Analysis on Urine and Other Body Fluids

(Clinical Microscopy)
Physical Examination of Urine
• The physical examination of urine
includes the determination of the urine
color, clarity, and specific gravity.
• observation of these characteristics
provides preliminary information
concerning disorders such as glomerular
bleeding, liver disease, inborn errors of
metabolism, and urinary tract infection.

COLOR
• The color of urine varies from almost
colorless to black. These variations may
be due to normal metabolic functions,
physical activity, ingested materials, or
pathologic conditions
• Normal Urine Color - Common
descriptions include pale yellow, yellow,
and dark yellow.
• Urochrome - yellow color of urine is
caused by the presence of a pigment.

Laboratory Correlation of Urine Color

• Abnormal Urine Color - abnormal urine
colors are as numerous as their causes.
Certain colors, however, are seen more
frequently and have a greater clinical
significance than do others.
o Dark Yellow/Amber/Orange - may not
always signify a normal concentrated urine
but can be caused by the presence of the
abnormal pigment bilirubin.
o Red/Pink/Brown - most common causes of
abnormal urine color is the presence of
blood. Red is the usual color that blood
produces in urine, but the color may range
from pink to brown, depending on the
amount of blood, the pH of the urine, and
the length of contact.
o Brown/Black - Additional testing is
recommended for urine specimens that
turn brown or black on standing and have
negative chemical test results for blood,
inasmuch as they may contain melanin or
homogentisic acid. Melanin is an oxidation
product of the colorless pigment,
melanogen, produced in excess when a
malignant melanoma is present.
o Blue/Green - Pathogenic causes of
blue/green urine are limited to bacterial
infections, including urinary tract infection
by Pseudomonas species and intestinal
tract infections resulting in increased
urinary indican.

CLARITY
• is a general term that refers to the
transparency or turbidity of a urine
specimen.

