22 Part One | Background Chapter 1 | Safety and Quality Assessment 23

15. All of the following are safe to do when removing the 23. The classification of a fire that can be extinguished with
Study Questions source of an electric shock except: water is:
A. Pulling the person away from the instrument A. Class A
1. In the urinalysis laboratory the primary source in the 8. An acceptable disinfectant for blood and body fluid B. Turning off the circuit breaker B. Class B
chain of infection would be: decontamination is:
C. Using a glass container to move the instrument C. Class C
A. Patients A. Sodium hydroxide
D. Unplugging the instrument D. Class D
B. Needlesticks B. Antimicrobial soap
16. The acronym PASS refers to: 24. Employers are required to provide free immunization for:
C. Specimens C. Hydrogen peroxide
A. Presence of vital chemicals A. HIV
D. Biohazardous waste D. Sodium hypochlorite
B. Operation of a fire extinguisher B. HTLV-1
2. The best way to break the chain of infection is: 9. Proper handwashing includes all of the following
C. Labeling of hazardous material C. HBV
except:
A. Hand sanitizing D. Presence of radioactive substances D. HCV
A. Using warm water
B. Personal protective equipment
B. Rubbing to create a lather 17. The system used by firefighters when a fire occurs in the 25. A possible physical hazard in the hospital is:
C. Aerosol prevention laboratory is:
C. Rinsing hands in a downward position A. Wearing closed-toed shoes
D. Decontamination A. MSDS B. Not wearing jewelry
D. Turning on the water with a paper towel
3. The current routine infection control policy developed B. RACE C. Having short hair
10. Centrifuging an uncapped specimen may produce a
by CDC and followed in all health-care settings is: C. NFPA D. Running to answer the telephone
biologic hazard in the form of:
A. Universal Precautions D. PASS
A. Vectors 26. Quality assessment refers to:
B. Isolation Precautions 18. A class ABC fire extinguisher contains:
B. Sharps contamination A. Analysis of testing controls
C. Blood and Body Fluid Precautions A. Sand
C. Aerosols B. Increased productivity
D. Standard Precautions D. Specimen contamination B. Water C. Precise control results
4. An employee who is accidentally exposed to a possible C. Dry chemicals D. Quality of specimens and patient care
11. An employee who accidentally spills acid on his arm
blood-borne pathogen should immediately: should immediately: D. Acid
27. During laboratory accreditation inspections, procedure
A. Report to a supervisor A. Neutralize the acid with a base 19. The first thing to do when a fire is discovered is to: manuals are examined for the presence of:
B. Flush the area with water B. Hold the arm under running water for 15 minutes A. Rescue persons in danger A. Critical values
C. Clean the area with disinfectant C. Consult the MSDSs B. Activate the alarm system B. Procedure references
D. Receive HIV prophylaxis D. Wrap the arm in gauze and go to the emergency C. Close doors to other areas C. Procedures for specimen preservation
5. Personnel in the urinalysis laboratory should wear lab department D. Extinguish the fire if possible D. All of the above
coats that: 12. When combining acid and water, ensure that: 20. If a red rash is observed after removing gloves, the 28. As supervisor of the urinalysis laboratory, you have just
A. Do not have buttons A. Acid is added to water employee: adopted a new procedure. You should:
B. Are fluid-resistant B. Water is added to acid A. May be washing her hands too often A. Put the package insert in the procedure manual
C. Have short sleeves C. They are added simultaneously B. May have developed a latex allergy B. Put a complete, referenced procedure in the manual
D. Have full-length zippers D. Water is slowly added to acid C. Should apply cortisone cream C. Notify the microbiology department
6. All of the following should be discarded in biohazardous 13. An employee can learn the carcinogenic potential of D. Should not rub the hands so vigorously D. Put a cost analysis study in the procedure manual
waste containers except: potassium chloride by consulting the: 21. Pipetting by mouth is: 29. Indicate whether each of the following would be consid-
A. Urine specimen containers A. Chemical hygiene plan A. Acceptable for urine but not serum ered a 1) preexamination, 2) examination, or 3) postex-
B. Material safety data sheets amination factor by placing the appropriate number in
B. Towels used for decontamination B. Not acceptable without proper training
the blank:
C. Disposable lab coats C. OSHA standards C. Acceptable for reagents but not specimens
_____ Reagent expiration date
D. Blood collection tubes D. Urinalysis procedure manual D. Not acceptable in the laboratory
_____ Rejecting a contaminated specimen
7. An employer who fails to provide sufficient gloves for 14. Employees should not work with radioisotopes if 22. The NPFA classification symbol contains information on _____ Constructing a Levy-Jennings chart
the employees may be fined by the: they are: all of the following except:
_____ Telephoning a positive Clinitest result on a
A. CDC A. Wearing contact lenses A. Fire hazards newborn
B. NFPA B. Allergic to iodine B. Biohazards _____ Calibrating the centrifuge
C. Sensitive to latex C. Reactivity
C. OSHA _____ Collecting a timed urine specimen
D. Pregnant D. Health hazards
D. FDA
24 Part One | Background Chapter 1 | Safety and Quality Assessment 25

30. The testing of sample from an outside agency and the com- 33. When a new bottle of QC material is opened, what 4. An outpatient urine specimen was delivered to the b. Where would the information concerning what
parison of results with participating laboratories is called: information is placed on the label? laboratory at 0800 and placed on the counter in the should have been done with this specimen be
A. External QC A. The supervisor’s initials Urinalysis department. The medical laboratory scientist found and the criteria for rejection?
performed urinalysis on the specimen at 1130. The c. What QA procedure may have detected this error?
B. Electronic QC B. The lot number
following results were abnormal:
C. Internal QC C. The date and the laboratory worker’s initials d. What form will need to be completed for this
Clarity: Cloudy scenario?
D. Proficiency testing D. The time the bottle was opened
pH: 9.0 e. How might this affect this patient’s care?
31. A color change that indicates that a sufficient amount of 34. When a control is run, what information is Nitrite: Positive f. How will the corrected results be documented?
patient’s specimen or reagent is added correctly to the documented?
The patient was a known diabetic; however, the
test system would be an example of: A. The lot number glucose result was negative.
A. External QC B. Expiration date of the control a. What could be a possible cause for the abnormal
B. Equivalent QC C. The test results results?
C. Internal QC D. All of the above
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 3. The medical technologist was assigned to test 10 urine
report a deficiency in the following situations: specimens chemically. She removed 10 strips from the
container and proceeded with testing. Several patients’
a. The urine microscopic reporting procedure has
urine indicated a trace positive glucose in the urine.
been recently revised.
She then opened a new bottle of reagent dipsticks and
b. An unusually high number of urine specimens are proceeded to perform the QC. The negative control
being rejected because of improper collection. also tested as a trace positive for glucose. The medical
c. A key statement is missing from the Clinitest technologist consulted the supervisor. The supervisor
procedure. ran the QC and the results were in the correct range.
After observing the medical technologist’s technique,
d. Open control bottles in the refrigerator are examined. the supervisor realized that the medical technologist
2. As the new supervisor of the urinalysis section, you was waiting too long to read the glucose results and
encounter the following situations. Explain whether therefore reporting erroneous results.
you would accept them or take corrective action. a. What is wrong with this scenario?
a. You are told that the supervisor always performs b. Who should run the QC for each test? Why?
the CAP proficiency survey. c. When should controls be run?
b. QC is not performed daily on the reagent strips. d. What do you do when the QC is out of range?
c. The urinalysis section is primarily staffed by e. When can you report patient results?
personnel assigned to other departments for whom
you have no personnel data.
36 Part One | Background 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
PROCEDURE 2-4
A. Sodium a random specimen is that it:
Urine Drug Specimen Collection Procedure records the in-range temperature on the COC form B. Phosphate A. Is less contaminated
1. The collector washes hands and wears gloves. (COC step 2). If the specimen temperature is out of C. Chloride B. Is more concentrated
range or the specimen is suspected of having been C. Is less concentrated
2. The collector adds bluing agent (dye) to the toilet D. Calcium
diluted or adulterated, a new specimen must be
water reservoir to prevent an adulterated specimen. D. Has a higher volume
collected and a supervisor notified. 4. A patient presenting with polyuria, nocturia, polydipsia,
3. The collector eliminates any source of water other and a low urine specific gravity is exhibiting symptoms of: 12. If a routine urinalysis and a culture are requested on a
12. The specimen must remain in the sight of the donor and
than toilet by taping the toilet lid and faucet handles. catheterized specimen, then:
collector at all times. A. Diabetes insipidus
4. The donor provides photo identification or positive A. Two separate containers must be collected
13. With the donor watching, the collector peels off the B. Diabetes mellitus
identification from employer representative.
specimen identification strips from the COC form (COC C. Urinary tract infection B. The routine urinalysis is performed first
5. The collector completes step 1 of the chain-of-custody step 3) and puts them on the capped bottle, covering
D. Uremia C. The patient must be recatheterized
(COC) form and has the donor sign the form. both sides of the cap.
D. The culture is performed first
6. The donor leaves his or her coat, briefcase, and/or 14. The donor initials the specimen bottle seals. 5. A patient with oliguria might progress to having:
purse outside the collection area to avoid the possibil- 13. If a patient fails to discard the first specimen when
15. The date and time are written on the seals. A. Nocturia
ity of concealed substances contaminating the urine. collecting a timed specimen the:
16. The donor completes step 4 on the COC form. B. Polyuria
7. The donor washes his or her hands and receives a A. Specimen must be recollected
specimen cup. 17. The collector completes step 5 on the COC form. C. Polydipsia
B. Results will be falsely elevated
8. The collector remains in the restroom but outside the 18. Each time the specimen is handled, transferred, D. Anuria
C. Results will be falsely decreased
stall, listening for unauthorized water use, unless a or placed in storage, every individual must be
6. All of the following are characteristics of recommended D. Both A and B
witnessed collection is requested. identified and the date and purpose of the change
urine containers except:
recorded. 14. The primary cause of unsatisfactory results in an un-
9. The donor hands specimen cup to the collector. A. A flat bottom
Transfer is documented. 19. The collector follows laboratory-specific instructions for preserved routine specimen not tested for 8 hours is:
packaging the specimen bottles and laboratory copies of B. A capacity of 50 mL A. Bacterial growth
10. The collector checks the urine for abnormal color and
the COC form. C. A snap-on lid B. Glycolysis
for the required amount (30 to 45 mL).
20. The collector distributes the COC copies to appropriate D. Are disposable C. Decreased pH
11. The collector checks that the temperature strip on the
personnel.
specimen cup reads 32.5°C to 37.7°C. The collector 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:
Log on to 3. Torora, GJ, and Anagnostakos, NP: Principles of Anatomy C. Placed on the container prior to collection A. Decreased glucose
www.fadavis.com/strasinger and Physiology, ed 6, Harper & Row, New York, 1990, D. Not detachable B. Increased cells and casts
for additional content related p. 51.
to this chapter. 4. Becton, Dickinson and Company: BD Vacutainer Urine Products 8. A urine specimen may be rejected by the laboratory for C. Decreased bilirubin
for collection, storage, and transport of urine specimens. Product all of the following reasons except the fact that the: D. Increased bacteria
Circular, 2011.
References 5. Baer, DM: Glucose tolerance test: Tips from the clinical experts. A. Requisition states the specimen is catheterized 16. Which of the following would be least affected in a
1. Herman, JR: Urology: A View Through the Retrospectroscope. Medical Laboratory Observer, Sept. 2003. B. Specimen contains toilet paper specimen that has remained unpreserved at room
Harper & Row, Hagerstown, MD, 1973. 6. Rous, SN: The Prostate Book. Consumers Union, Mt. Vernon, temperature for more than 2 hours?
2. Clinical and Laboratory Standards Institute (formerly NCCLS), NY, 1988. C. Label and requisition do not match
Approved Guideline GP16-A3: Urinalysis and Collection, 7. Stevermer, JJ, and Easley, SK: Treatment of prostatitis. Am Fam D. Outside of the container has fecal material A. Urobilinogen
Transportation, and Preservation of Urine Specimens; Approved Physician 61(10), 2000. B. Ketones
Guideline—ed 3, CLSI, Wayne, PA, 2009. contamination
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:
Study Questions B. Chloroform A. Decrease clarity
C. Refrigeration B. Increase bilirubin
1. The average daily output of urine is: 2. An unidentified fluid is received in the laboratory with a
D. Formalin C. Decrease pH
A. 200 mL request to determine whether the fluid is urine or another
body fluid. Using routine laboratory tests, what tests 10. For general screening the most frequently collected D. Increase glucose
B. 500 mL would determine that the fluid is most probably urine? specimen is a: 18. The most sterile specimen collected is a:
C. 1200 mL A. Glucose and ketones A. Random one A. Catheterized
D. 2500 mL B. Urea and creatinine B. First morning B. Midstream clean-catch
C. Uric acid and amino acids C. Midstream clean-catch C. Three-glass
D. Protein and amino acids D. Timed D. Suprapubic aspiration
38 Part One | Background Chapter 3 | Renal Function 53

19. Which of the following would not be given to a patient 20. Urine specimen collection for drug testing requires the the ammonium concentration can be calculated as the differ-
HISTORICAL NOTE
prior to the collection of a midstream clean-catch specimen? collector to do all of the following except: ence between the titratable acidity and the total acidity.
A. Sterile container A. Inspect the specimen color Phenolsulfonphthalein Test
Log on to
B. Iodine cleanser B. Perform reagent strip testing www.fadavis.com/strasinger
C. Antiseptic towelette C. Read the specimen temperature Historically, excretion of the dye phenolsulfonphthalein for additional content related
(PSP) was used to evaluate these functions. Standardiza- to this chapter.
D. Instructions D. Fill out a chain-of-custody form
tion and interpretation of PSP results are difficult, how-
ever, because of interference by medications, elevated References
waste products in patients’ serum, the necessity to obtain 1. Berger, A: Renal function and how to assess it. Brit J Med
several very accurately timed urine specimens, and the 321:1444, 2000.
Case Studies and Clinical Situations possibility of producing anaphylactic shock. Therefore, 2. Pincus, MR, Preuss, HG, and Henry, JB: Evaluation of renal func-
tion and water, electrolyte and acid-base balance. In Henry, JB
the PSP test is not currently performed. (ed): Clinical Diagnosis and Management by Laboratory Meth-
1. A patient brings a first morning specimen to the 5. A worker suspects that he or she will be requested to ods. WB Saunders, Philadelphia, 1996.
laboratory at 1:00 p.m. collect an unwitnessed urine specimen for drug analysis. 3. Levey, AS, et al: A new equation to estimate glomerular filtration
a. How could this affect the urinalysis results? He or she carries a substitute specimen in his or her rate. Ann Intern Med 150(9):601–612, 2009.
The inability to produce an acid urine in the presence of 4. Laterza, OE, Price, CP, and Scott, MG: Cystatin C: An improved
pocket for 2 days before being told to collect the speci-
b. What could the patient say that would make the metabolic acidosis is called renal tubular acidosis. This condi- estimator of glomerular filtration rate? Clin Chem 48(5):
men. Shortly after the worker delivers the specimen to
specimen satisfactory for testing? tion may result from impaired tubular secretion of hydrogen 699–707, 2002.
the collector, he or she is instructed to collect another 5. Tan, GS, et al: Clinical usefulness of cystatin C for the estimation
ions associated with the proximal convoluted tubule or defects
2. A patient collecting a midstream clean-catch specimen specimen. of glomerular filtration rate in type 1 diabetes. Crit Care
in ammonia secretion associated with the distal convoluted
voids immediately into the container. a. What test was performed on the specimen to 9(2):139–143, 2005.
tubule. 6. Inker, LA: Estimating glomerular filtration rate from serum crea-
a. How could this affect the clarity of the specimen? determine possible specimen manipulation? Urine pH, titratable acidity, and urinary ammonia meas- tinine and cystatin C. N Engl J Med 367:20–29, 2012.
b. How could this affect the microscopic examination? b. How was the specimen in this situation affected? urements can be used to determine the defective function. The 7. Foley, K: Beta 2 microglobulin: a facultative marker. Advance for
tests can be run simultaneously on either fresh or toluene- MLP, Sept 30, 2008, p 13.
c. If a specimen for drug analysis tests positive, state a
3. A patient brings a 24-hour timed specimen to the preserved urine specimens collected at 2-hour intervals from 8. Chachati, A, et al: Rapid method for the measurement of differ-
possible defense related to specimen collection and ential renal function: Validation. J Nucl Med 28(5): 829–836,
laboratory and reports that he or she forgot to collect handling that an attorney might employ. patients who have been primed with an acid load consisting 1987.
a specimen voided during the night. of oral ammonium chloride. By titrating the amount of free H+ 9. Daves, BB, and Zenser, TV: Evaluation of renal concentrating and
d. How can this defense be avoided?
a. How will this affect the results of a quantitative test (titratable acidity) and then the total acidity of the specimen, diluting ability. Clin Lab Med 13(1):131–134, 1993.
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 Study Questions
below the minimum fill line.
a. Could this affect the culture? 1. The type of nephron responsible for renal concentration 4. Filtration of protein is prevented in the glomerulus by:
is the: A. Hydrostatic pressure
b. Why?
A. Cortical B. Oncotic pressure
B. Juxtaglomerular C. Renin
2. The function of the peritubular capillaries is: D. The glomerular filtration barrier
A. Reabsorption 5. The renin-angiotensin-aldosterone system is responsible for
all of the following except:
B. Filtration
A. Vasoconstriction of the afferent arteriole
C. Secretion
B. Vasoconstriction of the efferent arteriole
D. Both A and C
C. Reabsorbing sodium
3. Blood flows through the nephron in the following order: D. Releasing aldosterone
A. Efferent arteriole, peritubular capillaries, vasa recta,
6. The primary chemical affected by the renin-angiotensin-
afferent arteriole
aldosterone system is:
B. Peritubular capillaries, afferent arteriole, vasa recta, A. Chloride
efferent arteriole
B. Sodium
C. Afferent arteriole, peritubular capillaries, vasa recta,
C. Potassium
efferent arteriole
D. Hydrogen
D. Efferent arteriole, vasa recta, peritubular capillaries,
afferent arteriole
54 Part One | Background Chapter 3 | Renal Function 55

