Hematuria Mind Map.jpg

The organization of this clinical mind map is based upon duration. Often patients complain about their symptom as having been present for only a few days, such that a clinician might be misled into thinking that this is a case of acute hematuria, but upon further probing patients might reveal that they have had a recurrence of symptoms. In that case, a clinician should consider chronic hematuria as well, because most pathologies causing chronic hematuria do so in a recurrent fashion. For example, patients with glomerulonephritis often have on and off symptoms as opposed to persistent symptoms. This is similar to migraines which recur, but often do not last for days or weeks at a time.

Patients can either present with the subjective complaint of hematuria (blood in the urine) or hematuria may be noticed as a lab finding on a urine dipstick or a urinalysis. The difference is the dipstick only reports blood as negative or positive and the urinalysis gives the red blood cell count. A case of false hematuria, which is defined as positive blood on a dipstick but negative red blood cells on urinalysis, results in a diagnosis of false hematuria, is secondary to a number of agents noted on this clinical mind map.

If a patient is complaining of seeing blood in the urine, clarification must be made as to whether there is blood in the urine or if this is a case of menstrual blood, fecal blood, or blood from a superficial skin ulcer that is mixed in the urine. This clarification saves time and unnecessary work up. Once it is clear that the patient presentation is that of hematuria, the steps of the Epi-logical approach can be followed. In routine practice settings, often a dipstick, followed by complete urinalysis and reflex culture are ordered concomitantly. While waiting for those results, a clinician can start the rest of the clinical evaluation.

Differentials are further divided into those with pelvic pain and those without pelvic pain, although exceptions may occur. In order to address urgent/emergent situations, the vital signs and patient appearance must be reviewed, although hematuria as a chief complaint presents in a very few life-threatening conditions. A clinician can think of massive trauma in hemodynamically unstable patients, although in that case hematuria will most likely not be the chief complaint. Most hematuria is microscopic, and gross hematuria often requires urgent and full evaluation.

Additional notes on this clinical mind map about lab tips help narrow down the differentials. Since often a dipstick and/or urinalysis are available before the history and the physical exam are performed, this information can be used in the diagnostic reasoning process to weigh the differentials. Patients with chronic hematuria must always be evaluated for a serious underlying pathology, especially if risk factors are present. One example is transitional cell cancer in the bladder, in which patients present with painless recurrent hematuria.

A helpful mnemonic to remember differentials for Hematuria is to think “when it’s not infection, stones or cancer in the pelvic organs, GAIL takes Meds and Exercises and develops False Purpura.”