Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint:
New or follow-up for microscopic hematuria (MH)
(Specify) Hematuria may not be visible (gross hematuria) but detected on urine dipstick or microscopy.
History of Present Illness:
For new patients:
Presence of any urinary symptoms (dysuria, frequency, urgency, nocturia, flank pain)
Gross hematuria (visible blood in urine) – inquire even if negative.
Passage of clots.
Any recent infections, urinary tract infections (UTIs).
History of kidney stones.
For established MH:
Follow-up since initial diagnosis.
Changes in urinary symptoms.
Medication adherence and side effects.
Past Medical History:
Underlying medical conditions that may increase risk of MH:
Urinary tract infections (UTIs)
Kidney stones
Glomerulonephritis (kidney inflammation)
Polycystic kidney disease (PKD)
Prostate conditions (prostatitis, benign prostatic hyperplasia – BPH)
Medications (blood thinners, certain antibiotics)
Recent urinary tract procedures (cystoscopy)
Medications:
List all current medications, including blood thinners and any medications associated with MH.
Social History:
Smoking history (risk factor for bladder cancer).
Family history of kidney disease or urologic malignancies.
Physical Exam:
Focused on urinary system and general health.
Vital signs (evaluate for fever suggestive of infection).
Abdominal exam: Assess for kidney tenderness or masses.
Genital exam (males): Assess for prostate enlargement or tenderness.
Laboratory Tests:
Urinalysis: Microscopic hematuria confirmed by presence of red blood cells (RBCs) on microscopy.
Urine culture: To rule out UTI if there are suggestive symptoms.
Serum creatinine and electrolytes: Assess kidney function.
Imaging Studies (as indicated):
Abdominal ultrasound: Initial imaging study to screen for kidney stones or other abnormalities.
Intravenous pyelogram (IVP) or CT urogram: May be used for a more detailed evaluation of the urinary tract, particularly if ultrasound findings are concerning.
Cystoscopy: Direct visualization of the bladder and urethra to evaluate for bladder lesions or ureteral abnormalities. May be used for both diagnostic and therapeutic purposes (e.g., removal of bladder stones).
Assessment:
Microscopic hematuria: Confirmed by urinalysis.
Evaluation for underlying cause: Consider the clinical picture, urinalysis findings, and risk factors to determine the most likely cause of MH.
Severity of MH: Evaluate the degree of hematuria and any associated symptoms.
Plan:
Management depends on the underlying cause:
Treatment of identified cause: e.g., antibiotics for UTI, pain management for kidney stones, medications or lifestyle changes for BPH.
If no clear cause identified: Consider watchful waiting with repeat urinalysis monitoring or further workup depending on risk factors and severity of MH.
Evaluation for malignancy: If risk factors or clinical presentation suggest malignancy, urologic consultation and cystoscopy may be indicated.
Follow-up: Schedule regular follow-up visits with repeat urinalysis to monitor MH and identify any potential complications.
Consultations:
Referral to a urologist may be necessary for further evaluation and management, particularly if a urologic cause is suspected or cystoscopy is needed.
Nephrology consultation may be indicated for complex cases or those with suspected glomerular disease.
Education:
Educate the patient about microscopic hematuria, potential causes, risk factors, and the importance of follow-up.
Discuss potential treatment options based on the underlying cause.
Advise on lifestyle modifications that may reduce risk factors (e.g., smoking cessation, increased fluid intake).
Disclaimer: This template is for informational purposes only and should be adapted to the specific needs of each patient. Microscopic hematuria can be a sign of various underlying conditions. Prompt diagnosis and treatment of the cause are crucial to prevent complications.