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Domain – Kidney and urinary health (case)

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Choy, a 68-year-old male of Cambodian origin presents with a history of blood in his urine. Choy is new to your practice. He has been brought in by his daughter as he does not speak fluent English.


Communication and Consultation Skills

Question: What communication strategies could you use to gather information and explore Choy’s ideas, concerns, and expectations?

Answer:

  1. Use a professional interpreter to ensure accurate communication.
  2. Speak directly to Choy, not just his daughter, to show respect and ensure he is involved in his care.
  3. Use simple language and avoid medical jargon.
  4. Observe non-verbal cues and ask open-ended questions to encourage Choy to express his concerns.
  5. Provide visual aids or translated written materials to support understanding.

Question: What services are available to help you communicate with people of non-English speaking backgrounds? How do you access them?

Answer: Services available include:

  1. Telephone Interpreting Service: Provided by the Translating and Interpreting Service (TIS National).
  2. On-site Interpreting: Arrange an interpreter to attend the consultation in person via TIS National or local health services.
  3. Video Interpreting Services: Available through TIS National or state health departments. To access these services, register with TIS National, book an interpreter via their online portal or phone service, and ensure patient consent for interpreter use.

Question: What medico-legal issues do you need to consider when a close family member is interpreting (e.g., consent, confidentiality, privacy)?

Answer:

  1. Consent: Ensure Choy consents to his daughter acting as an interpreter.
  2. Confidentiality: Be aware of potential breaches of confidentiality when family members interpret.
  3. Accuracy: Family members may not accurately translate medical information, leading to miscommunication.
  4. Bias: Family members may introduce personal bias, affecting the quality of information exchanged.
  5. Legal Documentation: Document the use of a family member as an interpreter and any consent obtained.

Clinical Information Gathering and Interpretation

Question: What further history and office tests would help you arrive at a diagnosis and differential diagnoses?

Gross Hematuria
  • Visible blood in the urine
    • Color:
      • Reddish or pink (lower tract abnormalities)
      • Brown or tea-colored (oxidation of urinary heme pigments)
    • Associated with significant urological disease (symptomatic or asymptomatic)
    • History may explain hematuria:
      • Recent urological surgery or instrumentation
      • Urinary tract infection (UTI)
      • Passage of a kidney stone
    • Unexplained cases require further workup:
      • Imaging
      • Cystoscopy
      • Especially important for patients >35 years old to rule out urological malignancies
    • Presence of gross hematuria:
      • Automatically high-risk
Microscopic Hematuria
  • Subtypes:
    • Asymptomatic Microscopic Hematuria:
      • Associated with: Bladder and other urological cancers
      • RBCs: Normal RBCs seen microscopically
      • Workup: Requires further risk-stratified workup
    • Asymptomatic Microscopic Hematuria with Proteinuria:
      • Suggestive of: Glomerulonephritis
      • RBCs: Dysmorphic, atypical RBCs seen microscopically
      • Workup: Requires workup for glomerular disorders, may need renal biopsy
    • Symptomatic Microscopic Hematuria:
      • Associated with urinary symptoms:
        • Infection
        • Prostatitis
        • Benign Prostatic Hyperplasia (BPH)
        • Other urinary disorders
      • Investigation: Further investigation and follow-up as warranted

Etiology

  • Genitourinary disorders/systemic diseases.
  • Classification: glomerular or nonglomerular.
  • Causes in infants/young children:
    • Wilms tumor
    • Polycystic kidney disease
    • Alport syndrome
    • Inherited nephritis
    • Glomerulonephritis
    • Hypercalciuria
    • UTIs
    • Sickle cell disease (Black population)
  • Causes in older individuals:
    • UTIs
    • Urological malignancies (kidney/bladder cancers)
    • Urolithiasis
    • Postinfectious glomerulonephritis
    • Trauma
    • Prostatic enlargement
    • Urinary instrumentation
  • Hematuria with proteinuria/casts/dysmorphic RBCs:
    • Glomerular pathology (moderate kidney disease)
  • Common glomerular causes:
    • Alport syndrome
    • Crescentic glomerulonephritis
    • Diffuse progressive glomerulonephritis
    • Focal segmental glomerulonephritis
    • Goodpasture syndrome
    • IgA vasculitis (Henöch-Schonlein purpura)
    • Hypercalciuria
    • IgA nephropathy
    • Lupus nephritis
    • Membranous glomerulonephritis
    • Minimal change disease
    • Nephrotic syndrome
    • Rapidly progressive (pauci-immune) glomerulonephritis
    • Polycystic kidney disease
    • Post-streptococcal glomerulonephritis
    • Thin basement membrane disease (formerly benign familial hematuria)
  • Common nonglomerular causes:
    • Bladder calculi
    • Benign prostatic hyperplasia
    • Endometriosis of the urinary tract
    • Strenuous exercise
    • Foreign bodies (stones, catheters, stents)
    • Genitourinary mucosal injury (instrumentation)
    • Hematological disorders (sickle cell anemia, thrombocytopenia, coagulopathies)
    • Hemorrhagic cystitis
    • Infections (cystitis, urethritis, prostatitis)
    • Malignancy (renal cell carcinoma, bladder/prostate cancer)
    • Medication-related (cyclophosphamide)
    • Nephrolithiasis, urolithiasis
    • Nutcracker Syndrome
    • Radiation cystitis
    • Schistosomiasis (endemic regions)
    • Trauma (genitourinary tract)

