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Lab ‐ UrinalysisPFN: 18DLAL04
Hours: 2.0
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Lab ‐ Urinalysis
OBJECTIVE:
Action: Perform a complete Urinalysis on 5 separate specimens
Condition: Given the necessary equipment
Standard: Within 75% accuracy
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Lab ‐ Urinalysis
References used to develop this Lesson:
Laboratory subjects book
TM 8‐227‐4 Clinical Lab Procedures, Urinalysis
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Topics
Describe proper urine collection procedures
Describe methods of urine preservation
Describe normal/abnormal urine output
Given the proper equipment describe and perform a
macroscopic and microscopic procedure
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Reason
Urinalysis can be an important diagnostic tool providing evidence of the disease process since 25% of the bodies blood flows through the Kidneys each minute
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Types of Urine Specimen Collection
Random ‐ most commonly received specimen
Purpose
Routine screening
Inadequate for microbiological exam
Container
Clean dry container with tight fitting lid
Method
Void directly into container or bedpan
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Types of Urine Specimen Collection
First morning void ‐ specimen of choice for qualitative analysis
Purpose
Routine screening
Concentrated
Container
Clean dry container with tight fitting lid
Method
Collect first specimen immediately upon rising
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Types of Urine Specimen Collection
Midstream clean‐catch
Purpose
Most commonly used for bacteriological exam
Alternative to catheterized specimens
Container
Sterile container
Method
Clean area around urethra and discard initial stream
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Types of Urine Specimen Collection
Catheterized
Purpose
Bacterial culture
Routine urinalysis
Collection
Container
Same as midstream clean‐catch
Method
Collected under sterile conditions from catheter
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Types of Urine Specimen Collection
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Types of Urine Specimen Collection
Suprapubic aspiration
Purpose
Bacterial culture
Cytological exam
Container
Same as clean catch
Method
External introduction of a needle into the bladder
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Types of Urine Specimen Collection
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Types of Urine Specimen Collection
Two‐hour postprandial
Purpose
Monitoring insulin therapy (diabetes mellitus)
Used to compare fasting specimen results
Container
Clean and dry with tight fitting lid
Method
Void, Consume meal, collect specimen 2 hours later
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Types of Urine Specimen Collection Twenty‐four hour urine
Purpose
To measure exact amount of urine chemicals
Specimen of choice for quantitative chemical testing
Container
Clean, dark, dry container designed to hold large volume
Method
Void first morning, collect all other voids to include day 2 first morning void
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Types of Urine Specimen Collection
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Urine Preservative Purpose ‐ to prevent changes in urine composition
Increased Ph
Decreased glucose
Decreased ketones
Decreased bilirubin
Decreased urobilinogen
Increased nitrite
Increased bacteria
Increased turbidity
Disintegration cellular elements
Color changes
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Functions of Preservatives
Prevent oxygen contact with specimen
Maintains acid pH
Retard microbial growth
Fix organized sediment
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Types of Urine Preservatives
Refrigeration
Tolulene
Formaline
Boric Acid /HCL
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Refrigeration
Short term preservation of chemical and cellular elements
Advantages and disadvantages
Easiest and most common
No interference
Acceptable for urine culture
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Freezing
Used for bilirubin and urobilinogen
Advantages and disadvantages
Preserves bilirubin and urobilinogen
Turbidity occurs upon freezing
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Formalin
Used for sediment preservation
Preserves formed elements
Disadvantage
May cause clumping of sediment
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Boric Acid
Used for proteins, uric acid and hormones
Advantage
Acceptable for urine culture
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Hydrochloric Acid (HCL)
Used for calcium, d‐aminolevulinic acid, and oxalate testing
Disadvantages
Destroys formed elements
Precipitates solutes
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Boric acid/HCL
Test dependent
Precautions
May interfere with some tests
When in doubt look it up
When shipping ‐ Preserve the specimen as directed by the receiving Laboratory
CAUTION: Chemicals may cause burns
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Sub Summary
Do chemical preservatives interfere with urine dip stix tests?
Yes
What is the most common urine preservative?
