Exam 4: Review Flashcards
Transudate or Exudate?
Occur during pressure changes; systemic disorders that disrupt fluid filtration, fluid reabsorption, or both.
Transudate
Transudate or Exudate?
Occur because of inflammation of blood vessels; body cavity membrane damage, or decreased reabsorption by the lymphatic system.
Exudate
Transudate or Exudate?
Fluid moves but not proteins
Transudate
Transudate or Exudate?
Both fluid and protein move.
Exudate
Transudate or Exudate?
Systemic disorders such as:
Congestive heart failure
Hepatic cirrhosis
Nephrotic syndrome
Transudate
Transudate or Exudate?
Pathological processes:
Infections
Inflammations
Hemorrhages
Malignancies
Exudate
What are lab tests to differentiate between Transudate and Exudate?
-Fluid appearance
-Specific gravity
-Amylase
-Glucose
-LD
-Proteins
What is the appearance of transudate fluid?
clear
colorless or straw
What is the appearance of exudate fluid?
cloudy
cloudy/yellow/bloody
What is the volume difference between transudate and exudate?
Transudate: smaller
Exudate: copious
Transudate or Exudate?
Specific gravity: < 1.015
Total protein: < 3.0 g/dL
Lactate dehydrogenase: < 200 IU
Transudate
Transudate or Exudate?
Specific gravity: > 1.015
Total protein: > 3.0 g/dL
Lactate dehydrogenase: > 200 IU
Exudate
Transudate or Exudate?
WBC count: < 1000/uL
Transudate
( > 1000/uL for exudate)
Is spontaneous clotting possible with transudate or exudate?
Exudate
Lumbar puncture is the intervertebral space between lumbar vertebrae L___ and L___.
Why is it done here?
3, 4
avoids damage to the spinal cord in adults because the spinal cord does not extend that far down.
What is the function of CSF?
-cushioning and lubricating the brain and spinal column.
- circulates in the space between two membranes, the arachnoid and the pia mater.
-It bathes the brain and spinal cord and serves as a nutrient and also metabolic waste exchange fluid.
-CSF adjusts its volume in response to changes in cerebral vessel changes
What are the two sources of CSF?
- the tufts of capillary blood vessels in the cerebral ventricles, choroid plexus, that produce 70% of the CSF.
-Approximately 30% is formed by the ependymal lining cells of the ventricles and the cerebral/subarachnoid space.
What is normal CSF volume in adults?
Neonates?
90-150 mL
10-60 mL
What is the rate of CSF production?
500 mL/day
CSF Bloody or hemolyzed could be due to…
-Traumatic tap: Inadvertent blood vessel trauma from puncture
Intracerebral or
-subarachnoid hemorrhage (ICH or SAH): MUST be differentiated from traumatic tap
Oily CSF could be due to…
radiographic contrast media
In __________ , overnight CSF refrigeration may cause a “weblike pellicle” (scum) to form. This is not clotting!
tubercular meningitis
Traumatic tap or Intracerebral Hemorrhage?
-Serum protein contamination may cause xanthochromic supernatant
-Uneven distribution of blood in collection tubes (Heaviest in first)
-Sample is often (not always) clotted due to plasma fibrinogen contamination; may even have bloody streaks.
Traumatic tap
Traumatic tap or Intracerebral Hemorrhage?
-Clear supernatant if recent, but xanthochromic supernatant if old!
(Good clue but not specific)
-Blood evenly distributed through collection tubes (‘Best bet’)
-NO blood clots
-Siderophages highly indicative!
Intracerebral Hemorrhage
What is the order of CSF tubes by department?
Tube 1 → For chem and serology
Tube 2 → Micro
Tube 3 → Hematology
Tube 4 → Frozen (‘Just in case’ tube)
How soon does CSF need to be tested?
Test STAT! If not, refrigerate!
-Cell count must be done with-in 1 hour
Can leftover CSF fluid be discarded?
Never! save in case more tests are ordered.
What temp for mirco CSF tubes?
RT and set up ASAP
What temp for chem/sero CSF tubes?
may be frozen after centrifugation
Lots of neutrophils in CSF indicates?
Lots of monocytes?
bacterial infection
viral infection
Plasma cells in CSF fluid could indicate…
Multiple Sclerosis
Macrophages in CSF fluid could indicate…
Viral and bacterial meningitides
Also, any RBCs in CSF from long-term cause
a protein that helps stabilize the internal skeleton of nerve cells (neurons) in the brain.