7. Secretion of renin is stimulated by: 14. ADH regulates the final urine concentration by 22. Performing a clearance test using radionucleotides: 29. After controlled fluid intake, the urine-to-serum osmolarity
A. Juxtaglomerular cells controlling: A. Eliminates the need to collect urine ratio should be at least:
B. Angiotensin I and II A. Active reabsorption of sodium B. Does not require an infusion A. 1:1
C. Macula densa cells B. Tubular permeability C. Provides visualization of the filtration B. 2:1
D. Circulating angiotensin-converting enzyme C. Passive reabsorption of urea D. Both A and C
C. 3:1
D. Passive reabsorption of chloride
8. The hormone aldosterone is responsible for: 23. Variables that are included in the MDRD-IDSM estimated D. 4:1
A. Hydrogen ion secretion 15. Decreased production of ADH: creatinine clearance calculations include all of the
A. Produces a low urine volume following except: 30. Calculate the free water clearance from the following
B. Potassium secretion
B. Produces a high urine volume A. Serum creatinine results:
C. Chloride retention
C. Increases ammonia excretion B. Weight urine volume in 6 hours: 720 mL; urine osmolarity:
D. Sodium retention
D. Affects active transport of sodium C. Age 225 mOsm; plasma osmolarity: 300 mOsm
9. The fluid leaving the glomerulus has a specific
16. Bicarbonate ions filtered by the glomerulus are returned D. Gender
gravity of: 31. To provide an accurate measure of renal blood flow, a test
to the blood: 24. An advantage to using cystatin C to monitor GFR is that:
A. 1.005 substance should be completely:
A. In the proximal convoluted tubule A. It does not require urine collection
B. 1.010 A. Filtered by the glomerulus
B. Combined with hydrogen ions B. It is not secreted by the tubules
C. 1.015
C. By tubular secretion B. Reabsorbed by the tubules
D. 1.020 C. It can be measured by immunoassay
D. All of the above C. Secreted when it reaches the distal convoluted
D. All of the above
10. For active transport to occur, a chemical: tubule
17. If ammonia is not produced by the distal convoluted
A. Must combine with a carrier protein to create 25. Solute dissolved in solvent will:
tubule, the urine pH will be: D. Cleared on each contact with functional renal
electrochemical energy A. Raise the vapor pressure
A. Acidic tissue
B. Must be filtered through the proximal convoluted B. Lower the boiling point
B. Basic
tubule C. Decrease the osmotic pressure 32. Given the following data, calculate the effective renal
C. Must be in higher concentration in the filtrate than 18. Place the appropriate letter in front of the following clear- plasma flow:
D. Lower the freezing point
in the blood ance substances:
A. Exogenous 26. Substances that may interfere with freezing point meas- urine volume in 2 hours: 240 mL; urine PAH: 150 mg/dL;
D. Must be in higher concentration in the blood than in
urement of urine and serum osmolarity include all of the plasma PAH: 0.5 mg/dL
the filtrate B. Endogenous
following except:
11. Which of the tubules is impermeable to water? ____ beta2-microglobulin 33. Renal tubular acidosis can be caused by the:
A. Ethanol
A. Proximal convoluted tubule ____ creatinine A. Production of excessively acidic urine due to
B. Lactic acid
B. Descending loop of Henle ____ cystatin C increased filtration of hydrogen ions
C. Sodium
C. Ascending loop of Henle ____ 125I-iothalmate B. Production of excessively acidic urine due to
D. Lipids
D. Distal convoluted tubule 19. The largest source of error in creatinine clearance tests is: increased secretion of hydrogen ions
27. Clinical osmometers use NaCl as a reference solution
A. Secretion of creatinine C. Inability to produce an acidic urine due to impaired
12. Glucose will appear in the urine when the: because:
B. Improperly timed urine specimens production of ammonia
A. Blood level of glucose is 200 mg/dL A. 1 g molecular weight of NaCl will lower the freezing
C. Refrigeration of the urine point 1.86oC D. Inability to produce an acidic urine due to increased
B. Tm for glucose is reached
D. Time of collecting blood sample B. NaCl is readily frozen production of ammonia
C. Renal threshold for glucose is exceeded
D. All of the above 20. Given the following information, calculate the creatinine C. NaCl is partially ionized similar to the composition 34. Tests performed to detect renal tubular acidosis after
clearance: of urine
13. Concentration of the tubular filtrate by the countercur- administering an ammonium chloride load include all
rent mechanism depends on all of the following 24-hour urine volume: 1000 mL; serum creatinine: D. 1 g equivalent weight of NaCl will raise the freezing
of the following except:
except: 2.0 mg/dL; urine creatinine: 200 mg/dL point 1.86oC
A. Urine ammonia
A. High salt concentration in the medulla 21. Clearance tests used to determine the glomerular filtration 28. The normal serum osmolarity is:
rate must measure substances that are: B. Arterial pH
B. Water-impermeable walls of the ascending loop of A. 50 to 100 mOsm
Henle A. Not filtered by the glomerulus B. 275 to 300 mOsm C. Urine pH
C. Reabsorption of sodium and chloride from the B. Completely reabsorbed by the proximal convoluted C. 400 to 500 mOsm D. Titratable acidity
ascending loop of Henle tubule
D. 3 times the urine osmolarity
D. Reabsorption of water in the descending loop of C. Secreted in the distal convoluted tubule
Henle D. Neither reabsorbed or secreted by the tubules
56 Part One | Background Chapter 4 | Physical Examination of Urine 67

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

Case Studies and Clinical Situations 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.
1. A 44-year-old man diagnosed with acute tubular necrosis 4. A laboratory is obtaining erratic serum osmolarity results
Table 4–6. 2. Drabkin, DL: The normal pigment of urine: The relationship of
has a blood urea nitrogen of 60 mg/dL and a blood on a patient who is being monitored at 6 a.m., 12 p.m., urinary pigment output to diet and metabolism. J Biol Chem
glucose level of 100 mg/dL. A 2+ urine glucose is also 6 p.m., and 12 a.m. Osmolarities are not performed on 75:443–479, 1927.
reported. the night shift; therefore, the midnight specimen is run at 3. Ostow, M, and Philo, S: The chief urinary pigment: The rela-
Table 4–6 Possible Causes of Urine Odor1
the same time as the 6 a.m. specimen. tionship between the rate of excretion of the yellow pigment
a. State the renal threshold for glucose. Odor Cause and the metabolic rate. Am J Med Sci 207:507–512, 1944.
a. What two reasons could account for these 4. Berman, L: When urine is red. JAMA 237:2753–2754, 1977.
b. What is the significance of the positive urine
discrepancies? Aromatic Normal 5. Reimann, HA: Re: Red urine. JAMA 241(22):2380, 1979.
glucose and normal blood glucose? 6. Evans, B: The greening of urine: Still another “Cloret sign.”
b. What substance is causing the erratic results? Foul, ammonia-like Bacterial decomposition, urinary N Engl J Med 300(4):202, 1979.
2. A patient develops a sudden drop in blood pressure. c. If a friend were secretly bringing the patient a pint of tract infection 7. Bowling, P, Belliveau, RR, and Butler, TJ: Intravenous medica-
a. Diagram the reactions that take place to ensure whiskey every night, would this affect the Fruity, sweet Ketones (diabetes mellitus, tions and green urine. JAMA 246(3):216, 1981.
adequate blood pressure within the nephrons. results? Explain your answer. 8. Dealler, SF, et al: Purple urine bags. J Urol 142(3):769–770,
starvation, vomiting) 1989.
b. How do these reactions increase blood volume? 5. Following overnight (6 p.m. to 8 a.m.) fluid deprivation, Maple syrup Maple syrup urine disease 9. Clinical and Laboratory Standards Institute (Formerly NCCLS)
the urine-to-serum osmolarity ratio in a patient who is Approved Guideline GP16-A3: Urinalysis and Collection,
c. When blood pressure returns to normal, how does the Mousy Phenylketonuria Transportation, and Preservation of Urine Specimens;
kidney respond? exhibiting polyuria and polydipsia is 1:1. The ratio re- Rancid Tyrosinemia Approved Guideline, ed 3, CLSI, Wayne, PA, 2009.
mains the same when a second specimen is tested at 10. Smith, C, Arbogast, C, and Phillips, R: Effect of x-ray contrast
3. A physician would like to prescribe a nephrotoxic antibi- 10 a.m. ADH is then administered subcutaneously to Sweaty feet Isovaleric acidemia media on results for relative density of urine. Clin Chem
otic for a 60-year-old Caucasian man. The patient has a the patient, and the fluid deprivation is continued until Cabbage Methionine malabsorption 19(4):730–731, 1983.
serum creatinine level of 1.5 mg/dL. 2 p.m., when another specimen is tested. 11. Mitchell, SC, et al: Odorous urine following asparagus inges-
Bleach Contamination tion in man. Experimenta 43(4):382–383, 1987.
a. How can the physician determine whether it is safe to a. What disorder do these symptoms and initial laboratory
prescribe this medication before the patient leaves the results indicate?
Log on to
office? b. If the urine-to-serum osmolarity ratio on the 2 p.m. www.fadavis.com/strasinger
b. State two additional blood tests that the physician specimen is 3:1, what is the underlying cause of the for additional content related
could use to continue monitoring this patient. patient’s disorder? to this chapter.

c. If the patient has a history of prostate malignancy, c. If the urine-to-serum osmolarity ratio on the 2 p.m.
would both of these methods provide reliable results? specimen remains 1:1, what is the underlying cause of
the patient’s disorder?
Explain your answer.
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
68 Part Two | Urinalysis Chapter 4 | Physical Examination of Urine 69

7. The presence of a pink precipitate in a refrigerated speci- 14. A cloudy urine specimen turns black upon standing and 21. An osmole contains: 23. In the reagent strip specific gravity reaction the
men is caused by: has a specific gravity of 1.012. The major concern about A. One gram molecular weight of solute dissolved in polyelectrolyte:
A. Hemoglobin this specimen would be: one liter of solvent A. Combines with hydrogen ions in response to ion
B. Urobilin A. Color B. One gram molecular weight of solute dissolved concentration
C. Uroerythrin B. Turbidity in one kilogram of solvent B. Releases hydrogen ions in response to ion
C. Specific gravity C. Two gram molecular weights of solute dissolved in concentration
D. Beets
D. All of the above one liter of solvent C. Releases hydrogen ions in response to pH
8. Microscopic examination of a clear urine that produces a
D. Two gram molecular weights of solute dissolved D. Combines with sodium ions in response to pH
white precipitate after refrigeration will show: 15. A specimen with a specific gravity of 1.035 would be con-
in one kilogram of solvent
A. Amorphous urates sidered: 24. Which of the following will react in the reagent strip
A. Isosthenuric 22. The unit of osmolality measured in the clinical laboratory specific gravity test?
B. Porphyrins
is the: A. Glucose
C. Amorphous phosphates B. Hyposthenuric
A. Osmole B. Radiographic dye
D. Yeast C. Hypersthenuric
B. Milliosmole C. Protein
D. Not urine
9. The color of urine containing porphyrins will be: C. Molecular weight
16. A specimen with a specific gravity of 1.001 would be con- D. Chloride
A. Yellow-brown D. Ionic charge
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
Case Studies and Clinical Situations
D. Isosthenuric
likely to correlate with a pale yellow urine?
17. A strong odor of ammonia in a urine specimen could 1. Given the following physical urinalysis results, determine c. If the specific gravity was also checked using osmome-
A. 1.005
indicate: additional urinalysis results that may be abnormal. try, should the result agree with the laboratory or the
B. 1.010 urology clinic results? Why or why not?
A. Ketones a. A green specimen with a strong foul odor of ammonia
C. 1.020
B. Normalcy b. A pale yellow urine with a specific gravity of 1.030 3. State two pathologic causes of a clear red urine.
D. 1.030
C. Phenylketonuria c. A dark yellow specimen with yellow foam a. State a method that could distinguish between the two
11. A urine specific gravity measured by refractometer is D. An old specimen causes that does not require laboratory testing.
d. A cloudy red urine
1.029, and the temperature of the urine is 14°C. The spe-
18. The microscopic of a clear red urine is reported as many 2. The urology clinic questions a urinalysis report from the 4. Mrs. Smith frequently shops at the farmer’s market near
cific gravity should be reported as:
WBCs and epithelial cells. What does this suggest? laboratory. her home. She notices her urine has a red color and
A. 1.023 brings a sample to her physician. The specimen tests
A. Urinary tract infection The laboratory report states that a reagent strip reading
B. 1.027 negative for blood.
B. Dilute random specimen of a specific gravity of 1.020, protein 3 g/dL, and glucose
C. 1.029 2 g/dL. The specific gravity in the urology clinic was a. What is a probable cause of Mrs. Smith’s red urine?
C. Hematuria
D. 1.032 greater than 1.035. b. Mrs. Smith collects a specimen at the physician’s
D. Possible mix-up of specimen and sediment office. The color is yellow and the pH is 5.5. Is
12. The principle of refractive index is to compare: a. Correct the refractometer reading to account for the
19. Which of the following would contribute the most to a protein and glucose concentrations. What is the cor- this consistent with the previous answer? Why or
A. Light velocity in solutions with light velocity in urine osmolality? why not?
solids rected specific gravity?
A. One osmole of glucose b. Do the specific gravities correlate? 5. Is a clear urine always normal? Explain your answer.
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
92 Part Two | Urinalysis Chapter 5 | Chemical Examination of Urine 93

