History Taking · Intermediate · Urology

Blood in Urine

Practise this PLAB 2 history taking station on Visible Haematuria. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in the GP surgery. Ms Louise Nichols, a 62-year-old woman, has presented with frank red blood in her urine for two weeks. She is concerned about the appearance. Please take a focused history to differentiate urological from nephrological causes and discuss two-week wait referral.

Background notes: PMH: Hypertension, Atrial fibrillation, Appendicectomy

What this station tests

  • NICE NG12 referral criteria: visible haematuria in patients over 45 requires urgent 2-week-wait urology referral
  • Painless haematuria as a red flag: painless frank haematuria in an older patient is malignancy until proven otherwise
  • Anticoagulation does not explain haematuria: warfarin may unmask an underlying lesion, and cancer still needs exclusion
  • Total haematuria pattern: blood throughout the stream suggests bladder or upper tract source
  • Cystoscopy and CT urogram as the investigation pathway for visible haematuria

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself, confirm identity, open question. 'What's brought you in today?'
  • 1-4 min — Systematic History: Presenting complaint detail (SOCRATES for pain, timeline, severity). Systems review. PMH, medications, allergies.
  • 4-6 min — Context and ICE: Social history (smoking, alcohol, occupation, living situation). Family history. Ideas, Concerns, Expectations.
  • 6-7 min — Summary and Plan: Summarise findings back to patient. Share differential/working diagnosis. Outline investigation and management plan.
  • 7-8 min — Closing: Safety netting with specific red flags. Arrange follow-up. Check for questions.

Consultation approach

The opening

Frank haematuria in a patient over 45 is urological malignancy until proven otherwise and requires 2-week-wait referral per NICE NG12. The candidate must identify alarm features, arrange appropriate investigation, and address the cancer anxiety. Ms Nichols is 62, presenting with 2 weeks of visible blood in her urine. Open with: 'Ms Nichols, blood in the urine is something we always take seriously. Tell me about what you have noticed.'

Core approach

Characterise the haematuria. Bright red, mixed throughout the stream (total haematuria, suggesting bladder or upper tract source rather than urethral). Present with every void for 2 weeks. No pain on urination (painless haematuria in an older patient is cancer until proven otherwise). No clots. No fever.

Screen for malignancy risk factors. Age over 45 with visible haematuria: meets NICE criteria for urgent referral. Smoking history: ask (smoking is the strongest modifiable risk factor for bladder cancer). Occupational exposure: dyes, rubber, leather, petrochemicals. Previous pelvic radiotherapy. Check for weight loss, reduced appetite, fatigue.

Exclude other causes through history. UTI: no dysuria, no frequency (though check dipstick). Renal stones: no colicky pain. Menstrual contamination: confirm it is definitely urinary, not vaginal. Anticoagulation: she is on warfarin for AF. Anticoagulation can cause haematuria but does not explain it: anticoagulated patients with haematuria still need cancer exclusion. The anticoagulation may have unmasked an underlying lesion.

ICE: She is terrified of bladder or kidney cancer. She has never had this before.

Closing and safety netting

Arrange urgent 2-week-wait referral per NICE NG12: visible haematuria in a patient over 45 requires urgent urology referral. She will need cystoscopy (camera into the bladder) and upper tract imaging (CT urogram). Explain: 'I am referring you urgently because visible blood in the urine always needs investigation to find the cause. The referral is within a 2-week pathway.'

Bloods: FBC (anaemia from blood loss), U&E (renal function), clotting (she is on warfarin, check INR). Urine: dipstick and culture (exclude concurrent UTI). Check INR is therapeutic.

Address her cancer anxiety directly but proportionately: 'Blood in the urine has many causes, and cancer is only one of them. But because you are over 45, we investigate thoroughly to be certain.' Safety net: 'If you pass large clots, cannot pass urine, or feel faint, go to A&E.' Follow-up after urology assessment.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for visible haematuria. Domain 1 (Data Gathering) carries the most weight: expect marks for systematic coverage of presenting complaint, red flags, PMH, medications, social and family history. Domain 2 (Clinical Management) requires a clear differential, appropriate investigations, and a safe management plan with safety netting. Domain 3 (Interpersonal Skills) is assessed throughout: genuine exploration of ICE, active listening, empathic responses, and clear communication without jargon.

