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Clinical-Microscopy Must Knows
Clinical-Microscopy Must Knows
URINALYSIS
Urethra F: 3-4 cm
M: 20 cm
Urine formation (order) Glomerulus 🡪 Bowman’s capsule 🡪 PCT 🡪 Loop of Henle 🡪 DCT 🡪 CD
60g TS in 24 hrs
35g: Organic = Urea (major)
25g: Inorganic = Cl (#1) > Na+ > K+
Glomerular Filtration
Tubular Reabsorption
Fishberg test (Old) Patient is deprived of fluid for 24hrs then measure urine SG
(SG ≥ 1.026)
Mosenthal test (Old) Compare day and night urine in terms of volume and SG
Methods of Collection
Drug Specimen Collection Chain of custody: step by step documentation of handling and testing of
legal specimen
Required amount: 30-45 mL
Temperature (urine): 32.5-35.7’C (w/in 4 mins)
Blueing agent 🡪 Toilet bowl (to prevent adulteration)
Occasional/Single/Random Routine
Qualitative UA
Decreased
Glucose Glycolysis
Ketones Volatilization
Bilirubin Photooxidation
Increased
Bacteria Multiplication
Preservation
Refrigeration 2-8’C
🡩 SG (hydrometer/urinometer)
Precipitate AU/AP
Volume NV:
24 hr = 600-1200 mL
Ave (24 hr) = 1200-1500 mL
Night: Day ratio = 1:2 to 1:3
Urine Color
Normal Colorless to deep yellow
Bright orange-red (acid) Rifampin (Tx: TB) = all body fluids are red
Clarity/Transparency/Turbidity
Acidic urine AU
RCM
Alkaline urine AP
Carbonates
Soluble w/ heat AU
Uric acid
Rf < U by 0.002 Refractometer reading is lower than the urinometer reading by 0.002
Urine Odor
Aromatic/Odorless Normal
Mousy Phenylketonuria
Bleach Contamination
Sulfur Cystine disorder
Specific Gravity
pH
Principle (Rgt Strip) Double indicator system (Methyl red & Bromthymol blue)
MR + H+ ------------> BTB – H+
pH 4.0-6.0 pH 6.0-9.0
(Red-Yellow) (Yellow-Blue)
Protein
Sulfosalicylic acid Cold precipitation test that reacts equally to all types of
precipitation test protein If (-) rgt strip, (+) SSA = presence of other proteins
Ketones
Blood
Hematuria Speckled/spotted
Bilirubin
Significance Hepatitis
Cirrhosis
Bile duct obstruction
Urobilinogen
Hoesch test (Inverse Rapid screening test for urine porphobilinogen (≥2mg/dL)
Ehrlich reaction) Hoesch reagent: Ehrlich reagent in 6M (6N) HCl
2 gtts urine + Hoesch rgt -------------> (+) Red
Nitrite
Leukocytes
Significance UTI/inflammation
Screening of urine culture specimen
40 seconds Ketones
45 seconds SG
60 seconds “PPBUN”
pH
Protein
Blood
Urobilinogen
Nitrite
False-positive False-negative
Sediment Constituents
Sources of error:
-Yeasts
-Oil droplets
-Air bubbles
-CaOx crystals
♫ Remedy: add 2% acetic acid
-RBCs: lysed
-Other cells: intact
WBCs NV = 0-5 or 0-8/hpf
Glitter cells (Hypotonic urine)
-Granules swell
-Brownian movement
>1% eosinophils: significant
-🡩 Drug-induced allergic reaction
-🡩 Inflammation of renal interstitium
S. haematobium “Hematuria”
Specimen: 24 hr unpreserved urine
E. vermicularis Most common fecal contaminant
Calcium Phosphate Colorless, flat rectangular plates or thin prisms often in rosette
(Normal) formation Rosettes may resemble sulfonamides
(pH: alkaline/neutral) -To differentiate: CaPO4 dissolves in acetic acid
1. Calcium Phosphate = Apatite
2. Basic Calcium Phosphate = Hydroxyapatite
3. Calcium Hydrogen Phosphate = Brushite
Cyanide-Nitroprusside test - +
Urinary Sediment Artifacts 1. Starch granules (gloves):
-Most common
-Maltese cross (O, FC, S)
-Dimpled center
2. Oil droplets
3. Air bubbles
4. Pollen grains = spheres w/ concentric circles
5. Hair and fibers = (+) Birefringence (polarizing microscope)
6. Fecal contaminants
Renal Diseases