History:

  • Duration, frequency, and volume of hematuria.
  • Associated symptoms:
    • pain – back or flank
    • dysuria
    • Joint pains, oral ulcers, rash
    • Leg swelling
    • Lower abdominal pain
    • Passing urinary calculi
  • Voiding and urinary symptoms such as:
    • Dysuria
    • Frequency
    • Hesitancy
    • Incomplete emptying
    • Intermittent stream
    • Urgency
    • Weak urinary stream
  • Constitutional symptoms like
    • weight loss
    • anorexia
    • cachexia
  • History of trauma, recent infections, medications (including anticoagulants).
  • Family history of kidney disease or malignancy.
  • Occupational history and exposure to chemicals.
  • Female patients during menstruation or with vaginal bleeding:
    • Should either have a catheterized urine sample.
    • Use a tampon with cleaning of any residual blood before voiding.
    • Be reevaluated when the gynecologic bleeding has resolved.
  • After a UTI:
    • At least 4 to 6 weeks should elapse before a repeat urinalysis for hematuria.
  • Evaluation for hematuria:
    • Ask about previous episodes.
    • Inquire about any family history of hematuria.
    • Take a detailed medical history, including recent surgical procedures or biopsies.
    • Review medications, particularly blood thinners.
  • Medications causing false positive dipstick readings:
    • Peroxidases from organic sources.
    • Semen.
    • Metronidazole.
    • Sodium hypochlorite.
  • False-negative dipstick results:
    • Possible from extremely high urinary ascorbic acid levels.
  • Smoking history:
    • Significant risk factor for urothelial malignancies such as bladder cancer.
    • 10 pack-years or more is considered significant.
    • Risk increases with the extent of smoking history.
  • Persistent or recurrent microhematuria:
    • Reclassified as either “Intermediate” or “High-Risk” even after a negative full evaluation.
Physical Examination
  • Conduct abdominal and urogenital examination.
  • Assess blood pressure for potential glomerulopathic causes.
  • Evaluate for renal angle or flank tenderness (renal colic).
  • Inspect external genitalia to exclude sensitive pathologies.
  • In female patients, consider speculum examination to exclude vaginal, cervical, and uterine sources of bleeding.
  • Perform digital rectal examination and prostate-specific antigen testing in men over 50 years to evaluate for prostate cancer.

Office Tests:

  • Urinalysis: dipstick for blood, protein, nitrites, leukocytes.
  • Urine microscopy and culture.
  • Blood tests: CBC, renal function, coagulation profile.
  • Blood pressure measurement.

General Issues in Hematuria Evaluation

  • Often deficient, inadequate, or incomplete in primary care practices.
  • More than half of patients with hematuria are not properly worked up or referred to urology promptly.
  • Cystoscopy is underutilized, with over-reliance on diagnostic imaging alone.
  • Bladder neoplasms, which are optimally diagnosed by cystoscopy, are frequently missed.
  • Renal ultrasonography is commonly ordered, though more detailed imaging (e.g., CT urogram) is generally required.
  • Proper use of urological imaging and cystoscopy occurs in fewer than 20% of patients.
  • Evaluation of hematuria, especially microhematuria, is often delayed in women due to assumptions of UTI or menstrual contamination, leading to poorer outcomes.

Urinalysis

  • Initial and most useful test for detecting hematuria.
  • Urine dipsticks can give false-positive or false-negative results
  • Urine Microscopy: Confirm hematuria and identify contaminants.
    • Diagnosis established by finding 3 or more RBCs per high power field (HPF) on microscopic examination.
  • Abnormal findings in urine appearance, pH, protein, white blood cells, nitrites, leukocyte esterase, bacteria, crystals, or casts help identify the hematuria source.

Nonglomerular Hematuria Evaluation

  • Normal red blood cells without apparent cause.
  • Possible causes: Benign prostatic hyperplasia (BPH), urolithiasis, urinary tract malignancy.
  • Further evaluation based on overall stratified urological cancer risk.

