CCE-CE-182

CASE INFORMATION

Case ID: HU-002
Case Name: Michael Stevenson
Age: 55
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: U06 (Haematuria)​

COMPETENCY OUTCOMES

Competency DomainCompetency Element
1. Communication and Consultation Skills1.1 Engages the patient to understand their concerns and expectations
1.2 Explains diagnosis and management clearly
1.5 Uses active listening skills and empathy
2. Clinical Information Gathering and Interpretation2.1 Conducts an appropriate history to explore haematuria characteristics, risk factors, and red flags
2.2 Identifies relevant investigations based on clinical suspicion
3. Diagnosis, Decision-Making and Reasoning3.1 Forms an appropriate differential diagnosis
3.2 Identifies red flag features requiring urgent referral
4. Clinical Management and Therapeutic Reasoning4.2 Develops a management plan including appropriate investigations and follow-up
4.3 Provides safety netting and referral if required
5. Preventive and Population Health5.1 Identifies and addresses modifiable risk factors for urological malignancy
5.3 Provides preventive health advice relevant to the patient’s risk factors
6. Professionalism6.2 Maintains patient confidentiality and establishes a therapeutic relationship
7. General Practice Systems and Regulatory Requirements7.3 Ensures appropriate documentation and follow-up in line with clinical guidelines
9. Managing Uncertainty9.1 Recognises when further investigations or specialist referral are required
10. Identifying and Managing the Patient with Significant Illness10.1 Identifies red flag features suggestive of significant underlying pathology

CASE FEATURES

  • Middle-aged male presenting with painless macroscopic haematuria
  • Need to differentiate between benign and serious causes (e.g., UTI, stones, malignancy)
  • Exploration of red flag symptoms (e.g., weight loss, dysuria, clot retention)
  • Consideration of modifiable risk factors (e.g., smoking, occupational exposure)
  • Importance of appropriate investigations (e.g., urinalysis, imaging, cystoscopy)
  • Discussion of need for specialist referral
  • Patient anxiety about possible cancer diagnosis

INSTRUCTIONS

You have 15 minutes to complete the tasks for this case.

You should treat this consultation as if it is face to face.

You are not required to perform an examination.

A patient record summary is provided for your information.

Perform the following tasks:

  1. Take an appropriate history.
  2. Outline the differential diagnosis and key investigations required.
  3. Address the patient’s concerns.
  4. Develop a safe and patient-centred management plan.

SCENARIO

Michael Stevenson, a 55-year-old office worker, presents to your general practice after noticing blood in his urine for the past two days. He describes it as bright red but without pain, dysuria, or fever. There are no visible clots. He is otherwise well but admits he was shocked and worried when he saw the blood.

He is concerned about bladder cancer and wants to know what’s going on.


PATIENT RECORD SUMMARY

Patient Details

  • Name: Michael Stevenson
  • Age: 55
  • Gender: Male
  • Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

  • Nil known

Medications

  • None

Past History

  • Hypertension (diagnosed 5 years ago, well controlled)
  • No history of kidney stones or recurrent UTIs

Social History

  • Works as a mechanic, exposure to chemicals and industrial fumes

Family History

  • Father had prostate cancer in his late 60s
  • No family history of kidney disease or bladder cancer

Smoking

  • Current smoker

Alcohol

  • 6-8 standard drinks per week

Vaccination and Preventative Activities

  • Up to date with vaccinations

ROLE PLAYER INSTRUCTIONS

Just like a consultation with a doctor, the candidate will ask you a series of questions.
The OPENING LINE is always to be said exactly as written. This is the only part of the script
which will be the same for all candidates. Where the candidate goes after the opening line is
up to them.

The remainder of the information is to be given based on the questions asked by the
candidate.

The information in the following script are core pieces of information. The core pieces of
information will not necessarily follow the order in the script but should be given when cued
by the candidate’s question.

GENERAL INFORMATION can be given relatively freely. After the opening line, most
candidates will ask an open question like “Can you tell me more about that?” You can provide
the GENERAL INFORMATION in response to that sort of question.