Reaction Interference Log on to 5. Quality control of reagent strips is performed: 12. All of the following will cause false-positive protein
www.fadavis.com/strasinger reagent strip values except:
for additional content related A. Using positive and negative controls
The reagent strip specific gravity measures only ionic solutes,
to this chapter. B. When results are questionable A. Microalbuminuria
thereby eliminating the interference by the large organic mol-
ecules, such as urea and glucose, and by radiographic contrast C. At least once every 24 hours B. Highly buffered alkaline urines
media and plasma expanders that are included in physical D. All of the above C. Delay in removing the reagent strip from the specimen
measurements of specific gravity. This difference must be con-
References
1. Chemstrip 10UA product Insert, Roche Diagnostics, Indianapolis, D. Contamination by quaternary ammonium compounds
sidered when comparing specific gravity results obtained by 6. All of the following are important to protect the integrity
IN, 2004. 13. A patient with a 2+ protein reading in the afternoon is asked
a different method. Elevated concentrations of protein slightly 2. Multistix Pro Reagent Strips Product Insert. Siemens Diagnos- of reagent strips except:
increase the readings as a result of protein anions. tics, Tarrytown, NY 2005. to submit a first morning specimen. The second specimen
A. Removing the desiccant from the bottle
Specimens with a pH of 6.5 or higher have decreased 3. TechniTips, Miles Diagnostics, Elkhart, IN, October, 1992. has a negative protein reading. This patient is:
4. Clinical and Laboratory Standards Institute Approved Guide- B. Storing in an opaque bottle
readings caused by interference with the bromthymol blue in- A. Positive for orthostatic proteinuria
dicator (the blue-green readings associated with an alkaline line GP16-A3: Urinalysis and Collection, Transportation, and C. Storing at room temperature
Preservation of Urine Specimens; Approved Guideline, ed 3, B. Negative for orthostatic proteinuria
pH correspond to a low specific gravity reading). Therefore, CLSI, Wayne, PA, 2009. D. Resealing the bottle after removing a strip
C. Positive for Bence Jones protein
manufacturers recommend adding 0.005 to specific gravity 5. College of American Pathologists, CAP Today, Confirmatory
readings when the pH is 6.5 or higher. The correction is per- testing. Chicago, IL. December 2011. 7. The principle of the reagent strip test for pH is the: D. Negative for clinical proteinuria
formed by automated strip readers. 6. Tips from the Clinical Experts, Medical Laboratory Observer. A. Protein error of indicators
Web site: http://www.mlo-online.com/articles/mlo0802tips.htm 14. Testing for microalbuminuria is valuable for early detec-
7. Pugia, MJ, and Lott, JA: New developments in urinalysis strip B. Greiss reaction tion of kidney disease and monitoring patients with:
tests for proteins. In Bayer Encyclopedia of Urinalysis. Bayer C. Dissociation of a polyelectrolyte A. Hypertension
SUMMARY 5-22 Urine Specific Gravity Diagnostics, Elkhart, IN, 2002.
8. Bhuwnesh, A, et al: Microalbumin screening by reagent strip D. Double indicator reaction B. Diabetes mellitus
Reagent Strip predicts cardiovascular risk in hypertension. J Hypertens 14:
8. A urine specimen with a pH of 9.0: C. Cardiovascular disease risk
223–228, 1992.
Reagents Multistix: Poly (methyl vinyl ether/maleic 9. Bianchi, S, et al: Microalbuminurea in essential hypertension. A. Indicates metabolic acidosis D. All of the above
anhydride) bromthymol blue J Nephrol 10(4):216–219, 1997.
10. Clinitek Microalbumin Reagent Strip Product Insert. Bayer B. Should be recollected 15. The primary chemical on the reagent strip in the Micral-
Chemstrip: Ethylene glycol diaminoethyl Diagnostics, Elkhart, IN, 2006. Test for microalbumin binds to:
C. May contain calcium oxalate crystals
ether tetraacetic acid, bromthymol 11. Benedict, SR: A reagent for the detection of reducing sugars.
D. Is seen after drinking cranberry juice A. Protein
blue J Biol Chem 5:485–487, 1909.
12. Lane R, and Phillips, M: Rhabdomyolysis has many causes B. Antihuman albumin antibody
Sensitivity 1.000 to 1.030 9. In the laboratory, a primary consideration associated
including statins and may be fatal. Brit J Med 327:115–116, C. Conjugated enzyme
Interference False-positive: High concentrations of 2003. with pH is:
protein 13. Hager, CB, and Free, AH: Urine urobilinogen as a component D. Galactoside
A. Identifying urinary crystals
of routine urinalysis. Am J Med Technol 36(5):227–233, 1970.
False-negative: Highly alkaline urines 14. Wise, KA, Sagert, LA, and Grammens, GL: Urine leukocyte es- B. Monitoring vegetarian diets 16. All of the following are true for the ImmunoDip test for
(greater than 6.5) terase and nitrite tests as an aid to predict urine culture results. microalbumin except:
C. Determining specimen acceptability
Lab Med 15(3):186–187, 1984. 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
Study Questions
A. ____Microalbuminuria antibody
1. Leaving excess urine on the reagent strip after removing 3. Testing a refrigerated specimen that has not warmed to B. ____Acute phase reactants D. It utilizes an immunochromographic principle
it from the specimen will: room temperature will adversely affect: C. ____Pre-eclampsia 17. The principle of the protein-high pad on the Multistix
A. Cause run-over between reagent pads A. Enzymatic reactions D. ____Vaginal inflammation Pro reagent strip is the:
B. Alter the color of the specimen B. Dye-binding reactions E. ____Multiple myeloma A. Diazo reaction
C. Cause reagents to leach from the pads C. The sodium nitroprusside reaction F. ____Orthostatic proteinuria B. Enzymatic dye-binding reaction
D. Not affect the chemical reactions D. Diazo reactions G. ____Prostatitis C. Protein error of indicators
2. Failure to mix a specimen before inserting the reagent 4. The reagent strip reaction that requires the longest reac- 11. The principle of the protein error of indicators reaction D. Microalbumin-Micral-Test
strip will primarily affect the: tion time is the: is that: 18. Which of the following is not tested on the Multistix Pro
A. Glucose reading A. Bilirubin A. Protein keeps the pH of the urine constant reagent strip?
B. Blood reading B. pH B. Albumin accepts hydrogen ions from the indicator A. Urobilinogen
C. Leukocyte reading C. Leukocyte esterase C. The indicator accepts hydrogen ions from B. Specific gravity
D. Both B and C D. Glucose albumin C. Creatinine
D. Albumin changes the pH of the urine D. Protein-high
94 Part Two | Urinalysis Chapter 5 | Chemical Examination of Urine 95

19. The principle of the protein-low reagent pad on the Mul- 27. The most significant reagent strip test that is associated 34. List the following products of hemoglobin degradation 42. All of the following can cause a negative nitrite reading
tistix Pro is the: with a positive ketone result is: in the correct order by placing numbers 1 to 4 in the except:
A. Binding of albumin to sulphonphthalein dye A. Glucose blank. A. Gram-positive bacteria
B. Immunologic binding of albumin to antibody B. Protein A. ____Conjugated bilirubin B. Gram-negative bacteria
C. Reverse protein error of indicators reaction C. pH B. ____Urobilinogen and stercobilinogen C. Random urine specimens
D. Enzymatic reaction between albumin and dye D. Specific gravity C. ____Urobilin D. Heavy bacterial infections
D. ____Unconjugated bilirubin 43. A positive nitrite test and a negative leukocyte esterase
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 35. The principle of the reagent strip test for bilirubin test is an indication of a:
A. Double indicator reaction is the: A. Dilute random specimen
B. Lactose
B. Diazo reaction A. Diazo reaction B. Specimen with lysed leukocytes
C. Sodium hydroxide
C. Pseudoperoxidase reaction B. Ehrlich reaction C. Vaginal yeast infection
D. Sodium nitroprusside
D. Reduction of a chromogen C. Greiss reaction D. Specimen older than 2 hours
29. Ketonuria may be caused by all of the following except:
21. The purpose of performing an albumin:creatinine ratio D. Peroxidase reaction 44. All of the following can be detected by the leukocyte
A. Bacterial infections
is to: 36. An elevated urine bilirubin with a normal urobilinogen esterase reaction except:
B. Diabetic acidosis
A. Estimate the glomerular filtration rate is indicative of: A. Neutrophils
C. Starvation
B. Correct for hydration in random specimens A. Cirrhosis of the liver B. Eosinophils
D. Vomiting C. Lymphocytes
C. Avoid interference for alkaline urines B. Hemolytic disease
D. Correct for abnormally colored urines 30. Urinalysis on a patient with severe back and abdominal C. Hepatitis D. Basophils
pain is frequently performed to check for:
22. A patient with a normal blood glucose and a positive D. Biliary obstruction 45. Screening tests for urinary infection combine the leuko-
A. Glucosuria cyte esterase test with the test for:
urine glucose should be further checked for: 37. The primary cause of a false-negative bilirubin reaction is:
B. Proteinuria A. pH
A. Diabetes mellitus A. Highly pigmented urine
C. Hematuria B. Nitrite
B. Renal disease B. Specimen contamination
D. Hemoglobinuria C. Protein
C. Gestational diabetes C. Specimen exposure to light
D. Pancreatitis 31. Place the appropriate number or numbers in front of D. Blood
D. Excess conjugated bilirubin
each of the following statements. Use both numbers for
23. The principle of the reagent strip tests for glucose is the: 46. The principle of the leukocyte esterase reagent strip test
an answer if needed. 38. The purpose of the special mat supplied with the Ictotest
uses a:
A. Peroxidase activity of glucose 1. Hemoglobinuria tablets is that:
A. Peroxidase reaction
B. Glucose oxidase reaction 2. Myoglobinuria A. Bilirubin remains on the surface of the mat.
B. Double indicator reaction
C. Double sequential enzyme reaction A. ____ Associated with transfusion reactions B. It contains the dye needed to produce color.
C. Diazo reaction
D. Dye-binding of glucose and chromogen B. ____ Clear red urine and pale yellow plasma C. It removes interfering substances.
D. Dye-binding technique
24. All of the following may produce false-negative glucose C. ____ Clear red urine and red plasma D. Bilirubin is absorbed into the mat.
reactions except: 47. The principle of the reagent strip test for specific gravity
D. ____ Associated with rhabdomyolysis 39. The reagent in the Multistix reaction for urobilinogen is: uses the dissociation constant of a(n):
A. Detergent contamination E. ____ Produces hemosiderin granules in urinary A. A diazonium salt A. Diazonium salt
B. Ascorbic acid sediments B. Tetramethylbenzidine B. Indicator dye
C. Unpreserved specimens F. ____Associated with acute renal failure C. p-Dimethylaminobenzaldehyde C. Polyelectrolyte
D. Low urine temperature 32. The principle of the reagent strip test for blood is based D. Hoesch reagent D. Enzyme substrate
25. The primary reason for performing a Clinitest is to: on the:
40. The primary problem with urobilinogen tests using 48. A specific gravity of 1.005 would produce the reagent
A. Check for high ascorbic acid levels A. Binding of heme and a chromogenic dye Ehrlich reagent is: strip color:
B. Confirm a positive reagent strip glucose B. Peroxidase activity of heme A. Positive reactions with porphobilinogen A. Blue
C. Check for newborn galactosuria C. Reaction of peroxide and chromogen B. Lack of specificity B. Green
D. Confirm a negative glucose reading D. Diazo activity of heme C. Positive reactions with Ehrlich’s reactive substances C. Yellow
26. The three intermediate products of fat metabolism in- 33. A speckled pattern on the blood pad of the reagent strip D. All of the above D. Red
clude all of the following except: indicates:
41. The reagent strip test for nitrite uses the: 49. Reagent strip–specific gravity readings are affected by:
A. Acetoacetic acid A. Hematuria
A. Greiss reaction A. Glucose
B. Ketoacetic acid B. Hemoglobinuria
B. Ehrlich reaction B. Radiographic dye
C. β-hydroxybutyric acid C. Myoglobinuria
C. Peroxidase reaction C. Alkaline urine
D. Acetone D. All of the above
D. Pseudoperoxidase reaction D. All of the above
96 Part Two | Urinalysis Chapter 5 | Chemical Examination of Urine 97

5. Results of a urinalysis collected following practice from SP. GRAVITY: 1.017 BILIRUBIN: Negative
Case Studies and Clinical Situations 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
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 CLARITY: Hazy BLOOD: 1+ GLUCOSE: Negative LEUKOCYTES: Negative
pH: 6.0 UROBILINOGEN: 8 EU
of 450 mg/dL. Results of the routine urinalysis are as
SP. GRAVITY: 1.029 BILIRUBIN: Negative a. Would hematuria be suspected in this specimen?
follows: PROTEIN: Negative NITRITE: Negative
Why or why not?
COLOR: Yellow KETONES: 2+ pH: 6.5 UROBILINOGEN: 1 EU
GLUCOSE: Negative LEUKOCYTES: Negative b. What is the most probable cause of the positive
CLARITY: Clear BLOOD: Negative a. Would these results be indicative of hematuria or PROTEIN: 2+ NITRITE: Negative blood reaction?
SP. GRAVITY: 1.015 BILIRUBIN: Negative hemoglobinuria? GLUCOSE: Negative LEUKOCYTES: Negative c. What is the source of the substance causing the pos-
pH: 5.0 PROTEIN-LOW: 15 mg/dL b. Correlate the patient’s condition with the urobilino- itive blood reaction and the name of the condition?
gen result. The physician requests that the athlete collect another
PROTEIN-HIGH: NITRITE: Negative d. Would this patient be monitored for changes in
specimen in the morning prior to classes and practice.
30 mg/dL c. Why is the urine bilirubin result negative in this renal function? Why or why not?
jaundiced patient? a. What is the purpose of the second sample?
GLUCOSE: 250 mg/dL LEUKOCYTES: Negative 7. Considering the correct procedures for care, technique,
CREATININE: 200 mg/dL d. Would this method also measure urine porphyrins? b. What changes would you expect in the second and quality control for reagent strips, state a possible
Why or why not? sample? cause for each of the following scenarios.
a. Explain the correlation between the patient’s blood
and urine glucose results. 4. A female patient arrives at the outpatient clinic with c. Is the proteinuria present in the first sample of prer- a. The urinalysis supervisor notices that an unusually
symptoms of lower back pain and urinary frequency enal, renal, or postrenal origin? large number of reagent strips are becoming discol-
b. What is the most probable metabolic disorder asso-
ciated with this patient? with a burning sensation. She is a firm believer in the 6. A construction worker is pinned under collapsed scaf- ored before the expiration date has been reached.
curative powers of vitamins. She has tripled her usual b. A physician’s office is consistently reporting positive
c. Considering the patient’s condition, what is the sig- folding for several hours prior to being taken to the
dosage of vitamins in an effort to alleviate her symp- nitrite test results with negative LE test results.
nificance of the patient’s protein to creatinine ratio emergency room. His abdomen and upper legs are se-
toms; however, the symptoms have persisted. She is
result? verely bruised, but no fractures are detected. A speci- c. A student’s results for reagent strip blood and LE
given a sterile container and asked to collect a mid-
d. If the patient in this study had a normal blood men for urinalysis obtained by catheterization has the are consistently lower than those of the laboratory
stream clean-catch urine specimen. Results of this
glucose level and normal protein and creatinine following results: staff.
routine urinalysis are as follows:
results, to what would the urinary glucose be d. One morning the urinalysis laboratory was report-
COLOR: Dark yellow KETONES: Negative COLOR: Red-brown KETONES: Negative
attributed? ing results that were frequently questioned by
CLARITY: Hazy BLOOD: Negative CLARITY: Clear BLOOD: 4+ physicians.
2. Results of a urinalysis performed on a patient sched-
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.
 Chapter 6 | Microscopic Examination of Urine 141 142 Part Two | Urinalysis

