Senior Review 2017

Case Studies
 Case Study #1
• A 42-year old male presents with anorexia, nausea, fever and icterus of
the skin and mucous membranes. He noticed that his urine had appeared
dark for the past several days. The physician orders a series of tests.
Based on the following test results, what is the most likely diagnosis?
– ALP: 240 U/L (36-92 U/L) AST: 1500 U/L (0-35 U/L)
– GGT: 75 U/L (0-30 U/L) Total bilirubin: 1.9 mg/dL (0.-1.2 gm/dL)
– Urine bilirubin: positive Fecal urobilinogen: decreased

– A. Acute hepatitis
– B. Alcoholic cirrhosis
– C. Metastatic carcinoma of the pancreas
– D. Obstructive jaundice
• AST (0-35 U/L)
– will be very elevated in liver disease; Maybe 100 x normal with viral hepatitis
– Used to diagnose and monitor hepatocellular disease
• GGT (0-30 U/L)
– Very elevated in obstructive disease (hepatobilliary)
– Moderate increase in hepatocellular
– ALP + GGT are increased = Liver NOT bone
• ALP ( 36-92 U/L)
– Moderate Increase (3x normal) with extra hepatobiliary disease
– Biliary obstruction causes synthesis of ALP so will be very increased
• Bilirubin (Total 0.3-1.2 mg/dL; direct 0-0.3 mg/dL)
– Must pass through liver to be conjugated (water soluble)= direct bilirubin
– Direct  bile duct gall bladder  duodenum  bacteria reduce to
urobilinogen  excreted in feces
• Urobilinogen (Fecal)
– Decreased (chalk-clay color to feces) amounts indicate liver obstruction or
liver disease
 Case Study # 2
• A 4-year old male child is brought to the pediatrician because the parents
are concerned about the child’s frequent falling, which results in bruising.
The parents indicate that the child has difficulty running, walking, standing
up, climbing stairs, and even sitting up straight. The child also appears
somewhat weak. Which enzyme(s) would you expect to be elevated?
– A. AST B. ALP
– C. LD D. CK
– What diagnosis would you expect?
• Duchene's Muscular Dystrophy
• Duchene’s Muscular Dystrophy
– Muscle weakness due to destruction of muscle fibers
– X-linked recessive disorder, symptoms start in males 3-7 yrs old
– CK
• 50-100X normal. Indicates muscle destruction
– AST & LD
• Increased because they are found in skeletal muscle
– ALP
• Not present in skeletal muscle
• Used to assess hepatobiliary and bone disorders
 Case Study #3
• A 53-year old female presents with fatigue, pruritus (itch), and an
enlarged, non-tender liver. The physician orders a series of blood tests.
Based on the following serum test results, what is the most likely
diagnosis?
– ALP: 258 U/L (36-92 U/L) AST: 42 U/L(0-35 U/L)
– LD: 120 U/L(60-100 U/L) GGT: 126 U/L (0-30 U/L)
– Total Bilirubin: 1.6 mg/dL (0.3-1.2 mg/dL)

– A. Alcoholic cirrhosis
– B. Infectious mononucleosis
– C. Intrahepatic cholestasis
– D. Viral hepatitis
• Intrahepatic cholestasis means biliary tree obstruction
• ALP (36-92 U/L)
– Biliary obstruction causes synthesis of ALP so markedly increased
– In the other disease choices, ALP would be only slightly increased
• GGT (0-30 U/L)
– Marked elevation (5-30x normal) in hepatic obstruction
– ALP + GGT increased = Liver
• AST, ALT, LD (AST 0-35 U/L; ALT (0-35 U/L); LD (60-100 U/L)
– AST marked increase with hepatocellular disease
– ALT marked increase with hepatocellular disease
– LD increases with any tissue injury
• Total Bilirubin (0.3-1.2 mg/dL)
– Early in disease will remain normal or slightly increased
 Case Study #4
• A 68-year old male in an unconscious state is transported to the
emergency department after being involved in a one-car crash, where he
drove off the road and hit a tree. Because he was alone at the time and
there was no apparent cause for the accident, it is assumed that he
blacked out, which caused him to lose control of the car. He was not
wearing a seat belt and has a broken leg, multiple contusions, and cuts.
Blood samples were drawn upon arrival to the ED and in 3-hr intervals for
12 hours; all control values were within acceptable range. Selected test
results follow:
 Test Initial Values 3 Hours 9 Hours Reference
Ranges
Myoglobin 57 ng/mL 140 ng/mL 281 ng/mL 30-90 ng/mL
Total CK 112 U/L 170 U/L 390 U/L 15-160 U/L
CK-MB 3 ng/mL 6 ng/mL 8 ng/mL 0-5 ng/mL
Troponin I 0.10 ng/mL 0.12 ng/mL 0.11 ng/mL <0.40 ng/mL

What do these test results suggest?

A. The man had a myocardial infarction, which caused the accident

B. The elevated results are from the skeletal muscle injuries sustained in the car
crash
C. The elevated results are a combination of the car crash injuries and a myocardial
infarction
D. The elevated total CK and CK-MB results indicate that the man had a stroke
• Troponin
– No change indicates results due to muscle injury from car crash
– Marker of choice for AMI
– During AMI will increase at 4-6 hours post muscle damage; will remain
increased 10-14 days
• CK & Myoglobin
– Not tissue specific; will increase with any muscle damage
– Myoglobin is negative indicator of AMI. If remains normal for 2-6 hour
period then no muscle (cardiac or skeletal) injury has occurred
• CK-MB
– Not tissue specific; will increase with any muscle damage
 Case Study #5
• A 10-year old female presents with varicella (chicken pox). The child has
been experiencing fever, nausea, vomiting, lethargy and disorientation. A
diagnosis of Reye syndrome is determined. Which of the following is not
consistent with this diagnosis?

– A. AST: 50 U/L (0-35 U/L)

– B. ALT: 112 U/L (0-35 U/L)
– C. Ammonia (Plasma): 98 μg/L (40-80 μg/L)
– D. Total bilirubin: 1.8 mg/dL (0.3-1.2 mg/dL)
• Reye’s syndrome is associated with viral infection, toxins and aspirin use
• Usually seen in children 2-13 years of age
• Encephalopathy and fatty degeneration of the liver are hallmarks
• AST
– Slightly increased; markedly elevated in hepatocellular disease
• ALT
– Markedly increased in hepatocellular disorders that are viral
• Ammonia
– Increased due to inability of liver to convert to Urea
– Elevated in advanced liver disease and renal failure
– Can be toxic to patient causing seizures and coma
• PT
– Will increase with Reye’s syndrome
• Bilirubin
– Usually remains normal
 Case Study #6
• A 42-year old woman is admitted to the hospital with complaints of abdominal
pain and inability to eat, symptoms have increased in intensity during the past
several weeks. Although the pain had been uncomfortable, what alarmed her
was noticing a slight yellow color in her eyes. Blood was drawn with the
following results

– Total bilirubin: 3.9 mg/dL (0.3-1.2 mg/dL)

– Direct bilirubin 2.7 mg/dL (0-0.3 mg/dL)
– AST 86 U/L (0-35 U/L) ALP 203 U/L (0-35 U/L)
– Urine urobilinogen decreased
– What diagnosis do these test results support?