Refrigeration
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Volume
Normal excretory output of the kidneys
Normal void (600 to 2,000) ml/24 hours
Normal average void per 24 hours (1200 to 1500) ml/24hrs
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Volume
Factors affecting normal urine production
Temperature
• Cold (increased)
• Heat (decreased)
Diet
• Liquid (increased)
• Less (decreased)
Exercise
• Sweat (decreased)
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Abnormal Urine Volume
Polyuria
Oliguria
Anuria
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Polyuria
Increased urine production ‐ greater than 2,000 mL/24 hrs
Clinical conditions
Diabetes insipidus
Diabetes mellitus
Nervousness and anxiety
Increased fluid intake
Diuretic medications
Diuretic drinks
Chronic renal disease
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Oliguria
Decreased urine production ‐ less than 500 mL/24 hr
Clinical conditions
Decrease fluid intake
Increase ingestion of salt
Excessive perspiration
Dehydration
Partial renal shutdown
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Anuria
Cessation of urine flow ‐ 100 mL/24 hr
Clinical conditions
Total renal shutdown
Massive fluid loss
Heavy metal poisoning
Blockage of renal tubules
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Sub Summary
What is increased urine out put?
Polyurea
What is normal urine output?
Normal void 600 to 2,000 mL/24 hours
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Color
Normal color ‐ due to varying amounts of pigment called urochrome
Straw
Yellow
Amber‐ normal unless caused by the presence of bilirubin
Colorless‐ normal if caused by recent fluid consumption
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Abnormal Urine Color
Red‐ Fresh blood
Orange‐ Medications
Brown‐ Hemoglobin
Black‐ Malaria
Blue‐green‐ Pseudomonas infections; medications
Colorless‐ Due to the absence of urochrome
Amber‐ Bilirubin
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Appearance
Clear
No turbidity
Hazy
Slightly turbid
Cloudy
Excessive turbidity
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Sub Summary
What will cause a normal urine to become cloudy?
If it sits for more then an hour the pH changes and amorphous sediment builds up
What are normal urine colors?
Yellow, straw, amber
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Specific Gravity
Measure of total solids in urine
Density of urine sample compared to the density of distilled water
Purpose
Measures concentrating and diluting abilities of kidneys
Best routine test for total kidney function
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Specific Gravity
Clinical significance
Hyposthenuric ‐ Low specific gravity <1.010
Glomerulonephritis
Pyelonephritis
Diabetes insipidus
Large intake of fluids
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Specific Gravity
Hypersthenuric ‐ High specific gravity >1.010
Hepatic disease
Congestive heart failure
Excessive loss of water (dehydration)
First morning specimen
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Specific Gravity
Isosthenuric ‐ Specific gravity of 1.010 consistently
Severe renal damage
Indicates loss of both the concentrating and diluting abilities of the kidneys
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Specific Gravity Determination
Refractometer
QC
•Use one or two drops
• Hold refractometer
• Read far left scale
• Reference range 1.000
•Wipe clean
Test sample
• DI water
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Specific Gravity Determination
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Specific Gravity Determination
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pH
Determines the acidity/alkalinity of urine
Urine becomes alkaline upon standing
Useful in identification of crystals
Used to rule out acidosis/alkalosis
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pH
Clinical significance
Acidic
Diabetic acidosis
Gout
Dehydratioin
Severe diarrhea
High protein diet
Certain medicatioin
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pH
Clinical significance
Alkaline
Vomiting
Renal tubular acidosis
Certain medications
Urinary tract infection
After meals
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Protein
Purpose ‐ best routine test to detect renal disease
Clinical significance ‐ proteinuria (increase protein)
Strenuous physical exercise
Emotional stress
Pregnancy
Infections
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Protein
Epithelial cells in urine
Severe renal disease
Multiple myeloma
Leukemia
Glomerulonephrites
Hematuria
Hemoglobinuria
WBC in urine
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Protein Confirmation
Sulfosalicylic acid (SSA)
Confirmation of urinary proteins
