Exam 1 - Urine Part 2 Flashcards
What age group is more likely to get MM?
Older population (think around 70)
What is the name of the visual indicator seen with PEP to diagnosis MM?
M-spike
What are the definitive tests for immunoglobulins in urine?
Electrophoresis and immunoelectrophoresis
What is the “CRAB” mnemonic to remember signs and symptoms associated with MM?
Calcium (elevated), Renal failure/dysfunction, Anemia, Bone lesions
What is the best next step to determine if a pathological fracture is due to osteoporosis (most common)?
Look at old films
If old films are not helpful or nonexistent when evaluating whether a pathological fracture is due to osteoporosis or not, what should the next move be?
Lab work: CBC, ESR, C-RP, BCP, UA
What are the steps when suspecting lytic metastasis as a cause for a pathological fracture due to findings on X-ray?
Bone scan —> MRI —> Biopsy
What are the steps when suspecting MM as a cause for a pathological fracture due to findings on X-ray?
PEP —> Skeletal Survey —> MRI —> Biopsy
Why don’t bone scans contribute to a MM diagnosis?
Lack of osteoblastic activity
Should we run bone scans when suspected MM?
NOPE - not sensitive for MM at all!
In the 3% of MM patients where the M-spike is not noted following PEP, what other test should be done?
Serum free light chain assay
What condition is present with a serum M protein level less than 3g/dL,
Monoclonal gammopathy of undetermined significance (MGUS)
What condition is present with a serum M protein level greater than 3g/dL, >10% bone marrow plasma cells present, and no CRAB signs and symptoms?
Smoldering MM
What condition is present with a serum M protein level greater than 3g/dL, >10% bone marrow plasma cells present, AND CRAB signs and symptoms?
True MM
What is the normal glucose measurement for urine?
Negative
What is the condition where blood glucose levels are okay, but glucose is being dumped into the urine?
Renal glycosuria (probably due to kidney disease affecting renal tubules and therefore lowering renal threshold levels)
What is the classic condition that causes hyperglycemia and glucosuria?
Diabetes mellitus
Why would ketones be found in the urine?
Due to lack of available sugar getting to the cells due to lack of insulin, so the body metabolizes fat for energy therefore forming the ketones instead (physiological cause)
What are ketones?
Byproduct of fat metabolism (used for energy when glucose isn’t present)
What are examples of possible ketones?
Acetone, beta hydroxybutric acid, acetoacetic acid
Higher levels of ketones in the body indicate that what substance is being used as the major source of energy?
FAT
What does ketonuria indicate in diabetic patients?
Uncontrolled disease
What does ketonuria indicate in non diabetic patients?
Reduced carbohydrate metabolism and excessive fat metabolism
Where does bilirubin come from?
Formed in the reticuloendothelial system as a breakdown product of RBC/hemoglobin
Why can’t unconjugated bilirubin pass through the glomerular filter?
Not water soluble
What conjugates the released bilirubin to make it become water soluble?
Glucuronic acid in the liver
What binds to bilirubin to transport it to the liver to be conjugated?
Albumin
Where does direct/conjugated bilirubin then go?
Into bile then ultimately the small intestine
What would conjugated bilirubin in the urine indicate?
Obstruction to flow of bile from liver (possible gall stones, tumor, pancreatic cancer, liver inflammation/infection)
When acted on by bacteria, what is the byproduct of bilirubin?
Urobilinogen
What color feces are associated with bilirubinuria?
Pale
What kind of bilirubin does NOT appear in the urine?
Unconjugated (therefore, a positive test for urine bilirubin confirms that any raised plasma levels are from CONJUGATED hyperbilirubinemia)
What could be the cause of pre-hepatic liver disease?
Anemias, excessive breakdown of RBCs
What could be the cause of liver disease?
Hepatitis, cirrhosis, biliary duct obstruction, toxic liver damage
What could be the cause of post-hepative liver disease?