– A. Viral hepatitis B. Cirrhosis

– C. Exposure to toxic chemicals D. Biliary obstruction
• Post Hepatic biliary obstruction
– ALP is markedly elevated; biliary obstruction causes the synthesis of
ALP
– ALT and AST will be increased
– Increase in conjugated bilirubin because the liver is functioning but
the bilirubin is unable to pass into the intestine. This means that
urobilinogen is decreased
– Other choices would show hepatocyte damage with markedly
increased ALT and AST. Unconjugated bilirubin would be increased.
 Case Study #7
• The following laboratory results were obtained on a 60-year old woman
who is complaining of anorexia, constipation, abdominal pain, nausea and
vomiting
– Ionized serum calcium: 11.2 mg/dL(9-10.5 mg/dL)
– Serum inorganic phosphate: 2.5 mg/dL(3-4.5 mg/dL)
– Urine calcium: 420 mg/24 hr(100-300 mg/24hr)
– Urine phosphate: 2.0 g/24 hrs (0.4-1.3 g/24 hrs)
– What do these results suggest?
• A. Primary hyperparathyroidism
• B. Vitamin D deficiency
• C. Hypoparathyroidism
• D. Paget disease
• Primary hyperparathyroidism causes PTH to be produced without the
stimulus of the parathyroid by a decreased Calcium level
– Usually caused by a single adenoma
• PTH: Parathyroid Hormone is stimulated by decreased calcium ion
– Increased PTH = Increased Ca and Vit D3, and decreased PO4
– PTH causes kidneys to decrease reabsorption of PO4 and increase
renal synthesis of Vit D3
• Diagnosis of PHPT: ↑Ca with ↓PO4, ↑ ↑Urine Ca
• Vit. D Deficiency
– ↓Ca absorption from GI
– Synthesized by skin with sun exposure
– Mineralization of bone and abnormal bone formation
• Hypoparathyroidism
– ↓Ca, ↓PTH
– Most common after thyroidectomy, also seen due to autoimmune
destruction
– Treat with Ca and Vit. D
• Paget Disease
– Bone lose Ca, it is not recycled
– Show ↑ALP
– Bones generate faster than normal producintg soft weak bones that
are fragile and misshapen
– Common in pelvis, skull, spine and legs
 Case Study #8
• A patient’s serum inorganic phosphate level is found to be elevated but
the physician cannot determine a physiological basis for this abnormal
result. What could possibly have caused an erroneous result to be
reported?
– A. Patient not fasting when blood was drawn
– B. Specimen was hemolyzed
– C. Effect of diurnal variation
– D. Patient receiving intravenous glucose therapy
• PO4 is a major intracellular anion
• Hemolysis should be avoided
– Components affected by hemolysis
• Increases
– Ammonia, Total protein, iron, phosphate, potassium,
magnesium, ALT, AST, CK, LD, ALP, ACP, Cholesterol,
Triglyceride, catecholamines
• Decreases
– Albumin, bilirubin, sodium,
• Remove from clot ASAP to avoid leakage of PO4 into serum
• Decreased PO4 levels seen
– Following meals, menstrual period, IV glucose and fructose therapy
 Case Study #9
• A 30-year old woman is admitted to the hospital. She has truncal obesity,
buffalo humpback, moon face, purple striae, hypertension, hyperglycemia,
increased facial hair, acne, and amenorrhea. The physician orders
endocrine testing. The results are
– Urine free cortisol: increased
– Serum cortisol (8 a.m.) Increased
– Plasma ACTH: decreased
– Dexamethasone suppression test:
• Overnight low dose: no suppression of serum cortisol
• High dose: no suppression of serum cortisol
– What is the most probable diagnosis?
• A. Pituitary adenoma
• B. Ectopic ACTH lung cancer
• C. Adrenocortical carcinoma
• D. Addison disease
• Diagnosis: Cushing’s syndrome by Adrenocortical carcinoma
– Increased urine and serum Cortisol
– Decreased ACTH due to negative feedback of cortisol
• ACTH: stimulates synthesis of glucocorticoid compounds (cortisol) by
adrenal cortex
• Normal secretion of cortisol follows a diurnal pattern
– Carcinoma produces excess cortisol that Dexamethasone cannot suppress
– Physical symptoms: moon face, truncal obesity with buffalo hump, occasional
hirsutism
• Be careful!! There is a Cushing’s syndrome by adrenocortical carcinoma and a
Cushing’s syndrome by pituitary (Cushing’s disease). Both show increased cortisol,
but pituitary will also have increased ACTH
• Other choices
– Pituitary adenoma or ectopic ACTH lung cancer
• Increased ACTH levels
– Addison’s
• Hypofunction of adrenal cortex
 Case Study #10
• In a patient with suspected primary hyperthyroidism associated with
Graves disease, one would expect the following laboratory serum results:
• (use increased and decreased)
• Free thyroxine (FT4) Increased
_______ , thyroid hormone binding ratio (THBR)
__ ______and thyroid-stimulating hormone (TSH) ____________
Increased Decreased
• Graves disease
– Hyperactive thyroid producing thyrotoxicosis
• Thyrotoxicosis is a term used to describe
a condition that occurs when excessive amounts of thyroid
hormones in circulation affect peripheral tissue.
– FT4 & FT3 are increased
– THBR is increased due to increased T3 binding to TBG
– TSH is decreased because normal feedback mechanism is
working
– Occurs more often in women, typical onset 30-50 yrs of age
– Does not respond to normal feedback mechanism of T4 so
thyroid continues to produce hormones
 Case Study #11
• A mother brings her obese 4-year old child who is a known type 1 diabetic
to the laboratory for a blood work up. She states that the boy has been
fasting for the past 12 hours. After centrifugation the tech notes that the
serum looks turbid. The specimen had the following results
– Blood glucose: 150 mg/dL (70-100 mg/dL)
– Total cholesterol: 250 g/dL (150-199 mg/dL)
– HDL cholesterol: 32 mg/dL (>40 mg/dL)
– Triglyceride: 395 mg/dL (<250 mg/dL)
• what best explains these findings?
– A. Is a low risk for coronary artery disease
– B. Is a good candidate for a 3-hour oral glucose tolerance test
– C. Has secondary hyperlipidemia due to the diabetes
– D. Was not fasting when the specimen was drawn
• Fits description of secondary hyperlipidemia
– Secondary to Diabetes mellitus
• Hyperlipidemia prevalent in childhood
– Inability to utilize glucose causes release of fatty acids
• Known diabetics should NEVER undergo 3hr OGTT
• High risk for CAD
 Case Study #12
• A 46-year old known alcoholic with liver damage is brought into the
emergency department unconscious. In what way would you expect his
plasma lipid values to be affected?