SSA will precipitate protein
Rules out false positives
Procedure
Equal amounts
Turbidity
Reactions semi‐quantitated
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Protein Confirmation
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Glucose
Most common sugar found in urine
Presence of detectable amounts known as Glycosuria
Occurs when glucose levels exceeds reabsorption capacity
Clinical significance
Diabetes mellitus
Renal tubular dysfunction
Pregnancy with possible latent gestational diabetes
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Glucose Confirmation
Clinitest‐ confirmation for glucose
Non‐specific test
Clinitest procedures
Add 5 drops of urine and 10 drops of water
Add 1 clinitest tablet
NOTE: do not touch test tube
Shake tube
Compare color of liquid
Watch for pass through
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Ketone Bodies
Ketonuria
Intermediate products of fat metabolism
Presence do to altered carbohydrate metabolism
Clinical significance
Diabetes mellitus
Anorexia nervosa
Starvation or fad diets
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Ketone Bodies Confirmation
Acetest
Confirmation for ketone
Procedure
Place one drop on tablet
Compare color with reaction chart
Positive is any purple color
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Ketone Bodies Confirmation
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Blood and Hemoglobin
Hematuria ‐ presence of intact RBC’s in the urine
Bleeding in the urinary tract
Glomerular damage
Trauma
Hemoglobinuria ‐ presence of free hemoglobin in the urine
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Blood and Hemoglobin
Due to intravascular hemolysis
Hemolytic anemia
Hemolytic transfusion reactions
Malaria
Due to lysis of RBC’s in urinary tract
Traumatic passage of RBC’s thru kidney to bladder
Exposure of RBC’s to dilute urine in the bladder
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Bilirubin
Bilirubinuria
Degrades upon standing while exposed to light
Clinical significance
Diagnostic sign of liver disease
Possible billary obstruction
In crease in diseases that causes conjugated bilirubin to be increase in bloodstream
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Bilirubin Confirmation
Ictotest
Confirmation test for bilirubin in urine
Procedure
Place 10 drops of urine on test mat
Place one ictotest tablet on mat
Place one drop of water on tablet
Wait 5 seconds
Add one drop of water
After 60 seconds observe area around mat
Positive reaction (blue or purple color)
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Bilirubin Confirmation
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Urobilinogen
Increase in condition with increase bilirubin
Hemolytic anemia
Malaria
Increased in conditions that prevents reabsorption
Hepatitis
cirrhosis
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Nitrites
Suggests 10⁵ (100,000) or more bacteria per mL of urine
Indicative of a infection by nitrate reducing bacteria
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Leukocyte Esterase
White blood cells release esterases in urine
Pyuria ‐ white blood cells in urine
Indication of bacteriuria
Indirectly indicates UTI
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Leukocyte Esterase Determination
False negatives
High levels of glucose and proteins
High urine specific gravity
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Sub Summary
Which chemical test is indicative of a bacteria infection?
Nitrite
What is the purpose of specific gravity test?
To measure the kidneys ability to concentrate urine
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Microscopic Examination
Preparation of specimen
Pour specimen
Spin
Pour off supernatant
Resuspend button
Place one drop on slide
Add cover slip
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Microscopic Examination
Stains used in analysis
Sterheimer Malbin
• Protein
Peroxidase
• Differentiates WBC’s from renal epithelial cells
3% acetic acid
• Differentiates RBC’s from yeast
Sudan III
• Fat globules will stain orange
Iodine
• Starch globules will stain blue to black
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Microscopic Examination
Examine entire cover slipped area under 10X using subdued light
Low power
• Scan for casts, mucus and even distribution
Scan 10‐15 fields under high power 40X
High and Dry power objective
• Identify and enumerate sedimentary elements
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Sub Summary
How do you differentiate WBC’s from renal‐epithelial cells?
Peroxidase
How do you differentiate RBC’s from yeast?
3% acetic acid
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White Blood Cell
More than 5 WBC/HPF is abnormal
Indentifying characteristics
Round to oval shape.