Biliary tree obstruction
What is the normal range for urobilinogen?
0.1-1.0 mg/dL (just less than one..)
When urobilinogen levels are abnormal (aka greater than 1), problems with which organ would be indicated
Liver problems
Which form of bilirubin is pre hepatic?
Unconjugated
What would increased levels of urobilinogen indicate?
Excessive RBC breakdown, infection, liver cirrhosis, etc.
What would decreased levels of urobilinogen indicate?
Failure of bile production or obstruction of passage
What is the normal measurement for bilirubin in urine?
ZERO (remember: urobilinogen being under 1 is normal)
What are the general urobilinogen and bilirubin levels seen with liver/biliary disease?
Increased urobilinogen, positive bilirubin
What are the general urobilinogen and bilirubin levels seen with biliary tract obstruction?
Low/absent urobilinogen, positive bilirubin
What are the general urobilinogen and bilirubin levels seen with pre hepatic disease/hemolytic anemia?
Increased urobilinogen, negative/normal bilirubin
What are the main cause of biliary obstruction?
Gallstones (cholecystitis)
How do gallstones affect the color of feces?
Gray/white stools
How does liver/biliary tract disease affect liver enzyme amounts?
Increased
What is the initial and most common follow up for gallstones?
Expectant management (“wait and see”) while a patient has no symptoms
What does smokey colored urine imply?
Blood
For a diagnosis of hematuria, which substance must be elevated in the blood?
RBCs (if not, then look to hemoglobinuria or myoglobinuria)
What is an important fact to note with hematuria in kids?
1/3 of the time, it’s idiopathic
If a patient presents with yellow and clear urine with moderate occult blood but WBC and RBC counts are normal, what is the issue?
Either microhemo- or micromyoglobinuria (due to no RBC elevation but present occult blood)
What are external causes of hemolysis that could lead to hemoglobinuria?
Drugs, crushing injuries, transfusion reaction, burns
What is the internal cause of hemolysis that could lead to hemoglobinuria?
Hemolytic anemia
What kind of things could lead to free myoglobin in the urine?
Muscle trauma (like a snake bite), heart attack, crushing injuries
Occult blood in the urine with no elevation of RBCs following a heart attack would indicate what diagnosis?
Myoglobinuria
What would be the diagnosis with increased RBCs although there is no change in urine color (yellow)?
Microhematuria
What is the possible diagnosis of yellow colored urine and occult blood with normal RBC count?
Micromyo- or micro-hemoglobinuria
What is the diagnosis for red, pink, smokey colored urine with increased RBC count?
Hematuria
What is the diagnosis for red, pink, smokey colored urine with normal RBC count?
Myo- or hemoglobinuria
What screening test is used to detect WBCs in urine?
Leukocyte esterase
What does a positive leukocyte esterase test indicate?
UTI
What is leukocyte esterase?
Enzyme found in WBCs
What is pyuria?
Presence of pus in the urine
What does a positive nitrite test indicate with urine?
Bacteria present (enough gram negative bacteria to convert or reduce nitrates to nitrites)
What bacteria is usually to blame for positive nitrates seen in urine?
E. coli (normal flora in the GI tract that becomes pathological elsewhere)
Does a negative nitrite test mean there’s absence of bacteria?
Not necessarily (sometimes UTIs can be caused by infections that don’t convert nitrate to nitrite and therefore aren’t detected on this test…examples = staph and strep)
What are normal levels seen with urinary sediment?
A few RBCs, WBCs, epithelial cells, and casts (A FEW ONLY)
What is the normal WBC and RBC count for urinary sediment?
0-3/high powered field (HFP)
What would increased WBCs indicate?
Inflammation/infection
What can cause increased RBCs?
Glomerulonephritis, trauma, systemic and renal disease
What does TNTC mean?
Too numerous to count
What type of UTI is usually self-limiting: lower or upper?
Lower (uppers are more serious)
What would crystals found in urine sediment indicate?