Tau
-Tau represents the subunit protein of one of the major hallmarks of Alzheimer disease (AD), the neurofibrillary tangles, and is therefore of major interest as an indicator of disease mechanisms.
Tau transferrin is made primarily by the CNS. Discovering the protein band on protein electrophoresis of fluid from the ear or nose confirms diagnosis of…
otorrhea and rhinorrhea
Protein electrophoresis - Tau transferrin:
other protein bands include…
transferrin and small amounts of alpha 1 antitrypsin
Findings of oligoclonal bands in the gamma region in CSF and not in serum may help establish a diagnosis of…
multiple sclerosis
Other CSF disorders in which oligoclonal bands are present are:
-Subacute sclerosing -panencephalitis
-Neurosyphilis
-Bacterial, cryptococcal, and viral meningitis
-Acute necrotizing
-encephalitis
-Human immunodeficiency virus type I infections
-Gillian-Barre syndrome
Guillain-Barre syndrome:
An elevation in CSF protein (_____ g/L) without an elevation in white blood cells. The increase in CSF protein is thought to reflect the widespread inflammation of the nerve roots
> 0.55 g/L
Diagnosis of Guillain-Barre syndrome depends what clinical presentation?
Sudden onset of acute ascending paralysis (flaccid paralysis in limbs)
Key indicators of MS:
Maybe lymphocytes, monocytes, and plasma cells
Oligoclonal bands in the gamma region in CSF
Elevated TP
Myelin basic protein (MBP)*
Normal levels of MBP are less than 4 ng/mL
During acute exacerbations of MS, MBP levels can be in excess of ____ ng/mL
8
How can the degree of permeability of the blood-brain barrier be evaluated?
quantitative measurements of albumin in the CSF compared to serum albumin
-CSF/serum albumin index
CSF/serum albumin index:
-An index value of <__ is considered consistent with an intact barrier.
-Values of _____ are interpreted as slight impairment
-_____ moderate impairment
9
9-14
14-30
CSF/serum albumin index:
-______ severe impairment
-Values of ______ indicate complete breakdown of barrier
30-100
> 100
Viral meningitis:
Lactate-
protein-
glucose-
Lactate- decreased*
protein- increased
glucose- decreased
Bacterial Meningitis (neutrophilic pleocytosis):
Lactate-
protein-
glucose-
Lactate- increased*
protein- increased
glucose- decreased
What is the normal appearance and viscosity of synovial fluid?
-Appears clear and pale yellow
-Egg-white consistency
-Forms continuous string when poured
The viscosity of synovial fluid is due to
hyaluronic acid
(Essential for proper joint lubrication)
What is the cause of decreased synovial fluid viscosity?
Unhealthy joints secrete malfunctioning hyaluronic acid (unable to polymerize), so viscosity is decreased – and this can be measured
What can be mixed into synovial fluid to make for easier handling?
Hyaluronidase
What is normal WBC count in synovial fluid?
< 200 mononuclear cells/uL
Lymphs, monos, macrophages, and a few synovial lining cells
Synovial fluid:
Segs should make up ______% of N. differential.
<30
-FYI – WBCT count may reach > 100,000 cells/uL in severe infection
What is normal string test results?
Synovial fluid
5cm long before breaking
-low viscosity indicates inflammation
What are the four major categories of joint diseases?
-Non-inflammatory
-inflammatory
-Septic
-Hemorrhagic
category of Joint disease:
Degenerative joint disorders
Ex. osteoarthritis***
non-inflammatory
category of Joint disease:
Immunologic or crystal problems
Ex. RA & SLE, gout, and pseudogout
Inflammatory
category of Joint disease:
Microbial infections
Septic
category of Joint disease:
Traumatic injury, coagulation deficiencies
Hemorrhagic
What are the lab findings with non-inflammatory joint disorders?
-Clear, yellow fluid*
-Pretty good viscosity ↓ with ↑ severity
-WBCs < 5000/uL, Segs < 30%
-N. glucose
What are the lab findings with inflammatory joint disorders?
-Cloudy, yellow fluid
-Poor viscosity
-Mod. - mkd. ↑ WBCs (2k-100k/uL)
Segs > 50%
-↓ glucose
-Possible auto-Abs present (RF & ANAs)
-Possible “LE cells”
What are the lab findings with septic joint disorders?
-Cloudy, yellow-green* fluid
-Poor viscosity
-Mkd. ↑ WBCs (10k - 200k/uL)
Segs > 90%
-↓ glucose Positive culture!
What are the lab findings with hemorrhagic joint disorders?