Domain 1: Data Gathering, Technical and Assessment Skills (Primary focus)

Scores well: Haematuria characterised (total, painless, 2 weeks). Cancer risk factors assessed (age, smoking, occupation). Anticoagulation noted but not used to explain. Other causes excluded (UTI, stones, menstrual). Clotting checked.

Costs marks: Not characterising the haematuria. Attributing to warfarin. Not checking smoking. Not excluding UTI.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: 2-week-wait referral arranged. Correct investigation pathway (cystoscopy, CT urogram). Bloods including INR. Urine culture. Clot retention safety netting.

Costs marks: Routine referral. Wrong investigation pathway. Not checking INR. No safety netting.

Domain 3: Interpersonal Skills (Throughout)

Scores well: Addressing cancer anxiety proportionately (one of many causes, but thorough investigation needed). Explaining the 2-week pathway. Acknowledging this is frightening. Honest without being alarmist.

Costs marks: Being falsely reassuring ('probably nothing'). Being alarmist. Not explaining the referral pathway.

Common examiner feedback (and how to fix it)

Did not gather sufficient information to make an adequate assessment of the patient's condition

Fix: Use a consistent framework for every history. After covering the presenting complaint, systematically move through PMH, drug history, social history, family history, and ICE. Keep a mental checklist.

Did not identify the patient's problems and/or did not develop a management plan adequately

Fix: Reserve the final 2 minutes to summarise your findings, share your working diagnosis with the patient, and outline your investigation and management plan including safety netting.

Common mistakes in this station

  1. Attributing haematuria to anticoagulation. She is on warfarin, and candidates may be tempted to say 'it is probably the warfarin.' Anticoagulated patients with haematuria still need full investigation. The warfarin may have unmasked an underlying cancer.
  2. Not arranging urgent referral. Visible haematuria over age 45 requires 2-week-wait referral, not routine outpatient urology. Candidates who arrange routine referral demonstrate inadequate urgency.
  3. Not asking about smoking. Smoking is the strongest modifiable risk factor for bladder cancer. Candidates who investigate haematuria without taking a smoking history miss a key risk assessment.

Resitting PLAB 2?

If you have previously struggled with history taking stations, focus on building a consistent systematic framework that you apply to every case. Practise structuring your history into clear phases (presenting complaint, systems review, PMH, social, ICE) so that even under pressure, you cover all domains. Many resitters lose marks not on knowledge but on organisation and time management.

Example opening

Good morning/afternoon, my name is Dr [Name], I'm one of the doctors here today. Could I confirm your name and date of birth please? Thank you. So, what's brought you in to see me today?

Frequently asked questions

How should I structure the visible haematuria history in this PLAB 2 station?

Frank haematuria in a patient over 45 is urological malignancy until proven otherwise and requires 2-week-wait referral per NICE NG12. The candidate must identify alarm features, arrange appropriate investigation, and address the cancer anxiety. Ms Nichols is 62, presenting with 2 weeks of visible blood in her urine.

What are examiners marking in this visible haematuria station?

Marks are won for: Haematuria characterised (total, painless, 2 weeks). Cancer risk factors assessed (age, smoking, occupation). Anticoagulation noted but not used to explain. Marks are lost for: Not characterising the haematuria. Attributing to warfarin. Not checking smoking. Not excluding UTI.

What is the most common mistake candidates make in this visible haematuria station?

Attributing haematuria to anticoagulation. She is on warfarin, and candidates may be tempted to say 'it is probably the warfarin.' Anticoagulated patients with haematuria still need full investigation. The warfarin may have unmasked an underlying cancer.

How do I prepare for this station if I have not managed visible haematuria in clinical practice?

Structure beats experience here. Focus on painless haematuria as a red flag: painless frank haematuria in an older patient is malignancy until proven otherwise. Work through the consultation approach above, then rehearse it aloud under the 8-minute time pressure so the structure holds up in the exam.

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