– A. Increased total cholesterol, triglyceride, LDL and VLDL

– B. Increased total cholesterol and triglyceride, decreased LDL and
VLDL
– C. Decreased total cholesterol, triglyceride, LD and VLDL
– D. Normal lipid metabolism, unaffected by the alcoholism
• Liver damage due to alcohol use can make it inefficient in metabolizing
fats.
– Increase in total cholesterol, triglycerides, LDL and/or VLDL in blood
– Poor prognosis for the patient
• Liver is unable to oxidize the fatty acids (β-oxidation) to acetyl Co A due to
the lack of NAD. This causes a build up of fat in the liver.
• NAD is used to metabolize alcohol so it is not available for β-oxidation
 Case Study #13
• A healthy active 10-year old boy with no prior history of illness comes to
the lab after school for a routine chemistry screen in order to meet
requirements for summer camp. After centrifugation, the serum looks
cloudy. The specimen had the following results
– Blood glucose: 135 mg/dL (70-100 mg/dL)
– Total cholesterol: 195 mg/dL ((150-199 mg/dL)
– Triglyceride: 185 mg/dL (<250 mg/dL)
• What would be the most probable explanation
– A. Risk for coronary artery disease
– B. Has Type 1 Diabetes mellitus that is undiagnosed
– C. Has an inherited genetic disease causing lipid imbalance
– D. Was most likely not fasting when the specimen was drawn
• This is a 10 year-old healthy child. He is probably not suffering from any
lipid disorder or glucose disorder.
– Lipids were within high normal range
– Glucose was elevated, but if from a non-fasting (random) specimen
was within an acceptable range
• Should never be >200 mg/dL
• Since he came directly from school, he was probably not fasting.
 Case study #14
• A 54-year old male, with a history of Type 2 diabetes mellitus for the past
8 years is seen by his family physician. The patient indicates that during
the past week he had experienced what he described as feeling
lightheaded and faint. He also indicated that he became out of breath and
had experienced mild chest pain when doing heavy yard work, but the
chest pain subsided when he sat down and rested. The physician
performed an ECG immediately, which was normal, and he ordered blood
tests. The patient fasted overnight and had blood drawn the next
morning. The laboratory test values follow:
Test Patient Values Reference Ranges
Glucose (fasting) 175 mg/dL 74-99 mg/dL
Hemoglobin A1c 8.1% 4-6%
Total cholesterol 272 mg/dL <200 mg/dL
HDL cholesterol 30 mg/dL >40 mg/dL
LDL cholesterol 102 mg/dL <130 mg/dL
Triglyceride 250 mg/dL <150 mg/dL
Hs-CRP 6.2 mg/L 0.3-8.6 mg/L
<1.0 mg/L low risk

Based on the patient’s test results, history and symptoms, which of the laboratory
value(s) in the chart do not support the patient’s diagnosis?
a. LDL cholesterol
b. HDL cholesterol
c. Hemoglobin A1c
d. Hs-CRP
• Likely diagnosis is Angina Pectoris
– Chest pain due to ischemia of the heart muscle
• Lipoproteins and lipids
– Chylomicrons: TG & cholesterol VLDL: TG & cholesterol
– IDL: TG, Cholesterol, Phospholipids LDL: Cholesterol & phospholipids
– HDL: Protein & phospholipids
• LDL does not correlate, it is lower than expected.
𝑇𝑟𝑖𝑔
– Calculated LDL = TC –[HDL + 5 ]= 192 mg/dL
• HDL and TG correlate indicating hyperlipidemia
• Increased FBG = poor CHO metabolism
• Increased A1c = lack of glucose control
• Increased CAD risk supported by
– Increased FBG, Lipids, hs-CRP
– High risk range for hs-CRP: >30 mg/L
 Case Study #15
• Laboratory tests are performed on a postmenopausal, 57-year old female
as part of an annual physical examination. The patient’s casual plasma
glucose is 220 mg/dL, and the glycated hemoglobin (HbA1c) is 11%. Based
on this information, how should the patient be classified?
– A. Normal glucose tolerance
– B. Impaired glucose tolerance
– C. Gestational diabetes mellitus
– D. Type 2 diabetes mellitus
• “Normal” random glucose should be <200 mg/dL
• HbA1c reference range is 4-6%
• Probable diagnosis is Type 2 Diabetes mellitus.
– In absence of any hyperglycemic symptoms, the glucose and HbA1c
should be repeated on another day, using a fasting sample
Classification Lab value
Hypoglycemia FBG < 40mg/dL
Normal fasting glucose FPG < 100 mg/dL
Normal Glucose Tolerance 2hr PG <140 mg/dL
Increased risk for diabetes A1C = 5.7-6.1%
Impaired fasting glucose FPG >100 mg/dl < 125 mg/dL
Impaired glucose tolerance 2hr PG >140 mg/dL <199
mg/dL
Diabetes mellitus Random glucose
> 200 mg/dL with
hyperglycemic symptoms
OGTT > 200 mg/dL
 Case Study #16
• A 30 year-old pregnant woman has a gestational diabetes mellitus
screening test performed at 26 weeks of gestation. Her physician chooses
to order a 50-g oral glucose load. Her serum glucose level is 150 mg/dL at
1 hour.
• What should occur next?
• A. This confirms diabetes mellitus; give insulin
• B. This confirms diabetes mellitus; dietary intake of CHO should be
lessened
• C This is suspicious of diabetes mellitus; an oral glucose tolerance test
should be performed
• D. This is an expected glucose level in a pregnant woman
• Screening test for GDM
– 1 hr glucose after 50g glucose load (glucose challenge)
– If glucose is >140 mg/dL, then perform OGTT
• Increased insulin resistance is common in late 2nd and 3rd trimesters
– Most women compensate with increased insulin production
• GDM: cannot make enough insulin to compensate so glucose increases
 Case Study # 17
• The physician determined that the patient needed an oral glucose
tolerance test (OGTT) to assist in diagnosis. The patient had blood drawn
for the OGTT, and the following serum glucose results were obtained.
These results are indicative of what state?
– Fasting serum glucose: 124 mg/dL
– 2 hrpp serum glucose: 227 mg/dL
• A. Normal
• B. Diabetes mellitus
• C. Addison disease
• D. Hyperinsulinism
• Criteria for diagnosis of DM
– Classical symptoms of hyperglycemia
– Random glucose >200 mg/dL
– FBG >126 mg/dL
– HbA1c > 6.5%
– 2hrpp (part of OGTT) >200 mg/dL
– Repeat test on subsequent day to confirm
 Case Study #18
• A 23-year old woman with a history of asthma was brought to the
emergency department by ambulance. She was extremely short of
breath. Her level of consciousness was diminished greatly, and she was
only able to respond to questions with nods or one word responses. She
had a weak cough, with nearly inaudible breath sounds. After drawing
blood gases, she was placed on supplemental oxygen.
 Arterial Blood gases
Patient Reference Range
pH 7.330 7.35-7.45
pCO2 25 mm Hg 35-45 mmHg
pO2 58 mmHg 80-110 mm Hg
HCO3- 13 mmol/L 22-26 mmol/L
tHb 12.4 g/L 12-16 g/dL
• What is this patient’s acid-base status?
– A. Uncompensated respiratory acidosis
– B. Compensated metabolic acidosis
– C. Partially compensated metabolic acidosis
• Uncompensated: initial parameter and pH are affected
• Partially compensated: all parameters are increased or
decreased
• Fully compensated :pH is back to normal, but pH is only
parameter in the normal range
• Respiratory: pCO2 parameter initially affected
• Metabolic: HCO3- parameter initially affected
 Case Study # 19
• An 80 year old man with a history of chronic obstructive pulmonary
disease (COPD) and respiratory infections, was admitted through the ER
with a chronic cough and extreme dyspnea (extreme respiratory distress).
He complained that he was unable to climb stairs or anything else that
required any exertion (even washing his hair). He had been a heavy
smoker but had been attempting to stop smoking by cutting back on the
number of cigarettes per day. The nurse noted his temperature was
101.2oF.
Arterial Blood Gas on Admission
Patient Reference Range
pH 7.230 7.35-7.45
PCO2 75.0 mmHg 35-45 mmHg
PO2 28.2 mmHg 83-108 mmHg
HCO3 32.7 mEq/L 22-28 mEq/L
SaO2 49.6 % 95-98%
• What condition does this patient have?
– A. Compensated respiratory acidosis
– B. Uncompensated respiratory acidosis
– C. Partially Compensated respiratory acidosis
– D. Compensated metabolic acidosis
– E. Uncompensated metabolic acidosis
– F. Partially Compensated metabolic acidosis

