Urinalysis & Body Fluids Question 1. Which hormones affect the kidney? Explain your answer Question 2. What is Specific Gravity? What does it say about the urine specimen? Question 3. What are some of the sources of error associated with Urine Chemical Testing? Question 4. What characteristics (physical, chemical, microscopic) does a urine sample from a diabetic patient exhibit? Question 5. What are the physical properties of urine that are evaluated? What are some causes of abnormal colors of urine? What are some of the causes for changes in the clarity of urine? Question 6-8. Case Study#1 A patient visits the doctor complaining of chronic pain near the bottom of his rib cage. The doctor collects a urine sample and asks the patient to submit a stool specimen as soon as possible. The patient returns the next day with a stool specimen that is very pale in color. Urinalysis Results: Physical Exam Color Amber Clarity Clear Chemical Analysis pH Specific Gravity 1.015 Protein Glucose Ketone Nitrite Blood Bilirubin Urobilinogen Leukocyte E Other Tests SSA 6.0 Trace Neg Neg Neg Neg 2+ Normal Neg Trace Question 6. Which results are outside of normal range? Question 7. Is it likely that the urobilinogen is actually normal? 1 Question 8. What is the significance, if any, of the stool specimen? Question 9-12. Refer to the Chemical Examination of urine (reagent strip, confirmatory test) Question 9. Which urine test is most indicative of impending kidney disease? Question 10. Which urine tests are more indicative of liver disease? Question 11. Which urine test may indicate a Urinary Tract Infection(UTI)? Question 12. Which urine test may indicate hematuria? What would the results look like? 2 CASE STUDIES AND CLINICAL SITUATIONS 1. A patient taken to the emergency department following an episode of syncope has a fasting blood glucose level of 450 mg/dL. Results of the routine urinalysis are as follows: COLOR: Pale yellow CLARITY: Clear SP. GRAVITY: 1.020 PH: 5.0 PROTEIN: 1+ GLUCOSE: 250 mg/dL KETONES: Negative BLOOD: Negative BILIRUBIN: Negative UROBILINOGEN: Negative NITRITE: Negative LEUKOCYTES: Negative a. Explain the correlation between the patient’s blood and urine glucose results. A) The renal threshold for glucose is exceeded. B) The episode of sycope interfered with glucose reabsorption. C) The specimen was not tested within 2 hours. D) The renal threshold for glucose is lowered by syncope. b. What is the most probable metabolic disorder associated with this patient? A) Tubular necrosis B) Neurologic damage C) Diabetes mellitus D) Pancreatic insufficiency c. Considering the patient’s condition, what is the significance of the patient’s protein result? A) No significance B) Interference with the protein reaction by the acid pH C) Possible onset of nephropathy D) Proteinuria often occurs with syncope d. What could have been done to delay the onset of proteinuria in this patient? A) Nothing could be done because the syncope was sudden. B) Regulate the patient’s blood glucose. C) Ensure better hydration of the patient. D) Keep the patient in a supine position. e. If the patient in this study had a normal blood glucose level, to what would the urinary glucose be attributed? A) Diabetes insipidus B) Diabetes mellitus C) High carbohydrate diet D) Tubular necrosis 2. Results of a urinalysis performed on a patient scheduled for gallbladder surgery are as follows: COLOR: Amber KETONES: Negative CLARITY: Hazy BLOOD: Negative 1 SP. GRAVITY: 1.022 PH: 6.0 PROTEIN: Negative GLUCOSE: Negative BILIRUBIN: Moderate UROBILINOGEN: Normal NITRITE: Negative LEUKOCYTES: Negative a. What would you see if you were to shake this specimen? A) A cloudy specimen B) Yellow foam C) White foam D) No change b. What confirmatory test can be performed on this specimen? A) Ictotest B) Clinitest C) Acetest D) Watson-Schwartz c. Explain the correlation