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You are an Foundation doctor working in GP. Mr Carl Sinoma is a 63-year-old man, presenting to your surgery concerned about trouble when urinating.

Please take a history from Carl and undertake an appropriate examination. You will then be asked to discuss the case with the examiner.

You are Carl Sinoma, a 63 year old gentleman who enjoys countryside walks and birdwatching. You hate going to the doctor, but feel that this time around it is pretty much unavoidable.

HPC: You have been having some trouble when urinating. You’ve been noticing more and more that your urine is going a “funny colour”. It had been starting to go pinkish in colour for about a week, but you decided to come into today because you saw a bit that was bright red. You weren’t paying attention at first, but you think it might have been towards the end of your urinating. It isn’t this colour every time you go, but it’s been happening more and more frequently over the past few weeks. There isn’t any pain associated with it but you have been going to the bathroom more often. When you pass urine, sometimes you feel that you have a bit more to get rid of, but can’t quite manage it.

You haven’t noticed that you’ve been getting up in the middle of the night to pass urine – you sleep far too deeply for that. You really need your sleep!

In terms of other problems, you haven’t noticed anything major. You have had one or two aches and pains, but you’ve tried to go more walking recently as it’s nesting season for your favourite bird – the puffin. There are some puffins on the little islands near your home at the coast, and you really enjoy going walking to see them. Anything that made you unwell would really distract you from that, and you couldn’t have that!

You haven’t had any bad leg pains, haven’t had any coughs, shortness of breath or abdominal pain. Your bowels and waterworks are absolutely fine. You’re not sure if you’ve lost any weight, but have felt rather tired recently. PMH: You have had a few water infections in the past, but nothing major. You never really went to the doctors about those – you felt that they should just ‘run their course’. Occasionally you have a little bit of pain in knees from arthritis, but you’re seeing a nice surgeon about that soon.

DH: You take some painkillers for the knees, but otherwise nothing to report. You have never taken anything stronger than paracetamol or ibuprofen.

FH: Your father died of a sudden heart attack in his 70s. You have a couple of other family members with diabetes. Your mum had endometrial cancer and unfortunately died as a result of that. You miss them both very much: especially your dad, as he was the person who got you into birdwatching and walks in the countryside. You think you might have been a bit depressed after he died, however you have come to terms with things since. SH: You live with your wife at home. You used to be a cleaner in a few factories. The last factory you worked in made tins for a food company, and the factory before that made some kind of dye. You’ve never worked on any shipyards.

You have no issues getting about your home – you don’t envisage that being a problem any time soon. Whilst you do enjoy a sherry at family events, you don’t drink much else. You still smoke 15 cigarettes per day - you have done since you were 19 years old – however you have tried to stop recently. It’s just so hard!

You have never been abroad, and have never been swimming in any African lakes. Who would ever ask you such a strange question?

ICE: You’ve had a few water infections in the past, so you reckon that this might be another one, though the blood in disturbing you. Could it be a really bad water infection? Could it be something scarier, like cancer? You feel that everybody worries about cancer, so that should be normal. You expect some tests to find out what’s going on.

Examiner Instructions The student should take a comprehensive urinary history, focusing on red flags of malignancy and ruling out important risk factors. An appropriate examination would be an abdominal examination. An example of a competent differential diagnosis would sound something like:

“My differential diagnosis would consist of a urological cause: more specifically bladder cancer. This is because of the presentation of painless frank haematuria, on a background of cigarette smoking and history of working with dyes. An alternative differential diagnosis would include other urological causes, such as small kidney stones causing haematuria, though this is made less likely by the lack of abdominal pain.”

Possible questions for discussion may include:

  • How would you investigate this gentleman’s haematuria?
  • What is flexible cystoscopy?
  • What referral criteria would this patient meet?
  • How is bladder cancer managed?
  • What types of bladder cancer do you know about?
  • What risk factors are you aware of for bladder cancer?