GROUP 1- Sweat and Urine A 55-year old obese housewife complains of perineal itching and soreness which prompted her OB-Gyne. Upon pelvic examination, Dr. Smith noted the presence of white vaginal discharge which she promptly collected and sent to the lab for culture and sensitivity. To facilitate her diagnosis, she also instructed her patient to collect “clean-catch” urine for culture and routine urinalysis. Parameter Result Confirmatory Test Color Yellow Clarity Cloudy Odor NA Glucose 500 Bilirubin Negative Sp. Gravity 1.015 Blood Negative Ketone Negative pH 5.0 Protein Negative Urobilinogen Normal Nitrate Negative LE Positive RBC’s 0 to 2 WBC’s 10 to 25; clumps Casts 0 to 10 hyaline Epithelial cells Few squamous epithelials Bacteria Negative Crystals Few urates 1. Identify abnormal findings 2. Identify discrepancies 3. Identify correlations 4. Which is the most likely cause of the patient’s vaginitis? 5. Which two microscopic findings suggest that the urine tested is not from a midstream “clean-catch” specimen? 6. Is the patient showing signs of renal damage or dysfunction? 7. Explain the physiologic mechanism most likely responsible for the presence of glucose in the patient’s urine. 8. What diagnosis best accounts for the glucosuria observed in this specimen?
Transcript
GROUP 1- Sweat and Urine
A 55-year old obese housewife complains of perineal itching and soreness which prompted her OB-Gyne. Upon pelvic examination, Dr. Smith noted the presence of white vaginal discharge which she promptly collected and sent to the lab for culture and sensitivity. To facilitate her diagnosis, she also instructed her patient to collect “clean-catch” urine for culture and routine urinalysis.
Parameter Result Confirmatory TestColor YellowClarity CloudyOdor NAGlucose 500Bilirubin NegativeSp. Gravity 1.015Blood NegativeKetone NegativepH 5.0Protein NegativeUrobilinogen NormalNitrate NegativeLE PositiveRBC’s 0 to 2WBC’s 10 to 25; clumps Casts 0 to 10 hyalineEpithelial cells Few squamous epithelialsBacteria NegativeCrystals Few urates
1. Identify abnormal findings2. Identify discrepancies3. Identify correlations4. Which is the most likely cause of the patient’s vaginitis?5. Which two microscopic findings suggest that the urine tested is not from a midstream
“clean-catch” specimen?6. Is the patient showing signs of renal damage or dysfunction?7. Explain the physiologic mechanism most likely responsible for the presence of glucose
in the patient’s urine.8. What diagnosis best accounts for the glucosuria observed in this specimen?
Dr. Art Lambino, examined the four-month-old infant that had been admitted to the regional hospital earlier in the day. The baby's parents, Alyssa and Jake Keppler, had brought young Allan to the emergency room because he had been suffering from a chronic cough and diarrhea for almost a week. In addition, they said that Allan sometimes would "wheeze" a lot more than they thought was normal for a child with a cold. Their pediatrician had told them that Allan had a cold and would be better in a few days.Upon arriving at the emergency room, the attending pediatrician detected a possible ear infection and noted that salt crystals were present on Allan's skin. Chest auscultation revealed
the presence of rhonchi in the right upper lobe (RUL) of the lung. The attending pediatrician had Allan admitted immediately and called Dr. Lambino, a pediatric pulmonologist. After Dr. Lambino completed his examination and concluded that Allan has cystic fibrosis.
1. What tests and results could have obtained that lead Dr. Lambino to this diagnosis?2. What do scientists currently believe is the cause of CF? In other words, how is the faulty
gene inherited and what direct effect does that have on the affected cells? 3. Draw a flow chart/concept map that illustrates the mechanism whereby the faulty CF
gene causes the production of thick mucus with less water in it than normal. 4. Why does Alvin have salt crystals forming on his skin? Explain the mechanism for this. 5. What is the accepted treatment for children with cystic fibrosis? Make sure to list at least
three and explain why they work (i.e., what is the purpose of each individual treatment). 6. List and explain the mechanism of at least two experimental treatments that are currently
being tried to help patients with cystic fibrosis.