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 • Common terminology used to report clarity
includes clear, hazy, cloudy, turbid, and
milky.
• Normal Clarity - Freshly voided normal
urine is usually clear, particularly if
it is a midstream clean-catch specimen.
URINE CLARITY
Urine Color and Clarity Procedure
1. Evaluate an adequate volume of specimen.
2. Use a well-mixed specimen.
3. View the urine through a clear container.
4. View the urine against a white background
using
1. adequate room lighting.
5. Maintain adequate room lighting
6. Evaluate a consistent volume of urine
- Determine the urine color.
- Describe the urine clarity
• Nonpathologic Turbidity - The presence of
squamous epithelial cells and mucus,
particularly in specimens from women, can
result in a hazy but normal urine.
• Additional nonpathologic causes of
urine turbidity include semen, fecal
contamination, radiographic
contrast media, talcum powder, and
vaginal creams
• Pathologic Turbidity - The most commonly
encountered pathologic causes of turbidity in
a fresh specimen are RBCs, white blood cells
(WBCs), and bacteria caused by infection or a
systemic organ disorder.
Nonpathologic Causes of Urine Turbidity
Pathologic Causes Of Urine Turbidity
Specific Gravity
• is defined as the density of a solution
compared with the density of a similar
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volume of distilled water (SG 1.000) at a
similar temperature.
Refractometer
• determines the concentration of dissolved
particles in a specimen by measuring
refractive index. Refractive index is a
comparison of the velocity of light in air
with the velocity of light in a solution.
ODOR
• Although it is seldom of clinical significance
and is not a part of the routine urinalysis,
urine odor is a noticeable physical property
• Freshly voided urine has a faint aromatic
odor.
Possible Causes of Urine Odor
Chemical Examination of Urine
Reagent Strips
• Routine chemical examination of urine has
changed dramatically since the early days
of urine testing, due to the development of
the reagent strip method for chemical
analysis.
• Reagent strips currently provide a simple,
rapid means for performing medically
significant chemical analysis of urine,
including pH, protein, glucose, ketones,
blood, bilirubin, urobilinogen, nitrite,
leukocytes, and specific gravity.
• The two major types of reagent strips are
manufactured under the trade names
Multistix (Siemens Healthcare Diagnostics,
Deerfield, IN) and Chemstrip (Roche
Diagnostics, Indianapolis, IN).
• Reagent strips consist of chemical-
impregnated absorbent pads attached to a
plastic strip.
Reagent Strip Technique
1. Dip the reagent strip briefly into a well-
mixed uncentrifuged urine specimen at
room temperature.
 2. Remove excess urine by touching the edge
of the strip to the container as the strip is
withdrawn.
3. Blot the edge of the strip on a disposable
absorbent pad.
4. Wait the specified amount of time for the
reaction to occur.
5. Compare the color reaction of the strip
pads to the manufacturer’s color chart in
good lighting.
Care of Reagent Strips
1. Store with desiccant in an opaque, tightly
closed container.
2. Store below 30°C; do not freeze.
3. Do not expose to volatile fumes.
4. Do not use past the expiration date.
5. Do not use if chemical pads become
discolored.
6. Remove strips immediately prior to use.
Confirmatory Testing
• Confirmatory tests are defined as test using
different reagents or methodologies to
detect the same substances as detected by
the reagent strips with the same or greater
sensitivity or specificity.
CHEMICALS IN REAGENT STRIPS (that is clinical
significant)
PH -- reagents: Methyl red, bromthymol blue – 60
secs
• Along with the lungs, the kidneys are the
major regulators of the acid–base content
in the body
• A healthy individual usually produces a first
morning specimen with a slightly acidic pH
of 5.0 to 6.0
• The pH of normal random samples can
range from 4.5 to 8.0.
Clinical Significance
• Respiratory or metabolic acidosis/ketosis
• Respiratory or metabolic alkalosis
• Defects in renal tubular secretion and
reabsorption of acids and bases—renal
tubular acidosis
• Renal calculi formation and prevention
• Treatment of urinary tract infections
• Precipitation/identification of crystals
• Determination of unsatisfactory specimens
Causes of Acid and Alkaline Urine
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PROTEIN – reagent Tetrabromophenol blue – 60
secs,
• the most indicative of renal disease is the
protein determination. Proteinuria is often
associated with early renal disease, making
the urinary protein test an important part of
any physical examination.
• Normal urine contains very little protein:
usually, less than 10 mg/dL or 100 mg per
24 hours is excreted.
• Due to its low molecular weight, albumin is
the major serum protein found in normal
urine.
Clinical Significance
• Demonstration of proteinuria in a routine
analysis does not always signify renal
disease; however, its presence does
require additional testing to determine
whether the protein represents a normal or
a pathologic condition. Clinical proteinuria
is indicated at 30 mg/dL or greater (300
mg/L).
• Renal Proteinuria - Proteinuria associated
with true renal disease may be the result of
either glomerular or tubular damage.
GLUCOSE – reagent: Glucose oxidase, Peroxidase,
kiodipide – 30 secs.
• its value in the detection and monitoring of
diabetes mellitus, the glucose test is the
most frequently performed chemical
analysis on urine.
Clinical Significance of Urine Glucose
KETONES – reagent: Na nitropusside – 40s
• The term “ketones” represents three
intermediate products of fat metabolism,
namely, acetone (2%), acetoacetic acid
(20%), and β -hydroxybutyrate (78%).
• Normally, measurable amounts of ketones
do not appear in the urine, because all the
 metabolized fat is completely broken down
into carbon dioxide and water.
Clinical Significance
• Testing for urinary ketones is most
valuable in the management and
monitoring of insulin-dependent (type 1)
diabetes mellitus.
• Ketonuria shows a deficiency in insulin,
indicating the need to regulate dosage.
BLOOD – Diisopropylbenzene, dihydroperoxide and
3,3’,5,5’- tetramethylbenzidine – 60s
• Blood may be present in the urine either in
the form of intact red blood cells
(hematuria) or as the product of red blood
cell destruction, hemoglobin
(hemoglobinuria).
• blood greater than 5 cells/ul of urine is
considered clinically significant
Clinical Significance
• The finding of a positive reagent strip
test result for blood indicates the
presence of red blood cells,
hemoglobin, or myoglobin. Each of
these has a different clinical
significance
• Hematuria is most closely related to
disorders of renal or genitourinary
origin in which bleeding is the result of
trauma or damage to the organs of
these systems
• Hemoglobinuria may result from the
lysis of red blood cells produced in the
urinary tract, particularly in dilute,
alkaline urine. It also may result from
intravascular hemolysis and the
subsequent filtering of hemoglobin
through the glomerulus.
• Myoglobinuria - a heme-containing
protein found in muscle tissue, not only
reacts positively with the reagent strip
test for blood but also produces a clear
red-brown urine.
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BILIRUBUN – reagent: 2,4-dichloroaniline
diazonium salt – 30s
• The appearance of bilirubin in the urine can
provide an early indication of liver disease.
It is often detected long before the patient
exhibits jaundice.
Clinical Significance
• Only conjugated bilirubin can appear in the
urine when the normal degradation cycle is
disrupted by bile duct obstruction (post-
hepatic jaundice) (e.g., gallstones or
cancer) or when the integrity of the liver is
damaged (hepatic jaundice), allowing
leakage of conjugated bilirubin into the
circulation.
Urobilinogen – reagent: p-dimethyl-
aminobenzaldehyde 60s
• Urobilinogen appears in the urine because,
as it circulates in the blood back to the
liver, it passes through the kidney and is
filtered by the glomerulus.
• Therefore, a small amount of urobilinogen—
less than 1 mg/dL or Ehrlich unit—is
normally found in the urine.
Clinical Significance
• Increased urine urobilinogen (greater than 1
mg/dL) is seen in liver disease and
hemolytic disorders.
Nitrite: p-arsanilic acid Tetrahydrobenzo(h)-
quinolin-3-ol – 60s
Clinical Significance
• The reagent strip test for nitrite provides a
rapid screening test for the presence of
urinary tract infection (UTI). The test is
designed to detect cases in which the need
for a culture may not be apparent; it is not
intended to replace the urine culture as the
primary test for diagnosing and monitoring
bacterial infection
Leukocyte Esterase: Derivatized pyrrole amino
acid ester – 2 mins.
• Prior to the development of the reagent
strip leukocyte esterase (LE) test, detection
of increased urinary leukocytes required
microscopic examination of the urine
sediment.
 • For detection of leukocyte only, not for developed protocols whereby microscopic
measurement examination of the urine sediment is
Clinical Significance performed only on specimens meeting
• Normal values for leukocytes are based specified criteria.
on the microscopic sediment • Abnormalities in the physical and chemical
examination and vary from 0 to 2 to 0 to portions of the urinalysis play a primary
5 per high-power field. role in the decision to perform a
microscopic analysis, thus the use of the
term “macroscopic screening.”

Macroscopic Screening and Microscopic

SUMMARY Correlations

Microscopic Examination of Urine

• The third part of routine urinalysis,
after physical and chemical
examination, is the microscopic
examination of the urinary sediment.
• Its purpose is to detect and to identify
insoluble materials present in the
urine. The blood, kidney, lower
genitourinary tract, and external
contamination all contribute formed
elements to the urine.
• These include red blood cells (RBCs),
white blood cells (WBCs), epithelial
cells, casts, bacteria, yeast, parasites,
mucus, spermatozoa, crystals, and
artifacts.