15. Differentiation among RBCs, yeast, and oil droplets may 23. Forms of transitional epithelial cells include all of the
Study Questions be accomplished by all of the following except: following except:
A. Observation of budding in yeast cells A. Spherical
1. Macroscopic screening of urine specimens is used to: 8. Which of the following are reported as number per lpf? B. Increased refractility of oil droplets B. Caudate
A. Provide results as soon as possible A. RBCs C. Lysis of yeast cells by acetic acid C. Convoluted
B. Predict the type of urinary casts present B. WBCs D. Lysis of RBCs by acetic acid D. Polyhedral
C. Increase cost-effectiveness of urinalysis C. Crystals
16. A finding of dysmorphic RBCs is indicative of: 24. Increased transitional cells are indicative of:
D. Decrease the need for polarized microscopy D. Casts
A. Glomerular bleeding A. Catheterization
2. Variations in the microscopic analysis of urine include all 9. The Sternheimer-Malbin stain is added to urine sediments B. Malignancy
B. Renal calculi
of the following except: to do all of the following except:
C. Traumatic injury C. Pyelonephritis
A. Preparation of the urine sediment A. Increase visibility of sediment constituents
D. Coagulation disorders D. Both A and B
B. Amount of sediment analyzed B. Change the constituents’ refractive index
C. Method of reporting C. Decrease precipitation of crystals 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:
D. Identification of formed elements D. Delineate constituent structures
A. Indicative of pyelonephritis A. Elongated structure
3. All of the following can cause false-negative microscopic 10. Nuclear detail can be enhanced by:
B. Basophils B. Centrally located nucleus
results except: A. Prussian blue
C. Mononuclear leukocytes C. Spherical appearance
A. Braking the centrifuge B. Toluidine blue
D. Glitter cells D. Eccentrically located nucleus
B. Failing to mix the specimen C. Acetic acid
C. Dilute alkaline urine 18. Mononuclear leukocytes are sometimes mistaken for: 26. Following an episode of hemoglobinuria, RTE cells may
D. Both B and C
A. Yeast cells contain:
D. Using midstream clean-catch specimens
11. Which of the following lipids is/are stained by Sudan III? A. Bilirubin
4. The two factors that determine relative centrifugal force are: B. Squamous epithelial cells
A. Cholesterol B. Hemosiderin granules
A. Radius of rotor head and rpm C. Pollen grains
B. Neutral fats C. Porphobilinogen
B. Radius of rotor head and time of centrifugation D. Renal tubular cells
C. Triglycerides D. Myoglobin
C. Diameter of rotor head and rpm D. Both B and C 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:
D. RPM and time of centrifugation
12. Which of the following lipids is/are capable of polarizing A. Histiocyte
A. RBCs
5. When using the glass slide and cover-slip method, which of light?
B. Bacteria B. Urothelial cell
the following might be missed if the cover slip is overflowed? A. Cholesterol
A. Casts C. Hyaline casts C. Monocyte
B. Neutral fats
B. RBCs D. Mucus D. Renal tubular cell
C. Triglycerides
C. WBCs D. Both A and B 20. Transitional epithelial cells are sloughed from the: 28. A structure believed to be an oval fat body produced a
D. Bacteria Maltese cross formation under polarized light but does not
13. The purpose of the Hansel stain is to identify: A. Collecting duct
stain with Sudan III. The structure:
6. Initial screening of the urine sediment is performed using A. Neutrophils B. Vagina
A. Contains cholesterol
an objective power of: C. Bladder
B. Renal tubular cells B. Is not an oval fat body
A. 4× C. Eosinophils D. Proximal convoluted tubule
C. Contains neutral fats
B. 10× D. Monocytes 21. The largest cells in the urine sediment are: D. Is contaminated with immersion oil
C. 40×
14. Crenated RBCs are seen in urine that is: A. Squamous epithelial cells
D. 100× 29. The finding of yeast cells in the urine is commonly asso-
A. Hyposthenuric B. Urothelial epithelial cells ciated with:
7. Which of the following should be used to reduce light B. Hypersthenuric C. Cuboidal epithelial cells A. Cystitis
intensity in bright-field microscopy?
C. Highly acidic D. Columnar epithelial cells B. Diabetes mellitus
A. Centering screws
D. Highly alkaline 22. A clinically significant squamous epithelial cell is the: C. Pyelonephritis
B. Aperture diaphragm
A. Cuboidal cell D. Liver disorders
C. Rheostat
B. Clue cell
D. Condenser aperture diaphragm
C. Caudate cell
D. Columnar cell
 Chapter 6 | Microscopic Examination of Urine 143 144 Part Two | Urinalysis

30. The primary component of urinary mucus is: 38. The presence of fatty casts is associated with: 46. Casts and fibers can usually be differentiated using: 50. Match the following types of microscopy with their
A. Bence Jones protein A. Nephrotic syndrome A. Solubility characteristics descriptions:
B. Microalbumin B. Crush injuries B. Patient history ____ Bright-field 1. Indirect light is reflected
off the object
C. Uromodulin C. Diabetes mellitus C. Polarized light
____ Phase 2. Objects split light into two
D. Orthostatic protein D. All of the above D. Fluorescent light
beams
31. The majority of casts are formed in the: 39. Nonpathogenic granular casts contain: 47. Match the following crystals seen in acidic urine with their ____ Polarized 3. Low refractive index
A. Proximal convoluted tubules A. Cellular lysosomes description/identifying characteristics: objects may be overlooked
B. Ascending loop of Henle B. Degenerated cells ____ Amorphous urates 1. Envelopes ____ Dark-field 4. Three-dimensional images
C. Distal convoluted tubules C. Protein aggregates ____ Uric acid 2. Thin needles ____Fluorescent 5. Forms halo of light around
D. Collecting ducts ____ Calcium oxalate 3. Yellow-brown, object
D. Gram-positive cocci
monohydrate whetstone ____Interference 6. Detects electrons
32. Cylindruria refers to the presence of: 40. All of the following are true about waxy casts except they: contrast emitted from objects
____ Calcium oxalate 4. Pink sediment
A. Cylindrical renal tubular cells A. Represent extreme urine stasis dihydrate 7. Detects specific wavelengths
B. Mucus-resembling casts B. May have a brittle consistency 5. Ovoid of light emitted from objects
C. Hyaline and waxy casts C. Require staining to be visualized 48. Match the following crystals seen in alkaline urine with
D. All types of casts D. Contain degenerated granules their description/identifying characteristics:
33. A person submitting a urine specimen following a stren- 41. Observation of broad casts represents: ____ Triple phosphate 1. Yellow granules
uous exercise routine can normally have all of the follow- ____ Amorphous phosphate 2. Thin prisms
ing in the sediment except: A. Destruction of tubular walls
B. Dehydration and high fever ____ Calcium phosphate 3. “Coffin lids”
A. Hyaline casts
C. Formation in the collecting ducts ____ Ammonium biurate 4. Dumbbell shape
B. Granular casts
D. Both A and C ____ Calcium carbonate 5. White precipitate
C. RBC casts
6. Thorny apple
D. WBC casts 42. All of the following contribute to urinary crystals forma-
tion except: 49. Match the following abnormal crystals with their
34. Prior to identifying an RBC cast, all of the following description/identifying characteristics:
should be observed except: A. Protein concentration
____ Cystine 1. Bundles following
A. Free-floating RBCs B. pH
refrigeration
B. Intact RBCs in the cast C. Solute concentration
____ Tyrosine 2. Highly alkaline pH
C. Presence of a cast matrix D. Temperature
____ Cholesterol 3. Bright yellow clumps
D. A positive reagent strip blood reaction 43. The most valuable initial aid for identifying crystals in a ____ Leucine 4. Hexagonal plates
35. WBC casts are primarily associated with: urine specimen is:
____ Ampicillin 5. Flat plates, high
A. Pyelonephritis A. pH specific gravity
B. Cystitis B. Solubility ____ Radiographic dye 6. Concentric circles,
C. Glomerulonephritis C. Staining radial striations

D. Viral infections D. Polarized microscopy ____ Bilirubin 7. Notched corners

44. Crystals associated with severe liver disease include all of 8. Fine needles seen in
36. The shape of the RTE cell associated with renal tubular liver disease
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
 Chapter 6 | Microscopic Examination of Urine 145 146 Part Two | Urinalysis

5. A 2-year-old left unattended in the garage for 5 minutes SP. GRAVITY: 1.030 BILIRUBIN: Negative
Case Studies and Clinical Situations 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
1. An 85-year-old woman with diabetes and a broken hip Additional testing detects a superinfection with delta examination. Two distinct forms of crystals are observed
in the microscopic examination. GLUCOSE: Negative LEUKOCYTE: Negative
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: a. What type of crystals would you expect to be present? Microscopic:
physician orders additional blood tests and a routine COLOR: Amber KETONES: Negative b. What is the other form of this crystal? 0 to 3 WBCs/hpf
urinalysis. The urinalysis report is as follows: 0 to 4 hyaline casts/lpf
CLARITY: Hazy BLOOD: Negative c. Describe the two forms.
COLOR: Pale yellow KETONES: Negative SP. GRAVITY: 1.011 BILIRUBIN: Large d. Which form would you expect to be predominant? 0 to 3 granular casts/lpf
CLARITY: Hazy BLOOD: Moderate pH: 7.0 UROBILINOGEN: 4.0 EU Few squamous epithelial cells
6. A female patient comes to the outpatient clinic with
SP. GRAVITY: 1.020 BILIRUBIN: Negative PROTEIN: 2+ NITRITE: Negative symptoms of UTI. She brings a urine specimen with her. a. Are these results of clinical significance?
pH: 5.5 UROBILINOGEN: Normal GLUCOSE: Negative LEUKOCYTES: Negative Results of the routine analysis performed on this speci- b. Explain the discrepancy between the chemical and
PROTEIN: Trace NITRITE: Negative men are as follows: microscopic blood results.
Microscopic:
GLUCOSE: 100 mg/dL LEUKOCYTES: 2+ COLOR: Yellow KETONES: Negative c. What is the probable cause of the granular casts?
2 to 4 WBCs/hpf 1 to 2 hyaline casts/lpf
Microscopic: CLARITY: Hazy BLOOD: Small 8. As supervisor of the urinalysis section, you are reviewing
1 to 3 RBCs/hpf 1 to 2 granular casts/lpf
20 to 25 WBCs/hpf SP. GRAVITY: 1.015 BILIRUBIN: Negative results. State why or why not each of the following results
2 to 4 bile-stained RTE
pH: 9.0 UROBILINOGEN: Normal would concern you.
Many yeast cells and hyphae cells/hpf
PROTEIN: Negative NITRITE: Negative a. The presence of waxy casts and a negative protein in
a. Why are yeast infections common in patients with 0 to 1 RTE casts/lpf
urine from a 6–month-old girl
diabetes mellitus? 0 to 1 bile-stained waxy GLUCOSE: Negative LEUKOCYTE: 2+
b. Increased transitional epithelial cells in a specimen
b. With a blood glucose level of 250 mg/dL, should casts/lpf Microscopic:
obtained following cystoscopy
glucose be present in the urine? Why or why not? a. Based on the urinalysis results, in what area of the 1 to 3 RBCs/hpf Heavy bacteria
c. Tyrosine crystals in a specimen with a negative
c. Is there a discrepancy between the negative nitrite and nephron is damage occurring? 8 to 10 WBCs/hpf Moderate squamous bilirubin test result
the positive leukocyte esterase results? Explain your b. Is this consistent with the patient’s primary diagnosis? epithelial cells
answer. d. Cystine crystals in a specimen from a patient diag-
Explain your answer. a. What discrepancies are present between the chemical nosed with gout
d. What is the major discrepancy between the chemical c. What is causing the RTE cells to be bile stained? and microscopic test results?
e. Cholesterol crystals in urine with a specific gravity
and microscopic results? d. Why is the urobilinogen level elevated? b. State a reason for the discrepancies. greater than 1.040
e. Considering the patient’s history, what is the most e. State a disorder in which the urobilinogen level would c. Identify a chemical result in the urinalysis that con- f. Trichomonas vaginalis in a male urine specimen
probable cause for the discrepancy? be elevated, but the bilirubin result would be negative. firms your reason for the discrepancies.
g. Amorphous urates and calcium carbonate crystals in
2. A medical technology student training in a newly reno- 4. A 30-year-old woman being treated for a UTI brings a d. What course of action should the laboratory take to a specimen with a pH of 7.0
vated STAT laboratory is having difficulty performing a urine specimen to the Employee Health Clinic at 4:00 p.m. obtain accurate results for this patient?
microscopic urinalysis. Reagent strip testing indicates the The nurse on duty tells her that the specimen will be re- 7. A high school student is taken to the emergency room
presence of moderate blood and leukocytes, but the stu- frigerated and tested by the technologist the next morning. with a broken leg that occurred during a football game.
dent is also observing some large unusual objects resem- The technologist has difficulty interpreting the color of the The urinalysis results are as follows:
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: Dark yellow KETONES: Negative
COLOR: Amber CLARITY: Slightly cloudy
at the same time. CLARITY: Hazy BLOOD: Moderate
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?
158 Part Two | Urinalysis Chapter 7 | Renal Disease 159