Specific Conditions

  1. Urinary Tract Infection (UTI)
    • Suspected with significant white blood cells, positive nitrites, leukocyte esterase, and urinary symptoms.
    • Perform urine culture and treat infection appropriately.
    • Repeat urinalysis post-treatment to verify resolution; if persistent, adopt a risk-stratified management approach.
  2. Bladder, Ureteral, and Renal Malignancies
    • Potentially troubling etiologies of painless hematuria.
    • Full diagnostic urological evaluation designed to detect cancers.
  3. Nephrolithiasis
    • Common cause of hematuria, urinalysis may show crystals.
    • Symptoms may include chronic infection, acute renal colic with severe pain, nausea, vomiting.
    • Diagnosis via renal ultrasound, kidney, ureter, bladder x-ray, or CT scan of the abdomen.
  4. Prostatic Bleeding
    • Suspected in older male patients with known or suspected BPH.
    • Requires full workup including genitourinary imaging and cystoscopy.
    • Refer to StatPearls article on “Benign Prostatic Hyperplasia” for more information.
  5. Traumatic Urinary Bleeding
    • Can be minimal or severe, life-threatening.
    • Requires urgent evaluation in trauma settings.
    • Suspected in abdominal or pelvic trauma cases.
    • Blood at urethral meatus or inability to void suggests urethral or bladder injury.
    • Immediate CT imaging for renal trauma; cystogram for bladder injury.
    • Refer to StatPearls articles on “Kidney Trauma” and “Lower Genitourinary Trauma.”

Standard Evaluation Components

  • Biochemical Investigations:
    • Renal Function Tests: Blood urea nitrogen (BUN) and serum creatinine.
    • Coagulation Profile: Prothrombin time (PT), international normalized ratio (INR).
    • Hemoglobin Levels: Check for anemia.
  • Upper Tract Imaging:
    • CT IVP: Gold standard for urinary tract malignancy
      • CT urogram over obsolete intravenous pyelogram.
      • Risks: Contrast allergy, radiation exposure, higher cost.
    • Renal Ultrasonography:
      • Benefits: Less costly, no radiation, no contrast.
      • Limitations: User-dependent, less detailed views of ureters and bladder.
      • Suitable for younger patients or those with significant renal impairment.
  • Urine Cytology:
    • Recommended for both macroscopic and microscopic hematuria (australia)
    • High sensitivity for high-grade bladder tumors, particularly CIS.
    • Low sensitivity for low-grade tumors.
    • Not recommended as a sole diagnostic tool but useful as an adjunct with cystoscopy.
    • Used as an adjunctive tool with cystoscopy.
  • Cystoscopy: 98% sensitive for detecting bladder cancer, essential in evaluation

Urology and Nephrology Referral

  • Urological Referral: Recommended for all patients with gross hematuria.
  • Nephrology Referral: Indicated for glomerulopathic causes of hematuria (proteinuria, dysmorphic RBCs, casts, renal insufficiency, or hypertension in those <40 years).

Follow-Up of Patients with Negative Hematuria Work-Up

  • Repeat Urinary Microscopy:
    • Recommended at 6–12 months.
    • No further evaluation necessary following two negative analyses.
  • Persistent Microscopic Hematuria:
    • Shared decision-making for further intervention.
    • Consider nephrological work-up if not previously done.
  • Annual Monitoring:
    • For persistent microscopic hematuria without proteinuria or other risk factors.
    • Monitor with urinary microscopy, renal function tests, and blood pressure assessment.

    Glomerular Hematuria Evaluation

    Indicators of Glomerular Hematuria

    • Excessive urinary protein (>500 mg/24 hours)
    • Dysmorphic RBCs
    • Casts, especially red cell casts
    • Associated clinical findings: hypertension, peripheral edema, “frothy” or “foamy” urine

    Diagnostic Specificity

    • Dysmorphic RBCs >25% per HPF: Specificity >96%, positive predictive value 94.6%, low sensitivity (20%) for glomerulonephritis
    • RBC casts: Rare but highly diagnostic and specific for glomerular pathology

    Referral and Evaluation

    • Referral to nephrology for further evaluation
    • Risk-based urological evaluation still performed

    Glomerulonephritis Overview

    • Characterized by damage to the glomerular basement membrane, capillary endothelium, or mesangium due to abnormal immune system activity
    • Progressive damage leads to tubulointerstitial fibrosis, reduced plasma filtering, sclerotic glomeruli, and renal failure
    • Accounts for 10% to 15% of end-stage renal failure cases in the US, third most common cause after diabetes and hypertension