Macroscopic Screening
• To enhance the cost-effectiveness of
urinalysis, many laboratories have

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 Urine Sediment Constituents
The normal urine sediment may contain a variety of
formed elements. Even the appearance of small
numbers of the usually pathologically significant
RBCs, WBCs, and casts can be normal. Likewise,
many routine urine specimens contain nothing more
than a rare epithelial cell or mucous strand.

Red Blood Cells

In the urine, RBCs appear as smooth, non-nucleated,
biconcave disks measuring approximately 7 mm in
diameter (Fig. 6–8). They must be identified using
high-power (40×) objective (×400 magnification).
RBCs are routinely reported as the average number
seen in 10 hpfs.
Clinical Significance
The presence of RBCs in the urine is associated with
damage to the glomerular membrane or vascular
injury within the genitourinary tract. The number of
cells present is indicative of the extent of the
damage or injury.

WBCs. A. One segmented and one non-segmented WBC

(×400). B. Notice the multilobed nucleoli (×400).

Epithelial Cells
Normal RBCs (×400).
It is not unusual to find epithelial cells in the urine,
because they are derived from the linings of the
genitourinary system. Three types of epithelial cells
are seen in urine: squamous, transitional
(urothelial), and renal tubular. They are classified
according to their site of origin within the
genitourinary system.
Squamous Epithelial Cells - Squamous cells
are the largest cells found in the urine sediment.
They contain abundant, irregular cytoplasm and a
prominent nucleus about the size of an RBC
Microcytic and crenated RBCs (×100).

White Blood Cells

WBCs are larger than RBCs, measuring an average
of about 12 mm in diameter

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Sediment-containing squamous, caudate transitional,
and RTE cells (×400).
A. Squamous epithelial cells identifiable under
lowpower (×100).
B. KOVA-stained squamous epithelial cells (×400).
Transitional Epithelial (Urothelial) Cells- Transitional
epithelial cells are smaller than squamous cells and
appear in several forms, including spherical,
polyhedral, and caudate (Figs. 6–24, 6–25, and 6–26).
These differences are caused by the ability of
transitional epithelial cells to absorb large amounts
of water.

Phenazopyridine-stained sediment showing squamous

epithelial cells and phenazopyridine crystals formed
following refrigeration (×400)

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 Bacteria
Bacteria are not normally present in urine. However,
unless specimens are collected under sterile
conditions (catheterization), a few bacteria are
usually present as a result of vaginal, urethral,
external genitalia, or collection-container
contamination.

A. Rod-shaped bacteria often seen in urinary

tract infections. B. KOVA-stained bacteria and
WBC (×400).

A. Budding yeast B. Yeast showing mycelial forms

(×400).

Yeast
Yeast cells appear in the urine as small, refractile
oval structures that may or may not contain a bud. In
severe infections, they may appear as branched,
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 mycelial forms. Yeast cells are reported as rare,
few, moderate, or many per hpf.

Parasites
The most frequent parasite encountered in the urine
is Trichomonas vaginalis. The Trichomonas
trophozoite is a pearshaped flagellate with an
undulating membrane. It is easily identified in wet
preparations of the urine sediment by its rapid
darting movement in the microscopic field.
Trichomonas is usually reported as rare, few, Mucus
moderate, or many per hpf. Mucus is a protein material produced by the glands
and epithelial cells of the lower genitourinary tract
and the RTE cells. Immunologic analysis has shown
that uromodulin is a major constituent of mucus.
Uromodulin is a glycoprotein excreted by the RTE
cells of the distal convoluted tubules and upper
collecting ducts.
Mucus appears microscopically as thread-like
structures with a low refractive index

A. Mucus threads (×400). B. Mucus clump (×400).

A. Enterobius vermicularis ova (×100)
B. Enterobius vermicularis ova (×400).
Spermatozoa
Spermatozoa are easily identified in the urine
sediment by their oval, slightly tapered heads and
long, flagella-like tails Urine is toxic to spermatozoa;
therefore, they rarely exhibit the motility observed
when examining a semen specimen.
Spermatozoa are occasionally found in the urine of
both men and women following sexual intercourse,
masturbation, or nocturnal emission. They are rarely
of clinical significance except in cases of male
infertility or retrograde ejaculation in which sperm
is expelled into the bladder instead of the urethra.
Casts
are the only elements found in the urinary sediment
that are unique to the kidney. They are formed within
the lumens of the distal convoluted tubules and
collecting ducts, providing a microscopic view of
conditions within the nephron. Their shape is
representative of the tubular lumen, with parallel
sides and somewhat rounded ends, and they may
contain additional elements present in the filtrate.
Hyaline Casts
The most frequently seen cast is the hyaline type,
which consists almost entirely of uromodulin. The
presence of zero to two hyaline casts per lpf is
considered normal, as is the finding of increased
numbers following strenuous exercise, dehydration,
heat exposure, and emotional stress.15
Pathologically, hyaline casts are increased in acute
glomerulo-nephritis, pyelonephritis, chronic renal
disease, and congestive heart failure.

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 RBC Casts
Whereas the finding of RBCs in the urine indicates
bleeding from an area within the genitourinary tract,
the presence of RBC casts is much more specific,
showing bleeding within the nephron.

WBC Casts
The appearance of WBC casts in the urine signifies
infection or inflammation within the nephron. They
are most frequently associated with pyelonephritis
and are a primary marker for distinguishing
pyelonephritis (upper UTI) from cystitis (lower UTI).