15. Differentiation between cystitis and pyelonephritis is aided 18. Prerenal acute renal failure could be caused by:
Study Questions by the presence of: A. Massive hemorrhage
A. WBC casts B. Acute tubular necrosis
1. Most glomerular disorders are caused by: 8. The highest levels of proteinuria are seen with: B. RBC casts C. Acute interstitial nephritis
A. Sudden drops in blood pressure A. Alport syndrome C. Bacteria D. Malignant tumors
B. Immunologic disorders B. Diabetic nephropathy D. Granular casts
19. The most common composition of renal calculi is:
C. Exposure to toxic substances C. IgA nephropathy
16. The presence of WBCs and WBC casts with no bacteria is A. Calcium oxalate
D. Bacterial infections D. Nephrotic syndrome indicative of:
B. Magnesium ammonium phosphate
2. Dysmorphic RBC casts would be a significant finding with 9. Ischemia frequently produces: A. Chronic pyelonephritis
C. Cystine
all of the following except: A. Acute renal tubular necrosis B. Acute tubular necrosis
D. Uric acid
A. Goodpasture syndrome B. Minimal change disorder C. Acute interstitial nephritis
20. Urinalysis on a patient with severe back pain being eval-
B. Acute glomerulonephritis C. Renal glycosuria D. Both B and C
uated for renal calculi would be most beneficial if it
C. Chronic pyelonephritis D. Goodpasture’s syndrome 17. End-stage renal disease is characterized by all of the showed:
D. Henoch-Schönlein purpura 10. A disorder associated with polyuria and low specific following except: A. Heavy proteinuria
3. Occasional episodes of macroscopic hematuria over periods gravity is: A. Hypersthenuria B. Low specific gravity
of 20 or more years are seen with: A. Renal glucosuria B. Isosthenuria C. Uric acid crystals
A. Crescentic glomerulonephritis B. Minimal change disease C. Azotemia D. Microscopic hematuria
B. IgA nephropathy C. Nephrogenic diabetes insipidus D. Electrolyte imbalance
C. Nephrotic syndrome D. Focal segmental glomerulosclerosis
D. Wegener granulomatosis 11. An inherited disorder producing a generalized defect in
tubular reabsorption is: Case Studies and Clinical Situations
4. Antiglomerular basement membrane antibody is seen with:
A. Alport syndrome
A. Wegener granulomatosis
B. Acute interstitial nephritis 1. A 14-year-old boy who has recently recovered from a sore e. What is the expected prognosis of this patient?
B. IgA nephropathy throat develops edema and hematuria. Significant labora-
C. Fanconi syndrome f. If the above urinalysis results were seen in a 5-year-old
C. Goodpasture syndrome tory results include a BUN of 30 mg/dL (normal 8 to boy who has developed a red, patchy rash following
D. Renal glycosuria
D. Diabetic nephropathy 23 mg/dL) and a positive group A streptococcal antibody recovery from a respiratory infection, what disorder
12. A teenage boy who develops gout in his big toe and has a test. Results of a urinalysis are as follows: would you suspect?
5. Antineutrophilic cytoplasmic antibody is diagnostic for: high serum uric acid should be monitored for:
Color: Red Ketones: Negative 2. B.J. is a seriously ill 40-year-old man with a history of
A. IgA nephropathy A. Fanconi syndrome
Clarity: Cloudy Blood: Large several episodes of macroscopic hematuria in the past
B. Wegener granulomatosis B. Renal calculi
Sp. gravity: 1.020 Bilirubin: Negative 20 years. The episodes were associated with exercise or
C. Henoch-Schönlein purpura C. Uromodulin-associated kidney disease stress. Until recently the macroscopic hematuria had
pH: 5.0 Urobilinogen: Normal spontaneously reverted to asymptomatic microscopic
D. Goodpasture syndrome D. Chronic interstitial nephritis
Protein: 3+ Nitrite: Negative hematuria. Significant laboratory results include a BUN of
6. Respiratory and renal symptoms are associated with all of 13. The only protein produced by the kidney is: 80 mg/dL (normal 8 to 23 mg/dL), serum creatinine of
Glucose: Negative Leukocyte: Trace
the following except: A. Albumin 4.5 mg/dL (normal 0.6 to 1.2 mg/dL), creatinine clearance
Microscopic:
A. IgA nephropathy B. Uromodulin 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-
B. Wegener granulomatosis C. Uroprotein
5–8 WBCs/hpf rus of 6.0 mg/dL (normal 2.3 to 4.7 mg/dL), and an ele-
C. Henoch-Schönlein purpura D. Globulin
0–2 granular casts/lpf vated level of serum IgA. Results of a routine urinalysis
D. Goodpasture syndrome are as follows:
14. The presence of renal tubular epithelial cells and casts is
0–1 RBC casts/lpf
7. The presence of fatty casts is associated with all of the fol- an indication of: Color: Red Ketones: Negative
lowing except: a. What disorder do these results and history
A. Acute interstitial nephritis Clarity: Slightly cloudy Blood: Large
indicate?
A. Nephrotic syndrome B. Chronic glomerulonephritis Sp. gravity: 1.010 Bilirubin: Negative
b. What specific characteristic was present in the
B. Focal segmental glomerulosclerosis C. Minimal change disease pH: 6.5 Urobilinogen: Normal
organism causing the sore throat?
C. Nephrogenic diabetes insipidus D. Acute tubular necrosis Protein: 300 mg/dL Nitrite: Negative
c. What is the significance of the dysmorphic RBCs?
D. Minimal change disease Glucose: 250 mg/dL Leukocyte: Trace
d. Are the WBCs significant? Why or why not?
160 Part Two | Urinalysis Chapter 7 | Renal Disease 161

Microscopic: and creatinine results and markedly decreased total Her pregnancy has been normal up to this time. She Microscopic:
>100 RBCs/hpf 2–4 hyaline casts/lpf protein and albumin values. Urinalysis results are as is given a sterile container and asked to collect a 6–10 RBCs/hpf Many bacteria
follows: midstream clean-catch urine specimen. Routine 0–2 WBC casts/lpf
8–10 WBCs/hpf 1–5 granular casts/lpf
Color: Yellow Ketones: Negative urinalysis results are as follows:
0–2 waxy casts/lpf 0–2 broad waxy >100 WBCs/hpf Moderate birefringent,
Clarity: Hazy Blood: Small Color: Pale yellow Ketones: Negative 0–1 bacterial casts/lpf flat crystals
a. What specific disease do the patient’s laboratory
Sp. gravity: 1.018 Bilirubin: Negative Clarity: Hazy Blood: Small a. What diagnostic procedure was performed on the pa-
results and history suggest?
pH: 6.5 Urobilinogen: Normal Sp. gravity: 1.005 Bilirubin: Negative tient that could account for the differences in the two
b. Which laboratory result is most helpful in diagnosing
pH: 8.0 Urobilinogen: Normal urinalysis results?
this disease? Protein: 4+ Nitrite: Negative
Protein: Trace Nitrite: Positive b. Considering the patient’s age and history, what is the
c. What additional diagnosis does his current condition Glucose: Negative Leukocyte: Negative
most probable diagnosis?
suggest? Microscopic: Glucose: Negative Leukocyte: 2+
c. What microscopic constituent is most helpful to this
d. What is the significance of the positive result for urine 10–15 RBCs/hpf 0–1 hyaline casts/lpf Microscopic:
diagnosis?
glucose? 6–10 RBCs/hpf Heavy bacteria
0–4 WBCs/hpf 0–2 granular casts/lpf d. What is the most probable cause of this disorder?
e. Is the specific gravity significant? Why or why not? 40–50 WBCs/hpf Moderate squamous
Moderate fat droplets 0–1 oval fat bodies/hpf e. How can the presence of the bacterial cast be
f. What is the significance of the waxy casts? epithelial cells
a. What disorder do the patient history, physical confirmed?
3. A 45-year-old woman is recovering from injuries received appearance, and laboratory results suggest? a. What is the most probable diagnosis for this
f. What is the most probable source of the crystals
in an automobile accident that resulted in her being taken patient?
b. What other renal disorders produce similar present in the sediment?
to the emergency department with severe hypotension. urinalysis results? b. What is the correlation between the color and the
g. Without surgical intervention, what is the patient’s
She develops massive edema. Significant laboratory re- specific gravity?
c. What is the expected prognosis for this patient? prognosis?
sults include a BUN of 30 mg/dL (normal 8 to 23 mg/dL), c. What is the significance of the blood and protein
cholesterol of 400 mg/dL (normal 150 to 240 mg/dL), 5. A 32-year-old construction worker experiences tests? 8. A 35-year-old patient being treated for a sinus infection
triglycerides of 840 mg/dL (normal 10 to 190 mg/dL), respiratory difficulty followed by the appearance with methicillin develops fever, a skin rash, and edema.
d. Is this specimen suitable for the appearance of
serum protein of 4.5 mg/dL (normal 6.0 to 7.8 mg/dL), of blood-streaked sputum. He delays visiting a Urinalysis results are as follows:
glitter cells? Explain your answer.
albumin of 2.0 mg/dL (normal 3.2 to 4.5 mg/dL), and physician until symptoms of extreme fatigue and Color: Dark yellow Ketones: Negative
a total urine protein of 3.8 g/d (normal 100 mg/d). red urine are present. A chest radiograph shows pul- e. What other population is at a high risk for
developing this condition? Clarity: Cloudy Blood: Moderate
Urinalysis results are as follows: monary infiltration, and sputum culture is negative
for pathogens. Blood test results indicate anemia, f. What disorder might develop if this disorder is not Sp. gravity: 1.012 Bilirubin: Negative
Color: Yellow Ketones: Negative
increased BUN and creatinine, and the presence treated? pH: 6.0 Urobilinogen: Normal
Clarity: Cloudy Blood: Moderate
of antiglomerular basement membrane antibody. Protein: 3+ Nitrite: Negative
Sp. gravity: 1.015 Bilirubin: Negative 7. A 10-year-old patient with a history of recurrent UTIs is
Urinalysis results are as follows:
admitted to the hospital for diagnostic tests. Initial urinal- Glucose: Negative Leukocyte: 2+
pH: 6.0 Urobilinogen: Normal Color: Red Ketones: Negative ysis results are as follows: Microscopic:
Protein: 4+ Nitrite: Negative Clarity: Cloudy Blood: Large Color: Yellow Ketone: Negative 20–30 RBCs/hpf 1–2 WBC casts/lpf
Glucose: Negative Leukocyte: Negative Sp. gravity: 1.015 Bilirubin: Negative Clarity: Cloudy Blood: Small >100 WBCs/hpf 1–2 granular casts/lpf
Microscopic: ph: 6.0 Urobilinogen: Normal Sp. gravity: 1.025 Bilirubin: Negative After receiving the urinalysis report, the physician
15–20 RBCs/hpf Moderate free fat droplets Protein: 3+ Nitrite: Negative pH: 8.0 Urobilinogen: Normal orders a test for urinary eosinophils. The urinary
0–2 granular casts/lpf
Glucose: Negative Leukocyte: Trace Protein: 2+ Nitrite: Positive eosinophil result is 10%.
0–5 WBCs/hpf Moderate cholesterol
Microscopic: Glucose: Negative Leukocyte: 2+ a. Is the urinary eosinophil result normal or
0–2 fatty casts/lpf crystals
100 RBCs/hpf 0–3 hyaline casts/lpf abnormal?
0–2 oval fat bodies/hpf Microscopic:
10–15 WBCs/hpf 0–3 granular casts/lpf b. What is the probable diagnosis for this patient?
a. What renal disorder do these results suggest? 6–10 RBCs/hpf 0–2 WBC casts/lpf Many
0–2 RBCs casts/lpf bacteria c. Discuss the significance of the increased WBCs
b. How does the patient’s history relate to this and WBC casts in the absence of bacteria.
disorder? a. What disorder do the laboratory results suggest? >100 WBCs/hpf 0–1 bacterial casts/lpf with
clumps d. How can this condition be corrected?
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- A repeat urinalysis a day later has the following results: 9. Following surgery to correct a massive hemorrhage, a
tive, what disorder might be considered? Color: Yellow Ketones: Negative 55-year-old patient exhibits oliguria and edema. Blood
d. What is the relationship of the proteinuria to the
test results indicate increasing azotemia and electrolyte
edema? d. What is the diagnostic test for this disorder? clarity: Cloudy Blood: Small
imbalance. The glomerular filtration rate is 20 mL/min.
e. What mechanism produces the oval fat bodies? e. By what mechanism does this disorder affect the Sp. gravity: >1.035 bilirubin: Negative Urinalysis results are as follows:
glomerulus? pH: 7.5 Urobilinogen: Normal
4. A routinely active 4-year-old boy becomes increasingly Color: Yellow Ketones: Negative
less active after receiving several preschool immuniza- 6. A 25-year-old pregnant woman comes to the outpatient Protein: 2+ Nitrite: Positive Clarity: Cloudy Blood: Moderate
tions. His pediatrician observes noticeable puffiness clinic with symptoms of lower back pain, urinary Glucose: Negative Leukocyte: 2+ Sp. gravity: 1.010 Bilirubin: Negative
around the eyes. A blood test shows normal BUN frequency, and a burning sensation when voiding.
162 Part Two | Urinalysis Chapter 8 | Urine Screening for Metabolic Disorders 175

pH: 7.0 Urobilinogen: Normal and an amylase are normal. Results of a routine
Protein: 3+ Nitrite: Negative urinalysis are as follows: Study Questions
Glucose: 2+ Leukocyte: Negative Color: Dark yellow Ketones: Negative
Clarity: Hazy Blood: Moderate 1. All states require newborn screening for PKU for early: 8. An overflow disorder that could produce a false-positive
Microscopic:
A. Modifications of diet reaction with Clinitest procedure is:
50–60 RBCs/hpf 2–3 granular casts/lpf Sp. gravity: 1.030 Bilirubin: Negative
B. Administration of antibiotics A. Cystinuria
3–6 WBCs/hpf 2–3 RTE cell casts/lpf pH: 5.0 Urobilinogen: Normal
C. Detection of diabetes B. Alkaptonuria
3–4 RTE cells/hpf 0–1 waxy casts/lpf Protein: Trace Nitrite: Negative
D. Initiation of gene therapy C. Indicanuria
0–1 broad granular casts/lpf Glucose: Negative Leukocytes: Negative
D. Porphyrinuria
a. What diagnosis do the patient’s history and labora- Microscopic 2. All of the following disorders can be detected by newborn
tory results suggest? 15–20 RBCs/hpf screening except: 9. A urine that turns black after sitting by the sink for
several hours could be indicative of:
b. What is the most probable cause of the patient’s 0–2 WBCs/hpf A. Tyrosyluria
disorder? Is this considered to be of prerenal, renal, A. Alkaptonuria
Few squamous epithelial cells B. MSUD
or postrenal origin? B. MSUD
a. What condition could these urinalysis results and C. Melanuria
c. What is the significance of the specific gravity the patient’s symptoms represent? C. Melanuria
result? D. Galactosemia
b. What would account for the crenated RBCs? D. Both A and C
d. What is the significance of the RTE cells? 3. The best specimen for early newborn screening is a:
c. Is there a correlation between the urine color and 10. Ketonuria in a newborn is an indication of:
e. State two possible reasons for the presence of the specific gravity and the patient’s symptoms? A. Timed urine specimen
A. MSUD
broad casts. B. Blood specimen
d. Based on the primary substance that causes this B. Isovaleric acidemia
10. A 40-year-old man develops severe back and abdomi- condition, what type of crystals might have been C. First morning urine specimen
C. Methylmalonic acidemia
nal pain after dinner. The pain subsides during the present? D. Fecal specimen
night but recurs in the morning, and he visits his D. All of the above
e. What changes will the patient be advised to make
family physician. Results of a complete blood count 4. Abnormal urine screening tests categorized as an overflow
in his lifestyle to prevent future occurrences? 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
176 Part Two | Urinalysis Chapter 8 | Urine Screening for Metabolic Disorders 177

