Quick case here.

I have a current 31 year old female patient who is seeking my care for shoulder pain following a work injury.  She arrived to our clinic the other day with excruciating left flank pain.

Subjective: She says she started having left low back pain that morning but very mild.  However, when she got to our clinic and used the restroom, her back pain became excruciating (10/10…to the point of tears).  She said it hurt more while using the restroom.

What is your diagnosis so far? 

Upon further questioning, she said she had some painful urination (dysuria) for the last few days but wasn’t as bad as currently in the clinic.

Does this change your diagnosis?

Upon further questioning, I ask the patient what she thinks is her problem.  She says a kidney stone.

Does this change your diagnosis?

She had reproduction of symptoms with percussion sign over involved costovertebral junction of 12th rib.

Should you perform further mechanical testing (i.e. active range, passive physiologicals?) or do you have enough info?


I referred out immediately….

Okay, so this case was quite straight forward to refer out but good to share.

One thing I wanted to highlight is my question of “what do you think is your problem?”.  This is a simple question and we forget it sometimes.  Patients often times know is something is “mechanical or non-mechanical”.

Follow-up: She came back to me a few days later and said CT scan showed kidney stone in ureter (actually on both sides) and she thinks the stone has passed on one side but not the other.  She was put on morphine in the ER and now on Norco at home.  Occassional sharp back pain and is scheduled to see urologist.



    1. Yes, she has. That would have made it TOO easy though 🙂

      Wasn’t really much DD for me as the patient knew it. BUT with that said, I was one who pushed her to go to ER (why did she come to me and not cancel…)

  1. I had a pt with flank pain once. 2 MD referrals an xray and MRI later turned out he had UPJ obstruction. Turned out his kidney had been working at about 20% for most of his life and did not know it. He had surgery and is better now. Used him as my capstone paper for my DPT at St Augustine.

    1. Good stuff Jeffre! Yeh great to get this information out to public for Direct Access. We are able to perform a decent DD for mechanical issues.

  2. This is a bit of a case in point when discussing special tests and CPRs versus clinical reasoning, DDX and experience as well I think. There is no clear cut set of rules for determining the cause of flank pain. Your experience and clinical reasoning from seeing how mechanical LBP has presented thousands of times in the past showed you immediately. That is the art behind the science, great reminder case.

    1. Thanks Keith. Absolutely, no CPR will take over clinical judgement, but it should just add to the hypothesis to give it more substance.

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