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 Mixed Cellular Casts
Considering that a variety of cells may be present in
the urinary filtrate, observing casts containing
Bacterial Casts
multiple cell types is not uncommon.
Bacterial casts containing bacilli both within and
bound to the protein matrix are seen in
Granular Casts
pyelonephritis.23 They may be pure bacterial casts
Coarsely and finely granular casts are frequently
or mixed with WBCs.
seen in the urinary sediment and may be of
pathologic or non-pathologic significance. It is not
Epithelial Cell Casts
considered necessary to distinguish between
Casts containing RTE cells represent the presence
coarsely and finely granular casts.
of advanced tubular destruction, producing urinary
stasis along with disruption of the tubular linings.
Similar to RTE cells, they are associated with heavy
metal and chemical or drug-induced toxicity, viral
infections, and allograft rejection. They also
accompany WBC casts in cases of pyelonephritis.

Epithelial Cell Casts

Casts containing RTE cells represent the presence
of advanced tubular destruction, producing urinary
stasis along with disruption of the tubular linings.
Similar to RTE cells, they are associated with heavy
metal and chemical or drug-induced toxicity, viral
infections, and allograft rejection. They also
accompany WBC casts in cases of pyelonephritis.
Fatty Casts
Fatty casts are seen in conjunction with oval fat
bodies and free fat droplets in disorders causing
lipiduria. They are most frequently associated with
the nephrotic syndrome, but are also seen in toxic
tubular necrosis, diabetes mellitus, and crush
injuries.

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Waxy Casts
Waxy casts are representative of extreme urine
stasis, indicating chronic renal failure. They are
usually seen in conjunction with other types of casts
associated with the condition that has caused the
renal failure.
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Broad Casts
Often referred to as renal failure casts, broad casts
like waxy casts represent extreme urine stasis. As a
mold of the distal convoluted tubules, the presence
of broad casts indicates destruction (widening) of
the tubular walls. Also, when the flow of urine to the
larger collecting ducts becomes severely
compromised, casts form in this area and appear
broad.
Urinary Crystals
Crystals frequently found in the urine are rarely of
clinical significance. They may appear as true
geometrically formed structures or as amorphous
material. The primary reason for the identification
of urinary crystals is to detect the presence of the
relatively few abnormal types that may represent
such disorders as liver disease, inborn errors of
metabolism, or renal damage caused by
crystallization of medications compounds within
the tubules. Crystals are usually reported as rare,
few, moderate, or many per hpf. Abnormal crystals
may be averaged and reported per lpf.
 (iatrogeniccompounds). Precipitation is subject to
changes in temperature, solute concentration, and
pH, which affect solubility

Crystal Formation
Crystals are formed by the precipitation of urine
solutes, including inorganic salts, organic
compounds, and medications

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 Normal Crystals Seen in Alkaline Urine
Phosphates represent the majority of the crystals
seen in alkaline urine and include amorphous
phosphate, triple phosphate, and calcium
phosphate. Other normal crystals associated with
alkaline urine are calcium carbonate and
ammonium biurate.

A. Uric acid crystals under polarized light (×100).

B. Uric acid crystals under polarized light (×400).

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 Ammonium biurate crystals

A. Ammonium biurate and triple phosphate crystals

(×100). Note thorn (arrow).

B. Ammonium biurate and triple phosphate crystals

(×400).

Abnormal Urine Crystals

Abnormal urine crystals are found in acidic urine or
rarely in neutral urine. Most abnormal crystals have
very characteristic shapes. However, their identity
can be confirmed by patient information, including
disorders and medication.
Cystine Crystals
Cystine crystals are found in the urine of persons
who inherit a metabolic disorder that prevents
reabsorption of cystine by the renal tubules
(cystinuria). Persons with cystinuria have a tendency
to form renal calculi, particularly at an early age

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Cholesterol Crystals
Cholesterol crystals are rarely seen unless
specimens have been refrigerated, because the
lipids remain in droplet form. However, when
observed, they have a most characteristic
appearance, resembling a rectangular plate with a
notch in one or more corners

Urinary Sediment Artifacts

Contaminants of all types can be found in urine,
particularly in specimens collected under improper
conditions or in dirty containers. The most frequently
encountered artifacts include starch, oil droplets, air
bubbles, pollen grains, fibers, and fecal
contamination. Because artifacts frequently
resemble pathologic elements such as RBCs and
casts, artifacts can present a major problem to
students. They are often very highly refractile or
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occur in a different microscopic plane than the true
sediment constituents. The reporting of artifacts is
not necessary.

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Questions: C. Uroerythrin

PHYSICAL EXAMINATION D. Beets

1. The concentration of a normal urine specimen can be 8. Microscopic examination of a clear urine that
estimated by which of the following? produces a white precipitate after refrigeration will
show:
A. Color
A. Amorphous urates
B. Clarity
B. Porphyrins
C. Foam
C. Amorphous phosphates
D. Odor
D. Yeast
2. The normal yellow color of urine is produced by:
9. The color of urine containing porphyrins will be:
A. Bilirubin
A. Yellow-brown
B. Hemoglobin
B. Green
C. Urobilinogen
C. Orange
D. Urochrome
D. Port wine
3. The presence of bilirubin in a urine specimen
produces a: 10. Which of the following specific gravities would be
most likely to correlate with a pale yellow urine?
A. Yellow foam when shaken
A. 1.005
B. White foam when shaken
B. 1.010
C. Cloudy specimen
C. 1.020
D. Yellow-red specimen
D. 1.030
4. A urine specimen containing melanin will appear:
11. A urine specific gravity measured by refractometer
A. Pale pink is 1.029, and the temperature of the urine is 14°C. The
B. Dark yellow specific gravity should be reported as:

