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Clin Lab Med II > Evaluation of Body Fluids > Flashcards

Evaluation of Body Fluids Flashcards

1
Q

What are the main body cavities and how much fluid do they hold

A
  1. Pleural cavity: visceral and parietal membrane contain pleural fluid
  2. Pericardium: contains pericardial fluid
  3. Peritoneum: contains peritoneal fluid

*norm 1-10cc in pleural and pericardial space

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2
Q

Collection of Body fluids.. how do you get to them?

A

Thoracentesis, Pericardiocentesis, Paracentesis, Arthrocentesis, LP, Venipuncture for blood cultures

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3
Q

What are the two main types of Effusions and main distinctions between them?

A
  1. Transudative: due to filtration of blood serum across physiologically intact vascular wall usually due to SYSTEMIC dz (CHF, cirrhosis, nephrotic syndrome)
  2. Exudative: due to active accumulation of fluid w/in body cavity due to inflam and vascular wall damage. Caused by infection, malig, inflam d/o
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4
Q

Components of chemical analysis of body fluid?

A

a) Total protein
b) Total pro fluid to serum ratio
c) LDH with fluid to serum ratio
d) glucose level (lower in exudate)
e) amylase (help dz pancreatitis, bowel perf, mets)
d) TAG (confirm chylous effusion)
e) pH of pleural fluid (ID parapneumonic effusion)
f) CEA (eval effusion in pt with CEA prod tumor)

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5
Q

Transudative vs Exudative: Total protein level

A

Transudative: < 3 g/dl
Exudative: > 3 g/dl

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6
Q

Transudative vs Exudative: total protein fluid/serum ratio

A

Transudative: < 0.5

Exudative: >0.5

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7
Q

Transudative vs Exudative: LDH fluid/serum ratio

A

Transudative: < 0.6
Exudative: >0.6

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8
Q

Transudative vs Exudative: WBC cell count and diff

A

Transudative: 500 cells/uL, neutrophils

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9
Q

Transudative vs Exudative: Gluocse compared to plasma/serum

A

Transudative: glucose equal to serum
Exudative: glucose less

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10
Q

Transudative vs Exudative: appearance

A

Transudative: clear, thin fluid
Exudative: cloudy, viscous

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11
Q

Transudative vs Exudative: etiology

A

Transudative: cirrhosis, nephrosis, HF, low pro
Exudative: infection, inflammation, malignancy, collagen vascular dz (lupus, etc)

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12
Q

Microbiological eval of body fluid includes

A

gram stain, C&S (bacterial, fungal, viral, TB)

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13
Q

Hematologic Eval and Cytology: cells found in normal serous fluid include?

A

Lymphocytes
Monocytes and macrophages
Mesothelial lining cells

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14
Q

Hematologic Eval and Cytology: nonmalignant cells found in dz states

A
  1. Neutrophils: in exudate in inflammation/infection
  2. Eosinophils: in hypersensitvity rxn, infections, malignancy, and MI
  3. RBCs: in hemorrhage, malignancy, traumatic procedure
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15
Q

Malignant cells

A

Leukemia, lymphoma, Mets

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16
Q

Rule of thumb: Transudative vs Exudative

A

Transudates dues to PRESSURE diff bw body compartments; form the same way interstitial fluid does; usually do NOT need further testing

Exudates: significant; imply inflammation, infection or malignancy; require further testing (cytology for malignancy, culture to check infection, cell count, differential; chemistries)

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17
Q

Lab values consistent with pleural effusion are?

A

Specific gravity: >1.016
Pleural fluid pro: > 3 g/dL
Pleural fluid/serum pro: >0.5
Pleural fluid/serum LDH: >0.6

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18
Q

How do you dx Hemothorax?

A

RBC >100,000/uL

Hct of body fluid usually >50% of peripheral blood

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19
Q

Common causes of hemothorax? BOARD*

A

Trauma
Malignancy
Pulmonary Embolism

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20
Q

What is empyema and how is it dx

A

pus in pleural space
WBC >50,000-100,000 cell/uL

if >50% neutrophils = inflammation/infection
if >50% lymphocytes = neoplasm or TB
If eosinophilia: collagen vascular dz, drug induced pleuritis, neoplasm, TB

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21
Q

If pleural fluid has bw 50,000-100,000 WBC/uL and >50% are neutrophils then…

A

Empyema due to inflammation/infection

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22
Q

If pleural fluid has bw 50,000-100,000 WBC/uL and >50% are lymphocytes then..