between the patient’s scheduled surgery and the normal urobilinogen. A) Possible bile duct obstruction B) Presurgery transfusion C) Patient is required to fast D) Possible liver degeneration d. If blood were drawn from this patient, how might the appearance of the serum be described? A) Milky B) Clear C) Red D) Icteric e. What special handling is needed for serum and urine specimens from this patient? A) Refrigeration B) Immediate testing C) Protection from light D) Transport in ice 2 3. Results of a urinalysis on a very anemic and jaundiced patient are as follows: COLOR: Red KETONES: Negative CLARITY: Clear BLOOD: Large SP. GRAVITY: 1.020 BILIRUBIN: Negative PH: 6.0 UROBILINOGEN: 12 EU PROTEIN: Negative NITRITE: Negative GLUCOSE: Negative LEUKOCYTES: Negative a. Would these results indicate hematuria or hemoglobinuria? A) Hematuria B) Hemoglobinuria b. Correlate the patient’s condition with the urobilinogen result. A) Megaloblastic anemia B) Iron deficiency anemia C) Porphyria D) Hemolytic anemia c. Why is the urine bilirubin result negative in this jaundiced patient? A) The bilirubin is conjugated. B) The bilirubin is unconjugated. C) The urobilinogen interferes with the bilirubin reaction. D) Excess bilirubin is not being produced. 4. A female patient arrives at the outpatient clinic with symptoms of lower back pain and urinary frequency with a burning sensation. She is a firm believer in the curative powers of vitamins. She has tripled her usual dosage of vitamins to alleviate her symptoms, but her symptoms have persisted. She is given a sterile container and asked to collect a midstream clean-catch urine specimen. Results of this routine urinalysis are as follows: COLOR: Dark yellow CLARITY: Hazy SP. GRAVITY: 1.012 PH: 7.0 PROTEIN: Trace KETONES: Negative BLOOD: Negative BILIRUBIN: Negative UROBILINOGEN: Normal NITRITE: Negative a. What discrepancies between the chemical and microscopic test results are present? A) Color and specific gravity B) Negative blood and microscopic C) Negative nitrite and microscopic D) All of the above b. What additional chemical tests can be affected by the patient’s vitamin dosage? A) Bilirubin and protein B) Glucose and ketones C) Bilirubin, LE, and glucose D) Glucose, LE and protein 3 c. Discuss the urine color and specific gravity results regarding correlation, and give a possible cause for any discrepancy. A) The dark yellow color is caused by beta carotene. B) The dark yellow color is caused by urobilinogen. C) The specific gravity result correlates with a dark yellow urine. D) The specific gravity is lowered by vitamin intake. d. All of the following are reasons for a negative nitrite test in the presence of increased bacteria except: A) Nitrite converted to nitrogen by heavy amount of bacteria B) Presence of Gram-negative bacteria C) Hydration of the patient to quickly produce urination D) Presence of Gram-positive bacteria 5. Results of a urinalysis collected following practice from a 20-year-old college athlete are as follows: COLOR: Dark yellow KETONES: Negative CLARITY: Hazy BLOOD: 1+ SP. GRAVITY: 1.029 BILIRUBIN: Negative PH: 6.5 UROBILINOGEN: 1 EU PROTEIN: 2+ NITRITE: Negative GLUCOSE: Negative LEUKOCYTES: Negative GLUCOSE: Negative LEUKOCYTES: 1+ Microscopic Examination 8–12 RBC/HPF 40–50 WBC/HPF Heavy bacteria Moderate squamous epithelial cells The physician requests the athlete to collect another specimen in the morning prior to classes and practice. a. What is the purpose of the second sample? A) To analyze a fasting sample B) To detect exercise-induced abnormalities C) To confirm the negative glucose D) To test for performance-enhancing drugs b. What changes would you expect in the second sample? A) Blood and protein B) Protein and glucose C) Bilirubin and urobilinogen D) Blood and urobilinogen 4 c. Is the proteinuria present in the first sample of