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? Case Studies and Clinical Situations
A. Meat A. Urine
B. Carbohydrates B. Blood 1. A premature infant develops jaundice. Laboratory tests c. If amino acid chromatography was performed on
are negative for hemolytic disease of the newborn, but this specimen, what additional amino acids could be
C. Starch C. Feces
the infant’s bilirubin level continues to rise. Abnormal present?
D. Bananas D. All of the above urinalysis results include a dark yellow color, positive d. Why are they not present in the microscopic
16. Place the appropriate letter in front of the following 23. The two stages of heme formation affected by lead bilirubin, and needle-shaped crystals seen on micro- constituents?
statements. poisoning are: scopic examination. e. Based on the family history, what genetic disorder
A. Cystinuria A. Porphobilinogen and uroporphyrin a. What is the most probable cause of the infant’s should be considered?
B. Cystinosis B. Aminolevulinic acid and porphobilinogen jaundice?
4. An 8–month-old boy is admitted to the pediatric unit
____ IEM C. Coproporphyrin and protoporphyrin b. Could these same urine findings be associated with an with a general diagnosis of failure to thrive. The parents
adult? Explain your answer. have observed slowness in the infant’s development of
____ Inherited disorder of tubular reabsorption D. Aminolevulinic acid and protoporphyrin
c. What kinds of crystals are present? Name another type motor skills. They also mention the occasional appear-
____ Fanconi syndrome 24. Hurler, Hunter, and Sanfilippo syndromes are hereditary of crystal with a spherical shape that is associated with ance of a substance resembling orange sand in the child’s
____ Cystine deposits in the cornea disorders affecting metabolism of: this condition. diapers. Urinalysis results are as follows:
____ Early renal calculi formation A. Porphyrins d. When blood is drawn from this infant, what precau- COLOR: Yellow KETONES: Negative
17. Blue diaper syndrome is associated with: B. Purines tion should be taken to ensure the integrity of the APPEARANCE: Slightly BLOOD: Negative hazy
A. Lesch-Nyhan syndrome C. Mucopolysaccharides specimen? SP. GRAVITY: 1.024 BILIRUBIN: Negative
B. Phenylketonuria D. Tryptophan 2. A newborn develops severe vomiting and symptoms pH: 5.0 UROBILINOGEN: Normal
C. Cystinuria 25. Many uric acid crystals in a pediatric urine specimen may of metabolic acidosis. Urinalysis results are positive for PROTEIN: Negative NITRITE: Negative
indicate: ketones and negative for glucose and other reducing
D. Hartnup disease GLUCOSE: Negative LEUKOCYTE: Negative
substances.
A. Hurler syndrome Microscopic:
18. Homocystinuria is caused by failure to metabolize: a. If the urine had an odor of “sweaty feet,” what meta-
B. Lesch-Nyhan disease Many uric acid crystals
A. Lysine bolic disorder would be suspected?
C. Melituria a. Is the urine pH consistent with the appearance of uric
B. Methionine b. If the newborn was producing dark brown urine with
D. Sanfilippo syndrome a sweet odor, what disorder would be suspected? acid crystals?
C. Arginine
26. Deficiency of the GALT enzyme will produce a: c. Would an MS/MS screen be helpful for the diagnosis? b. Is there any correlation between the urinalysis results
D. Cystine
and the substance observed in the child’s diapers?
A. Positive Clinitest 3. A 13-year-old boy is awakened with severe back and
19. The Ehrlich reaction will only detect the presence of: Explain your answer.
B. Glycosuria abdominal pain and is taken to the emergency depart-
A. Uroporphyrin c. What disorder do the patient’s history and the urinaly-
C. Galactosemia ment by his parents. A complete blood count is normal. sis results indicate?
B. Porphobilinogen
D. Both A and C Family history shows that both his father and uncle are
C. Coproporphyrin d. Is the fact that this is a male patient of any significance?
chronic kidney stone formers. Results of a urinalysis
27. Match the metabolic urine disorders with their classic Explain your answer.
D. Protoporphyrin are as follows:
urine abnormalities. e. Name the enzyme that is missing.
20. Acetyl acetone is added to the urine before performing the COLOR: Yellow KETONES: Negative
____ PKU A. Sulfur odor 5. Shortly after arriving for the day shift in the urinalysis
Ehrlich test when checking for: APPEARANCE: Hazy BLOOD: Moderate
____ Indicanuria B. Sweaty feet odor laboratory, a technician notices that an undiscarded urine
A. Aminolevulinic acid SP. GRAVITY: 1.025 BILIRUBIN: Negative
____ Cystinuria C. Orange sand in diaper has a black color. The previously completed
B. Porphobilinogen pH: 6.0 UROBILINOGEN: Normal report indicates the color to be yellow.
____ Alkaptonuria D. Mousy odor
C. Uroporphyrin PROTEIN: Negative NITRITE: Negative a. Is this observation significant? Explain your answer.
____ Lesch-Nyhan disease E. Black color
D. Coproporphyrin GLUCOSE: Negative LEUKOCYTE: Negative b. The original urinalysis report showed the specimen
____ Isovaleric acidemia F. Blue color
21. The classic urine color associated with porphyria is: Microscopic: to be positive for ketones. Is this significant? Why or
why not?
A. Dark yellow >15–20 RBCs/hpf Few squamous epithelial
cells c. If the ketones are negative and the pH is 8.0 is this
B. Indigo blue
significant? Why or why not?
C. Pink 0–3 WBCs/hpf Many cystine crystals
a. What condition does the patient’s symptoms represent? 6. Bobby Williams, age 8, is admitted through the emer-
D. Port wine
gency department with a ruptured appendix. Although
b. What is the physiologic abnormality causing this
surgery is successful, Bobby’s recovery is slow, and the
condition?
178 Part Two | Urinalysis 198 Part Three | Other Body Fluids

physicians are concerned about his health prior to the 7. An anemic patient is suspected of having lead poisoning. Log on to 16. Whitaker, JN: Myelin basic protein in cerebrospinal fluid and
ruptured appendix. Bobby’s mother states that he has www.fadavis.com/strasinger other body fluids. Multiple Sclerosis 4(1):16–21, 1998.
a. What historical urine test was requested? for additional content related 17. Okta, M, et al: Evaluation of an enzyme immunoassay for
always been noticeably underweight despite eating a
b. What should be added to the urine before testing? to this chapter. myelin basic protein in CSF. Clin Chem 46:1326–1330, 2000.
balanced diet and having strong appetite and that his 18. Menkes, J: The causes of low spinal fluid sugar in bacterial
younger brother exhibits similar characteristics. A note c. What element of heme synthesis would this be meningitis: Another look. Pediatrics 44(1):1–3, 1969.
in his chart from the first postoperative day reports that testing for? 19. Hourani, BT, Hamlin, EM, and Reynolds, TB: Cerebrospinal
References
the evening nurse noticed a blue coloration in the urinary d. Name another substance that can be tested for lead fluid glutamine as a measure of hepatic encephalopathy. Arch
1. Scanlon,VC and Sanders,T: Essentials of Anatomy and Physiol- Intern Med 127:1033–1036, 1971.
catheter bag. poisoning. ogy, 5th ed. FA Davis Company, Philadelphia, 2007. 20. Glasgow, AM, and Dhiensiri, K: Improved assay for spinal fluid
a. Is the catheter bag color significant? e. What element of heme synthesis would this test for? 2. Edlow, JA, and Caplan, LR: Avoiding pitfalls in the diagnosis of glutamine and values for children with Reye’s syndrome. Clin
subarachnoid hemorrhage. N Engl J Med 342:29–36, 2000. Chem 20(6):642–644, 1974.
b. What condition can be suspected from this history? 3. Nagda, KK: Procoagulant activity of cerebrospinal fluid in 21. Murray, PR, and Hampton, CM: Recovery of pathogenic bac-
c. What is Bobby’s prognosis? health and disease. Indian J Med Res 74:107–110, 1981. teria from cerebrospinal fluid. J Clin Microbiol 12:554–557,
4. Chow, G, and Schmidley, JW: Lysis of erythrocytes and leukocytes 1980.
in traumatic lumbar punctures. Arch Neurol 41:1084–1085, 1984. 22. Sato, Y, et al: Rapid diagnosis of cryptococcal meningitis by
5. Seehusen, DA, Reeves, MM, and Fomin, DA: Cerebrospinal microscopic examination of centrifuged cerebrospinal fluid
fluid analysis. Am Fam Physician 68(6):1103–1108, 2003. sediment. J Neurol Sci 164(1):72–75, 1999.
6. Glasser, L: Tapping the wealth of information in CSF. Diagn 23. Eng, RHK, and Person, A: Serum cryptococcal antigen determi-
Med 4(1):23–33, 1981. nation in the presence of rheumatoid factor. J Clin Microbiol
7. University of Virginia Health Sciences Center: Clinical Labora- 14:700–702, 1981.
tory Procedure Manual. Charlottesville, VA, 1993. 24. Stockman, L, and Roberts, GD: Specificity of the latex test for
8. Kjeldsberg, CR, and Knight, JA: Body Fluids: Laboratory Exam- cryptococcal antigen: A rapid simple method for eliminating
ination of Amniotic, Cerebrospinal, Seminal, Serous and Syn- interference. J Clin Microbiol 17(5):945–947, 1983.
ovial Fluids: A Textbook Atlas. ASCP, Chicago, 1993. 25. Knight, FR: New enzyme immunoassay for detecting crypto-
9. Abrams, J, and Schumacher, HR: Bone marrow in cerebrospinal coccal antigen. J Clin Pathol 45(9):836–837, 1992.
fluid and possible confusion with malignancy. Arch Pathol Lab 26. Klausner, JD, Vijayan, T, Chiller,T: Sensitivity and specificity of
Med 110:366–369, 1986. a new cryptococcal antigen lateral flow assay in serum and
10. Bentz, JS: Laboratory investigation of multiple sclerosis. Lab cerebrospinal fluid. MLO, March 2013.
Med 26(6):393–399, 1995. 27. Wojewoda,C: Bacterial Antigen Testing, The Good, the Not So
11. Biou, D, et al: Cerebrospinal fluid protein concentrations in Bad and the Ugly. NewsPath. Accessed February 14, 2013
children: Age-related values in patients without disorders of the 28. Leventhal, R and Cheadle, RF: Medical Parasitology, ed.6,
central nervous system. Clin Chem 46(3):399–403, 2000. FA Davis Company, Philadelphia, 2012.
12. Fishman, RA: Cerebrospinal Fluid in Diseases of the Nervous 29. Davis, LE, and Schmitt, JW: Clinical significance of cere-
System, ed 2. WB Saunders, Philadelphia, 1992. brospinal fluid tests for neurosyphilis. Ann Neurol 25:50–53,
13. Hershey, LA, and Trotter, JL: The use and abuse of the cere- 1989.
brospinal fluid IgG profile in the adult: A practical evaluation. 30. Albright, RE, et al: Issues in cerebrospinal fluid management.
Ann Neurol 8(4):426–434, 1980. Am J Clin Pathol 95(3):397–401, 1991.
14. Grimaldi, LME, et al: Oligoclonal IgG bands in cerebrospinal 31. Lofsness, KG, and Jensen, TL: The preparation of simulated
fluid and serum during asymptomatic human immunodefi- spinal fluid for teaching purposes. Am J Med Technology
ciency virus infection. Ann Neurol 24:277–279, 1988. 49(7):493–496, 1983.
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 3. Substances present in the CSF are controlled by the:
except: A. Arachnoid granulations
A. Removing metabolic wastes B. Blood–brain barrier
B. Producing an ultrafiltrate of plasma C. Presence of one-way valves
C. Supplying nutrients to the CNS D. Blood–CSF barrier
D. Protecting the brain and spinal cord 4. What department is the CSF tube labeled 3 routinely
sent to?
2. The CSF flows through the:
A. Hematology
A. Choroid plexus
B. Chemistry
B. Pia mater C. Microbiology
C. Arachnoid space D. Serology
D. Dura mater
 Chapter 9 | Cerebrospinal Fluid 199 200 Part Three | Other Body Fluids

5. The CSF tube that should be kept at room temperature is: 12. The purpose of adding albumin to CSF before cytocen- 19. Hemosiderin granules and hematoidin crystals are seen in: 27. Given the following results, calculate the IgG index: CSF IgG,
A. Tube 1 trifugation is to: A. Lymphocytes 50 mg/dL; serum IgG, 2 g/dL; CSF albumin, 70 mg/dL;
A. Increase the cell yield serum albumin, 5 g/dL.
B. Tube 2 B. Macrophages
B. Decrease the cellular distortion A. 0.6
C. Tube 3 C. Ependymal cells
C. Improve the cellular staining B. 6.0
D. Tube 4 D. Neutrophils
D. Both A and B C. 1.8
6. Place the appropriate letter in front of the statement that 20. Myeloblasts are seen in the CSF:
D. 2.8
best describes CSF specimens in these two conditions: 13. The primary concern when pleocytosis of neutrophils and A. In bacterial infections
A. Traumatic tap lymphocytes is found in the CSF is: 28. The CSF IgG index calculated in Study Question 27
B. In conjunction with CNS malignancy
A. Meningitis indicates:
B. Intracranial hemorrhage C. After cerebral hemorrhage
B. CNS malignancy A. Synthesis of IgG in the CNS
____ Even distribution of blood in all tubes D. As a complication of acute leukemia
C. Multiple sclerosis B. Damage to the blood–brain barrier
____ Xanthochromic supernatant
21. Cells resembling large and small lymphocytes with C. Cerebral hemorrhage
____ Concentration of blood in tube 1 is greater D. Hemorrhage
cleaved nuclei represent:
than in tube 3 D. Lymphoma infiltration
14. Neutrophils with pyknotic nuclei may be mistaken for: A. Lymphoma cells
____ Specimen contains clots A. Lymphocytes 29. The finding of oligoclonal bands in the CSF and not in
B. Choroid cells
the serum is seen with:
7. The presence of xanthochromia can be caused by all of B. Nucleated RBCs C. Melanoma cells
the following except: A. Multiple myeloma
C. Malignant cells D. Medulloblastoma cells
A. Immature liver function B. CNS malignancy
D. Spindle-shaped cells
22. The reference range for CSF protein is: C. Multiple sclerosis
B. RBC degradation
15. The presence of which of the following cells is increased A. 6 to 8 g/dL
C. A recent hemorrhage D. Viral infections
in a parasitic infection?
B. 15 to 45 g/dL
D. Elevated CSF protein A. Neutrophils 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:
8. A web-like pellicle in a refrigerated CSF specimen B. Macrophages
D. 15 to 45 mg/dL A. Fungal meningitis
indicates: C. Eosinophils
A. Tubercular meningitis 23. CSF can be differentiated from serum by the presence of: B. Viral meningitis
D. Lymphocytes
B. Multiple sclerosis A. Albumin C. Tubercular meningitis
16. Macrophages appear in the CSF after:
C. Primary CNS malignancy B. Globulin D. Bacterial meningitis
A. Hemorrhage
D. Viral meningitis C. Prealbumin 31. A patient with a blood glucose of 120 mg/dL would have
B. Repeated spinal taps
D. Tau transferrin a normal CSF glucose of:
9. Given the following information, calculate the CSF WBC C. Diagnostic procedures
count: cells counted, 80; dilution, 1:10; large Neubauer 24. In serum, the second most prevalent protein is IgG; in A. 20 mg/dL
D. All of the above
squares counted, 10. CSF, the second most prevalent protein is: B. 60 mg/dL
A. 8 17. Nucleated RBCs are seen in the CSF as a result of: A. Transferrin C. 80 mg/dL
B. 80 A. Elevated blood RBCs B. Prealbumin D. 120 mg/dL
C. 800 B. Treatment of anemia C. IgA 32. CSF lactate will be more consistently decreased in:
D. 8000 C. Severe hemorrhage D. Ceruloplasmin A. Bacterial meningitis
D. Bone marrow contamination
10. A CSF WBC count is diluted with: 25. Elevated CSF protein values can be caused by all of the B. Viral meningitis
A. Distilled water 18. After a CNS diagnostic procedure, which of the following following except: C. Fungal meningitis
might be seen in the CSF? A. Meningitis
B. Normal saline D. Tubercular meningitis
A. Choroidal cells B. Multiple sclerosis
C. Acetic acid 33. Measurement of which of the following can be replaced by
B. Ependymal cells C. Fluid leakage
D. Hypotonic saline CSF glutamine analysis in children with Reye syndrome?
C. Spindle-shaped cells D. CNS malignancy
11. A total CSF cell count on a clear fluid should be: A. Ammonia
D. All of the above
A. Reported as normal 26. The integrity of the blood–brain barrier is measured using B. Lactate
the: C. Glucose
B. Not reported
A. CSF/serum albumin index D. α-Ketoglutarate
C. Diluted with normal saline
B. CSF/serum globulin ratio
D. Counted undiluted
C. CSF albumin index
D. CSF IgG index
 Chapter 9 | Cerebrospinal Fluid 201 202 Part Three | Other Body Fluids