– Patient is in acidosis shown by the pH being lower (more acidic) than

normal.
– Respiratory acidosis is characterized by decreased pH, increased pCO2, and
normal HCO3- (if compensated)
• Primary compensatory mechanism is to increase HCO3-
• Kidney provides primary compensatory mechanism: increase
excretion of acids, retain sodium and bicarbonate, increase production
of renal ammonia
• Hyperventilation may occur if lungs are working properly: increase
PCO2
– Metabolic acidosis is characterized by decreased pH and HCO3- and normal
PCO2
• Six hours later, the patient had ABGs drawn with the following results
ABG Results 6 hours postadmission
pH 7.38 7.35-7.45
pCO2 60.0 mmHg 35-45 mmHg
PO2 78.2 mmHg 83-108 mmHg
HCO3- 36.2mEq/L 22-28 mEq/L
SaO2 90.6 % 95-98%

• The patient’s status is now

– A. Compensated respiratory acidosis
– B. Uncompensated respiratory acidosis
– C. Compensated metabolic acidosis
– D. Uncompensated metabolic acidosis
 Respiratory Metabolic
Acidosis Alkalosis

Normal PCO2
Metabolic Respiratory
Acidosis Alkalosis

Normal pH

This chart only works when compensation is not a consideration

 Case Study # 20
• A 37 year old man was admitted to the emergency department. He was
short of breath, dizzy, flushed (hyperemic), sweating (diaphoretic), and
nauseous. Shortly after being admitted, blood gases were drawn

Arterial Blood Gases

Patient Reference Range

pH 7.48 7.35-7.45

pCO2 32 mmHg 35-45 mmHg

pO2 96 mmHg 80-110 mmHg

HCO3- 24 mmol/L 22-26

SO2 98% >95%

• What is the acid base status of this man?
– A. Compensated respiratory acidosis
– B. Uncompensated respiratory acidosis
– C. Partially Compensated respiratory acidosis
– D. Compensated metabolic acidosis
– E. Uncompensated metabolic acidosis
– F. Partially Compensated metabolic acidosis
– G. Compensated respiratory alkalosis
– H. Uncompensated respiratory alkalosis
– I. Partially Compensated respiratory alkalosis
– J. Compensated metabolic alkalosis
– K. Uncompensated metabolic alkalosis
– L. Partially Compensated metabolic alkalosis
 Case Study # 21
• Which of the following disorders is best characterized by laboratory
findings that include increased serum levels of inorganic phosphorus,
magnesium, potassium, uric acid, urea and creatinine and decreased
serum calcium and erythropoietin levels?
– A. Chronic renal failure
– B. Renal tubular disease
– C. Nephrotic syndrome
– D. Acute glomerulonephritis
• Acute glomerulonephritis
– Urine will show blood, protein and RBC casts
– May be seem post Strep. Infection
– Increase in BUN but will return to normal
• Nephrotic syndrome
– Increase in lipids, decrease in serum albumin and large increase in
urine protein
• Renal Tubular disease
– Override of tubular reabsorption
• CRF
– loss of excretory function of the kidneys
– Inability to regulate water and electrolyte balance
– Increase in parathyroid hormone (PTH)
– Decrease in erythropoietin will cause anemia to develop
 Glucose, Amino Acids, Salts,
Chloride, Sodium

H2O

Sodium
H2O, urea

urea

H2O
 Case Study # 22
• Androgens
– Testosterone (principal and most biologically active)
– Dihydrotestosterone (DHT)
– Dehydroepiandosterone (DHEA)
– Androstenediol
• Testosterone
– Produced in Leydig cells of testes (95%)
• Also produced in Adrenal Cortex (controlled by ACTH) and Ovaries
– 1. Females
• 5-10% level of males
• Precursor to estrogen production
• No clinical significance to decreased levels except to decrease
estrogen level
• Excess causes disruption of menstrual cycle, and excess facial and
body hair
– Males
• Rarely in excess
• Decreased levels: decrease libido, potency and infertility
• Produced by fetus (XY) in first trimester. Then decreases until child
reaches about 12 years old
• Low level due to negative feedback
– Hypothalamus  GNRH  adenohypophysis  FSH and LH
– LH: stimulate Leydig to secrete testosterone
– FSH: enhance LH by increasing receptor on Leydig cells
– Testosterone suppresses LH
– At puberty hypothalamus changes sensitivity level and increases
testosterone production.
• Puberty change originates in CNS
• Female
– Hormones primarily produced by ovaries
– Estrogen: sex characteristics
– Progesterone: prep of uterus for pregnancy and breast for lactation
– 1. Estrogens
• Primarily produced by ovarian follicles
– Small amount by testes and adrenal cortex
• Estradiol (most potent), Estrone, Estriol
• Pre-puberty: like testosterone, neg feedback keeps level low
• Puberty: Hypothalamus resets sensitivity causing increase in FSH
• FSH stimulates ovary causing increase in estrogen
– 2. Progesterone
• Regulates organs involved in menstruation
• Secreted by corpus luteum in non-pregnant females
• Production regulated by LH
• Increases throughout pregnancy
• Reproductive Cycle
– Menstrual (Ovarian) & Estrous (Uterine)
– 1. Menstrual (20-50 days)
• A. FSH increases causing follicle
to mature
– Follicle produces estradiol
» Positive feedback: As
matures produces more
estradiol which causes it
to grow producing more
estradiol
– Eventually FSH decreases, but
follicle is large enough to produce estradiol on its own
• B. LH spikes prior to ovulation
– Follicles start producing progesterone and some estradiol
– Follicle ruptures releasing ovum: ovulation
 – Increase in prolactin
• Increased production progesterone
– Day 21 Corpus luteum functions to keep progesterone and estradiol
increasing
• Uterine
– Ovum implants 2-5 days post fertilization
– If not fertilized, CL regresses causing vasoconstriction and vasodilation
in endometrial tissue (menstruation)
– If fertilized, CL produces estradiol and progesterone
– HCG: signal hormone, tells ovaries that uterus is pregnant
– End of 2nd trimester, placenta produces progesterone and estradiol
• Birth (Parturition)
– Stretching of uterus and head pressing on cervix stimulates production
of oxytocin (neurohyphophosis)
• Causes contraction of myometrium
– Estrogens increase irritability of myometrium
– Progesterone decreases irritability of myometrium
– Immediately prior to birth, progesterone decreases allowing estrogen
to trigger parturition
• Great Review Website for Reproductive hormones
• http://webmedia.unmc.edu/alliedhealth/CLS/CLS415%2010/Reproductive
%20Hormones%20Handout.pdf
 Case Study #23
• A male patient, 48 years old, was brought into the ED with multiple
gunshot wounds. Following 22 hours of surgery, he was admitted to the
SICU in critical condition. Forty-eight hours post-surgery, he has become
comatose. The surgeon believes the coma is due to hepatic failure. What
assay would be most helpful in this diagnosis?
– A. Ammonia
– B. ALT
– C. AST
– D. GGT
• AST
– Markedly elevated in hepatocellular disease
• ALT
– Markedly increased in hepatocellular disorders that are viral
• Ammonia
– Increased due to inability of liver to convert to Urea
– Elevated in advanced liver disease and renal failure
– Can be toxic to patient causing seizures and coma
• GGT (0-30 U/L)
– Marked elevation (5-30x normal) in hepatic obstruction
– ALP + GGT increased = Liver
 Case Study #24
• A black male, 62-years of age, is admitted in a semiconscious state
experiencing shortness of breath and a temperature of 100oF. His skin is
pale and cool, and he has been experiencing severe pain in his back and
jaw for approximately 75 minutes. He experienced these same symptoms
2 days earlier. The laboratory data shows the following:
– Total CK: 240 U/L (30-170 U/L) CK-MB: 22 ng/mL (0-5 ng/mL)
– Myoglobin: 140 ng/mL (30-90 mg/mL) cTnI: 1.8 (0-0.5 ng/dL)
– What is the most likely diagnosis for this patient?
• A. Pulmonary infarction
• B. Acute myocardial infarction
• C. Muscular dystrophy
• D. Angina pectoris
 Case Study #25
• If a patient has AST and ALT serum levels increased 50x normal, what
would be the most consistent diagnosis?
– A. Extrahepatic cholestasis
– B. Cirrhosis
– C. Carcinoma of the liver
– D. Viral hepatitis
 Case Study #26
• The following results were obtained on a pregnant female patient
following the ingestion of 75 g of glucose as part of an oral glucose
tolerance test
Time specimen collected Plasma Glucose
Fasting 124 mg/dL
1 hour 220 mg/dL
2 hour 170 mg/dL

