A 70-year-old white woman presents with a 2-week history of asymptomatic, intermittent gross hematuria. She has no history of urinary tract problems. Her urinalysis shows 4+ heme, trace leukocyte esterase, and a small number of WBCs. Repeat urinalysis the next day shows persistent hematuria and a negative urine culture. She has a history of hysterectomy more than 20 years earlier. She is a longstanding patient in your practice and is followed regularly for hypertension. Her blood pressure today is 130/90. She is 5΄5΄ and weighs 160 lbs.
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What additional data would you want to gather?
The healthcare practitioner should carefully inspect the skin for possible pallor and hemorrhagic rash. Then the cardiovascular system is examined: hematuria is observed in case of a kidney infarction (one of the complications of infective endocarditis), and pleural effusion is possible in pyelonephritis and paranephritis. Then it is necessary to palpate the abdomen: possible volumetric formation of the left abdominal area may be either an enlarged left kidney and/or an enlarged spleen. The kidney enlargement is observed in kidney cancer, hydronephrosis, and polycystic, while the spleen enlargement − in blood diseases (Gulati, 2017).
What are the risk factors for bladder cancer, renal cancer? What are the statistics regarding the incidence/prevalence of these disorders? Are any health disparities associated?
Along with dysuria, abdominal pain, reduced appetite, and weight loss, “visible haematuria is accepted as an important pointer to urinary tract cancer (with bladder cancer being the most common), warranting urgent urological investigation” (Price, Shephard, Stapley, Barraclough, & Hamilton, 2014, p. e585). Bladder and renal cancers occur mostly in people of advanced age: nearly 9 out of 10 patients with bladder cancer are over 55, and the mean age of patients diagnosed with renal cancer is 64 (American Cancer Society [ACS], 2018a; ACS, 2018b). Both kidney and bladder cancers are more common among men than among women.
What other differential diagnoses should be included in cases of hematuria?
Acute cystitis is associated with an inflammatory process of the bladder mucosa, which is the most frequent manifestation of uncomplicated urinary tract infection. Along with pain and abnormal patterns of urination, the patient may observe an admixture of blood in the urine. Other differential diagnoses characterized by similar symptoms may include urethritis, glomerular or interstitial nephritis, and ureteral stones.
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What additional laboratory and/or imaging tests might you order at this time?
Along with standard urinalysis, the following tests should be performed in case of persistent hematuria: phase-contrast microscopy (to examine the morphology of RBCs); intravenous pyelogram/renal ultrasound; CT scan; PT, PTT, PPD, ESR, ANA, ASO, and urinalysis for cytology (Dunphy, Winland-Brown, Porter, & Thomas, 2015). The assessment of antistreptolysin O titer and the level of complement components in the serum can help diagnose glomerulonephritis. The cytological examination of urinary sediment supports the identification of lower urinary tract tumors, while urine cytology is considered one of the most valuable tools for bladder cancer diagnostics (Abdullah, 2013).
What follow-up and education are needed for this patient?
“If no underlying cause for hematuria is found during the initial evaluation, follow-up urine testing and blood pressure monitoring may be recommended every three to six months” to monitor the progress of any renal disease (“Patient education,” 2018, para. 5). At the given stage, it is important to answer the patient’s questions regarding possible causes of her condition and inform her about possible risks, as well as important diagnostic and assessment measures.
How would you bill for this visit? What is the E&M level?
It would be appropriate to bill this code as 99214 as the established patient comes with a new problem, which requires a detailed exam and assessment, as well as counseling for at least 15 minutes. It is associated with the decision making of low/moderate complexity, and moderate/high severity of the presenting problem. The E&M level for this patient is 4.
What Healthy People 2020 objectives are relevant to this case?
The objectives are as follows:
- “Improve the health, function, and quality of life of older adults” (Office of Disease Prevention and Health Promotion [ODPHP], 2014c, para. 1).
- “Reduce the number of new cancer cases, as well as illness, disability, and death caused by cancer” (ODPHP, 2014a, para. 1).
- “Reduce new cases of chronic kidney disease (CKD) and associated complications, disability, death, and economic costs” (ODPHP, 2014b, para. 1).
What health-care disparities are documented with this diagnosis?
Hematuria is one of the major symptoms of bladder and renal cancers. Although the diagnosis of this type of cancer is more frequent in males, “women present with advanced disease and have poorer survival, suggesting delays in bladder cancer diagnosis” (Garg et al., 2014, p. 1072). Thus, timely identification of an underlying cause of hematuria in the patient is of great importance.
Abdullah, L.S. (2013). The value of urine cytology in the diagnosis of bladder cancer. Cytopathological correlation. Saudi Medical Journal, 34(9), 937-41.
American Cancer Society. (2018a). Key statistics for bladder cancer. Web.
American Cancer Society. (2018b). Key statistics about kidney cancer. Web.
Dunphy, L., Winland-Brown, J., Porter, B., & Thomas, D. (2015). Primary care: The art and science of advanced practice nursing (4th ed.). Philadelphia, PA: F.A. Davis
Garg, T., Pinheiro, L. C., Atoria, C. L., Donat, S. M., Weissman, J. S., Herr, H. W., & Elkin, E. B. (2014). Gender disparities in hematuria evaluation and bladder cancer diagnosis: A population-based analysis. The Journal of Urology, 192(4), 1072–1077.
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Gulati, S. (2017). Hematuria clinical presentation. Web.
Office of Disease Prevention and Health Promotion. (2014a). Cancer. Web.
Office of Disease Prevention and Health Promotion. (2014b). Chronic kidney disease. Web.
Office of Disease Prevention and Health Promotion. (2014c). Older adults. Web.
Price, S. J., Shephard, E. A., Stapley, S. A., Barraclough, K., & Hamilton, W. T. (2014). Non-visible versus visible haematuria and bladder cancer risk: A study of electronic records in primary care. The British Journal of General Practice, 64(626), e584–e589.