34. Before performing a Gram stain on CSF, the specimen 36. The test of choice to detect neurosyphilis is the: 4. Mary Howard, age 5, is admitted to the pediatrics ward c. Are the lymphocytes significant? Why or why not?
must be: A. RPR with a temperature of 105%F, lethargy, and cervical rigid- d. Would a CSF lactate test be of any value for the diag-
A. Filtered ity. A lumbar spinal tap is performed, and three tubes of nosis? Why or why not?
B. VDRL
cloudy CSF are delivered to the laboratory. Preliminary
B. Warmed to 37°C C. FAB 5. State possible technical errors that could result in the fol-
test results are as follows:
C. Centrifuged D. FTA-ABS lowing discrepancies:
Appearance: Cloudy
D. Mixed a. An unusual number of Gram stains reported as gram-
WBC count: 800 cells/µL
positive cocci fail to be confirmed by positive cultures.
35. All of the following statements are true about cryptococcal Differential: 80% lymphocytes, 15% monocytes,
meningitis except: b. A physician complains that CSF differentials are being
5% neutrophils
reported only as polynuclear and mononuclear cells.
A. An India ink preparation is positive Protein: 65 mg/dL
c. Bacteria observed on the cytospin differential cannot
B. A starburst pattern is seen on Gram stain Glucose: 70 mg/dL be confirmed by Gram stain or culture.
C. The WBC count is over 2000 Gram stain: No organisms seen d. The majority of CSF specimens sent to the laboratory
D. A confirmatory immunology test is available 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?
Case Studies and Clinical Situations
1. Three tubes of CSF containing evenly distributed visible d. What could cause a false-positive reaction in this test?
blood are drawn from a 75-year-old disoriented patient e. If the tests named in a and c are negative, the glucose
and delivered to the laboratory. Initial test results are as level is 35 mg/dL, and a pellicle is observed in the
follows: fluid, what additional testing should be performed?
WBC count: 250 µL Protein: 150 mg/dL f. If CSF and serum IEF was performed on this patient,
Glucose: 70 mg/dL Gram stain: No organisms what unusual findings might be present?
seen
3. A 35-year-old woman is admitted to the hospital with
Differential: Neutrophils, 68%; monocytes, 3%; lympho- symptoms of intermittent blurred vision, weakness, and
cytes, 28%; eosinophils, 1% loss of sensation in her legs. A lumbar puncture is per-
Many macrophages containing ingested RBCs formed with the following results:
a. What is the most probable condition indicated by Appearance: Colorless, clear
these results? State two reasons for your answer. WBC count: 35 cells/µL (90% lymphocytes)
b. Are the elevated WBC count and protein significant? Glucose: 60 mg/dL (plasma: 100 mg/dL)
Explain your answer. Protein: 60 mg/dL (serum: 8 g/dL)
c. Are the percentages of the cells in the differential of Albumin: 40 mg/dL (serum: 6 g/dL)
any significance? Explain your answer.
IgG globulin: 20 mg/dL (serum: 2 g/dL)
d. What two other structures besides RBCs might be
contained in the macrophages? a. Name and perform the calculation to determine the
integrity of the patient’s blood–brain barrier.
e. If the blood was unevenly distributed and nucleated
RBCs and capillary structures were seen instead of b. Does the patient have an intact barrier?
macrophages, what would this indicate? c. Name and perform the calculation used to determine
if IgG is being synthesized within the CNS.
2. A patient with AIDS is hospitalized with symptoms of
high fever and rigidity of the neck. Routine laboratory d. What does this result indicate?
tests on the CSF show a WBC count of 100/µL with a e. Considering the patient’s clinical symptoms and the
predominance of lymphocytes and monocytes, glucose calculation results, what diagnosis is suggested?
of 55 mg/dL (plasma: 85 mg/dL), and a protein of f. If immunofixation electrophoresis is performed on
70 mg/dL. The Gram stain shows a questionable starburst the patient’s serum and CSF, what findings would be
pattern. expected?
a. What additional microscopic examination should be g. What substance in the CSF can be measured to moni-
performed? tor this patient?
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?
266 Part Three | Other Body Fluids Chapter 14 | Fecal Analysis 267

15. Microscopic examination of stools provides preliminary 23. What is the recommended number of samples that should
Study Questions information as to the cause of diarrhea because: be tested to confirm a negative occult blood result?
A. Neutrophils are present in conditions caused by A. One random specimen
1. In what part of the digestive tract do pancreatic enzymes 8. Stools from persons with steatorrhea will contain excess toxin-producing bacteria B. Two samples taken from different parts of three
and bile salts contribute to digestion? amounts of: B. Neutrophils are present in conditions that affect the stools
A. Large intestine A. Barium sulfate intestinal wall C. Three samples taken from the outermost portion of
B. Liver B. Blood C. Red and white blood cells are present if the cause is the stool
C. Small intestine bacterial D. Three samples taken from different parts of two
C. Fat
D. Neutrophils are present if the condition is of nonbac- stools
D. Stomach D. Mucus terial etiology
24. The immunochemical tests for occult blood:
2. Where does the reabsorption of water take place in the 9. Which of the following pairings of stool appearance and 16. True or False: The presence of fecal neutrophils would be A. Test for human globulin
primary digestive process? cause does not match? expected with diarrhea caused by a rotavirus.
A. Large intestine B. Give false-positive reactions with meat hemoglobin
A. Black, tarry: blood 17. Large orange-red droplets seen on direct microscopic
B. Pancreas C. Can give false-positive reactions with aspirin
B. Pale, frothy: steatorrhea examination of stools mixed with Sudan III represent:
C. Small intestine D. Are inhibited by porphyrin
C. Yellow-gray: bile duct obstruction A. Cholesterol
D. Stomach 25. Guaiac tests for detecting occult blood rely on the:
D. Yellow-green: barium sulfate B. Fatty acids
3. Which of the following tests is not performed to detect A. Reaction of hemoglobin with hydrogen peroxide
C. Neutral fats
osmotic diarrhea? 10. Stool specimens that appear ribbon-like are indicative of B. Pseudoperoxidase activity of hemoglobin
which condition? D. Soaps
A. Clinitest C. Reaction of hemoglobin with ortho-toluidine
A. Bile-duct obstruction 18. Microscopic examination of stools mixed with Sudan III
B. Fecal fats D. Pseudoperoxidase activity of hydrogen peroxide
and glacial acetic acid and then heated will show small
B. Colitis
C. Fecal neutrophils orange-red droplets that represent: 26. What is the significance of an APT test that remains pink
D. Muscle fibers C. Intestinal constriction A. Fatty acids and soaps after addition of sodium hydroxide?
D. Malignancy B. Fatty acids and neutral fats A. Fecal fat is present.
4. The normal composition of feces includes all of the following
except: 11. A black tarry stool is indicative of: C. Fatty acids, soaps, and neutral fats B. Fetal hemoglobin is present.
A. Bacteria A. Upper GI bleeding D. Soaps C. Fecal trypsin is present.
B. Blood D. Vitamin C is present.
B. Lower GI bleeding 19. When performing a microscopic stool examination for
C. Electrolytes C. Excess fat muscle fibers, the structures that should be counted: 27. In the Van de Kamer method for quantitative fecal fat
A. Are coiled and stain blue determinations, fecal lipids are:
D. Water D. Excess carbohydrates
B. Contain no visible striations A. Converted to fatty acids prior to titrating with
5. What is the fecal test that requires a 3-day specimen? 12. Chemical screening tests performed on feces include all sodium hydroxide
C. Have two-dimensional striations
A. Fecal occult blood of the following except: B. Homogenized and titrated to a neutral endpoint with
D. Have vertical striations and stain red
B. APT test A. APT test sodium hydroxide
C. Elastase I 20. A value of 85% fat retention would indicate: C. Measured gravimetrically after washing
B. Clinitest
D. Quantitative fecal fat testing A. Dumping syndrome D. Measured by spectrophotometer after addition of
C. Pilocarpine iontophoresis
B. Osmotic diarrhea Sudan III
6. The normal brown color of the feces is produced by: D. Quantitative fecal fats
C. Secretory diarrhea 28. A patient whose stool exhibits increased fats, undigested
A. Cellulose 13. Secretory diarrhea is caused by: D. Steatorrhea muscle fibers, and the inability to digest gelatin may
B. Pancreatic enzymes A. Antibiotic administration have:
21. Which of the following tests would not be indicative of
C. Undigested foodstuffs B. Lactose intolerance A. Bacterial dysentery
steatorrhea?
D. Urobilin B. A duodenal ulcer
C. Celiac sprue A. Fecal elastase-I
7. Diarrhea can result from all of the following except: D. Vibrio cholerae B. Fecal occult blood C. Cystic fibrosis
A. Addition of pathogenic organisms to the normal C. Sudan III D. Lactose intolerance
14. The fecal osmotic gap is elevated in which disorder?
intestinal flora
D. Van de Kamer
B. Disruption of the normal intestinal bacterial flora A. Dumping syndrome
B. Osmotic diarrhea 22. The term “occult” blood describes blood that:
C. Increased concentration of fecal electrolytes
C. Secretory diarrhea A. Is produced in the lower GI tract
D. Increased reabsorption of intestinal water and
B. Is produced in the upper GI tract
electrolytes D. Steatorrhea
C. Is not visibly apparent in the stool specimen
D. Produces a black, tarry stool
268 Part Three | Other Body Fluids 298 Answers to Study Questions and Case Studies and Clinical Situations

29. A stool specimen collected from an infant with diarrhea 30. Which of the following tests differentiates a malabsorp- Chapter 3 Chapter 4
has a pH of 5.0. This result correlates with a: tion cause from a maldigestion cause in steatorrhea?
A. Positive APT test A. APT test Study Questions Study Questions
B. Negative trypsin test B. D-xylose test 1. B 14. B 23. B 1. A 9. D 17. D
C. Positive Clinitest C. Lactose tolerance test 2. D 15. B 24. D 2. D 10. A 18. D
D. Negative occult blood test D. Occult blood test 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
Case Studies and Clinical Situations 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
1. Microscopic screening of a stool from a patient exhibiting 3. A physician’s office laboratory is experiencing inconsisten- 8. D 30. +0.5 8. C 16. B 24. D
C; D. 125I-
prolonged diarrhea shows increased fecal neutrophils and cies in the results of patient-collected specimens for
9. B iodothalamate 31. D
normal qualitative fecal fats and meat fibers. FOBT. Patients are instructed to submit samples from two
areas of three different stools. Positive and negative con- 10. A 19. B 32. 600 mL/min Case Studies and Clinical Situations
a. What type of diarrhea do these results suggest?
trols are producing satisfactory results. Patient #1 is a 30- 11. C 20. 69 mL/min 33. C 1. a. An elevated pH and a positive reagent strip reaction
b. Name an additional test that could provide more diag- year-old woman taking over-the-counter medications for 12. D 21. D 34. B for nitrite.
nostic information. gastric reflux who has reported passing frequent, black
13. D 22. D b. The reagent strip specific gravity would be much
c. Name one probable result for this test and one im- stools. The results of all three specimens are negative for lower if the patient had been given radiographic dye.
probable result. occult blood. Patient #2 is a 70-year-old woman suffering
from arthritis. She is taking the test as part of a routine Case Studies and Clinical Situations c. The reagent strip test for bilirubin would be positive.
d. If the test for fecal neutrophils were negative and the
physical. The results of all three specimens are positive d. The reagent strip reaction for blood would be positive
fecal fat concentration increased, what type of diarrhea 1. a. 160-mg/dL to 180-mg/dL.
for occult blood. Patient #3 is a 50-year-old man advised and red blood cells would be seen in the microscopic.
would be suggested? b. Renal tubular reabsorption is impaired.
by the doctor to lose 30 lb. He has been doing well on a 2. a. 1.018
2. Laboratory studies are being performed on a 5-year-old high-protein, low-carbohydrate diet. Two of his three 2. a. Juxtaglomerular apparatus → Angiotensinogen
b. Yes.
boy to determine whether there is a metabolic reason for specimens are positive for occult blood. → Renin → Angiotensin I → Angiotensin II.
c. It would agree with the reagent strip reading because
his continued failure to gain weight. In addition to having a. What is the possible nonpathologic cause of the unex- b. Vasoconstriction, increased sodium reabsorption, and
like the osmometer, the reagent strip is not affected
blood drawn, the patient has a sweat chloride collected, pected results for Patient #1? Patient #2? Patient #3? increased aldosterone to retain sodium.
by high-molecular-weight substances.
provides a random stool sample, and is asked to collect a b. How could the physician’s office staff avoid these dis- c. Production of renin decreases and, therefore, the
72-hour stool sample. 3. Hemoglobin and myoglobin.
crepancies? actions of the renin-angiotensin-aldosterone system.
a. How can the presence of steatorrhea be screened for a. Examine the patient’s plasma /serum. The breakdown
c. What testing methodology could be used for Patients #2 3. a. The physician can calculate the approximate creatinine
of red blood cells to hemoglobin produces a red
by testing the random stool sample? and #3? clearance using the MDRD-IDMS-traceable formula.
serum. Myoglobin is produced from skeletal muscle
b. How does this test distinguish among neutral fats, b. The cystatin C test and the beta2-microglobulin test and is rapidly cleared from the plasma/serum.
4. A watery black stool from a neonate is received in the lab-
soaps, and fatty acids? serum tests.
oratory with requests for an APT test, fecal pH, and a 4. a. Mrs. Smith has been eating fresh beets.
c. What confirmatory test should be performed? Clinitest. 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
d. Describe the appearance of the stool specimens if a. Can all three tests be performed on this specimen? not recently consumed fresh beets.
immune system; therefore, the test cannot be reli-
steatorrhea is present. Why? 5. No. The urine can contain increased pH, glucose, ketones,
able in patients with immunologic disorders and
e. If a diagnosis of cystic fibrosis is suspected, state two b. If the Clinitest is positive, what pH reading can be malignancies. bilirubin, urobilinogen, nitrite, and small amounts of
screening tests that could be performed on a stool expected? Why? cellular structures.
4. a. Yes. Serum from the midnight specimen is not being
specimen to aid in the diagnosis. c. The infant’s hemoglobin remains constant at 18 g/dL. separated from the clot and refrigerated in a timely
f. State a possible reason for a false-negative reaction in What was the significance of the black stool? manner.
each of these tests. d. Would this infant be expected to have ketonuria? Why
Chapter 5
b. Lactic acid will be present in serum that is not
g. What confirmatory test could be performed? or why 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
 Answers to Study Questions and Case Studies and Clinical Situations 299 300 Answers to Study Questions and Case Studies and Clinical Situations