-Cloudy, red fluid
-Poor viscosity
-Mod.↑ WBCs (< 5,000/uL)
Segs < 50%
-N. glucose Numerous RBCs present!!
What are the 3 most common crystal causing arthritis?
-Monosodium urate (MSU) – gout
-Ca pyrophosphate (CPPD) – pseudogout
-Cholesterol (chronic effusions such as RA)
Large, needle-shaped crystals that may be inside or outside the cells
Monosodium urate (MSU) – gout
Small rhombic-shaped or rod-shaped crystals, inside cells
Ca pyrophosphate (CPPD) – pseudogout
Cholesterol (chronic effusions such as RA)
Large, flat, extracellular notched plates
Polarized microscopy with red compensator:
MSU crystals have “___________ birefringence” – pale yellow when aligned parallel with the axis.
negative
Polarized microscopy with red compensator:
CPPD crystals have “____________ Birefringence” – BLUE when aligned parallel with axis
positive
One membrane lines cavity wall = _________
Other membrane covers the organ inside the body cavity = ___________
Parietal
Visceral
What is the fluid between membranes?
serous fluid (provides lubrication)
any abnormal accumulation of serous fluid is called…
Effusion
Abnormal accumulation of peritoneal fluid
Ascites
What is the most common cause of ascites?
ascites in liver disease due to pressure changes (transudate). Specimen will be clear and may be yellow
In general, transudates means what conditions?
congestive heart failure, cirrhosis, nephrotic syndrome
In general, exudates means what conditions?
infection, malignancy, pancreatitis or other inflammatory conditions.
What does chylous (milky fluid) indicate?
-Chylous appearance is due to an emulsion of lymph and chylomicrons.
-Obstruction or damage of lymphatic vessels contribute to the development of a chylous effusion.
-Sheets of cholesterol crystals may be present in serous fluids when a lymphatic vessel located near a cavity is damaged.
Peritonitis is a bacterial infection in the peritoneal fluid (cloud exudate). Often in patients with _________ disease.
liver
-Peritonitis is diagnosed in microbiology labs with stains and cultures
A condition in which excess amniotic fluid accumulates during pregnancy
Hydramnios or polyhydramnios
when you have too little amniotic fluid
Oligohydraminos
Fetal age can be estimated by creatinine:
< 36 weeks →
> 36 weeks →
1.5 - 2.0 mg/dL
2.0
What are the lab values that indicate mature fetal lungs?
-Foam stability > 0.47 indicates fetal lung maturity
-L/S ratio of 2 or higher indicates safe preterm delivery
-Lamellar body count of more than 50,000/uL indicate fetal lung maturity
What is the reference method for fetal lung maturity testing?
Lecithin-Sphingomyelin (L/S) Ratio
Fetal lung maturity test:
-Lung surface lipid phosphatidyl glycerol is needed for lung maturity
-Amniostat-FLM is an immunologic agglutination test for PG using antibody specific for phosphatidyl glycerol that can replace the L/S ratio (no special equipment needed)
-Blood and meconium do not interfere with the test
Phosphatidylglycerol
Fetal lung maturity test:
-Performed at bedside
-Amniotic fluid is mixed with 95% ethanol, shaken for 15 seconds, and allowed to sit undisturbed for 15 minutes
-A continuous line of bubbles around the outside edge indicates the presence of a sufficient amount of surfactant to maintain alveolar stability (alcohol is an antifoaming agent, and fluid can overcome this)
Foam stability
Fetal lung maturity test:
-Lamellar bodies are the storage form of surfactant
Approximately 90% phospholipid and 10% protein
-Secreted by the type II pneumocytes of the fetal lung to the alveolar space at about 24 weeks of gestation
-Increase in amniotic concentration from 50,000 to 200,000/L by the end of the third trimester
Lamellar Bodies
-Plots ΔA40 against gestational age
-Consists of 3 zones based on hemolytic severity
Liley graph
What are the 3 zones on the Liley graph?
Zone I – mildly affected fetus
Zone II – requires careful monitoring
Zone III – severely affected fetus, may require induction of labor or intrauterine exchange transfusion
Liley graph:
normal scan —> bilirubin peak at ____nm
450
What can be examined for the presence of amniotic fluid as evidence of fetal membrane rupture?
vaginal secretions
Premature rupture of membrane (PROM) can happen before full term and is a situation that must be managed quickly to avoid fetal and maternal complications.
How will the pH change if there is amniotic leakage?
vaginal fluid will be higher than normal
Normal vaginal pH is between 4.5 and 6.0
Amniotic fluid has a higher pH of 7.1 to 7.3
How does the Ph test- Nitrazine work?