    Evaluation of Glomerulonephritis

    • Urine Collection: 24-hour collection for urea, creatinine clearance, and protein measurement
    • Antistreptolysin O Titer
    • Autoantibodies: Antinuclear, antineutrophil cytoplasmic, antiglomerular basement membrane, anti-ds-DNA
    • C-reactive Protein (CRP)
    • Complete Blood Count (CBC)
    • Complement Levels: C3, C4
    • Cryoglobulins
    • Immunoglobulins
    • Liver Function Tests
    • Renal Function Tests: BUN, creatinine
    • Serology: HIV, hepatitis B, hepatitis C
    • Serum Electrolytes
    • Serum Levels: Free light chain immunoglobulins, serum immunofixation
    • Sickle Cell Testing: Peripheral smear, solubility sickling tests, hemoglobin electrophoresis, isoelectric focusing, high-performance liquid chromatography, PCR-based testing, genetic testing
    • Urine Analysis Ratios: Albumin to creatinine, protein to creatinine ratios
    • Urinary Bence-Jones Proteins

    Renal Biopsy

    • Considered based on clinical evaluation results
    • Necessary for definitive diagnosis of glomerulonephritis and glomerular bleeding
    • Procedure performed by a nephrologist or interventional radiologist
    • Typically requires only 2 or 3 biopsy cores
    • Techniques: Light microscopy, electron microscopy, immunofluorescence

    Outcomes and Risks

    • Glomerulonephritis can lead to 10% to 15% of end-stage renal disease cases in the US
    • Chronic glomerulonephritis is the third most common cause of end-stage renal disease
    • Hematuria with glomerular podocytopathies (e.g., focal segmental glomerulosclerosis, membranous nephropathy, minimal change disease) indicates worse outcomes and increased risk of progressive renal failure

    (Reference: StatPearls article on “Glomerulonephritis” for additional information.)

    Question: What information would help you assess risk factors for possible underlying malignancies (e.g., occupation, radiotherapy, smoking)?

    Answer:

    1. Occupational History: Exposure to industrial chemicals, dyes, rubber, or solvents.
      • Arsenic (found in drinking water in some regions).
      • Chemicals used in the textile, rubber, leather, dye, paint, and print industries.
      • Aromatic amines (used in dye, rubber, chemical, and leather industries).
      • Aniline dyes.
      • Benzidine and beta-naphthylamine.
      • Painters, hairdressers, and truck drivers due to exposure to chemicals and diesel exhaust.
    2. Smoking History: Duration and quantity of smoking. 0
      • Smoking as a Risk Factor
        • Causes cancers of kidney, bladder, renal pelvis
        • 2004 US Surgeon General: Sufficient evidence of causal relationship
        • Recent meta-analyses confirm increased risk
      • Statistics
        • IARC: 66% of bladder cancer in men, 30% in women due to smoking
        • Australia: 35% of bladder cancer in men, 29% in women caused by smoking
        • Risk of bladder cancer >3-fold higher in current smokers aged 45+ compared to non-smokers
      • Impact of Smoking Cessation
        • Reduces risk of bladder and kidney cancers
        • Rapid decline in bladder cancer risk in the first 1-4 years post-cessation
        • Long-term risk remains higher than non-smokers even after 25 years
    3. Radiation Exposure: History of radiotherapy to the pelvic area.
    4. Family History: Incidence of genitourinary cancers or syndromes (e.g., Lynch syndrome).
    5. Previous Medical History: History of chronic UTIs, bladder stones, or hematuria.

    Question: How would you modify your approach if Choy was a child?

    Answer:

    1. Communication: Use age-appropriate language and involve parents/caregivers in the discussion.
    2. History: Focus on symptoms, recent infections, trauma, and congenital abnormalities.
    3. Examination: Be gentle and use distraction techniques to minimize anxiety.
    4. Tests: Pediatric-specific reference ranges for tests and consider ultrasound over more invasive procedures.
    5. Consent: Obtain parental consent for examinations and procedures.

    Making a Diagnosis, Decision Making, and Reasoning

    Question: What possible malignant causes for this presentation would you consider, and how will you arrive at the diagnosis?

    Answer:

    Risk Factors for Urological Malignancy:

    • Male Sex
    • Smoking History: Current or past history.
    • Increased Age: Older age groups have higher risk.
    • Occupational Exposures: Exposure to dyes, benzenes, and aromatic amines.
    • Prior Cyclophosphamide Exposure: Known to increase risk.
    • History of Pelvic Irradiation: Previous radiation therapy in the pelvic area.
    • History of Chronic Urinary Tract Infections (UTIs): Frequent infections can be a risk factor.

    Possible Malignancies:

    • Bladder cancer.
    • Renal cell carcinoma.
    • Prostate cancer.
    • Urothelial carcinoma.

    Diagnosis:

    • Imaging: Ultrasound, CT urogram.
    • Cystoscopy and biopsy.
    • Urine cytology.
    • Referral to urology for further evaluation.

      Question: What are the possible differentials to consider if the hematuria is transient?