22. B 32. B 42. B 6. a. No, the specimen is clear. 2. a. The large objects are in a different plane from that of g. No, calcium carbonate crystals are found in alkaline
23. C 33. A 43. D b. Myoglobinuria. the urinary constituents. urine; therefore, clumps of amorphous phosphates
b. Contamination by artifacts. may be present.
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. c. No, because they are in a different plane.
26. B 36. D 46. C 7. a. Laboratory personnel are not tightly capping the d. Polarizing microscopy. Chapter 7
27. A 37. C 47. C reagent strip containers in a timely manner. 3. a. Renal tubules.
b. Personnel performing the CLIA-waived reagent strip b. Yes, viral infections can cause tubular damage. Study Questions
28. D 38. A 48. A
test are not waiting 2 minutes to read the LE reaction. c. RTE cells absorb the bilirubin-containing urinary
29. A 39. C 49. C 1. B 8. D 15. A
c. The student is not mixing the specimen. filtrate.
30. C 40. A 2. C 9. A 16. C
d. The reagent strips have deterioated and the quality d. Liver damage inhibits processing of reabsorbed
31. 1, 2, 1, 2, 1, 2 41. B 3. B 10. C 17. A
control on the strips was not performed prior to urobilinogen.
reporting the results. e. Hemolytic anemia. 4. C 11. C 18. A
Case Studies and Clinical Situations
4. a. The patient is taking a pigmented medication, such as 5. B 12. C 19. A
1. a. The blood glucose is elevated and has exceeded the phenazopyridine.
renal tubular maximum (Tm) for glucose. Chapter 6 6. D 13. B 20. D
b. Yes. 7. C 14. D
b. Diabetes mellitus.
Study Questions c. Ask what medications the patient is taking.
c. It indicates diabetes mellitus related renal disease.
1. A 18. D 35. A d. Ampicillin. Case Studies and Clinical Situations
d. Renal tubular reabsorption disorders.
2. D 19. B 36. C 5. a. Calcium oxalate. 1. a. Acute glomerulonephritis.
2. a. Yellow foam.
3. C 20. C 37. A b. Monohydrate and dihydrate calcium oxalate. b. M protein in the cell wall of the group A
b. Possible biliary-duct obstruction preventing bilirubin
4. C 21. A 38. D c. Oval: monohydrate; envelope: dihydrate. streptococcus.
from entering the intestine.
5. A 22. B 39. A d. Monohydrate. c. Glomerular bleeding.
c. Icteric.
6. B 23. C 40. C 6. a. Microscopic results do not match the chemical tests d. No, they are also passing through the damaged
d. Protection from light.
for blood, nitrite, and leukocyte esterase. glomerulus.
3. a. Hemoglobinuria. 7. C 24. D 41. D
b. The specimen has been unpreserved at room temper- e. Good prognosis with appropriate management of
b. Increased hemoglobin presented to the liver results 8. D 25. D 42. A
ature for too long, the cells have disintegrated, and secondary complications.
in increased bilirubin entering the intestine for 9. C 26. B 43. A the bacteria have converted the nitrite to nitrogen. f. Henoch-Schönlein purpura.
conversion to urobilinogen. 10. D 27. D 44. C c. The pH. 2. a. IgA nephropathy.
c. The circulating bilirubin is unconjugated. 11. D 28. A 45. D d. Ask the clinic personnel to instruct the patient to col- b. Serum IgA level.
d. It would if a multisix reagent strip is used and would 12. A 29. B 46. C lect a midstream clean-catch specimen and have the
not if a Chemstrip is used. A Watson-Schwartz test is c. Chronic glomerulonephritis/end-stage renal
13. C 30. C 47. 4, 3, 5, 1 specimen delivered immediately to the laboratory.
more specific for porphobilinogen. disease.
14. B 31. C 48. 3, 5, 2, 6, 4 7. a. No, because they are associated with strenuous
4. a. Negative chemical reactions for blood and nitrite. d. Impaired renal tubular reabsorption associated with
exercise.
Ascorbic acid interference for both reactions. A ran- 15. C 32. D 49. 4, 8, 7, 6, 1, 5 end-stage renal disease.
b. The positive blood reaction is from hemoglobinuria
dom specimen or further reduction of nitrite could 16. A 33. D 50. 3, 5, 2, 1, 7, 4 e. The specific gravity is the same as that of the ultrafil-
or myoglobinuria resulting from participating in a
cause the negative nitrite. 17. D 34. B trate, indicating a lack of tubular concentration.
contact sport. The protein is orthostatic.
b. Glucose, bilirubin, LE. Ascorbic acid is a strong re- f. The presence of extreme urinary stasis.
c. Increased excretion of RTE cell lysosomes in the
ducing agent that interfers with the oxidation reaction Case Studies and Clinical Situations presence of dehydration. 3. a. Nephrotic syndrome.
in the glucose test. Ascorbic acid combines with the
1. a. Yeast grows best at a low pH with an increased con- 8. a. Yes, the waxy casts are probably an artifact such as b. Nephrotic syndrome may be caused by sudden,
diazo reagent in the bilirubin and LE tests, lowering
centration of glucose. a diaper fiber. Waxy casts are not associated with severe hypotension.
the sensitivity.
b. Yes, this exceeds the renal threshold. negative urine protein. c. Changes in the electrical charges of the shield of
c. The dark yellow color may be caused by beta-carotene
b. No, this is normal following an invasive procedure. negativity produce increased membrane permeability.
and vitamin A, and some B vitamins also produce c. No, yeast is not capable of reducing nitrate to
yellow urine. nitrite. 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
d. Non-nitrite–reducing microorganisms; lack of dietary d. Moderate blood with no RBCs.
crystals may be an artifact or from a medication. tissue.
nitrate; antibiotic administration. e. Myoglobin is the cause of the positive chemical test
d. Yes, uric acid crystals may be mistaken for cystine e. Reabsorption of filtered lipids by the RTE cells.
5. a. To check for possible exercise-induced abnormal results. result for blood. The patient has been bed-ridden
for an extended period of time, causing muscle crystals. 4. a. Minimal change disease.
b. Negative protein and blood, possible changes in color
and specific gravity. destruction. e. Yes, radiographic dye crystals associated with a high b. Nephrotic syndrome, focal segmental
specific gravity resemble cholesterol crystals. glomerulosclerosis.
c. Renal.
f. No, Trichomonas is carried asymptomatically by men. c. Good prognosis with complete remission.
 Answers to Study Questions and Case Studies and Clinical Situations 301 302 Answers to Study Questions and Case Studies and Clinical Situations

5. a. Goodpasture syndrome. Chapter 8 Chapter 9 5. a. Stain precipitate is being confused with Gram-
b. The autoantibody attaches to the glomerular capillar- positive cocci.
ies, causing complement activation and destruction of Study Questions Study Questions b. Differentials are being reported from the counting
the capillaries. chamber.
1. A 10. D 19. B 1. B 13. A 25. C
c. Wegener’s granulomatosis. c. The albumin is contaminated.
2. C 11. D 20. B 2. C 14. B 26. A
d. Antineutrophilic cytoplasmic antibody. d. The specimens are not being promptly delivered to
3. B 12. B 21. D 3. B 15. C 27. C the laboratory.
e. Granuloma formation resulting from autoantibodies
binding to neutrophils in the vascular walls and 4. C 13. C 22. D 4. A 16. D 28. A
initiating an immune response. 5. A 14. A 23. D 5. B 17. D 29. C
6. a. Cystitis, UTI. 6. A 15. D 24. C 6. B, B, A, A 18. D 30. D
Chapter 10
b. The specimen is very dilute. 7. C 16. B, A, B, B, A 25. B 7. C 19. B 31. B Study Questions
c. Irritation of the urinary tract will cause a small 8. B 17. D 26. D 8. A 20. D 32. A
1. C 12. C 23. D
amount of bleeding. The cells and bacteria may cause 9. D 18. B 27. D, F, A, E, C, B 9. C 21. A 33. A
a trace protein or it may be a false-positive due to the 2. D 13. A 24. B
10. C 22. B 34. C
high pH. 3. B 14. A 25. D
Case Studies and Clinical Situations 11. D 23. B 35. C
d. Yes, glitter cells are seen in hypotonic urine. 4. C 15. B 26. B
1. a. Underdevelopment of the liver. 12. D 24. B 36. D
e. Female children. 5. D 16. B 27. D
b. Yes, with severe acquired liver disease.
f. Pyelonephritis. 6. A 17. A 28. B
c. Tyrosine crystals; leucine crystals, bilirubin crystals. Case Studies and Clinical Situations
7. a. Intravenous pyelogram. 7. B 18. C 29. C
d. Protect the specimen from light. 1. a. Cerebral hemorrhage because of the presence of
b. Chronic pyelonephritis. 8. D 19. A 30. A
2. a. Isovaleric acidemia. erythrophagocytosis, even distribution of blood, and
c. WBC cast. patient’s history. 9. C 20. C 31. B
b. Maple syrup urine disease.
d. Reflux nephropathy. b. No, they would be consistent with peripheral blood 10. B 21. A
c. Yes, the MS/MS screen would be positive.
e. Performing a Gram stain. entering the CSF. 11. B 22. A
3. a. Renal lithiasis.
f. Radiographic dye. c. No, they are consistent with the percentages seen in
b. Impaired renal tubular reabsorption of cystine. peripheral blood. Case Studies and Clinical Situations
g. Permanent tubular damage and progression to
chronic, end-stage renal disease. c. Lysine, arginine, ornithine. d. Hemosidern granules and hemotoidin crystals. 1. a. Sperm concentration, motility, and morphology.
8. a. Abnormal. d. They are more soluble than is cystine. e. A traumatic tap. b. 21,000,000; no.
b. Acute interstitial nephritis. e. The disorder is inherited. 2. a. An India ink preparation. c. 1,800,000; no.
c. This disorder is an inflammation not an infection. 4. a. Yes. b. Cryptococcus meningitis. d. Yes. The normal sperm concentration is 20 to
d. Discontinue the medication because it is causing the b. Yes, uric acid crystals accumulating on the surface of c. Immunologic testing for Cryptococcus. 60 million/mL. Spermatid counts over 1 million
allergic reaction. the diaper could have an orange color. are considered abnormal. Both of these abnormal
d. Rheumatoid factor.
9. a. Acute renal failure. c. Lesch-Nyhan disease. results and the abnormal motility are related to de-
e. Acid-fast staining and culture.
d. Yes, the disease is inherited as a sex-linked recessive. fects in sperm maturation.
b. The prerenal sudden decrease in blood flow to the f. Noticeable oligoclonal bands in both the CSF and
kidneys. e. Hypoxanthine guanine phosphoribosyltransferase. 2. a. Male antisperm antibodies may form following
serum.
vasovasostomy procedures.
c. Lack of renal concentrating ability. 5. a. Yes. The urine may contain melanin or homogentisic 3. a. CSF/serum albumin index = 6.7.
acid. b. The MAR test and the immunobead test.
d. Tubular damage. b. Yes.
b. Yes. Melanin will react with sodium nitroprusside, the c. The MAR test detects the presence of IgG male sperm
e. The increased diameter of the damaged distal convo- c. IgG index = 1.5.
reagent used on reagent strips for the detection of ketones. antibodies. The immunobead test delineates the areas
luted tubule and extreme urinary stasis allowing casts d. Immunoglobulin synthesis within the CNS. of the sperm (head, tail, neck) that are affected by the
to form in the collecting ducts. c. Yes. Homogentisic acid turns black in alkaline urine.
e. Multiple sclerosis. antibodies.
10. a. Renal lithiasis. 6. a. Yes, the purple blue color could indicate the presence
f. Oligoclonal banding only in the CSF. d. Clumping, ovum penetration, and motility.
b. The high specific gravity. of indican in the urine.
g. Myelin basic protein. 3. The specimen contains urine, which is toxic to sperm,
c. Yes, the dark yellow color and high specific gravity b. Hartnup disease.
therefore decreasing viability.
indicate a concentrated urine, which induces the c. Good with proper dietary supplements. 4. a. Viral, tubercular, or fungal meningitis.
4. The specimen was improperly collected, and the first
formation of renal calculi. 7. a. The Ehrlich reaction b. No, the Gram stain would be negative in viral and
part of the ejaculation was lost.
d. Calcium oxalate. tubercular and not always positive in fungal meningitis.
b. Acetylacetone. 5. a. Yes, there is insufficient prostatic fluid present.
e. Increased hydration and dietary changes. c. Yes. Lymphocytes are very predominant in viral
c. Porphobilinogen. b. Zinc, citrate, and acid phosphatase.
meningitis.
d. Blood. c. Sperm motility is severely affected.
d. Yes, a CSF lactate level of 25 mg/dL or less would aid
e. Free erythocyte protoporphyrin (FEP). 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.
 Answers to Study Questions and Case Studies and Clinical Situations 303 304 Answers to Study Questions and Case Studies and Clinical Situations

Chapter 11 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:
1. a. Pleural fluid. medications such as aspirin and other NSAIDs may
Study Questions c. No effect.
b. Transudate, because all the test results are consistent cause gastric bleeding; Patient #3: red meat was not
1. B 9. B 18. D with those of a transudate. d. False-positive result. avoided for 3 days prior to sample collection.
2. A 10. C 19. B c. Pleural fluid to serum ratios of cholesterol and 4. a. False-positive result. b. Provide dietary and medication instructions to patients.
3. A 11. A 20. Negative bilirubin. b. False-positive result. c. The Hemoccult ICT immunochemical test.
4. B 12. A 21. C 2. a. Pneumonia. c. False-positive or test interference. 4. a. The APT test cannot be performed because the
5. B, C, B, A, D, 13. C 22. A b. Chest tube drainage. d. No effect. hemoglobin is already denatured.
B, D 14. A 23. C 3. a. 1.6. 5. a. The specimen was exposed to light, possible wrong b. The pH will be low because increased carbohydrates
6. A 15. B 25. A b. Transudate. The SAAG is above 1.1. specimen sent. are available for bacterial metabolism.
7. B 16. B c. Hepatic disorder. c. The infant had ingested maternal blood.
d. Yes, adequate carbohydrates are not present, and fats
8. B 17. A 4. a. To differentiate between cirrhosis and peritonitis; Chapter 14 are being metabolized for energy.
cirrhosis.
Case Studies and Clinical Situations b. Pancreatitis or gastrointestinal perforation; alkaline Study Questions
phosphatase.
1. a. 1. Sterile, heparinized tube, liquid EDTA tube, 1. C 11. A 21. B Chapter 15
c. Rupture or accidental puncture of the bladder.
nonanticoagulated tube. 2. A 12. C 22. C
b. MSU crystals are seen in gout.
d. To detect the presence of gastrointestinal (CEA) and
3. C 13. D 23. B
Study Questions
ovarian (CA 125) cancers.
c. Highly birefringent, needle-shaped crystals under 4. B 14. B 24. A 1. D 6. A 11. C
5. The patient has been a victim of blunt trauma and the
polarized light that turn yellow when aligned with 5. D 15. B 25. B 2. B 7. B 12. B
physician wants to determine if abdominal bleeding is
the slow vibration of red compensated polarized light. 3. C 8. A 13. C
occurring; abdominal bleeding. 6. D 16. False 26. B
d. Infection is frequently a complication of severe 4. A 9. C 14. A
6. Thyroid profile; CA 125. 7. D 17. C 27. A
inflammation.
8. C 18. C 28. C 5. C 10. A 15. D
2. a. WBC diluting fluid containing acetic acid was used.
9. D 19. C 29. C
b. Normal, hypotonic, or saponin-containing saline Chapter 13 Case Studies and Clinical Situations
should be used. 10. C 20. D 30. B
Study Questions 1. a. Vaginal pH, saline and KOH wet preps, Gram stain.
c. Crystal-induced inflammatory and septic.
d. Gram stain and culture, crystal examination. 1. B 8. 2, 4, 1, 3 15. C
Case Studies and Clinical Situations b. KOH will reveal budding yeast.
1. a. Secretory diarrhea. c. Culture and DNA direct hybridization probe
3. a. Noninflammatory. 2. C 9. A 16. True
(Affirm VPIII).
b. Hydroxyapatite crystals. 3. A 10. C 17. C b. Stool culture.
d. Vulvovaginal candidiasis caused by Candida albicans.
c. Glucose. A normal result is consistent with nonin- 4. C 11. B 18. B c. Probable: Salmonella, Shigella, Campylobacter, Yersinia,
E. coli; Improbable: Staphylococcus, Vibrio. e. Antifungal agents.
flammatory arthritis. 5. B 12. True 19. B
d. Osmotic diarrhea. 2. a. Trichomoniasis caused by Trichomonas vaginalis.
4. a. Fibrinogen. 6. A 13. A 20. D
2. a. Microscopic examination for fecal fats. b. Wet mount, vaginal pH, amine test from KOH prep,
b. EDTA or heparinized tube. 7. D 14. True DNA probe (Affirm VPIII), OSOM Trichomonas
c. No, the bacteria will be trapped in the clot. b. Neutral fats stain directly and appear as large, orange-
Rapid Test.
red droplets; soaps and fatty acids appear as smaller
Case Studies and Clinical Situations orange-red droplets after pretreatment of the specimen c. Metronidazole.
Chapter 12 1. a. Yes. with heat and acetic acid. d. Yes.
b. FLM. c. Quantitative fecal fat test. e. Complications include low birth rate, premature rupture
Study Questions c. The level of phosphatidylglycerol present in the fetal d. Bulky and frothy. of membranes, preterm delivery during pregnancy.
1. C 9. B 18. B lungs. e. Muscle fiber screening and the gelatin test for trypsin. 3. a. Desquamative inflammatory vaginitis secondary to
2. D 10. C 19. C d. Phosphatidylglycerol is essential for FLM, and levels atrophic vaginitis.
f. Muscle fiber: failure to include red meat in the diet;
3. A 11. D 20. B do not always parallel lecithin levels in fetuses of gelatin test: intestinal degradation of trypsin or the b. Reduced estrogen production in postmenopausal
diabetic mothers. presence of trypsin inhibitors. women.
4. D 12. D 21. B
2. a. A neural tube disorder such as spina bifida or g. Chymotrypsin or elastase I. c. Hormone replacement therapy (estrogen).
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