Segmented or lobulated nucleus (if visible)
Granular cytoplasm
Report all WBC’s as number per high power field (#/HPF)
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Red Blood Cell
More than 3 RBC/HPF is abnormal
Increased in
Internal bleeding
UTI
Traumatic catherterization
Some type of trauma
Strenuous exercise
Menstruation
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Red Blood Cell
Indentifying characteristics
Pale, refractive biconcave discs
Variation in size
• In concentrated urine, small and crenated
• In dilute urine, large and swollen
Report all RBC’s number per high power field (#/HPF)
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Red Blood Cell
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Red Blood Cell
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Epithelial Cell
Originate from the genitourinary system
Three types
Squamous
Transitional
Renal
Report all epithelial cells number per high power field (#/HPF)
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Epithelial Cell
Squamous
From distal of urethra
Large, flat irregularly shaped
Small central nucleus
Abundant cytoplasm
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Epithelial Cell
Transitional
From renal pelvis and bladder
Round or pear‐shaped
May have tail‐like projections
Large, centrally located nucleus
May have two nuclei
May be seen in renal disease
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Epithelial Cell
Renal
From renal tubules and nephron
Slightly larger than WBC
Nucleus usually off‐center
May be flay, cubodial or columnar
Suggestive of tubular damage
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Sub Summary
What would cause RBC’s in urine?
Bleeding, UTI, or menstrual cycles for women
What type of disease would you find transitional cells in?
Renal
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Casts
Formation
Usually in distal convoluted tubule and collecting
duct
May also be formed in the ascending loop of henle
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Casts
Cast formation
Aggregation of Tamm‐Horsfall protein
Attachment of fibrils
Interweaving of fibrils
Further protein fibril interweaving
Possible attachment
Detachment of protein fibrils
Excretion of cast
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Casts
General identifying characteristics
Parallel sides
Round to blunt ends
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Types of Casts
Hyaline cast
White blood cell cast
Red blood cell cast
Hemoglobin cast
Epithelial cell cast
Granular cast
Waxy cast
Fatty cast
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Types of Casts
Hyaline casts consist of
Refractive index
Normal following strenuous exercise, dehydration, heat exposure and emotional stress
Increased in acute glomerulonephritis, pyelonephritis, chronic renal disease, and congestive heart failure
Possible basis for all other casts
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Types of Casts
White blood cell cast
Refractile and granulated
Unless disintegration has begun
Indicate infection or inflammation
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Types of Casts
Red blood cell cast
Refractive, yellow to brown
May contain RBC’s
Primarily associated with glomerulonephrites
Other conditions
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Types of Casts
Hemoglobin cast
Homogenous
Reddish brown color
Associated with same conditions as RBC cast
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Types of Casts
Epithelial cell cast
Formed by excessive shedding of epithelial cells
Indicative of
• Glomerulonephritis
• Pyelonephrites
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Types of Casts
Granular cast
Contains homogenous granular material
Represent stages of degeneration
May occasionally be seen in normal urine
May indicate glomerulonephritis or pyelonephritis
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Types of Casts
Waxy cast
Result of granular cast degeneration
Refractile
Brittle appearance
Irregularly shaped
Indicative of extreme stasis of urine flow
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Types of Casts
Fatty cast
Formed by attachment of lipids
Highly refractile
Contains yellow brown fat droplets
Seen in disorders causing lipiduria
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Report all casts as number per high power field #/LPF
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Mucous
Irregularly shaped
Low refractive index
Increased amounts
Not considered clinically significant
Report as occasional, few, or many (OFM)
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Miscellanious Structures
Schistosoma hematobium
Common in the Nile valley, Middle East and Mediterranean regions
Infection with this parasite occurs from contaminated water
The adult worms live in bladder
Ovum has terminal spine
Rarely seen in united states
Report as present
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Miscellanious Structures
Trichomonas Vaginalis
Results of contamination
In fresh specimen
• Highly motile
•Multiple flagella
Left out specimens
• Loss of motility
• Degeneration
Report as Trichomonas spp. present