      Answer:

      1. UTI: Common cause, especially with dysuria.
      2. Kidney Stones: Painful hematuria.
      3. Trauma: Recent injury to the urinary tract.
      4. Exercise-induced Hematuria: Post strenuous exercise.
      5. Benign Prostatic Hyperplasia (BPH): In older males.

      Question: What are the possible non-malignant causes of hematuria?

      Answer:

      1. Infections: UTIs, prostatitis, pyelonephritis.
      2. Stones: Nephrolithiasis, ureterolithiasis.
      3. Trauma: Recent injury or catheterization.
      4. Glomerular Disease: Glomerulonephritis, IgA nephropathy.
      5. Medications: Anticoagulants, NSAIDs.
      6. Benign Prostatic Hyperplasia (BPH): In older males.

      Question: What are the possible causes of hematuria in young sexually active adults?

      Answer:

      1. UTI: Common, especially in females.
      2. Sexually Transmitted Infections (STIs): Chlamydia, gonorrhea.
      3. Trauma: Sexual activity-related trauma.
      4. Menstrual Hematuria: In females, related to menses.

      Question: What would you consider in a child presenting with hematuria?

      • Prevalence: Hematuria is common in children, with urine dipsticks testing positive 1% to 4% of the time.
      • Causes:
        • Microscopic Hematuria: Often idiopathic and suggests an upper urinary tract source.
        • Gross Hematuria: More likely from the bladder or urethra.
      • Common Diagnoses:
        • Glomerulonephritis (e.g., poststreptococcal or infectious, IgA nephropathy, thin basement membrane disease)
        • Urinary Tract Infections (UTIs)
        • Hypercalciuria
      • Glomerulonephritis:
        • Most common in children is poststreptococcal or infectious types.
        • Signs: Proteinuria, fluid overload, casts or dysmorphic RBCs on urine microscopy, brown “cola” colored urine, hypertension.
      • IgA Vasculitis (Henöch-Schonlein Purpura):
        • Incidence: 10 to 20 cases per 100,000 children, mainly under 10 years old.
        • Features: Immune-mediated glomerulonephritis, gastrointestinal bleeding.
        • Treatment: Steroids, ACE inhibitors, immunosuppressants, plasma exchange.
        • Prognosis: Usually self-limited, 1% may progress to end-stage renal failure.
      • Hemolytic Uremic Syndrome (HUS):
        • Incidence: 3 cases per 100,000 children.
        • Features: Anemia, thrombocytopenia, azotemia, follows bacterial infection (often linked to unpasteurized milk or undercooked beef).
        • Treatment: Mainly supportive.

      Note: A thorough family history can help identify potential hereditary causes of hematuria.

      Question: How would you approach this presentation if your practice was in a rural or remote location with limited access to imaging and specialist urology services?

      Answer:

      1. Initial Workup: Comprehensive history, physical examination, urinalysis, and basic blood tests.
      2. Telehealth: Use telehealth services to consult with specialists.
      3. Referral: Arrange for transport to a regional center if advanced imaging or specialist care is needed.
      4. Follow-up: Regular follow-up and monitoring with available resources.
      5. Local Support: Utilize local community health workers and nurses for ongoing care.

      Clinical Management and Therapeutic Reasoning

      Question: How would your management change if Choy had recently started taking an oral anticoagulant?

      Answer:

      1. Review Medication: Check anticoagulant dosage and indication.
      2. INR/PTT: Monitor coagulation status and adjust anticoagulant dosage if necessary.
      3. Bleeding Risk: Assess and manage bleeding risk, considering alternative anticoagulation strategies.
      4. Referral: Consider referral to hematology if bleeding is severe or recurrent.

      Question: How would your management change if the hematuria is microscopic and Choy is asymptomatic?

      Initial Evaluation

      1. Confirm Hematuria:
        • Use urine microscopy to confirm the presence of hematuria, defined as 3 or more RBCs per high power field (HPF).
      2. Exclude Contamination:
        • Ensure the urine sample is not contaminated (e.g., from menstruation in women).
        • Repeat urine microscopy after any potential contaminants are resolved.
      3. Medical History and Physical Examination:
        • Obtain a detailed medical history focusing on risk factors for urological malignancy (age, smoking, occupational exposures, prior chemotherapy or radiation).
        • Perform a physical examination, including blood pressure measurement and abdominal, renal, and genitourinary examination.

      Initial Investigations

      1. Urine Culture:
        • Perform to rule out infection, especially if leukocytes, nitrites, or bacteria are present.
        • Treat any detected UTI and repeat urinalysis 6-12 weeks post-treatment.
      2. Biochemical Tests:
        • Assess renal function (serum creatinine, BUN).
        • Perform a complete blood count (CBC) and coagulation profile if indicated.
      3. Imaging:
        • Low-risk patients (<50 years, non-smokers, <10 RBCs/HPF):
          • Consider renal ultrasound as initial imaging.
        • Higher-risk patients (>50 years, smokers, >10 RBCs/HPF, other risk factors):
          • Recommend CT urogram (CT IVP) for comprehensive evaluation.

