Solve the Medical Riddle: She Has Intermittent Severe Pain in Her Abdomen, and She Saw Blood in Her Urine, Fourth Week

By Marie Savard MD

Editor’s note: Welcome to our thirdAGE feature that gives you a chance to play medical sleuth as we share the details of what happened when a patient presented with a problem that stumped the physician at first.

The first week of this riddle, the patient reported her symptoms to her PCP. The doctor proceeded with the examination using the classic S-O-A-P notes as follows:

S=Symptoms or Chief Complaint

O=Objective Findings

A=Assessment or Analysis

P=Treatment Plan or Recommendation

Last week, we let you know what some people had suggested as possible diagnoses. This week, the doctor will reveal the actual diagnosis. Then we’ll begin a new riddle for the following month!

The Doctor Reveals the Diagnosis

Thumbs up to Georgia L. for guessing the correct diagnosis! Barbara did indeed have calcium kidney stones. The tip off was high calcium in the urine, often from a type of kidney leak of calcium that is hereditary. Georgia is correct that Barbara’s father’s generation often did not discuss personal medical issues in detail with family members. That’s a big mistake, since family medical history can help with diagnoses of family members’ medical issues.

Also, Georgia is right about the fact that plenty of people think that only men get kidney stones, even though women can get them as well. In Barbara’s case, the family predisposition to the calcium stones was precipitated by her dehydration and her intake of Tums, which are almost pure calcium. Dehydration leads to calcified urine sediments or crystals that solidify, enlarge, and then drop through the tiny part of the ureter called the lumen. The sharp, crystallized stone “cut” or irritated Barbara’s ureter on the way down, leading to severe pain and eventually microscopic or even “grossly visible” blood in the urine. Her pain finally stopped after the stone passed on its own into the large bladder.

Fortunately for Barbara, the blood in her urine was a sign that she needed to be checked out even though the pain stopped. Some people may have microscopic blood in the urine and not even know it!

The doctor advised Barbara to avoid dehydration by drinking lots of fluids throughout day. He told her to get dietary calcium from yogurt, milk, and cheese because she needs calcium to help prevent bone loss, and she loses calcium in her urine due to her hereditary condition. He prescribed Hydrochlorothiazide (HCTZ) 25 mg daily to stop the renal leak of calcium given her history and family history of stones. He also told Barbara NOT to take calcium supplements or Tums.

However, the doctor told her to continue her daily multivitamin, which gives her 400 IU of vitamin D. Most people in northern climates – Barbara lives in Boston — may need more vitamin D, but it is controversial whether to take extra vitamin D with a history of kidney stones. Kidney stone patients often have low vitamin D levels but taking too much vitamin D could lead to increased calcium absorption and increase kidney leaking of calcium.

Here is Barbara’s take on her kidney stone diagnosis:

“That was the worst pain I’ve ever experienced, but I don’t even care because the outcome was so good! When I saw that blood in my urine, I thought I might have cancer. What a relief to find out that I passed kidney stone on my own and that there are ways to prevent getting another one. I’ve made it a point to drink plenty of water and I just run to the bathroom between classes when I’m teaching. We have five-minute breaks so I usually have no problem. If I’m late by a minute or two getting back to class, that’s not the end of the world. I have appointed one student in each class as the ‘leader’, and he or she starts collecting homework and making sure the rest of the kids sit down and behave in an orderly fashion. Oh, and we did get to go on our February vacation to Disney World! It was fabulous! My grandchildren are beyond adorable. I’m going to make sure they know my medical history when they’re a little older since these calcium stones can run in the family. Better safe than sorry!”

Come back to thirdAGE.com next Thursday when we’ll introduce a new medical riddle!

Marie Savard, M.D., a former Medical Contributor for ABC News and a frequent keynote speaker around the world, is one of the most trusted voices on women’s health, wellness, and patient empowerment. She is the author of four books, including one that made the Wall Street Journal list of the best health books of 2009: “Ask Dr. Marie: What Women Need to Know about Hormones, Libido, and the Medical Problems No One Talks About.” Dr. Marie earned a B.S. in Nursing and an M.D. degree at the University of Pennsylvania. She has served as Director of the Center for Women’s Health at the Medical College of Pennsylvania, technical advisor to the United Nations’ Fourth World Conference on Women in Beijing, advisor to the American Board of Internal Medicine Subcommittee on Clinical Competency in Women’s Health, health columnist for Woman’s Day magazine, and senior medical consultant to Lifetime Television’s Strong Medicine. Please visit DrSavard.com.