Exam 1 - Urine Part 2

Question 1

What age group is more likely to get MM?

Answer 1

Older population (think around 70)

Question 2

What is the name of the visual indicator seen with PEP to diagnosis MM?

Answer 2

M-spike

Question 3

What are the definitive tests for immunoglobulins in urine?

Answer 3

Electrophoresis and immunoelectrophoresis

Question 4

What is the “CRAB” mnemonic to remember signs and symptoms associated with MM?

Answer 4

Calcium (elevated), Renal failure/dysfunction, Anemia, Bone lesions

Question 5

What is the best next step to determine if a pathological fracture is due to osteoporosis (most common)?

Answer 5

Look at old films

Question 6

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?

Answer 6

Lab work: CBC, ESR, C-RP, BCP, UA

Question 7

What are the steps when suspecting lytic metastasis as a cause for a pathological fracture due to findings on X-ray?

Answer 7

Bone scan —> MRI —> Biopsy

Question 8

What are the steps when suspecting MM as a cause for a pathological fracture due to findings on X-ray?

Answer 8

PEP —> Skeletal Survey —> MRI —> Biopsy

Question 9

Why don’t bone scans contribute to a MM diagnosis?

Answer 9

Lack of osteoblastic activity

Question 10

Should we run bone scans when suspected MM?

Answer 10

NOPE - not sensitive for MM at all!

Question 11

In the 3% of MM patients where the M-spike is not noted following PEP, what other test should be done?

Answer 11

Serum free light chain assay

Question 12

What condition is present with a serum M protein level less than 3g/dL,

Answer 12

Monoclonal gammopathy of undetermined significance (MGUS)

Question 13

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?

Answer 13

Smoldering MM

Question 14

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?

Answer 14

True MM

Question 15

What is the normal glucose measurement for urine?

Answer 15

Negative

Question 16

What is the condition where blood glucose levels are okay, but glucose is being dumped into the urine?

Answer 16

Renal glycosuria (probably due to kidney disease affecting renal tubules and therefore lowering renal threshold levels)

Question 17

What is the classic condition that causes hyperglycemia and glucosuria?

Answer 17

Diabetes mellitus

Question 18

Why would ketones be found in the urine?

Answer 18

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)

Question 19

What are ketones?

Answer 19

Byproduct of fat metabolism (used for energy when glucose isn’t present)

Question 20

What are examples of possible ketones?

Answer 20

Acetone, beta hydroxybutric acid, acetoacetic acid

Question 21

Higher levels of ketones in the body indicate that what substance is being used as the major source of energy?

Answer 21

FAT

Question 22

What does ketonuria indicate in diabetic patients?

Answer 22

Uncontrolled disease

Question 23

What does ketonuria indicate in non diabetic patients?

Answer 23

Reduced carbohydrate metabolism and excessive fat metabolism

Question 24

Where does bilirubin come from?

Answer 24

Formed in the reticuloendothelial system as a breakdown product of RBC/hemoglobin

Question 25

Why can't unconjugated bilirubin pass through the glomerular filter?

Answer 25

Not water soluble

Question 26

What conjugates the released bilirubin to make it become water soluble?

Answer 26

Glucuronic acid in the liver

Question 27

What binds to bilirubin to transport it to the liver to be conjugated?

Answer 27

Albumin

Question 28

Where does direct/conjugated bilirubin then go?

Answer 28

Into bile then ultimately the small intestine

Question 29

What would conjugated bilirubin in the urine indicate?

Answer 29

Obstruction to flow of bile from liver (possible gall stones, tumor, pancreatic cancer, liver inflammation/infection)

Question 30

When acted on by bacteria, what is the byproduct of bilirubin?

Answer 30

Urobilinogen

Question 31

What color feces are associated with bilirubinuria?

Answer 31

Pale

Question 32

What kind of bilirubin does NOT appear in the urine?

Answer 32

Unconjugated (therefore, a positive test for urine bilirubin confirms that any raised plasma levels are from CONJUGATED hyperbilirubinemia)

Question 33

What could be the cause of pre-hepatic liver disease?

Answer 33

Anemias, excessive breakdown of RBCs

Question 34

What could be the cause of liver disease?

Answer 34

Hepatitis, cirrhosis, biliary duct obstruction, toxic liver damage

Question 35

What could be the cause of post-hepative liver disease?

Answer 35

Biliary tree obstruction

Question 36

What is the normal range for urobilinogen?

Answer 36

0.1-1.0 mg/dL (just less than one..)

Question 37

When urobilinogen levels are abnormal (aka greater than 1), problems with which organ would be indicated

Answer 37

Liver problems

Question 38

Which form of bilirubin is pre hepatic?

