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Week 2:Physical Examination of Urine January 24, 2018

`Learning Objectives:  Describe the proper techniques for performing reagent


strip testing.
 List the common terminology used to report normal urine  Discuss all the clinical significance of chemicals in reagent
color. strips.
 State the clinical significance of urine clarity.  Explain all the principles, method, interferences in
 State possible causes of abnormal urine odor. chemical examinations of urine.

PHYSICAL EXAMINATION OF URINE: o Straw- (Over hydrated)


o Pale yellow- (well hydrated)
1. COLOR: o Yellow
 Variations may be due to normal metabolic o Dark yellow- dehydration or accumulation of urobilin
functions, physical activity, ingested materials or pigments
pathologic conditions. Urine color is produce by the
pres Urochrome: is a product of endogenous metabolism, and under
normal condition
Normal urine color

Decreased excretion seen in: o Chronic renal failure.


o Deposition in their subcutaneous fat.

DAYLE DANIEL SORVETO,RMT 1


Week 2:Physical Examination of Urine January 24, 2018

Foam:

Normal urine specimen is shaken or agitated sufficiently, a white


foam can be seen.

High Protein:

o Precipitation of white foam

High Bilirubin:

o Precipitation of Yellow foam

RECOMMENDATIONS FOR EVALUATION OF URINE PHYSICAL


CHARACTERISTICS:

-use a well-mixed specimen.


- View through a clear container- plastic or glass.
- View against a white background.
- Evaluate a consistent depth or volume of the specimen.
- View using room lighting that is adequate and consistent.

Figure 1: A: high concentration of bilirubin


in urine. B, High concentration of protein

DAYLE DANIEL SORVETO,RMT 2


Week 2:Physical Examination of Urine January 24, 2018

 Dehydration due to vomiting, diarrhea, fever, sweating


Physical Examination and hemorrhage.
 OBJECTIVE observation of color, volume, clarity, odor, &  Uremia
specific gravity that will provide PRELIMINARY information  Shock
for diagnosing a disorder.  Transfusion reaction
 can also be used to confirm the chemical and microscopic  Toxic agents
findings in urine sample.  mercury chloride, carbon tetrachloride, sulfonamides and
ethylene glycol
VOLUME
Anuria
 Adult- 600-2000 mL/ 24 hours - total suppression of urine production
 Less than 1 year old- 100-500 mL/ 24 hours Seen in cases of:
 1 to 14 years old- 500-1400 mL/ 24 hours  Acute nephritis
 Poisoning with bichloride of mercury
Urine volume is greatly affected by…  Transfusion reaction
 water intake  Toxic agents
 kidney diseases  Complete obstruction
 foods  Collapse
 drugs
 temperature Nocturia
 occupation - increase amount of urine at night
 metabolism - due to the inability of the kidney to regulate water excretion
 age competently
Seen in cases of:
Night Volume  renal dysfunction
 normally smaller than the day volume - glomerulonephritis
 Day volume - polyuric state
- 3-4 times larger than the night volume output
 influenced by body weight, diet, exercises, metabolism, 1. COLOR
age
Normal Urine Color (yellow- dark yellow)
Residual urine  Yellow - UROCHROME (Thudichum, 1864)
 Obtained by a catheter immediately after the patient has - Increased in fever, thyrotoxicosis, starvation.
emptied the bladder voluntarily - Increases in urine sample upon standing.
 Amount of urine that remains in the bladder after  Pink - UROERYTHRIN
voluntary urination - Seen in precipitation of Amorphous urates upon
refrigeration.
ABNORMAL VOLUME  Orange-brown - UROBILIN
- Smallest amount present
Polyuria - Indication that the urine sample is NOT FRESH!
- increased amount of urine
Seen in the following cases: Other Urine Color
 Diabetes mellitus Dark yellow/ Amber
 Diabetes insipidus Concentrated specimen (may be considered as normal)
 Chronic nephritis  Phenazopyridine (Pyridium) or Azo-gantrisin
 Nervous conditions administration
 Excessive fluid intake - given to patients with UTI
 Absorption of large quantity of edema fluid - thick orange pigment
- yellow foam (commonly mistaken with bilirubin)
Oliguria  Nitrofurantoin intake
- decreased amount of urine  Phenindione
Seen in cases of:
 Acute nephritis or glomerulonephritis Anticoagulant, can cause orange
 Calculus or tumor of the kidney - Bilirubin (positive yellow foam test; pathologic)
 Severe diarrhea - Bilirubin Biliverdin = beer-brown color, greenish foam

