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

By Marie Savard MD

Editor’s note: Welcome to our third AGE 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.

We’ll start this week by letting you know what the patient told her PCP and how the doctor proceeded with the examination. Next week, the PCP will continue to look for clues to the medical riddle. The third week, we’ll let you know what some people have suggested as possible diagnoses. The fourth week, the doctor will reveal the actual diagnosis. Then we’ll move on to a new riddle for the following month!

The Patient Reports Her Symptoms

Barbara, age 62, is worried because she has pain in her abdomen and back that comes and goes, and she saw some blood in her urine.

As always in thirdAGE Medical Riddles, the doctor uses 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 Recommendations

This week, we’ll learn what Barbara told the PCP:

 “For several weeks I’ve had pain off and on in my abdomen in the pelvic area, and sometimes one the right side of my mid and lower back. The pain can be very intense to the point that I can hardly stand it – definitely a 10 on a scale of 1 to 10. But at other times, it doesn’t seem so bad. I’ve also been nauseated every now and then. That’s why I’ve been putting off making an appointment to see you. I just kept praying that whatever was wrong would go away. Wishful thinking, I know! Anyway, what finally pushed me to come here is that yesterday I saw blood in my urine although the pain is now completely gone. Besides that, my urine looked kind of brownish. I freaked out! I’m a high school English teacher with a winter break coming up in February. My husband and I have a trip planned to Disney World with my daughter and son-in-law and the grandchildren. I dread the thought of having something serious wrong with me that could spoil our vacation. I hope you’ll have good news for me so I can look forward to enjoying time with my family!”

The doctor took a complete history and asked specific questions about prior urinary tract infections (UTI’s, cystitis), family history of genitourinary tract problems, and what medications Barbara takes, including over-the-counter products. Barbara said she had never had UTIs, but that her father may have had some urinary problems. The doctor already knew that Barbara is on Lipitor, a statin drug that can occasionally lead to brown urine from muscle breakdown and myalgia (muscle pain). The doctor had previously prescribed the Lipitor for high cholesterol. However, Barbara also told the doctor that she takes a lot of Tums for indigestion. She takes a multivitamin every day.

Then Barbara mentioned that often has a metallic tasted in her mouth. The doctor suspected dehydration as the cause, and Barbara admitted that she purposely limits her fluid intake so she won’t have to go to the bathroom often during the school day when she’s teaching.

The doctor did a physical examination that showed Barbara’s blood pressure was normal at 120/76; her pulse was a little high at 88 (probably from dehydration and from anxiety about her health issue); and her mouth appeared a bit dry explaining her metallic taste. All else was normal including a pelvic exam. She had very minimal pain in right CVA area (costovertebral tenderness) when the doctor “percussed it”, meaning tapped it firmly.

The doctor performed urinalysis in the office with a “dipstick”, a strip of special paper. Barbara’s urine was clear in the office, but the doctor sent a sample to a lab for further testing to rule out infection. He also sent Barbara for a non-contrast CT scan to help exclude serious conditions such as a pelvic mass or tumor, and diverticular abscesses.

Barbara’s rectal exam was negative and there was no blood in her stool.

The doctor asked Barbara to make an appointment for a second visit when the results of the lab test would be available.

To be continued . . .

Come back to thirdAGE.com next Thursday to learn the results of Barbara’s lab test and CT scan, and to find out how the doctor continued his quest for a diagnosis.

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.