• Based on the test results, what would be the most likely diagnosis?
– A. Normal glucose metabolism
– B. Diabetes mellitus
– C. Gestational diabetes mellitus
– D. Impaired glucose tolerance
 Case Study #27
• An 8-year old boy comes to see his family physician with his mother. He has
been urinating excessively and also has been drinking an excessive quantity of
water. He recently recovered from an upper respiratory viral infection and has
lost weight since his last visit. The following lab results were reported
Blood Urinalysis
FBG 300 mg/dL Sp gravity 1.025
WBC count 15 x 109/L Glucose 550 mg/dL
Hemoglobin 14.0 g/dL Ketones Moderate
• What lab test should be ordered to aid in the diagnosis of this patient?
– A. 3-hr OGTT
– B. β-cell autoantibodies
– C. 2-hr PP glucose
– D. Liver profile
• 3-hr OGTT: Blood sugar of 300 mg/dL does not warrant an OGTT
• 2hr PP: patient is already showing inability to handle glucose
• Marker of autoimmune destruction of β-cells
– 1. Islet cell autoantibody (ICA): Most common (75-85%)
– 2. Insulin autoantibody (IAA): present in children with type 1 under 5
years of age
– 3. autoantibody to glutamic acid decarboxylase (GAD65)
• Approx. 60% of new cases
• Identify who will progress to type 1 in approx. 10 years
– 4. Insulinoma associated antigens
• IA-2 and IA-2B
• Against tyrosine phosphate, secondary messenger in insulin-
receptor reaction
 Case Study #28
• A 60-year old female was seen in her physicians office for a routine
physical. She has no family history of CHD, reportedly smokes only when
she is stressed and walks three times a week. The following are the
results of her lab work.
– Cholesterol 220 mg/dL
– Triglycerides 85 mg/dL
– HDL 65 mg/dL
– Glucose 85 mg/dL
• Based on these results what do you think the physician’s plan of action for
this patient should be?
– A. Prescribe a low dosage of Lipitor
– B. The physician asked the patient to have her blood drawn again,
suspecting this specimen was not a fasting specimen
– C. Recommend that she decrease her fat intake and increase her fiber
intake
– D. Suggest that she go home, enjoy her life and he would see her
again next year.
 Case Study #29
• The following results were obtained on a 73 year old male
– ALP 431 U/L
– ACP 5 U/L
– GGT 13 U/L
• Which of the following is indicated by the laboratory data?
• A. Prostatic cancer
• B. Bone disease
• C. Liver cancer
• D. Hemolysis
• ALP increases with bone disease due to the increase in osteoblasts.
– Ex: Paget’s Disease
 Case Study #30
• A 10 year old female visits her pediatrician with complaint of bone pain.
Following enzyme studies the following results were obtained
– ALP 450 U/L
– NTP 8 U/L
– GGT 19 U/L
• What diagnosis is consistent with these results?
• A. Hepatobiliary disease
• B. Normal bone growth
• C. Viral hepatitis
• D. Cirrhosis of the liver

• Increased ALP and normal GGT and 5’NT  R/O hepatobiliary, so

probably bone related. ALP is increased in any type of bone building
 Case Study #31
• A 2-year-old child with a decreased serum T4 is described as being
somewhat dwarfed, stocky, overweight, and having coarse features. Of
the following, the most informative additional laboratory test would be
the serum:
– A. Thyroxine-binding globulin (TBG)
– B. Thyroid-stimulating hormone (TSH)
– C. Triiodothyronine (T3)
– D. Thyroid –regulating hormone (TRH)
• TRH
– Produced by hypothalamus in response to need
for T3 and T4 in the blood stream
• Stress, temperature, low levels
• TSH
– Pituitary hormone that stimulates the thyroid
to secrete thyroid hormone
• T4
– Prohormone
– Almost 100% found bound to protein (TBG, TBPA,
Albumin)
• T3
– Most potent of thyroid hormones, Secreted in lesser amounts than T4
– 20% from direct secretion, 80% from removal of iodine from T4
• Occurs mainly in liver and kidney
• TBG
– Binds most of T4 and majority of T3
– Provides constant supply of thyroid hormone (acts as reservoir)
 Case Study # 32
• A 54-year old female arrived at her physician’s office with
complaints of lethargy, excessive thirst and diminished appetite.
The lab results indicate a calcium value of 12.0 mg/dL, albumin <1.0
g/dL, total protein 10.9 g/dL, globulins ***, and increased BUN and
Creatinine. What is her most probable diagnosis?
– A. Multiple Myeloma
– B. Dehydration
– C. Primary hyperparathyroidism
– D. Congestive Heart Failure

70
• Multiple Myeloma
– Common in people over 60 yrs old
– Increase in one immunoglobulin (IgG or IgA) with decrease in all
other proteins. May see Bence Jones proteins in urine, Increase
in calcium due to bone lesions
• Dehydration
– Increase in proteins is relative to water loss through vascular
system
• Primary hyperparathyroidism
– Most common cause of increased calcium
– Over production of PTH due to adenoma parathyroid gland
• Congestive Heart Failure
– Leading cause of hospitalization in 65yrs and older
– Key test is BNP, indicates sustained stretch
– Increased blood volume would have decreased total protein
 Case Study #33
• A 55 year old female reported for her annual physical examination
and had comprehensive blood work drawn. On the examination,
the physician noted that she had the beginning of Osteopenia. Her
lab work revealed a low normal ionized calcium, normal
electrolytes, glucose, BUN and creatinine.
• What therapies would be suggested?
– A. Calcium supplements
– B. Calcium and vitamin D supplements
– C. Calcium and phosphorus supplements
– D. No therapy is required

72
• Osteopenia:
– Decreased bone mass due to imbalance between bone
resorption and formation
• Osteoporosis:
– Most prevalent metabolic bone disease in adults, more
common in women causing skeletal fragility
– Decreased bone density measured using spine and hip
• Best to prevent with adequate nutrition including calcium and
vitamin D and exercise

73
 Case Study #34
• A 21 year old male went to his physician with complaints of tender
joints following a weekend trip to the beach. His lab results follow,

• Which result(s) are concerning?