A

Empyema due to neoplasm or TB

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23
Q

If pleural fluid has bw 50,000 - 100,000 WBC/uL and eosinophilia then

A

Empyema due to collagen vascular disease, neoplasm, TB, drug induced pleuritis

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24
Q

If pleural fluid pH<7.2 what does this suggest

A

infection, neoplasm, RA, esophageal rupture

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25
Q

If pleural fluid has glucose <60 what does this suggest (exudative)

A

infection, neoplasm, RA

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26
Q

If pleural fluid is +amylase, then suggests

A

pancreatitis, esophageal rupture

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27
Q

If pleural fluid +TAG this suggests

A

chylous effusions seen in trauma, neoplasm, obstructed lymphatics

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28
Q

*note that PE may cause what type of effusion

A

either transudative OR exudative can be cause by pulmonary embolism

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29
Q

pH of pleural fluid helps identify what

A

parapneumonic effusion

pH<7.2

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30
Q

The most common types of exudative pleural effusions are

A
  1. Parapneumonic effusion: due to bacterial pneumonia, lung abscess or bronchiectasis
  2. Malignant effusion: 3 tumors responsible for 75% malignant exudative pleural effusions are lung, breast, lymphoma CAs
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31
Q

How do you obtain pericardial fluid

A

Needle aspiration below xiphoid process

  • alligator clip EKG monitoring is emergent
  • ECHO GUIDED is PREFERRED

*general features similar to pleural and peritoneal fluid

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32
Q

When should you NOT perform pericardiocentesis

A

Most of the time you DONT
Do not if pericarditis and no effusion
Do not if pericardial effusion without tamponade unless need fluid for dx purpose

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33
Q

When is pericardiocentesis indicated

A

if need fluid for dx purpose

Pericardial effusion with tamponade

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34
Q

Elevated platelet count (thrombocytosis) think..

A

MALIGNANCY

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35
Q

An enlarged heart on a CXR could be?

A

cardiomyopathy, or pericardial effusion (potentially malignant)
*cardiac failure, myocarditis, or dilated cardiomyopathy are all potential dx

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36
Q

How do you obtain peritoneal fluid (Paracentesis)

A

Abdominal “tap” 4 quadran

look for signs of bleeding

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37
Q

What are the types of guarding (tensing of abdominal wall) and what do they suggest

A
  1. voluntary (pt does consciously)

2. Involuntary (usually occurs due to inflammation of peritoneum)

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38
Q

General process for development of ascites due to cirrhosis

A

1) decreased albumin, decreased oncotic pressure = ascites
2) increased intrahepatic vascular resistance (due to build up of tissue), increase protal HTN, increased hepatic lymph = ascites
3) increased portal HTN, increased central SNS, decrease effective intravascular volume, sodium retention, increase plasma renin and aldosteron = ascites

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39
Q

Routine ascitic fluid tests include

A

albumin, cell count, culture

40
Q

Peritoneal Fluid (ascites) lab findings

A

Lab findings and significant similar to pleural fluid

  • following trauma: r/o intraabdominal bleed
  • If tender: r/o peritonitis (sometimes Spontaneous Bacterial Peritonitis in cirrhosis)
  • Malignant ascites: check cytology on fluid
  • infectious process: gram stain, C&S, AFB smear and culture (peritoneal biopsy better0
41
Q

What is the SAAG classification (serum to ascites albumin gradient)

A

replaced separating ascitic fluid into transudative vs exudative
*SAAG = serum alb - ascitic fluid alb

42
Q

If SAAG gradient >1.1 g/dL, then ascites is due to

A

PORTAL HTN condition (transudative high gradient)

*cirrhosis, alcoholic hep, CHF, liver mets, portal vein thrombosis, veno-occlusive dz, myxedema, mixed ascites

43
Q

If SAAG gradient <1.1 g/dL then ascites is due to

A

NON portal HTN condition (exudative, low gradient)

  • malignancy or infection:
    • peritoneal carcinomatosis, peritoneal TB, pancreatic ascites, biliary ascites, nephrotic syndrome, serositis, bowel obstruction or infarction
44
Q

What is the most useful test in ascitic fluid analysis

A

Ascitic fluid cell count

WBC uncomplicated cirrhosis <500 cell/ mm^3

45
Q

in ascitic fluid cell count (most useful ascitic fluid analysis test), WBC cound increase may occur with