Answer 38

Unconjugated

Question 39

What would increased levels of urobilinogen indicate?

Answer 39

Excessive RBC breakdown, infection, liver cirrhosis, etc.

Question 40

What would decreased levels of urobilinogen indicate?

Answer 40

Failure of bile production or obstruction of passage

Question 41

What is the normal measurement for bilirubin in urine?

Answer 41

ZERO (remember: urobilinogen being under 1 is normal)

Question 42

What are the general urobilinogen and bilirubin levels seen with liver/biliary disease?

Answer 42

Increased urobilinogen, positive bilirubin

Question 43

What are the general urobilinogen and bilirubin levels seen with biliary tract obstruction?

Answer 43

Low/absent urobilinogen, positive bilirubin

Question 44

What are the general urobilinogen and bilirubin levels seen with pre hepatic disease/hemolytic anemia?

Answer 44

Increased urobilinogen, negative/normal bilirubin

Question 45

What are the main cause of biliary obstruction?

Answer 45

Gallstones (cholecystitis)

Question 46

How do gallstones affect the color of feces?

Answer 46

Gray/white stools

Question 47

How does liver/biliary tract disease affect liver enzyme amounts?

Answer 47

Increased

Question 48

What is the initial and most common follow up for gallstones?

Answer 48

Expectant management ("wait and see") while a patient has no symptoms

Question 49

What does smokey colored urine imply?

Answer 49

Blood

Question 50

For a diagnosis of hematuria, which substance must be elevated in the blood?

Answer 50

RBCs (if not, then look to hemoglobinuria or myoglobinuria)

Question 51

What is an important fact to note with hematuria in kids?

Answer 51

1/3 of the time, it's idiopathic

Question 52

If a patient presents with yellow and clear urine with moderate occult blood but WBC and RBC counts are normal, what is the issue?

Answer 52

Either microhemo- or micromyoglobinuria (due to no RBC elevation but present occult blood)

Question 53

What are external causes of hemolysis that could lead to hemoglobinuria?

Answer 53

Drugs, crushing injuries, transfusion reaction, burns

Question 54

What is the internal cause of hemolysis that could lead to hemoglobinuria?

Answer 54

Hemolytic anemia

Question 55

What kind of things could lead to free myoglobin in the urine?

Answer 55

Muscle trauma (like a snake bite), heart attack, crushing injuries

Question 56

Occult blood in the urine with no elevation of RBCs following a heart attack would indicate what diagnosis?

Answer 56

Myoglobinuria

Question 57

What would be the diagnosis with increased RBCs although there is no change in urine color (yellow)?

Answer 57

Microhematuria

Question 58

What is the possible diagnosis of yellow colored urine and occult blood with normal RBC count?

Answer 58

Micromyo- or micro-hemoglobinuria

Question 59

What is the diagnosis for red, pink, smokey colored urine with increased RBC count?

Answer 59

Hematuria

Question 60

What is the diagnosis for red, pink, smokey colored urine with normal RBC count?

Answer 60

Myo- or hemoglobinuria

Question 61

What screening test is used to detect WBCs in urine?

Answer 61

Leukocyte esterase

Question 62

What does a positive leukocyte esterase test indicate?

Answer 62

UTI

Question 63

What is leukocyte esterase?

Answer 63

Enzyme found in WBCs

Question 64

What is pyuria?

Answer 64

Presence of pus in the urine

Question 65

What does a positive nitrite test indicate with urine?

Answer 65

Bacteria present (enough gram negative bacteria to convert or reduce nitrates to nitrites)

Question 66

What bacteria is usually to blame for positive nitrates seen in urine?

Answer 66

E. coli (normal flora in the GI tract that becomes pathological elsewhere)

Question 67

Does a negative nitrite test mean there's absence of bacteria?

Answer 67

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)

Question 68

What are normal levels seen with urinary sediment?

Answer 68

A few RBCs, WBCs, epithelial cells, and casts (A FEW ONLY)

Question 69

What is the normal WBC and RBC count for urinary sediment?

Answer 69

0-3/high powered field (HFP)

Question 70

What would increased WBCs indicate?

Answer 70

Inflammation/infection

Question 71

What can cause increased RBCs?

Answer 71

Glomerulonephritis, trauma, systemic and renal disease

Question 72

What does TNTC mean?

Answer 72

Too numerous to count

Question 73

What type of UTI is usually self-limiting: lower or upper?

Answer 73

Lower (uppers are more serious)

Question 74

What would crystals found in urine sediment indicate?

Answer 74

Possible stone formation

Question 75

Which are alkaline urine crystals?

Answer 75

Amorphous phosphates, calcium carbonate, triple phosphate

Question 76

Which are acid urine crystals?

