Mr. A is a 56-year-old man who has had several episodes of red urine in the past few days.

Mr. A reports several episodes of painless visible hematuria over the last several days, along with occasional mild lower abdominal discomfort. He is feeling well otherwise and has no other complaints. His medical history is significant for chronic kidney disease (CKD) stage 3, hypertension treated with hydrochlorothiazide and enalapril, and a remote appendectomy. He has no family history of kidney stones, but his father did have prostate cancer. He has smoked 1 pack per day of cigarettes for 35 years. He is a philosophy professor, and has no known toxin exposures. Initial urinalysis shows many nondysmorphic RBCs, with no WBCs, bacteria, casts, or proteinuria.

Mr. A’s physical exam is normal, with no abdominal masses or tenderness. External genitalia are normal, and digital rectal exam shows a symmetric, nontender prostate without nodules. Serum creatinine is 1.8 mg/dL, unchanged from previous values.

Urine culture is negative.

Although you are concerned about malignancy, because of his CKD you order an ultrasound rather than a CT scan. It shows a 1 mm stone in the right renal pelvis, and a 2 cm cyst in the left kidney. You order a PSA and refer him to urology for a cystoscopy.

SOAP NOTE

S: 56 y/o man complains of several episodes of painless visible hematuria and occasional mild lower abdominal discomfort over the last several days. He states that he is feeling well and has no other complaints. He has a history of Chronic kidney disease (CKD) stage 3 and hypertension treated with hydrochlorothiazide and enalapril. He denies history of kidney stones but reports that his father did have prostate cancer. Admits to smoking 1 pack per day of cigarettes for 35 years.

O:  Urinalysis:  Many nondysmorphic RBC’s, with no WBC’s, bacteria, casts, or proteinuria.

Physical Exam: No abdominal masses or tenderness, external genitalia is normal. Digital rectal exam shows a symmetric, non-tender prostate without nodules.

Serum Creatinine: 1.8mg/dl, unchanged from previous values.

Ultrasound: 1 mm stone in the right renal pelvis. 2 cm cyst in the left kidney.

Urine Culture: negative

A:    Bladder Cancer- 56 y/o male, 35 pack year smoking hx, with painless visible  hematuria and occasional mild lower abdominal pain. All are risk factors suggesting bleeding from urothelial bladder cancer.

Nephrolithiasis -1 mm stone in the right renal pelvis

R/O Prostatitis, Prostate Cancer, Renal Cell Carcinoma

P:   Will order a PSA and refer him to urology for a cystoscopy.

 

/s/  Markenzie Jean-baptiste PA-S

Summary

      The diagnostic approach for my patient who had visible macroscopic hematuria followed the following path to the differential diagnoses of bladder cancer. The patient presented with visible macroscopic hematuria so a urinalysis and urine culture was performed. For patients presenting with hematuria, it is important to try to distinguish glomerular hematuria from nonglomerular hematuria. In glomerular hematuria, a urinalysis may show dysmorphic red blood cells, red cell casts, protein and creatine in the urine. Also,visible blood clots which Mr. A presented with are not a glomerular cause. Since the urinalysis showed red blood cells that were nondysmorphic and absent of red cell casts and proteins, this suggested that a lower urinary tract problem like the bladder was the source of hematuria. This also ruled out urinary tract infection as the source of blood since the urinalysis was bland and there was an absence of nitrates and leukocytes. Since the urine culture was negative, the provider ultimately referred the patient to urology for cystoscopy. Through cystoscopy, the physician was able to detect a small papillary tumor in the bladder.

Nephrolithiasis was in the differential diagnosis because it is common and a kidney stone can irritate the lining of the kidney or ureter. Prostate Cancer and Prostatitis were also in the differential diagnosis because they too are very common and patients may experience vague abdominal discomfort like Mr. A did. The patient’s father also had a history of prostate cancer. Renal Cell Carcinoma, even though it is rare, must always be considered for patients with hematuria.