C. Blue-green A. 1.023

D. Black B. 1.027

5. Specimens that contain hemoglobin can be visually C. 1.029

distinguished from those that contain RBCs because:
A. Hemoglobin produces a clear, yellow specimen
B. Hemoglobin produces a cloudy pink specimen
C. RBCs produce a cloudy red specimen
D. RBCs produce a clear red specimen
6. A patient with a viscous orange specimen may have
been:
A. Treated for a urinary tract infection
B. Taking vitamin B pills
C. Eating fresh carrots
D. 1.032
12. The principle of refractive index is to compare:
A. Light velocity in solutions with light velocity in
solids
B. Light velocity in air with light velocity in solutions
C. Light scattering by air with light scattering by
solutions
D. Light scattering by particles in solution
13. A correlation exists between a specific gravity by
refractometer of 1.050 and a:

D. Taking antidepressants A. 2+ glucose

7. The presence of a pink precipitate in a refrigerated B. 2+ protein

specimen is caused by: C. First morning specimen
A. Hemoglobin D. Radiographic dye infusion
B. Urobilin
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14. A cloudy urine specimen turns black upon standing B. The freezing point is raised by solute
and has a specific gravity of 1.012. The major concern
about this specimen would be: C. The vapor pressure is lowered by solute

D. The osmotic pressure is raised by solute

A. Color

B. Turbidity 21. An osmole contains:

C. Specific gravity A. One-gram molecular weight of solute dissolved in

one liter of solvent
D. All of the above
B. One-gram molecular weight of solute dissolved in
15. A specimen with a specific gravity of 1.035 would be one kilogram of solvent
considered:
C. Two-gram molecular weights of solute dissolved in
A. Isosthenuric one liter of solvent

B. Hyposthenuric D. Two-gram molecular weights of solute dissolved in

one kilogram of solvent
C. Hypersthenuric
22. The unit of osmolality measured in the clinical
D. Not urine
laboratory is the:
16. A specimen with a specific gravity of 1.001 would be A. Osmole
considered:
B. Milliosmole
A. Hyposthenuric
C. Molecular weight
B. Not urine
D. Ionic charge
C. Hypersthenuric
23. In the reagent strip specific gravity reaction the
D. Isosthenuric
polyelectrolyte:
17. A strong odor of ammonia in a urine specimen could A. Combines with hydrogen ions in response to ion
indicate: concentration
A. Ketones B. Releases hydrogen ions in response to ion
B. Normalcy concentration
C. Phenylketonuria C. Releases hydrogen ions in response to pH
D. An old specimen
D. Combines with sodium ions in response to pH
18. The microscopic of a clear red urine is reported as 24. Which of the following will react in the reagent strip
many specific gravity test?
WBCs and epithelial cells. What does this suggest?
A. Glucose
A. Urinary tract infection B. Radiographic dye
B. Dilute random specimen C. Protein
C. Hematuria
D. Chloride
D. Possible mix-up of specimen and sediment

19. Which of the following would contribute the most to

CHEMICAL EXAMINATION
a urine osmolality?
1. Leaving excess urine on the reagent strip after
A. One osmole of glucose removing it from the specimen will:
B. One osmole of urea A. Cause run-over between reagent pads
C. One osmole of sodium chloride B. Alter the color of the specimen
D. All contribute equally C. Cause reagents to leach from the pads
20. Which of the following colligative properties is not
D. Not affect the chemical reactions
stated correctly?

A. The boiling pointing is raised by solute

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2. Failure to mix a specimen before inserting the C. May contain calcium oxalate crystals
reagent
D. Is seen after drinking cranberry juice
strip will primarily affect the:
9. In the laboratory, a primary consideration
A. Glucose reading associatedwith pH is:

B. Blood reading A. Identifying urinary crystals

C. Leukocyte reading B. Monitoring vegetarian diets

D. Both B and C C. Determining specimen acceptability

3. Testing a refrigerated specimen that has not warmed D. Both A and C

to room temperature will adversely affect:
10. Indicate the source of the following proteinurias by
A. Enzymatic reactions placing a 1 for prerenal, 2 for renal, or 3 for postrenal
in front of the condition.
B. Dye-binding reactions
A. ____Microalbuminuria
2
C. The sodium nitroprusside reaction
B. ____Acute
1 phase reactants
D. Diazo reactions
2
C. ____Pre-eclampsia
4. The reagent strip reaction that requires the longest
reaction time is the: 3
D. ____Vaginal inflammation

A. Bilirubin 1
E. ____Multiple myeloma

B. pH F. ____Orthostatic
2 proteinuria

C. Leukocyte esterase G. ____Prostatitis

3

D. Glucose 11. The principle of the protein error of indicators

reaction
5. Quality control of reagent strips is performed:
is that:
A. Using positive and negative controls
A. Protein keeps the pH of the urine constant
B. When results are questionable
B. Albumin accepts hydrogen ions from the indicator
C. At least once every 24 hours
C. The indicator accepts hydrogen ions from albumin
D. All of the above
D. Albumin changes the pH of the urine
6. All of the following are important to protect the
integrity 12. All of the following will cause false-positive protein
reagent strip values except:
of reagent strips except:
A. Microalbuminuria
A. Removing the desiccant from the bottle
B. Highly buffered alkaline urines
B. Storing in an opaque bottle
C. Delay in removing the reagent strip from the
C. Storing at room temperature specimen
D. Resealing the bottle after removing a strip D. Contamination by quaternary ammonium compounds
7. The principle of the reagent strip test for pH is the: 13. A patient with a 2+ protein reading in the afternoon
A. Protein error of indicators is asked to submit a first morning specimen. The
second specimen has a negative protein reading. This
B. Greiss reaction patient is:
C. Dissociation of a polyelectrolyte A. Positive for orthostatic proteinuria
D. Double indicator reaction B. Negative for orthostatic proteinuria
8. A urine specimen with a pH of 9.0: C. Positive for Bence Jones protein
A. Indicates metabolic acidosis D. Negative for clinical proteinuria
B. Should be recollected