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Miscellanious Structures
Examples of parasites that can be found in urine as a result of fecal contamination
Enterobious vermicularis
Ascaris lumbricoides
Giardia lamblia
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Miscellanious Structures
Report all parasites as present
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Miscellanious Structures
Bacteria
Not normally present in urine
May indicate UTI or contamination
Presence of WBC’s and positive nitrite
Report Bacteria as present
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Miscellanious Structures
Yeast ‐ Candida albicans most common
Smooth, colorless, usually ovoid cells
Often confused with RBC’s
Addition of 3% acetic acid will lyse RBC’s
May show budding or hyphae
Found in UTI’s
Report as present
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Miscellanious Structures
Spermatozoa
Oval bodies with, thin tails
Usually found
• After sexual intercourse
• Nocturnal emissions
Found in female patient due to contact
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Miscellanious Structures
Verbally report spermatozoa as present
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Artifact
Many contaminants can be found in urine
Cotton threads
Hair
Starch granules, powder granules
Plant matter
Vegetable fibers
Glass fragments
Must be recognize but not reported
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Normal crystalsAcidic urine
Amorphous urates pH <7.0
Yellow‐brown small granules
If present in large amounts, may give urine sediment pink color
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Normal crystalAcidic urine
Uric acid
Yellow‐reddish‐brown
May take on a variety of shapes
• Rhombic plates
• Rosettes
•Wedges
• Needles
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Normal crystalAcidic urine
Calcium oxalate
Colorless squares with a prismatic X inside
Dumbbell and oval forms also occur
May also be seen in neutral urine
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Normal crystalAcidic urine
Sodium urate
Colorless
Appears as elongated plates in a Chinese fan arrangement
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Normal crystalAlkaline urine
Amorphous phosphate pH >7.0
Appear as small irregularly shaped granules
When present in large amounts, cause a white turbidity in specimen
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Normal crystalAlkaline urine
Triple phosphate
Three to six sided
Often referred to as coffin lids
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Normal crystalAlkaline urine
Ammonium biurate
Yellow‐brown color
Frequently described as thorny apples
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Normal crystalAlkaline urine
Calcium carbonate
Colorless
Wedge shaped prisms, seen in singles or rosettes
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Normal crystalAlkaline urine
Calcium phosphate
Colorless thin prisms
May be found in neutral pH
Soluble in dilute acetic acid
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Abnormal crystalNeutral or Acidic urine
Leucine
Yellow brown spheres with concentric circles with radial striations
Seen in liver disease
Present in conjunction tyrosine crytsals
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Abnormal crystalNeutral or Acidic urine
Tyrosine
Resembles fine silky needles
Seen in liver disease
Present with leucine
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Abnormal crystalNeutral or Acidic urine
Cystine
Appears as colorless hexagonal plates
Appear due to inherited inability to reabsorb cysitne
Indicates potential for renal calculi formation
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Abnormal crystalNeutral or Acidic urine
Cholesterol
Appears as a rectangular plate with notched corners
May have a stair step affect
Indicative of renal damage
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Abnormal crystalNeutral or Acidic urine
Sulfonamids (sulfa crystals)
Presence due to sulfa drug therapy
Many different forms
Must know patient drug history to rule out
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Crystals
Report all crystals as occasional, few or many (OFM)
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Sub Summary
Leucine is found in what disease?
Acute liver disease due to hepatitis
What causes cholesterol?
Renal damage
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Summary
What is increased urine output?
Polyuria
How long can you refrigerate a urine specimen?
8 hours
How could you get a normal cloudy Urine?
If it sits for more then an hour the pH changes and
amorphous sediment builds up
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Summary
Which chemical test is indicative of a bacterial infection?
Nitrite
How do you differentiate WBC’s from renal‐epithelial cells?
Peroxidase
What would cause RBC’s in urine?
Bleeding, UTI, or menstrual cycles for women
Slide 192JSOMTC, SWMG(A)
Summary
What does 3% acetic acid do?
It lyses RBC’c to differentiate from yeast
How do you report Sperm?
Verbally to the Dr
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Slide 193JSOMTC, SWMG(A)
Questions?
Slide 194JSOMTC, SWMG(A)
Break