Hematuria History

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MRCS Part B OSCE - Urology History Taking

Mr. John Matthews is a 62-year-old man referred by his GP to the urology clinic after developing persistent painless visible blood in his urine. He also reports unintentional weight loss and a poor appetite over the past few months. He is a long-term smoker and currently works in a dye manufacturing factory. Your task is to take a focused history and address his concerns. You do not need to examine the patient.

Markscheme
Station: Focused History - 62-year-old Male with Painless Haematuria
Time: 6 minutes
Total Marks: 20 (16 clinical + 4 lay observer)

Introduction (1)

Haematuria Assessment (3 marks)
Duration and frequency of blood in urine (1 mark)
Appearance of blood (visible/macroscopic vs microscopic, colour, clots present) (1 mark)
Timing of haematuria (initial, terminal, throughout stream) (1 mark)

Associated Urological Symptoms (3 marks)
Lower urinary tract symptoms: frequency, urgency, nocturia, hesitancy, poor stream, incomplete emptying (2 marks)
Pain assessment: dysuria, loin pain, suprapubic pain (1 mark)

Weight loss: quantification and timeframe (1 mark)
Appetite changes, night sweats, fatigue (1 mark)

Systems Review (1 mark)

Bowel habits, abdominal pain, respiratory symptoms (1 mark)

RISK FACTORS & PAST MEDICAL HISTORY (4 MARKS)
Smoking History (1 mark)
Quantifies smoking history (pack years) and acknowledges as bladder cancer risk factor (1 mark)
Occupational History (1 mark)
Explores dye manufacturing exposure and other occupational carcinogens (1 mark)
Past Medical History (1 mark)
Previous urological problems, diabetes, hypertension, medications (1 mark)
Family History (1 mark)
Family history of urological or other cancers (1 mark)

Differential Diagnosis Discussion (2 marks)

Identifies bladder cancer as primary concern given age, smoking, painless haematuria
most likely diagnosis (1 mark): Bladder cancer/urothelial carcinoma
Mentions other differentials: BPH, UTI, stones, renal causes (1 mark)

Appropriate next steps: urgent flexible cystoscopy, imaging (CT urogram), urine cytology...
Two urgent investigations (1 mark):
Flexible cystoscopy (0.5 marks)
CT urogram/CT IVU (0.5 marks)
[Acceptable alternatives for investigations:
Rigid cystoscopy
Ultrasound KUB (though CT preferred)
Urine cytology (supportive but not primary investigation)]

** If time, Examiner Follow-up Question 2 (2 marks):
"This patient works in a dye manufacturing factory. Name two specific chemical groups that are occupational carcinogens for bladder cancer, and explain why smoking significantly increases his risk."**

Two chemical groups (1 mark):

Aromatic amines (0.5 marks)
Polycyclic aromatic hydrocarbons/PAHs (0.5 marks)

Acceptable alternatives: benzidine, 2-naphthylamine, 4-aminobiphenyl
Smoking mechanism (1 mark):

Carcinogenic metabolites concentrated and excreted in urine, causing direct contact with urothelium/bladder lining (1 mark)

LAY OBSERVER ASSESSMENT (4 MARKS)
COMMUNICATION SKILLS (2 MARKS)

Introduction and Rapport (1 mark)
Introduces self appropriately and establishes good rapport with patient
Clear Communication (1 mark)
Uses appropriate language, avoids excessive medical jargon, checks understanding

PROFESSIONALISM (2 MARKS)

Empathy and Sensitivity (1 mark)

Shows appropriate concern for patient's symptoms and anxiety about potential diagnosis

Structure and Time Management (1 mark)

Maintains good structure throughout consultation and uses time effectively

ADDITIONAL GUIDANCE FOR EXAMINERS
PASS CRITERIA

Pass: 12/20 overall (minimum 10/16 clinical, minimum 2/4 lay observer)
Merit: 16/20 overall
Distinction: 18/20 overall

KEY TEACHING POINTS

Painless visible haematuria in a male >50 years is bladder cancer until proven otherwise
Smoking is the most significant modifiable risk factor for bladder cancer
Occupational exposure to aromatic amines (dye industry) is a well-established risk factor
Urgent 2-week wait referral criteria are met in this case
Constitutional symptoms may indicate advanced disease

COMMON CANDIDATE ERRORS

Failing to quantify smoking history adequately
Not exploring occupational exposure risks
Inadequate assessment of constitutional symptoms
Poor time management leading to incomplete history
Not demonstrating understanding of red flag symptoms

EXAMINER NOTES

Stop candidate at 6 minutes regardless of completion
May ask specific questions about differential diagnosis or next steps
Assess clinical reasoning throughout the encounter, not just at the end