ABEGAIL AVIÑANTE MMLS3-5

14. Testing for microalbuminuria is valuable for early A. Double indicator reaction
detection of kidney disease and monitoring patients
with: B. Diazo reaction

C. Pseudoperoxidase reaction
A. Hypertension

B. Diabetes mellitus D. Reduction of a chromogen

C. Cardiovascular disease risk 21. The purpose of performing an albumin:creatinine

D. All of the above
15. The primary chemical on the reagent strip in the
MicralTest for microalbumin binds to:
ratio is to:
A. Estimate the glomerular filtration rate
B. Correct for hydration in random specimens

C. Avoid interference for alkaline urines

A. Protein

B. Antihuman albumin antibody D. Correct for abnormally colored urines

C. Conjugated enzyme 22. A patient with a normal blood glucose and a

positive
D. Galactoside
urine glucose should be further checked for:
16. All of the following are true for the ImmunoDip test
for microalbumin except: A. Diabetes mellitus

B. Renal disease
A. Unbound antibody migrates farther than bound
antibody C. Gestational diabetes
B. Blue latex particles are coated with antihuman D. Pancreatitis
albumin antibody
23. The principle of the reagent strip tests for glucose
C. Bound antibody migrates further than unbound is the:
antibody
A. Peroxidase activity of glucose
D. It utilizes an immunochromographic principle
B. Glucose oxidase reaction
17. The principle of the protein-high pad on the Multistix
Pro reagent strip is the: C. Double sequential enzyme reaction

A. Diazo reaction D. Dye-binding of glucose and chromogen

B. Enzymatic dye-binding reaction 24. All of the following may produce false-negative
glucose reactions except:
C. Protein error of indicators
A. Detergent contamination
D. Microalbumin-Micral-Test
B. Ascorbic acid
18. Which of the following is not tested on the Multistix
Pro reagent strip? C. Unpreserved specimens

A. Urobilinogen D. Low urine temperature

B. Specific gravity 25. The primary reason for performing a Clinitest is to:

C. Creatinine A. Check for high ascorbic acid levels

D. Protein-high B. Confirm a positive reagent strip glucose

19. The principle of the protein-low reagent pad on the
Multistix Pro is the:
A. Binding of albumin to sulphonphthalein dye
B. Immunologic binding of albumin to antibody
C. Check for newborn galactosuria
D. Confirm a negative glucose reading
26. The three intermediate products of fat metabolism
include all of the following except:

C. Reverse protein error of indicators reaction A. Acetoacetic acid

D. Enzymatic reaction between albumin and dye B. Ketoacetic acid

20. The principle of the creatinine reagent pad on C. β -hydroxybutyric acid

microalbumin reagent strips is the:
D. Acetone
ABEGAIL AVIÑANTE MMLS3-5
27. The most significant reagent strip test that is C. Reaction of peroxide and chromogen
associated with a positive ketone result is:
D. Diazo activity of heme
A. Glucose
33. A speckled pattern on the blood pad of the reagent
B. Protein strip indicates:

C. pH A. Hematuria

D. Specific gravity B. Hemoglobinuria

28. The primary reagent in the reagent strip test for C. Myoglobinuria
ketones is:
D. All of the above
A. Glycine
34. List the following products of hemoglobin
B. Lactose degradation

C. Sodium hydroxide in the correct order by placing numbers 1 to 4 in the

blank.
D. Sodium nitroprusside
A. ____Conjugated
1 bilirubin
29. Ketonuria may be caused by all of the following
except: B. ____Urobilinogen
3 and stercobilinogen

A. Bacterial infections 4
C. ____Urobilin

B. Diabetic acidosis 2
D. ____Unconjugated bilirubin

C. Starvation 35. The principle of the reagent strip test for bilirubin is
the:
D. Vomiting
A. Diazo reaction
30. Urinalysis on a patient with severe back and
abdominal pain is frequently performed to check for: B. Ehrlich reaction

A. Glucosuria C. Greiss reaction

B. Proteinuria D. Peroxidase reaction

C. Hematuria 36. An elevated urine bilirubin with a normal

urobilinogen is indicative of:
D. Hemoglobinuria
A. Cirrhosis of the liver
31. Place the appropriate number or numbers in front
of each of the following statements. Use both numbers B. Hemolytic disease
for an answer if needed.
C. Hepatitis
1. Hemoglobinuria
D. Biliary obstruction
2. Myoglobinuria
37. The primary cause of a false-negative bilirubin
A. ____
1 Associated with transfusion reactions reaction is:
2 Clear red urine and pale yellow plasma
B. ____ A. Highly pigmented urine
1 Clear red urine and red plasma
C. ____ B. Specimen contamination
2 Associated with rhabdomyolysis
D. ____ C. Specimen exposure to light

E. ____
1 Produces hemosiderin granules in urinary D. Excess conjugated bilirubin

sediments 38. The purpose of the special mat supplied with the
Ictotest tablets is that:
F. ____Associated
2 with acute renal failure
A. Bilirubin remains on the surface of the mat.
32. The principle of the reagent strip test for blood is
based on the: B. It contains the dye needed to produce color.