A

any inflammatory process

ex: Spontaneous bacterial peritonitis is most common (WBC >500 cell/mm^3)
other: TB peritonitis, Carcinomatosis, bloody or chylous ascites

46
Q

Who develops Spontaneous Bacterial Peritonitis and what are the features of SBP

A

occurs in pt with cirrhosis and ascites

  • often no infectious source, may originate in bowel
  • abrupt onset fever, chills, abdominal pain
  • rebound tenderness
  • ascitic fluid WBC count >500cell/uL with >50% neutrophils
  • treat with abx NOT surgery
47
Q

How do you treat SBP

A

ABX!

not surgery

48
Q

where do you aspirate joint fluid from

A

synovial fluid from knee, shoulder, ankle and elbow usually

49
Q

What are indications for arthrocentesis

A

single inflamed joint! worry about septic arthritis

*remove as much fluid as possible

50
Q

what are the categories of synovial fluid

A 
Normal
Group I (noninflammatory): OA
Group II (mild inflam): SLE, scleroderma
Group III (severe inflam): RA, gout, pseudogout
Group IV (infectious): acute bacterial, TB

*can be overlap dependign on severity of dz process

51
Q

What information is the most helpful in categorizing synovial fluid

A

synovial fluid appearance
WBC with diff
Presence of RBC (hemorrhage, malig, trauma)
Crystal exam (+/- birefringent)
*gram stain and culture if clinically indicated

52
Q

OA is what synovial fluid category

A

group I (noninflammatory)

53
Q

SLE, scleroderma are what synovial fluid category

A

group II (mild inflam)

54
Q

RA, gout, pseudogout are what synovial fluid category

A

Group III (severe inflam)

55
Q

TB, acute bacterial are what synovial fluid category

A

Group IV (infectious)

56
Q

hemorrhagic synovial fluid can be due to

A

traumatic aspiration vs bloody fluid from underlying process

*traumatic aspiration will have significantly lower RBC count in 3rd tube compared to 1st

57
Q

appearance of synovial fluid may be

A

clear or pale yellow vs turbid vs very turbid or purulent

*if can read newsprint through it, it is clear

58
Q

SYnovial fluid WBC <150 cell/uL is

A

normal

59
Q

Synovial fluid WBC <2000 is

A

noninflam

60
Q

Synovial fluid WBC >100,000 is

A

septic till proven otherwise

61
Q

Synovial fluid WBC 50,000-100,000…?

A

hard to dx, need to r/o sepsis

62
Q

WBC diff of synovial fluid: 90% neutrophils? RA?

A

90% neutrophils implies infection

*RA <90% neutrophils

63
Q

What should you do if you suspect a septic joint

A

Gram stain to check for bacteria
culture for bacteria
if indicated, check for fungi, TB, etc

*URGENT condition, dx prompty, tx with ABX

64
Q

Hemarthrosis (hemorrhagic joint) can be due to

A

a) trauma, with or w/o fx
b) coagulation d/o or anticoagulation tx
c) thrombocytopenia (low platelet)
d) Malignancy
e) sickle cell
f) postop joint surgery
g) pigmented villonodular synovitis
h) unknown

65
Q

When should you consider synovial fluid aspiration and analysis?

A

Monarthritis (acute or chronic)
Trauma w/ joint effusion
Monarthritis in pt with chronic polyarthritis
Suspicious of joint infection, crystal induced arthritis or hemarthrosis

66
Q

Just for the heck of it, what other joint fluid tests are there (limited or no additional value in joint fluid evaluation)

A
  • glucose (usually low in setting of severe inflam
  • Pro: little value
  • viscosity: low in inflam fluid
  • Mucin clot: suggests fluid is synovial, little value
  • immunologic tests: since synovial fluid is derived from plasma, not much advantage over plasma
67
Q

What is the gold standard for evaluating crystals

A

Polarized light microscopy

  • crystal is Birefringent if it shines white aginst dark background produced by two polarizing plates, *direction +/- based on lab criteria
  • if not birefringent, no direction associated
68
Q

under polarized microscopy gout will be confirmed by

A

monosodium urate crystal that is needle shaped, strongly (-) birefringence

69
Q

Under polarized microscopy, pseudogout will be confirmed by

A

calcium pyrophosphate dihydrate crystal that is rhomboid shpaed and weakly (+) birefringence

70
Q

under polarized microscopy, hydroxyapatite arthropathy will be confirmed by

A

hydroxyapatite crystal that is very small and nonbirefringent

71
Q

what significance does intracellular vs extracellular crystals have on dx?