      Follow-Up and Risk Stratification

      1. Low-Risk Patients:
        • Age < 50 years
        • Never or <10 pack-year history of smoking
        • <10 RBCs/HPF
        • No other risk factors (e.g., no history of gross hematuria, occupational exposures)
        • Management: Shared decision-making for repeat urinalysis within 6 months. No immediate referral if repeat urinalysis is negative and no new symptoms develop.
      2. Intermediate-Risk Patients:
        • Age 50-60 years
        • History of smoking
        • Occupational exposures
        • Persistent hematuria with 10-20 RBCs/HPF
        • Management: Consider urological referral for cystoscopy and further imaging if not already performed.
      3. High-Risk Patients:
        • Age > 60 years
        • 20 RBCs/HPF
        • Gross hematuria history
        • Significant smoking history
        • Cyclophosphamide exposure, chronic UTIs, pelvic irradiation history
        • Management: Prompt referral to urology for cystoscopy and upper tract imaging (CT urogram).

      Nephrology Referral

      • Indications:
        • Proteinuria
        • Dysmorphic RBCs or casts on urine microscopy
        • Renal insufficiency or hypertension, especially in patients <40 years
      • Management: Coordinate with urology for comprehensive evaluation, as some patients may have overlapping urological and nephrological issues.

      Ongoing Monitoring

      • Persistent Microscopic Hematuria:
        • Annual monitoring with urine microscopy, renal function tests, and blood pressure.
        • Re-evaluate if new symptoms develop or risk factors change.
      • Negative Initial Work-Up:
        • If no significant findings on initial evaluation and imaging, repeat urinalysis in 6-12 months.
        • Ensure patient education on reporting new symptoms promptly.

      Question: How would your management change if a patient with a history of recurrent UTI presents with hematuria?

      Answer:

      1. Culture and Sensitivity: Perform urine culture and sensitivity to guide antibiotic treatment.
      2. Antibiotics: Prescribe appropriate antibiotics based on culture results.
      3. Imaging: Consider imaging (ultrasound or CT) to rule out structural abnormalities.
      4. Prevention: Discuss preventive measures, including hydration and hygiene.

      Question: What investigations or referrals would you arrange to detect an underlying urinary tract malignancy in patients presenting with hematuria or asymptomatic microscopic hematuria?

      Answer:

      1. Imaging: Renal ultrasound, CT urogram.
      2. Cystoscopy: Referral to urology for cystoscopy.
      3. Urine Cytology: To detect malignant cells.
      4. Specialist Referral: Referral to urology for further evaluation and management.

      Question: What other resources could you consider to support Choy? What resources could you consider for Aboriginal or Torres Strait Islander patients with urinary tract presentations? Or patients from culturally and linguistically diverse backgrounds?

      Answer:

      1. Interpreters: Professional interpreters for consultations.
      2. Community Health Workers: Utilize local community health workers for support.
      3. Patient Education: Provide translated educational materials.
      4. Cultural Support: Access to culturally appropriate care and support services.
      5. Aboriginal Health Services: Collaboration with Aboriginal Medical Services.

      Question: How would you support a patient with hematuria as a symptom of advanced malignancy who prefers to stay in the community for end-of-life care?

      Answer:

      1. Palliative Care: Refer to palliative care services.
      2. Symptom Management: Focus on managing symptoms such as pain and bleeding.
      3. Home Care: Arrange for home health care support.
      4. Emotional Support: Provide psychological and emotional support to the patient and family.
      5. Advanced Care Planning: Discuss and document the patient’s wishes and advanced care directives.

      Preventive and Population Health

      Question: How would you approach a situation where an Aboriginal or Torres Strait Islander patient presents with hematuria and diagnosed malignancy but does not consent to further treatment?

      Answer:

      1. Cultural Sensitivity: Approach with cultural sensitivity and respect for the patient’s decisions.
      2. Counselling: Provide counselling and information about the benefits and risks of treatment.
      3. Support Services: Engage Aboriginal Health Workers and support services to assist in decision-making.
      4. Document: Clearly document the patient’s decision and the information provided.
      5. Palliative Care: Discuss palliative care options if the patient prefers symptom management.

      Question: What screening procedures/investigations would you consider to detect an early asymptomatic urinary tract malignancy or chronic kidney disease?