Possible stone formation
Which are alkaline urine crystals?
Amorphous phosphates, calcium carbonate, triple phosphate
Which are acid urine crystals?
Calcium oxalate, uric acid
What is the gender bias for renal calculi/kidney stones?
Men
What is the peak age for kidney stones?
20-30
What condition would be an example of an inborn error of metabolism that could be a hereditary factor for developing kidney stones?
Gout (associated with uric acid crystals)
Most kidney stones are made with what kind of crystals?
Calcium oxalate (75%)
What is the pain pattern for kidney stones?
Starts in kidney region and radiates into the abdomen, genitalia, and legs
Where would kidney stones appear on a lateral X-ray?
Either overly vertebral bodies or be slightly anterior (because they’re retroperitoneal)
Where would gallstones be on an AP X-ray?
Right UPPER abdominal quadrant
What is the term for an upper urinary tract stone that involves the renal pelvis and involves 2 calyces?
Staghorn calculus
Which crystals are seen in kidney stones with gout patients?
Uric acid
Bilateral sacroilitis would be indicative of which group of pathologies?
Seronegative spondyloarthropathies like reactive/Reiter’s arthritis, enteropathic, and psoriatic
Most amino acids are usually insignificant except for which 3, and what do they possible indicate?
Tyrosine, leucine, cysteine; indicative of severe liver disease
With present epithelial cells in the urine, what type should always initially be assumed to be present if not reported specifically?
Squamous (other options would be transitional or renal cell)
What is the least serious and most common type of epithelial cells seen in the urine?
Squamous
Where is squamous epithelium found in the urinary that?
Lower half of bladder and urethra
Where is transitional epithelium found in the urinary tract?
Upper half of bladder and ureters
What would renal cell epithelium indicate if found in urine?
Kidney disease (way more serious than other epithelium)
If bacteria and epithelial cells are found with no other bacterial findings like increased WBCs, mucus, nitrites, etc., what is most likely the issue?
Contamination (it would be weird to have a UTI without increased WBCs, for example)
Mucus present in the urine is usually associated with what general problem
Infection
Casts in the urine give an overall picture and condition of what specific piece of anatomy?
Nephron (where they come from directly)
What can enhance urinary cast formation?
Acidic pH, urinary stasis, increased solutes and proteins
What does a RBC cast indicate?
Bleeding in the nephron due to GLOMERULONEPHRITIS, which is a form of an upper UTI (is usually immune related)
What is the most common cause of hematuria due to glomerulonephritis?
Mismanaged strep
RBC casts usually come from which specific part of the nephron?
Distal convoluted tubule
What is the most common age range for strep derived glomerulonephritis?
6-10 YOA
What do WBC casts indicate?
Infection/inflammation of kidney due to PYELONEPHRITIS
What is pyelonephritis??
Infection of the kidney INTERSTITIUM (also a form of a UTI just like glomerulonephritis, just a different kind of one)
Which physical exam test would be positive with a patient with WBC casts in the urine?
Punch test (kidneys –> pyelonephritis
What are the 2 upper UTIs discussed?
Pyelonephritis and glomerulonephritis
What are the 2 lower UTIs discussed?
Cystitis and urethritis
If hyaline casts are present alone, what is the issue? If with other abnormalities?
Alone = insignificant
With others = increase usually means renal problems
What is the term for neutrophils seen in the urine (WBCs undergoing phagocytosis), and what does it indicate?
Glitter cells; indicates UTI
What do waxy, broad, and fatty casts indicate?
Chronic renal failure (NOT GOOD)
What is usually the culprit of yeast cells being present?
Candida
Cholesterol plates in the urine are usually indicative of what condition?
Hyperlipidemia
Which type of UTI has proteins present and is more serious: lower or upper?
UPPER
What is the pain location for upper vs lower UTIs?
Upper = flank pain; Lower = lower back and pubic pain