Nephrotic syndrome Disruption of the electrical charges that produce tightly fitting podocyte barrier
Acute tubular necrosis Damage to the renal tubules caused by ischemia or toxic agents
Phenylalanine-Tyrosine Disorders
Phenylalanine (-)
PAH PKU Phenylpyruvic acid
Tyrosine
Tyrosine transaminase (-)
p-Hydroxyphenylpyruvic acid Tyrosinemia Tyrosyluria:
p-Hydroxyphenylpyruvic acid oxidase p-OHPPA
Homogentisic acid (-) p-OHPLA
Homogentisic acid oxidase Alkaptonuria
Maleylacetoacetic acid Homogentisic acid Fumarylacetoacetic acid
Tryptophan Disorders
Cystine Disorders
Cystinuria (Renal type) Defect in renal tubular transport of:
-Cystine (least soluble 🡪 urine)
-Ornithine
-Lysine
-Arginine
Mucopolysaccharide Disorders
Purine Disorders
Porphyrias
Tests for NPN 1. Urea: Urease, DAM (NV = 6-17 g/24 hr urine)
2. Creatinine: Jaffe (NV = 1-2 g/24 hr urine)
3. Uric acid: Uricase, PTA (NV = 0.25-0.75 g/24 hr urine)
Other Topics
PPE Gloves
Fluid-resistant gowns
Eye and face shields
Plexiglas countertop shields
Chemical spills on skin Flush the area w/ water for at least 15 mins 🡪 seek medical
attention Do not neutralize chemicals
Always add acid 🡪 water To avoid the possibility of sudden splashing caused by the rapid generation
of heat in some chemical reactions
Hippocrates Uroscopy
Richard Bright Introduced the concept of UA as part of doctor’s routine patient examination
QC (Reagent Strips) 1. Test open bottles of reagent strips w/ known positive and negative
controls every 24 hr (some: at the beginning of each shift)
2. Resolve control results that are out of range by further testing 3. Test
reagents used in backup tests w/ positive and negative controls 4. Perform
positive and negative controls on new reagents and newly opened bottles
of reagent strips
5. Record all control results and reagent lot numbers
Parfocal (Microscope) Require only minimum adjustment when switching among objectives
Quality system Refers to all of the laboratory’s policies, processes, procedures, and
resources needed to achieve quality testing
Policy for Handling 1. Do NOT assume any information about the specimen or
Mislabeled Specimens patient 2. Do NOT relabel an incorrectly labeled specimen
3. Do NOT discard the specimen until investigation is complete 4.
Leave specimen EXACTLY as you receive it; put in the refrigeration for
preservation until errors can be resolved
5. Notify floor, nursing station, doctor’s office, etc. of problem and why it
must be corrected for analysis to continue
6. Identify problem on specimen requisition with date, time and your
initials 7. Make person responsible for specimen collection participate in
solution of problem(s). Any action taken should be documented on the
requisition slip 8. Report all mislabeled specimens to the quality assurance
board
Microscopic Quantitations
None 0 0 0 -
Rare 0-5 0-2 0-10 0-1
TQM Based on a team concept involving personnel at all levels working together
to achieve a final outcome of customer satisfaction through
implementation
PDCA Plan-Do-Check-Act
PDSA Plan-Do-Study-Act
lec.mt 04 |Page | 156
OTHER BODY FLUIDS
Cerebrospinal Fluid
Production Filtration
Active transport secretion
Layers Skin 🡪 Skull 🡪 Dura Mater 🡪 Arachnoid mater 🡪 Subarachnoid space 🡪 Pia
mater 🡪 Brain
CSF Appearance
Oily RCM
Hemolyzed/Bloody RBCs
Xanthochromia - +
RBC count Used for the correction of CSF WBC count and CSF protein count when
a traumatic tap has occurred
Normal Lymphocytes
Monocytes
Neutrophils (occasional)
CSF Protein
