Cases/Renal and Urology

Older Man Who Has Seen Blood in His Urine — Free SCA Practice Case

Older man who has seen blood in his urine

Station Timer

12:00

Golden Minute

Initial Introduction

•Introduce yourself

•Ask an open question — "How can I help you today?"

•Listen — don't interrupt

•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

12:00

Golden Minute

Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Peter Hallam

Age

67 years

Consultation Type

Telephone

Age

Situation

Urgent Telephone Consultation, following an out-of-hours attendance.

Reason for Encounter

"The out-of-hours nurse told me to book an appointment with you. I've had blood in my urine."

Medical Records

●PMH: Osteoarthritis.
●Medications: Co-codamol PRN (1–2 tablets 4–6 hourly, maximum 8 daily).
●Allergies: NKDA.
●Out-of-hours letter (yesterday): Seen with a several-day history of bloody urine. Clinically well; no dysuria, abdominal pain, or systemic symptoms. Urine dipstick 4+ blood, no leucocytes, no nitrites. No treatment required. Advised to follow up with GP for further assessment.

Patient Script

For the friend playing the patient role

Character Overview: You are Peter, a 67-year-old retired train driver. You noticed blood in your urine three times, starting five days ago; you have not seen it since yesterday. It was painless and you feel completely well. You found it frightening because it has never happened before. You were seen at out-of-hours yesterday and told to see your own GP. You wonder whether it could be related to the yellow fever vaccination you had six days ago at a private travel clinic. You and your wife fly to Tanzania tomorrow for three weeks for your 30th wedding anniversary — you have been planning it for over a year. You are firm: you will not cancel the trip, whatever is explained to you. You do not smoke or drink.

Opening Sentence: "Hello Doctor. The nurse at out-of-hours said I should ring you. I had blood in my urine — three times, starting about five days ago, though none since yesterday. It gave me a real fright. I wondered if it's from the yellow fever jab I had last week. And I should say — my wife and I fly to Tanzania tomorrow for three weeks, for our 30th anniversary."

History if Asked (Data Gathering Phase)

●The bleeding: "Three separate times, starting five days ago. Bright blood in the urine. Nothing since yesterday."
●Pain: "No pain at all — that's what struck me. No burning, no back or tummy pain."
●How he feels: "Completely well in myself, that's the odd thing."
●His theory: "I had the yellow fever jab six days ago at a travel clinic for the trip. Could that have caused it?"
●The trip: "We fly tomorrow. Three weeks in Tanzania for our 30th anniversary. We've been planning it over a year. I'm not cancelling it."

ICE — Ideas, Concerns, Expectations

The patient does not volunteer this information unprompted. These responses surface only when the candidate directly explores his perspective.

●Ideas: Peter wonders whether the yellow fever vaccination caused the bleeding. "I've convinced myself it's the jab I had last week."
●Concerns: He found the episode frightening and is worried it could be something serious such as cancer. "It shook me. Underneath, I'm worried it's something serious — cancer."
●Expectations: He wants an explanation and, above all, to be told whether it is safe to travel tomorrow — while making clear he intends to go. "I want to know what's causing it and whether we can still go. I'm going either way, to be honest."

If Asked — Haematuria Assessment and Red-Flag Screen

The patient answers these only when directly asked.

●If asked about painless vs painful haematuria: "Completely painless." (Painless visible haematuria is the more concerning pattern.)
●If asked about dysuria, frequency, or urgency (UTI): "No burning, no going more often, no urgency."
●If asked about other lower urinary tract symptoms (nocturia, weak stream, hesitancy, dribbling): "My waterworks have been normal — no weak stream or getting up at night."
●If asked about fever, rigors, or feeling unwell: "No fever, no shivers, I feel fine."
●If asked about flank/loin, suprapubic, perineal, or testicular pain: "No pain anywhere."
●If asked about clots or difficulty passing urine/retention: "No clots that I saw, and no trouble passing water."
●If asked about weight loss, appetite, night sweats, or lumps: "No weight loss, appetite's normal, no sweats, no lumps."
●If asked about anticoagulants, antiplatelets, or NSAIDs: "Only the co-codamol for my joints. No blood thinners."
●If asked about bleeding elsewhere (gums, nosebleeds, bruising): "No, nothing like that."
●If asked about recent heavy exercise or trauma: "No, nothing strenuous, no injury."
●If asked about smoking (an important bladder-cancer risk factor) and occupational exposures: "Never smoked. I was a train driver — no chemicals or dyes."
●If asked about previous haematuria, stones, or urological history: "Never happened before, no stones, no prostate problems."
●If asked about anaemia symptoms (light-headedness, breathlessness, palpitations): "None of those."
●If asked about travel insurance/medical cover: "We've got insurance, though I haven't declared this."