GROUP 2 – HCG and Seminal fluid
A 35 year-old woman came to your laboratory and requested for a pregnancy test. After testing a random urine specimen, the result turned out to be positive. The woman is experiencing vaginal bleeding and that prompted her to visit her doctor. During her prenatal check up, the doctor failed to hear fetal heart beat and palpated a mass in her pelvic area. She then requested for a serum HCG titer and it turned out to be abnormally high.
1. What is your working diagnosis?2. What can you suggest with the blood result?3. Is the woman pregnant?
A 35-year old man undergoing a fertility work-up was requested to submit his seminal fluid to the laboratory. The day after his honeymoon, he collected the specimen in an airconditioned laboratory and immediately submitted it to the MT on duty. The analysis showed the following:
Immotile cells were revived upon addition of Ringer’s solution.1. List the abnormal parameters noted.2. What can you conclude with the change in motility upon the addition of the Ringer’s
solution.3. What are your recommendations?
GROUP 3 + Mr. Natividad – SYNOVIAL AND CSF
Ms. Brown, a 28 year old pre-school teacher experienced numbness in her left leg and difficulty walking last Christmas vacation. Since then, the numbness has seemed to come and go along with episodes of dizziness. A week before her hospital confinement, she noticed numbness on the ride side of her face and a “blurred” vision in the right eye that comes and goes. She complains that she gets tired easily. During her classes, she suddenly lost balance, was unconscious until she was brought to the hospital to be examined. Blood and CSF samples were tested and gave the following results:
B. Microscopic exama. Leukocyte: 3 cells/uLb. Differential count:
i. Monocytes 24%ii. Lymphocytes 75%iii. Neutrophils 1%
C. Chemical exama. Total protein 45 mg/dLb. Glucose 72 mg/dLc. Lactate 28 mg/dLd. IgG 12.4 mg/dLe. Lactate: 18 mg/dL
D. Gram stain results: no organisms seen
1. Enumerate any abnormal results.2. Calculate the CSF/serum albumin index.3. Why is the CSF/serum albumin index a good indicator of Blood-brain barrier
integrity?4. Calculate the CSF IgG index.5. State a diagnosis that is consistent with the results obtained.6. List two additional chemical tests, with the results expected that could be used to
confirm his diagnosis.
Carla, a 37 year old woman met a vehicular accident. The surgeon performed an arthroscopic repair of the torn ligament. After a week, she comes back to the doctor complaining of a persistent and painful swelling in her left knee. Arthrocentesis is performed and synovial fluid analysis reveals the following:
i. Monocytes 13%ii. Lymphocytes 5%iii. Neutrophils 82%
C. Chemical exama. Total protein 5.3 g/dLb. Glucose 35 mg/dLc. Lactate 35 mg/dLd. Uric acid 5.9 mg/dL
D. Gram stain results: GPC present; many leukocytes present
1. Enumerate any abnormal results.2. Calculate the plasma-synovial fluid glucose difference.3. How may the Synovial fluid be classified based on the results obtained?4. What is the most likely diagnosis?
GROUP 4 – SPUTUM AND BALA 57 year old man with persistent cough was asked to collect sputum for 3 consecutive days, the results are as follows:
Day 1Physical
Slightly mucoidMicroscopic
Numerous squamous epithelial cellsNo organisms found
Day 2Physical
Mucopurulent, rustyMicroscopic
Gram’s stain shows Curshmann’s spirals and Charcot-Leyden crystals
Day 3Same as day 2 but with numerous eosinophils
1. Classify whether the results are abnormal or normal2. What can be the reason for the difference in the result on Day 13. What is the possible causes of the results obtained?
A physician performed bronchoscopy from the lower respiratory tract of a 53 year old woman. During culture and sensitivity, the specimen was negative for growth. Giemsa stain revealed Round cysts that resemble H. capsulatum.
1. What is the most probable condition of the patient?2. How come the culture and sensitivity was negative?3. What other tests can be done to confirm your diagnosis?
GROUP 10 – DUODENAL, GASTRIC AND FECAL
Recently, Lola Aning feels she lacks stamina and tires easily. She has consistently been taking ascorbic acid to boost her immune resistance. On one of her regular check-ups, routine urinalysis and hematology tests were performed. She was asked to collect 3 different stool samples for the detection of occult blood and during the gross examination, the stool appeared bloody.
