a tray with the needed supplies close to the exam chair. Mitch donned a clean pair of gloves and sat down on the stool.

“You’ll feel me touching you.” He touched her inner thigh before starting to run his fingers over her pelvic area, feeling the lymph nodes there. He grasped her labia majora and separated them, carefully palpating the tissue. He then grasped her labia minora and separated them, revealing the rest of her vulva and perineum. He quickly palpated her clitoral shaft and hood, retracting the latter for a brief inspection of her clitoris. Fingers then went lower to palpate around and over her urethral opening.

Mitch inserted one finger just inside the vaginal orifice and used index finger and thumb to milk the glands there. He then inserted the index finger a little farther, palpating her urethra from inside the vagina. He withdrew his finger and picked up a metal medium Graves speculum and lubricated it. “I’m going to insert a speculum now, Meghan. Relax for me.”

He reintroduced his index finger just into the vaginal introitus and applied downward pressure as he inserted the speculum, rotating it into position. He opened the bills enough to see inside until he located her cervix, then opened the bills fully and secured the instrument open with the thumb screw. He adjusted the overhead exam light and clicked on the smaller gooseneck lamp to provide maximum illumination. He took his time visualizing her cervix and what he could see of her vaginal walls. Finally, Mitch undid the screw and carefully removed the speculum from Meghan’s vagina. He set the speculum aside and reached for another speculum – this time, a small metal Collin’s speculum. He lubricated this as well.

“Meghan, I’m going to use a Collin’s speculum as well. This will feel a little different – it will open side to side, not up and down.” Meghan nodded in understanding, and Mitch once again inserted a finger to provide downward pressure as he inserted the speculum. He carefully started opening the blades with the thumb screw, careful to not cause undue pain. When he had it sufficiently opened, he looked again at the cervix and the vaginal walls.

“Meghan, I want to get a second urine sample, this time a sterile sample. I’m going to do a quick catheterization.” Meghan sighed, and he knew she wasn’t looking forward to it. “I’ll be quick, I promise.”

“Yeah, I know. Do what you need to do. I’ll live.”

Mitch removed the tray with the previous speculum from the stand, replacing it with a clean tray. He set the cath kit on the tray and proceeded to open and prep it. Standing between Meghan’s legs, he cleaned her vulva with the alcohol swabs, holding her vaginal lips open and apart with one hand. He picked up the catheter and placed it at her urethral opening. “Deep breath, Meghan.” As she did so, he inserted the catheter and advanced it up to her bladder. He brought the specimen cup up to the end of the catheter just as urine started flowing. He collected a good sample before letting the rest of her urine flow into the catheter tray. Once she was empty, he clamped the end of the catheter, leaving it in. He reached a couple of fingers into her wide vagina through the speculum and palpated her urethra as best as he could, the catheter making the palpation easier. Satisfied, he removed the catheter and then the speculum.

“You’re doing great, Meghan. Let’s get a bimanual exam done.” He changed his gloves before putting lubricant on his fingers and inserting them into her vagina, his other hand on her stomach. “Any pain?” he asked as he examined her uterus and ovaries.

“Thankfully no,” Meghan replied. Mitch removed his hand, added more lubricant, and brought it to her vagina again, one finger poised at her anus.

“Bear down, Meghan. I’m going to do a rectovaginal.” She did as requested, and his fingers slipped into both orifices. Another careful palpation, and his fingers were removed.

Mitch stripped his gloves and went to stand by her. “Well, so far I’m not seeing much of anything. I do want to do a rectal exam before I call the exam done. When’s the last time you had a bowel movement?”

Meghan thought for a minute. “A couple days ago, I think.”

Mitch nodded. “I’m going to give you an enema, then. It’ll help clean you out and make it easier to do your rectal exam.” Meghan groaned. “No soap with this one, Meghan. It’ll just be one with plain tap water.”

She nodded, resigned. Mitch took that as consent, and went over to the cabinets to gather supplies and prep the enema. He brought the bulging bag over to her side, hanging it on the IV pole. Mitch added some lubricant to the end of the temperature probe he brought over with him and positioned it at Meghan’s anus. “Thermometer first, Meghan. Relax for me.” He inserted the thermometer and waited for it to read. Once it beeped, he removed it. “99.3, so that’s normal.” He set the thermometer aside, lubricated his finger, and brought it to her anus. He massaged her anal ring until she relaxed and inserted his finger. He did a quick digital exam, lubricating her anus as he did so. Removing his finger, he lubricated the enema nozzle and inserted it deep into her anus. He opened the clamp, and let water enter her colon.