SPECIFIC INFORMATION should only be given when the candidate asks a relevant question.
Candidates don’t need to ask for all the information in the SPECIFIC INFORMATION section,
but all the relevant information is given there should they want to.

Each line or dot point in the SPECIFIC INFORMATION section is an appropriate chunk of
information which can be provided to the candidate when asked a relevant question.

Do not give extra information than asked.

Do not provide details which are not given in the information chunks (i.e.: do not elaborate
or ad-lib).

If the candidate asks a question that is not given in the script, the best way to respond is with
a generic response indicating there is no problem. For example:

Candidate: “How many hours do you sleep?”
Response: “I’m sleeping fine.” / “I don’t have any concerns about my sleep.”

The case may have specific QUESTIONS to ask the candidate. You can start asking the
QUESTIONS if the candidate asks about your ideas or concerns or questions.

Ask the other questions in a conversational way. You do not need to ask all the questions. The
aim should be to ask most of the questions but without interrupting the candidate.

The Patient Record Summary is also included. This is not part of the script but is included for
your general information.

If you need help in understanding any of the medical information in the script, ask the College
examiner who will be with you, and they can help to explain the terms or the conditions.


ROLE-PLAYER SCRIPT

Opening Line

“Doctor, I noticed blood in my urine two days ago, and I’m really worried. It was bright red, and I don’t know what’s causing it.”


General Information

(Freely Shared If Asked Open-Ended Questions)

  • The haematuria started two days ago.
  • The urine appeared bright red rather than brown or tea-coloured.
  • The blood was mixed with urine (not just at the beginning or end of the stream).
  • No pain, burning, or difficulty urinating.

Specific Information

(Only If Asked Targeted Questions)

Background Information

  • No clots or changes in urinary frequency.
  • He has felt slightly fatigued, but no weight loss or night sweats.
  • No recent illness, fever, or trauma.
  • He has never experienced this before and is worried something serious is wrong.

Urinary Symptoms

  • No painful urination (dysuria).
  • No urgency or increased frequency.
  • No nocturia or dribbling.
  • No recent difficulty starting or stopping urination.
  • No flank or abdominal pain.
  • No history of kidney stones or previous urinary infections.
  • No recent strenuous exercise (e.g., no long-distance running).

Bowel and Systemic Symptoms

  • No blood in stools or changes in bowel habits.
  • No persistent lower back pain.
  • No unexplained fever or recent infections.
  • No recent history of prolonged travel or dehydration.
  • No history of easy bruising or bleeding from other sites.

Lifestyle & Risk Factors

  • Smoking history: Smokes 10 cigarettes per day for the last 30 years.
  • Occupational exposure: Works as a mechanic, regularly exposed to chemicals and industrial solvents (e.g., petroleum products, degreasers).
  • Alcohol consumption: 6-8 standard drinks per week.
  • Diet: No excessive intake of beets or food that could cause discolouration.

Family History

  • Father had prostate cancer at age 68.
  • No known family history of kidney or bladder cancer.
  • No history of bleeding disorders or clotting problems in the family.

Emotional Cues & Reactions

  • Concerned and anxious about the possibility of bladder cancer.
  • Feels frustrated because he has no pain or other symptoms but is worried this could be serious.
  • Listens carefully to the doctor’s explanation but may appear slightly tense and impatient.
  • Becomes more anxious if the doctor mentions further tests or referral.
  • May push for reassurance but also wants a clear explanation of what tests are needed.
  • If the doctor does not acknowledge his concern, he may press for a CT scan or specialist referral immediately.