Myelin basic protein Protein component of the lipid-protein complex that insulate the nerve
fibers Monitor the progress of MS
Identify individuals w/ MS who do not show oligoclonal bands (approx. 10%)
β-amyloid protein 42 🡩 CSF levels of microtubule associated Tau protein and decreased levels of
β AP42 have been shown to significantly increase the accuracy of
Alzheimer’s disease
Meningitis
L. monocytogenes Infants
Elderly
Immunocompromised patients
CSF Glucose
CSF Lactate
CSF Enzymes
LD Serum: LD 2 > 1 > 3 > 4 > 5 [MI: LD 1 > 2 > 3 > 4 > 5]
CSF (normal): LD 1 > 2 > 3 > 4 > 5
Neurologic abnormalities: LD 2 > 1
Bacterial meningitis: LD 5 > 4 > 3 > 2 > 1
CSF Glutamine
Gram Stain Concentrated specimen = often very few organisms are present at the onset
of disease
Organisms:
-S. pneumoniae
-H. influenzae
-E. coli
-N. meningitidis
-S. agalactiae (NB)
-L. monocytogenes (NB)
-C. neoformans
Seminal Fluid
Bulbourethral gland 5%
Semen Analysis
Viscosity 0 (watery)
4 (gel-like)
Tail 45 μm long
Stains Giemsa
Papanicolau = method of choice
Wright’s
Aspermia No ejaculate
Synovial Fluid
Fluid Diarthroses/joints
LE cell Neutrophil
Normal No crystals
Joint Disorders
Group I: Non-inflammatory OA
Traumatic arthritis
Neuroarthropathy
Serous Fluids
Serous fluids Fluids that are formed between the parietal and visceral
membrane Ultrafiltrate of plasma
Provides lubrication
Fluid: Serum LD ratio Most reliable differentiation between transudates and exudates
Fluid: Serum protein ratio (except peritoneal fluid: SAAG)
Pleural Fluid
AMS Pancreatitis
Esophageal rupture
ADA TB
Malignancy
Mesothelial cells 🡫 TB
Glucose 🡫 infection
pH 🡫 in pneumonia
🡫🡫🡫 in esophageal rupture
Pericardial Fluid
Glucose 🡫 TB peritonitis
AMS Pancreatitis
GI perforation
Sweat Test
Amniotic Fluid
Green Meconium
Foam stability test Amniotic fluid + 95% ethanol 🡪 shake for 15 secs 🡪 stand (15
(Foam/Shake test) mins) (+) Continuous line of bubbles
Can be done bedside
Basal Acid Output (BAO) Total gastric secretion during unstimulated fasting state
Maximal Acid Output Total acid secreted in the hour after stimulation
(MAO)
Yeast cells in Gastric fluid Fermentation in stomach because large amounts of food have been retained
Fecalysis
Stool Color
Green Biliverdin
Vegetables
Mucus/RBCs Dysentery
Colitis
Malignancies
Consistency Variations
Rice watery Cholera
Type 7 Watery
Occult Blood
False (+) Turnips, broccoli, cauliflower, banana, apple, melon, horseradish (to avoid,
3 days free)
Aspirin, aspilet (promote GIT bleeding; to avoid, 7 days free)
Red meat (to avoid, should be 3 days free)
APT test Distinguish fetal blood and maternal blood in an infant’s stool
Specimen: infant stool/vomitus
Rgt: 1% NaOH
HbF: alkali-resistant
Maternal Hgb: not alkali-resistant
lec.mt 04 |Page | 172
(+) Pink = HbF
(-) Yellow brown = Maternal Hgb
Split fat stain Free fatty acids and fatty acids from hydrolysis of soaps and neutral
fats NV = 100 droplets (<4 μm)
Slightly increased = 100 droplets (1-8 μm)
Increased = 100 droplets (6-75 μm)
Duodenal Fluid
Sputum
24 hr Volume measurement:
🡩 vol = bronchiectasis, lung abscess, edema, gangrene, TB
🡫 vol = bronchial asthma, acute bronchitis, early pneumonia
Sputum Color
Transparent Normal
Mucus only
Green P. aeruginosa
(+) Bile
Brown CHF
Sputum Odor
Odorless Normal
Foul/putrid Cavitary TB
Fruity P. aeruginosa
Sweetish TB, Bronchiectasis
Consistency
Microscopic Elements
Elastic fibers TB
Fungi C. albicans
C. neoformans (Torulosis)
C. immitis
Bronchoalveolar Lavage
Bioassays