Meghan had been dreading the enema as soon as Mitch announced he was going to give her one, but she was pleasantly surprised to find that she didn’t mind it nearly as much as she was afraid she would. She had a couple bouts of cramps, but they weren’t bad. Mitch had her hold the enema for about 10 minutes before sending her to the restroom to expel.

Mitch took this time to both clean up some of the equipment and supplies he had used, but also to prepare for her rectal exam. He wanted to get a deeper look than he had in the past, so pulled out equipment to assist him in his examination.

When Meghan returned, Mitch had her lie down on her stomach on the exam chair. He extended the table extension for her legs. “Raise up for a minute, Meghan.” Mitch shoved a large bolster under her hips. “Okay, lower yourself back over the bolster. It’ll make it a little easier to do your exam.”

Meghan lowered herself over the bolster, well aware that her bottom was now jutting out in a very obvious way. She was also very much aware of the breeze caressing her buttocks since she was in the open-backed gown without the drape she had previously.

Mitch brought over a new tray of equipment and a bottle of lube. He pulled on a pair of gloves. “I’m going to lubricate your rectum, and then use a couple of different scopes to take a closer look. There might be some discomfort, but I’ll be as gentle as possible.” Mitch squeezed a generous amount of lube onto his finger and brought it to her anus. “Okay, now, relax for me.”

Meghan felt the cold of the lube on his finger and did her best to relax. She felt his finger slip inside her anus and make its way deep into her rectum. She could feel his palpations as he rotated his finger around, carefully feeling for any abnormalities. He removed his finger and stripped off the glove before replacing it with a new one.

“Okay, Meghan. I’m going to use the first scope now. It’ll feel larger than my finger, but it’s not much bigger.” Mitch lubricated the scope and brought it to her anus. He gently inserted the scope all the way into Meghan’s rectum before removing the obturator and shining a light so he could see the tissue. It looked nicely pink and healthy, but he wanted to take a deeper look just to be sure. He replaced the obturator and gently removed the anoscope. He set it aside and picked up the rigid sigmoidoscope.

“Meghan, you’re doing great. I want to look a little deeper into your rectum. I’m going to use another scope. This one is longer, and I will be inflating some air into your colon to help advance the scope. It shouldn’t hurt, but it might be a bit uncomfortable.”

Mitch lubed the scope generously and brought it to Meghan’s anus and started to insert it slowly into the depths of her bowels. This scope was connected to wiring that allowed him to visualize everything on CCTV, so he switched on the monitor and looked at her colon tissue as he advanced the scope. He saw a little bit of fecal material towards the top of the rectum, but he wasn’t concerned, as the enema had just been to rinse out the worst of the feces. He finally withdrew the scope from Meghan’s backside and set it aside, turning the CCTV back off.

Mitch stripped off the gloves and moved to Meghan’s side. “Lift up,” he instructed, and removed the bolster from under Meghan’s hips. Gratefully, Meghan turned back over and sat up with Mitch’s help.

Mitch put the mechanics of the examination chair into motion, bringing the back up and lowering the table extension so that Meghan was sitting comfortably. He also lowered the chair to be easier to get out of. Mitch brought over the chart he was making notations in and sat down on his rolling stool in front of her.

“So, what did you discover?” Meghan asked.

Mitch ran a hand through his hair. “Well, aside from some darker patches of pigmentation in a few places, not a lot. Based on your physical exam, you’re healthy, with no reason to have blood pressure crashes. We need to see what those lab results are before I can go much further. However, I have some health questions that I want to ask, as that might help shed some light on this situation as well.” Meghan nodded. “But first, let’s get you warmed up.”

Mitch rose, placing the chart on his stool, and walked over to the blanket warmer. He pulled out the two blankets there and tucked one around Meghan’s shoulders, placing the other one over her lap. Meghan snuggled into the warmth.

“Thanks. That feels better. Okay, ask your questions.”

Mitch sat back down, smiling. “Well, if you insist! When did you first become aware of the bouts of low blood pressure?”

Meghan thought back for a minute. “Hmmm. I guess it’s really been since I got hit by that car. Although, I think I’ve had it happen a few times before that, but never really connected the dots. Probably blamed it on being sick or dehydrated or moving too quickly, that sort of thing.”

Mitch nodded. “And how would you say you feel on a typical day? Do you have enough energy? Normal appetite? Any issues with urination or bowel movements?”

Meghan still felt a little awkward talking about this with Mitch, but plunged ahead. “Well, I’m tired all the time, to be brutally honest. I’ve been constantly tired for years, though, so I can’t really say that’s anything new. Maybe a little bit more intense since the accident, but then again, I’m not as young as I once was!