-A drop of vaginal fluid is put on paper strips containing nitrazine dye
-The strips will turn blue if the pH is greater than 6.0*
-A blue strip means it’s more likely the membranes have ruptured.
Used to differentiate amniotic fluid from maternal urine
Fern test
How is the Fern test performed?
-This test is where vaginal fluid is spread out on a glass slide and allowed to dry at RT.
-The slide is observed for fern like crystals that are a positive SCREEN test for amniotic fluid
-Placental alpha microglobulin-1 is a protein produced by the placenta and is present throughout pregnancy in low levels.
-It appears in vaginal secretions upon PROM.
Amnisure – detects PAMG-1
-fFN (fetal fibronectin) binds the fetal sac to the uterine lining and begins to break down toward the end of pregnancy.
-If it has leaked into the vagina, preterm birth is likely although a positive result may be inconclusive
-A negative test means little chance of preterm labor
Fetal fibronectin
is an inflammation of the vagina that can result in discharge, itching, and pain. The cause is usually a change in the balance of vaginal bacteria or an infection.
Vaginitis
-Reduced estrogen levels after menopause and some skin disorders also can cause vaginitis
What are the most common types of vaginitis?
-Bacterial
-Yeast infections
-Tricomoniasis
BV – Bacterial Vaginosis
Normal flora is usually predominantly composed of lactobacilli.
If the pH increases, organisms present at low levels will proliferate.
Organisms that increase at higher pH include…
-Gardnerella vaginalis
-Mobiluncus spp.
-Other anaerobes
What is the significance of clue cells?
-Good indication of BV
-Higher pH causes bacteria to adhere to epithelial cells in a biofilm
-Look for epi cells with “fuzzy” appearance; nucleus may be obscured
What are other indicators of BV?
-Malodorous vaginal discharge or ‘wiff” test (add KOH to specimen)
-Vaginal pH will be > 4.5
-Caused by a parasite that is often sexually transmitted.
-Women often have itching and a yellow-green discharge or may be asymptomatic.
-Males are often asymptomatic.
-Easy to see on wet mount due to characteristic “jerky” motility.
-May also be seen in urine
Trichomoniasis
-is normally present in the vagina but can proliferate due to antimicrobial use, elevated estrogen (pregnancy), immunosuppression, diabetes
-Can see yeast on wet mount
-WBC usually present
Candidiasis
What does it mean if semen is….
Grey/white?
Turbid?
Red?
Yellow?
Grey/white: normal
Turbid: WBCs, infection
Red: RBCs, trauma
Yellow: urine contamination, prolonged abstinence, certain medications
Normal volume of semen?
viscosity?
2-5 mL
pours in droplets
What is the normal pH of semen?
Concentration?
7.2-7.78
20-250 million/mL
What is the normal morphology of semen?
laboratory dependent (>70%)
What is the normal Motility of semen?
Viability?
> 50% within 1 hour, 60% progressively motile,
75%
How do you dilute semen to do a count?
-Concentration – 20 million
-Count – (Concentration x volume)
-Use hemocytometer
-Counts per mL
-Dilute 1:20*
-Count 5 small squares
-Multiply by 106
What are the reagents used in the occult blood test?
(guiac and hydrogen peroxide)
Occult blood testing…
Tests for the presence of blood in stool
Helps diagnose:
-Infection
-Trauma
-Colorectal cancer
-Ulcers, esophageal bleeding
Why is Guiac used in the Occult test?
less sensitive than urinalysis reagent because up to 2.5 mL of blood in stool is normal, therefore, it eliminates false positives from vegetable and bacterial peroxidases and diet.
Occult blood testing:
what does a weak positive look like?
Negative?
Weak positive → look for blue color spreading away from specimen
Negative → may see faint blue color due to the specimen, but NO spreading
Steatorrhea
increased fat in stools
What can cause steatorrhea?
Pancreatic insufficiency
Decreased pancreatic enzymes for lipid breakdown
Lack of bile salts
Malabsorption
Cystic fibrosis
Pancreatitis
Malignancy
What are the stains for fat in stool?
Sudan III or IV
Oil red O
What can bulky/frothy stools indicate?
pancreatic disorder
What can Mucous/bloody streaked stools indicate?
colitis, dysentery, malignancy, constipation
What can Ribbon-like stools indicate?
Obstruction
Microscopic fecal exam:
What bacteria are associated with fecal leukocytes?
Salmonella, Shigella, Campylobacter, yersinia, E. coli0157
Microscopic fecal exam:
