Gen Med Station 9

 

Station 9

Pain when I Pee

 

Candidate Instructions

Setting:

You are a Foundation Year doctor working in a GP surgery. This patient has presented with pain on urination.


Amy Watson


Tasks:

1. Take a history from the patient.

2. Request investigations to the examiner

3. Interpret the results to the examiner.

4. Give your initial management plan to the examiner.

Simulated Patient Instructions

Briefing

Diagnosis: Uncomplicated UTI
You are Amy Watson a 23yo female.
You have presented to your GP practice with pain on urination.

Appearance and Behaviour

Appear fidgety/unable to get comfortable

Opening statement

“So... I had been struggling with pain... when I went to the toilet...”

Presenting Complaint

Site - “down below” (urethra) and in your pelvis (put your hand on your pelvis/bladder).
Onset - gradual onset yesterday morning
Character - stinging pain when passing urine
Radiations - around pelvis/lower abdomen
Associated symptoms - ONLY IF ASKED SPECIFICALLY SHOULD YOU GIVE THIS INFO
  • Colour - it has been red/dark orange colour for 12 hours
  • Hesitancy - struggling to start urinating
  • Urgency- feeling the need to go to the toilet and having to rush to the toilet.
  • Smell - it has a “funny smell”.
  • Strangury - only passing small volumes of urine when going to the toilet and having to strain despite needing to go.
    • Timing - seems to gradually be getting more painful.
    Exacerbating/relieving factors - Paracetamol has helped.
    Severity - constant 6/10 lower abdo pain, 8/10 when passing urine. You've been to the toilet 15+ times today
    Sexual History - sexually active with boyfriend. Only one partner, condoms used. No previous partners. Boyfriend also has no previous partners. LMP ended 3 days ago, it was normal. No abnormal discharge.

    Past Medical History

    Previous similar episodes - Nil
    Other medical conditions - Depression, hayfever
    Previous surgeries - Ankle repair for a fracture 4 years ago

    Drug History

    Prescribed - sertraline
    Over the counter - cetirizine, paracetamol
    Allergies - penicillin : anaphylaxis
    Recreational drugs- Nil

    Family History

    Mother- breast cancer

    Social History

    Smoking - never smoked
    Alcohol - Social only, < 14 units per week.
    Home - Fully Independent. Lives in a flat with boyfriend Trevor who is currently fit & well.
    Work - Data Analyst

    Systems Review

    General/red flags - Nil (specifically NO fever or flank pain)
    Neuro - Nil
    Resp - Nil
    Cardio - Nil
    GI - some nausea, bowels open this morning
    GU - Frequency, urgency, dysuria, haematuria, suprapubic tenderness, LMP= 3 days ago. No unusual discharge.

    Ideas / Concerns / Expectation

    Ideas - “Maybe an STI?"
    Concerns - “Has my boyfriend cheated on me?” (there are no social reasons the patient believes this. She is concerned because a friend suggested her symptoms sounded like an STI. She is happy and feels safe in her relationship.)
    Expectations - “an I have some tablets to treat it?”

    Start the Timer and Begin

    Intro

     

    Presenting complaint

     

    Obtains clear history of presenting complaint, establishing:

    Past Medical History

     

    Drug History

     

    Family History

     

    Social History

     

    Systems Reviews

     

    Ideas, Concerns, Expectations

     

    Examiner Instruction

     

    At this point please direct the candidate to give their initial investigations.

    Investigation

     

    Examiner Instruction

     

    At this point please direct the candidate to interpret the following investigations.

    Interpretation & Diagnosis

     

    Management

     

    Summary

     

    A UTI is a largely clinical diagnosis. Urine dips should only be done when patients are symptomatic as false positives are common. Clinical diagnosis is based on 2 or more of; dysuria, frequency, urgency, cloudy urine, visible haematuria, supra-pubic tenderness, or new nocturia. 

    A mid stream urine sample is the preferred conclusive diagnostic test but in GP if there are no systemic symptoms it would be appropriate to initiate outpatient antibiotic therapy before culture has returned. If there are symptoms of STI then swabs would also be indicated. 

    Note, women receive 3 days of Abs for simple UTIs where as men receive 7. Women are generally more susceptible due to their urethral anatomy.

    Submit for Scoring

    Tags | GP | Urology | UTI | Cystitis

    Station Written by: Dr Joanna Mantio

    Peer Reviewed by: Dr Polly McGrath

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