Blood Hematology ResultsHemoglobin – 9.8 g/dL (Reference range for female: 12 to 16 g/dL)Hematocrit – 36 % (Reference range for female: 38% to 47%)
1. Enumerate any abnormal results2. Ingestion of what substances can cause a false positive fecal occult blood test?3. List at least two compounds other than hemoglobin that contain the heme moiety.4. What could account for the occult blood results obtained?5. In this case, the data are suggestive of what condition?
A 46-year old hypertensive woman went for a check-up complaining of left-sided abdominal pain and diarrhea, and was found to have multiple gastric and duodenal ulcers. The patient improved on proton-pump inhibitors, but withdrawal of proton-pump inhibitors led to a recurrence of symptoms, and recurrent duodenal ulcers. There were no significant findings on physical examination, and a serum gastrin level taken initially was normal. Radiological studies were remarkable for diffusely thickened gastric folds in the face of a distended stomach, and a hypervascular 1cm nodule within the liver. This patient had additional serum gastrin levels drawn, all of which came back elevated. The highest value was 900 picograms/mL Importantly, all of these were taken while the patient was not taking proton pump inhibitors. Gastric fluid analysis revealed acid pH, despite the fact that the patient was taking proton-pump inhibitors. His BAO was at 11 mEq/hour while his MAO 12 mEq/hour. The patient was then taken to the operating room for an intraoperative exploration. Careful visual examination and palpation, guided by intraoperative ultrasound, failed to reveal any tumors aside from that which was identified in the left lobe of the liver. The patient then underwent an uncomplicated left hepatectomy. The patient's postoperative course was unremarkable. The patient left the hospital after one week, with normal liver function tests. The gastrin level returned to normal at one month, after which the patient was asymptomatic off of proton pump inhibitor therapy.
1. What syndrome is being presented by the patient? Explain.2. What are the medical tests that have replaced gastric fluid analysis in this present day
and age?3. What other laboratory results, signs and symptoms might be expected in this patient?4. What are other diseases that may present similar signs and symptoms that may confuse
the clinician in diagnosing this patient?
GROUP 6 + Kevin Nicdao – AMNIOTIC FLUID (one case only)
On July 15 of last year, a 38 year old female found she was 2 weeks pregnant with her 2nd baby. On her first pre-natal check-up, she failed to reveal to her new obstetrician that on the last trimester of her pregnancy for her first baby, she was diagnosed with gestational diabetes. Although her pregnancy was uncomplicated, her blood glucose level peaked a week after her delivery. Her blood glucose levels remained elevated until her baby was about 5 months of age (with the levels becoming lower and lower each month) afterwhich, she stopped coming in for monthly check-ups. Up until January of the present year, with the exception of extremely painful and enlarged varicose veins in her genitals, her routine pre-natal visits and routine laboratory work-ups (CBC, U/A and F/A) and are all normal. She has been gaining a noticeably greater weight relative to what is expected in her condition and the doctor is worried that her varicose veins might rupture if she continues to gain more weight until she reaches full-term. Also, if her veins continue to enlarge, she might bleed to death during delivery. The doctor requested for an amniotic fluid analysis.
RESULTS:Absorbance at 350 nm – 0.25 Absorbance at 400 nm – 0.30Absorbance at 425 nm – 0.40 Absorbance at 450 nm – 0.50Absorbance at 475 nm – 0.32 Absorbance at 500 nm – 0.20Absorbance at 550 nm – 0.15 Absorbance at 600 nm – 0.10PG – absentLecithin – 4.7 mg/dLSphingomyelin – 2.3 mg/dL
1. Regarding specimen collection of amniotic fluid:a. Compare and contrast the two ways by which amniocentesis is carried out.b. If the specimen is contaminated with blood, which parameters would be affected?
Explain and support your answer.c. For what reason was the amniotic fluid analysis performed?d. What factors may affect the parameters that are most important in this case? e. What are the necessary precautions for the collection, handling and transport of
the specimen?2. Regarding the analysis of amniotic fluid:
a. What other reasons are there for testing the amniotic fluid aside from the one involved in this case?
b. For every given reason, what parameter in amniotic fluid analysis is most important? (please cite normal and abnormal results and their significance)
c. Explain the methodology/ies (name of method, principle involved, reagents, advantages, disadvantages, sources of error, relative sensitivity and specificity, and other pertinent information) of the following:
i. Confirmation of specimen as amniotic fluid / differentiation from urineii. Fetal lung maturityiii. Fetal bleedingiv. Metabolic diseases
3. Identify and explain the results:
a. L/S ratiob. ∆ A450
4. Give a probable explanation for the following:a. Blood glucose level peak 1 week after delivery
b. Decrease of blood glucose levels in the succeeding monthsc. Significance of her gestational diabetes to her present pregnancyd. Discrepancies and correlations in the given case.e. Results obtained (state whether the doctor will pursue premature delivery or not.