– A. Globulin
– B. BUN:Creat
– C. Cholesterol
– D. Sodium
 Chemistry CBC
• GLU 112 74-143 mg/dL • RBC 8.29 5.65-8.87 M/μL
• BUN 13 7-27 md/dL • HCT 53.5 37.3-61.7%
• CREA 1.5 0.5-1.8 mg/dL • HGB 19.3 13.1-20.5 g/dL
• TP 7.8 5.2-8.2 g/dL • MCV 64.5 61.6-73.5 fL
• ALB 3.2 2.3-4.0 g/dL • MCH 23.3 21.2-25.9 pg
• GLOB 4.6 * 2.5-4.5 g/dL • MCHC 36.1 32.0-37.9 g/dL
• TBIL 0.3 0.0-0.9 mg/dL • RDW 19.4 13.6-21.7 %
• CHOL 211 110-320 mg/dL • WBC 9.68 5.05-16.76 K/μL
• Na >180 * 144-160 mmol/L • PLT 190 148-484 K/μL
• K 4.8 3.5-5.8 mmol/L • MPV 12.3 8.7-13.2 fL
• CL 119 109-122 mmol/L
• Globulins
– Increased to 4.6 g/dL with a normal total protein
– Increase in liver disease, infections, myeloma, parasitic disease and
rheumatic disorders
• BUN:Creatinine ratio is 9:1 (Normal 10:1-20:1)
– Pre-Renal: Increase BUN normal Creatinine; increased BUN:Creat
– Renal: Low BUN:Creat, associated with low protein intake, acute
tubular necrosis, severe liver disease
– Post-Renal: Elevated BUN and Creatinine; increased BUN:Creat
• Cholesterol (Normal 140-200 mg/dL), May not be fasting
• Sodium
– Hypernatremia: Excessive water loss relative to sodium loss
• Can be caused by any condition where there is an increase in
water loss: Fever, burns, diarrhea, heat exposure
– Evaluate with osmolality (increased)
– >160 mmol/L associated with 60-75% mortality rate
76
• Osmolality
– Measure of dissolved solutes in a solution
– Use osmotically active substances: Na,
BUN, Glucose
– Two equations
𝑚𝑔 𝑚𝑔
𝑔𝑙𝑢𝑐𝑜𝑠𝑒 ( 𝑑𝐿 ) 𝐵𝑈𝑁 ( 𝑑𝐿 )
– 2 Na + +
20 3
𝑚𝑔
𝑔𝑙𝑢𝑐𝑜𝑠𝑒 ( 𝑑𝐿 ) 𝐵𝑈𝑁
– 1.86 Na + + +9
18 2.8
– Osmolality= 355-370 mOsmol
 Case Study #35
• A 52 year old man came to the ED following his last chemotherapy
session. To celebrate the last chemotherapy he had gone out to
dinner and had all of his favorite foods. He was now feeling
nauseous, weak and dizzy.
• The physician ordered a chemistry panel and CBC
• What is the probable diagnosis?
– A. Anemia
– B. Metabolic Acidosis
– C. Hepatic biliary obstruction
– D. Uremia
– E. Celebration
 Chemistry CBC
• Na 139 136-145 mEq/L
• WBC 15.0 5-10 x 109/L
• K 4.2 3.6-5.0 mEq/L
• RBC 5.04 5-6 x 1012/L
• Cl 104 101-111 mEq/L
• Hb 15.3 135-175 g/L
• CO2 27.0 24.0-34.0 mEq/L
• Hct 0.4 0.41-0.53 L/L
• Glu 100 80-120 mg/dL
• MCV 92 80-100 fL
• TBIL 0.3 0.2-1.2 mg/dL
• MCH 29 26-34 pg
• Tpro 6.5 6.0-8.4 g/dL
• MCHC 33 31-37 %
• BUN 20 7-24 mg/dL
• Plts 240 150-400 x 109/L
• Creat 0.9 0.5-1.2 mg/dL
• Uric Acid 11.5 3.5-5.2 mg/dL
• Alb 3.6 3.5-5.0 g/dL
• Anemia
– Normal RBC, Hemoglobin and hematocrit
– Watch the units!
• Metabolic acidosis
– Decrease in pH not noted, CO2 normal (bicarbonate)
– Bicarb and CO2
• Obstruction
– Liver enzymes: AST and ALP are normal
• Uremia
– DNA = Increased uric acid
– Chemo caused increased uric acid
– Urea cycle purines
– Gout
• What foods may have contributed to the increased uric acid?
• Renal complications?
• Content of single high protein meal has minimal effect on urea, so fasting
is not required
• Urea used by bacteria so important to be sure to test urine asap
• Increased urea is azotemia
– Uremia is where there is highly increased plasma urea with renal
failure. Eventually this is fatal if not treated by dialysis or transplant.
• Conditions causing increased plasma urea
– Prerenal: Reduced renal blood flow
– Renal: Decreased renal function, compromised urea excretion
– Postrenal: obstruction
• BUN:Creat ratio
– Difference caused by abnormal urea concentration
– Normal 10:1-20:1

81
Urinalysis Review
 Case Study #1
– An 85 year old woman with diabetes and a broken hip has been
confined to bed for the past 3 months. Results of an ancillary blood
glucose test are 250 mg/dL, and her physician orders additional blood
tests and a routine urinalysis. The urinalysis report is as follows
– Color: Pale Yellow Ketones: Negative
– Clarity: Hazy Blood: Moderate
– Sp Gravity: 1.020 Bilirubin: Negative
– pH: 5.5 Urobilinogen: Normal
– Protein: Trace Nitrite: Negative
– Glucose: 100 mg/dL Leukocytes: 2+
• What confirmatory tests are indicated on this urine?
– Microscopic examination due to hazy appearance and leukocytes
• Microscopic

• 20-25 WBC/hpf, Many yeast and hyphae

• Why are yeast infections common in patients with Diabetes mellitus?
– Yeast grows best at low pH and increased glucose
• With a blood glucose level of 250 mg/dL, should glucose be present in the
urine? Why or why not?
– Yes, it exceeds the renal threshold for glucose
• Is there a discrepancy between the negative nitrite and positive leukocyte
esterase results? Explain
– No, yeast does not reduce nitrate to nitrite
• What is the major discrepancy between the chemical and microscopic
results?
– Moderate blood with no RBC’s
• Considering the patient's history what is the most probable cause for the
discrepancy?
– Myoglobin is the cause of the positive RBC. The patient was
bedridden possibly causing muscle destruction
 Case Study #2
• A high-school student is taken to the emergency room with a broken leg
that occurred during a football game. The urinalysis results are as follows
– Color: Dark yellow Ketones: Negative
– Clarity: Hazy Blood: small
– Sp Gravity: 1.030 Bilirubin: Negative
– pH: 5.5 Urobilinogen: Normal
– Protein: Trace Nitrite: Negative
– Glucose: Negative Leukocytes: Negative
• What confirmatory tests should be performed?
– Microscopic examination
• Microscopic