DAYLE DANIEL SORVETO,RMT 3


Week 2:Physical Examination of Urine January 24, 2018

Pink/ Red/ Red Brown Hazy Few particulates, print easily seen through
 most common abnormal color Cloudy Many particulates, print blurred through urine
 unstable hemoglobin Turbid Print cannot be seen through urine
- Dipyrrole or bilifuscin (negative for blood, negative Milky May precipitate or be clotted.
for bilirubin)
 For genetically susceptible person…
- Beets ingestion - red in alkaline urine
- Blackberries ingestion - red in acidic urine
 medication, menstrual contamination(non-pathologic)

SMOKEY CLEAR
- Hematuria (presence of - Hemoglobinuria
intact RBC’s) - Myoglobinuria
- Porphyrinuria (port wine
color)

Blue/ Green
PATHOLOGIC
 Green in the case of:
- Bacterial infections (Pseudomonas aeruginosa)
- Severe obstructive jaundice (dark green color)
 Blue in the case of: Bacterial Growth
- Increased urinary indican- INDICANURIA (Hartnup’s  uniform opalscence
Syndrome/ “Blue Diaper Syndrome”) - Not removed by acidification/ titration
NON-PATHOLOGIC  uses double beam turbidimeter
 Green in the case of: - Useful for urine infection screening
- Clorets ingestion (breath deodorizer)
 Blue in the case of: Chyluria
- Methocarbamol (Robaxin)  urine contains lymph fluids
- Amitriptyline (Elavil)  clots may usually form
- Methylene blue  caused by the obstruction of lymph flow or rupture of
- Phenol lymph vessels to renal pelvis
Brown/ Black
PATHOLOGIC Pseudochyluria
 Melanuria (brown-black)  use of paraffin based vaginal cream
- over production of melanin
SPECIFIC GRAVITY
- seen in cases if malignant melanoma
 Density of a solution compared with the density of a
 Alkaptonuria
similar volume of distilled water at same temperature.
- inborn error of metabolism
 Ratio of the weight of a substance to the weight of an
- deficiency in homogentisic acid oxidase
equal volume of a reference substance.
-
NON-PATHOLOGIC
Specific Gravity= weight of object/weight of equal volume of
 Intake of the following medications: reference substance
- Metronidazole (Flagyl)- treatment for amoebiasis = density of substance
- Levodopa/ Methydopa (antihypertension)
 Density of water is 1.0 g/mL at 40 C.
Cola-colored urine  Sp. gr. of solids or liquids are expressed in g/cm3 or g/mL
 Rhabdomyolysis - high hemiglobin Reference substance:
 L-dopa intake 1. For solid and liquids: WATER
2. For gases: AIR
CLARITY
 General term that refers to transparency/ turbidity of URINE SPECIFIC GRAVITY
urine specimen.  Measure of
- concentration of solutes
Manner of Reporting in the Laboratory - concentrating and diluting power of the kidney
Clarity Term
 Specific gravity of glomerular filtrate: 1.007
Clear No visible particulates, TRANSPARENT  Fixed urinary specific gravity of 1.007