prerenal, renal, or postrenal origin? A) Prerenal B) Renal C) Postrenal 6. A 14-year-old boy who has recently recovered from a sore throat develops edema and hematuria. Significant laboratory results include a BUN of 30 mg/dL (normal 8 to 23 mg/dL) and a positive Streptozyme test result. Results of a urinalysis are as follows: COLOR: Red CLARITY: Cloudy SP. GRAVITY: 1.020 PH: 5.0 PROTEIN: 3+ GLUCOSE: Negative KETONES: Negative BLOOD: Large BILIRUBIN: Negative UROBILINOGEN: Normal NITRITE: Negative LEUKOCYTE: Trace Microscopic Examination: 100 RBCs/hpf—many dysmorphic forms 5–8 WBCs/hpf 0–2 granular casts/lpf 0–1 RBC casts/lpf a. What disorder do these results and history indicate? A) Acute post-streptococcal glomerulonephritis B) Rapidly progressive glomerulonephritis C) Henoch-Schönlein purpura D) Alport syndrome c. What is the significance of the dysmorphic RBCs? A) Anemia of infection B) Glomerular bleeding C) Autoimmune hemolytic anemia D) Glomerular membrane thickening d. Are the WBCs significant? A) Yes B) No e. What is the expected prognosis of this patient? A) Good recovery with treatment B) Recovery requiring several blood transfusions C) Gradual progression to nephrotic syndrome D) May require renal transplant 5 7. B.J. is a seriously ill 40-year-old man with a history of several episodes of macroscopic hematuria in the past 20 years. The episodes were associated with exercise or stress. Until recently the macroscopic hematuria had spontaneously reverted to asymptomatic microscopic hematuria. Significant laboratory results include a BUN of 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 of 20 mL/min (normal 107 to 139 mL/min), and an elevated level of serum IgA. Results of a routine urinalysis are as follows: COLOR: Red CLARITY: Slightly cloudy SP. GRAVITY: 1.010 PH: 6.5 PROTEIN: 300 mg/dL GLUCOSE: 250 mg/dL KETONES: Negative BLOOD: Large BILIRUBIN: Negative UROBILINOGEN: Normal NITRITE: Negative LEUKOCYTE: Trace Microscopic Examination: >100 RBCs/hpf 2–4 hyaline casts/lpf 8–10 WBCs/hpf 1–5 granular casts/lpf 0–2 waxy casts/lpf 0–2 broad waxy a. What specific disease do the patient’s laboratory results and history suggest? A) Rapidly progressive glomerulonephritis B) Nephrotic syndrome C) IgA nephropathy D) Diabetic nephropathy b. Which laboratory result is most helpful in diagnosing this disease? A) Creatinine clearance B) Serum IgA C) Serum calcium D) Urine glucose c. What additional diagnosis does his current condition suggest? A) End-stage renal disease B) Chronic glomerulonephritis C) Focal segmental glomerulosclerosis D) Acute renal failure d. What is the significance of the positive result for urine glucose? A) Diabetic nephropathy B) Tubular damage C) Polyuria D) No significance e. Is the specific gravity significant? Why or why not? A) Yes, renal concentration is affected. B) Yes, it should be higher due to the glucosuria. C) No, the patient is forcing fluids. 6 D) Specific gravity is not significant. f. What is the significance of the waxy casts? A) They are probably artifacts. B) They indicate acute tubular damage. C) They are associated with severe oliguria. D) They indicate the patient is recovering. 8. A routinely active 4-year-old boy becomes increasingly less active after receiving several preschool immunizations. His pediatrician observes noticeable puffiness around the eyes. A blood test shows normal BUN and creatinine results and markedly decreased total protein and albumin values. Urinalysis results are as follows: COLOR: Yellow CLARITY: Hazy SP. GRAVITY: 1.018 PH: 6.5 PROTEIN: 4+ GLUCOSE: Negative KETONES: Negative BLOOD: Small BILIRUBIN: Negative UROBILINOGEN: Normal NITRITE: Negative LEUKOCYTE: Negative Microscopic Examination 10–15 RBCs/hpf 0–4 WBCs/hpf Moderate fat droplets 0–1 hyaline casts/lpf 0–2 granular casts/lpf 0–1 oval fat bodies/hpf a. What disorder do the patient