Questions the Patient Might Ask

  1. Could this be bladder cancer?
    • (If not reassured, he may press further: “But isn’t blood in the urine a big warning sign?”)
  2. Do I need a scan or a cystoscopy?
    • (If investigations are suggested, he may ask: “How soon can I get them done?”)
  3. What else can cause blood in the urine?
    • (If given other possibilities, he might ask: “But how can you be sure it’s not something serious?”)
  4. Is this serious? Do I need urgent tests?
    • (If the doctor downplays the urgency, he might respond: “I read online that this could be cancer. Are you sure I don’t need more tests?”)
  5. What can I do to prevent this from happening again?
    • (If lifestyle advice is given, he might say: “So is my smoking a big risk factor for this?”)

How to Play the Role

Opening Scene (First Few Minutes)

  • Appear visibly anxious when explaining the symptom.
  • Look concerned and serious, possibly leaning forward in the chair.
  • Express uncertainty about what might be causing the haematuria.

If the Doctor Explains the Possible Causes Well:

  • Start to calm down slightly but still want more reassurance.
  • Ask about tests and the need for a specialist referral.
  • If the doctor mentions smoking as a risk factor, show mild defensiveness but acknowledge the concern.

If the Doctor Is Dismissive or Doesn’t Provide a Clear Plan:

  • Show frustration and press for further tests.
  • Insist on getting a CT scan or seeing a specialist quickly.
  • Become more anxious if the doctor hesitates to order investigations.

If the Doctor Suggests Referral to a Specialist (Urologist):

  • Ask, “Do I really need that? What will they do?”
  • Show nervousness about undergoing procedures like a cystoscopy.
  • Express concern about waiting times and what could happen in the meantime.

Ending the Consultation (Final Reaction Depending on the Doctor’s Approach)

If the Doctor Provides a Clear Plan and Reassurance:

  • Look relieved but still a bit cautious.
  • Ask about how long it will take to get test results.
  • Thank the doctor but mention you will be back if the symptoms persist.

If the Doctor Is Unclear or Doesn’t Address Concerns Fully:

  • Remain visibly worried and insist on getting a scan as soon as possible.
  • Say something like, “I think I’ll get a second opinion just to be sure.”
  • Appear frustrated and dissatisfied with the consultation.

Key Features for the Examiner to Observe

  • How well the candidate gathers relevant history, including urinary, systemic, lifestyle, and risk factor details.
  • Whether they identify red flags (e.g., age >50, smoking history, occupational exposure).
  • How effectively they provide reassurance while appropriately recommending investigations.
  • Whether they safety-net appropriately, advising follow-up and warning signs.
  • How they manage the patient’s anxiety, particularly about bladder cancer.

THE COMPETENT CANDIDATE

The competent candidate should be able to:


Task 1: Take an appropriate history from the patient, including haematuria characteristics, risk factors, and red flag symptoms.

The competent candidate should:

  • Use open-ended questions to allow the patient to describe their symptoms in their own words.
  • Clarify haematuria characteristics:
    • Duration: When it started and whether it has persisted.
    • Appearance: Bright red, brown, or tea-coloured.
    • Pattern: Throughout urination, terminal, or initial.
    • Clots: Presence may suggest a urological cause.
    • Associated symptoms: Dysuria, frequency, urgency, nocturia, or pain.
  • Explore red flag symptoms:
    • Unexplained weight loss, night sweats, persistent fatigue.
    • Recent trauma or history of renal stones.
    • Symptoms of systemic disease (e.g., fever, rash, arthralgia).
  • Identify relevant risk factors:
    • Smoking history (major risk factor for bladder cancer).
    • Occupational exposure to chemicals, dyes, or industrial fumes.
    • History of recurrent UTIs, kidney stones, or pelvic irradiation.
    • Family history of urological malignancy or bleeding disorders.
  • Summarise key findings and check for patient’s concerns and expectations.

Task 2: Discuss your differential diagnosis and explain the most likely cause of the haematuria.

