3920_Ch01_002-026 23/01/14 9:20 AM Page 22

22 Part One | Background

Study Questions
1. In the urinalysis laboratory the primary source in the 8. An acceptable disinfectant for blood and body fluid
chain of infection would be: decontamination is:
A. Patients A. Sodium hydroxide
B. Needlesticks B. Antimicrobial soap
C. Specimens C. Hydrogen peroxide
D. Biohazardous waste D. Sodium hypochlorite

2. The best way to break the chain of infection is: 9. Proper handwashing includes all of the following
except:
A. Hand sanitizing
A. Using warm water
B. Personal protective equipment
B. Rubbing to create a lather
C. Aerosol prevention
C. Rinsing hands in a downward position
D. Decontamination
D. Turning on the water with a paper towel
3. The current routine infection control policy developed
10. Centrifuging an uncapped specimen may produce a
by CDC and followed in all health-care settings is:
biologic hazard in the form of:
A. Universal Precautions
A. Vectors
B. Isolation Precautions
B. Sharps contamination
C. Blood and Body Fluid Precautions
C. Aerosols
D. Standard Precautions D. Specimen contamination
4. An employee who is accidentally exposed to a possible 11. An employee who accidentally spills acid on his arm
blood-borne pathogen should immediately: should immediately:
A. Report to a supervisor A. Neutralize the acid with a base
B. Flush the area with water B. Hold the arm under running water for 15 minutes
C. Clean the area with disinfectant C. Consult the MSDSs
D. Receive HIV prophylaxis D. Wrap the arm in gauze and go to the emergency
5. Personnel in the urinalysis laboratory should wear lab department
coats that: 12. When combining acid and water, ensure that:
A. Do not have buttons A. Acid is added to water
B. Are fluid-resistant B. Water is added to acid
C. Have short sleeves C. They are added simultaneously
D. Have full-length zippers D. Water is slowly added to acid
6. All of the following should be discarded in biohazardous 13. An employee can learn the carcinogenic potential of
waste containers except: potassium chloride by consulting the:
A. Urine specimen containers A. Chemical hygiene plan
B. Towels used for decontamination B. Material safety data sheets
C. Disposable lab coats C. OSHA standards
D. Blood collection tubes D. Urinalysis procedure manual

7. An employer who fails to provide sufficient gloves for 14. Employees should not work with radioisotopes if
the employees may be fined by the: they are:
A. CDC A. Wearing contact lenses
B. NFPA B. Allergic to iodine
C. Sensitive to latex
C. OSHA
D. Pregnant
D. FDA
3920_Ch01_002-026 23/01/14 9:20 AM Page 23
15. All of the following are safe to do when removing the
source of an electric shock except:
A. Pulling the person away from the instrument
B. Turning off the circuit breaker
C. Using a glass container to move the instrument
D. Unplugging the instrument
16. The acronym PASS refers to:
A. Presence of vital chemicals
B. Operation of a fire extinguisher
C. Labeling of hazardous material
D. Presence of radioactive substances
17. The system used by firefighters when a fire occurs in the
laboratory is:
A. MSDS
B. RACE
C. NFPA
D. PASS
18. A class ABC fire extinguisher contains:
A. Sand
B. Water
C. Dry chemicals
D. Acid
19. The first thing to do when a fire is discovered is to:
A. Rescue persons in danger
B. Activate the alarm system
C. Close doors to other areas
D. Extinguish the fire if possible
20. If a red rash is observed after removing gloves, the
employee:
A. May be washing her hands too often
B. May have developed a latex allergy
C. Should apply cortisone cream
D. Should not rub the hands so vigorously
21. Pipetting by mouth is:
A. Acceptable for urine but not serum
B. Not acceptable without proper training
C. Acceptable for reagents but not specimens
D. Not acceptable in the laboratory
22. The NPFA classification symbol contains information on
all of the following except:
A. Fire hazards
B. Biohazards
C. Reactivity
D. Health hazards
Chapter 1 | Safety and Quality Assessment 23
23. The classification of a fire that can be extinguished with
water is:
A. Class A
B. Class B
C. Class C
D. Class D
24. Employers are required to provide free immunization for:
A. HIV
B. HTLV-1
C. HBV
D. HCV
25. A possible physical hazard in the hospital is:
A. Wearing closed-toed shoes
B. Not wearing jewelry
C. Having short hair
D. Running to answer the telephone
26. Quality assessment refers to:
A. Analysis of testing controls
B. Increased productivity
C. Precise control results
D. Quality of specimens and patient care
27. During laboratory accreditation inspections, procedure
manuals are examined for the presence of:
A. Critical values
B. Procedure references
C. Procedures for specimen preservation
D. All of the above
28. As supervisor of the urinalysis laboratory, you have just
adopted a new procedure. You should:
A. Put the package insert in the procedure manual
B. Put a complete, referenced procedure in the manual
C. Notify the microbiology department
D. Put a cost analysis study in the procedure manual
29. Indicate whether each of the following would be consid-
ered a 1) preexamination, 2) examination, or 3) postex-
amination factor by placing the appropriate number in
the blank:
_____ Reagent expiration date
_____ Rejecting a contaminated specimen
_____ Constructing a Levy-Jennings chart
_____ Telephoning a positive Clinitest result on a
newborn
_____ Calibrating the centrifuge
_____ Collecting a timed urine specimen
3920_Ch01_002-026 23/01/14 9:20 AM Page 24
24 Part One | Background
30. The testing of sample from an outside agency and the com-
parison of results with participating laboratories is called:
A. External QC
B. Electronic QC
C. Internal QC
D. Proficiency testing
31. A color change that indicates that a sufficient amount of
patient’s specimen or reagent is added correctly to the
test system would be an example of:
A. External QC
B. Equivalent QC
C. Internal QC
D. Proficiency testing
32. What steps are taken when the results of reagent strip
QC are outside of the stated confidence limits?
A. Check the expiration date of the reagent strip
B. Run a new control
C. Open a new reagent strips container
D. All of the above
Case Studies and Clinical Situations
1. State a possible reason for an accreditation team to
report a deficiency in the following situations:
a. The urine microscopic reporting procedure has
been recently revised.
b. An unusually high number of urine specimens are
being rejected because of improper collection.
c. A key statement is missing from the Clinitest
procedure.
d. Open control bottles in the refrigerator are examined.
2. As the new supervisor of the urinalysis section, you
encounter the following situations. Explain whether
you would accept them or take corrective action.
a. You are told that the supervisor always performs
the CAP proficiency survey.
b. QC is not performed daily on the reagent strips.
c. The urinalysis section is primarily staffed by
personnel assigned to other departments for whom
you have no personnel data.
33. When a new bottle of QC material is opened, what
information is placed on the label?
A. The supervisor’s initials
B. The lot number
C. The date and the laboratory worker’s initials
D. The time the bottle was opened
34. When a control is run, what information is
documented?
A. The lot number
B. Expiration date of the control
C. The test results
D. All of the above
3. The medical technologist was assigned to test 10 urine
specimens chemically. She removed 10 strips from the
container and proceeded with testing. Several patients’
urine indicated a trace positive glucose in the urine.
She then opened a new bottle of reagent dipsticks and
proceeded to perform the QC. The negative control
also tested as a trace positive for glucose. The medical
technologist consulted the supervisor. The supervisor
ran the QC and the results were in the correct range.
After observing the medical technologist’s technique,
the supervisor realized that the medical technologist
was waiting too long to read the glucose results and
therefore reporting erroneous results.
a. What is wrong with this scenario?
b. Who should run the QC for each test? Why?
c. When should controls be run?
d. What do you do when the QC is out of range?
e. When can you report patient results?
3920_Ch01_002-026 23/01/14 9:20 AM Page 25
4. An outpatient urine specimen was delivered to the
laboratory at 0800 and placed on the counter in the
Urinalysis department. The medical laboratory scientist
performed urinalysis on the specimen at 1130. The
following results were abnormal:
Clarity: Cloudy
pH: 9.0
Nitrite: Positive
The patient was a known diabetic; however, the
glucose result was negative.
a. What could be a possible cause for the abnormal
results?
Chapter 1 | Safety and Quality Assessment 25
b. Where would the information concerning what
should have been done with this specimen be
found and the criteria for rejection?
c. What QA procedure may have detected this error?
d. What form will need to be completed for this
scenario?
e. How might this affect this patient’s care?
f. How will the corrected results be documented?
3920_Ch02_027-038 23/01/14 10:08 AM Page 36
36 Part One | Background
PROCEDURE 2-4
Urine Drug Specimen Collection Procedure
1. The collector washes hands and wears gloves.
2. The collector adds bluing agent (dye) to the toilet
water reservoir to prevent an adulterated specimen.
3. The collector eliminates any source of water other
than toilet by taping the toilet lid and faucet handles.
4. The donor provides photo identification or positive
identification from employer representative.
5. The collector completes step 1 of the chain-of-custody
(COC) form and has the donor sign the form.
6. The donor leaves his or her coat, briefcase, and/or
purse outside the collection area to avoid the possibil-
ity of concealed substances contaminating the urine.
7. The donor washes his or her hands and receives a
specimen cup.
8. The collector remains in the restroom but outside the
stall, listening for unauthorized water use, unless a
witnessed collection is requested.
9. The donor hands specimen cup to the collector.
Transfer is documented.
10. The collector checks the urine for abnormal color and
for the required amount (30 to 45 mL).
11. The collector checks that the temperature strip on the
specimen cup reads 32.5°C to 37.7°C. The collector
Log on to
www.fadavis.com/strasinger
for additional content related
to this chapter.
References
1. Herman, JR: Urology: A View Through the Retrospectroscope.
Harper & Row, Hagerstown, MD, 1973.
2. Clinical and Laboratory Standards Institute (formerly NCCLS),
Approved Guideline GP16-A3: Urinalysis and Collection,
Transportation, and Preservation of Urine Specimens; Approved
Guideline—ed 3, CLSI, Wayne, PA, 2009.
Study Questions
1. The average daily output of urine is:
A. 200 mL
B. 500 mL
C. 1200 mL
D. 2500 mL
records the in-range temperature on the COC form
(COC step 2). If the specimen temperature is out of
range or the specimen is suspected of having been
diluted or adulterated, a new specimen must be
collected and a supervisor notified.
12. The specimen must remain in the sight of the donor and
collector at all times.
13. With the donor watching, the collector peels off the
specimen identification strips from the COC form (COC
step 3) and puts them on the capped bottle, covering
both sides of the cap.
14. The donor initials the specimen bottle seals.
15. The date and time are written on the seals.
16. The donor completes step 4 on the COC form.
17. The collector completes step 5 on the COC form.
18. Each time the specimen is handled, transferred,
or placed in storage, every individual must be
identified and the date and purpose of the change
recorded.
19. The collector follows laboratory-specific instructions for
packaging the specimen bottles and laboratory copies of
the COC form.
20. The collector distributes the COC copies to appropriate
personnel.
3. Torora, GJ, and Anagnostakos, NP: Principles of Anatomy
and Physiology, ed 6, Harper & Row, New York, 1990,
p. 51.
4. Becton, Dickinson and Company: BD Vacutainer Urine Products
for collection, storage, and transport of urine specimens. Product
Circular, 2011.
5. Baer, DM: Glucose tolerance test: Tips from the clinical experts.
Medical Laboratory Observer, Sept. 2003.
6. Rous, SN: The Prostate Book. Consumers Union, Mt. Vernon,
NY, 1988.
7. Stevermer, JJ, and Easley, SK: Treatment of prostatitis. Am Fam
Physician 61(10), 2000.
2. An unidentified fluid is received in the laboratory with a
request to determine whether the fluid is urine or another
body fluid. Using routine laboratory tests, what tests
would determine that the fluid is most probably urine?
A. Glucose and ketones
B. Urea and creatinine
C. Uric acid and amino acids
D. Protein and amino acids
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Chapter 2 | Introduction to Urinalysis 37

3. The primary inorganic substance found in urine is: 11. The primary advantage of a first morning specimen over
A. Sodium a random specimen is that it:
B. Phosphate A. Is less contaminated
C. Chloride B. Is more concentrated
D. Calcium C. Is less concentrated
D. Has a higher volume
4. A patient presenting with polyuria, nocturia, polydipsia,
and a low urine specific gravity is exhibiting symptoms of: 12. If a routine urinalysis and a culture are requested on a
A. Diabetes insipidus catheterized specimen, then:
B. Diabetes mellitus A. Two separate containers must be collected
C. Urinary tract infection B. The routine urinalysis is performed first
D. Uremia C. The patient must be recatheterized
D. The culture is performed first
5. A patient with oliguria might progress to having:
13. If a patient fails to discard the first specimen when
A. Nocturia
collecting a timed specimen the:
B. Polyuria
A. Specimen must be recollected
C. Polydipsia
B. Results will be falsely elevated
D. Anuria
C. Results will be falsely decreased
6. All of the following are characteristics of recommended D. Both A and B
urine containers except:
14. The primary cause of unsatisfactory results in an un-
A. A flat bottom preserved routine specimen not tested for 8 hours is:
B. A capacity of 50 mL A. Bacterial growth
C. A snap-on lid B. Glycolysis
D. Are disposable C. Decreased pH
7. Labels for urine containers are: D. Chemical oxidation
A. Attached to the container 15. Prolonged exposure of a preserved urine specimen to
B. Attached to the lid light will cause:
C. Placed on the container prior to collection A. Decreased glucose
D. Not detachable B. Increased cells and casts
8. A urine specimen may be rejected by the laboratory for C. Decreased bilirubin
all of the following reasons except the fact that the: D. Increased bacteria
A. Requisition states the specimen is catheterized 16. Which of the following would be least affected in a
B. Specimen contains toilet paper specimen that has remained unpreserved at room
C. Label and requisition do not match temperature for more than 2 hours?
D. Outside of the container has fecal material A. Urobilinogen
contamination B. Ketones
C. Protein
9. A cloudy specimen received in the laboratory may have
been preserved using: D. Nitrite
A. Boric acid 17. Bacterial growth in an unpreserved specimen will:
B. Chloroform A. Decrease clarity
C. Refrigeration B. Increase bilirubin
D. Formalin C. Decrease pH
10. For general screening the most frequently collected D. Increase glucose
specimen is a: 18. The most sterile specimen collected is a:
A. Random one A. Catheterized
B. First morning B. Midstream clean-catch
C. Midstream clean-catch C. Three-glass
D. Timed D. Suprapubic aspiration
3920_Ch02_027-038 23/01/14 10:08 AM Page 38
38 Part One | Background
19. Which of the following would not be given to a patient
prior to the collection of a midstream clean-catch specimen?
A. Sterile container
B. Iodine cleanser
C. Antiseptic towelette
D. Instructions
Case Studies and Clinical Situations
1. A patient brings a first morning specimen to the
laboratory at 1:00 p.m.
a. How could this affect the urinalysis results?
b. What could the patient say that would make the
specimen satisfactory for testing?
2. A patient collecting a midstream clean-catch specimen
voids immediately into the container.
a. How could this affect the clarity of the specimen?
b. How could this affect the microscopic examination?
3. A patient brings a 24-hour timed specimen to the
laboratory and reports that he or she forgot to collect
a specimen voided during the night.
a. How will this affect the results of a quantitative test
for creatinine?
b. What should the patient be told to do?
4. You receive a urine preservative tube for culture
containing a volume of specimen that is considerably
below the minimum fill line.
a. Could this affect the culture?
b. Why?
20. Urine specimen collection for drug testing requires the
collector to do all of the following except:
A. Inspect the specimen color
B. Perform reagent strip testing
C. Read the specimen temperature
D. Fill out a chain-of-custody form
5. A worker suspects that he or she will be requested to
collect an unwitnessed urine specimen for drug analysis.
He or she carries a substitute specimen in his or her
pocket for 2 days before being told to collect the speci-
men. Shortly after the worker delivers the specimen to
the collector, he or she is instructed to collect another
specimen.
a. What test was performed on the specimen to
determine possible specimen manipulation?
b. How was the specimen in this situation affected?
c. If a specimen for drug analysis tests positive, state a
possible defense related to specimen collection and
handling that an attorney might employ.
d. How can this defense be avoided?
3920_Ch03_039-057 23/01/14 10:10 AM Page 53
HISTORICAL NOTE
Phenolsulfonphthalein Test
Historically, excretion of the dye phenolsulfonphthalein
(PSP) was used to evaluate these functions. Standardiza-
tion and interpretation of PSP results are difficult, how-
ever, because of interference by medications, elevated
waste products in patients’ serum, the necessity to obtain
several very accurately timed urine specimens, and the
possibility of producing anaphylactic shock. Therefore,
the PSP test is not currently performed.
The inability to produce an acid urine in the presence of
metabolic acidosis is called renal tubular acidosis. This condi-
tion may result from impaired tubular secretion of hydrogen
ions associated with the proximal convoluted tubule or defects
in ammonia secretion associated with the distal convoluted
tubule.
Urine pH, titratable acidity, and urinary ammonia meas-
urements can be used to determine the defective function. The
tests can be run simultaneously on either fresh or toluene-
preserved urine specimens collected at 2-hour intervals from
patients who have been primed with an acid load consisting
of oral ammonium chloride. By titrating the amount of free H+
(titratable acidity) and then the total acidity of the specimen,
Study Questions
1. The type of nephron responsible for renal concentration
is the:
A. Cortical
B. Juxtaglomerular
2. The function of the peritubular capillaries is:
A. Reabsorption
B. Filtration
C. Secretion
D. Both A and C
3. Blood flows through the nephron in the following order:
A. Efferent arteriole, peritubular capillaries, vasa recta,
afferent arteriole
B. Peritubular capillaries, afferent arteriole, vasa recta,
efferent arteriole
C. Afferent arteriole, peritubular capillaries, vasa recta,
efferent arteriole
D. Efferent arteriole, vasa recta, peritubular capillaries,
afferent arteriole
Chapter 3 | Renal Function 53
the ammonium concentration can be calculated as the differ-
ence between the titratable acidity and the total acidity.
Log on to
www.fadavis.com/strasinger
for additional content related
to this chapter.
References
1. Berger, A: Renal function and how to assess it. Brit J Med
321:1444, 2000.
2. Pincus, MR, Preuss, HG, and Henry, JB: Evaluation of renal func-
tion and water, electrolyte and acid-base balance. In Henry, JB
(ed): Clinical Diagnosis and Management by Laboratory Meth-
ods. WB Saunders, Philadelphia, 1996.
3. Levey, AS, et al: A new equation to estimate glomerular filtration
rate. Ann Intern Med 150(9):601–612, 2009.
4. Laterza, OE, Price, CP, and Scott, MG: Cystatin C: An improved
estimator of glomerular filtration rate? Clin Chem 48(5):
699–707, 2002.
5. Tan, GS, et al: Clinical usefulness of cystatin C for the estimation
of glomerular filtration rate in type 1 diabetes. Crit Care
9(2):139–143, 2005.
6. Inker, LA: Estimating glomerular filtration rate from serum crea-
tinine and cystatin C. N Engl J Med 367:20–29, 2012.
7. Foley, K: Beta 2 microglobulin: a facultative marker. Advance for
MLP, Sept 30, 2008, p 13.
8. Chachati, A, et al: Rapid method for the measurement of differ-
ential renal function: Validation. J Nucl Med 28(5): 829–836,
1987.
9. Daves, BB, and Zenser, TV: Evaluation of renal concentrating and
diluting ability. Clin Lab Med 13(1):131–134, 1993.
4. Filtration of protein is prevented in the glomerulus by:
A. Hydrostatic pressure
B. Oncotic pressure
C. Renin
D. The glomerular filtration barrier
5. The renin-angiotensin-aldosterone system is responsible for
all of the following except:
A. Vasoconstriction of the afferent arteriole
B. Vasoconstriction of the efferent arteriole
C. Reabsorbing sodium
D. Releasing aldosterone
6. The primary chemical affected by the renin-angiotensin-
aldosterone system is:
A. Chloride
B. Sodium
C. Potassium
D. Hydrogen
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54 Part One | Background

7. Secretion of renin is stimulated by: 14. ADH regulates the final urine concentration by
A. Juxtaglomerular cells controlling:
B. Angiotensin I and II A. Active reabsorption of sodium
C. Macula densa cells B. Tubular permeability
D. Circulating angiotensin-converting enzyme C. Passive reabsorption of urea
D. Passive reabsorption of chloride
8. The hormone aldosterone is responsible for:
A. Hydrogen ion secretion 15. Decreased production of ADH:

B. Potassium secretion A. Produces a low urine volume

B. Produces a high urine volume
C. Chloride retention
C. Increases ammonia excretion
D. Sodium retention
D. Affects active transport of sodium
9. The fluid leaving the glomerulus has a specific
gravity of: 16. Bicarbonate ions filtered by the glomerulus are returned
to the blood:
A. 1.005
A. In the proximal convoluted tubule
B. 1.010
B. Combined with hydrogen ions
C. 1.015
C. By tubular secretion
D. 1.020
D. All of the above
10. For active transport to occur, a chemical:
17. If ammonia is not produced by the distal convoluted
A. Must combine with a carrier protein to create tubule, the urine pH will be:
electrochemical energy
A. Acidic
B. Must be filtered through the proximal convoluted
B. Basic
tubule
C. Must be in higher concentration in the filtrate than 18. Place the appropriate letter in front of the following clear-
in the blood ance substances:
D. Must be in higher concentration in the blood than in A. Exogenous
the filtrate B. Endogenous
11. Which of the tubules is impermeable to water? ____ beta2-microglobulin
A. Proximal convoluted tubule ____ creatinine
B. Descending loop of Henle ____ cystatin C
C. Ascending loop of Henle ____ 125I-iothalmate

D. Distal convoluted tubule
12. Glucose will appear in the urine when the:
A. Blood level of glucose is 200 mg/dL
B. Tm for glucose is reached
C. Renal threshold for glucose is exceeded
D. All of the above
13. Concentration of the tubular filtrate by the countercur-
rent mechanism depends on all of the following
except:
A. High salt concentration in the medulla
B. Water-impermeable walls of the ascending loop of
Henle
C. Reabsorption of sodium and chloride from the
ascending loop of Henle
D. Reabsorption of water in the descending loop of
Henle
19. The largest source of error in creatinine clearance tests is:
A. Secretion of creatinine
B. Improperly timed urine specimens
C. Refrigeration of the urine
D. Time of collecting blood sample
20. Given the following information, calculate the creatinine
clearance:
24-hour urine volume: 1000 mL; serum creatinine:
2.0 mg/dL; urine creatinine: 200 mg/dL
21. Clearance tests used to determine the glomerular filtration
rate must measure substances that are:
A. Not filtered by the glomerulus
B. Completely reabsorbed by the proximal convoluted
tubule
C. Secreted in the distal convoluted tubule
D. Neither reabsorbed or secreted by the tubules
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Chapter 3 | Renal Function 55

22. Performing a clearance test using radionucleotides: 29. After controlled fluid intake, the urine-to-serum osmolarity
A. Eliminates the need to collect urine ratio should be at least:
B. Does not require an infusion A. 1:1
C. Provides visualization of the filtration B. 2:1
D. Both A and C
C. 3:1
23. Variables that are included in the MDRD-IDSM estimated D. 4:1
creatinine clearance calculations include all of the
following except: 30. Calculate the free water clearance from the following
A. Serum creatinine results:
B. Weight urine volume in 6 hours: 720 mL; urine osmolarity:
C. Age 225 mOsm; plasma osmolarity: 300 mOsm
D. Gender
31. To provide an accurate measure of renal blood flow, a test
24. An advantage to using cystatin C to monitor GFR is that: substance should be completely:
A. It does not require urine collection
A. Filtered by the glomerulus
B. It is not secreted by the tubules
B. Reabsorbed by the tubules
C. It can be measured by immunoassay
C. Secreted when it reaches the distal convoluted
D. All of the above
tubule
25. Solute dissolved in solvent will:
D. Cleared on each contact with functional renal
A. Raise the vapor pressure
tissue
B. Lower the boiling point
C. Decrease the osmotic pressure 32. Given the following data, calculate the effective renal
D. Lower the freezing point plasma flow:

26. Substances that may interfere with freezing point meas- urine volume in 2 hours: 240 mL; urine PAH: 150 mg/dL;
urement of urine and serum osmolarity include all of the plasma PAH: 0.5 mg/dL
following except:
33. Renal tubular acidosis can be caused by the:
A. Ethanol
A. Production of excessively acidic urine due to
B. Lactic acid
increased filtration of hydrogen ions
C. Sodium
D. Lipids B. Production of excessively acidic urine due to
increased secretion of hydrogen ions
27. Clinical osmometers use NaCl as a reference solution
because: C. Inability to produce an acidic urine due to impaired
A. 1 g molecular weight of NaCl will lower the freezing production of ammonia
point 1.86oC D. Inability to produce an acidic urine due to increased
B. NaCl is readily frozen production of ammonia
C. NaCl is partially ionized similar to the composition 34. Tests performed to detect renal tubular acidosis after
of urine
administering an ammonium chloride load include all
D. 1 g equivalent weight of NaCl will raise the freezing
of the following except:
point 1.86oC
A. Urine ammonia
28. The normal serum osmolarity is:
B. Arterial pH
A. 50 to 100 mOsm
B. 275 to 300 mOsm C. Urine pH
C. 400 to 500 mOsm D. Titratable acidity
D. 3 times the urine osmolarity
3920_Ch03_039-057 23/01/14 10:10 AM Page 56
56 Part One | Background
Case Studies and Clinical Situations
1. A 44-year-old man diagnosed with acute tubular necrosis
has a blood urea nitrogen of 60 mg/dL and a blood
glucose level of 100 mg/dL. A 2+ urine glucose is also
reported.
a. State the renal threshold for glucose.
b. What is the significance of the positive urine
glucose and normal blood glucose?
2. A patient develops a sudden drop in blood pressure.
a. Diagram the reactions that take place to ensure
adequate blood pressure within the nephrons.
b. How do these reactions increase blood volume?
c. When blood pressure returns to normal, how does the
kidney respond?
3. A physician would like to prescribe a nephrotoxic antibi-
otic for a 60-year-old Caucasian man. The patient has a
serum creatinine level of 1.5 mg/dL.
a. How can the physician determine whether it is safe to
prescribe this medication before the patient leaves the
office?
b. State two additional blood tests that the physician
could use to continue monitoring this patient.
c. If the patient has a history of prostate malignancy,
would both of these methods provide reliable results?
Explain your answer.
4. A laboratory is obtaining erratic serum osmolarity results
on a patient who is being monitored at 6 a.m., 12 p.m.,
6 p.m., and 12 a.m. Osmolarities are not performed on
the night shift; therefore, the midnight specimen is run at
the same time as the 6 a.m. specimen.
a. What two reasons could account for these
discrepancies?
b. What substance is causing the erratic results?
c. If a friend were secretly bringing the patient a pint of
whiskey every night, would this affect the
results? Explain your answer.
5. Following overnight (6 p.m. to 8 a.m.) fluid deprivation,
the urine-to-serum osmolarity ratio in a patient who is
exhibiting polyuria and polydipsia is 1:1. The ratio re-
mains the same when a second specimen is tested at
10 a.m. ADH is then administered subcutaneously to
the patient, and the fluid deprivation is continued until
2 p.m., when another specimen is tested.
a. What disorder do these symptoms and initial laboratory
results indicate?
b. If the urine-to-serum osmolarity ratio on the 2 p.m.
specimen is 3:1, what is the underlying cause of the
patient’s disorder?
c. If the urine-to-serum osmolarity ratio on the 2 p.m.
specimen remains 1:1, what is the underlying cause of
the patient’s disorder?
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Chapter 4 | Physical Examination of Urine 67

cause an unusual or pungent urine odor. Studies have shown References

that although everyone who eats asparagus produces an odor, 1. Henry, JB, Lauzon, RB, and Schumann, GB: Basic examination
only certain genetically predisposed people can smell the of urine. In Henry, JB (ed): Clinical Diagnosis and Management
odor.11 Common causes of urine odors are summarized in by Laboratory Methods. WB Saunders, Philadelphia, 1996.
Table 4–6. 2. Drabkin, DL: The normal pigment of urine: The relationship of
urinary pigment output to diet and metabolism. J Biol Chem
75:443–479, 1927.
3. Ostow, M, and Philo, S: The chief urinary pigment: The rela-
Table 4–6 Possible Causes of Urine Odor1
tionship between the rate of excretion of the yellow pigment
Odor Cause and the metabolic rate. Am J Med Sci 207:507–512, 1944.
4. Berman, L: When urine is red. JAMA 237:2753–2754, 1977.
Aromatic Normal 5. Reimann, HA: Re: Red urine. JAMA 241(22):2380, 1979.
6. Evans, B: The greening of urine: Still another “Cloret sign.”
Foul, ammonia-like Bacterial decomposition, urinary N Engl J Med 300(4):202, 1979.
tract infection 7. Bowling, P, Belliveau, RR, and Butler, TJ: Intravenous medica-
Fruity, sweet Ketones (diabetes mellitus, tions and green urine. JAMA 246(3):216, 1981.
8. Dealler, SF, et al: Purple urine bags. J Urol 142(3):769–770,
starvation, vomiting) 1989.
Maple syrup Maple syrup urine disease 9. Clinical and Laboratory Standards Institute (Formerly NCCLS)
Approved Guideline GP16-A3: Urinalysis and Collection,
Mousy Phenylketonuria Transportation, and Preservation of Urine Specimens;
Rancid Tyrosinemia Approved Guideline, ed 3, CLSI, Wayne, PA, 2009.
10. Smith, C, Arbogast, C, and Phillips, R: Effect of x-ray contrast
Sweaty feet Isovaleric acidemia media on results for relative density of urine. Clin Chem
Cabbage Methionine malabsorption 19(4):730–731, 1983.
11. Mitchell, SC, et al: Odorous urine following asparagus inges-
Bleach Contamination tion in man. Experimenta 43(4):382–383, 1987.

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to this chapter.

Study Questions
1. The concentration of a normal urine specimen can be 4. A urine specimen containing melanin will appear:
estimated by which of the following? A. Pale pink
A. Color B. Dark yellow
B. Clarity C. Blue-green
C. Foam D. Black
D. Odor 5. Specimens that contain hemoglobin can be visually dis-
tinguished from those that contain RBCs because:
2. The normal yellow color of urine is produced by:
A. Hemoglobin produces a clear, yellow specimen
A. Bilirubin
B. Hemoglobin produces a cloudy pink specimen
B. Hemoglobin
C. RBCs produce a cloudy red specimen
C. Urobilinogen D. RBCs produce a clear red specimen
D. Urochrome
6. A patient with a viscous orange specimen may have been:
3. The presence of bilirubin in a urine specimen produces a: A. Treated for a urinary tract infection
A. Yellow foam when shaken B. Taking vitamin B pills
B. White foam when shaken C. Eating fresh carrots
C. Cloudy specimen D. Taking antidepressants
D. Yellow-red specimen
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68 Part Two | Urinalysis

7. The presence of a pink precipitate in a refrigerated speci- 14. A cloudy urine specimen turns black upon standing and
men is caused by: has a specific gravity of 1.012. The major concern about
A. Hemoglobin this specimen would be:
B. Urobilin A. Color
C. Uroerythrin B. Turbidity
D. Beets C. Specific gravity
D. All of the above
8. Microscopic examination of a clear urine that produces a
white precipitate after refrigeration will show: 15. A specimen with a specific gravity of 1.035 would be con-
A. Amorphous urates sidered:
B. Porphyrins A. Isosthenuric
C. Amorphous phosphates B. Hyposthenuric
D. Yeast C. Hypersthenuric
D. Not urine
9. The color of urine containing porphyrins will be:
16. A specimen with a specific gravity of 1.001 would be con-
A. Yellow-brown
sidered:
B. Green
A. Hyposthenuric
C. Orange
B. Not urine
D. Port wine
C. Hypersthenuric
10. Which of the following specific gravities would be most D. Isosthenuric
likely to correlate with a pale yellow urine?
17. A strong odor of ammonia in a urine specimen could
A. 1.005
indicate:
B. 1.010
A. Ketones
C. 1.020
B. Normalcy
D. 1.030
C. Phenylketonuria
11. A urine specific gravity measured by refractometer is D. An old specimen
1.029, and the temperature of the urine is 14°C. The spe-
cific gravity should be reported as: 18. The microscopic of a clear red urine is reported as many
WBCs and epithelial cells. What does this suggest?
A. 1.023
A. Urinary tract infection
B. 1.027
B. Dilute random specimen
C. 1.029
C. Hematuria
D. 1.032
D. Possible mix-up of specimen and sediment
12. The principle of refractive index is to compare:
19. Which of the following would contribute the most to a
A. Light velocity in solutions with light velocity in urine osmolality?
solids
A. One osmole of glucose
B. Light velocity in air with light velocity in solutions
B. One osmole of urea
C. Light scattering by air with light scattering by
C. One osmole of sodium chloride
solutions
D. All contribute equally
D. Light scattering by particles in solution
20. Which of the following colligative properties is not stated
13. A correlation exists between a specific gravity by refrac-
correctly?
tometer of 1.050 and a:
A. The boiling pointing is raised by solute
A. 2+ glucose
B. The freezing point is raised by solute
B. 2+ protein
C. The vapor pressure is lowered by solute
C. First morning specimen
D. The osmotic pressure is raised by solute
D. Radiographic dye infusion
3920_Ch04_058-070 23/01/14 10:56 AM Page 69
21. An osmole contains:
A. One gram molecular weight of solute dissolved in
one liter of solvent
B. One gram molecular weight of solute dissolved
in one kilogram of solvent
C. Two gram molecular weights of solute dissolved in
one liter of solvent
D. Two gram molecular weights of solute dissolved
in one kilogram of solvent
22. The unit of osmolality measured in the clinical laboratory
is the:
A. Osmole
B. Milliosmole
C. Molecular weight
D. Ionic charge
Case Studies and Clinical Situations
1. Given the following physical urinalysis results, determine
additional urinalysis results that may be abnormal.
a. A green specimen with a strong foul odor of ammonia
b. A pale yellow urine with a specific gravity of 1.030
c. A dark yellow specimen with yellow foam
d. A cloudy red urine
2. The urology clinic questions a urinalysis report from the
laboratory.
The laboratory report states that a reagent strip reading
of a specific gravity of 1.020, protein 3 g/dL, and glucose
2 g/dL. The specific gravity in the urology clinic was
greater than 1.035.
a. Correct the refractometer reading to account for the
protein and glucose concentrations. What is the cor-
rected specific gravity?
b. Do the specific gravities correlate?
Chapter 4 | Physical Examination of Urine 69
23. In the reagent strip specific gravity reaction the
polyelectrolyte:
A. Combines with hydrogen ions in response to ion
concentration
B. Releases hydrogen ions in response to ion
concentration
C. Releases hydrogen ions in response to pH
D. Combines with sodium ions in response to pH
24. Which of the following will react in the reagent strip
specific gravity test?
A. Glucose
B. Radiographic dye
C. Protein
D. Chloride
c. If the specific gravity was also checked using osmome-
try, should the result agree with the laboratory or the
urology clinic results? Why or why not?
3. State two pathologic causes of a clear red urine.
a. State a method that could distinguish between the two
causes that does not require laboratory testing.
4. Mrs. Smith frequently shops at the farmer’s market near
her home. She notices her urine has a red color and
brings a sample to her physician. The specimen tests
negative for blood.
a. What is a probable cause of Mrs. Smith’s red urine?
b. Mrs. Smith collects a specimen at the physician’s
office. The color is yellow and the pH is 5.5. Is
this consistent with the previous answer? Why or
why not?
5. Is a clear urine always normal? Explain your answer.
3920_Ch05_071-098 23/01/14 10:16 AM Page 92
92 Part Two | Urinalysis
Reaction Interference
The reagent strip specific gravity measures only ionic solutes,
thereby eliminating the interference by the large organic mol-
ecules, such as urea and glucose, and by radiographic contrast
media and plasma expanders that are included in physical
measurements of specific gravity. This difference must be con-
sidered when comparing specific gravity results obtained by
a different method. Elevated concentrations of protein slightly
increase the readings as a result of protein anions.
Specimens with a pH of 6.5 or higher have decreased
readings caused by interference with the bromthymol blue in-
dicator (the blue-green readings associated with an alkaline
pH correspond to a low specific gravity reading). Therefore,
manufacturers recommend adding 0.005 to specific gravity
readings when the pH is 6.5 or higher. The correction is per-
formed by automated strip readers.
SUMMARY 5-22 Urine Specific Gravity
Reagent Strip
Reagents Multistix: Poly (methyl vinyl ether/maleic
anhydride) bromthymol blue
Chemstrip: Ethylene glycol diaminoethyl
ether tetraacetic acid, bromthymol
blue
Sensitivity 1.000 to 1.030
Interference False-positive: High concentrations of
protein
False-negative: Highly alkaline urines
(greater than 6.5)
Study Questions
1. Leaving excess urine on the reagent strip after removing
it from the specimen will:
A. Cause run-over between reagent pads
B. Alter the color of the specimen
C. Cause reagents to leach from the pads
D. Not affect the chemical reactions
2. Failure to mix a specimen before inserting the reagent
strip will primarily affect the:
A. Glucose reading
B. Blood reading
C. Leukocyte reading
D. Both B and C
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to this chapter.
References
1. Chemstrip 10UA product Insert, Roche Diagnostics, Indianapolis,
IN, 2004.
2. Multistix Pro Reagent Strips Product Insert. Siemens Diagnos-
tics, Tarrytown, NY 2005.
3. TechniTips, Miles Diagnostics, Elkhart, IN, October, 1992.
4. Clinical and Laboratory Standards Institute Approved Guide-
line GP16-A3: Urinalysis and Collection, Transportation, and
Preservation of Urine Specimens; Approved Guideline, ed 3,
CLSI, Wayne, PA, 2009.
5. College of American Pathologists, CAP Today, Confirmatory
testing. Chicago, IL. December 2011.
6. Tips from the Clinical Experts, Medical Laboratory Observer.
Web site: http://www.mlo-online.com/articles/mlo0802tips.htm
7. Pugia, MJ, and Lott, JA: New developments in urinalysis strip
tests for proteins. In Bayer Encyclopedia of Urinalysis. Bayer
Diagnostics, Elkhart, IN, 2002.
8. Bhuwnesh, A, et al: Microalbumin screening by reagent strip
predicts cardiovascular risk in hypertension. J Hypertens 14:
223–228, 1992.
9. Bianchi, S, et al: Microalbuminurea in essential hypertension.
J Nephrol 10(4):216–219, 1997.
10. Clinitek Microalbumin Reagent Strip Product Insert. Bayer
Diagnostics, Elkhart, IN, 2006.
11. Benedict, SR: A reagent for the detection of reducing sugars.
J Biol Chem 5:485–487, 1909.
12. Lane R, and Phillips, M: Rhabdomyolysis has many causes
including statins and may be fatal. Brit J Med 327:115–116,
2003.
13. Hager, CB, and Free, AH: Urine urobilinogen as a component
of routine urinalysis. Am J Med Technol 36(5):227–233, 1970.
14. Wise, KA, Sagert, LA, and Grammens, GL: Urine leukocyte es-
terase and nitrite tests as an aid to predict urine culture results.
Lab Med 15(3):186–187, 1984.
3. Testing a refrigerated specimen that has not warmed to
room temperature will adversely affect:
A. Enzymatic reactions
B. Dye-binding reactions
C. The sodium nitroprusside reaction
D. Diazo reactions
4. The reagent strip reaction that requires the longest reac-
tion time is the:
A. Bilirubin
B. pH
C. Leukocyte esterase
D. Glucose
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Chapter 5 | Chemical Examination of Urine 93

5. Quality control of reagent strips is performed: 12. All of the following will cause false-positive protein
A. Using positive and negative controls reagent strip values except:
B. When results are questionable A. Microalbuminuria
C. At least once every 24 hours B. Highly buffered alkaline urines
D. All of the above C. Delay in removing the reagent strip from the specimen
D. Contamination by quaternary ammonium compounds
6. All of the following are important to protect the integrity
of reagent strips except: 13. A patient with a 2+ protein reading in the afternoon is asked
to submit a first morning specimen. The second specimen
A. Removing the desiccant from the bottle
has a negative protein reading. This patient is:
B. Storing in an opaque bottle
A. Positive for orthostatic proteinuria
C. Storing at room temperature
B. Negative for orthostatic proteinuria
D. Resealing the bottle after removing a strip
C. Positive for Bence Jones protein
7. The principle of the reagent strip test for pH is the: D. Negative for clinical proteinuria
A. Protein error of indicators 14. Testing for microalbuminuria is valuable for early detec-
B. Greiss reaction tion of kidney disease and monitoring patients with:
C. Dissociation of a polyelectrolyte A. Hypertension
D. Double indicator reaction B. Diabetes mellitus
8. A urine specimen with a pH of 9.0: C. Cardiovascular disease risk
A. Indicates metabolic acidosis D. All of the above
B. Should be recollected 15. The primary chemical on the reagent strip in the Micral-
C. May contain calcium oxalate crystals Test for microalbumin binds to:
D. Is seen after drinking cranberry juice A. Protein
B. Antihuman albumin antibody
9. In the laboratory, a primary consideration associated
with pH is: C. Conjugated enzyme
D. Galactoside
A. Identifying urinary crystals
B. Monitoring vegetarian diets 16. All of the following are true for the ImmunoDip test for
microalbumin except:
C. Determining specimen acceptability
A. Unbound antibody migrates farther than bound
D. Both A and C
antibody
10. Indicate the source of the following proteinurias by plac- B. Blue latex particles are coated with antihuman
ing a 1 for prerenal, 2 for renal, or 3 for postrenal in front albumin antibody
of the condition. C. Bound antibody migrates further than unbound
A. ____Microalbuminuria antibody
B. ____Acute phase reactants D. It utilizes an immunochromographic principle
C. ____Pre-eclampsia 17. The principle of the protein-high pad on the Multistix
D. ____Vaginal inflammation Pro reagent strip is the:
E. ____Multiple myeloma A. Diazo reaction
F. ____Orthostatic proteinuria B. Enzymatic dye-binding reaction
G. ____Prostatitis C. Protein error of indicators
11. The principle of the protein error of indicators reaction D. Microalbumin-Micral-Test
is that: 18. Which of the following is not tested on the Multistix Pro
A. Protein keeps the pH of the urine constant reagent strip?
B. Albumin accepts hydrogen ions from the indicator A. Urobilinogen
C. The indicator accepts hydrogen ions from B. Specific gravity
albumin C. Creatinine
D. Albumin changes the pH of the urine D. Protein-high
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94 Part Two | Urinalysis

19. The principle of the protein-low reagent pad on the Mul- 27. The most significant reagent strip test that is associated
tistix Pro is the: with a positive ketone result is:
A. Binding of albumin to sulphonphthalein dye A. Glucose
B. Immunologic binding of albumin to antibody B. Protein
C. Reverse protein error of indicators reaction C. pH
D. Enzymatic reaction between albumin and dye D. Specific gravity
20. The principle of the creatinine reagent pad on microal- 28. The primary reagent in the reagent strip test for ketones is:
bumin reagent strips is the: A. Glycine
A. Double indicator reaction B. Lactose
B. Diazo reaction C. Sodium hydroxide
C. Pseudoperoxidase reaction D. Sodium nitroprusside
D. Reduction of a chromogen
29. Ketonuria may be caused by all of the following except:
21. The purpose of performing an albumin:creatinine ratio A. Bacterial infections
is to:
B. Diabetic acidosis
A. Estimate the glomerular filtration rate
C. Starvation
B. Correct for hydration in random specimens
D. Vomiting
C. Avoid interference for alkaline urines
D. Correct for abnormally colored urines 30. Urinalysis on a patient with severe back and abdominal
pain is frequently performed to check for:
22. A patient with a normal blood glucose and a positive
A. Glucosuria
urine glucose should be further checked for:
B. Proteinuria
A. Diabetes mellitus
C. Hematuria
B. Renal disease
D. Hemoglobinuria
C. Gestational diabetes
D. Pancreatitis 31. Place the appropriate number or numbers in front of
each of the following statements. Use both numbers for
23. The principle of the reagent strip tests for glucose is the: an answer if needed.
A. Peroxidase activity of glucose 1. Hemoglobinuria
B. Glucose oxidase reaction 2. Myoglobinuria
C. Double sequential enzyme reaction A. ____ Associated with transfusion reactions
D. Dye-binding of glucose and chromogen B. ____ Clear red urine and pale yellow plasma
24. All of the following may produce false-negative glucose C. ____ Clear red urine and red plasma
reactions except: D. ____ Associated with rhabdomyolysis
A. Detergent contamination E. ____ Produces hemosiderin granules in urinary
B. Ascorbic acid sediments
C. Unpreserved specimens F. ____Associated with acute renal failure
D. Low urine temperature 32. The principle of the reagent strip test for blood is based
25. The primary reason for performing a Clinitest is to: on the:
A. Check for high ascorbic acid levels A. Binding of heme and a chromogenic dye
B. Confirm a positive reagent strip glucose B. Peroxidase activity of heme
C. Check for newborn galactosuria C. Reaction of peroxide and chromogen
D. Confirm a negative glucose reading D. Diazo activity of heme
26. The three intermediate products of fat metabolism in- 33. A speckled pattern on the blood pad of the reagent strip
clude all of the following except: indicates:
A. Acetoacetic acid A. Hematuria
B. Ketoacetic acid B. Hemoglobinuria
C. β -hydroxybutyric acid C. Myoglobinuria
D. Acetone D. All of the above
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Chapter 5 | Chemical Examination of Urine 95

34. List the following products of hemoglobin degradation 42. All of the following can cause a negative nitrite reading
in the correct order by placing numbers 1 to 4 in the except:
blank. A. Gram-positive bacteria
A. ____Conjugated bilirubin B. Gram-negative bacteria
B. ____Urobilinogen and stercobilinogen C. Random urine specimens
C. ____Urobilin D. Heavy bacterial infections
D. ____Unconjugated bilirubin 43. A positive nitrite test and a negative leukocyte esterase
35. The principle of the reagent strip test for bilirubin test is an indication of a:
is the: A. Dilute random specimen
A. Diazo reaction B. Specimen with lysed leukocytes
B. Ehrlich reaction C. Vaginal yeast infection
C. Greiss reaction D. Specimen older than 2 hours
D. Peroxidase reaction 44. All of the following can be detected by the leukocyte
36. An elevated urine bilirubin with a normal urobilinogen esterase reaction except:
is indicative of: A. Neutrophils
A. Cirrhosis of the liver B. Eosinophils
B. Hemolytic disease C. Lymphocytes
C. Hepatitis D. Basophils
D. Biliary obstruction 45. Screening tests for urinary infection combine the leuko-
cyte esterase test with the test for:
37. The primary cause of a false-negative bilirubin reaction is:
A. pH
A. Highly pigmented urine
B. Nitrite
B. Specimen contamination
C. Protein
C. Specimen exposure to light
D. Blood
D. Excess conjugated bilirubin
46. The principle of the leukocyte esterase reagent strip test
38. The purpose of the special mat supplied with the Ictotest
uses a:
tablets is that:
A. Peroxidase reaction
A. Bilirubin remains on the surface of the mat.
B. Double indicator reaction
B. It contains the dye needed to produce color.
C. Diazo reaction
C. It removes interfering substances.
D. Dye-binding technique
D. Bilirubin is absorbed into the mat.
47. The principle of the reagent strip test for specific gravity
39. The reagent in the Multistix reaction for urobilinogen is: uses the dissociation constant of a(n):
A. A diazonium salt A. Diazonium salt
B. Tetramethylbenzidine B. Indicator dye
C. p-Dimethylaminobenzaldehyde C. Polyelectrolyte
D. Hoesch reagent D. Enzyme substrate
40. The primary problem with urobilinogen tests using 48. A specific gravity of 1.005 would produce the reagent
Ehrlich reagent is: strip color:
A. Positive reactions with porphobilinogen A. Blue
B. Lack of specificity B. Green
C. Positive reactions with Ehrlich’s reactive substances C. Yellow
D. All of the above D. Red
41. The reagent strip test for nitrite uses the: 49. Reagent strip–specific gravity readings are affected by:
A. Greiss reaction A. Glucose
B. Ehrlich reaction B. Radiographic dye
C. Peroxidase reaction C. Alkaline urine
D. Pseudoperoxidase reaction D. All of the above
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96 Part Two | Urinalysis

Case Studies and Clinical Situations

1. A patient taken to the emergency department after an SP. GRAVITY: 1.020 BILIRUBIN: Negative
episode of syncope has a fasting blood glucose level
pH: 6.0 UROBILINOGEN: 8 EU
of 450 mg/dL. Results of the routine urinalysis are as
follows: PROTEIN: Negative NITRITE: Negative
COLOR: Yellow KETONES: 2+ GLUCOSE: Negative LEUKOCYTES: Negative
CLARITY: Clear BLOOD: Negative a. Would these results be indicative of hematuria or
SP. GRAVITY: 1.015 BILIRUBIN: Negative hemoglobinuria?
pH: 5.0 PROTEIN-LOW: 15 mg/dL b. Correlate the patient’s condition with the urobilino-
PROTEIN-HIGH: NITRITE: Negative gen result.
30 mg/dL c. Why is the urine bilirubin result negative in this
GLUCOSE: 250 mg/dL LEUKOCYTES: Negative jaundiced patient?
CREATININE: 200 mg/dL d. Would this method also measure urine porphyrins?
Why or why not?
a. Explain the correlation between the patient’s blood
and urine glucose results. 4. A female patient arrives at the outpatient clinic with
b. What is the most probable metabolic disorder asso- symptoms of lower back pain and urinary frequency
ciated with this patient? with a burning sensation. She is a firm believer in the
curative powers of vitamins. She has tripled her usual
c. Considering the patient’s condition, what is the sig-
dosage of vitamins in an effort to alleviate her symp-
nificance of the patient’s protein to creatinine ratio
toms; however, the symptoms have persisted. She is
result?
given a sterile container and asked to collect a mid-
d. If the patient in this study had a normal blood stream clean-catch urine specimen. Results of this
glucose level and normal protein and creatinine routine urinalysis are as follows:
results, to what would the urinary glucose be
attributed? COLOR: Dark yellow KETONES: Negative

2. Results of a urinalysis performed on a patient sched- CLARITY: Hazy BLOOD: Negative

uled for gallbladder surgery are as follows: SP. GRAVITY: 1.012 BILIRUBIN: Negative
COLOR: Amber KETONES: Negative pH: 7.0 UROBILINOGEN: Normal
CLARITY: Hazy BLOOD: Negative PROTEIN: Trace NITRITE: Negative
SP. GRAVITY: 1.022 BILIRUBIN: Moderate GLUCOSE: Negative LEUKOCYTES: 1+
pH: 6.0 UROBILINOGEN: Normal Microscopic
PROTEIN: Negative NITRITE: Negative 8 TO 12 RBC/HPF Heavy bacteria
GLUCOSE: Negative LEUKOCYTES: Negative 40 TO 50 WBC/HPF Moderate squamous epithelial
a. What would be observed if this specimen were cells
shaken? a. What discrepancies between the chemical and mi-
b. Explain the correlation between the patient’s sched- croscopic test results are present? State and explain
uled surgery and the normal urobilinogen. a possible reason for each discrepancy.
c. If blood were drawn from this patient, how might b. What additional chemical tests could be affected by
the appearance of the serum be described? the patient’s vitamin dosage? Explain the principle
d. What special handling is needed for serum and of the interference.
urine specimens from this patient? c. Discuss the urine color and specific gravity results
with regard to correlation and give a possible cause
3. Results of a urinalysis on a very anemic and jaundiced
for any discrepancy.
patient are as follows:
d. State three additional reasons not previously given
COLOR: Red KETONES: Negative for a negative nitrite test in the presence of in-
CLARITY: Clear BLOOD: Large creased bacteria.
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Chapter 5 | Chemical Examination of Urine 97

5. Results of a urinalysis collected following practice from SP. GRAVITY: 1.017 BILIRUBIN: Negative
a 20-year-old college athlete are as follows:
pH: 6.5 UROBILINOGEN: 0.4 EU
COLOR: Dark yellow KETONES: Negative PROTEIN: Trace NITRITE: Negative
CLARITY: Hazy BLOOD: 1+ GLUCOSE: Negative LEUKOCYTES: Negative
SP. GRAVITY: 1.029 BILIRUBIN: Negative a. Would hematuria be suspected in this specimen?
Why or why not?
pH: 6.5 UROBILINOGEN: 1 EU
b. What is the most probable cause of the positive
PROTEIN: 2+ NITRITE: Negative blood reaction?
GLUCOSE: Negative LEUKOCYTES: Negative c. What is the source of the substance causing the pos-
itive blood reaction and the name of the condition?
The physician requests that the athlete collect another
d. Would this patient be monitored for changes in
specimen in the morning prior to classes and practice.
renal function? Why or why not?
a. What is the purpose of the second sample?
7. Considering the correct procedures for care, technique,
b. What changes would you expect in the second and quality control for reagent strips, state a possible
sample? cause for each of the following scenarios.
c. Is the proteinuria present in the first sample of prer- a. The urinalysis supervisor notices that an unusually
enal, renal, or postrenal origin? large number of reagent strips are becoming discol-
6. A construction worker is pinned under collapsed scaf- ored before the expiration date has been reached.
folding for several hours prior to being taken to the b. A physician’s office is consistently reporting positive
emergency room. His abdomen and upper legs are se- nitrite test results with negative LE test results.
verely bruised, but no fractures are detected. A speci- c. A student’s results for reagent strip blood and LE
men for urinalysis obtained by catheterization has the are consistently lower than those of the laboratory
following results: staff.
d. One morning the urinalysis laboratory was report-
COLOR: Red-brown KETONES: Negative
ing results that were frequently questioned by
CLARITY: Clear BLOOD: 4+ physicians.
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Chapter 6 | Microscopic Examination of Urine 141

Study Questions
1. Macroscopic screening of urine specimens is used to: 8. Which of the following are reported as number per lpf?
A. Provide results as soon as possible A. RBCs
B. Predict the type of urinary casts present B. WBCs
C. Increase cost-effectiveness of urinalysis C. Crystals
D. Decrease the need for polarized microscopy D. Casts
2. Variations in the microscopic analysis of urine include all 9. The Sternheimer-Malbin stain is added to urine sediments
of the following except: to do all of the following except:
A. Preparation of the urine sediment A. Increase visibility of sediment constituents
B. Amount of sediment analyzed B. Change the constituents’ refractive index
C. Method of reporting C. Decrease precipitation of crystals
D. Identification of formed elements D. Delineate constituent structures
3. All of the following can cause false-negative microscopic 10. Nuclear detail can be enhanced by:
results except: A. Prussian blue
A. Braking the centrifuge B. Toluidine blue
B. Failing to mix the specimen C. Acetic acid
C. Dilute alkaline urine D. Both B and C
D. Using midstream clean-catch specimens
11. Which of the following lipids is/are stained by Sudan III?
4. The two factors that determine relative centrifugal force are: A. Cholesterol
A. Radius of rotor head and rpm B. Neutral fats
B. Radius of rotor head and time of centrifugation C. Triglycerides
C. Diameter of rotor head and rpm D. Both B and C
D. RPM and time of centrifugation
12. Which of the following lipids is/are capable of polarizing
5. When using the glass slide and cover-slip method, which of light?
the following might be missed if the cover slip is overflowed? A. Cholesterol
A. Casts B. Neutral fats
B. RBCs C. Triglycerides
C. WBCs D. Both A and B
D. Bacteria
13. The purpose of the Hansel stain is to identify:
6. Initial screening of the urine sediment is performed using A. Neutrophils
an objective power of:
B. Renal tubular cells
A. 4× C. Eosinophils
B. 10× D. Monocytes
C. 40×
14. Crenated RBCs are seen in urine that is:
D. 100×
A. Hyposthenuric
7. Which of the following should be used to reduce light B. Hypersthenuric
intensity in bright-field microscopy?
C. Highly acidic
A. Centering screws
D. Highly alkaline
B. Aperture diaphragm
C. Rheostat
D. Condenser aperture diaphragm
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142 Part Two | Urinalysis

15. Differentiation among RBCs, yeast, and oil droplets may 23. Forms of transitional epithelial cells include all of the
be accomplished by all of the following except: following except:
A. Observation of budding in yeast cells A. Spherical
B. Increased refractility of oil droplets B. Caudate
C. Lysis of yeast cells by acetic acid C. Convoluted
D. Lysis of RBCs by acetic acid D. Polyhedral
16. A finding of dysmorphic RBCs is indicative of: 24. Increased transitional cells are indicative of:
A. Glomerular bleeding A. Catheterization
B. Renal calculi B. Malignancy
C. Traumatic injury C. Pyelonephritis
D. Coagulation disorders D. Both A and B
17. Leukocytes that stain pale blue with Sternheimer-Malbin 25. A primary characteristic used to identify renal tubular
stain and exhibit brownian movement are: epithelial cells is:
A. Indicative of pyelonephritis A. Elongated structure
B. Basophils B. Centrally located nucleus
C. Mononuclear leukocytes C. Spherical appearance
D. Glitter cells D. Eccentrically located nucleus
18. Mononuclear leukocytes are sometimes mistaken for: 26. Following an episode of hemoglobinuria, RTE cells may
A. Yeast cells contain:
B. Squamous epithelial cells A. Bilirubin
C. Pollen grains B. Hemosiderin granules
D. Renal tubular cells C. Porphobilinogen
D. Myoglobin
19. When pyuria is detected in a urine sediment, the slide
should be carefully checked for the presence of: 27. The predecessor of the oval fat body is the:
A. RBCs A. Histiocyte
B. Bacteria B. Urothelial cell
C. Hyaline casts C. Monocyte
D. Mucus D. Renal tubular cell

20. Transitional epithelial cells are sloughed from the: 28. A structure believed to be an oval fat body produced a
Maltese cross formation under polarized light but does not
A. Collecting duct
stain with Sudan III. The structure:
B. Vagina
A. Contains cholesterol
C. Bladder
B. Is not an oval fat body
D. Proximal convoluted tubule
C. Contains neutral fats
21. The largest cells in the urine sediment are: D. Is contaminated with immersion oil
A. Squamous epithelial cells
29. The finding of yeast cells in the urine is commonly asso-
B. Urothelial epithelial cells ciated with:
C. Cuboidal epithelial cells A. Cystitis
D. Columnar epithelial cells B. Diabetes mellitus
22. A clinically significant squamous epithelial cell is the: C. Pyelonephritis
A. Cuboidal cell D. Liver disorders
B. Clue cell
C. Caudate cell
D. Columnar cell
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Chapter 6 | Microscopic Examination of Urine 143

30. The primary component of urinary mucus is: 38. The presence of fatty casts is associated with:
A. Bence Jones protein A. Nephrotic syndrome
B. Microalbumin B. Crush injuries
C. Uromodulin C. Diabetes mellitus
D. Orthostatic protein D. All of the above
31. The majority of casts are formed in the: 39. Nonpathogenic granular casts contain:
A. Proximal convoluted tubules A. Cellular lysosomes
B. Ascending loop of Henle B. Degenerated cells
C. Distal convoluted tubules C. Protein aggregates
D. Collecting ducts D. Gram-positive cocci
32. Cylindruria refers to the presence of: 40. All of the following are true about waxy casts except they:
A. Cylindrical renal tubular cells A. Represent extreme urine stasis
B. Mucus-resembling casts B. May have a brittle consistency
C. Hyaline and waxy casts C. Require staining to be visualized
D. All types of casts D. Contain degenerated granules
33. A person submitting a urine specimen following a stren- 41. Observation of broad casts represents:
uous exercise routine can normally have all of the follow-
ing in the sediment except: A. Destruction of tubular walls
A. Hyaline casts B. Dehydration and high fever
B. Granular casts C. Formation in the collecting ducts
C. RBC casts D. Both A and C
D. WBC casts 42. All of the following contribute to urinary crystals forma-
tion except:
34. Prior to identifying an RBC cast, all of the following
should be observed except: A. Protein concentration
A. Free-floating RBCs B. pH
B. Intact RBCs in the cast C. Solute concentration
C. Presence of a cast matrix D. Temperature
D. A positive reagent strip blood reaction 43. The most valuable initial aid for identifying crystals in a
35. WBC casts are primarily associated with: urine specimen is:
A. Pyelonephritis A. pH
B. Cystitis B. Solubility
C. Glomerulonephritis C. Staining
D. Viral infections D. Polarized microscopy

36. The shape of the RTE cell associated with renal tubular 44. Crystals associated with severe liver disease include all of
epithelial casts is primarily: the following except:
A. Elongated A. Bilirubin
B. Cuboidal B. Leucine
C. Round C. Cystine
D. Columnar D. Tyrosine
37. When observing RTE casts, the cells are primarily: 45. All of the following crystals routinely polarize except:
A. Embedded in a clear matrix A. Uric acid
B. Embedded in a granular matrix B. Cholesterol
C. Attached to the surface of a matrix C. Radiographic dye
D. Stained by components of the urine filtrate D. Cystine
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144 Part Two | Urinalysis

46. Casts and fibers can usually be differentiated using: 50. Match the following types of microscopy with their
A. Solubility characteristics descriptions:
B. Patient history ____ Bright-field 1. Indirect light is reflected
off the object
C. Polarized light
____ Phase 2. Objects split light into two
D. Fluorescent light
beams
47. Match the following crystals seen in acidic urine with their ____ Polarized 3. Low refractive index
description/identifying characteristics: objects may be overlooked
____ Amorphous urates 1. Envelopes ____ Dark-field 4. Three-dimensional images
____ Uric acid 2. Thin needles ____Fluorescent 5. Forms halo of light around
____ Calcium oxalate 3. Yellow-brown, object
monohydrate whetstone ____Interference 6. Detects electrons
____ Calcium oxalate 4. Pink sediment contrast emitted from objects
dihydrate 7. Detects specific wavelengths
5. Ovoid of light emitted from objects

48. Match the following crystals seen in alkaline urine with

their description/identifying characteristics:
____ Triple phosphate 1. Yellow granules
____ Amorphous phosphate 2. Thin prisms
____ Calcium phosphate 3. “Coffin lids”
____ Ammonium biurate 4. Dumbbell shape
____ Calcium carbonate 5. White precipitate
6. Thorny apple
49. Match the following abnormal crystals with their
description/identifying characteristics:
____ Cystine 1. Bundles following
refrigeration
____ Tyrosine 2. Highly alkaline pH
____ Cholesterol 3. Bright yellow clumps
____ Leucine 4. Hexagonal plates
____ Ampicillin 5. Flat plates, high
specific gravity
____ Radiographic dye 6. Concentric circles,
radial striations
____ Bilirubin 7. Notched corners
8. Fine needles seen in
liver disease
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Chapter 6 | Microscopic Examination of Urine 145

Case Studies and Clinical Situations

1. An 85-year-old woman with diabetes and a broken hip Additional testing detects a superinfection with delta
has been confined to bed for the past 3 months. Results hepatitis virus and decreased renal concentrating ability.
of an ancillary blood glucose test are 250 mg/dL, and her Urinalysis results are as follows:
physician orders additional blood tests and a routine COLOR: Amber KETONES: Negative
urinalysis. The urinalysis report is as follows:
CLARITY: Hazy BLOOD: Negative
COLOR: Pale yellow KETONES: Negative SP. GRAVITY: 1.011 BILIRUBIN: Large
CLARITY: Hazy BLOOD: Moderate pH: 7.0 UROBILINOGEN: 4.0 EU
SP. GRAVITY: 1.020 BILIRUBIN: Negative PROTEIN: 2+ NITRITE: Negative
pH: 5.5 UROBILINOGEN: Normal GLUCOSE: Negative LEUKOCYTES: Negative
PROTEIN: Trace NITRITE: Negative Microscopic:
GLUCOSE: 100 mg/dL LEUKOCYTES: 2+ 2 to 4 WBCs/hpf 1 to 2 hyaline casts/lpf
Microscopic: 1 to 3 RBCs/hpf 1 to 2 granular casts/lpf
20 to 25 WBCs/hpf 2 to 4 bile-stained RTE
Many yeast cells and hyphae cells/hpf
a. Why are yeast infections common in patients with 0 to 1 RTE casts/lpf
diabetes mellitus? 0 to 1 bile-stained waxy
b. With a blood glucose level of 250 mg/dL, should casts/lpf
glucose be present in the urine? Why or why not? a. Based on the urinalysis results, in what area of the
c. Is there a discrepancy between the negative nitrite and nephron is damage occurring?
the positive leukocyte esterase results? Explain your b. Is this consistent with the patient’s primary diagnosis?
answer. Explain your answer.
d. What is the major discrepancy between the chemical c. What is causing the RTE cells to be bile stained?
and microscopic results? d. Why is the urobilinogen level elevated?
e. Considering the patient’s history, what is the most e. State a disorder in which the urobilinogen level would
probable cause for the discrepancy? be elevated, but the bilirubin result would be negative.
2. A medical technology student training in a newly reno- 4. A 30-year-old woman being treated for a UTI brings a
vated STAT laboratory is having difficulty performing a urine specimen to the Employee Health Clinic at 4:00 p.m.
microscopic urinalysis. Reagent strip testing indicates the The nurse on duty tells her that the specimen will be re-
presence of moderate blood and leukocytes, but the stu- frigerated and tested by the technologist the next morning.
dent is also observing some large unusual objects resem- The technologist has difficulty interpreting the color of the
bling crystals and possible casts. The student is also reagent strip tests and reports only the following results:
having difficulty keeping all of the constituents in focus COLOR: Amber CLARITY: Slightly cloudy
at the same time.
Microscopic:
a. Why is the student having difficulty focusing?
3 to 5 RBCs/hpf
b. What is a possible cause of the unusual microscopic
8 to 10 WBCs/hpf
constituents?
Moderate bacteria
c. Should the student be concerned about the unusual
microscopic constituents? Explain your answer. Moderate colorless crystals appearing in bundles
d. What microscopy technique could be used to aid in a. What could have caused the technologist to have
differentiating a cast and an artifact? difficulty interpreting the reagent strip results?
b. Could this specimen produce a yellow foam when
3. A prisoner sentenced to 10 years for selling illegal drugs
shaken?
develops jaundice, lethargy, and hepatomegaly.
A test for hepatitis B surface antigen is positive, and the c. What could the technologist do to aid in the identifi-
patient is placed in the prison infirmary. When his condi- cation of the crystals?
tion appears to worsen and a low urinary output is ob- d. What is the probable identification of the colorless
served, the patient is transferred to a local hospital. crystals?
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146 Part Two | Urinalysis

5. A 2-year-old left unattended in the garage for 5 minutes SP. GRAVITY: 1.030 BILIRUBIN: Negative
is suspected of ingesting antifreeze (ethylene glycol). The pH: 5.5 UROBILINOGEN: Normal
urinalysis has a pH of 6.0 and is negative on the chemical
PROTEIN: 2+ NITRITE: Negative
examination. Two distinct forms of crystals are observed
in the microscopic examination. GLUCOSE: Negative LEUKOCYTE: Negative
a. What type of crystals would you expect to be present? Microscopic:
b. What is the other form of this crystal? 0 to 3 WBCs/hpf
c. Describe the two forms. 0 to 4 hyaline casts/lpf
d. Which form would you expect to be predominant? 0 to 3 granular casts/lpf
Few squamous epithelial cells
6. A female patient comes to the outpatient clinic with
symptoms of UTI. She brings a urine specimen with her. a. Are these results of clinical significance?
Results of the routine analysis performed on this speci- b. Explain the discrepancy between the chemical and
men are as follows: microscopic blood results.
COLOR: Yellow KETONES: Negative c. What is the probable cause of the granular casts?
CLARITY: Hazy BLOOD: Small 8. As supervisor of the urinalysis section, you are reviewing
SP. GRAVITY: 1.015 BILIRUBIN: Negative results. State why or why not each of the following results
pH: 9.0 UROBILINOGEN: Normal would concern you.
PROTEIN: Negative NITRITE: Negative a. The presence of waxy casts and a negative protein in
urine from a 6–month-old girl
GLUCOSE: Negative LEUKOCYTE: 2+
b. Increased transitional epithelial cells in a specimen
Microscopic:
obtained following cystoscopy
1 to 3 RBCs/hpf Heavy bacteria
c. Tyrosine crystals in a specimen with a negative
8 to 10 WBCs/hpf Moderate squamous bilirubin test result
epithelial cells
d. Cystine crystals in a specimen from a patient diag-
a. What discrepancies are present between the chemical nosed with gout
and microscopic test results?
e. Cholesterol crystals in urine with a specific gravity
b. State a reason for the discrepancies. greater than 1.040
c. Identify a chemical result in the urinalysis that con- f. Trichomonas vaginalis in a male urine specimen
firms your reason for the discrepancies.
g. Amorphous urates and calcium carbonate crystals in
d. What course of action should the laboratory take to a specimen with a pH of 7.0
obtain accurate results for this patient?
7. 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: Moderate
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158 Part Two | Urinalysis

Study Questions
1. Most glomerular disorders are caused by: 8. The highest levels of proteinuria are seen with:
A. Sudden drops in blood pressure A. Alport syndrome
B. Immunologic disorders B. Diabetic nephropathy
C. Exposure to toxic substances C. IgA nephropathy
D. Bacterial infections D. Nephrotic syndrome

2. Dysmorphic RBC casts would be a significant finding with 9. Ischemia frequently produces:
all of the following except: A. Acute renal tubular necrosis
A. Goodpasture syndrome B. Minimal change disorder
B. Acute glomerulonephritis C. Renal glycosuria
C. Chronic pyelonephritis D. Goodpasture’s syndrome
D. Henoch-Schönlein purpura 10. A disorder associated with polyuria and low specific
3. Occasional episodes of macroscopic hematuria over periods gravity is:
of 20 or more years are seen with: A. Renal glucosuria
A. Crescentic glomerulonephritis B. Minimal change disease
B. IgA nephropathy C. Nephrogenic diabetes insipidus
C. Nephrotic syndrome D. Focal segmental glomerulosclerosis
D. Wegener granulomatosis 11. An inherited disorder producing a generalized defect in
tubular reabsorption is:
4. Antiglomerular basement membrane antibody is seen with:
A. Alport syndrome
A. Wegener granulomatosis
B. Acute interstitial nephritis
B. IgA nephropathy
C. Fanconi syndrome
C. Goodpasture syndrome
D. Renal glycosuria
D. Diabetic nephropathy
12. A teenage boy who develops gout in his big toe and has a
5. Antineutrophilic cytoplasmic antibody is diagnostic for: high serum uric acid should be monitored for:
A. IgA nephropathy A. Fanconi syndrome
B. Wegener granulomatosis B. Renal calculi
C. Henoch-Schönlein purpura C. Uromodulin-associated kidney disease
D. Goodpasture syndrome D. Chronic interstitial nephritis
6. Respiratory and renal symptoms are associated with all of 13. The only protein produced by the kidney is:
the following except: A. Albumin
A. IgA nephropathy B. Uromodulin
B. Wegener granulomatosis C. Uroprotein
C. Henoch-Schönlein purpura D. Globulin
D. Goodpasture syndrome
14. The presence of renal tubular epithelial cells and casts is
7. The presence of fatty casts is associated with all of the fol- an indication of:
lowing except: A. Acute interstitial nephritis
A. Nephrotic syndrome B. Chronic glomerulonephritis
B. Focal segmental glomerulosclerosis C. Minimal change disease
C. Nephrogenic diabetes insipidus D. Acute tubular necrosis
D. Minimal change disease
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Chapter 7 | Renal Disease 159

15. Differentiation between cystitis and pyelonephritis is aided 18. Prerenal acute renal failure could be caused by:
by the presence of: A. Massive hemorrhage
A. WBC casts B. Acute tubular necrosis
B. RBC casts C. Acute interstitial nephritis
C. Bacteria D. Malignant tumors
D. Granular casts
19. The most common composition of renal calculi is:
16. The presence of WBCs and WBC casts with no bacteria is A. Calcium oxalate
indicative of:
B. Magnesium ammonium phosphate
A. Chronic pyelonephritis
C. Cystine
B. Acute tubular necrosis
D. Uric acid
C. Acute interstitial nephritis
20. Urinalysis on a patient with severe back pain being eval-
D. Both B and C
uated for renal calculi would be most beneficial if it
17. End-stage renal disease is characterized by all of the showed:
following except: A. Heavy proteinuria
A. Hypersthenuria B. Low specific gravity
B. Isosthenuria C. Uric acid crystals
C. Azotemia D. Microscopic hematuria
D. Electrolyte imbalance

Case Studies and Clinical Situations

1. A 14-year-old boy who has recently recovered from a sore e. What is the expected prognosis of this patient?
throat develops edema and hematuria. Significant labora- f. If the above urinalysis results were seen in a 5-year-old
tory results include a BUN of 30 mg/dL (normal 8 to boy who has developed a red, patchy rash following
23 mg/dL) and a positive group A streptococcal antibody recovery from a respiratory infection, what disorder
test. Results of a urinalysis are as follows: would you suspect?
Color: Red Ketones: Negative 2. B.J. is a seriously ill 40-year-old man with a history of
Clarity: Cloudy Blood: Large several episodes of macroscopic hematuria in the past
Sp. gravity: 1.020 Bilirubin: Negative 20 years. The episodes were associated with exercise or
stress. Until recently the macroscopic hematuria had
pH: 5.0 Urobilinogen: Normal spontaneously reverted to asymptomatic microscopic
Protein: 3+ Nitrite: Negative hematuria. Significant laboratory results include a BUN of
Glucose: Negative Leukocyte: Trace 80 mg/dL (normal 8 to 23 mg/dL), serum creatinine of
4.5 mg/dL (normal 0.6 to 1.2 mg/dL), creatinine clearance
Microscopic:
of 20 mL/min (normal 107 to 139 mL/min), serum calcium
100 RBCs/hpf—many dysmorphic forms of 8.0 mg/dL (normal 9.2 to 11.0 mg/dL), serum phospho-
5–8 WBCs/hpf rus of 6.0 mg/dL (normal 2.3 to 4.7 mg/dL), and an ele-
0–2 granular casts/lpf vated level of serum IgA. Results of a routine urinalysis
are as follows:
0–1 RBC casts/lpf
Color: Red Ketones: Negative
a. What disorder do these results and history
Clarity: Slightly cloudy Blood: Large
indicate?
Sp. gravity: 1.010 Bilirubin: Negative
b. What specific characteristic was present in the
organism causing the sore throat? pH: 6.5 Urobilinogen: Normal
Protein: 300 mg/dL Nitrite: Negative
c. What is the significance of the dysmorphic RBCs?
Glucose: 250 mg/dL Leukocyte: Trace
d. Are the WBCs significant? Why or why not?
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160 Part Two | Urinalysis

Microscopic: and creatinine results and markedly decreased total

>100 RBCs/hpf 2–4 hyaline casts/lpf protein and albumin values. Urinalysis results are as
follows:
8–10 WBCs/hpf 1–5 granular casts/lpf
Color: Yellow Ketones: Negative
0–2 waxy casts/lpf 0–2 broad waxy
Clarity: Hazy Blood: Small
a. What specific disease do the patient’s laboratory
results and history suggest? Sp. gravity: 1.018 Bilirubin: Negative
b. Which laboratory result is most helpful in diagnosing pH: 6.5 Urobilinogen: Normal
this disease? Protein: 4+ Nitrite: Negative
c. What additional diagnosis does his current condition Glucose: Negative Leukocyte: Negative
suggest? Microscopic:
d. What is the significance of the positive result for urine 10–15 RBCs/hpf 0–1 hyaline casts/lpf
glucose?
0–4 WBCs/hpf 0–2 granular casts/lpf
e. Is the specific gravity significant? Why or why not?
Moderate fat droplets 0–1 oval fat bodies/hpf
f. What is the significance of the waxy casts?
a. What disorder do the patient history, physical
3. A 45-year-old woman is recovering from injuries received appearance, and laboratory results suggest?
in an automobile accident that resulted in her being taken b. What other renal disorders produce similar
to the emergency department with severe hypotension. urinalysis results?
She develops massive edema. Significant laboratory re-
c. What is the expected prognosis for this patient?
sults include a BUN of 30 mg/dL (normal 8 to 23 mg/dL),
cholesterol of 400 mg/dL (normal 150 to 240 mg/dL), 5. A 32-year-old construction worker experiences
triglycerides of 840 mg/dL (normal 10 to 190 mg/dL), respiratory difficulty followed by the appearance
serum protein of 4.5 mg/dL (normal 6.0 to 7.8 mg/dL), of blood-streaked sputum. He delays visiting a
albumin of 2.0 mg/dL (normal 3.2 to 4.5 mg/dL), and physician until symptoms of extreme fatigue and
a total urine protein of 3.8 g/d (normal 100 mg/d). red urine are present. A chest radiograph shows pul-
Urinalysis results are as follows: monary infiltration, and sputum culture is negative
Color: Yellow Ketones: Negative for pathogens. Blood test results indicate anemia,
increased BUN and creatinine, and the presence
Clarity: Cloudy Blood: Moderate
of antiglomerular basement membrane antibody.
Sp. gravity: 1.015 Bilirubin: Negative Urinalysis results are as follows:
pH: 6.0 Urobilinogen: Normal Color: Red Ketones: Negative
Protein: 4+ Nitrite: Negative Clarity: Cloudy Blood: Large
Glucose: Negative Leukocyte: Negative Sp. gravity: 1.015 Bilirubin: Negative
Microscopic: ph: 6.0 Urobilinogen: Normal
15–20 RBCs/hpf Moderate free fat droplets Protein: 3+ Nitrite: Negative
0–2 granular casts/lpf
Glucose: Negative Leukocyte: Trace
0–5 WBCs/hpf Moderate cholesterol
Microscopic:
0–2 fatty casts/lpf crystals
100 RBCs/hpf 0–3 hyaline casts/lpf
0–2 oval fat bodies/hpf
10–15 WBCs/hpf 0–3 granular casts/lpf
a. What renal disorder do these results suggest?
0–2 RBCs casts/lpf
b. How does the patient’s history relate to this
disorder? a. What disorder do the laboratory results suggest?
c. What physiologic mechanism accounts for the b. How is this disorder affecting the glomerulus?
massive proteinuria? c. If the antiglomerular membrane antibody test is nega-
d. What is the relationship of the proteinuria to the tive, what disorder might be considered?
edema? d. What is the diagnostic test for this disorder?
e. What mechanism produces the oval fat bodies? e. By what mechanism does this disorder affect the
glomerulus?
4. A routinely active 4-year-old boy becomes increasingly
less active after receiving several preschool immuniza- 6. A 25-year-old pregnant woman comes to the outpatient
tions. His pediatrician observes noticeable puffiness clinic with symptoms of lower back pain, urinary
around the eyes. A blood test shows normal BUN frequency, and a burning sensation when voiding.
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Chapter 7 | Renal Disease 161

Her pregnancy has been normal up to this time. She Microscopic:

is given a sterile container and asked to collect a 6–10 RBCs/hpf Many bacteria
midstream clean-catch urine specimen. Routine 0–2 WBC casts/lpf
urinalysis results are as follows:
>100 WBCs/hpf Moderate birefringent,
Color: Pale yellow Ketones: Negative 0–1 bacterial casts/lpf flat crystals
Clarity: Hazy Blood: Small a. What diagnostic procedure was performed on the pa-
Sp. gravity: 1.005 Bilirubin: Negative tient that could account for the differences in the two
pH: 8.0 Urobilinogen: Normal urinalysis results?
Protein: Trace Nitrite: Positive b. Considering the patient’s age and history, what is the
most probable diagnosis?
Glucose: Negative Leukocyte: 2+
c. What microscopic constituent is most helpful to this
Microscopic:
diagnosis?
6–10 RBCs/hpf Heavy bacteria
d. What is the most probable cause of this disorder?
40–50 WBCs/hpf Moderate squamous
e. How can the presence of the bacterial cast be
epithelial cells
confirmed?
a. What is the most probable diagnosis for this
f. What is the most probable source of the crystals
patient?
present in the sediment?
b. What is the correlation between the color and the
g. Without surgical intervention, what is the patient’s
specific gravity?
prognosis?
c. What is the significance of the blood and protein
tests? 8. A 35-year-old patient being treated for a sinus infection
with methicillin develops fever, a skin rash, and edema.
d. Is this specimen suitable for the appearance of
Urinalysis results are as follows:
glitter cells? Explain your answer.
Color: Dark yellow Ketones: Negative
e. What other population is at a high risk for
developing this condition? Clarity: Cloudy Blood: Moderate
f. What disorder might develop if this disorder is not Sp. gravity: 1.012 Bilirubin: Negative
treated? pH: 6.0 Urobilinogen: Normal
7. A 10-year-old patient with a history of recurrent UTIs is Protein: 3+ Nitrite: Negative
admitted to the hospital for diagnostic tests. Initial urinal- Glucose: Negative Leukocyte: 2+
ysis results are as follows: Microscopic:
Color: Yellow Ketone: Negative 20–30 RBCs/hpf 1–2 WBC casts/lpf
Clarity: Cloudy Blood: Small >100 WBCs/hpf 1–2 granular casts/lpf
Sp. gravity: 1.025 Bilirubin: Negative After receiving the urinalysis report, the physician
pH: 8.0 Urobilinogen: Normal orders a test for urinary eosinophils. The urinary
Protein: 2+ Nitrite: Positive eosinophil result is 10%.
Glucose: Negative Leukocyte: 2+ a. Is the urinary eosinophil result normal or
abnormal?
Microscopic:
b. What is the probable diagnosis for this patient?
6–10 RBCs/hpf 0–2 WBC casts/lpf Many
bacteria c. Discuss the significance of the increased WBCs
and WBC casts in the absence of bacteria.
>100 WBCs/hpf 0–1 bacterial casts/lpf with
clumps d. How can this condition be corrected?
A repeat urinalysis a day later has the following results: 9. Following surgery to correct a massive hemorrhage, a
Color: Yellow Ketones: Negative 55-year-old patient exhibits oliguria and edema. Blood
test results indicate increasing azotemia and electrolyte
clarity: Cloudy Blood: Small
imbalance. The glomerular filtration rate is 20 mL/min.
Sp. gravity: >1.035 bilirubin: Negative Urinalysis results are as follows:
pH: 7.5 Urobilinogen: Normal Color: Yellow Ketones: Negative
Protein: 2+ Nitrite: Positive Clarity: Cloudy Blood: Moderate
Glucose: Negative Leukocyte: 2+ Sp. gravity: 1.010 Bilirubin: Negative
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162 Part Two | Urinalysis

pH: 7.0 Urobilinogen: Normal and an amylase are normal. Results of a routine
Protein: 3+ Nitrite: Negative urinalysis are as follows:
Glucose: 2+ Leukocyte: Negative Color: Dark yellow Ketones: Negative
Microscopic: Clarity: Hazy Blood: Moderate
50–60 RBCs/hpf 2–3 granular casts/lpf Sp. gravity: 1.030 Bilirubin: Negative
3–6 WBCs/hpf 2–3 RTE cell casts/lpf pH: 5.0 Urobilinogen: Normal
3–4 RTE cells/hpf 0–1 waxy casts/lpf Protein: Trace Nitrite: Negative
0–1 broad granular casts/lpf Glucose: Negative Leukocytes: Negative
a. What diagnosis do the patient’s history and labora- Microscopic
tory results suggest? 15–20 RBCs/hpf
b. What is the most probable cause of the patient’s 0–2 WBCs/hpf
disorder? Is this considered to be of prerenal, renal, Few squamous epithelial cells
or postrenal origin?
a. What condition could these urinalysis results and
c. What is the significance of the specific gravity the patient’s symptoms represent?
result?
b. What would account for the crenated RBCs?
d. What is the significance of the RTE cells?
c. Is there a correlation between the urine color and
e. State two possible reasons for the presence of the specific gravity and the patient’s symptoms?
broad casts.
d. Based on the primary substance that causes this
10. A 40-year-old man develops severe back and abdomi- condition, what type of crystals might have been
nal pain after dinner. The pain subsides during the present?
night but recurs in the morning, and he visits his e. What changes will the patient be advised to make
family physician. Results of a complete blood count in his lifestyle to prevent future occurrences?
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Chapter 8 | Urine Screening for Metabolic Disorders 175

Study Questions
1. All states require newborn screening for PKU for early: 8. An overflow disorder that could produce a false-positive
A. Modifications of diet reaction with Clinitest procedure is:
B. Administration of antibiotics A. Cystinuria
C. Detection of diabetes B. Alkaptonuria
D. Initiation of gene therapy C. Indicanuria
D. Porphyrinuria
2. All of the following disorders can be detected by newborn
screening except: 9. A urine that turns black after sitting by the sink for
several hours could be indicative of:
A. Tyrosyluria
A. Alkaptonuria
B. MSUD
B. MSUD
C. Melanuria
C. Melanuria
D. Galactosemia
D. Both A and C
3. The best specimen for early newborn screening is a:
10. Ketonuria in a newborn is an indication of:
A. Timed urine specimen
A. MSUD
B. Blood specimen
B. Isovaleric acidemia
C. First morning urine specimen
C. Methylmalonic acidemia
D. Fecal specimen
D. All of the above
4. Abnormal urine screening tests categorized as an overflow
11. Urine from a newborn with MSUD will have a
disorder include all of the following except: significant:
A. Alkaptonuria A. Pale color
B. Galactosemia B. Yellow precipitate
C. Melanuria C. Milky appearance
D. Cystinuria D. Sweet odor
5. Which of the following disorders is not associated with the 12. Hartnup disease is a disorder associated with the metab-
phenylalanine-tyrosine pathway? olism of:
A. MSUD A. Organic acids
B. Alkaptonuria B. Tryptophan
C. Albinism C. Cystine
D. Tyrosinemia D. Phenylalanine
6. The least serious form of tyrosylemia is: 13. 5-HIAA is a degradation product of:
A. Immature liver function A. Heme
B. Type 1 B. Indole
C. Type 2 C. Serotonin
D. Type 3 D. Melanin

7. An overflow disorder of the phenylalanine-tyrosine path- 14. Elevated urinary levels of 5-HIAA are associated with:
way that would produce a positive reaction with the reagent A. Carcinoid tumors
strip test for ketones is: B. Hartnup disease
A. Alkaptonuria C. Cystinuria
B. Melanuria D. Platelet disorders
C. MSUD
D. Tyrosyluria
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176 Part Two | Urinalysis

15. False-positive levels of 5-HIAA can be caused by a diet 22. Which of the following specimens can be used for
high in: porphyrin testing?
A. Meat A. Urine
B. Carbohydrates B. Blood
C. Starch C. Feces
D. Bananas D. All of the above
16. Place the appropriate letter in front of the following 23. The two stages of heme formation affected by lead
statements. poisoning are:
A. Cystinuria A. Porphobilinogen and uroporphyrin
B. Cystinosis B. Aminolevulinic acid and porphobilinogen
____ IEM C. Coproporphyrin and protoporphyrin
____ Inherited disorder of tubular reabsorption D. Aminolevulinic acid and protoporphyrin
____ Fanconi syndrome 24. Hurler, Hunter, and Sanfilippo syndromes are hereditary
____ Cystine deposits in the cornea disorders affecting metabolism of:
____ Early renal calculi formation A. Porphyrins
17. Blue diaper syndrome is associated with: B. Purines
A. Lesch-Nyhan syndrome C. Mucopolysaccharides
B. Phenylketonuria D. Tryptophan
C. Cystinuria 25. Many uric acid crystals in a pediatric urine specimen may
D. Hartnup disease indicate:
A. Hurler syndrome
18. Homocystinuria is caused by failure to metabolize:
B. Lesch-Nyhan disease
A. Lysine
C. Melituria
B. Methionine
D. Sanfilippo syndrome
C. Arginine
D. Cystine 26. Deficiency of the GALT enzyme will produce a:
A. Positive Clinitest
19. The Ehrlich reaction will only detect the presence of:
B. Glycosuria
A. Uroporphyrin
C. Galactosemia
B. Porphobilinogen
D. Both A and C
C. Coproporphyrin
D. Protoporphyrin 27. Match the metabolic urine disorders with their classic
urine abnormalities.
20. Acetyl acetone is added to the urine before performing the
____ PKU A. Sulfur odor
Ehrlich test when checking for:
____ Indicanuria B. Sweaty feet odor
A. Aminolevulinic acid
____ Cystinuria C. Orange sand in diaper
B. Porphobilinogen
____ Alkaptonuria D. Mousy odor
C. Uroporphyrin
____ Lesch-Nyhan disease E. Black color
D. Coproporphyrin
____ Isovaleric acidemia F. Blue color
21. The classic urine color associated with porphyria is:
A. Dark yellow
B. Indigo blue
C. Pink
D. Port wine
3920_Ch08_163-179 23/01/14 10:24 AM Page 177
Case Studies and Clinical Situations
1. A premature infant develops jaundice. Laboratory tests
are negative for hemolytic disease of the newborn, but
the infant’s bilirubin level continues to rise. Abnormal
urinalysis results include a dark yellow color, positive
bilirubin, and needle-shaped crystals seen on micro-
scopic examination.
a. What is the most probable cause of the infant’s
jaundice?
b. Could these same urine findings be associated with an
adult? Explain your answer.
c. What kinds of crystals are present? Name another type
of crystal with a spherical shape that is associated with
this condition.
d. When blood is drawn from this infant, what precau-
tion should be taken to ensure the integrity of the
specimen?
2. A newborn develops severe vomiting and symptoms
of metabolic acidosis. Urinalysis results are positive for
ketones and negative for glucose and other reducing
substances.
a. If the urine had an odor of “sweaty feet,” what meta-
bolic disorder would be suspected?
b. If the newborn was producing dark brown urine with
a sweet odor, what disorder would be suspected?
c. Would an MS/MS screen be helpful for the diagnosis?
3. A 13-year-old boy is awakened with severe back and
abdominal pain and is taken to the emergency depart-
ment by his parents. A complete blood count is normal.
Family history shows that both his father and uncle are
chronic kidney stone formers. Results of a urinalysis
are as follows:
COLOR: Yellow KETONES: Negative
APPEARANCE: Hazy BLOOD: Moderate
SP. GRAVITY: 1.025 BILIRUBIN: Negative
pH: 6.0 UROBILINOGEN: Normal
PROTEIN: Negative NITRITE: Negative
GLUCOSE: Negative LEUKOCYTE: Negative
Microscopic:
>15–20 RBCs/hpf Few squamous epithelial
cells
0–3 WBCs/hpf Many cystine crystals
a. What condition does the patient’s symptoms represent?
b. What is the physiologic abnormality causing this
condition?
Chapter 8 | Urine Screening for Metabolic Disorders 177
c. If amino acid chromatography was performed on
this specimen, what additional amino acids could be
present?
d. Why are they not present in the microscopic
constituents?
e. Based on the family history, what genetic disorder
should be considered?
4. An 8–month-old boy is admitted to the pediatric unit
with a general diagnosis of failure to thrive. The parents
have observed slowness in the infant’s development of
motor skills. They also mention the occasional appear-
ance of a substance resembling orange sand in the child’s
diapers. Urinalysis results are as follows:
COLOR: Yellow KETONES: Negative
APPEARANCE: Slightly BLOOD: Negative hazy
SP. GRAVITY: 1.024 BILIRUBIN: Negative
pH: 5.0 UROBILINOGEN: Normal
PROTEIN: Negative NITRITE: Negative
GLUCOSE: Negative LEUKOCYTE: Negative
Microscopic:
Many uric acid crystals
a. Is the urine pH consistent with the appearance of uric
acid crystals?
b. Is there any correlation between the urinalysis results
and the substance observed in the child’s diapers?
Explain your answer.
c. What disorder do the patient’s history and the urinaly-
sis results indicate?
d. Is the fact that this is a male patient of any significance?
Explain your answer.
e. Name the enzyme that is missing.
5. Shortly after arriving for the day shift in the urinalysis
laboratory, a technician notices that an undiscarded urine
has a black color. The previously completed
report indicates the color to be yellow.
a. Is this observation significant? Explain your answer.
b. The original urinalysis report showed the specimen
to be positive for ketones. Is this significant? Why or
why not?
c. If the ketones are negative and the pH is 8.0 is this
significant? Why or why not?
6. Bobby Williams, age 8, is admitted through the emer-
gency department with a ruptured appendix. Although
surgery is successful, Bobby’s recovery is slow, and the
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178 Part Two | Urinalysis

physicians are concerned about his health prior to the
ruptured appendix. Bobby’s mother states that he has
always been noticeably underweight despite eating a
balanced diet and having strong appetite and that his
younger brother exhibits similar characteristics. A note
in his chart from the first postoperative day reports that
the evening nurse noticed a blue coloration in the urinary
catheter bag.
a. Is the catheter bag color significant?
b. What condition can be suspected from this history?
c. What is Bobby’s prognosis?
7. An anemic patient is suspected of having lead poisoning.
a. What historical urine test was requested?
b. What should be added to the urine before testing?
c. What element of heme synthesis would this be
testing for?
d. Name another substance that can be tested for lead
poisoning.
e. What element of heme synthesis would this test for?
3920_Ch09_180-202 23/01/14 10:30 AM Page 198
198 Part Three | Other Body Fluids
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www.fadavis.com/strasinger
for additional content related
to this chapter.
References
1. Scanlon,VC and Sanders,T: Essentials of Anatomy and Physiol-
ogy, 5th ed. FA Davis Company, Philadelphia, 2007.
2. Edlow, JA, and Caplan, LR: Avoiding pitfalls in the diagnosis of
subarachnoid hemorrhage. N Engl J Med 342:29–36, 2000.
3. Nagda, KK: Procoagulant activity of cerebrospinal fluid in
health and disease. Indian J Med Res 74:107–110, 1981.
4. Chow, G, and Schmidley, JW: Lysis of erythrocytes and leukocytes
in traumatic lumbar punctures. Arch Neurol 41:1084–1085, 1984.
5. Seehusen, DA, Reeves, MM, and Fomin, DA: Cerebrospinal
fluid analysis. Am Fam Physician 68(6):1103–1108, 2003.
6. Glasser, L: Tapping the wealth of information in CSF. Diagn
Med 4(1):23–33, 1981.
7. University of Virginia Health Sciences Center: Clinical Labora-
tory Procedure Manual. Charlottesville, VA, 1993.
8. Kjeldsberg, CR, and Knight, JA: Body Fluids: Laboratory Exam-
ination of Amniotic, Cerebrospinal, Seminal, Serous and Syn-
ovial Fluids: A Textbook Atlas. ASCP, Chicago, 1993.
9. Abrams, J, and Schumacher, HR: Bone marrow in cerebrospinal
fluid and possible confusion with malignancy. Arch Pathol Lab
Med 110:366–369, 1986.
10. Bentz, JS: Laboratory investigation of multiple sclerosis. Lab
Med 26(6):393–399, 1995.
11. Biou, D, et al: Cerebrospinal fluid protein concentrations in
children: Age-related values in patients without disorders of the
central nervous system. Clin Chem 46(3):399–403, 2000.
12. Fishman, RA: Cerebrospinal Fluid in Diseases of the Nervous
System, ed 2. WB Saunders, Philadelphia, 1992.
13. Hershey, LA, and Trotter, JL: The use and abuse of the cere-
brospinal fluid IgG profile in the adult: A practical evaluation.
Ann Neurol 8(4):426–434, 1980.
14. Grimaldi, LME, et al: Oligoclonal IgG bands in cerebrospinal
fluid and serum during asymptomatic human immunodefi-
ciency virus infection. Ann Neurol 24:277–279, 1988.
15. Rouah, E, Rogers, BB, and Buffone, GJ: Transferrin analysis by
immunofixation as an aid in the diagnosis of cerebrospinal fluid
otorrhea. Arch Pathol Lab Med 111:756–757, 1987.
Study Questions
1. The functions of the CSF include all of the following
except:
A. Removing metabolic wastes
B. Producing an ultrafiltrate of plasma
C. Supplying nutrients to the CNS
D. Protecting the brain and spinal cord
2. The CSF flows through the:
A. Choroid plexus
B. Pia mater
C. Arachnoid space
D. Dura mater
16. Whitaker, JN: Myelin basic protein in cerebrospinal fluid and
other body fluids. Multiple Sclerosis 4(1):16–21, 1998.
17. Okta, M, et al: Evaluation of an enzyme immunoassay for
myelin basic protein in CSF. Clin Chem 46:1326–1330, 2000.
18. Menkes, J: The causes of low spinal fluid sugar in bacterial
meningitis: Another look. Pediatrics 44(1):1–3, 1969.
19. Hourani, BT, Hamlin, EM, and Reynolds, TB: Cerebrospinal
fluid glutamine as a measure of hepatic encephalopathy. Arch
Intern Med 127:1033–1036, 1971.
20. Glasgow, AM, and Dhiensiri, K: Improved assay for spinal fluid
glutamine and values for children with Reye’s syndrome. Clin
Chem 20(6):642–644, 1974.
21. Murray, PR, and Hampton, CM: Recovery of pathogenic bac-
teria from cerebrospinal fluid. J Clin Microbiol 12:554–557,
1980.
22. Sato, Y, et al: Rapid diagnosis of cryptococcal meningitis by
microscopic examination of centrifuged cerebrospinal fluid
sediment. J Neurol Sci 164(1):72–75, 1999.
23. Eng, RHK, and Person, A: Serum cryptococcal antigen determi-
nation in the presence of rheumatoid factor. J Clin Microbiol
14:700–702, 1981.
24. Stockman, L, and Roberts, GD: Specificity of the latex test for
cryptococcal antigen: A rapid simple method for eliminating
interference. J Clin Microbiol 17(5):945–947, 1983.
25. Knight, FR: New enzyme immunoassay for detecting crypto-
coccal antigen. J Clin Pathol 45(9):836–837, 1992.
26. Klausner, JD, Vijayan, T, Chiller,T: Sensitivity and specificity of
a new cryptococcal antigen lateral flow assay in serum and
cerebrospinal fluid. MLO, March 2013.
27. Wojewoda,C: Bacterial Antigen Testing, The Good, the Not So
Bad and the Ugly. NewsPath. Accessed February 14, 2013
28. Leventhal, R and Cheadle, RF: Medical Parasitology, ed.6,
FA Davis Company, Philadelphia, 2012.
29. Davis, LE, and Schmitt, JW: Clinical significance of cere-
brospinal fluid tests for neurosyphilis. Ann Neurol 25:50–53,
1989.
30. Albright, RE, et al: Issues in cerebrospinal fluid management.
Am J Clin Pathol 95(3):397–401, 1991.
31. Lofsness, KG, and Jensen, TL: The preparation of simulated
spinal fluid for teaching purposes. Am J Med Technology
49(7):493–496, 1983.
3. Substances present in the CSF are controlled by the:
A. Arachnoid granulations
B. Blood–brain barrier
C. Presence of one-way valves
D. Blood–CSF barrier
4. What department is the CSF tube labeled 3 routinely
sent to?
A. Hematology
B. Chemistry
C. Microbiology
D. Serology
3920_Ch09_180-202 23/01/14 10:30 AM Page 199

Chapter 9 | Cerebrospinal Fluid 199

5. The CSF tube that should be kept at room temperature is: 12. The purpose of adding albumin to CSF before cytocen-
A. Tube 1 trifugation is to:
B. Tube 2 A. Increase the cell yield
C. Tube 3 B. Decrease the cellular distortion
D. Tube 4 C. Improve the cellular staining
D. Both A and B
6. Place the appropriate letter in front of the statement that
best describes CSF specimens in these two conditions: 13. The primary concern when pleocytosis of neutrophils and
A. Traumatic tap lymphocytes is found in the CSF is:
B. Intracranial hemorrhage A. Meningitis
____ Even distribution of blood in all tubes B. CNS malignancy
____ Xanthochromic supernatant C. Multiple sclerosis
____ Concentration of blood in tube 1 is greater D. Hemorrhage
than in tube 3 14. Neutrophils with pyknotic nuclei may be mistaken for:
____ Specimen contains clots A. Lymphocytes
7. The presence of xanthochromia can be caused by all of B. Nucleated RBCs
the following except: C. Malignant cells
A. Immature liver function D. Spindle-shaped cells
B. RBC degradation
15. The presence of which of the following cells is increased
C. A recent hemorrhage in a parasitic infection?
D. Elevated CSF protein A. Neutrophils
8. A web-like pellicle in a refrigerated CSF specimen B. Macrophages
indicates: C. Eosinophils
A. Tubercular meningitis D. Lymphocytes
B. Multiple sclerosis
16. Macrophages appear in the CSF after:
C. Primary CNS malignancy
A. Hemorrhage
D. Viral meningitis
B. Repeated spinal taps
9. Given the following information, calculate the CSF WBC C. Diagnostic procedures
count: cells counted, 80; dilution, 1:10; large Neubauer
D. All of the above
squares counted, 10.
A. 8 17. Nucleated RBCs are seen in the CSF as a result of:
B. 80 A. Elevated blood RBCs
C. 800 B. Treatment of anemia
D. 8000 C. Severe hemorrhage
D. Bone marrow contamination
10. A CSF WBC count is diluted with:
A. Distilled water 18. After a CNS diagnostic procedure, which of the following
might be seen in the CSF?
B. Normal saline
A. Choroidal cells
C. Acetic acid
B. Ependymal cells
D. Hypotonic saline
C. Spindle-shaped cells
11. A total CSF cell count on a clear fluid should be:
D. All of the above
A. Reported as normal
B. Not reported
C. Diluted with normal saline
D. Counted undiluted
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200 Part Three | Other Body Fluids

19. Hemosiderin granules and hematoidin crystals are seen in: 27. Given the following results, calculate the IgG index: CSF IgG,
A. Lymphocytes 50 mg/dL; serum IgG, 2 g/dL; CSF albumin, 70 mg/dL;
serum albumin, 5 g/dL.
B. Macrophages
A. 0.6
C. Ependymal cells
B. 6.0
D. Neutrophils
C. 1.8
20. Myeloblasts are seen in the CSF:
D. 2.8
A. In bacterial infections
28. The CSF IgG index calculated in Study Question 27
B. In conjunction with CNS malignancy
indicates:
C. After cerebral hemorrhage
A. Synthesis of IgG in the CNS
D. As a complication of acute leukemia
B. Damage to the blood–brain barrier
21. Cells resembling large and small lymphocytes with C. Cerebral hemorrhage
cleaved nuclei represent:
D. Lymphoma infiltration
A. Lymphoma cells
29. The finding of oligoclonal bands in the CSF and not in
B. Choroid cells
the serum is seen with:
C. Melanoma cells
A. Multiple myeloma
D. Medulloblastoma cells
B. CNS malignancy
22. The reference range for CSF protein is: C. Multiple sclerosis
A. 6 to 8 g/dL D. Viral infections
B. 15 to 45 g/dL
30. A CSF glucose of 15 mg/dL, WBC count of 5000,
C. 6 to 8 mg/dL 90% neutrophils, and protein of 80 mg/dL suggests:
D. 15 to 45 mg/dL A. Fungal meningitis
23. CSF can be differentiated from serum by the presence of: B. Viral meningitis
A. Albumin C. Tubercular meningitis
B. Globulin D. Bacterial meningitis
C. Prealbumin 31. A patient with a blood glucose of 120 mg/dL would have
D. Tau transferrin a normal CSF glucose of:
24. In serum, the second most prevalent protein is IgG; in A. 20 mg/dL
CSF, the second most prevalent protein is: B. 60 mg/dL
A. Transferrin C. 80 mg/dL
B. Prealbumin D. 120 mg/dL
C. IgA 32. CSF lactate will be more consistently decreased in:
D. Ceruloplasmin A. Bacterial meningitis
25. Elevated CSF protein values can be caused by all of the B. Viral meningitis
following except: C. Fungal meningitis
A. Meningitis D. Tubercular meningitis
B. Multiple sclerosis
33. Measurement of which of the following can be replaced by
C. Fluid leakage CSF glutamine analysis in children with Reye syndrome?
D. CNS malignancy A. Ammonia
26. The integrity of the blood–brain barrier is measured using B. Lactate
the: C. Glucose
A. CSF/serum albumin index D. α -Ketoglutarate
B. CSF/serum globulin ratio
C. CSF albumin index
D. CSF IgG index
3920_Ch09_180-202 23/01/14 10:30 AM Page 201
34. Before performing a Gram stain on CSF, the specimen
must be:
A. Filtered
B. Warmed to 37°C
C. Centrifuged
D. Mixed
35. All of the following statements are true about cryptococcal
meningitis except:
A. An India ink preparation is positive
B. A starburst pattern is seen on Gram stain
C. The WBC count is over 2000
D. A confirmatory immunology test is available
Case Studies and Clinical Situations
1. 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: 250 µ L Protein: 150 mg/dL
Glucose: 70 mg/dL Gram stain: No organisms
seen
Differential: Neutrophils, 68%; monocytes, 3%; lympho-
cytes, 28%; eosinophils, 1%
Many macrophages containing ingested RBCs
a. What is the most probable condition indicated by
these results? State two reasons for your answer.
b. Are the elevated WBC count and protein significant?
Explain your answer.
c. Are the percentages of the cells in the differential of
any significance? Explain your answer.
d. What two other structures besides RBCs might be
contained in the macrophages?
e. If the blood was unevenly distributed and nucleated
RBCs and capillary structures were seen instead of
macrophages, what would this indicate?
2. A patient with AIDS is hospitalized with symptoms of
high fever and rigidity of the neck. Routine laboratory
tests on the CSF show a WBC count of 100/µ L with a
predominance of lymphocytes and monocytes, glucose
of 55 mg/dL (plasma: 85 mg/dL), and a protein of
70 mg/dL. The Gram stain shows a questionable starburst
pattern.
a. What additional microscopic examination should be
performed?
b. If the test is positive, what is the patient’s diagnosis?
c. If the results of the test are questionable, what addi-
tional testing can be performed?
Chapter 9 | Cerebrospinal Fluid 201
36. The test of choice to detect neurosyphilis is the:
A. RPR
B. VDRL
C. FAB
D. FTA-ABS
d. What could cause a false-positive reaction in this test?
e. If the tests named in a and c are negative, the glucose
level is 35 mg/dL, and a pellicle is observed in the
fluid, what additional testing should be performed?
f. If CSF and serum IEF was performed on this patient,
what unusual findings might be present?
3. A 35-year-old woman is admitted to the hospital with
symptoms of intermittent blurred vision, weakness, and
loss of sensation in her legs. A lumbar puncture is per-
formed with the following results:
Appearance: Colorless, clear
WBC count: 35 cells/µ L (90% lymphocytes)
Glucose: 60 mg/dL (plasma: 100 mg/dL)
Protein: 60 mg/dL (serum: 8 g/dL)
Albumin: 40 mg/dL (serum: 6 g/dL)
IgG globulin: 20 mg/dL (serum: 2 g/dL)
a. Name and perform the calculation to determine the
integrity of the patient’s blood–brain barrier.
b. Does the patient have an intact barrier?
c. Name and perform the calculation used to determine
if IgG is being synthesized within the CNS.
d. What does this result indicate?
e. Considering the patient’s clinical symptoms and the
calculation results, what diagnosis is suggested?
f. If immunofixation electrophoresis is performed on
the patient’s serum and CSF, what findings would be
expected?
g. What substance in the CSF can be measured to moni-
tor this patient?
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202 Part Three | Other Body Fluids

4. Mary Howard, age 5, is admitted to the pediatrics ward c. Are the lymphocytes significant? Why or why not?
with a temperature of 105%F, lethargy, and cervical rigid- d. Would a CSF lactate test be of any value for the diag-
ity. A lumbar spinal tap is performed, and three tubes of nosis? Why or why not?
cloudy CSF are delivered to the laboratory. Preliminary
test results are as follows: 5. State possible technical errors that could result in the fol-
lowing discrepancies:
Appearance: Cloudy
a. An unusual number of Gram stains reported as gram-
WBC count: 800 cells/µ L
positive cocci fail to be confirmed by positive cultures.
Differential: 80% lymphocytes, 15% monocytes,
b. A physician complains that CSF differentials are being
5% neutrophils
reported only as polynuclear and mononuclear cells.
Protein: 65 mg/dL
c. Bacteria observed on the cytospin differential cannot
Glucose: 70 mg/dL be confirmed by Gram stain or culture.
Gram stain: No organisms seen d. The majority of CSF specimens sent to the laboratory
a. From these results, what preliminary diagnosis could from the neurology clinic have glucose readings less
the physician consider? than 50% of the corresponding blood glucose results
b. Is the Gram stain result of particular significance? performed in the clinic.
Why or why not?
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214 Part Three | Other Body Fluids

Study Questions

1. Maturation of spermatozoa takes place in the: 8. An increased semen pH may be caused by:
A. Sertoli cells A. Prostatic infection
B. Seminiferous tubules B. Decreased prostatic secretions
C. Epididymis C. Decreased bulbourethral gland secretions
D. Seminal vesicles D. All of the above

2. Enzymes for the coagulation and liquefaction of semen are 9. Proteolytic enzymes may be added to semen specimens to:
produced by the: A. Increase the viscosity
A. Seminal vesicles B. Dilute the specimen
B. Bulbourethral glands C. Decrease the viscosity
C. Ductus deferens D. Neutralize the specimen
D. Prostate gland 10. The normal sperm concentration is:
3. The major component of seminal fluid is: A. Less than 20 million/µ L
A. Glucose B. More than 20 million/mL
B. Fructose C. Less than 20 million/mL
C. Acid phosphatase D. More than 20 million/µ L
D. Citric acid 11. Given the following information, calculate the sperm con-
centration: dilution, 1:20; sperm counted in five RBC
4. If the first portion of a semen specimen is not collected, the squares on each side of the hemocytometer, 80 and 86;
semen analysis will have which of the following? volume, 3 mL.
A. Decreased pH A. 80 million/mL
B. Increased viscosity B. 83 million/mL
C. Decreased sperm count C. 86 million/mL
D. Decreased sperm motility D. 169 million/µ L
5. Failure of laboratory personnel to document the time a 12. Using the above information, calculate the sperm concen-
semen sample is collected primarily affects the interpreta- tration when 80 sperm are counted in 1 WBC square and
tion of semen: 86 sperm are counted in another WBC square.
A. Appearance A. 83 million/mL
B. Volume B. 166 million per ejaculate
C. pH C. 16.6 million/mL
D. Viscosity D. 50 million per ejaculate
6. Liquefaction of a semen specimen should take place within: 13. The primary reason to dilute a semen specimen before
A. 1 hour performing a sperm concentration is to:
B. 2 hours A. Immobilize the sperm
C. 3 hours B. Facilitate the chamber count
D. 4 hours C. Decrease the viscosity
D. Stain the sperm
7. A semen specimen delivered to the laboratory in a condom
has a normal sperm count and markedly decreased sperm
motility. This indicates:
A. Decreased fructose
B. Antispermicide in the condom
C. Increased semen viscosity
D. Increased semen alkalinity
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Chapter 10 | Semen 215

14. When performing a sperm concentration, 60 sperm are 22. Additional parameters measured by Kruger’s strict mor-
counted in the RBC squares on one side of the hemocy- phology include all of the following except:
tometer and 90 sperm are counted in the RBC squares on A. Vitality
the other side. The specimen is diluted 1:20. The:
B. Presence of vacuoles
A. Specimen should be rediluted and counted
C. Acrosome size
B. Sperm count is 75 million/mL
D. Tail length
C. Sperm count is greater than 5 million/mL
23. Round cells that are of concern and may be included in
D. Sperm concentration is abnormal
sperm counts and morphology analysis are:
15. Sperm motility evaluations are performed: A. Leukocytes
A. Immediately after the specimen is collected B. Spermatids
B. Within 1 hour of collection C. RBCs
C. After 3 hours of incubation D. Both A and B
D. At 6-hour intervals for 1 day
24. If 5 round cells per 100 sperm are counted in a sperm mor-
16. The percentage of sperm showing average motility that is phology smear and the sperm concentration is 30 million,
considered normal is: the concentration of round cells is:
A. 25% A. 150,000
B. 50% B. 1.5 million
C. 60% C. 300,000
D. 75% D. 15 million
17. The purpose of the acrosomal cap is to: 25. Following an abnormal sperm motility test with a normal
A. Penetrate the ovum sperm count, what additional test might be ordered?
B. Protect the the nucleus A. Fructose level
C. Create energy for tail movement B. Zinc level
D. Protect the neckpiece C. MAR test
D. Eosin-nigrosin stain
18. The sperm part containing a mitochondrial sheath is the:
A. Head 26. Follow-up testing for a low sperm concentration would
include testing for:
B. Neckpiece
A. Antisperm antibodies
C. Midpiece
B. Seminal fluid fructose
D. Tail
C. Sperm vitality
19. All of the following are associated with sperm motility
D. Prostatic acid phosphatase
except the:
A. Head 27. The immunobead test for antisperm antibodies:
B. Neckpiece A. Detects the presence of male antibodies
C. Midpiece B. Determines the presence of IgG, IgM, and IgA
antibodies
D. Tail
C. Determines the location of antisperm antibodies
20. The morphologic shape of a normal sperm head is:
D. All of the above
A. Round
28. Measurement of α -glucosidase is performed to detect a
B. Tapered
disorder of the:
C. Oval
A. Seminiferous tubules
D. Amorphous
B. Epididymis
21. Normal sperm morphology when using the WHO criteria is: C. Prostate gland
A. >30% normal forms D. Bulbourethral glands
B. <30% normal forms
C. >15% abnormal forms
D. <15% normal forms
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216 Part Three | Other Body Fluids

29. A specimen delivered to the laboratory with a request 31. Standardization of procedures and reference values for
for prostatic acid phosphatase and glycoprotein p30 was semen analysis is primarily provided by the:
collected to determine: A. Manufacturers of instrumentation
A. Prostatic infection B. WHO
B. Presence of antisperm antibodies C. Manufacturers of control samples
C. A possible rape D. Clinical Laboratory Improvement Amendments
D. Successful vasectomy
30. Following a negative postvasectomy wet preparation, the
specimen should be:
A. Centrifuged and reexamined
B. Stained and reexamined
C. Reported as no sperm seen
D. Both A and B

Case Studies and Clinical Situations

1. A repeat semen analysis for fertility testing is reported as
follows:
VOLUME: 3.5 mL SPERM COUNT: 6 million/mL
VISCOSITY: Normal SPERM MOTILITY: 30%—
grade 1.0
pH: 7.5 MORPHOLOGY: <30% normal
forms—30 spermatids/100 sperm
The results correspond with the first analysis.
a. List three abnormal parameters.
b. What is the sperm concentration? Is this normal?
c. What is the spermatid count? Is this normal?
d. Could the sperm concentration and the spermatid
count be related to the infertility? Explain your answer.
2. A semen analysis on a vasovasostomy patient has a nor-
mal sperm concentration; however, motility is decreased,
and clumping is observed on the wet preparation.
a. Explain the possible connection between these obser-
vations and the patient’s recent surgery.
b. What tests could be performed to further evaluate the
patient’s infertility?
c. Briefly explain the different interpretations offered by
these two tests.
d. State three ways in which a positive result on these
tests could be affecting male fertility.
3. A yellow-colored semen specimen is received in the labo-
ratory. The analysis is normal except for decreased sperm
motility. Explain the possible connection between the two
abnormal findings.
4. Abnormal results of a semen analysis are volume = 1.0 mL
and sperm concentration = 1 million/mL. State a non-
pathologic cause of these abnormal results.
5. A semen specimen with normal initial appearance fails to
liquefy after 60 minutes.
a. Would a specimen pH of 9.0 be consistent with this
observation? Why or why not?
b. State three chemical tests that would be of value in
this analysis.
c. How does this abnormality affect fertility?
6. A specimen is delivered to the laboratory with a request to
determine if semen is present.
a. What two chemical tests could be performed on the
specimen?
b. What additional examination could be performed on
the specimen?
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Chapter 11 | Synovial Fluid 225

References 4. Brown, W, et al: Validation of body fluid analysis on the Coulter

LH 750. Lab Hem 9(3):155–159, 2004.
1. Shmerling, RH: Synovial fluid analysis. A critical reappraisal.
5. Schumacher, HD, Clayburne, G, and Chen, L: Synovial fluid
Rheum Dis Clin North Am 20(2):503–512, 1994.
aspiration and analysis in evaluation of gout and other crystal-
2. Clinical and Laboratory Science Institute (CLSI): Analysis of
induced diseases. Arthritis Foundation: Bulletin on the
Body Fluids in Clinical Chemistry, Approved Guideline, C49-A,
Rheumatic Diseases 53(3), 2004.
Wayne, PA, 2007, CLSI.
6. Harris, MD, Siegel, LB, and Alloway, JA: Gout and hyperuricemia.
3. Smith, GP, and Kjeldsberg, CR: Cerebrospinal, synovial, and serous
Am Fam Physician 59(4):925–934, 1999.
body fluids. In Henry, JB (ed): Clinical Diagnosis and Management
7. Cornbleet, PJ: Synovial fluid crystal analysis. Lab Med 28(12):
by Laboratory Methods. WB Saunders, Philadelphia, 2001.
774–779, 1997.

Study Questions
1. The functions of synovial fluid include all of the following 6. Normal synovial fluid resembles:
except: A. Egg white
A. Lubrication for the joints B. Normal serum
B. Removal of cartilage debris C. Dilute urine
C. Cushioning joints during jogging D. Lipemic serum
D. Providing nutrients for cartilage 7. Before testing, very viscous synovial fluid should be
2. The primary function of synoviocytes is to: treated with:
A. Provide nutrients for the joints A. Normal saline
B. Secrete hyaluronic acid B. Hyaluronidase
C. Regulate glucose filtration C. Distilled water
D. Prevent crystal formation D. Hypotonic saline

3. Which of the following is not a frequently performed test 8. Addition of a cloudy, yellow synovial fluid to acetic acid
on synovial fluid? produces a/an:
A. Uric acid A. Yellow-white precipitate
B. WBC count B. Easily dispersed clot
C. Crystal examination C. Solid clot
D. Opalescent appearance
D. Gram stain
9. Which of the following could be the most significantly
4. The procedure for collecting synovial fluid is called:
affected if a synovial fluid is refrigerated before testing?
A. Synovialcentesis
A. Glucose
B. Arthrocentesis
B. Crystal examination
C. Joint puncture
C. Mucin clot test
D. Arteriocentesis
D. Differential
5. Match the following disorders with their appropriate group: 10. The highest WBC count can be expected to be seen with:
A. Noninflammatory A. Noninflammatory arthritis
B. Inflammatory B. Inflammatory arthritis
C. Septic C. Septic arthritis
D. Hemorrhagic D. Hemorrhagic arthritis
____ Gout
11. When diluting a synovial fluid WBC count, all of the
____ Neisseria gonorrhoeae infection following are acceptable except:
____ Systemic lupus erythematosus A. Acetic acid
____ Osteoarthritis B. Isotonic saline
____ Hemophilia C. Hypotonic saline
____ Rheumatoid arthritis D. Saline with saponin
____ Heparin overdose
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226 Part Three | Other Body Fluids

12. The lowest percentage of neutrophils would be seen in: 19. In an examination of synovial fluid under compensated
A. Noninflammatory arthritis polarized light, rhomboid-shaped crystals are observed.
What color would these crystals be when aligned parallel
B. Inflammatory arthritis
to the slow vibration?
C. Septic arthritis
A. White
D. Hemorrhagic arthritis
B. Yellow
13. All of the following are abnormal when seen in synovial C. Blue
fluid except:
D. Red
A. Neutrophages
20. If crystals shaped like needles are aligned perpendicular
B. Ragocytes
to the slow vibration of compensated polarized light, what
C. Synovial lining cells color are they?
D. Lipid droplets A. White
14. Synovial fluid crystals that occur as a result of purine B. Yellow
metabolism or chemotherapy for leukemia are: C. Blue
A. Monosodium urate D. Red
B. Cholesterol
21. Negative birefringence occurs under red-compensated po-
C. Calcium pyrophosphate larized light when:
D. Apatite A. Slow light is impeded more than fast light
15. Synovial fluid crystals associated with inflammation in B. Slow light is less impeded than fast light
dialysis patients are: C. Fast light runs against the molecular grain of the
A. Calcium pyrophosphate dihydrate crystal
B. Calcium oxalate D. Both B and C
C. Corticosteroid 22. Synovial fluid cultures are often plated on chocolate agar
D. Monosodium urate to detect the presence of:
16. Crystals associated with pseudogout are: A. Neisseria gonorrhoeae
A. Monosodium urate B. Staphylococcus agalactiae
B. Calcium pyrophosphate dihydrate C. Streptococcus viridans
C. Apatite D. Enterococcus faecalis
D. Corticosteroid 23. The most frequently performed chemical test on synovial
fluid is:
17. Synovial fluid for crystal examination should be examined
as a/an: A. Total protein
A. Wet preparation B. Uric acid
B. Wright's stain C. Calcium
C. Gram stain D. Glucose
D. Acid-fast stain 24. Which of the following chemistry tests can be performed
on synovial fluid to determine the severity of RA?
18. Crystals that have the ability to polarize light are:
A. Glucose
A. Corticosteroid
B. Protein
B. Monosodium urate
C. Lactate
C. Calcium oxalate
D. Uric acid
D. All of the above
25. Serologic tests on patients’ serum may be performed to
detect antibodies causing arthritis for all of the following
disorders except:
A. Pseudogout
B. Rheumatoid arthritis
C. Systemic lupus erythematosus
D. Lyme arthritis
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Chapter 11 | Synovial Fluid 227

Case Studies and Clinical Situations

1. A 50-year-old man presents in the emergency department
with severe pain and swelling in the right knee. Arthro-
centesis is performed and 20 mL of milky synovial fluid is
collected. The physician orders a Gram stain, culture, and
crystal examination of the fluid, as well as a serum uric
acid. She requests that the synovial fluid be saved for
possible additional tests.
a. Describe the tubes into which the fluid would be
routinely placed.
b. If the patient’s serum uric acid level is elevated, what
type of crystals and disorder are probable?
c. Describe the appearance of these crystals under direct
and compensated polarized light.
d. Why were the Gram stain and culture ordered?
2. A medical laboratory science student dilutes a synovial
fluid sample before performing a WBC count. The fluid
forms a clot.
a. Why did the clot form?
b. How can the student perform a correct dilution of the
fluid?
c. After the correct dilution is made, the WBC count is
100,000/␮L. State two arthritis classifications that
could be considered.
d. State two additional tests that could be run to
determine the classification.
3. Fluid obtained from the knee of an obese 65-year-old
woman being evaluated for a possible knee replacement
has the following results:
APPEARANCE: Pale yellow and hazy
WBC COUNT: 500 cells/␮L
GRAM STAIN: Negative
GLUCOSE: 110 mg/dL (serum glucose: 115 mg/dL)
a. What classification of joint disorder do these results
suggest?
b. Under electron microscopy, what crystals might be
detected?
c. How does the glucose result aid in the disorder
classification?
4. A synovial fluid sample delivered to the laboratory for a
cell count is clotted.
a. What abnormal constituent is present in the fluid?
b. What type of tube should be sent to the laboratory for
a cell count?
c. Could the original tube be used for a Gram stain and
culture? Why or why not?
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240 Part Three | Other Body Fluids

Serologic Tests 4. Kjeldsberg, CR, and Knight, JA: Body Fluids: Laboratory
Examination of Amniotic, Cerebrospinal, Seminal, Serous and
Measurement of the tumor markers CEA and CA 125 is a valu- Synovial Fluids. A Textbook Atlas. ASCP, Chicago, 1993.
able procedure for identifying the primary source of tumors 5. Valdez, L, et al: Cholesterol: A useful parameter for distinguish-
producing ascitic exudates. The presence of CA 125 antigen ing between pleural exudates and transudates. Chest 99(5):
1097–1102, 1991.
with a negative CEA suggests the source is from the ovaries, 6. Porcel, JM, and Light, RW: Diagnostic approach to pleural fluid
fallopian tubes, or endometrium.7 effusion in adults. Am Fam Physician 73:1211–1220, 2006.
7. Colice, GL, et al: Medical and surgical treatment of parapneu-
monic effusions: An evidence-based guideline. Chest
Log on to 118:1158–1171, 2000.
www.fadavis.com/strasinger 8. Porcel, JM, et al: Use of a panel of tumor markers (carcinoem-
for additional content related bryonic antigen, cancer antigen 125, carbohydrate antigen 15-3
to this chapter. and cytokeratin 19 fragments) in pleural fluid for differential
diagnosis of benign and malignant effusions. Chest 126:
References 1757–1763, 2004.
1. Clinical and Laboratory Standards Institute (CLSI): Body Fluid 9. Runyan, BA, et al: The serum-ascites albumin gradient is
Analysis for Cellular Composition, Approved Guideline C49-A, superior to the exudate transudate concept in the differential
Wayne, PA, 2006. diagnosis of ascites. Ann Intern Med 117:215–218, 1992.
2. Jay, SJ: Pleural effusions: Definitive evaluation of the exudate. 10. Clinical and Laboratory Science Institute (CLSI): Analysis of
Postgrad Med 80(5):180–188, 1986. Body Fluids in Clinical Chemistry, Approved Guideline,
3. Light, RW: Clinical practice: Pleural effusion. N Engl J Med C49-A, Wayne, PA, 2007, CLSI.
346:1971–1977, 2002.

Study Questions
1. The primary purpose of serous fluid is to: 5. An increase in the amount of serous fluid is called a/an:
A. Remove waste products A. Exudate
B. Lower capillary pressure B. Transudate
C. Lubricate serous membranes C. Effusion
D. Nourish serous membranes D. Malignancy

2. The membrane that lines the wall of a cavity is the: 6. Pleural fluid is collected by:
A. Visceral A. Pleurocentesis
B. Peritoneal B. Paracentesis
C. Pericentesis
C. Pleural
D. Thoracentesis
D. Parietal
7. Place the appropriate letter in front of the following state-
3. During normal production of serous fluid, the slight excess
ments describing transudates and exudates.
of fluid is:
A. Transudate
A. Absorbed by the lymphatic system
B. Exudate
B. Absorbed through the visceral capillaries
____ Caused by increased hydrostatic pressure
C. Stored in the mesothelial cells
____ Caused by increased capillary permeability
D. Metabolized by the mesothelial cells ____ Caused by decreased oncotic pressure
4. Production of serous fluid is controlled by: ____ Caused by congestive heart failure
A. Capillary oncotic pressure ____ Malignancy related
B. Capillary hydrostatic pressure ____ Tuberculosis related
C. Capillary permeability ____ Endocarditis related
D. All of the above ____ Clear appearance
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Chapter 12 | Serous Fluid 241

8. Fluid:serum protein and lactic dehydrogenase ratios are 16. A pleural fluid pH of 6.0 indicates:
performed on serous fluids: A. Esophageal rupture
A. When malignancy is suspected B. Mesothelioma
B. To classify transudates and exudates C. Malignancy
C. To determine the type of serous fluid D. Rheumatoid effusion
D. When a traumatic tap has occurred
17. Plasma cells seen in pleural fluid indicate:
9. Which of the following requires the most additional A. Bacterial endocarditis
testing?
B. Primary malignancy
A. Transudate
C. Metastatic lung malignancy
B. Exudate
D. Tuberculosis infection
10. An additional test performed on pleural fluid to classify
18. A significant cell found in pericardial or pleural fluid that
the fluid as a transudate or exudate is the:
should be referred to cytology is a:
A. WBC count
A. Reactive lymphocyte
B. RBC count
B. Mesothelioma cell
C. Fluid:cholesterol ratio
C. Monocyte
D. Fluid-to-serum protein gradient
D. Mesothelial cell
11. A milky-appearing pleural fluid indicates:
19. Another name for a peritoneal effusion is:
A. Thoracic duct leakage
A. Peritonitis
B. Chronic inflammation
B. Lavage
C. Microbial infection
C. Ascites
D. Both A and B
D. Cirrhosis
12. Which of the following best represents a hemothorax?
20. A test performed primarily on peritoneal lavage fluid is
A. Blood HCT: 42 Fluid HCT: 15 a/an:
B. Blood HCT: 42 Fluid HCT: 10 A. WBC count
C. Blood HCT: 30 Fluid HCT: 10 B. RBC count
D. Blood HCT: 30 Fluid HCT: 20 C. Absolute neutrophil count
13. All of the following are normal cells seen in pleural fluid D. Amylase
except:
21. The recommended test for determining whether peri-
A. Mesothelial cells toneal fluid is a transudate or an exudate is the:
B. Neutrophils A. Fluid:serum albumin ratio
C. Lymphocytes B. Serum ascites albumin gradient
D. Mesothelioma cells C. Fluid:serum lactic dehydrogenase ratio
14. A differential observation of pleural fluid associated with D. Absolute neutrophil count
tuberculosis is:
22. Given the following results, classify this peritoneal fluid:
A. Increased neutrophils serum albumin, 2.2 g/dL; serum protein, 6.0 g/dL; fluid
B. Decreased lymphocytes albumin, 1.6 g/dL.
C. Decreased mesothelial cells A. Transudate
D. Increased mesothelial cells B. Exudate
15. All of the following are characteristics of malignant cells 23. Differentiation between bacterial peritonitis and cirrhosis
except: is done by performing a/an:
A. Cytoplasmic molding A. WBC count
B. Absence of nucleoli B. Differential
C. Mucin-containing vacuoles C. Absolute neutrophil count
D. Increased nucleus:cytoplasm ratio D. Absolute lymphocyte count
3920_Ch12_229-242 23/01/14 10:35 AM Page 242
242 Part Three | Other Body Fluids
24. Detection of the CA 125 tumor marker in peritoneal fluid
indicates:
A. Colon cancer
B. Ovarian cancer
C. Gastric malignancy
D. Prostate cancer
25. Chemical tests primarily performed on peritoneal fluid in-
clude all of the following except:
A. Lactose dehydrogenase
B. Glucose
C. Alkaline phosphatase
D. Amylase
Case Studies and Clinical Situations
1. Fluid from a patient with congestive heart failure is col-
lected by thoracentesis and sent to the laboratory for
testing. It appears clear and pale yellow and has a WBC
count of 450/mL, fluid:serum protein ratio of 0.35, and
fluid:serum LD ratio of 0.46.
a. What type of fluid was collected?
b. Based on the laboratory results, would this fluid be
considered a transudate or an exudate? Why?
c. List two other tests that could be performed to aid in
classifying this fluid.
2. A cloudy pleural fluid has a glucose level of 30 mg/dL
(serum glucose level is 100 mg/dL) and a pH of 6.8.
a. What condition do these results indicate?
b. What additional treatment might the patient receive,
based on these results?
3. The following results were obtained on a peritoneal fluid:
serum albumin, 2.8 g/dL; fluid albumin, 1.2 g/dL.
a. Calculate the SAAG.
b. Is this a transudate or an exudate? Why?
c. What is the most probable cause of the effusion?
26. Cultures of peritoneal fluid are incubated:
A. Aerobically
B. Anaerobically
C. At 37°C and 42°C
D. Both A and B
4. Paracentesis is performed on a patient with ascites. The
fluid appears turbid and has an elevated WBC count.
Additional tests ordered include an absolute granulocyte
count, amylase, creatinine, CEA, and CA 125.
a. What is the purpose for the absolute granulocyte
count? If it is less than 250 cells/mL, what condition
is indicated?
b. If the amylase level is elevated, what is its significance?
State an additional test that might be ordered.
c. Explain the significance of an elevated creatinine level.
d. What is the purpose of the CEA and CA 125 tests?
5. Describe a situation in which paracentesis might be
performed on a patient who does not have ascites. If the
RBC count is 300,000/mL, what does this indicate?
6. Microscopic examination of an ascitic fluid shows many
cells with nuclear and cytoplasmic irregularities contain-
ing psammoma bodies. The CEA test result is normal.
What additional test would be helpful?
3920_Ch13_243-254 23/01/14 10:37 AM Page 251
4. Wenk, RE, and Rosenbaum, JM: Examination of amniotic fluid.
In Henry, JB (ed): Clinical Diagnosis and Management by
Laboratory Methods. WB Saunders, Philadelphia, 1996.
5. Heron, HJ: The use of the Fern test to differentiate amniotic
fluid from urine. Triangle Jul:20:60–62, 1963.
6. Liley, AW: Liquor amnii analysis in the management of the
pregnancy complicated by Rhesus sensitization. Am J Obstet
Gynecol 82:1359, 1961.
7. Spinnato, JA, et al: Amniotic bilirubin and fetal hemolytic
disease. Am J Obstet Gynecol 165(4):1030–1035, 1991.
8. McDonald, OL, and Watts, MT: Use of commercially prepared
control sera as quality control materials for spectrophotometric
bilirubin determinations in amniotic fluid. Am J Clin Pathol
84(4):513–517, 1985.
9. Grenache, D: Fetal lung maturity testing: what labs need to
know now. Medical Lab Observer (MLO), February 2012.
10. Gluck, L, et al: Diagnosis of the respiratory distress syndrome
by amniocentesis. Am J Obstet Gynecol 109(3):440–445, 1971.
11. Dubin, SB: Assessment of FLM: Practice parameter. Am J Clin
Pathol 110:723–732, 1998.
12. Kulovich, MV, Hallman, MB, and Gluck, L: The lung profile:
Normal pregnancy. Am J Obstet Gynecol 135:57–60, 1979.
13. Eisenbrey, AB, et al: Phosphatidyl glycerol in amniotic fluid:
Comparison of an “ultrasensitive” immunologic assay with TLC
and enzymatic assay. Am J Clin Pathol 91(3):293–297, 1989.
Study Questions
1. Which of the following is not a function of amniotic fluid?
A. Allows movement of the fetus
B. Allows carbon dioxide and oxygen exchange
C. Protects fetus from extreme temperature changes
D. Acts as a protective cushion for the fetus
2. What is the primary cause of the normal increase in amni-
otic fluid as a pregnancy progresses?
A. Fetal cell metabolism
B. Fetal swallowing
C. Fetal urine
D. Transfer of water across the placenta
3. Which of the following is not a reason for decreased
amounts of amniotic fluid?
A. Fetal failure to begin swallowing
B. Increased fetal swallowing
C. Membrane leakage
D. Urinary tract defects
4. Why might a creatinine level be requested on an amniotic
fluid?
A. Detect oligohydramnios
B. Detect polyhydramnios
C. Differentiate amniotic fluid from maternal urine
D. Evaluate lung maturity
Chapter 13 | Amniotic Fluid 251
14. Chapman, JF: Current methods for evaluating FLM. Lab
Med 17(10):597–602, 1986.
15. Saad, SA, et al: The reliability and clinical use of a rapid
phosphatidyl glycerol assay in normal and diabetic pregnan-
cies. Am J Obstet Gynecol 157(6):1516–1520, 1987.
16. Winn-McMillan, T, and Karon, BS: Comparison of the
TDx-FLM II and lecithin to sphingomyelin ratio assays in
predicting fetal lung maturity. Am J Obstet Gynecol
193,778–782, 2005.
17. TDx/TDxFLx Fetal Lung Maturity II (FLM II) package insert.
Reference 7A76. Abbott Laboratories, Diagnostics Division,
Abbott Park, IL, April 2003.
18. Clinical and Laboratory Standards Institute. Assessment of fetal
lung maturity by the lamellar body count; approved guideline,
CLSI document C58-A. Wayne, PA, CLSI, 2011.
19. Khazardoost, S, et al: Amniotic fluid lamellar body count and
its sensitivity and specificity in evaluating of fetal lung maturity.
J Obstet Gynaecol 25(3):257–259, 2005.
20. Sbarra, AJ, et al: Correlation of amniotic fluid optical density at
650 nm and lecithin/sphingomyelin ratios. Obstet Gynecol
48:613, 1976.
21. Lu Ji, Gronowski, AM, Eby, C,: Lamellar Body Counts Performed
on Automated Hematology Analyzers to Assess Fetal Lung Matu-
rity. LabMedicine 39(7): 419–423, 2008.
5. Amniotic fluid specimens are placed in amber-colored tubes
prior to sending them to the laboratory to prevent the
destruction of:
A. Alpha-fetoprotein
B. Bilirubin
C. Cells for cytogenetics
D. Lecithin
6. How are specimens for FLM testing delivered to and stored
in the laboratory?
A. Delivered on ice and refrigerated
B. Immediately centrifuged
C. Kept at room temperature
D. Delivered in a vacuum tube
7. Why are amniotic specimens for cytogenetic analysis incu-
bated at 37°C prior to analysis?
A. To detect the presence of meconium
B. To differentiate amniotic fluid from urine
C. To prevent photo-oxidation of bilirubin to biliverdin
D. To prolong fetal cell viability and integrity
8. Match the following colors in amniotic fluid with their
significance.
___ A. Colorless 1. Fetal death
___ B. Dark green 2. Normal
___ C. Red-brown 3. Presence of bilirubin
___ D. Yellow 4. Presence of meconium
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252 Part Three | Other Body Fluids

9. A significant rise in the OD of amniotic fluid at 450 nm
indicates the presence of which analyte?
A. Bilirubin
B. Lecithin
C. Oxyhemoglobin
D. Sphingomyelin
10. Plotting the amniotic fluid OD on a Liley graph represents
the severity of hemolytic disease of the newborn. A value
that is plotted in zone II indicates what condition of the
fetus?
A. No hemolysis
B. Mildly affected fetus
C. Moderately affected fetus that requires close monitoring
D. Severely affected fetus that requires intervention
11. The presence of a fetal neural tube disorder may be
detected by:
A. Increased amniotic fluid bilirubin
B. Increased maternal serum alpha-fetoprotein
C. Decreased amniotic fluid phosphatidyl glycerol
D. Decreased maternal serum acetylcholinesterase
12. True or False: An AFP MoM value greater than two times
the median value is considered an indication of a neural
tube disorder.
13. When severe HDN is present, which of the following tests
on the amniotic fluid would the physician not order to
determine whether the fetal lungs are mature enough to
withstand a premature delivery?
A. AFP levels
B. Foam stability index
C. Lecithin/sphingomyelin ratio
D. Phosphatidyl glycerol detection
14. True or False: Prior to 35 weeks’ gestation, the normal L/S
ratio is less than 1.6.
15. When performing an L/S ratio by thin-layer chromatography,
a mature fetal lung will show:
A. Sphingomyelin twice as concentrated as lecithin
B. No sphingomyelin
C. Lecithin twice as concentrated as sphingomyelin
D. Equal concentrations of lecithin and sphingomyelin
16. True or False: Phosphatidyl glycerol is present with an L/S
ratio of 1.1.
17. A rapid immunologic test for FLM that does not require
performance of thin-layer chromatography is:
A. AFP levels
B. Amniotic acetylcholinesterase
C. Aminostat-FLM
D. Bilirubin scan
18. Does the failure to produce bubbles in the Foam Stability
Index indicate increased or decreased lecithin?
A. Increased
B. Decreased
19. The presence of phosphatidyl glycerol in amniotic fluid
fetal lung maturity tests must be confirmed when:
A. Hemolytic disease of the newborn is present
B. The mother has maternal diabetes
C. Amniotic fluid is contaminated by hemoglobin
D. Neural tube disorder is suspected
20. A lamellar body count of 50,000 correlates with:
A. Absent phosphatidyl glycerol and L/S ratio of 1.0
B. L/S ratio of 1.5 and absent phosphatidyl glycerol
C. OD at 650 nm of 1.010 and an L/S ratio of 1.1
D. OD at 650 nm of 0.150 and an L/S ratio of 2.0

Case Studies and Clinical Situations

1. Amniocentesis is performed on a woman believed to be c. What information did this test provide for the physician?
in approximately the 31st week of gestation. This is the d. Why did the physician prefer an Aminostat-FLM to an
second pregnancy for this Rh-negative woman with dia- L/S ratio in this situation?
betes. Spectrophotometric analysis of the fluid shows a
2. Amniocentesis is performed following a maternal serum
∆ A450 of 0.3.
AFP level of 2.2 MoM at 15 weeks’ gestation.
a. Based on the Liley graph, should the physician
a. What fetal condition is suspected?
consider inducing labor?
b. If the amniotic fluid AFP is 2.5 MoM, what additional
b. What else must the physician consider prior to inducing test could be performed?
labor?
c. In what situation would this additional test not be
The physician decides to induce labor based on a performed?
positive Aminostat-FLM.
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Chapter 13 | Amniotic Fluid 253

3. How might a dark green amniotic fluid affect the results 5. Amniocentesis is performed on a woman whose last two
of the following tests? pregnancies resulted in stillbirths due to hemolytic disease
a. Foam Stability Index of the newborn. A screening test performed at the hospital
is positive for bilirubin, and the specimen is sent to a
b. L/S ratio
reference laboratory for a bilirubin scan. Physicians are
c. Aminostat-FLM concerned when the report comes back negative. What
d. OD650 factors would be considered in evaluating this result.
4. How might a blood-streaked amniotic fluid affect the a. Correct specimen was sent
results of the following tests? b. Specimen was refrigerated
a. L/S ratio c. Specimen was exposed to light
b. AChE d. Specimen reached the reference lab within 30 mins
c. Bilirubin analysis
d. Aminostat-FLM
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266 Part Three | Other Body Fluids

Study Questions
1. In what part of the digestive tract do pancreatic enzymes 8. Stools from persons with steatorrhea will contain excess
and bile salts contribute to digestion? amounts of:
A. Large intestine A. Barium sulfate
B. Liver B. Blood
C. Small intestine C. Fat
D. Stomach D. Mucus
2. Where does the reabsorption of water take place in the 9. Which of the following pairings of stool appearance and
primary digestive process? cause does not match?
A. Large intestine
A. Black, tarry: blood
B. Pancreas
B. Pale, frothy: steatorrhea
C. Small intestine
C. Yellow-gray: bile duct obstruction
D. Stomach
D. Yellow-green: barium sulfate
3. Which of the following tests is not performed to detect
osmotic diarrhea? 10. Stool specimens that appear ribbon-like are indicative of
which condition?
A. Clinitest
A. Bile-duct obstruction
B. Fecal fats
B. Colitis
C. Fecal neutrophils
D. Muscle fibers C. Intestinal constriction
D. Malignancy
4. The normal composition of feces includes all of the following
except: 11. A black tarry stool is indicative of:
A. Bacteria A. Upper GI bleeding
B. Blood B. Lower GI bleeding
C. Electrolytes C. Excess fat
D. Water D. Excess carbohydrates
5. What is the fecal test that requires a 3-day specimen? 12. Chemical screening tests performed on feces include all
A. Fecal occult blood of the following except:
B. APT test A. APT test
C. Elastase I B. Clinitest
D. Quantitative fecal fat testing C. Pilocarpine iontophoresis
6. The normal brown color of the feces is produced by: D. Quantitative fecal fats
A. Cellulose 13. Secretory diarrhea is caused by:
B. Pancreatic enzymes A. Antibiotic administration
C. Undigested foodstuffs B. Lactose intolerance
D. Urobilin
C. Celiac sprue
7. Diarrhea can result from all of the following except: D. Vibrio cholerae
A. Addition of pathogenic organisms to the normal
14. The fecal osmotic gap is elevated in which disorder?
intestinal flora
B. Disruption of the normal intestinal bacterial flora A. Dumping syndrome

C. Increased concentration of fecal electrolytes B. Osmotic diarrhea

D. Increased reabsorption of intestinal water and C. Secretory diarrhea
electrolytes D. Steatorrhea
3920_Ch14_255-268 23/01/14 10:39 AM Page 267
15. Microscopic examination of stools provides preliminary
information as to the cause of diarrhea because:
A. Neutrophils are present in conditions caused by
toxin-producing bacteria
B. Neutrophils are present in conditions that affect the
intestinal wall
C. Red and white blood cells are present if the cause is
bacterial
D. Neutrophils are present if the condition is of nonbac-
terial etiology
16. True or False: The presence of fecal neutrophils would be
expected with diarrhea caused by a rotavirus.
17. Large orange-red droplets seen on direct microscopic
examination of stools mixed with Sudan III represent:
A. Cholesterol
B. Fatty acids
C. Neutral fats
D. Soaps
18. Microscopic examination of stools mixed with Sudan III
and glacial acetic acid and then heated will show small
orange-red droplets that represent:
A. Fatty acids and soaps
B. Fatty acids and neutral fats
C. Fatty acids, soaps, and neutral fats
D. Soaps
19. When performing a microscopic stool examination for
muscle fibers, the structures that should be counted:
A. Are coiled and stain blue
B. Contain no visible striations
C. Have two-dimensional striations
D. Have vertical striations and stain red
20. A value of 85% fat retention would indicate:
A. Dumping syndrome
B. Osmotic diarrhea
C. Secretory diarrhea
D. Steatorrhea
21. Which of the following tests would not be indicative of
steatorrhea?
A. Fecal elastase-I
B. Fecal occult blood
C. Sudan III
D. Van de Kamer
22. The term “occult” blood describes blood that:
A. Is produced in the lower GI tract
B. Is produced in the upper GI tract
C. Is not visibly apparent in the stool specimen
D. Produces a black, tarry stool
Chapter 14 | Fecal Analysis 267
23. What is the recommended number of samples that should
be tested to confirm a negative occult blood result?
A. One random specimen
B. Two samples taken from different parts of three
stools
C. Three samples taken from the outermost portion of
the stool
D. Three samples taken from different parts of two
stools
24. The immunochemical tests for occult blood:
A. Test for human globulin
B. Give false-positive reactions with meat hemoglobin
C. Can give false-positive reactions with aspirin
D. Are inhibited by porphyrin
25. Guaiac tests for detecting occult blood rely on the:
A. Reaction of hemoglobin with hydrogen peroxide
B. Pseudoperoxidase activity of hemoglobin
C. Reaction of hemoglobin with ortho-toluidine
D. Pseudoperoxidase activity of hydrogen peroxide
26. What is the significance of an APT test that remains pink
after addition of sodium hydroxide?
A. Fecal fat is present.
B. Fetal hemoglobin is present.
C. Fecal trypsin is present.
D. Vitamin C is present.
27. In the Van de Kamer method for quantitative fecal fat
determinations, fecal lipids are:
A. Converted to fatty acids prior to titrating with
sodium hydroxide
B. Homogenized and titrated to a neutral endpoint with
sodium hydroxide
C. Measured gravimetrically after washing
D. Measured by spectrophotometer after addition of
Sudan III
28. A patient whose stool exhibits increased fats, undigested
muscle fibers, and the inability to digest gelatin may
have:
A. Bacterial dysentery
B. A duodenal ulcer
C. Cystic fibrosis
D. Lactose intolerance
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268 Part Three | Other Body Fluids
29. A stool specimen collected from an infant with diarrhea
has a pH of 5.0. This result correlates with a:
A. Positive APT test
B. Negative trypsin test
C. Positive Clinitest
D. Negative occult blood test
Case Studies and Clinical Situations
1. Microscopic screening of a stool from a patient exhibiting
prolonged diarrhea shows increased fecal neutrophils and
normal qualitative fecal fats and meat fibers.
a. What type of diarrhea do these results suggest?
b. Name an additional test that could provide more diag-
nostic information.
c. Name one probable result for this test and one im-
probable result.
d. If the test for fecal neutrophils were negative and the
fecal fat concentration increased, what type of diarrhea
would be suggested?
2. Laboratory studies are being performed on a 5-year-old
boy to determine whether there is a metabolic reason for
his continued failure to gain weight. In addition to having
blood drawn, the patient has a sweat chloride collected,
provides a random stool sample, and is asked to collect a
72-hour stool sample.
a. How can the presence of steatorrhea be screened for
by testing the random stool sample?
b. How does this test distinguish among neutral fats,
soaps, and fatty acids?
c. What confirmatory test should be performed?
d. Describe the appearance of the stool specimens if
steatorrhea is present.
e. If a diagnosis of cystic fibrosis is suspected, state two
screening tests that could be performed on a stool
specimen to aid in the diagnosis.
f. State a possible reason for a false-negative reaction in
each of these tests.
g. What confirmatory test could be performed?
30. Which of the following tests differentiates a malabsorp-
tion cause from a maldigestion cause in steatorrhea?
A. APT test
B. D-xylose test
C. Lactose tolerance test
D. Occult blood test
3. A physician’s office laboratory is experiencing inconsisten-
cies in the results of patient-collected specimens for
FOBT. Patients are instructed to submit samples from two
areas of three different stools. Positive and negative con-
trols are producing satisfactory results. Patient #1 is a 30-
year-old woman taking over-the-counter medications for
gastric reflux who has reported passing frequent, black
stools. The results of all three specimens are negative for
occult blood. Patient #2 is a 70-year-old woman suffering
from arthritis. She is taking the test as part of a routine
physical. The results of all three specimens are positive
for occult blood. Patient #3 is a 50-year-old man advised
by the doctor to lose 30 lb. He has been doing well on a
high-protein, low-carbohydrate diet. Two of his three
specimens are positive for occult blood.
a. What is the possible nonpathologic cause of the unex-
pected results for Patient #1? Patient #2? Patient #3?
b. How could the physician’s office staff avoid these dis-
crepancies?
c. What testing methodology could be used for Patients #2
and #3?
4. A watery black stool from a neonate is received in the lab-
oratory with requests for an APT test, fecal pH, and a
Clinitest.
a. Can all three tests be performed on this specimen?
Why?
b. If the Clinitest is positive, what pH reading can be
expected? Why?
c. The infant’s hemoglobin remains constant at 18 g/dL.
What was the significance of the black stool?
d. Would this infant be expected to have ketonuria? Why
or why not?
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Chapter 15 | Vaginal Secretions 281

Study Questions
1. Which of the following would not be a reason to collect a 8. A positive amine (Whiff) test is observed in which of the
vaginal fluid for analysis? following syndromes?
A. Vaginitis A. Bacterial vaginosis
B. Complications of pregnancy resulting in preterm B. Vulvovaginal candidiasis
delivery C. Atrophic vaginitis
C. Forensic testing in a sexual assault D. Desquamative inflammatory vaginitis
D. Pregnancy testing
9. A squamous epithelial cell covered with coccobacilli that
2. Which of the following organisms might not be detected extends beyond the cytoplasm margin is a:
if the specimen for vaginal secretion analysis had been A. Basal cell
refrigerated?
B. Parabasal cell
A. Prevotella bivia
C. Clue cell
B. Lactobacillus acidophilus
d. Blastospore
C. Trichomonas vaginalis
10. All of the following are diagnostic of bacterial vaginosis
D. Candida albicans
except:
3. The appearance of the vaginal discharge in vulvovaginal A. Vaginal pH of 3.8
candidiasis is described as:
B. Presence of clue cells
A. Clear and colorless
C. Positive amine (Whiff) test
B. Thin, homogeneous white-to-gray discharge
D. Thin, homogeneous white-to-gray vaginal
C. White, curd-like discharge
D. Yellow-green and frothy
11. Which of the following organisms produces lactic acid
4. A normal range for a vaginal pH is: and hydrogen peroxide to maintain an acid vaginal
A. 3.8 to 4.5 environment?
B. 5.0 to 6.0 A. Gardnerella vaginalis
C. 6.0 to 7.0 B. Mobiluncus spp.
D. 7.0 to 7.4 C. Lactobacilli spp.
D. β -Hemolytic streptococci
5. Which of the following tests differentiates budding yeast
cells from RBCs? 12. All of the following are diagnostic of vulvovaginal candidi-
A. pH asis except:
B. Saline wet mount A. Large numbers of WBCs
C. KOH prep B. Presence of clue cells
D. Whiff test C. Positive KOH test
D. Vaginal pH of 4.0
6. Which of the following constituents is normal in healthy
vaginal fluid secretions? 13. All of the following are diagnostic of trichomoniasis
A. Lactobacilli except:
B. Basal cells A. Vaginal pH of 6.0
C. Trichomonas vaginalis B. Positive amine test
D. Pseudohyphae C. Positive KOH test
D. Motile trichomonads present
7. Vaginal specimens collected for a saline wet prep should be:
A. Refrigerated to preserve motility
B. Prepared as soon as possible
C. Mailed to a reference laboratory
D. Preserved with potassium hydroxide
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282 Part Three | Other Body Fluids

14. The bacteria associated with desquamative inflammatory 15. The protein present in vaginal secretions that can identify
vaginitis is: patients who are at risk for preterm delivery is:
A. β -Hemolytic streptococci A. Human chorionic gonadotropin
B. Trichomonas vaginalis B. Estrogen
C. Gardnerella vaginalis C. PAMG-1
D. Mycoplasma hominis D. Fetal fibronectin

Case Studies and Clinical Situations

1. A 30-year-old woman has symptoms of dysuria, vaginal 3. During a routine visit with the gynecologist, a 60-year-old
itching, and a white, curd-like discharge. During her woman complained of vaginal dryness and soreness. During
visit at the Women’s Clinic, the patient revealed that she the examination, the health-care provider noted erythema
had recently completed a regimen of broad-spectrum of the vaginal mucosa. The pH of the vaginal secretions
antibiotics as treatment for a urinary tract infection. Her was 6.0. The KOH and amine (Whiff) tests were negative.
health-care provider takes a swab of the vaginal secretions The microscopic examination revealed epithelial cells, basal
for analysis. cells, decreased lactobacilli, and increased gram-positive
cocci and gram-negative rods.
a. What tests will be performed on the vaginal specimen?
a. What is the name of this condition?
b. Based on the patient history and observation of the
b. Explain how this condition can occur.
vaginal secretion, which test will be diagnostic for the
probable diagnosis? c. What is the treatment for this condition?
c. What confirmatory test can be performed?
d. What is the probable diagnosis?
e. What is the first choice of treatment?
2. A sexually active teenager visited the Women’s Clinic com-
plaining of vaginal itching and soreness. She indicated that
she was experiencing increased vaginal secretions that were
frothy and yellow to green. Upon examination, the health-
care provider noted a strawberry-like cervix and performed
a pH test on the secretions. The pH was 5.5 and the wet
prep demonstrated “swimming” organisms.
a. What is the probable diagnosis?
b. What other tests can be performed to confirm this
diagnosis?
c. What is the best course of treatment?
d. Should her sexual partner be treated?
e. List three complications that can occur with this
disorder.
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Answers to Study Questions and Case

Studies and Clinical Situations

Chapter 1 d. Refer to the procedure manual. Check expiration

dates of controls and reagents. Open and test a new
Study Questions bottle of control or reagents.
e. When the controls are within range.
1. C 13. B 25. D
4. a. Delay in testing the specimen.
2. A 14. D 26. D
b. Incident report.
3. D 15. A 27. D
c. Delta check.
4. A 16. B 28. B
d. Treatment of the patient will be delayed because the
5. B 17. C 29. 2, 1, 2, 3, 2, 1 specimen will need to be recollected and tested. Extra
6. A 18. C 30. D expense incurred.
7. C 19. A 31. C e. Errors should be corrected as soon as possible follow-
8. D 20. B 32. D ing the institution’s policy. The original result must
9. D 21. D 33. C not be erased.
10. C 22. B 34. D
11. B 23. A Chapter 2
12. A 24. C
Study Questions
Case Studies and Clinical Situations 1. C 8. D 15. C
1. a. Review of the procedure by a designated authority 2. B 9. A 16. C
has not been documented. 3. C 10. A 17. A
b. Instructions and training are not being provided to 4. A 11. B 18. D
personnel performing collections. 5. D 12. B 19. B
c. A safety statement about the heat produced by the 6. C 13. D 20. B
reaction is not in the procedure manual.
7. C 14. A
d. The bottles have not been dated and initialled.
2. a. Correct; proficiency survey tests should be rotated Case Studies and Clinical Situations
among personnel performing the tests.
b. Accept; QC on the Clinitest tablets must only be 1. a. It could have increased pH, nitrite and bacteria
performed when they are used to perform a test. and decreased clarity, glucose, ketones, bilirubin,
urobilinogen and WBCs, RBCs and casts.
c. Correct; documentation of technical competency
should be performed on all personnel working in the b. The specimen was refrigerated and was brought
section and educational qualifications assessed. immediately to the laboratory.
3. a. The procedure was being performed incorrectly. 2. a. It would be less clear.
The correct timing of the glucose reaction was not b. Additional epithelial cells and bacteria (making it not
being done. acceptable for a culture).
b. The technologist performing the test. QC ensures 3. a. The results would be falsely decreased.
that the reagents and instrument are working prop- b. The patient needs to collect another specimen.
erly and that the technologist is performing the test 4. a. Yes.
correctly.
b. The temperature would be lower than body temperature.
c. At the beginning of each shift, when a new bottle
of reagent is opened or as stated in the procedure c. The specimen tested was not from the defendant.
manual. d. An accurately filled out chain of custody form (COC).

297
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298 Answers to Study Questions and Case Studies and Clinical Situations

Chapter 3 Chapter 4
Study Questions Study Questions
1. B 14. B 23. B 1. A 9. D 17. D
2. D 15. B 24. D 2. D 10. A 18. D
3. C 16. D 25. D 3. A 11. C 19. C
4. D 17. B 26. C 4. D 12. B 20. B
5. A 18. A. Beta2-mi- 27. C 5. A 13. D 21. B
6. B croglobulin; 28. B 6. A 14. A 22. A
B. Creatinine;
7. C 29. A 7. C 15. C 23. B
C. Cystatin
8. D C; D. 125I- 30. +0.5 8. C 16. B 24. D
9. B iodothalamate 31. D
10. A 19. B 32. 600 mL/min Case Studies and Clinical Situations
11. C 20. 69 mL/min 33. C 1. a. An elevated pH and a positive reagent strip reaction
12. D 21. D 34. B for nitrite.
13. D 22. D b. The reagent strip specific gravity would be much
lower if the patient had been given radiographic dye.
Case Studies and Clinical Situations c. The reagent strip test for bilirubin would be positive.
d. The reagent strip reaction for blood would be positive
1. a. 160-mg/dL to 180-mg/dL.
and red blood cells would be seen in the microscopic.
b. Renal tubular reabsorption is impaired.
2. a. 1.018
2. a. Juxtaglomerular apparatus → Angiotensinogen
b. Yes.
→ Renin → Angiotensin I → Angiotensin II.
c. It would agree with the reagent strip reading because
b. Vasoconstriction, increased sodium reabsorption, and
like the osmometer, the reagent strip is not affected
increased aldosterone to retain sodium.
by high-molecular-weight substances.
c. Production of renin decreases and, therefore, the
3. Hemoglobin and myoglobin.
actions of the renin-angiotensin-aldosterone system.
a. Examine the patient’s plasma /serum. The breakdown
3. a. The physician can calculate the approximate creatinine
of red blood cells to hemoglobin produces a red
clearance using the MDRD-IDMS-traceable formula.
serum. Myoglobin is produced from skeletal muscle
b. The cystatin C test and the beta2-microglobulin test and is rapidly cleared from the plasma/serum.
serum tests.
4. a. Mrs. Smith has been eating fresh beets.
c. No. The beta2-microglobulin test requires a normal
b. Yes. The pH of Mrs. Smith’s urine is acidic or she has
immune system and malignancies can affect the
not recently consumed fresh beets.
immune system; therefore, the test cannot be reli-
able in patients with immunologic disorders and 5. No. The urine can contain increased pH, glucose, ketones,
malignancies. bilirubin, urobilinogen, nitrite, and small amounts of
cellular structures.
4. a. Yes. Serum from the midnight specimen is not being
separated from the clot and refrigerated in a timely
manner.
Chapter 5
b. Lactic acid will be present in serum that is not
separated from the clot and will affect the freezing Study Questions
point osmolarity readings.
1. A 8. B 15. B
c. If the laboratory is using a freezing point osmometer,
results will be affected by alcohol ingestion; vapor 2. D 9. D 16. A
pressure results would not be affected and could be 3. A 10. 2,1,2,3,1,2,3 17. C
used as a comparison. 4. C 11. B 18. A
5. a. Diabetes insipidus. 5. D 12. A 19. A
b. Neurogenic diabetes insipidus. 6. A 13. A 20. C
c. Nephrogenic diabetes insipidus. 7. D 14. D 21. A
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Answers to Study Questions and Case Studies and Clinical Situations 299

22. B 32. B 42. B 6. a. No, the specimen is clear.

23. C 33. A 43. D b. Myoglobinuria.
24. A 34. 1,3,4,2 44. C c. Muscle damage from the accident (rhabdomyolysis).
25. C 35. A 45. B d. Yes. Myoglobin is toxic to the renal tubules.
26. B 36. D 46. C 7. a. Laboratory personnel are not tightly capping the
27. A 37. C 47. C reagent strip containers in a timely manner.
28. D 38. A 48. A b. Personnel performing the CLIA-waived reagent strip
test are not waiting 2 minutes to read the LE reaction.
29. A 39. C 49. C
c. The student is not mixing the specimen.
30. C 40. A
d. The reagent strips have deterioated and the quality
31. 1, 2, 1, 2, 1, 2 41. B
control on the strips was not performed prior to
reporting the results.
Case Studies and Clinical Situations
1. a. The blood glucose is elevated and has exceeded the
renal tubular maximum (Tm) for glucose. Chapter 6
b. Diabetes mellitus.
Study Questions
c. It indicates diabetes mellitus related renal disease.
1. A 18. D 35. A
d. Renal tubular reabsorption disorders.
2. D 19. B 36. C
2. a. Yellow foam.
3. C 20. C 37. A
b. Possible biliary-duct obstruction preventing bilirubin
from entering the intestine. 4. C 21. A 38. D
c. Icteric. 5. A 22. B 39. A
d. Protection from light. 6. B 23. C 40. C
3. a. Hemoglobinuria. 7. C 24. D 41. D
b. Increased hemoglobin presented to the liver results 8. D 25. D 42. A
in increased bilirubin entering the intestine for 9. C 26. B 43. A
conversion to urobilinogen. 10. D 27. D 44. C
c. The circulating bilirubin is unconjugated. 11. D 28. A 45. D
d. It would if a multisix reagent strip is used and would 12. A 29. B 46. C
not if a Chemstrip is used. A Watson-Schwartz test is
13. C 30. C 47. 4, 3, 5, 1
more specific for porphobilinogen.
14. B 31. C 48. 3, 5, 2, 6, 4
4. a. Negative chemical reactions for blood and nitrite.
Ascorbic acid interference for both reactions. A ran- 15. C 32. D 49. 4, 8, 7, 6, 1, 5
dom specimen or further reduction of nitrite could 16. A 33. D 50. 3, 5, 2, 1, 7, 4
cause the negative nitrite. 17. D 34. B
b. Glucose, bilirubin, LE. Ascorbic acid is a strong re-
ducing agent that interfers with the oxidation reaction Case Studies and Clinical Situations
in the glucose test. Ascorbic acid combines with the
diazo reagent in the bilirubin and LE tests, lowering 1. a. Yeast grows best at a low pH with an increased con-
the sensitivity. centration of glucose.
c. The dark yellow color may be caused by beta-carotene b. Yes, this exceeds the renal threshold.
and vitamin A, and some B vitamins also produce c. No, yeast is not capable of reducing nitrate to
yellow urine. nitrite.
d. Non-nitrite–reducing microorganisms; lack of dietary d. Moderate blood with no RBCs.
nitrate; antibiotic administration. e. Myoglobin is the cause of the positive chemical test
5. a. To check for possible exercise-induced abnormal results. result for blood. The patient has been bed-ridden
b. Negative protein and blood, possible changes in color for an extended period of time, causing muscle
and specific gravity. destruction.
c. Renal.
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300 Answers to Study Questions and Case Studies and Clinical Situations

