EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What are your differential diagnoses for Michael’s haematuria?

• Prompt: What is the most likely diagnosis and why?
• Prompt: What other conditions should be considered?

Q2. What red flags would indicate the need for urgent referral or further investigations?

• Prompt: What features suggest a serious or malignant cause?
• Prompt: What initial investigations would you consider?

Q3. How would you manage Michael’s haematuria?

• Prompt: What investigations are required to rule out malignancy?
• Prompt: When would you refer him to a urologist?

Q4. Michael is worried about cancer. How would you counsel him?

• Prompt: How do you explain his risk factors and need for investigation?
• Prompt: How can you provide reassurance while ensuring appropriate follow-up?

Q5. What preventive strategies can Michael implement to reduce his urological cancer risk?

• Prompt: What lifestyle modifications should he consider?
• Prompt: What role does smoking cessation and regular screening play?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What are your differential diagnoses for Michael’s haematuria?

Michael’s most likely diagnosis is bladder cancer, given his age, smoking history, and painless macroscopic haematuria.

Key Differential Diagnoses:

1. Bladder Cancer (Most Likely) – Painless macroscopic haematuria in a smoker is highly suspicious.
2. Urinary Tract Infection (UTI) – Consider if dysuria, frequency, fever are present (less likely in men without prior UTI).
3. Nephrolithiasis (Kidney Stones) – Can cause haematuria with flank pain, but Michael is pain-free.
4. Benign Prostatic Hyperplasia (BPH) – Can cause microscopic haematuria, frequency, weak stream, but not painless macroscopic haematuria.
5. Glomerular Disease (IgA Nephropathy, Glomerulonephritis) – Consider if proteinuria, hypertension, or systemic symptoms are present.

Further investigations, including urinalysis, imaging, and cystoscopy, will refine the diagnosis.

---

Q2: What red flags would indicate the need for urgent referral or further investigations?

Red flags requiring urgent referral:

• Age >40 with macroscopic haematuria – Increased risk of malignancy.
• Smoking history – Significant risk factor for bladder cancer.
• Painless haematuria – More concerning for urothelial carcinoma.
• Persistent microscopic haematuria – Can indicate glomerular disease or malignancy.
• Associated systemic symptoms (weight loss, night sweats, fatigue) – Suggests malignancy or systemic disease.

Recommended Investigations:

• Urinalysis + Urine Microscopy, Culture & Sensitivity (MCS) – To check for infection, red cell casts (glomerular disease), or sterile pyuria.
• Urine Cytology – Screens for malignant cells in bladder cancer.
• Renal Function Tests (eGFR, Creatinine, Electrolytes) – Assesses for renal pathology.
• Imaging (CT IVP or Renal Ultrasound) – To evaluate for stones, masses, or hydronephrosis.
• Cystoscopy (Urologist Referral) – Definitive test to assess bladder pathology.

Michael has multiple red flags, so urgent urology referral is required.

---

Q3: How would you manage Michael’s haematuria?

1. Immediate Investigations:

• Urinalysis + Urine MCS + Urine Cytology – To assess for infection or malignancy.
• Renal Function Tests (eGFR, UECs, ACR) – To check for renal impairment or proteinuria.
• Imaging (CT IVP or Renal Ultrasound) – First-line to assess for stones, tumours, or hydronephrosis.

2. Urology Referral:

• Urgent cystoscopy is required due to his high malignancy risk (smoker, age >40, painless haematuria).
• If imaging suggests renal mass, nephrology referral may be needed.

3. If No Malignancy is Found:

• Monitor with repeat urinalysis every 6–12 months if idiopathic microscopic haematuria.
• Lifestyle modifications to reduce further urological risk (smoking cessation).

Michael must be followed up to ensure urological malignancy is excluded.

---

Q4: Michael is worried about cancer. How would you counsel him?

1. Acknowledge Concerns & Provide Reassurance
   • “Painless haematuria in a smoker does raise concerns for bladder cancer, but there are many possible causes.”
   • “Our goal is to rule out serious conditions early, so you can get the right treatment if needed.”
2. Explain the Next Steps Clearly
   • “We will start with urine tests and imaging, and you’ll be referred for a cystoscopy to examine your bladder.”
   • “Early detection significantly improves treatment outcomes if anything concerning is found.”
3. Address Emotional Concerns
   • “Even if this turns out to be benign, we can discuss preventive measures to reduce your future risk.”
4. Encourage Smoking Cessation
   • “Smoking is a major risk factor for bladder cancer, so quitting is one of the best ways to protect your health long-term.”

Providing clear, structured information helps reduce anxiety and promotes proactive health behaviours.

---

Q5: What preventive strategies can Michael implement to reduce his urological cancer risk?

1. Smoking Cessation:
   • Smoking is the strongest risk factor for bladder cancer.
   • Refer to Quitline, nicotine replacement therapy, or behavioural support.
2. Hydration & Bladder Health:
   • Encourage regular fluid intake to dilute urinary carcinogens.
   • Avoid occupational exposures to chemical dyes, solvents, or toxins.
3. Monitor for Recurrence:
   • Annual urinalysis if haematuria persists without clear cause.
   • Report any further episodes of haematuria for immediate follow-up.
4. Regular Medical Reviews:
   • Monitor renal function and cardiovascular health, especially with hypertension.
   • Discuss PSA screening in context of his father’s history of prostate cancer.

Michael can significantly reduce his risk by quitting smoking and maintaining regular health checks.

---

SUMMARY OF A COMPETENT ANSWER

• Comprehensive differential diagnosis, distinguishing benign vs. malignant causes of haematuria.
• Identification of red flags, ensuring urgent referral if needed.
• Structured, evidence-based investigation plan, including urinalysis, imaging, and cystoscopy.
• Clear patient-centred counselling, addressing cancer concerns and smoking cessation.
• Preventive strategies, including hydration, occupational risk avoidance, and regular screening.

PITFALLS

• Failing to assess for malignancy, missing bladder cancer in a high-risk patient.
• Overlooking smoking history, which significantly increases bladder cancer risk.
• Not referring for cystoscopy, delaying critical early diagnosis.
• Dismissing painless haematuria as benign, when it warrants full investigation.
• Lack of structured follow-up, missing recurrence or progressive disease.

REFERENCES

• 
  RACGP – RACGP Guidelines on Haematuria
• GP Exams – Haematuria

---

MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

1. Communication and Consultation Skills

1.1 Takes a structured urological history, including risk factors for malignancy.
1.2 Provides clear explanations about the diagnosis, investigations, and management plan.

2. Clinical Information Gathering and Interpretation

2.1 Conducts a systematic examination of the genitourinary system.
2.2 Differentiates between transient, benign, and serious causes of haematuria.

3. Diagnosis, Decision-Making and Reasoning

3.1 Diagnoses haematuria based on clinical presentation and urinalysis findings.
3.2 Determines when further investigations or specialist referral is required.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an appropriate investigation and management plan.
4.2 Ensures patient safety by recognising red flags requiring urgent referral.

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD