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AMT MT Exam > Review Cards - Urinalysis & Body Fluids > Flashcards

Review Cards - Urinalysis & Body Fluids Flashcards

1
Q

Urine specimens - random - use

A

routine urinalysis

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2
Q

Urine specimens - random - collection

A

Any time

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3
Q

Urine specimens - random - not ideal?

A

Because urine may be dilute & contaminated

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4
Q

Urine specimens - first morning - use

A

Routine urinalysis

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5
Q

Urine specimens - first morning - collection

A

Upon waking

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6
Q

Urine specimens - 2-hour postprandial - use

A

Diabetes mellitus monitoring

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7
Q

Urine specimens - 2-hour postprandial - collection

A

2 hours after eating

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8
Q

Urine specimens - 2-hour postprandial - best for detecting?

A

glycosuria

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9
Q

Urine specimens - 24-hour - use

A

quantitative chemical tests

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10
Q

Urine specimens - 24-hour - collection

A

-discard 1st void on day 1 & note time
-collect all urine for next 24 hours, including 1st void at same time on day 2

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11
Q

Urine specimens - 24-hour - common source of error

A

improper collection

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12
Q

Urine specimens - clean catch - use

A

routine, culture

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13
Q

Urine specimens - clean catch - collection

A

cleanse external genitalia & collect midstream in sterile container

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14
Q

Urine specimens - catheterized - use

A

culture

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15
Q

Urine specimens - catheterized - collection

A

catheter inserted into urethra

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16
Q

Urine specimens - suprapubic aspiration - use

A

culture

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17
Q

Urine specimens - suprapubic aspiration - collection

A

needle inserted through abdomen into bladder

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18
Q

Urine volume - normal daily volume

A

600-2,000 mL (average 1,200-1,500 mL)

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19
Q

Urine volume - normal day-to-night ratio

A

2:1 - 3:1

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20
Q

Urine volume - diuresis

A

increased urine production

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21
Q

Urine volume - polyuria

A

Marked increase in urine flow
-adult: >2,500 mL/day
-children: 2.5-3 mL/kg/day

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22
Q

Urine volume - oliguria

A

Marked decrease in urine flow
-adult: <400 mL/day
-children: <0.5 mL/kg/hour
-infants: <1 mL/kg/hour

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23
Q

Urine volume - anuria

A

no urine production

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24
Q

Urine color - normal

A

yellow due to urochrome

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25
Q

Urine color - diluted urine

A

colorless, pale yellow

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26
Q

Urine color - concentrated urine

A

dark yellow, amber

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27
Q

Urine color - bilirubin

A

amber, orange, yellow-green; yellow foam on shaking

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28
Q

Urine color - urobilin

A

amber, orange; NO yellow foam in shaking

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29
Q

Urine color - homogentisic acid

A

normal on voiding; brown or black on standing

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30
Q

Urine color - melanin

A

brown or black on standing

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31
Q

Urine color - methemoglobin

A

brown or black

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32
Q

Urine color - myoglobin

A

red; brown on standing

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33
Q

Urine color - blood/hemoglobin

A

pink or red when fresh; brown on standing

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34
Q

Urine color - porphyrin

A

port-wine

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35
Q

Urine color - drugs, medications, food

A

green, blue, red, orange

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36
Q

Urine color - Pseudomonas infection

A

green, blue-green

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37
Q

Changes in unpreserved urine at room temperature >2 hours - turbidity

A

increased
-cause:
—multiplication of bacteria
—precipitation of amorphous crystals

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38
Q

Changes in unpreserved urine at room temperature >2 hours - pH

A

increased

-cause: conversion of urea to ammonia by bacteria

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39
Q

Changes in unpreserved urine at room temperature >2 hours - glucose

A

decreased

-cause: metabolism by bacteria

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40
Q

Changes in unpreserved urine at room temperature >2 hours - ketones

A

decreased

-cause:
—volatilization of acetone
—breakdown of acetoacetate by bacteria

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41
Q

Changes in unpreserved urine at room temperature >2 hours - urobilinogen

A

decreased

-cause: oxidation to urobilin

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42
Q

Changes in unpreserved urine at room temperature >2 hours - bilirubin

A

decreased

-cause: oxidation to biliverdin

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43
Q

Changes in unpreserved urine at room temperature >2 hours - WBCs, RBCs, casts

A

decreased

-cause: lysis in dilute or alkaline urine

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44
Q

Chemical urinalysis by reagent strip - pH - normal

A

First AM: 5-6

Random: 4.5-8

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45
Q

Chemical urinalysis by reagent strip - pH - principle

A

double indicator system

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46
Q

Chemical urinalysis by reagent strip - pH - significance

A

-acid-base balance
-management of UTI/renal calculi

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47
Q

Chemical urinalysis by reagent strip - pH - acid

A

protein/meat diet

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48
Q

Chemical urinalysis by reagent strip - pH - alkaline

A

vegetarian diet

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49
Q

Chemical urinalysis by reagent strip - pH - pH 9

A

Improperly preserved specimen

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50
Q

Chemical urinalysis by reagent strip - protein - normal

A

negative - trace

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51
Q

Chemical urinalysis by reagent strip - protein - principle

A

protein error of indicators

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52
Q

Chemical urinalysis by reagent strip - protein - significance

A

possible renal disease

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53
Q

Chemical urinalysis by reagent strip - protein - buffered to a pH of?

A

3

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54
Q

Chemical urinalysis by reagent strip - protein - most sensitive to?

A

albumin

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55
Q

Chemical urinalysis by reagent strip - protein - orthostatic proteinuria

A

-benign condition
-protein is negative in 1st AM specimen
-protein is positive after standing

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56
Q

Chemical urinalysis by reagent strip - glucose - normal

A

Negative

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57
Q

Chemical urinalysis by reagent strip - glucose - principle

A

glucose oxidase/peroxidase

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58
Q

Chemical urinalysis by reagent strip - glucose - significance

A

possible diabetes mellitus

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59
Q

Chemical urinalysis by reagent strip - glucose - specific for?

A

glucose

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60
Q

Chemical urinalysis by reagent strip - glucose - normal renal threshold

A

160-180 mg/dL

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61
Q

Chemical urinalysis by reagent strip - ketones - normal

A

negative

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62
Q

Chemical urinalysis by reagent strip - ketones - principle

A

sodium nitroprusside reaction

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63
Q

Chemical urinalysis by reagent strip - ketones - significance

A

Increased fat metabolism:
-uncontrolled diabetes mellitus
-vomiting
-starvation
-low carb diet
-strenuous exercise

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64
Q

Chemical urinalysis by reagent strip - ketones - most sensitive to?

A

Acetoacetic acid

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65
Q

Chemical urinalysis by reagent strip - ketones - less sensitive to?

A

acetone

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66
Q

Chemical urinalysis by reagent strip - ketones - doesn’t react with?

A

beta-hydroxybutyric acid

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67
Q

Chemical urinalysis by reagent strip - blood - normal

A

negative

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68
Q

Chemical urinalysis by reagent strip - blood - principle

A

pseudoperoxidase activity of hemoglobin

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69
Q

Chemical urinalysis by reagent strip - blood - significance

A

-hematuria
-hemoglobinuria
-myoglobinuria

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70
Q

Chemical urinalysis by reagent strip - blood - uniform color vs. speckled

A

-uniform color: HGB or myoglobin
-speckled: RBCs

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71
Q

Chemical urinalysis by reagent strip - blood - bilirubin - normal

A

negative

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72
Q

Chemical urinalysis by reagent strip - blood - bilirubin - principle

A

Diazo reaction

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73
Q

Chemical urinalysis by reagent strip - blood - bilirubin - significance

A

-liver disease
-biliary obstruction

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74
Q

Chemical urinalysis by reagent strip - blood - bilirubin - what type excreted in urine?

A

conjugated bilirubin

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75
Q

Chemical urinalysis by reagent strip - blood - urobilinogen - normal

A

1 Ehrlich Unit or 1 mg/dL

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76
Q

Chemical urinalysis by reagent strip - blood - urobilinogen - principle

A

Ehrlich aldehyde reaction or diazo reaction

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77
Q

Chemical urinalysis by reagent strip - blood - urobilinogen - significance

A

-liver disease
-hemolytic disorders

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78
Q

Chemical urinalysis by reagent strip - blood - urobilinogen - reagent strips DO NOT detect?

A

they do not detect ABSENCE of urobilinogen, only increased

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79
Q

Chemical urinalysis by reagent strip - blood - nitrite - normal

A

negative

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80
Q

Chemical urinalysis by reagent strip - blood - nitrite - principle

A

Greiss reaction

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81
Q

Chemical urinalysis by reagent strip - blood - nitrite - significance

A

UTI

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82
Q

Chemical urinalysis by reagent strip - blood - nitrite - bacteria

A

some bacteria reduce nitrates to nitrites

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83
Q

Chemical urinalysis by reagent strip - blood - nitrite - increased sensitivity when?

A

Urine in bladder at least 4 hours

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84
Q

Chemical urinalysis by reagent strip - blood - leukocyte esterase - normal

A

negative

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85
Q

Chemical urinalysis by reagent strip - blood - leukocyte esterase - principle

A

LE reaction

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86
Q

Chemical urinalysis by reagent strip - blood - leukocyte esterase - significance

A

UTI

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87
Q

Chemical urinalysis by reagent strip - blood - leukocyte esterase - longest reaction time

A

2 minutes

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88
Q

Chemical urinalysis by reagent strip - blood - leukocyte esterase - detects

A

intact & lysed granulocytes and monocytes

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89
Q

Chemical urinalysis by reagent strip - blood - leukocyte esterase - does NOT detect?

A

lymphocytes

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90
Q

Chemical urinalysis by reagent strip - blood - specific gravity - normal

A

Random specimen: 1.003-1.030

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91
Q

Chemical urinalysis by reagent strip - blood - specific gravity - principle

A

pKa change of polyelectrolyte

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92
Q

Chemical urinalysis by reagent strip - blood - specific gravity - significance

A

Indication of kidney’s concentrating ability & state of hydration

-increased: DM due to glucose
-decreased: diabetes insipidus due to decreased ADH

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93
Q

Chemical urinalysis by reagent strip - blood - specific gravity - only measures?

A

ionic solute

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94
Q

Chemical urinalysis by reagent strip - blood - specific gravity - not affected by?

A

-urea
-glucose
-radiographic contrast media
-plasma expanders

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95
Q

General sources of error with reagent strip testing: failure to test within 2 hours of collection or to preserve correctly - possible effect?

A

changes in chemical composition

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96
Q

General sources of error with reagent strip testing: failure to bring refrigerated specimens to room temperature before testing - possible effect?

A

False negative enzymatic reactions

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97
Q

General sources of error with reagent strip testing: failure to mix specimen well- possible effect?

A

False negative leukocyte/blood
-WBCs, RBCs settle out

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98
Q

General sources of error with reagent strip testing: failure to perform quality control - possible effect?

A

Erroneous results
-perform pos & neg control every 24 hours & when opening new container

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99
Q

General sources of error with reagent strip testing: failure to dip all test pads in urine - possible effect?

A

False negative reactions

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100
Q

General sources of error with reagent strip testing: prolonged dipping - possible effect?

A

False negative reactions
-reagents may leach from pads

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101
Q

General sources of error with reagent strip testing: failure to remove excess urine from strip - possible effect?

A

run over of chemicals to adjacent pads, distortion of colors

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102
Q

General sources of error with reagent strip testing: highly pigmented urine - possible effect?

A

atypical colors, false positive reactions
-pigment masks true reactions
-test by alternate method

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103
Q

General sources of error with reagent strip testing: failure to read at recommended time - possible effect?

A

erroneous results

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104
Q

General sources of error with reagent strip testing: failure to store strips properly - possible effect?

A

erroneous results
-store in capped original container at RT

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105
Q

Specific sources of error with reagent strip testing - pH - increased or false positive

A

improperly preserved specimen

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106
Q

Specific sources of error with reagent strip testing - pH - decreased or false negative

A

acid run over from protein square

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107
Q

Specific sources of error with reagent strip testing - protein - increased or false positive

A

-highly buffered alkaline urine
-prolonged dipping
-contaminated container
-increased specific gravity

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108
Q

Specific sources of error with reagent strip testing - protein - decreased or false negative

A

proteins other than albumin

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109
Q

Specific sources of error with reagent strip testing - glucose - increased or false positive

A

contamination with peroxide or bleach

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110
Q

Specific sources of error with reagent strip testing - glucose - decreased or false negative

A

-unpreserved specimen
-increased ascorbic acid
-increased specific gravity
-decreased temperature

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111
Q

Specific sources of error with reagent strip testing - ketones - increased or false positive

A

-red pigments
-dyes
-some meds

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112
Q

Specific sources of error with reagent strip testing - ketones - decreased or false negative

A

-improper storage:
—acetone is volatile
—bacteria break down acetoacetic acid

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113
Q

Specific sources of error with reagent strip testing - blood - increased or false positive

A

-menstruation
-oxidizing agents
-bacterial peroxidase

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114
Q

Specific sources of error with reagent strip testing - blood - decreased or false negative

A

-increased ascorbic acid
-increased nitrite
-increased specific gravity (crenated RBCs)
-unmixed specimen

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115
Q

Specific sources of error with reagent strip testing - bilirubin - increased or false positive

A

highly pigmented urine

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116
Q

Specific sources of error with reagent strip testing - bilirubin - decreased or false negative

A

-exposure to light
-increased ascorbic acid
-increased nitrite

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117
Q

Specific sources of error with reagent strip testing - urobilinogen - increased or false positive

A

highly pigmented urine

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118
Q

Specific sources of error with reagent strip testing - urobilinogen - decreased or false negative

A

-improperly preserved specimen (oxidation to urobilin)
-formalin

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119
Q

Specific sources of error with reagent strip testing - nitrite - increased or false positive

A

-highly pigmented urine
-improperly preserved specimen (contaminating bacteria produce nitrites)

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120
Q

Specific sources of error with reagent strip testing - nitrite - decreased or false negative

A

-non-nitrate-reducing bacteria
-inadequate time in bladder
-reduction of nitrites to N2
-decreased dietary nitrate
-antibiotics
-increased ascorbic acid
-increased specific gravity

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121
Q

Specific sources of error with reagent strip testing - LE - increased or false positive

A

-highly pigmented urine
-oxidizing agents
-formalin
-nitrofurantoin
-vaginal discharge

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122
Q

Specific sources of error with reagent strip testing - LE - decreased or false negative

A

-increased glucose
-increased protein
-increased ascorbic acid
-increased specific gravity
-antibiotics
-reading too soon

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123
Q

Specific sources of error with reagent strip testing - SG - increased or false positive

A

increased protein

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124
Q

Specific sources of error with reagent strip testing - SG - decreased or false negative

A

-alkaline urine (add 0.005 if pH is 6.5 or higher; correction is made by automated readers)

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125
Q

Other urine chemistry tests - microalbumin - detects

A

albumin in low/moderate concentrations

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126
Q

Other urine chemistry tests - microalbumin - method(s)

A

-immunoassay on 24-hour urine
-albumin-to-creatinine ratio (ACR) on random sample
-dipsticks available for ACR

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127
Q

Other urine chemistry tests - microalbumin - not detected by?

A

most urine dipsticks

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128
Q

Other urine chemistry tests - microalbumin - concentration predictive of diabetic nephropathy

A

Males:
50-200 mg/24 hour OR
ACR >=2.8

Females:
50-200 mg/24 hour OR
ACR >=2.0

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129
Q

Other urine chemistry tests - Ictotest - detects

A

bilirubin

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130
Q

Other urine chemistry tests - Ictotest - method(s)

A

Diazo reagent

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131
Q

Other urine chemistry tests - Ictotest - sources of error - false positives

A

urine pigments

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132
Q

Other urine chemistry tests - Ictotest - sources of error - false negatives

A

-exposure to light
-improperly stored specimen
-increased ascorbic acid
-increased nitrite

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133
Q

Other urine chemistry tests - Ictotest - less affected by?