      Answer:

      1. Routine Urinalysis: For early detection of hematuria or proteinuria.
      2. Renal Function Tests: Serum creatinine, eGFR.
      3. Ultrasound: Renal ultrasound for structural abnormalities.
      4. Blood Pressure Monitoring: Regular blood pressure checks.
      5. Risk Factor Assessment: Evaluate for risk factors such as smoking, family history, and occupational exposures.

      Professionalism

      Question: How would you access evidence-based resources to help you both during and after the consultation?

      Answer:

      1. Clinical Guidelines: Refer to RACGP and local health department guidelines.
      2. Medical Databases: Use databases like PubMed, Cochrane Library for up-to-date research.
      3. Professional Networks: Consult with colleagues and specialists.
      4. Medical Apps: Utilize evidence-based medical apps for quick reference.
      5. Continuing Education: Engage in continuing medical education (CME) activities and courses.

      Question: Reflect on what your attitude and approach may be to patients who choose not to get treated for urinary tract malignancy or kidney replacement therapy.

      Answer:

      1. Respect: Respect the patient’s autonomy and decision.
      2. Support: Provide emotional and psychological support.
      3. Information: Ensure the patient is fully informed about the consequences of their decision.
      4. Symptom Management: Focus on managing symptoms and maintaining quality of life.
      5. Non-judgmental Approach: Maintain a non-judgmental and compassionate approach.

      General Practice Systems and Regulatory Requirement

      Question: How would you use your practice software system to make sure that you review Choy’s investigation results and follow up with him?

      Answer:

      1. Reminders: Set electronic reminders for follow-up appointments.
      2. Results Management: Use the software to track investigation results and flag abnormal results.
      3. Communication: Document all communication and follow-up plans in the patient’s electronic health record (EHR).
      4. Patient Portal: Encourage Choy or his daughter to use a patient portal for accessing results and communicating with the practice.
      5. Audit Trails: Utilize audit trails to ensure all actions are documented and reviewed.

      Question: What are the legal and ethical considerations in managing hematuria and urinary tract malignancies in people with disabilities (e.g., dementia)?

      1. Consent and Capacity

      • Informed Consent: Ensure that informed consent is obtained from the patient whenever possible. If the patient is unable to provide consent due to cognitive impairment, involve legal guardians or representatives.
      • Capacity Assessment: Regularly assess the patient’s capacity to make healthcare decisions. This involves evaluating their ability to understand the information relevant to the decision, appreciate the potential consequences, and communicate a choice.

      2. Best Interest

      • Best Interest Principle: Make decisions based on what is in the best interest of the patient. This includes considering their past and present wishes, beliefs, and values. Engage family members and caregivers in discussions to help determine the patient’s best interests.

      3. Confidentiality and Privacy

      • Maintaining Confidentiality: Ensure that all patient information is kept confidential. Only share information with individuals who are directly involved in the patient’s care and have a legitimate need to know.
      • Privacy Considerations: Respect the patient’s privacy during examinations and treatments. This is particularly important for vulnerable populations, including those with disabilities.

      4. Communication

      • Clear Communication: Use clear and simple language when explaining medical conditions and treatments to patients with cognitive impairments and their caregivers. Consider using visual aids or other communication tools if necessary.
      • Family and Caregiver Involvement: Engage family members and caregivers in the communication process. They can provide valuable insights into the patient’s preferences and assist in decision-making.

      5. Documentation

      • Thorough Documentation: Maintain comprehensive documentation of all assessments, decisions, and communications. This includes documenting the patient’s capacity assessments, consent discussions, treatment plans, and any decisions made by legal representatives.
      • Legal Documentation: Ensure that all legal documents, such as power of attorney or guardianship papers, are current and accurately reflect the patient’s wishes and legal status.

      6. Ethical Considerations

      • Autonomy: Respect the autonomy of the patient as much as possible. Even if they lack capacity, involve them in the decision-making process to the extent that they are able.
      • Non-Maleficence and Beneficence: Strive to do no harm (non-maleficence) and to benefit the patient (beneficence). Weigh the risks and benefits of diagnostic and therapeutic interventions carefully, particularly in patients with multiple comorbidities.
      • Justice: Ensure that the patient receives fair and equitable treatment. This includes providing appropriate access to medical care and resources.

      7. Legal Obligations

      • Compliance with Laws and Regulations: Adhere to relevant laws and regulations, including those related to patient consent, capacity, and guardianship. Be aware of state and federal laws that apply to the care of individuals with disabilities.

      8. Advance Directives

      • Advance Care Planning: Encourage discussions about advance directives and end-of-life care preferences. This can help ensure that the patient’s wishes are respected if they become unable to make decisions in the future.

      Procedural Skills

      Question: For non-English speaking patients, how would you obtain and document informed consent for sensitive examinations such as examination of the external genitalia?