DAYLE DANIEL SORVETO,RMT 4


Week 2:Physical Examination of Urine January 24, 2018

- Poor tubular reabsorption  Read the specific gravity at the lower meniscus of the
 High specific gravity urinometer.
- Dehydration
- Presence of abnormal solutes such as Diodrast,
protein, and glucose How to get corrected specific gravity?
 Get the specific gravity of the urine and specimen.
GENERAL USE OF SPECIFIC GRAVITY:  Get the temperature of the urinometer for which it was
 detection of diabetes insipidus standardized and the room temperature. (Always change
 to measure the hydration and dehydration state of a temperatures to centigrade; C=F-32 X 5/9 or .555)
person  Subtract the lower temperature from the higher
 to detect loss of the concentrating ability of the renal temperature or get the differences between the two
tubules temperatures, (Rule: In every 3 degrees centigrade rise
 Screening for unsuitable specimen due to low from the standard temperature; add .001 and for every 3
concentration. degrees centigrade fall from the standard temperature,
subtract .001)
GENERAL TERMS  Divide the difference by 3 (to find out how many 3s are
there in the difference).
Hypersthenuria  Add or subtract the product to or from the last two digits
 urine specific gravity is increased of the urinometer’s actual specific gravity reading of the
 above 1.010 specimen.
 Seen in cases of: DISADVANTAGE:
- Diabetes mellitus 1. Large volume required (10-15mL)
- Fever 2. Must be calibrated daily
- Acute nephritis 3. Temperature corrections are needed for specimens with
temperature difference greater than 3°C from the
Hyposthenuria calibrated temp.
 urine specific gravity is decreased. 4. Corrections are required when glucose or protein is
present.
 less than 1.007
 Seen in cases of:
Speegrav Method
- Chronic nephritis
 Temperature – compensated instrument
- Diabetes insipidus
 Operates on the principles of a float controlling a gate that
exposes a photocell to light
Isosthenuria
 Specific gravity is determined photoelectrically
 Urine specific gravity is normal
 Far superior to the hydrometer method
 Fixed at about 1.010
Refractometer/ Total Solid Meter/ TS meter
Normal values:
 Random urine sample: 1.015 - 1.025
PRINCIPLE: Refractive Index (comparison of the velocity of light in
 First morning specimen: 1.020
air with the velocity of light in a solution)
 Timed specimen: 1.010 - 1.030
 Reading is generally 0.002 lower than urinometer.
URINOMETER: A.K.A “HYDROMETER”
 temperature compensated at 60-100 F
 uses large drop of sample
PRINCIPLE: Density
 Subject to errors due to:
 less accurate than the other method for urine specific
- Presence of CHO and CHON
gravity determination.
 Must be calibrated daily with:
 not recommended by CLSI.
- Distilled water: 1.000
 requires large amount of urine sample
- 3% Sodium Chloride: 1.015 ± 0.001
 calibrated with distilled water at a specific temperature.
- 5% Sodium Chloride: 1.022 ± 0.001
 needs correction for the following instances:
- 9% Sucrose: 1.034 ± 0.001
- 3C increase or decrease in temperature
Three factors that affect the refractive index of a solution:
- Presence of protein and sugar in the specimen
1. Wavelength of light used.
2. Temperature of solution
Procedure:
3. Concentration of solution.
 Fill the cylinder with urine about ¾ full.
 Float the urinometer into it (rotate the urinometer to
Harmonic Oscillation Densitometry: (HOD)
avoid touching the sides of the cylinder).
PRINCIPLE: Density

DAYLE DANIEL SORVETO,RMT 5


Week 2:Physical Examination of Urine January 24, 2018

 more accurate than refractometer


 Based on the frequency of sound wave entering a solution  more precise than urinometer
that will change in proportion to the density of a solution.  Best method
 Highly accurate and precision determine urine specific  Utilizes graded series of oily solutions
gravity with linearity up to 1.080 - Mixture of bromobenzene and kerosene in services
proportions ranging in specific gravity from 1.000-
Falling Drop Method (Drogamad Method) 1.060
 A drop of urine is added to each bottle
 Observed to detect whether it rises or sinks in the solution
- Similar to copper sulfate method used for blood
specific gravity.
 Designed for a small amount of urine

Reagent Strip
PRINCIPLE: pKa changes of a polyelectrolyte pad.

Reagents:
 Bromthymol blue
 Polymethyl vinyl ether

ODOR CAUSE
Aromatic Normal
Ammonia-like “old” urine—improperly stored
Pungent, fetid UTI
Fruity, sweet Ketones (DM, Starvation, Vomiting,
diarrhea, dieting, malnutrition,
exercises)
Maple syrup Maple Syrup Urine Disease
Mousy/ Barny Phenylketonuria
Rancid Tyrosinemia
Sweaty Feet Isovaleric Acidemia
Cabbage, hops Methionine malabsorption
Bleach Contamination
Rotten Fish Odor Trimethyl Aminoaciduria
Sulfur Odor/ Burnt Gun Cysteinuria, homocysteinuria,
Powder cysteinosis
Rotting/ old fish trimethylaminuria
Menthol-like Phenol-containing medications
Bleach Adulteration of the specimen or
container contaminant.

DAYLE DANIEL SORVETO,RMT 6