A

interfering substances

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134
Q

Sediment stains - Sternheimer-Malbin - action

A

delineates cell structure and contrasting colors of nucleus vs. cytoplasm

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135
Q

Sediment stains - Sternheimer-Malbin - function

A

identify WBCs, epithelial cells, and casts

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136
Q

Sediment stains - Oil Red O and Sudan III - action

A

stains triglycerides and neutral fats, cholesterol will not stain

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137
Q

Sediment stains - Oil Red O and Sudan III - function

A

ID free fat droplets and lipid-containing cells or casts

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138
Q

Sediment stains - Hansel stain - action

A

methylene blue and eosin Y stain eosinophilic granules

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139
Q

Sediment stains - Hansel stain - function

A

ID eosinophils in the urine

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140
Q

Epithelial cells in the urine sediment - squamous epithelial cell - description

A

-40-50 um
-flat
-prominent round nucleus

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141
Q

Epithelial cells in the urine sediment - squamous epithelial cell - origin

A

-lower urethra
-vagina

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142
Q

Epithelial cells in the urine sediment - squamous epithelial cell - clinical significance

A

usually none

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143
Q

Epithelial cells in the urine sediment - squamous epithelial cell - increased numbers usually seen from?

A

females

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144
Q

Epithelial cells in the urine sediment - squamous epithelial cell - may obscure?

A

RBCs & WBCs

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145
Q

Epithelial cells in the urine sediment - squamous epithelial cell - reduced by?

A

collecting midstream clean-catch specimen

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146
Q

Epithelial cells in the urine sediment - transitional epithelial cell - description

A

-20-30 um
-spherical, pear-shaped, or polyhedral
-round central nucleus

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147
Q

Epithelial cells in the urine sediment - transitional epithelial cell - origin

A

-renal pelvis
-ureters
-bladder
-upper urethra

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148
Q

Epithelial cells in the urine sediment - transitional epithelial cell - clinical significance

A

seldom significant

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149
Q

Epithelial cells in the urine sediment - transitional epithelial cell - may form?

A

syncytia (clumps)

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150
Q

Epithelial cells in the urine sediment - renal tubular epithelial cell - description

A

-slightly larger than a WBC (12 um)
-round
-eccentric round nucleus

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151
Q

Epithelial cells in the urine sediment - renal tubular epithelial cell - origin

A

renal tubules

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152
Q

Epithelial cells in the urine sediment - renal tubular epithelial cell - clinical significance

A

-tubular necrosis
-toxins
-viral infections
-renal rejection

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153
Q

Epithelial cells in the urine sediment - renal tubular epithelial cell - must differentiate from?

A

WBCs

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154
Q

Epithelial cells in the urine sediment - oval fat body - description

A

renal tubular epithelial cell containing fat droplets

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155
Q

Epithelial cells in the urine sediment - oval fat body - origin

A

renal tubules

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156
Q

Epithelial cells in the urine sediment - oval fat body - clinical significance

A

-tubular necrosis
-toxins
-viral infections
-renal rejection

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157
Q

Epithelial cells in the urine sediment - oval fat body - polarized light

A

Maltese crosses

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158
Q

Blood cells in the urine sediment - WBCs - description

A

-usually polys
-about 12 um
-granular appearance

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159
Q

Blood cells in the urine sediment - WBCs - origin

A

kidney, bladder, or urethra

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160
Q

Blood cells in the urine sediment - WBCs - clinical significance

A

-cystitis
-pyelonephritis
-tumors
-renal calculi

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161
Q

Blood cells in the urine sediment - WBCs - normal

A

0-8/HPF

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162
Q

Blood cells in the urine sediment - WBCs - clumps

A

associated with acute infection

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163
Q

Blood cells in the urine sediment - glitter cell - description

A

-WBC with Brownian movement of granules
-stain faintly or not at all

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164
Q

Blood cells in the urine sediment - glitter cell - description

A

-WBC with Brownian movement of granules
-stain faintly or not at all

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165
Q

Blood cells in the urine sediment - glitter cell - origin

A

kidney, bladder, or urethra

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166
Q

Blood cells in the urine sediment - glitter cell - clinical significance

A

-cystitis
-pyelonephritis
-tumors
-renal calculi

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167
Q

Blood cells in the urine sediment - glitter cell - observed in?