Answer 76

Calcium oxalate, uric acid

Question 77

What is the gender bias for renal calculi/kidney stones?

Answer 77

Men

Question 78

What is the peak age for kidney stones?

Answer 78

20-30

Question 79

What condition would be an example of an inborn error of metabolism that could be a hereditary factor for developing kidney stones?

Answer 79

Gout (associated with uric acid crystals)

Question 80

Most kidney stones are made with what kind of crystals?

Answer 80

Calcium oxalate (75%)

Question 81

What is the pain pattern for kidney stones?

Answer 81

Starts in kidney region and radiates into the abdomen, genitalia, and legs

Question 82

Where would kidney stones appear on a lateral X-ray?

Answer 82

Either overly vertebral bodies or be slightly anterior (because they're retroperitoneal)

Question 83

Where would gallstones be on an AP X-ray?

Answer 83

Right UPPER abdominal quadrant

Question 84

What is the term for an upper urinary tract stone that involves the renal pelvis and involves 2 calyces?

Answer 84

Staghorn calculus

Question 85

Which crystals are seen in kidney stones with gout patients?

Answer 85

Uric acid

Question 86

Bilateral sacroilitis would be indicative of which group of pathologies?

Answer 86

Seronegative spondyloarthropathies like reactive/Reiter's arthritis, enteropathic, and psoriatic

Question 87

Most amino acids are usually insignificant except for which 3, and what do they possible indicate?

Answer 87

Tyrosine, leucine, cysteine; indicative of severe liver disease

Question 88

With present epithelial cells in the urine, what type should always initially be assumed to be present if not reported specifically?

Answer 88

Squamous (other options would be transitional or renal cell)

Question 89

What is the least serious and most common type of epithelial cells seen in the urine?

Answer 89

Squamous

Question 90

Where is squamous epithelium found in the urinary that?

Answer 90

Lower half of bladder and urethra

Question 91

Where is transitional epithelium found in the urinary tract?

Answer 91

Upper half of bladder and ureters

Question 92

What would renal cell epithelium indicate if found in urine?

Answer 92

Kidney disease (way more serious than other epithelium)

Question 93

If bacteria and epithelial cells are found with no other bacterial findings like increased WBCs, mucus, nitrites, etc., what is most likely the issue?

Answer 93

Contamination (it would be weird to have a UTI without increased WBCs, for example)

Question 94

Mucus present in the urine is usually associated with what general problem

Answer 94

Infection

Question 95

Casts in the urine give an overall picture and condition of what specific piece of anatomy?

Answer 95

Nephron (where they come from directly)

Question 96

What can enhance urinary cast formation?

Answer 96

Acidic pH, urinary stasis, increased solutes and proteins

Question 97

What does a RBC cast indicate?

Answer 97

Bleeding in the nephron due to GLOMERULONEPHRITIS, which is a form of an upper UTI (is usually immune related)

Question 98

What is the most common cause of hematuria due to glomerulonephritis?

Answer 98

Mismanaged strep

Question 99

RBC casts usually come from which specific part of the nephron?

Answer 99

Distal convoluted tubule

Question 100

What is the most common age range for strep derived glomerulonephritis?

Answer 100

6-10 YOA

Question 101

What do WBC casts indicate?

Answer 101

Infection/inflammation of kidney due to PYELONEPHRITIS

Question 102

What is pyelonephritis??

Answer 102

Infection of the kidney INTERSTITIUM (also a form of a UTI just like glomerulonephritis, just a different kind of one)

Question 103

Which physical exam test would be positive with a patient with WBC casts in the urine?

Answer 103

Punch test (kidneys --> pyelonephritis

Question 104

What are the 2 upper UTIs discussed?

Answer 104

Pyelonephritis and glomerulonephritis

Question 105

What are the 2 lower UTIs discussed?

Answer 105

Cystitis and urethritis

Question 106

If hyaline casts are present alone, what is the issue? If with other abnormalities?

Answer 106

Alone = insignificant | With others = increase usually means renal problems

Question 107

What is the term for neutrophils seen in the urine (WBCs undergoing phagocytosis), and what does it indicate?

Answer 107

Glitter cells; indicates UTI

Question 108

What do waxy, broad, and fatty casts indicate?

Answer 108

Chronic renal failure (NOT GOOD)

Question 109

What is usually the culprit of yeast cells being present?

Answer 109

Candida

Question 110

Cholesterol plates in the urine are usually indicative of what condition?

Answer 110

Hyperlipidemia

Question 111

Which type of UTI has proteins present and is more serious: lower or upper?

Answer 111

UPPER

Question 112

What is the pain location for upper vs lower UTIs?

Answer 112

Upper = flank pain; Lower = lower back and pubic pain