Now you are working in a Walk -In Clinic/Urgent care center. You meet a 17 year old girl. She complains of seeing blood in her urine for the past two days. She also complains of pain in her left flank. She denies any fever or chills. She also has had 9 sexual partners in the past one year.

Firstly, this a high risk patient. So no matter what else you do during the case, do not forget to address safe sex and screen for STDs. (during this case, the candidate felt that the examiner was trying to get to the bottom of HIV risk counselling. As soon as the candidate addressed this HIV counselling, he could see satisfied smiles in the faces of the two examiners).

Most likely, this patient has a UTI and associated hematuria. The diagnosis of a lower UTI is made in the presence of acute urinary symptoms and patient not being febrile. Pyelonephritis usually comes with fever and significant flank discomfort.

Another important point emphasized in the US is the importance of voiding after intercourse (which helps avoid 50% of UTIs. One also counsels about wiping after using the toilet i.e. wiping for females - the stroke of cleaning the genital/anal region should be from front to back in the perineal area.

As far as the H&P are concerned, one asks the routine questions but must address things like

HISTORY: S/H Drug usage, protection during sex, PMH of PID (increases chances of recurrence), recent antibiotics (think candida), blood in the beginning of the urine stream only (urethritis), blood only in th eend (bladder lesion), blood well mixed with urine (renal), frank blood (tumor), F/H polycystic disease, URI/Rash - HSP, hemoptysis (Goodpasture's syndrome) etc.