A. Binding of heme and a chromogenic dye C. It removes interfering substances.

B. Peroxidase activity of heme D. Bilirubin is absorbed into the mat.

ABEGAIL AVIÑANTE MMLS3-5

39. The reagent in the Multistix reaction for D. Blood
urobilinogen is:
46. The principle of the leukocyte esterase reagent
A. A diazonium salt strip test uses a:

B. Tetramethylbenzidine A. Peroxidase reaction

C. p-Dimethylaminobenzaldehyde B. Double indicator reaction

D. Hoesch reagent C. Diazo reaction

40. The primary problem with urobilinogen tests using D. Dye-binding technique
Ehrlich reagent is:
47. The principle of the reagent strip test for specific
A. Positive reactions with porphobilinogen gravity uses the dissociation constant of a(n):

B. Lack of specificity A. Diazonium salt

C. Positive reactions with Ehrlich’s reactive substances B. Indicator dye

D. All of the above C. Polyelectrolyte

41. The reagent strip test for nitrite uses the: D. Enzyme substrate

A. Greiss reaction 48. A specific gravity of 1.005 would produce the

reagent strip color:
B. Ehrlich reaction
A. Blue
C. Peroxidase reaction
B. Green
D. Pseudoperoxidase reaction
C. Yellow
42. All of the following can cause a negative nitrite
reading except: D. Red

A. Gram-positive bacteria 49. Reagent strip–specific gravity readings are affected

by:
B. Gram-negative bacteria
A. Glucose
C. Random urine specimens
B. Radiographic dye
D. Heavy bacterial infections
C. Alkaline urine
43. A positive nitrite test and a negative leukocyte
esterase test is an indication of a: D. All of the above

A. Dilute random specimen

B. Specimen with lysed leukocytes MICROSCOPY EXAMINATION

C. Vaginal yeast infection 1. Macroscopic screening of urine specimens is used to:

D. Specimen older than 2 hours A. Provide results as soon as possible

44. All of the following can be detected by the B. Predict the type of urinary casts present
leukocyte esterase reaction except:
C. Increase cost-effectiveness of urinalysis
A. Neutrophils
D. Decrease the need for polarized microscopy
B. Eosinophils
2. Variations in the microscopic analysis of urine
C. Lymphocytes include all of the following except:

D. Basophils A. Preparation of the urine sediment

45. Screening tests for urinary infection combine the B. Amount of sediment analyzed
leukocyte esterase test with the test for:
C. Method of reporting
A. pH
D. Identification of formed elements
B. Nitrite
3. All of the following can cause false-negative
C. Protein microscopic results except:
ABEGAIL AVIÑANTE MMLS3-5
A. Braking the centrifuge D. Delineate constituent structures

B. Failing to mix the specimen 10. Nuclear detail can be enhanced by:

C. Dilute alkaline urine A. Prussian blue

D. Using midstream clean-catch specimens B. Toluidine blue

4. The two factors that determine relative centrifugal C. Acetic acid

force are:
D. Both B and C
A. Radius of rotor head and rpm
11. Which of the following lipids is/are stained by Sudan
B. Radius of rotor head and time of centrifugation III?

C. Diameter of rotor head and rpm A. Cholesterol

D. RPM and time of centrifugation B. Neutral fats

5. When using the glass slide and cover-slip method, C. Triglycerides

which of the following might be missed if the cover slip
is overflowed? D. Both B and C

A. Casts 12. Which of the following lipids is/are capable of

polarizing light?
B. RBCs
A. Cholesterol
C. WBCs
B. Neutral fats
D. Bacteria
C. Triglycerides
6. Initial screening of the urine sediment is performed
using an objective power of: D. Both A and B

A. 4× 13. The purpose of the Hansel stain is to identify:

A. Neutrophils
B. 10×

C. 40× B. Renal tubular cells

D. 100× C. Eosinophils

7. Which of the following should be used to reduce light D. Monocytes

intensity in bright-field microscopy? 14. Crenated RBCs are seen in urine that is:
A. Centering screws A. Hyposthenuric
B. Aperture diaphragm B. Hypersthenuric
C. Rheostat C. Highly acidic
D. Condenser aperture diaphragm D. Highly alkaline
8. Which of the following are reported as number per 15. Differentiation among RBCs, yeast, and oil droplets
lpf? may be accomplished by all of the following except:
A. RBCs A. Observation of budding in yeast cells
B. WBCs B. Increased refractility of oil droplets
C. Crystals C. Lysis of yeast cells by acetic acid
D. Casts D. Lysis of RBCs by acetic acid
9. The Sternheimer-Malbin stain is added to urine 16. A finding of dysmorphic RBCs is indicative of:
sediments to do all of the following except:
A. Glomerular bleeding
A. Increase visibility of sediment constituents
B. Renal calculi
B. Change the constituents’ refractive index
C. Traumatic injury
C. Decrease precipitation of crystals
D. Coagulation disorders
ABEGAIL AVIÑANTE MMLS3-5
17. Leukocytes that stain pale blue with Sternheimer- 24. Increased transitional cells are indicative of:
Malbin stain and exhibit brownian movement are:
A. Catheterization
A. Indicative of pyelonephritis
B. Malignancy
B. Basophils
C. Pyelonephritis
C. Mononuclear leukocytes
D. Both A and B
D. Glitter cells
25. A primary characteristic used to identify renal
18. Mononuclear leukocytes are sometimes mistaken tubular epithelial cells is:
for:
A. Elongated structure
A. Yeast cells
B. Centrally located nucleus
B. Squamous epithelial cells
C. Spherical appearance
C. Pollen grains
D. Eccentrically located nucleus
D. Renal tubular cells
26. Following an episode of hemoglobinuria, RTE cells
19. When pyuria is detected in a urine sediment, the may contain:
slide should be carefully checked for the presence of:
A. Bilirubin
A. RBCs
B. Hemosiderin granules
B. Bacteria
C. Porphobilinogen
C. Hyaline casts
D. Myoglobin
D. Mucus
27. The predecessor of the oval fat body is the:
20. Transitional epithelial cells are sloughed from the:
A. Histiocyte
A. Collecting duct
B. Urothelial cell
B. Vagina
C. Monocyte
C. Bladder
D. Renal tubular cell
D. Proximal convoluted tubule
28. A structure believed to be an oval fat body
21. The largest cells in the urine sediment are: produced a Maltese cross formation under polarized
light but does not stain with Sudan III. The structure:
A. Squamous epithelial cells
A. Contains cholesterol
B. Urothelial epithelial cells
B. Is not an oval fat body
C. Cuboidal epithelial cells
C. Contains neutral fats
D. Columnar epithelial cells
D. Is contaminated with immersion oil
22. A clinically significant squamous epithelial cell is
the: 29. The finding of yeast cells in the urine is commonly
associated with:
A. Cuboidal cell
A. Cystitis
B. Clue cell
B. Diabetes mellitus
C. Caudate cell
C. Pyelonephritis
D. Columnar cell
D. Liver disorders
23. Forms of transitional epithelial cells include all of
the following except: 30. The primary component of urinary mucus is:

