AIM OSCE / OSPE • FINAL YEAR MBBS
Station 5 — Hematuria Focused History, Examination & Diagnostic Approach
Renal Module • Medicine / Nephrology • Surgery
Rapid Revision • Clinical Skills • Practical Skills • Viva
🎯 Candidate Task
An adult patient presents with blood in the urine. Take a focused history, describe the relevant physical examination, and explain your diagnostic approach and initial management plan to the examiner.
⚡ Model Station Answer
History: Clarify visible or non-visible hematuria, onset, timing, clots, dysuria, loin pain, fever, trauma and malignancy risk factors.
Examination: Assess vital signs, blood pressure, pallor, edema, abdominal or loin tenderness, bladder distension and relevant urological findings.
Interpretation: Proteinuria and red-cell casts suggest glomerular bleeding; clots, colic or lower urinary symptoms suggest a urological source.
Investigations: Urinalysis with microscopy, urine culture when indicated, CBC, renal function and appropriate urinary-tract imaging; consider cystoscopy.
Management: Assess stability, address infection or obstruction, urgently manage clot retention and refer suspicious persistent or visible hematuria for urological evaluation.
🔎 How to Perform / Approach
- Introduce and clarify the complaint:
Confirm patient identity, obtain consent and ask whether blood is visible or detected only on urine testing. Establish onset, duration, recurrence, color, timing during urination and presence of clots. - Ask associated symptoms:
Dysuria, urgency, frequency, fever, flank/loin pain, renal colic, reduced urine output, difficulty passing urine and symptoms suggesting anemia or systemic illness. - Identify relevant history and risk factors:
Previous urinary infections or stones, trauma, recent throat/skin infection, smoking, occupational chemical exposure, anticoagulant use, relevant family history and possible menstrual contamination. - Perform focused examination:
Assess vital signs, blood pressure, pallor and edema. Examine the abdomen for tenderness, masses and bladder distension; assess costovertebral-angle tenderness. Perform genital examination or DRE only when indicated, with consent and a chaperone. - Interpret the likely source:
Dysmorphic RBCs, red-cell casts and significant proteinuria suggest glomerular disease. Clots, severe colicky pain or lower urinary-tract symptoms favor a nonglomerular cause. Painless visible hematuria warrants assessment for urinary-tract malignancy. - Select investigations:
Confirm hematuria with urine microscopy; assess proteinuria, urine culture where infection is suspected, CBC, creatinine and eGFR. Choose ultrasound, non-contrast CT for suspected stones, or CT urography and cystoscopy for indicated urological evaluation. - State initial management:
Stabilize significant bleeding, investigate and treat the underlying cause, and urgently refer clot retention, hemodynamic instability or obstructed infected urinary systems. Arrange appropriate nephrology or urology referral and follow-up.
🖼️ Visual Learning
Hematuria — Clinical Recognition, Examination & Diagnostic Interpretation
📝 Important Viva Questions
Q1. How is microscopic hematuria defined?
Answer: The presence of three or more red blood cells per high-power field on microscopic examination of a properly collected urine sample.
Q2. Which urine findings suggest a glomerular source of hematuria?
Answer: Dysmorphic red blood cells, red-cell casts and significant proteinuria suggest glomerular bleeding.
Q3. Why is painless visible hematuria clinically important?
Answer: It may indicate urinary-tract malignancy, particularly bladder cancer, and requires appropriate urological investigation.
Q4. Which investigations are appropriate in a patient presenting with hematuria?
Answer: Urinalysis with microscopy, urine culture when indicated, CBC, renal function tests and risk-directed imaging. Cystoscopy is important when bladder pathology is suspected.
Q5. What is the immediate management priority in gross hematuria with clot retention?
Answer: Urgent urological assessment, evaluation of hemodynamic stability and restoration of urinary drainage, usually with an appropriate large-bore three-way catheter and bladder irrigation under clinical supervision.