You are an FY2 in a GP surgery

Personal Details:

Name: Peter Williams

Age: 55

Medical Record:

Past medical history: None.

Regular medication: None.

Allergies: None known.

Notes:

A 55-year-old man presents for his test results.

He recently had a urinary tract infection, which has resolved.

His urine dipstick test showed persistent microscopic blood in urine in repeated urine dipstick tests (repeated twice).

•Task:

1. Explain the urine test result.

2. Take a history and discuss management

Opening Sentence: “Hi, Doctor, you asked me to come in about my urine test. I thought the infection was all cleared up?”

Open History (to give freely): “The burning and frequency have gone since I took the antibiotics, but I’ve still got this dull ache in my lower tummy. I’ve also lost a bit of weight over the last few months, but I’ve been trying to eat a bit healthier.”

Cues to give: “I’ve worked at the local dye factory for the last 30 years.”

ICE (Ideas, Concerns, Expectations):

Ideas: “I don’t know what it could be. I thought the blood in the urine was just from the infection.”

Concerns: “Is it something serious? My dad died of prostate cancer.”

Expectation: “I’m expecting you to tell me what’s going on and what the next steps are.”

How to Act: You are a straightforward, working man. You are anxious but not overly emotional.

More History (only if asked): You have been a smoker for 40 years (15-20 per day). You have worked with industrial dyes your whole adult life. You eat a lot of processed and canned meat. You have no visible blood in your urine.

Social History:

Occupation: Works in a dye factory.

Smoking: 15-20/day.

Diet: High in processed meat.

Questions to ask:

“So you think it might be cancer?”

“What does the hospital do?”

History of Presenting Complaint:

I understand that this appointment was arranged to discuss your urine test, which was done after you had a treatment recently for a water infection.

How are your urinary symptoms now? Have these recovered? Do you still have any burning or stinging? Have you noticed any blood in your urine?

Have you had any fever? Any weight or appetite change? Any lumps or swelling? Any new lower back pain?

Risk Factor Assessment: Do you smoke, or have you ever smoked? Can you tell me about the work you used to do? Were you exposed to any chemicals?”

ICE (Ideas, Concerns, Expectations): What were your own thoughts on what might have caused this? What was your biggest worry when you saw the blood? What were you hoping I would do for you today?

Explain the test results:

Hi Peter, thanks for coming in. You’re right, the infection has cleared up, but the test we did on your urine still shows some persistent blood in urine. While this can sometimes happen after an infection, it should disappear and improve after the infection gets treated, which hasn’t been the case here.  

Addressing and answering the patient’s ICE:

You’re worried about it being something serious, especially with your father’s history of prostate cancer. The symptom of blood in the urine, even if it’s invisible, together with your age and some other factors, means we have to rule out the possibility of cancer, specifically cancer of the bladder. I’m not saying that’s what you have, but we need to check for it thoroughly.

Next Steps:

There are a few things in your history that put you at a higher risk for bladder cancer. The most significant are your long history of smoking and your work in the dye industry. Because of these risk factors and the blood in your urine, I am going to refer you to the hospital on an urgent ‘two-week wait’ pathway. This is the fast-track route to see a urology specialist.

The specialist will arrange for some investigations. The main one is a procedure called a cystoscopy. This is where they use a thin, flexible camera to look inside your bladder to check for any abnormalities. It’s a very quick and straightforward procedure done in the outpatient clinic.”

Support

I know this is a worrying time. The most important thing is that we are acting quickly to get you seen by the experts.

Lifestyle changes

Quitting smoking is one of the best things you can do for your health right now, and we can offer you support with that.

Addressing ideas, concerns, and expectations: Be direct and honest about the suspicion of bladder cancer. Explain why he is at risk, linking his smoking and occupation to the condition.

The single most important action is making an urgent two-week wait referral to urology. Explain the next step in the investigation pathway (cystoscopy).

What is scenario testing? This case tests the candidate’s ability to identify a patient with red flag symptoms and significant risk factors for a specific cancer (bladder). It requires knowledge of the risk factors and the urgent cancer referral guidelines. The communication challenge is to convey the seriousness of the situation to ensure the patient understands the need for urgent investigation, without causing unnecessary terror.