History Taking · Foundation · Urology

Severe Flank Pain with Haematuria

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

Clinical scenario

You are an FY2 doctor in an acute medical unit. Mr Dominic Brooks, a 45-year-old man, has presented to the emergency department with severe colicky pain radiating from the left flank to the groin. He has haematuria and is in obvious distress. Please take a focused history and discuss management including imaging and analgesia.

Background notes: PMH: Hypertension, Hypercholesterolaemia, Healthy otherwise

What this station tests

  • Immediate analgesia: IM diclofenac 75mg as first-line for renal colic, not delayed for history or investigations
  • Classic renal colic pattern: colicky flank-to-groin pain, haematuria, restlessness (cannot lie still), no fever
  • CT KUB as gold standard imaging: non-contrast CT, sensitivity >95% for renal stones
  • Stone size determining management: <5mm likely spontaneous passage, >10mm likely intervention needed
  • Medical expulsive therapy: tamsulosin for distal ureteric stones to facilitate passage

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

Acute renal colic is one of the most painful presentations in medicine. The candidate must provide analgesia immediately, exclude life-threatening differentials (ruptured AAA in older patients), and arrange appropriate imaging. Mr Brooks is 45, presenting with 4 hours of severe left flank-to-groin colicky pain with haematuria. He is in obvious distress. Open with: 'Mr Brooks, I can see you are in severe pain. I am going to get you pain relief right now while I ask some important questions.'

Core approach

Analgesia first. IM diclofenac 75mg is first-line for renal colic (evidence-based, superior to opioids for this indication). IV paracetamol as adjunct. Opioids (morphine) if NSAID contraindicated. Do not delay analgesia for history.

The pain is classic: sudden onset, severe, colicky (waves of intensity), left flank radiating to the groin. He is restless and cannot find a comfortable position (unlike peritonitis where patients lie still). Haematuria is present. No fever. These features strongly suggest ureteric calculus.

Exclude differentials through targeted questions. Ruptured AAA: age 45 is young for AAA, but check: any tearing quality to pain? Any abdominal pulsation? Haemodynamically stable? AAA typically presents in patients over 60 with vascular risk factors. Pyelonephritis: no fever, no rigors. Testicular torsion: no testicular pain. Appendicitis: wrong location.

Assess for complications. Fever suggests infected stone (urological emergency requiring urgent drainage). Anuria suggests bilateral obstruction or obstruction of a single functioning kidney. Previous stones? Family history of stones? Fluid intake (dehydration is a major risk factor)?

Closing and safety netting

Investigations: urine dipstick (haematuria supports diagnosis), bloods (FBC, U&E, calcium, urate, CRP), and CT KUB (non-contrast CT is gold standard for renal stones, sensitivity >95%). If CT unavailable: USS as first-line in some settings.

Management depends on stone size. Under 5mm: likely to pass spontaneously (90%), conservative management with hydration, analgesia, and a sieve to catch the stone for analysis. 5 to 10mm: may pass but may need intervention. Over 10mm: unlikely to pass, will need lithotripsy or ureteroscopy. Alpha-blocker (tamsulosin) as medical expulsive therapy for distal ureteric stones.

Address his fear: he thought he was having a heart attack. Reassure: 'This is a kidney stone. It is extremely painful but not life-threatening.' Safety net: 'If you develop fever, stop passing urine completely, or the pain becomes unmanageable despite medication, come back immediately.'

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for renal colic. 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: Classic pattern identified. Differentials excluded (AAA, pyelonephritis, torsion). Complications screened (fever, anuria). Stone history and risk factors assessed. Haematuria confirmed.

Costs marks: Not excluding differentials. Not screening for infected stone (fever). Not checking haematuria.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: Immediate analgesia (diclofenac). CT KUB arranged. Stone size-based management plan. Tamsulosin for expulsive therapy. Hydration advice. Sieve for stone analysis. Fever and anuria safety netting.

Costs marks: Delayed analgesia. Wrong imaging. No management plan based on stone size. No safety netting.

Domain 3: Interpersonal Skills (Throughout)

Scores well: Acknowledging severe pain immediately. Reassuring about diagnosis (painful but not life-threatening). Addressing his fear of heart attack. Practical recovery expectations.

Costs marks: Ignoring his distress. Not providing reassurance. Being dismissive of pain severity.

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. Delaying analgesia while taking a history. Renal colic is among the most severe pain a patient can experience. Candidates who take a full SOCRATES history before providing analgesia demonstrate poor prioritisation.
  2. Not excluding ruptured AAA in an appropriate age group. At 45 he is young for AAA, but in older patients with the same presentation, ruptured AAA must be excluded. Candidates should show awareness of this differential.
  3. Requesting an abdominal X-ray instead of CT KUB. Plain X-ray misses radiolucent stones (uric acid) and has poor sensitivity. CT KUB is the gold standard. Candidates who request X-ray first demonstrate outdated practice.

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 do I approach the consultation in this renal colic station?

Acute renal colic is one of the most painful presentations in medicine. The candidate must provide analgesia immediately, exclude life-threatening differentials (ruptured AAA in older patients), and arrange appropriate imaging. Mr Brooks is 45, presenting with 4 hours of severe left flank-to-groin colicky pain with haematuria.

What does a strong performance look like to the examiner in this station?

Strong performances show: Classic pattern identified. Differentials excluded (AAA, pyelonephritis, torsion). Complications screened (fever, anuria). Stone history and risk factors assessed. Weak performances: Not excluding differentials. Not screening for infected stone (fever). Not checking haematuria.

What is the biggest pitfall in this renal colic station?

Delaying analgesia while taking a history. Renal colic is among the most severe pain a patient can experience. Candidates who take a full SOCRATES history before providing analgesia demonstrate poor prioritisation.

How should I prepare for renal colic if I have never seen it in practice?

This station rewards process over personal experience. The skill being assessed: Classic renal colic pattern: colicky flank-to-groin pain, haematuria, restlessness (cannot lie still), no fever. Use the domain breakdown on this page to target your preparation, then practise the station aloud so your structure survives exam pressure.

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