A

hypotonic urine

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168
Q

Blood cells in the urine sediment - RBC - description

A

-biconcave disk
-about 7 um
-smooth
-non-nucleated

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169
Q

Blood cells in the urine sediment - RBC - origin

A

kidney, bladder, or urethra

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170
Q

Blood cells in the urine sediment - RBC - clinical significance

A

-infection
-trauma
-tumors
-renal calculi
-dysmorphic RBCs indicate glomerular bleeding

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171
Q

Blood cells in the urine sediment - RBC - normal

A

0-3/HPF

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172
Q

Blood cells in the urine sediment - RBC - hypertonic urine

A

crenated RBCs

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173
Q

Blood cells in the urine sediment - RBC - hypotonic urine

A

RBCs lyse

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174
Q

Blood cells in the urine sediment - RBC - 2% acetic acid

A

RBCs lyse

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175
Q

Normal crystals found in acid or neutral urine - amorphous urates - description

A

irregular granules

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176
Q

Normal crystals found in acid or neutral urine - amorphous urates - precipitate

A

pink

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177
Q

Normal crystals found in acid or neutral urine - amorphous urates - may obscure?

A

significant sediment

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178
Q

Normal crystals found in acid or neutral urine - amorphous urates - dissolve by?

A

warming to 60*C

179
Q

Normal crystals found in acid or neutral urine - uric acid - description

A

-pleomorphic
-4-sided, 6-sided, star-shaped, rosettes, spears, plates
-colorless, red-brown, or yellow

180
Q

Normal crystals found in acid or neutral urine - uric acid - birefringent?

181
Q

Normal crystals found in acid or neutral urine - uric acid - polarizes light?

182
Q

Normal crystals found in acid or neutral urine - calcium oxalate - description

A

-octahedral (8-sided) envelope form is most common
-dumbbell & ovoid forms

183
Q

Normal crystals found in acid or neutral urine - calcium oxalate - form that may be mistaken for RBCs

A

monohydrate form

184
Q

What is the most common constituent of renal calculi?

A

calcium oxalate

185
Q

Normal crystals found in acid or neutral urine - calcium oxalate - caused by?

A

oxalate-rich foods

186
Q

Normal crystals found in alkaline urine - amorphous phosphates - description

A

irregular granules

187
Q

Normal crystals found in alkaline urine - amorphous phosphates - precipitate

188
Q

Normal crystals found in alkaline urine - amorphous phosphates - dissolves with?

A

2% acetic acid

189
Q

Normal crystals found in alkaline urine - triple phosphate - description

A

“coffin-lid” crystal

190
Q

Normal crystals found in alkaline urine - ammonium biurate - description

A

yellow-brown “thorn apples” & spheres

191
Q

Normal crystals found in alkaline urine - ammonium biurate - seen in what type of urine specimens?

A

old specimens

192
Q

Normal crystals found in alkaline urine - calcium phosphate - description

A

-needles
-rosettes
-“pointing finger”

193
Q

Normal crystals found in alkaline urine - calcium phosphate - what form is the only form seen in alkaline urine?

A

needle form

194
Q

Normal crystals found in alkaline urine - calcium carbonate - description

A

colorless dumbbells or aggregates

195
Q

Abnormal crystals (acid or neutral urine) - leucine - description

A

-yellow, oily-looking spheres
-radial & concentric striations

196
Q

Abnormal crystals (acid or neutral urine) - leucine - significance

A

severe liver disease

197
Q

Abnormal crystals (acid or neutral urine) - leucine - often seen with what other crystal?