2. a. The large objects are in a different plane from that of g. No, calcium carbonate crystals are found in alkaline
the urinary constituents. urine; therefore, clumps of amorphous phosphates
b. Contamination by artifacts. may be present.
c. No, because they are in a different plane.
d. Polarizing microscopy. Chapter 7
3. a. Renal tubules.
b. Yes, viral infections can cause tubular damage. Study Questions
c. RTE cells absorb the bilirubin-containing urinary
filtrate. 1. B 8. D 15. A
d. Liver damage inhibits processing of reabsorbed 2. C 9. A 16. C
urobilinogen. 3. B 10. C 17. A
e. Hemolytic anemia. 4. C 11. C 18. A
4. a. The patient is taking a pigmented medication, such as 5. B 12. C 19. A
phenazopyridine. 6. D 13. B 20. D
b. Yes. 7. C 14. D
c. Ask what medications the patient is taking.
d. Ampicillin. Case Studies and Clinical Situations
5. a. Calcium oxalate. 1. a. Acute glomerulonephritis.
b. Monohydrate and dihydrate calcium oxalate. b. M protein in the cell wall of the group A
c. Oval: monohydrate; envelope: dihydrate. streptococcus.
d. Monohydrate. c. Glomerular bleeding.
6. a. Microscopic results do not match the chemical tests d. No, they are also passing through the damaged
for blood, nitrite, and leukocyte esterase. glomerulus.
b. The specimen has been unpreserved at room temper- e. Good prognosis with appropriate management of
ature for too long, the cells have disintegrated, and secondary complications.
the bacteria have converted the nitrite to nitrogen. f. Henoch-Schönlein purpura.
c. The pH. 2. a. IgA nephropathy.
d. Ask the clinic personnel to instruct the patient to col- b. Serum IgA level.
lect a midstream clean-catch specimen and have the
c. Chronic glomerulonephritis/end-stage renal
specimen delivered immediately to the laboratory.
disease.
7. a. No, because they are associated with strenuous
d. Impaired renal tubular reabsorption associated with
exercise.
end-stage renal disease.
b. The positive blood reaction is from hemoglobinuria
e. The specific gravity is the same as that of the ultrafil-
or myoglobinuria resulting from participating in a
trate, indicating a lack of tubular concentration.
contact sport. The protein is orthostatic.
f. The presence of extreme urinary stasis.
c. Increased excretion of RTE cell lysosomes in the
presence of dehydration. 3. a. Nephrotic syndrome.
8. a. Yes, the waxy casts are probably an artifact such as b. Nephrotic syndrome may be caused by sudden,
a diaper fiber. Waxy casts are not associated with severe hypotension.
negative urine protein. c. Changes in the electrical charges of the shield of
b. No, this is normal following an invasive procedure. negativity produce increased membrane permeability.
c. Yes, tyrosine crystals are seen in severe liver disease; d. Decreased plasma albumin lowers the capillary on-
therefore, the bilirubin should be positive. The cotic pressure, causing fluid to enter the interstitial
crystals may be an artifact or from a medication. tissue.
d. Yes, uric acid crystals may be mistaken for cystine e. Reabsorption of filtered lipids by the RTE cells.
crystals. 4. a. Minimal change disease.
e. Yes, radiographic dye crystals associated with a high b. Nephrotic syndrome, focal segmental
specific gravity resemble cholesterol crystals. glomerulosclerosis.
f. No, Trichomonas is carried asymptomatically by men. c. Good prognosis with complete remission.
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Answers to Study Questions and Case Studies and Clinical Situations 301

5. a. Goodpasture syndrome. Chapter 8

b. The autoantibody attaches to the glomerular capillar-
ies, causing complement activation and destruction of Study Questions
the capillaries.
1. A 10. D 19. B
c. Wegener’s granulomatosis.
2. C 11. D 20. B
d. Antineutrophilic cytoplasmic antibody.
3. B 12. B 21. D
e. Granuloma formation resulting from autoantibodies
binding to neutrophils in the vascular walls and 4. C 13. C 22. D
initiating an immune response. 5. A 14. A 23. D
6. a. Cystitis, UTI. 6. A 15. D 24. C
b. The specimen is very dilute. 7. C 16. B, A, B, B, A 25. B
c. Irritation of the urinary tract will cause a small 8. B 17. D 26. D
amount of bleeding. The cells and bacteria may cause 9. D 18. B 27. D, F, A, E, C, B
a trace protein or it may be a false-positive due to the
high pH. Case Studies and Clinical Situations
d. Yes, glitter cells are seen in hypotonic urine.
1. a. Underdevelopment of the liver.
e. Female children.
b. Yes, with severe acquired liver disease.
f. Pyelonephritis.
c. Tyrosine crystals; leucine crystals, bilirubin crystals.
7. a. Intravenous pyelogram.
d. Protect the specimen from light.
b. Chronic pyelonephritis.
2. a. Isovaleric acidemia.
c. WBC cast.
b. Maple syrup urine disease.
d. Reflux nephropathy.
c. Yes, the MS/MS screen would be positive.
e. Performing a Gram stain.
3. a. Renal lithiasis.
f. Radiographic dye.
b. Impaired renal tubular reabsorption of cystine.
g. Permanent tubular damage and progression to
chronic, end-stage renal disease. c. Lysine, arginine, ornithine.
8. a. Abnormal. d. They are more soluble than is cystine.
b. Acute interstitial nephritis. e. The disorder is inherited.
c. This disorder is an inflammation not an infection. 4. a. Yes.
d. Discontinue the medication because it is causing the b. Yes, uric acid crystals accumulating on the surface of
allergic reaction. the diaper could have an orange color.
9. a. Acute renal failure. c. Lesch-Nyhan disease.
b. The prerenal sudden decrease in blood flow to the d. Yes, the disease is inherited as a sex-linked recessive.
kidneys. e. Hypoxanthine guanine phosphoribosyltransferase.
c. Lack of renal concentrating ability. 5. a. Yes. The urine may contain melanin or homogentisic
d. Tubular damage. acid.
e. The increased diameter of the damaged distal convo- b. Yes. Melanin will react with sodium nitroprusside, the
luted tubule and extreme urinary stasis allowing casts reagent used on reagent strips for the detection of ketones.
to form in the collecting ducts. c. Yes. Homogentisic acid turns black in alkaline urine.
10. a. Renal lithiasis. 6. a. Yes, the purple blue color could indicate the presence
b. The high specific gravity. of indican in the urine.
c. Yes, the dark yellow color and high specific gravity b. Hartnup disease.
indicate a concentrated urine, which induces the c. Good with proper dietary supplements.
formation of renal calculi. 7. a. The Ehrlich reaction
d. Calcium oxalate. b. Acetylacetone.
e. Increased hydration and dietary changes. c. Porphobilinogen.
d. Blood.
e. Free erythocyte protoporphyrin (FEP).
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302 Answers to Study Questions and Case Studies and Clinical Situations

Chapter 9 5. a. Stain precipitate is being confused with Gram-

positive cocci.
Study Questions b. Differentials are being reported from the counting
chamber.
1. B 13. A 25. C
c. The albumin is contaminated.
2. C 14. B 26. A
d. The specimens are not being promptly delivered to
3. B 15. C 27. C the laboratory.
4. A 16. D 28. A
5. B 17. D 29. C
6. B, B, A, A 18. D 30. D
Chapter 10
7. C 19. B 31. B Study Questions
8. A 20. D 32. A
1. C 12. C 23. D
9. C 21. A 33. A
2. D 13. A 24. B
10. C 22. B 34. C
3. B 14. A 25. D
11. D 23. B 35. C
4. C 15. B 26. B
12. D 24. B 36. D
5. D 16. B 27. D
6. A 17. A 28. B
Case Studies and Clinical Situations
7. B 18. C 29. C
1. a. Cerebral hemorrhage because of the presence of
8. D 19. A 30. A
erythrophagocytosis, even distribution of blood, and
patient’s history. 9. C 20. C 31. B
b. No, they would be consistent with peripheral blood 10. B 21. A
entering the CSF. 11. B 22. A
c. No, they are consistent with the percentages seen in
peripheral blood. Case Studies and Clinical Situations
d. Hemosidern granules and hemotoidin crystals. 1. a. Sperm concentration, motility, and morphology.
e. A traumatic tap. b. 21,000,000; no.
2. a. An India ink preparation. c. 1,800,000; no.
b. Cryptococcus meningitis. d. Yes. The normal sperm concentration is 20 to
c. Immunologic testing for Cryptococcus. 60 million/mL. Spermatid counts over 1 million
d. Rheumatoid factor. are considered abnormal. Both of these abnormal
results and the abnormal motility are related to de-
e. Acid-fast staining and culture.
fects in sperm maturation.
f. Noticeable oligoclonal bands in both the CSF and
2. a. Male antisperm antibodies may form following
serum.
vasovasostomy procedures.
3. a. CSF/serum albumin index = 6.7.
b. The MAR test and the immunobead test.
b. Yes.
c. The MAR test detects the presence of IgG male sperm
c. IgG index = 1.5. antibodies. The immunobead test delineates the areas
d. Immunoglobulin synthesis within the CNS. of the sperm (head, tail, neck) that are affected by the
e. Multiple sclerosis. antibodies.
f. Oligoclonal banding only in the CSF. d. Clumping, ovum penetration, and motility.
g. Myelin basic protein. 3. The specimen contains urine, which is toxic to sperm,
therefore decreasing viability.
4. a. Viral, tubercular, or fungal meningitis.
4. The specimen was improperly collected, and the first
b. No, the Gram stain would be negative in viral and
part of the ejaculation was lost.
tubercular and not always positive in fungal meningitis.
5. a. Yes, there is insufficient prostatic fluid present.
c. Yes. Lymphocytes are very predominant in viral
meningitis. b. Zinc, citrate, and acid phosphatase.
d. Yes, a CSF lactate level of 25 mg/dL or less would aid c. Sperm motility is severely affected.
in confirming bacterial meningitis. The lactate level 6. a. Acid phosphatase and seminal glycoprotein p30 tests.
would be higher in tubercular and fungal meningitis. b. Microscopic examination for the presence of sperm.
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Answers to Study Questions and Case Studies and Clinical Situations 303

Chapter 11 Case Studies and Clinical Situations

1. a. Pleural fluid.
Study Questions
b. Transudate, because all the test results are consistent
1. B 9. B 18. D with those of a transudate.
2. A 10. C 19. B c. Pleural fluid to serum ratios of cholesterol and
3. A 11. A 20. Negative bilirubin.
4. B 12. A 21. C 2. a. Pneumonia.
5. B, C, B, A, D, 13. C 22. A b. Chest tube drainage.
B, D 14. A 23. C 3. a. 1.6.
6. A 15. B 25. A b. Transudate. The SAAG is above 1.1.
7. B 16. B c. Hepatic disorder.
8. B 17. A 4. a. To differentiate between cirrhosis and peritonitis;
cirrhosis.
Case Studies and Clinical Situations b. Pancreatitis or gastrointestinal perforation; alkaline
phosphatase.
1. a. 1. Sterile, heparinized tube, liquid EDTA tube,
c. Rupture or accidental puncture of the bladder.
nonanticoagulated tube.
d. To detect the presence of gastrointestinal (CEA) and
b. MSU crystals are seen in gout.
ovarian (CA 125) cancers.
c. Highly birefringent, needle-shaped crystals under
5. The patient has been a victim of blunt trauma and the
polarized light that turn yellow when aligned with
physician wants to determine if abdominal bleeding is
the slow vibration of red compensated polarized light.
occurring; abdominal bleeding.
d. Infection is frequently a complication of severe
6. Thyroid profile; CA 125.
inflammation.
2. a. WBC diluting fluid containing acetic acid was used.
b. Normal, hypotonic, or saponin-containing saline Chapter 13
should be used.
c. Crystal-induced inflammatory and septic. Study Questions
d. Gram stain and culture, crystal examination. 1. B 8. 2, 4, 1, 3 15. C
3. a. Noninflammatory. 2. C 9. A 16. True
b. Hydroxyapatite crystals. 3. A 10. C 17. C
c. Glucose. A normal result is consistent with nonin- 4. C 11. B 18. B
flammatory arthritis. 5. B 12. True 19. B
4. a. Fibrinogen. 6. A 13. A 20. D
b. EDTA or heparinized tube. 7. D 14. True
c. No, the bacteria will be trapped in the clot.
Case Studies and Clinical Situations
Chapter 12 1. a. Yes.
b. FLM.
Study Questions c. The level of phosphatidylglycerol present in the fetal
1. C 9. B 18. B lungs.
2. D 10. C 19. C d. Phosphatidylglycerol is essential for FLM, and levels
3. A 11. D 20. B do not always parallel lecithin levels in fetuses of
diabetic mothers.
4. D 12. D 21. B
2. a. A neural tube disorder such as spina bifida or
5. C 13. D 22. B anencephaly.
6. D 14. C 23. C b. An acetylcholinesterase level.
7. B, A, A, A, B, 15. B 24. B c. The amniotic fluid specimen contains blood.
A, B 16. A 25. D
8. B 17. D 26. D
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304 Answers to Study Questions and Case Studies and Clinical Situations

3. a. False-positive result. 3. a. Patient #1: gastric reflux medication containing

b. False-positive result. bismuth may produce black stools; Patient #2:
medications such as aspirin and other NSAIDs may
c. No effect.
cause gastric bleeding; Patient #3: red meat was not
d. False-positive result. avoided for 3 days prior to sample collection.
4. a. False-positive result. b. Provide dietary and medication instructions to patients.
b. False-positive result. c. The Hemoccult ICT immunochemical test.
c. False-positive or test interference. 4. a. The APT test cannot be performed because the
d. No effect. hemoglobin is already denatured.
5. a. The specimen was exposed to light, possible wrong b. The pH will be low because increased carbohydrates
specimen sent. are available for bacterial metabolism.
c. The infant had ingested maternal blood.

Chapter 14 d. Yes, adequate carbohydrates are not present, and fats

are being metabolized for energy.
Study Questions
1. C 11. A 21. B Chapter 15
2. A 12. C 22. C
3. C 13. D 23. B
Study Questions
4. B 14. B 24. A 1. D 6. A 11. C
5. D 15. B 25. B 2. B 7. B 12. B
6. D 16. False 26. B 3. C 8. A 13. C
7. D 17. C 27. A 4. A 9. C 14. A
8. C 18. C 28. C 5. C 10. A 15. D
9. D 19. C 29. C
10. C 20. D 30. B
Case Studies and Clinical Situations
1. a. Vaginal pH, saline and KOH wet preps, Gram stain.
Case Studies and Clinical Situations b. KOH will reveal budding yeast.
1. a. Secretory diarrhea. c. Culture and DNA direct hybridization probe
(Affirm VPIII).
b. Stool culture.
d. Vulvovaginal candidiasis caused by Candida albicans.
c. Probable: Salmonella, Shigella, Campylobacter, Yersinia,
E. coli; Improbable: Staphylococcus, Vibrio. e. Antifungal agents.
d. Osmotic diarrhea. 2. a. Trichomoniasis caused by Trichomonas vaginalis.
2. a. Microscopic examination for fecal fats. b. Wet mount, vaginal pH, amine test from KOH prep,
DNA probe (Affirm VPIII), OSOM Trichomonas
b. Neutral fats stain directly and appear as large, orange-
Rapid Test.
red droplets; soaps and fatty acids appear as smaller
orange-red droplets after pretreatment of the specimen c. Metronidazole.
with heat and acetic acid. d. Yes.
c. Quantitative fecal fat test. e. Complications include low birth rate, premature rupture
d. Bulky and frothy. of membranes, preterm delivery during pregnancy.
e. Muscle fiber screening and the gelatin test for trypsin. 3. a. Desquamative inflammatory vaginitis secondary to
atrophic vaginitis.
f. Muscle fiber: failure to include red meat in the diet;
gelatin test: intestinal degradation of trypsin or the b. Reduced estrogen production in postmenopausal
presence of trypsin inhibitors. women.
g. Chymotrypsin or elastase I. c. Hormone replacement therapy (estrogen).
3920_Abbreviations_305-306 23/01/14 9:14 AM Page 305

Abbreviations

AABB American Association of Blood Banks DNPH 2,4-dinitrophenylhydrazine

A:C albumin:creatinine [ratio] EDS early dumping syndrome
ACE angiotensin-converting enzyme EDTA ethylenediaminetetraacetic acid
AChE acetylcholinesterase eGFR estimated glomerular filtration rate
ADA adenosine deaminase ELISA enzyme-linked immunoabsorbent assay
ADH antidiuretic hormone EPS expressed prostatic secretions
AFP alpha-fetoprotein EQA external quality assessment
AGN acute glomerulonephritis EQC external quality control
AHG antihuman globulin EU Ehrlich unit
AIDS acquired immunodeficiency syndrome FAH fumarylacetoacetate hydrolase
AIN acute interstitial nephritis FDA Food and Drug Administration
ALA ␣ -aminolevulinic acid FEP free erythrocyte protoporphyrin
ANA antinuclear antibody fFN fetal fibronectin
ANCA antineutrophilic cytoplasmic antibody FISH fluorescence in situ hybridization
AOA American Osteopathic Association FLM fetal lung maturity
ARF acute renal failure FOBT fecal occult blood testing
ART assisted reproductive technology FSGS focal segmental glomerulosclerosis
ASHI American Society of Histocompatibility and FTA-ABS fluorescent treponemal antibody-absorption
Immunogenetics GALT galactose-1-phosphate uridyl transferase
ATN acute tubular necrosis gFOBT guaiac fecal occult blood test
BAL bronchoalveolar lavage GFR glomerular filtration rate
BAT bacterial antigen test GI gastrointestinal
BSI body substance isolation GTT glucose tolerance test
BUN blood urea nitrogen 1-H NMR hydrogen nuclear magnetic resonance
BV bacterial vaginosis spectroscopy
CAP College of American Pathologists H+ titratable acid/hydrogen ion
CASA computer-assisted semen analysis H2PO4 hydrogen phosphate ion
CDC Centers for Disease Control and Prevention Hb hemoglobin
CEA carcinoembryonic antigen HBV hepatitis B virus
CHP chemical hygiene plan HCV hepatitis C virus
CLIA Clinical Laboratory Improvement Amendments HCO3 bicarbonate ion
CLRW clinical laboratory reagent water HDN hemolytic disease of the newborn
CLSI Clinical and Laboratory Standards Institute HICPAC Healthcare Infection Control Practices
CNS central nervous system Advisory Committee
COC chain of custody 5-HIAA 5-hydroxyindoleacetic acid
COLA Commission on Laboratory Assessment HIV human immunodeficiency virus
CPPD calcium pyrophosphate dihydrate HLA-B12 human leukocyte antigen-B12
CPR cardiopulmonary resuscitation hpf high-power field
CSF cerebrospinal fluid HRCT high-resolution computerized tomography
CTAB cetyltrimethylammonium bromide HSV herpes simplex virus
Cu2O cuprous oxide IBS irritable bowel syndrome
CuSO4 copper sulfate IDMS isotope dilution mass spectrophotometry
CV coefficient of variation IEF isoelectric focusing
DBDH diisopropyl benzene dihydroperoxide IEM inborn error of metabolism
DCT distal convoluted tubule IFE immunofixation electrophoresis
DI diabetes insipidus iFOBT immunochemical fecal occult blood test
DIDNTB (3⬘,3⬙, diodo 4⬘,4⬙-dihydroxy-5⬙,5⬙- IgA immunoglobulin A
dinitrophenyl)-3,4,5,6-tetra-bromo- IgG immunoglobulin G
sulphonphtalein IgM immunoglobulin M
DIV desquamative inflammatory vaginitis ISO International Organization for Standardization

305
3920_Abbreviations_305-306 23/01/14 9:14 AM Page 306

306 Abbreviations

IUI intra-uterine insemination PEP postexposure prophylaxis

IVF in vitro fertilization PG phosphatidyl glycerol
JC Joint Commission PKU phenylketonuria
KOH potassium hydroxide PM preventive maintenance
LAF lateral flow assay POC point of care
LBC lamellar body count PPE personal protective equipment
LD lactate dehydrogenase PPMT pre- and post-massage test
LE leukocyte esterase PSA prostate-specific antigen
LED light-emitting diode PSP phenolsulfonphthalein
LIS laboratory information system PT proficiency testing
lpf low-power field QA quality assurance
L/S lecithin-sphingomyelin ratio QC quality control
MAR mixed agglutination reaction RA rheumatoid arthritis
MBP myelin basic protein RAAS renin-angiotensin-aldosterone system
MDRD modification of diet in renal disease RBC red blood cell
MESNA mercaptoethane sulfonate sodium RCF relative centrifugal force
MoM multiples of the median RDS respiratory distress syndrome
mOsm milliosmole RF rheumatoid factor
MPGN membranoproliferative glomerulonephritis RGE rapid gastric emptying
MSAFP maternal serum alpha-fetoprotein RPM revolutions per minute
MS/MS tandem mass spectrophotometry RPR rapid plasma reagin
MSDS Material Safety Data Sheet RTE renal tubular epithelial (cells)
MSU monosodium urate (uric acid) SAAG serum-ascites albumin gradient
MSUD maple syrup urine disease SD standard deviation
NaCl sodium chloride SKY fluorescent mapping spectral karyotyping
NFPA National Fire Protection Association SLE systemic lupus erythematosus
NH4+ ammonium ion SSA sulfosalicylic acid
NIRS near-infrared spectroscopy STI sexually transmitted infection
NKDEP National Kidney Disease Education Program TAT turnaround time
NRBC nucleated red blood cell Tm maximal reabsorptive capacity/tubular
NTD neural tube defect reabsorptive maximum
OD optical density TmG maximal tubular reabsorption capacity for
OSHA Occupational Safety and Health glucose
Administration TMB 3,3⬘,5,5⬘-tetramethylbenzidine
PAH p-aminohippuric acid UP Universal Precautions
PAMG-1 placental ␣ 1-microglobulin UTI urinary tract infection
PB peripheral blood VDRL Venereal Disease Research Laboratory
PCR polymerase chain reaction WBC white blood cell
PCT proximal convoluted tubule WHO World Health Organization