Painless Visible Blood in the Urine: A Focused Genitourinary and Abdominal Assessment of a 66-Year-Old Former Machinist
[Student Name]
University of Phoenix
NSG/523: Advanced Health Assessment
Week 5 Assignment
[Instructor Name]
[Date]
Composite patient written as a model document. No real patient, clinician or practice is described.
Subjective
The patient is a composite 66-year-old man who came to his new primary care nurse practitioner for red urine. Twelve days ago he noticed that his urine was the color of weak tea turning to red for the whole stream on two voids in one morning, with no clots. It cleared by afternoon. Four days ago the same thing happened once, again without pain. He has had no flank pain, no suprapubic pain, no burning with urination and no fever, and he came in only because his wife insisted. He has not had recent trauma, strenuous exercise, a urinary catheter or a urinary tract infection, and he has not eaten beets or taken new medicines that color urine.
Review of systems. For about two years he has woken twice each night to void and a slightly weaker stream than in the past, unchanged recently. He denies urgency, incontinence, straining, hesitancy beyond his baseline, testicular pain or swelling, penile discharge and sexual symptoms. He denies weight loss, night sweats, bone pain, cough, hemoptysis, easy bruising, nosebleeds or bleeding gums. Bowel habits are regular, with no blood in the stool or black stools.
Past medical history includes hypertension and hyperlipidemia. Medications are lisinopril 20 mg daily, atorvastatin 40 mg daily and aspirin 81 mg daily, which he started on his own two years ago after a friend's heart attack. He takes no anticoagulant. He has no known kidney disease or kidney stones.
Social history. He smoked one pack a day from age 17 to 55, a 38 pack-year history, and quit eleven years ago. He worked for 30 years as a machinist in a plant that made industrial parts, with daily exposure to metalworking fluids and, in his early years, to rubber and dye products. He drinks two beers on weekends. Family history includes a father who died of lung cancer and a brother with prostate cancer diagnosed at 70.
Objective
Vital signs: temperature 36.6 C orally, blood pressure 138/84 mm Hg, pulse 72 and regular, respirations 14, oxygen saturation 97% on room air, weight 88 kg, body mass index 28.1. He is alert, well appearing and in no distress. Conjunctivae are pink without pallor, and the skin shows no petechiae, bruising or jaundice.
Abdomen: flat and symmetric, with no scars or visible masses. Bowel sounds normal in all quadrants, and no bruit heard in the epigastrium or either upper quadrant. Tympany on percussion, liver span within normal limits; no suprapubic dullness to suggest a distended bladder. Soft throughout, with no tenderness on light or deep palpation, no masses and no hepatosplenomegaly. Kidneys not palpable. No costovertebral angle tenderness on either side.
Genitourinary: normal adult male genitalia. No penile lesions or discharge. Testes descended bilaterally, smooth and nontender, without masses; no scrotal swelling, and no inguinal hernia on standing with cough. Digital rectal examination with the patient's consent and a chaperone present: normal sphincter tone; the prostate is symmetrically enlarged, estimated at about 40 grams, smooth and rubbery, without nodules or tenderness. Stool on the glove is brown.
Office urinalysis by dipstick on a clean-catch midstream specimen: large blood, negative leukocyte esterase, negative nitrite, trace protein and specific gravity 1.018. The specimen was sent for microscopy and culture, and the microscopy later showed more than 25 red blood cells per high-power field with normal-appearing red cells and no casts.
The examination follows the sequence advanced texts describe for the abdomen, inspection and auscultation before percussion and palpation, and treats the rectal and genital examination as part of a genitourinary assessment in an older man rather than an optional add-on (Bickley et al., 2021; Ball et al., 2023).
Assessment
The primary concern is urothelial cancer, most likely of the bladder, presenting as painless gross hematuria. That concern rests on data recorded above: visible blood through the whole stream on three voids, no pain, confirmed red cells on microscopy, age 66, male sex, a 38 pack-year smoking history and decades of occupational exposure to industrial chemicals. Smoking is the leading established risk factor for bladder cancer, and Freedman et al. (2011), in a large prospective cohort, found that current and former smokers had substantially higher risk than never smokers. Cumberbatch et al. (2018), reviewing risk factors, confirmed tobacco and occupational exposure to aromatic amines and related chemicals as major causes. The absence of pain does not reassure; it is typical of bladder tumors.
The differential diagnosis is ranked by the recorded findings. Benign prostatic enlargement with bleeding from prostatic vessels is plausible given the enlarged gland and long-standing nocturia, but it is a diagnosis of exclusion that cannot be accepted until cancer has been ruled out. Kidney or ureteral stone is less likely because there was no colic and no costovertebral angle tenderness. Urinary tract infection is less likely with negative nitrite and leukocyte esterase, pending culture. Renal cell carcinoma remains possible because it can also cause painless hematuria and is not excluded by a normal abdominal examination. Glomerular disease is unlikely given normal-appearing red cells, no casts and only trace protein. Aspirin does not account for the bleeding and does not change the evaluation.