Responses to Management (The Negotiation Phase)

●If the Doctor explains the vaccine is not the cause: "So the jab wouldn't cause bleeding in the urine? Right — I'd pinned my hopes on that." (The tested point is gently correcting the misattribution rather than colluding with it.)
●If the Doctor explains the need for an urgent referral — key: "An urgent cancer referral? That sounds alarming. Does that mean you think I've got cancer?" (The tested point is conveying urgency without panic — explaining the pathway is precautionary and most causes are not cancer.)
●If the Doctor raises the conflict with the trip: "I hear you, but I'm not cancelling. We've waited a year for this. What can we do that works around it?" (The tested point is respecting autonomy while being honest about the risks of a three-week delay, and problem-solving.)
●If the Doctor arranges baseline tests and practical measures: "So bloods and a urine sample before I go, and the referral set up so I'm seen as soon as we're back?"
●If the Doctor safety-nets for while he is away: "And what should I do if it happens again out there, or if I can't pass water?"

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 18 indicators checked+0−0

Positive (0/9)

Negative (0/9)

Domain 2: Clinical Management and Medical Complexity

0 / 18 indicators checked+0−0

Positive (0/9)

Negative (0/9)

Domain 3: Relating to Others

0 / 12 indicators checked+0−0

Positive (0/6)

Negative (0/6)

Clinical Learning Points

Unexplained Visible Haematuria Is a Suspected-Cancer Presentation

●Unexplained visible haematuria in an adult aged 45 or over (without a urinary tract infection, or persisting after treatment of one) warrants an urgent suspected-cancer referral for bladder and renal cancer (NICE NG12). Painless visible haematuria is the more concerning pattern.

A Single Episode — and Resolution — Still Requires Investigation

●Haematuria that has stopped does not exclude a serious cause. Even a single episode of unexplained visible haematuria requires investigation; do not be falsely reassured by resolution.

Exclude Infection Properly

●Establish whether a UTI explains the bleeding — symptoms, and dipstick/culture (here negative for leucocytes and nitrites). Only then is the haematuria "unexplained". Note that haematuria persisting after treatment of a UTI also triggers referral.

Do Not Accept a Spurious Explanation

●Patients often offer their own explanation (here a recent vaccination). Attributing visible haematuria to an unrelated event is a common route to delayed diagnosis — correct it kindly but clearly.

Urgency Without Panic

●Explain that referral is precautionary and routine practice, and that most causes are not cancer, while making clear it must be investigated promptly. Pitching this correctly is the core communication skill.

Baseline Work-Up and Risk Factors

●Arrange urine culture, FBC, U&Es/eGFR, and blood pressure. Assess risk factors — smoking (the major bladder-cancer risk factor), occupational exposures (e.g. dyes/rubber), age, and medication (anticoagulants do not explain away haematuria).

When the Patient Chooses to Delay — Autonomy With Safeguards

●If a patient declines or delays assessment (here, a long-planned trip), respect autonomy but: be honest about the risk of delay, attempt to expedite what can be done now, make the referral and time it to their return, advise on travel insurance disclosure and accessing care abroad, give a robust safety-net (heavy bleeding, clots, retention, fever, loin pain), and document the discussion and the plan to ensure they are not lost to follow-up.

Common Candidate Mistakes in This Case

●Not referring urgently: failing to recognise unexplained visible haematuria as a suspected-cancer presentation.
●Accepting the vaccine explanation: colluding with a spurious cause and delaying diagnosis.
●Being reassured because the bleeding stopped: treating resolution as exclusion.
●Mishandling the travel conflict: either lecturing/issuing ultimatums, or passively accepting a three-week delay with no referral, expediting attempt, safety-net, or documentation.
●Getting the tone wrong: frightening him, or so under-playing it that he does not appreciate the urgency.

Free MRCGP SCA practice case for GP registrars covering Older Man Who Has Seen Blood in His Urine — Renal and Urology. Includes candidate brief, patient script, marking scheme mapped to the RCGP SCA marking domains, and learning points. Built directly from the RCGP curriculum topic stations listed under "How this might be tested in the MRCGP SCA," part of a free library of 79 SCA practice cases for simulated consultation assessment preparation.

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