First Aid for the USMLE Step 2 CS

Section 4. Practice Cases

Case 2. 57-Year-Old Man with Bloody Urine

Opening Scenario

Carl Fisher, a 57-year-old male, comes to the ED complaining of bloody urine.

Vital Signs

BP: 130/80 mm Hg Temp: 98.5°F (36.9°C)

RR: 13/minute HR: 72/minute, regular

Examinee Tasks

1. Take a focused history.

2. Perform a focused physical exam (do not perform rectal, genitourinary, or female breast exam).

3. Explain your clinical impression and workup plan to the patient.

4. Write the patient note after leaving the room.

Checklist/SP Sheet

Patient Description

Patient is a 57 yo M.

Notes for the SP

 Show pain when the examinee checks for CVA tenderness on the right.

 If the examinee mentions prostate disease, ask, “What’s prostate disease?”

Challenging Questions to Ask

“They told me that having blood in my urine is because of my old age. Is that true?”

Sample Examinee Response

“No. Bloody urine is rarely normal. We will need to run a few more tests to determine the cause of this finding.”

Examinee Checklist

Building the Doctor-Patient Relationship Entrance

 Examinee knocked on the door before entering.

 Examinee introduced self by name.

 Examinee identified his/her role or position.

 Examinee correctly used patient’s name.

 Examinee made eye contact with the SP.

Reflective Listening

 Examinee asked an open-ended question and actively listened to the response.

 Examinee asked the SP to list his/her concerns and listened to the response without interrupting.

 Examinee summarized the SP’s concerns, often using the SP’s own words.

Information Gathering

 Examinee elicited data efficiently and accurately.

Connecting with the Patient

 Examinee recognized the SP’s emotions and responded with PEARLS.

Physical Examination

 Examinee washed his/her hands.

 Examinee asked permission to start the exam.

 Examinee used respectful draping.

 Examinee did not repeat painful maneuvers.

Sample Closure

Mr. Fisher, the blood in your urine could be caused by a variety of factors, so I would like to do a few tests to elicit an answer. First I will draw some blood, and then I will perform a genital exam as well as a rectal exam to assess your prostate. I will then order a urine test to look for signs of infection. Depending on the results we obtain, I may also order some imaging studies to determine if there is a stone in your kidneys, an anatomic abnormality, or a tumor. Do you have any questions for me?


HPI: 57 yo male c/o 1 episode of painless hematuria yesterday morning. He has no fever, no abdominal or flank pain, and no dysuria. No history of renal stones. He has a 2-year history of straining on urination, polyuria, nocturia, weak urinary stream, and dribbling. No nausea, vomiting, diarrhea, or constipation. No change in appetite or weight loss. No previous similar episodes.

ROS: Negative except as above.

Allergies: NKDA.

Medications: Allopurinol.

PMH: Gout.

PSH: Appendectomy, age 23.

SH: 1 PPD for 30 years, 2 beers 2-3 times/week, no illicit drugs. Works as a painter. Heterosexual, has a partner, and uses condoms regularly.

FH: Father died from kidney disease at age 80.

Physical Examination

Patient is in no acute distress.


Chest: Clear breath sounds bilaterally.

Heart: RRR; normal S1/S2; no murmurs, rubs, or gallops.

Abdomen: Soft, nondistended, nontender,BS, no hepatosplenomegaly Mild right CVA tenderness.

Extremities: No edema.

Differential Diagnosis


Patient Note Differential Diagnoses

A useful mnemonic for the differential diagnosis of hematuria is HITTERS—etiologies include Hematologic or coagulation disorders, Infection, Trauma, Tumor, Exercise, Renal disorders, and Stones. Gynecologic sources may need to be excluded in women. The passage of clots often localizes the source of bleeding to the lower urinary tract.

Gross hematuria in adults represents malignancy until proven otherwise.

 Bladder cancer: Hematuria and irritative voiding symptoms are consistent with this diagnosis, and the patient’s cigarette smoking and possible occupational exposure to industrial solvents are risk factors. However, the finding of right CVA tenderness is unusual and could be a sign of upper urinary tract disease.

 Urolithiasis: Despite the presence of hematuria and CVA tenderness, this very common diagnosis is unlikely in the absence of sudden, severe colicky flank pain. Pain may migrate to the groin and is not alleviated by changes in position.

 Benign prostatic hypertrophy (BPH): The patient’s urinary symptoms are classic for this diagnosis except that hematuria (if present) is usually microscopic. Again, CVA tenderness may signal upper urinary tract pathology.

Additional Differential Diagnoses

 Prostate cancer: As above, this diagnosis is plausible but is hard to reconcile with the presence of CVA tenderness (could postulate metastasis to a right posterior rib).

 Renal cell carcinoma: The classic triad is hematuria, flank pain, and a palpable mass. Constitutional symptoms may be prominent. The patient’s other urinary symptoms may be due to coexisting BPH.

 Glomerulonephritis: The absence of hypertension or signs of volume overload (eg, edema) argues against intrinsic renal disease. However, remember that IgA nephropathy is the most common acute glomerulonephritis and most often presents with an episode of gross hematuria. Presentation is usually concurrent with URI, GI symptoms, or a flulike illness.

 UTI: This can cause hematuria but is uncommon in males. The patient has no other symptoms to suggest acute infection.

Diagnostic Workup

 Genital exam: To exclude a urologic source of bleeding in men.

 Rectal exam: To detect masses as well as prostatic enlargement or nodules.

 Cystoscopy: The gold standard for the diagnosis of bladder cancer.

 U/S—renal: Can detect bladder and renal masses and stones, but is operator dependent and less sensitive in detecting ureteral disease.

 UA: To assess hematuria, pyuria, bacteriuria, and the like. Dysmorphic RBCs or casts are signs of glomerular disease.

 CT—abdomen/pelvis: To evaluate the urinary tract. Can identify neoplasms and a variety of benign conditions, such as stones.

 PSA: The serum level correlates with the volume of both benign and malignant prostatic tissue. It can be normal in about 20% of patients with nonmetastatic prostate cancer.

 Urine culture: To exclude UTI.

 Urine cytology: Has variable sensitivity in detecting bladder cancers, depending on the grade and stage of the tumor. Three voided samples should be examined to maximize sensitivity.

 BUN/Cr: To evaluate kidney function.

 IVP: Provides an assessment of the kidneys, ureters, and bladder. IVP has generally been replaced by CT urography to circumvent the need for contrast administration.

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