A. Spherical A. Bence Jones protein

B. Caudate B. Microalbumin

C. Convoluted C. Uromodulin

D. Polyhedral D. Orthostatic protein

ABEGAIL AVIÑANTE MMLS3-5
31. The majority of casts are formed in the: 38. The presence of fatty casts is associated with:

A. Proximal convoluted tubules A. Nephrotic syndrome

B. Ascending loop of Henle B. Crush injuries

C. Distal convoluted tubules C. Diabetes mellitus

D. Collecting ducts D. All of the above

32. Cylindruria refers to the presence of: 39. Nonpathogenic granular casts contain:

A. Cylindrical renal tubular cells A. Cellular lysosomes

B. Mucus-resembling casts B. Degenerated cells

C. Hyaline and waxy casts C. Protein aggregates

D. All types of casts D. Gram-positive cocci

33. A person submitting a urine specimen following a 40. All of the following are true about waxy casts
strenuous exercise routine can normally have all of the except they:
following in the sediment except:
A. Represent extreme urine stasis
A. Hyaline casts
B. May have a brittle consistency
B. Granular casts
C. Require staining to be visualized
C. RBC casts
D. Contain degenerated granules
D. WBC casts
41. Observation of broad casts represents:
34. Prior to identifying an RBC cast, all of the following
should be observed except: A. Destruction of tubular walls

B. Dehydration and high fever

A. Free-floating RBCs

B. Intact RBCs in the cast C. Formation in the collecting ducts

C. Presence of a cast matrix D. Both A and C

D. A positive reagent strip blood reaction 42. All of the following contribute to urinary crystals
formation except:
35. WBC casts are primarily associated with:
A. Protein concentration
A. Pyelonephritis
B. pH
B. Cystitis
C. Solute concentration
C. Glomerulonephritis
D. Temperature
D. Viral infections
43. The most valuable initial aid for identifying crystals
36. The shape of the RTE cell associated with renal in a urine specimen is:
tubular epithelial casts is primarily:
A. pH
A. Elongated
B. Solubility
B. Cuboidal
C. Staining
C. Round
D. Polarized microscopy
D. Columnar
44. Crystals associated with severe liver disease
37. When observing RTE casts, the cells are primarily: include all of the following except:

A. Embedded in a clear matrix A. Bilirubin

B. Embedded in a granular matrix B. Leucine

C. Attached to the surface of a matrix C. Cystine

D. Stained by components of the urine filtrate D. Tyrosine

ABEGAIL AVIÑANTE MMLS3-5

45. All of the following crystals routinely polarize liver disease
except:
50. Match the following types of microscopy with their
A. Uric acid descriptions:

B. Cholesterol 3 Bright-field
____ 1. Indirect light is reflected off
the object
C. Radiographic dye
____
5 Phase 2. Objects split light into two
D. Cystine beams
46. Casts and fibers can usually be differentiated using: ____
2 Polarized 3. Low refractive index objects
A. Solubility characteristics may be overlooked

B. Patient history ____

1 Dark-field 4. Three-dimensional images
7
____Fluorescent 5. Forms halo of light around
C. Polarized light
object
D. Fluorescent light
____Interference
4 6. Detects electrons contrast
47. Match the following crystals seen in acidic urine emitted from objects
with their description/identifying characteristics:
7. Detects specific
____
4 Amorphous urates 1. Envelopes wavelengths of light emitted from
3 Uric acid objects
____ 2. Thin needles

____
5 Calcium oxalate 3. Yellow-brown,
monohydrate whetstone

____
1 Calcium oxalate 4. Pink sediment
dihydrate

5. Ovoid

48. Match the following crystals seen in alkaline urine

with their description/identifying characteristics:
3 Triple phosphate
____ 1. Yellow granules
5 Amorphous phosphate
____ 2. Thin prisms

____
2 Calcium phosphate 3. “Coffin lids”
6 Ammonium biurate
____ 4. Dumbbell shape

____
4 Calcium carbonate 5. White precipitate

6. Thorny apple

49. Match the following abnormal crystals with their

description/identifying characteristics:
4 Cystine
____ 1. Bundles following refrigeration
8 Tyrosine
____ 2. Highly alkaline pH
7 Cholesterol 3. Bright yellow clumps
____

____
6 Leucine 4. Hexagonal plates

____
1 Ampicillin 5. Flat plates, high

specific gravity
5
____ Radiographic dye 6. Concentric circles,
radial striations

____
3 Bilirubin 7. Notched corners

8. Fine needles seen in

ABEGAIL AVIÑANTE MMLS3-5