Legal, Ethical and Communication Considerations
Two parts of this encounter needed particular care. The first was the genital and rectal examination. The nurse practitioner explained why each part was needed, asked for the patient's permission before starting, offered a chaperone and documented both the consent and the chaperone's presence. Sensitive examinations carry legal and ethical risk when consent and purpose are not clear, and documenting them protects the patient and the clinician. The second was the conversation about what the findings might mean. The patient's first question was whether this was cancer. The nurse practitioner answered honestly that cancer was one possibility that needed to be ruled out, that many causes of blood in the urine are not cancer, and that the next tests would answer the question. She asked what he understood, invited his wife into the discussion with his permission and gave written instructions in plain language, including which symptoms would need a same-day call. Balancing honesty with reassurance keeps a patient engaged in an evaluation he might otherwise avoid, and his reluctance to come in at all showed that avoidance was a real risk.
Plan
Visible hematuria in an adult warrants evaluation even if it resolves and even if the patient takes an antiplatelet agent. National guidance on hematuria advises evaluation of the bladder with cystoscopy and of the upper tract with imaging, and it classifies patients with gross hematuria as needing full urologic evaluation (Barocas et al., 2020). The plan therefore includes an urgent referral to urology for cystoscopy, a computed tomography urogram after checking serum creatinine and estimated glomerular filtration rate, urine culture follow-up and a complete blood count. The nurse practitioner explains to the patient and his wife why the evaluation is needed despite the absence of pain and schedules a call to confirm that the referral appointment is made.
The impression would change with new findings. Fever, flank pain or a positive culture would move infection or an obstructing stone higher. Clots with difficulty voiding would require same-day evaluation for clot retention. A rising creatinine, casts or significant proteinuria would raise concern for kidney disease and prompt nephrology input.
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2023). Seidel's guide to physical examination: An interprofessional approach (10th ed.). Elsevier.
Barocas, D. A., Boorjian, S. A., Alvarez, R. D., Downs, T. M., Gross, C. P., Hamilton, B. D., Kobashi, K. C., Lipman, R. R., Lotan, Y., Ng, C. K., Nielsen, M. E., Peterson, A. C., Raman, J. D., Smith-Bindman, R., & Souter, L. H. (2020). Microhematuria: AUA/SUFU guideline. Journal of Urology, 204(4), 778-786. https://doi.org/10.1097/JU.0000000000001297
Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2021). Bates' guide to physical examination and history taking (13th ed.). Wolters Kluwer.
Cumberbatch, M. G. K., Jubber, I., Black, P. C., Esperto, F., Figueroa, J. D., Kamat, A. M., Kiemeney, L., Lotan, Y., Pang, K., Silverman, D. T., Znaor, A., & Catto, J. W. F. (2018). Epidemiology of bladder cancer: A systematic review and contemporary update of risk factors in 2018. European Urology, 74(6), 784-795. https://doi.org/10.1016/j.eururo.2018.09.001
Freedman, N. D., Silverman, D. T., Hollenbeck, A. R., Schatzkin, A., & Abnet, C. C. (2011). Association between smoking and risk of bladder cancer among men and women. JAMA, 306(7), 737-745. https://doi.org/10.1001/jama.2011.1142
How this NSG 523 Week 5 example is structured
The University of Phoenix library guide for NSG/523 lists Week 5 as Genitourinary and Abdominal Assessments. The write-up follows the order a graduate assessment note uses: the history first, because risk factors decide how seriously a single sign is taken; the focused examination second, including the abdominal, flank, genital and prostate findings; and the impression last, built only from what the first two sections record. The note closes with the findings that would change the plan, which is where diagnostic reasoning shows most clearly. Students search this week as NSG 523 Week 5, NSG523 Wk 5 or NSG/523 Wk 5; all three are the same assignment.
NSG/523 Week 5 questions, answered
What does NSG/523 Week 5 usually ask for?
The University of Phoenix library guide for NSG/523 lists Week 5 as genitourinary and abdominal assessments. Many sections ask for a focused history and physical examination write-up on a presenting complaint in that territory, with a supported differential diagnosis and plan. Your course instructions and rubric decide the exact form.
Why is painless hematuria taken so seriously?
Because visible blood in the urine without pain in an older adult, especially one who has smoked, is the most common presenting sign of bladder cancer. Urology guidance treats gross hematuria as needing evaluation even if it happens once and even if a later urinalysis is normal.
Does an advanced health assessment write-up include a plan?
Many do, in a brief form, because the plan shows how the assessment will be confirmed. In this course the emphasis stays on history, examination and reasoning, so the sample keeps the plan short and focused on diagnosis and referral.
Write yours, or have the desk draft it
This paper is an original model document written by our desk, not a submitted student paper and not an official University of Phoenix document. Read it for the moves, then write your own to the instructions in your classroom. If you want one built to your exact prompt and rubric, the first custom sample is free and arrives in 24 to 48 hours.