A

none

72
Q

What is CSF function, where is it produced, what information does it provide and how do we get it?

A
  • CSF protects and cushions CNS, provides nutrients to neural tissue and removes metabolic waste
  • produced by choroid plexus
  • analysis of CSF provides info about pt condition
  • obtain CSF via LP: at L3-4 or L4-5 interspace
73
Q

What disease can be detected by CSF analysis

A
  • Hemorrhage (subarachnoid or intracerebral)
  • Infection (meningitis -bacterial, fungal, viral, parasitic; abscess; encephalitis)
  • Malignant process (brain tumor -primary or mets; leukemia or lymphoma)
74
Q

How do you collect CSF for analysis

A

usually 3 tubes

1: chem analysis (glu, pro, immunology)
2: micro (gram, Acid fast, C&S, India ink prep for cryptococcus neoformans, VDRL, FTA abs)
3: hematology (cell count and diff)

  • prompt lab delivery
  • draw plasma protein and glucose to compare to CSF values
75
Q

CSF glucose compared to plasma glucose?

A

CSF glu is 2/3 plasma normally

*range 50-80 mg/dL

76
Q

CSF glucose (2/3 plasma glu usually) decreased suggests?

A

bacterial meningitis and fungal infections

77
Q

CSF glu (normal 2/3 plasma glu) INCREASED suggests

A

hyperglycemia

78
Q

What is the CSF pro range and when is it increases

A

CSF pro 20-50 mg/dL

*may increase w bleeding, hemolysis, infection

79
Q

Presence of oligoclonal bands in CSF is dx of

A

Multiple sclerosis

80
Q

Presence of myelin basic proteins in CSF helps dx

A

MS and other demyelinating disorders

81
Q

Are RBC present in CSF? what if RBCs are noted in CSF?

A

NOT NORMALLY
if present: cerebral hemorrhage or traumatic tap
*spin down: xanthochromic vs clear supernatant
- xanthochromic suggests blood present before tap, clear suggests traumatic tap

82
Q

in CSF WBC with diff, what is normal?

A

1-5 cells/uL (mononuclear)

83
Q

In CSF WBC with diff, if there are increased neutrophils this suggests

A

bacterial meningitis

84
Q

if increased lymphocytes in CSF WBC diff

A

suggests viral, TB, fungal infection

85
Q

If increased plasma cells in CSF WBC diff, suggests?

A

MS or chronic inflammation

86
Q

if eosinophilia in CSF WBC diff then?

A

parasitic or fungal infection

87
Q

In a pt with meningitis, how frequently does altered mental status occur?

A

in >75%

Note: N/V and photophobia are also common in meningitis

88
Q

ADEM? MNC?

A

acute disseminated encephalomyelitis

Mononuclear cells

89
Q

Why do we obtain blood cultures?

A

To assess fro presence of bacteria in blood stream (bacteremia)
*Bacteremia may be intermittent or continuous?

90
Q

Bacteremia may be frequently accompanied by what? and when is the best time to draw blood to check for bacteremia?

A

bacteremia may be accompanied by fever, chills

*best time to draw is during one of these episodes

91
Q

Intermittent/transient bacteremia occurs when?

A

may occur during manipulation of infected tissues (abscess, dental procedures, cystoscopy, sigmoidoscopy/colonoscopy) or at onset of infection (pneumonia)

92
Q

Continuous bacteremia is most likely if

A

there is an endovascular infection such as endocarditis, suppurative thrombophlebitis

93
Q

How do you obtain a blood culture

A

Draw blood from at least 2 sites

  • do not draw from existing IV catheter unless concerned that catheter is source of infection
  • cleanse site and memrane of BC bottle with antiseptic, let dry 1-2 min
  • collect 10-15 cc blood in sterile syring and inject into BC bottles with culture media (both anaerobic and aerobic bottles)
  • culture yield increases with increased volume of blood
94
Q

If there is bacterial growth in both sets of BC then

A

highly indicative of bacteremia

95
Q

If bacterial growth in only one set of BC

A

could be due to contamination esp if organism is normal skin flora (coag neg staph)
*probably real bacteremia if group A strep, pnemococci, H flu, pseudomonas or candida

Clin Lab Med II (3 decks)

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