• 0-2 RBC/hpf, 0-3 WBC/hpf, 0-4 hyaline casts/lpf, 0-3 granular casts/hpf,
Few squamous epithelial cells
• Are these results of clinical significance?
– No these are associated with strenuous exercise
• Explain the discrepancy between the chemical and microscopic blood
results
– The positive blood is from hemoglobinuria or myoglobinuria resulting
from participation in a contact sport
• What is the probable cause of the granular casts?
– Dehydration and increased excretion of RTE cell lysosomes
 Case Study #3
• Which of the following crystals would be seen in a urine with pH 5.0?
– Calcium oxalate
– Uric acid
– Amorphous urates
– Sulfonamides
– Calcium carbonate
– Ammonium biurate
 Normal Urine Crystals
• Acid
– Uric acid
– Amorphous urates
– Calcium oxalate
• Can also be seen in neutral and alkaline urine
• Alkaline
– Amorphous phosphates
• Can also be seen in neutral pH
– Calcium phosphate
• Can also be seen in neutral pH
– Triple phosphate
– Ammonium biurate
– Calcium carbonate
 Abnormal Crystals
• Found in Acid urine
• Cystine
• Cholesterol
• Leucine
– Can also be seen in neutral pH
• Tyrosine
– Can also be seen in neutral pH
• Bilirubin
• Sulfonamides
– Can also be seen in neutral pH
• Radiographic dye
• Ampicillin
– Can also be seen in neutral pH
 Case Study #4
• Results of a urinalysis performed on a patient scheduled for gallbladder
surgery are as follows:
– Color: Amber Ketones: Negative
– Clarity: Hazy Blood: Negative
– Sp Gravity: 1.022 Bilirubin: Moderate
– pH: 6.0 Urobilinogen: Negative
– Protein: Negative Nitrite: Negative
– Glucose: Negative Leukocytes: Negative
– What confirmatory test(s) should be performed?
• Ictotest and microscopic
– Explain the correlation between the patient’s scheduled surgery and
the urobilinogen
• Possible biliary-duct obstruction preventing conjugated bilirubin
from entering the intestine
– If blood were drawn from this patient, how might the serum appear?
• Icteric
 Case Study #5
• While performing a routine urinalysis on a specimen collected from a
patient in the urology clinic, the technologist finds a specific gravity
reading that exceeds the 1.035 scale on the refractometer
• If the urinalysis report has a 1+ protein and a negative glucose, what is the
most probable cause of this finding?
– Causes of sp Gravity interference: Radiographic dye, plasma
expanders, high levels of glucose, protein,
• The specific gravity can be corrected by using the equation
– Corrected SpG = SpG – 0.003 (protein g/dL)
– Corrected SpG = SpG – 0.004 (glucose g/dL)
• How could a specific gravity be obtained from this specimen without using
the calculation?
– Use a Reagent strip
 Case Study #6
• Patient complains of back pain with burning during urination
• Urine regent strip: Leu: 1+, Nit: Pos, Uro: neg, Pro: neg, pH: 6.5, Bld: 3+,
SG: 1.020, Ket: neg, Bil: neg, Glu: neg
• What confirmatory tests should you run? Why?
– Microscopic analysis due to positive leukocytes, RBCs and positive
nitrate.
• What would you expect to see on the microscopic?

Does this correlate with the reagent strip

result?
•
Case Study #7
A routine urinalysis arrives from the nursery on a newborn baby. What
tests should you perform?
– Dipstick, Clinitest
• Why did you perform a Clinitest
• Checking for deficiency in the glucose metabolism pathway,
galactosemia
• When the dipstick was done, you received the following results
• Urine dipstick: Leu: neg, Nit: neg, Uro: neg, Pro: neg, pH: 6.5, Bld: neg, SG:
1.010, Ket: neg, Bil: neg, Glu: neg
– Is a Clinitest still indicated?
• When the Clinitest is performed the results show a dark blue color on the
5 drop method. What does this tell you?
– The baby is negative for reducing sugars
 Case Study #8
• When performing a urinalysis, the following urine arrived in the lab.

• What components would you expect to test positive on the reagent strip?
• What is a possible disease causing this color?
• Would this bilirubin be conjugated or unconjugated?
– It must be water soluble to be in the urine so it must be conjugated
bilirubin
 Case Study #9
• It is the end of your shift at the hospital (3:00 p.m.) and a urine arrives
from a doctor’s office marked STAT. The urine was collected at 8:00 a.m.
You know that some of the components will have been affected by the
urine standing for so long before analysis.
• Which components do you expect to be affected?
– Glucose, pH, Bilirubin, RBC, Leukocytes
 Case Study #10
• A urinalysis performed on a 27-year old woman yields the following results
– Sp. Gravity 1.008 pH 5.0
– Protein 2+ Glucose Negative
– Ketones Negative Bilirubin Negative
– Blood 3+ Nitrite Negative
– Leukocytes Positive urobilinogen 0.1 EU/dL
– Microscopic
• WBC/HPF 20-30
• RBC/HPF 30-55
• Casts/LPF Hyaline 5-7; RBC 2-5; Coarse granular 2-3;
• Waxy 1-3
• Moderate Uric acid crystals
• This is most consistent with
– A. yeast infections C. Bacterial cystitis
– B. Pyelonephritis D. glomerulonephritis
• Yeast infection
– Commonly seen in patients with diabetes, immunocompromised and
women with vaginal moniliasis
– Urine will be acidic, glucose +
– True infection should also have WBC. Small numbers will multiply
rapidly if left at RT for extended periods
• Bacterial cystitis
– Inflammation of bladder, UTI
– More often in women and children
• Pyelonephritis
– Infection of renal tubules
– Upper UTI
– Urinary frequency and burning on urination, lower back pain
– Numerous WBC, WBC casts, RBC and bacteria present on microscopic
• Glomerulonephritis
– Inflammatory process affecting the glomerulus
– Will show RBCs, protein and RBC casts in urine
– May occur following strep Group A infection
– Can become chronic and progress to renal failure
• Chronic Renal Failure
– Slow progressive loss of functional nephrons, GFR continually
decreases. Initially healthy nephrons compensate for loss, but
eventually loss is too great
– Azotemia, acid-base imbalance, electrolyte and water imbalance,
hyperphosphatemia, hypocalcemia
– Anemia, bleeding tendencies, hypertension, neurologic dysfunction
– Sp Gravity =1.010, proteinuria, hematuria, numerous casts (waxy,
broad)
• Nephrotic syndrome
– Damage to podocyte barrier in kidney allowing loss of proteins and
lipids
– Massive proteinuria (>3.5 g/day), primarily albumin, High serum lipids
– May be complication of glomerulonephritis
– Microscopic will show free floating fat globules, oval fat bodies.
Increase in RBCs, casts (fatty and waxy)
 Case Study #11
• A 59 year old man is evaluated for back pain. Urine studies (urinalysis by
multiple reagent strip) include:
– Sp. Gravity 1.017 pH 6.5
– Protein Negative Glucose Negative
– Ketones Negative Bilirubin Negative
– Blood Negative Nitrite Negative
– Microscopic: Rare Epithelial Cells
– Urine Protein electrophoresis
• Monoclonal spike in gamma globulin region

– Which of the following statements best explains these results?