The competent candidate should:

  • Provide a structured differential diagnosis, including:
    • Common benign causes: Urinary tract infection (UTI), exercise-induced haematuria, benign prostatic hyperplasia (BPH), anticoagulant use.
    • Serious causes: Bladder cancer, renal cell carcinoma, prostate cancer, glomerulonephritis.
    • Other causes: Renal stones, interstitial nephritis, post-infectious glomerulonephritis.
  • Explain that bladder cancer is a key concern given his age (55 years), smoking history, and occupational exposure.
  • Exclude serious conditions using history and red flags.
  • Reassure the patient that while haematuria is a concerning symptom, most cases have benign or treatable causes.
  • Emphasise the importance of investigations to determine the exact cause.

Task 3: Address the patient’s concerns and explain the necessary investigations and management plan.

The competent candidate should:

  • Acknowledge and validate the patient’s anxiety about cancer.
  • Explain the importance of investigating haematuria, as early detection of malignancy improves outcomes.
  • Outline the investigations required:
    • Urinalysis: To detect infection, proteinuria, or casts.
    • Urine microscopy and culture: To rule out infection.
    • Urine cytology: To check for malignant cells.
    • Renal function tests (eGFR, creatinine, urea).
    • Imaging: Renal ultrasound or CT urography (preferred for malignancy assessment).
    • Cystoscopy: If no clear benign cause is found, to assess the bladder directly.
  • Explain the stepwise approach and what each test will rule out.
  • Provide reassurance while setting expectations that further investigations, including a referral to a urologist, may be necessary.

Task 4: Outline indications for referral and provide appropriate safety netting advice.

The competent candidate should:

  • Explain when urgent referral to a urologist or nephrologist is required, including:
    • Persistent or unexplained macroscopic haematuria.
    • Age >50 with risk factors (e.g., smoking, occupational exposure).
    • Presence of urinary tract mass on imaging.
    • Abnormal urine cytology suggesting malignancy.
  • Provide safety netting advice, instructing the patient to return if:
    • Symptoms worsen or persist.
    • He experiences pain, difficulty urinating, fever, or weight loss.
  • Offer smoking cessation advice, as smoking increases the risk of bladder and renal cancers.
  • Arrange follow-up to review test results and ensure specialist referral if needed.

SUMMARY OF A COMPETENT ANSWER

  • Comprehensive history-taking, covering haematuria characteristics, red flag symptoms, and risk factors.
  • Structured differential diagnosis, considering both benign and serious causes.
  • Clear explanation of the need for investigations, ensuring patient understanding and compliance.
  • Empathetic, patient-centred communication, addressing the patient’s concerns about cancer.
  • Holistic management approach, including lifestyle advice (smoking cessation) and follow-up planning.
  • Appropriate safety netting, advising urgent review if symptoms worsen.

PITFALLS

  • Failing to explore red flag symptoms, such as weight loss, clot retention, or systemic symptoms.
  • Overlooking malignancy risk factors, particularly smoking and occupational exposure.
  • Premature reassurance without arranging appropriate investigations.
  • Neglecting to explain the rationale for investigations, leading to patient anxiety or non-compliance.
  • Inappropriate referral (e.g., sending to a urologist before completing basic investigations).
  • Lack of safety netting, failing to advise when to return if symptoms change.

REFERENCES


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 Communication is appropriate to the person and the sociocultural context.
1.2 Engages the patient to gather information about their symptoms, ideas, concerns, expectations of healthcare, and the full impact of their illness experience.
1.5 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Conducts an appropriate history to explore haematuria characteristics, risk factors, and red flags.
2.2 Identifies relevant investigations based on clinical suspicion.

3. Diagnosis, Decision-Making and Reasoning

3.1 Forms an appropriate differential diagnosis.
3.2 Identifies red flag features requiring urgent referral.

4. Clinical Management and Therapeutic Reasoning

4.2 Develops a management plan including appropriate investigations and follow-up.
4.3 Provides safety netting and referral if required.

5. Preventive and Population Health

5.1 Identifies and addresses modifiable risk factors for urological malignancy.
5.3 Provides preventive health advice relevant to the patient’s risk factors.

9. Managing Uncertainty

9.1 Recognises when further investigations or specialist referral are required.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies red flag features suggestive of significant underlying pathology.


Competency at Fellowship Level

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