GROUP 7 – PERITONEAL FLUID (one case only)Nanay Celia, a 46 year old fish vendor, underwent paracentesis after being confined for an enlarged stomach and a pleural effusion. Blood is drawn, and a peritoneal fluid specimen is obtained and sent to the laboratory for analysis.
BLOOD CHEMISTRY RESULTSTotal protein: 6.5 g/dL (Reference range: 6.0 to 8.3 g/dL)Lactate dehydrogenase (LD) 300 U/L (Reference range: 275 to 645 U/L)FBS: 82 mg/dL (Referente range: 70 to 110 mg/dL)LFT (ALT, AST, GGT, ALP) normal
PERITONEAL FLUID RESULTSA. Physical exam
a. Color – yellowb. Clarity – clearc. Clots present - no
B. Microscopic exama. Leukocyte count: 8 cells/uLb. Chemical exam:
i. Total protein 2.9 g/dLii. LD 125 U/Liii. Glucose 67 mg/dL
C. Chemical exam: D. Gram stain: no organisms seenE. Cytology exam: no malignant cells seen
1. Calculate the fluid-to-serum total protein ratio.2. Calculate the fluid-to-serum lactate dehydrogenase ratio.3. Classify this peritoneal fluid specimen as a transudate or exudate and state two
physiologic mechanisms that can cause this type of effusion.4. What is the possible diagnosis of the patient? Explain.
GROUP 8 – PERICARDIAL FLUID (one case only)Thoracentesis was performed on a 60-year old female in-patient at the local hospital. She has been complaining of fatigue and inability to perform her favourite hobby which is gardening for a period longer than 10 minutes without experiencing any shortness of breath. Her ankles and legs seem edematous. She says that in some instances, she has awakened at night, gasping for air. On other nights, she was unable to sleep unless sitting upright. Upon hospitalization, the nurse has noticed that she is also exhibiting signs of nocturia, distended neck veins and distant heart sounds. The results of the pericardial specimen are as follows:
Appearance & color: Clear and Reddish-yellow
WBC count 450/µL
Fluid to serum protein ratio of 0.38 and fluid to serum LD ratio of 0.45
1. Is the specimen collected classified as an exudate or transudate? Why?2. List two other tests that could be performed to aid in classifying the fluid.3. What could be the patient’s diagnosis? Explain.4. In which other body cavity can effusion accumulate in these type of patients?5. If the WBC count is 10,000/ µL, would the diagnosis change? What other results will be
expected to change along with this finding?
GROUP 9 – PLEURAL FLUID (one case only)A 36-year old construction worker was rushed to the emergency room of AUFMC and was diagnosed to have unilateral pleural effusion. Thoracentesis was performed and the pleural fluid was sent to the laboratory for evaluation.
BLOOD CHEMISTRY RESULTSTotal protein: 7.0 g/dL (Reference range: 6.0 to 8.3 g/dL)Lactate dehydrogenase (LD) 520 U/L (Reference range: 275 to 645 U/L)FBS: 75 mg/dL (Referente range: 70 to 110 mg/dL)
PLEURAL FLUID RESULTSA. Physical exam
a. Color: yellowb. Clarity: cloudyc. Clots present: no
B. Microscopic exama. Leukocyte count: 1100 cells/uLb. Differential count:
i. Mononuclear cells 93%ii. Neutrophils 3%
C. Chemical exama. Total protein: 4.2 g/dLb. LD: 345 U/Lc. Glucose: 55 mg/dL
D. Gram stain: no organisms seen; leukocytes present
1. Calculate the fluid-to-serum total protein ratio.2. Calculate the fluid-to-serum lactate dehydrogenase ratio.3. Classify this pleural fluid specimen as a transudate or exudate and state two
physiologic mechanisms that can cause this type of effusion.4. What is the possible diagnosis of the patient? Explain.