      Answer:

      1. Interpreter: Use a professional interpreter to explain the procedure and obtain consent.
      2. Written Consent: Provide consent forms in the patient’s preferred language.
      3. Documentation: Document the use of an interpreter and the patient’s consent in the medical record.
      4. Visual Aids: Use diagrams or visual aids to explain the procedure.
      5. Cultural Sensitivity: Be mindful of cultural sensitivities and address any concerns.

      Question: How would you organize to obtain a catheter sample for urinalysis in babies and toddlers with hematuria? (Consider issues such as parental concerns and consent.)

      Answer:

      1. Explanation: Explain the procedure to the parents in detail, addressing any concerns.
      2. Consent: Obtain written consent from the parents.
      3. Comfort: Use distraction techniques and ensure the child is comfortable.
      4. Sterility: Ensure sterile techniques to prevent infection.
      5. Documentation: Document the procedure and parental consent in the medical record.

      Question: How confident are you to insert/replace an indwelling or suprapubic catheter for patients presenting with bladder outlet obstruction?

      Answer:

      1. Training: Ensure adequate training and competence in catheter insertion.
      2. Preparation: Prepare all necessary equipment and follow sterile techniques.
      3. Guidance: Use ultrasound guidance if available, especially for suprapubic catheter insertion.
      4. Complications: Be aware of potential complications and how to manage them.
      5. Support: Seek assistance from urology if needed and ensure patient comfort.

      Managing Uncertainty

      Question: What follow-up measures would you consider in patients presenting for ongoing care following negative urological workup for hematuria?

      1. Regular Monitoring

      • Follow-up Appointments: Schedule regular follow-up appointments to monitor the patient’s condition. These appointments should be tailored to the individual’s risk factors and the severity of their initial presentation.
      • Monitoring Frequency: For patients with persistent microscopic hematuria, consider follow-up every 6 to 12 months​​.

      2. Repeat Testing

      • Urinalysis: Repeat urinalysis at regular intervals, typically every 6 to 12 months, to monitor for the recurrence or persistence of hematuria. Ensure urine samples are free from contamination (e.g., menstrual blood, discharge) for accurate results.
      • Imaging: If hematuria persists or new symptoms develop, consider repeating imaging studies such as renal ultrasound or CT urogram to rule out any developing pathologies​​.

      3. Symptom Review

      • Continuous Symptom Evaluation: At each follow-up visit, review and document any new or persisting symptoms. Pay special attention to symptoms like dysuria, frequency, urgency, visible blood in urine, and any systemic symptoms such as fever or weight loss.
      • Documentation: Maintain detailed records of all symptoms, findings, and test results to track any changes over time.

      4. Lifestyle Advice

      • Hydration: Advise patients to maintain adequate hydration, as this can help reduce the risk of recurrent UTIs and other urinary symptoms.
      • Diet and Lifestyle: Recommend dietary modifications if necessary (e.g., reducing caffeine and alcohol intake) and encourage smoking cessation to reduce the risk of bladder cancer and other urinary tract issues​​​​.

      5. Referral to Specialist

      • Urology Referral: If there are changes in symptoms or if hematuria persists despite negative initial workup, consider referring the patient back to a urologist for further evaluation.
      • Nephrology Referral: If there are signs of renal impairment, such as worsening renal function tests, proteinuria, or hypertension, refer the patient to a nephrologist​​.
      • Other Specialists: Based on specific findings, consider referrals to other specialists (e.g., gynecologist for women with suspected gynecological sources of hematuria, oncologist for suspected malignancies).

      Additional Measures

      • Patient Education: Educate patients about the signs and symptoms of potential complications that should prompt immediate medical attention.
      • Advance Directives: Discuss and document advance care planning, especially in patients with multiple comorbidities or those at higher risk for serious conditions.

      Question: What additional resources could you consider for patients with negative initial workup for hematuria?

      Answer:

      1. Support Groups: Connect patients with support groups for reassurance and shared experiences.
      2. Education: Provide educational materials about potential causes and symptoms to watch for.
      3. Telehealth: Use telehealth for ongoing monitoring and consultations.
      4. Patient Portal: Encourage the use of patient portals for easy communication and follow-up.
      5. Community Resources: Utilize community health resources and support services.

      Identifying and Managing the Significantly Ill Patient

      Question: What follow-up measures would you consider in patients presenting for ongoing care following negative urological workup for hematuria?

      Answer:

      1. Regular Monitoring: Schedule follow-up visits every 6-12 months.
      2. Repeat Urinalysis: Repeat urinalysis at regular intervals.
      3. Symptom Diary: Ask patients to keep a diary of any new symptoms.
      4. Risk Factor Management: Address and manage any identified risk factors.
      5. Re-evaluation: Re-evaluate the patient if new symptoms or changes in condition occur.
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