“As far as my appetite… there’s times when I’m absolutely ravenous, but then it doesn’t take much before I’m full. And other times I don’t really want to eat. I think I’m urinating okay; at least, I’ve not noticed much changes aside from the fact that I’m trying to increase my daily water intake, so I’m peeing more frequently because of that,” she chuckled. Mitch smiled reassuringly.

“And I’m generally having a poop every day or two. I haven’t even needed prunes!” she joked.

“That’s good! And if you ever have issues, you know where to find me,” Mitch declared. Meghan looked away for a moment. Mitch sensed that she was still feeling timid about that, so moved on with his questions. “You said you weren’t eating like before. Are you having issues with nausea or heartburn?”

Meghan gave him a weird look. “Not heartburn, no, but sometimes I will think about eating and then start getting nauseous. I’ve never thrown up, but the nausea is enough for my appetite to go away.”

“Any abdominal pain with the nausea?”

“No.” She shook her head. “Just the nausea.”

“How about your weight? Have you noticed any fluctuations there?”

“No, but then I haven’t weighed in a while. It’s never been something I’ve kept track of,” Meghan confessed.

Mitch looked at her, then motioned for her to stand up. “Well, let’s get your current weight.” They walked over to the opposite end of the room where an old-fashioned scale stood. Meghan handed Mitch the blanket from around her shoulders before stepping up onto the scale. Mitch set the blanket aside and moved the weights around until he had her weight. “You’re currently at 105 pounds. You’ve lost weight again.”

Meghan just nodded and accepted her blanket back. “I was around 120 pounds when I went back on duty.” She headed for the exam chair and sat down, placing the other blanket back over her lap.

Mitch sat back down on the stool. “Is there anything else that you’ve noticed out of the ordinary. Even something small or maybe inconsequential?”

“Well… I get sore easier than I used to. And sometimes it doesn’t take much to have me stressed out or feeling a bit lightheaded. I’d say the lightheaded feeling is the most concerning to me, because I don’t know if I might be getting ready to pass out again.”

Mitch nodded. “I’m sure! Have you passed out?”

Meghan shook her head. “No, thankfully, but it is something that I’m afraid might happen.” Meghan sighed, and yawned. “Do you have any ideas as to what might be causing this?”

Mitch shook his head. “No, not really, at least not until I see your bloodwork. If you don’t mind, I might reach out to a couple of colleagues and see what they think.”

“Be my guest,” Meghan replied. “I’d just like to know what’s causing everything so we can treat it. I hate it when a doctor can’t deal with their lack of knowledge and just chalks patient symptoms up to phycological problems. I’ve transported several patients with bad health issues that were treated and ignored like that.”

Mitch placed his hand on Meghan’s arm. “I know you too well to think that you’re faking anything or that it’s a psych issue. I will get to the bottom of this, I promise.” Mitch stood up and placed the chart on the counter. “Well, let’s get you dressed and we’ll see about that lunch I promised!”

“Sounds like a plan to me!” Meghan stood and headed for the restroom. As she went to change, Mitch started cleaning up from her exam, setting the metal instruments in sterilizing solution to soak before being put in the autoclave later. He removed the soiled paper on the exam chair and sprayed it down with disinfectant before pulling more paper to cover the chair. He disposed of the other sundries and wiped down the countertops and trays.

Meghan emerged after a few minutes. She glanced at the tub of soaking instruments and did a double-take. “That was inside me?!” she asked, pointing to the sigmoidoscope. “That’s huge!”

Mitch chuckled. “Yes, it was. That’s the rigid sigmoidoscope, the second scope I used to visualize your colon.”

Meghan shook her head again. “It’s probably good you didn’t show that to me before using it.” She looked around the room. “Do you need to do anything else before we go? I can help clean, if you need it.”

Mitch smiled. “No, everything’s taken care of except for those instruments. I’ll let them soak for a few hours and run them through the autoclave tonight.” He led her out of the exam room, turning off the lights and shutting the door after retrieving the baggie of test tubes and urine samples. “We’ll take a detour to drop these off at the lab before we go eat.”

They found Kelsey in the living room, reading. She looked up. “So, is she gonna live?”

Mitch chuckled. “I think so. I need to swing by the lab to drop these off before we go eat.” Kelsey nodded and got up.

“Let me get my purse, and I’ll be ready.” She disappeared off into the bedroom.

“I forgot to ask, Meghan. Do you mind if I discuss your health with Kelsey?”

“Of course not. If there’s something I’d rather you not share, I’ll tell you, but otherwise I have no secrets from her.”

Kelsey rejoined them, slinging her purse over her shoulder, and followed Mitch as he led them to the car.