• A. The urine protein is falsely negative due to the specific gravity
• B. The urine protein is falsely negative because the method is not
sensitive for Bence Jones protein
• C. The microscopic examination is falsely negative due to the specific
gravity
• D. The electrophoresis is incorrect and should be repeated
 Case Study #12
• A urine sample with a pH of 6.0 produces an abundance of pink sediment
after centrifugation that appears as densely packed yellow-brown granules
under the microscope. The crystals are so dense that no other formed
elements can be evaluated. What is the best course of action?
– A. Request a new urine specimen
– B. Suspend the sediment in pre-warmed saline, then repeat
centrifugation
– C. Acidify a 12-mL aliquot with three drops of glacial acetic acid and
heat to 56 oC for 5 min before centrifuging
– D. Add five drops of 1 N HCl to the sediment and examine.
• Amorphous Urates
– Normal urinary Crystal
– Brick dust or yellow brown color
– Acid urine
– Frequently form in refrigerated specimens
– May dissolve if specimen is warmed
 Case Study #13
• A 2-year old left unattended in the garage for 5 minutes is suspected of
ingesting antifreeze (ethylene glycol). The urinalysis has a pH of 6.0 and is
negative on the chemical examination . Two distinct forms of crystals are
observed in the microscopic examination.
– A. What type of crystals would you expect to be present?
• Calcium Oxalate
– B. What are the two forms of this crystal?
• Monohydrate and dihydrate calcium oxalate
– C. Describe the two forms
• Oval: monohydrate; envelope (X) dihydrate
– D. Which form would you expect to be predominant?
• Monohydrate
 Case Study #14
• A 44 year old man develops a sudden drop in blood pressure
– 1. What reactions need to take place to ensure adequate blood
pressure within the nephron?
• Juxtaglomerular apparatus  Angiotensinogen  Renin 
Angiotensin I  Angiotensin II
– 2. How do these reactions increase blood volume?
• Vasoconstriction, increased sodium reabsorption, and increased
aldosterone to retain sodium
– 3. When blood pressure returns to normal, how does the kidney
respond?
• Production of renin decreases, therefore the actions of the RAAS
system decrease
 Case Study #15
• A worker suspects that he or she will be requested to collect an
unwitnessed urine specimen for drug analysis. He carries a substitute
specimen in his pocket for 2 days before being told to collect his specimen.
Shortly after the worker delivers the specimen to the collector, he is
instructed to collect another specimen
– 1. What test was performed on the specimen to determine possible
specimen manipulation?
• Temperature; the urine would be below body temperature
– 2. If the specimen for drug analysis tests positive, state a possible
defense related to specimen collection and handling that an attorney
might employ
• The specimen tested was not from the defendant
– 3. How can this defense be avoided?
• Chain of custody form
 Case Study #16
• Synovial fluid is analyzed with a polarizing microscope. Strongly
birefringent needles are seen,

• This most likely indicates

– A. Monosodium urate crystals
– B. Calcium pyrophosphate crystals
– C. Corticosteroid crystals
– D. Talc crystals
 Case Study #17

An effusion that forms due to a systemic disorder and disrupts the fluid
balance is called
A. Exudate
B. Transudate
C. Hydrostatic
D. Oncontic
• Exudate
– An effusion produced by conditions that directly involve the
membrane of the cavity
• Infections and malignancies
• Transudate
– An effusion that forms due to a systemic disorder and disrupts fluid
balance.
• Congestive heart failure, hypoproteinemia
• To differentiate between exudate and transudate
– fluid:serum protein and LD ratios
– Transudates will have lower (<0.5,<0.6) ratios
– Once determined to be a transudate, no further testing of fluid is
needed. The cause of the excess fluid will need to be addressed.
• Hydrostatic
– Pressure exerted by a liquid
• Oncontic
– Osmotic pressure of a substance in a solution due to the presence of
colloids (proteins)
 Case Study #18
• Three tubes of CSF containing evenly distributed visible blood are drawn
from a 75-year old disoriented patient and delivered to the laboratory.
Initial test results are as follows:
• WBC Count: 250μL Protein: 150 mg/dL Glucose: 70 mg/dL Gm Stain: no
organisms seen
• What is the probable reason for these test results
– A. Viral meningitis
– B. Bacterial meningitis
– C. Traumatic tap
– D. Cerebral hemorrhage
• WBC (0-5 μL)
– Elevated: viral, bacterial, Tubercular and fungal meningitis
• Glucose (60-70% plasma glucose)
– Decreased: bacterial, fungal, tuberculin meningitis
• Protein (15-45 mg/dL)
– Increased: meningitis, hemorrhage, multiple sclerosis
– Decreased: CSF leakage
 Chemical Examination
• pH Double indicator system-methyl red and bromthymol blue
– Interferences: Run over from adjacent pads

• Protein Protein error of indicators, sensitive to albumin. Acid buffer

keeps pH constant. Tetrabromophenol blue or
tetrachlorophenol, tetrabromosulfonphthalein.
– Interferences: alkaline urine, dye (pyridine), high sp gravity, detergent,

• Glucose Renal threshold of kidney 160-180 mg/dL. Glucose oxidase

reaction, double sequential reaction. End product is
oxidized color chromogen
– Interferences: oxidizing agents, ascorbic acid, high ketones, high sp
gravity
• Ketones Sodium nitroprusside (nitroferricyanide) rxn. Acetoacetic
acid reacts with nitroprusside to produce purple color
– Interferences: dyes
• Blood Reaction between heme (hemoglobin and myoglobin) and
tetramethylbenzidine producing blue green color
– Interferences: Oxidizing agents, high sp Gravity, ascorbic acid

• Bilirubin Diazo rxn. Bilirubin combines with diazo salt in acid

medium producing tan pink color
– Interferences: pyridine, exposure to light, ascorbic acid, high nitrite
concentration

• Urobilinogen Ehrlich’s aldehyde rxn (multistix) urobilinogen reacts with p-

dimethylaminobenzaoldehyde (Erlich’s reagent). Diazo dye
(chemstrip)
– Interferences: porphobilinogen, indican, pigmented urine, high nitrite

• Nitrite Greiss rxn, nitrite reacts with aromatic amine forming

diazonium salt. Salt reacts with tetrahydrobenzoquinolin to
produce pink color. Must occur in acid pH.
– Interferences: non-reducing bacteria (gram +, yeast), inadequate time
between urine and bladder (must be in bladder at least 4
hours), high ascorbic acid, high sp. gravity
• Leukocyte Esterase: LE catalyzes hydrolysis of acid ester on reagent pad
producing aromatic compound and acid. Aromatic
compound combines with diazo salt on the pad producing
purple azodye.
– Interferences: oxidizing agents, nitrofurantoin, high concentration of
glucose, ascorbic acid
• Specific Gravity: Based on change in pKa of polyelectrolyte. Causes
change in pH, indicator bromthymol blue changes color
from blue to green to yellow
– Interferences: High protein
• Clinitest
– Uses glucose’s ability to reduce copper
– CuSO4 + glucose  Cu2O + oxidized substance
(color)
– Benedict’s reaction
– Used to screen for galactosemia
• Sulfosalicytic Acid precipitation Test (SSA)
– Cold precipitation test that reacts equally with all forms of protein
– Must be performed on centrifuged specimen
• Ictotest
– Tablet contains p-nitrobenzene-diazonium-p-toluenesulfonate, SSA,
sodium carbonate and boric acid
– Positive: blue to purple color on mat
• Acetest
– Confirmation of ketones
– Tablet contains sodium nitroprusside, glycine, disodium posphate,
lactose