history, physical appearance, and laboratory results suggest? A) Nephrotic syndrome B) Alport syndrome C) Minimal change disease D) Focal segmental glomerulosclerosis c. What is the expected prognosis for this patient? A) Good B) Poor 9-11 State a disorder or disorders that relate(s) to each of the following descriptions: 9. A patient who tested positive for human immunodeficiency virus exhibits mild symptoms resembling the nephrotic syndrome. A) Minimal change disease B) Focal segmental glomerulosclerosis C) Fanconi syndrome D) Alport syndrome 7 10. A 40-year-old patient diagnosed with systemic lupus erythematosus develops macroscopic hematuria, proteinuria, and the presence of RBC casts in the urine sediment. A) Rapidly progressive glomerulonephritis B) Acute poststreptoccocal glomerulonephritis C) Nephrotic syndrome D) Diabetic nephropathy 11. A 50-year-old patient diagnosed with systemic lupus erythematosus exhibits symptoms of gradually declining renal function and increasing proteinuria. A) Alport syndrome B) Membranous glomerulonephritis C) Minimal change disease D) Nephrogenic diabetes insipidus 12. Which of the following elements are enumerated using low power magnification? 1. Bacteria 2. Casts 3. RBC’s 4. Renal tubular cells 13-17. True= A; False=B 13. A urine sediment that has 2 two or fewer hyaline casts is considered normal 14. Urinary casts are formed in the proximal and distal tubules 15. A patient with an obstruction of the bile duct may have a negative test for bilirubin and an increased amount of urobilinogen 16. A white precipitate in a normal alkaline urine is most likely caused by amorphous phosphates 17. The presence of hemoglobin in the urine may be indicative of a hepatic disorder 18-22. Classify each substance that can be present in urine by indicating an A=Pathologic or B=Nonpathologic condition. 18. ___Renal Epithelial Cells 19. ___Tyrosine crystals 20. ___Calcium carbonate 21. ___Waxy Cast 22. ___Transitional Epithelial Cells 23. When using brightfield microscopy, a urinary cast that appears homogenous with welldefined edges, blunt ends, and cracks is most likely a. Fatty cast b. Granular cast c. Hyaline cast d. Waxy cast 8 24. All the following can be found incorporated into a cast matrix except: a. White blood cells b. Crystals c. Yeast d. Pigments 25. Granular casts degenerate into a. cellular cast b. fatty casts c. hyaline casts d. waxy casts 26. Casts found in the urinary sediment are reported as a. Few, moderate, many, or marked per high power field b. Few, moderate, many, or marked per low power field c. Average number per high power field d. Average number per low power field 27. Which crystal is mostly found in acid urine a. Amorphous phosphates b. Tyrosine c. Calcium carbonate d. Triple phosphate 28. A person submitting a urine specimen following strenuous exercise can normally have all the following in the sediment except: a. Hyaline Casts b. Granular Casts c. WBC casts d. RBC casts 29. The following are initial results obtained during a routine urinalysis. Which results should be investigated further? a. Negative protein; 0-2 hyaline casts b. Urine pH 6.0; calcium oxalate crystals c. Cloudy, yellow urine; specific gravity 1.050 d. Amber urine with yellow foam; negative bilirubin by reagent strip; positive Ictotest 30. Which of the following statements regarding the microscopic examination of urine sediment is false? a. If large numbers of leukocytes are present microscopically, then bacteria are present b. If urinary fat is present microscopically, then the chemical test for protein should be positive c. If large numbers of casts are present microscopically, then the chemical test for protein should be positive d. If large numbers of RBC’s are present microscopically, then the chemical test for blood should be positive 9
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