A 49-year-old woman presents to her primary care practice 4 weeks after she underwent a retrograde ureteroscopy on the right side for extraction of an obstructed 6-mm ureteral stone. Since the procedure, the patient has experienced intensifying flank pain on her right side. She notified her urologist, who advised her to follow up with her primary care provider to rule out a nonrenal etiology for the pain. She was instructed to return to the urologist should her symptoms persist.


At presentation in 2020, the patient reports no significant medical history other than recurrent nephrolithiasis and a diagnosis of cervical human papillomavirus (HPV) 22 years earlier. She has had 7 previous kidney stones: 3 passed spontaneously, 2 were treated with lithotripsy (in 2006 and 2007), and 1 required stone extraction in 2016. 

The patient is a registered nurse who works 12-hour shifts, which rarely affords her time to hydrate or void at work. She does not take either calcium or vitamin D supplements out of concern of developing additional kidney stones. She runs 1 mile per day and rows 6 miles per week. Her last menstrual cycle was 11 months ago, and her Fracture Risk Assessment Tool (FRAX®) score shows a 10-year risk for osteoporosis-related fracture of 5.3%. She has not had any previous bone density screenings. All other annual screenings including a mammogram, colonoscopy, purified protein derivative skin test, and annual physical examination are up to date and normal. 

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The right-sided flank pain has been present for several months. She describes the pain as 9 out of 10 on visual analog scale and it occurs upon standing, bending, or lifting and improves when lying flat. Unlike all previous kidney stones, she denies any dysuria, nausea, vomiting, or colicky pain although she feels a constant pressure over her bladder and right flank. She denies any recent back injury, fever, shortness of breath, chills, myalgias, cough, or change in bladder or bowel habits. The patient does report extreme vasomotor symptoms, which she describes as hot flushes, when bending over.

Her current medications include ibuprofen 800 mg every 8 hours and, occasionally, acetaminophen 1 g up to twice daily, which affords short-term pain relief unless she bends forward or moves suddenly.


The patient’s vital signs are unremarkable (Table). She is a nonsmoker and reports consuming 1 to 2 alcoholic beverages a week. She has a family history of breast, renal, and colon cancer in second-degree relatives.

Her pulmonary, cardiac, breast, and abdominal examinations are unremarkable. She has no right upper quadrant pain on palpation and negative Murphy, Rosving, psoas, and obturator signs. There is no appreciable lymphadenopathy. Testing for costovertebral angle tenderness is negative, but palpation at the level of the lower thoracic and upper lumbar spines elicits some focal back pain.

Inspection of her back reveals no visible bony abnormalities, swelling, or discoloration.  She has a normal bilateral straight leg raise test, and her deep tendon reflexes are normal for both the quadriceps and Achilles tendons. There is no sign of clonus. Back symptoms are present when the patient leans forward. Crepitus is appreciated with a discrete snap in her thoracic spine that produces diaphoresis, nausea, and bilateral facial flushing. 

Urinalysis is positive for blood and with a negative urine human chorionic gonadotropin test. Urine is submitted for culture and cytology, which reveals atypical urothelial cells with negative culture. Her urologist is consulted, but the physician does not feel the cells are of any significance since a recent computed tomographic (CT) examination showed no signs of mass in the bladder or kidneys. The urologist is requested to provide the CT report and office notes, and a plain film of the spine is ordered, revealing compression fractures at multiple levels.