198
Q

Abnormal crystals (acid or neutral urine) - tyrosine - description

A

fine yellow needles in sheaves or rosettes

199
Q

Abnormal crystals (acid or neutral urine) - tyrosine - significance

A

severe liver disease

200
Q

Abnormal crystals (acid or neutral urine) - tyrosine - often seen with what other crystal?

201
Q

Abnormal crystals (acid or neutral urine) - cystine - description

A

hexagonal (6-sided)

202
Q

Abnormal crystals (acid or neutral urine) - cystine - significance

A

cystinuria

203
Q

Abnormal crystals (acid or neutral urine) - cystine - must differentiate from?

204
Q

Abnormal crystals (acid or neutral urine) - cystine - polarizes light?

205
Q

Abnormal crystals (acid or neutral urine) - cholesterol - description

A

-flat plates
-notched out corners
-“stair steps”

206
Q

Abnormal crystals (acid or neutral urine) - cholesterol - significance

A

nephrotic syndrome

207
Q

Abnormal crystals (acid or neutral urine) - cholesterol - birefringent?

208
Q

Abnormal crystals (acid or neutral urine) - bilirubin - description

A

yellowish brown needles, plates, granules

209
Q

Abnormal crystals (acid or neutral urine) - bilirubin - significance

A

liver disease

210
Q

Abnormal crystals (acid or neutral urine) - bilirubin - chemical tests should be?

211
Q

Casts - hyaline - description

A

homogeneous with parallel sides, rounded ends

212
Q

Casts - hyaline - normal

213
Q

Casts - hyaline - significance

A

increased:
-stress
-fever
-trauma
-exercise
-renal disease

214
Q

Casts - hyaline - type of protein?

A

Tamm-Horsfall

215
Q

Casts - hyaline - dissolve in?

A

alkaline urine

216
Q

Casts - hyaline - why might they be overlooked with bright light?

A

because they have the same refractive index as urine

217
Q

Casts - granular - description

A

-homogeneous with parallel sides, rounded ends
-granules

218
Q

Casts - granular - normal

219
Q

Casts - granular - significance

A

increased:
-stress
-exercise
-glomerulonephritis
-pyelonephritis

220
Q

Casts - granular - from disintegration of?

A

cellular casts

221
Q

Casts - RBC - description

A

-RBCs in cast matrix
-yellowish to orange color

222
Q

Casts - RBC - significance

A

-acute glomerulonephritis
-strenuous exercise

223
Q

Casts - RBC - source of bleeding?

224
Q

Which urinary cast is the most fragile and often found in fragments?

225
Q

Casts - blood - description

A

-contain hemoglobin
-yellowish to orange color

226
Q

Casts - blood - significance

A

-acute glomerulonephritis
-strenuous exercise

227
Q

Casts - blood - from disintegration of?

228
Q

Casts - WBC - description

A

-WBCs in cast matrix
-irregular in shape

229
Q

Casts - WBC - significance

A

pyelonephritis

230
Q

Casts - WBC - IDs what as the site of infection?

231
Q

Casts - epithelial cell - description

A

renal tubular epithelial cells in cast matrix

232
Q

Casts - epithelial cell - significance

A

renal tubular damage

233
Q

Where are casts formed?

A

renal tubules & collecting ducts

234
Q

Are transitional & squamous epithelial cells seen in casts?

235
Q

Casts - waxy - description

A

-homogeneous
-opaque
-notched edges
-broken ends

236
Q

Casts - waxy - significance

A

urinary stasis

237
Q

Casts - waxy - from degeneration of?

A

cellular & granular casts

238
Q

The presence of what type of urinary casts is considered an unfavorable sign?

239
Q

Casts - fatty - description

A

casts containing lipid droplets

240
Q

Casts - fatty - significance

A

nephrotic syndrome

241
Q

Casts - fatty - what is seen with polarized light if the lipid inside the cast is cholesterol?

A

Maltese crosses

242
Q

Casts - broad - description

A

-wide
-may be cellular, granular, or waxy

243
Q

Casts - broad - significance

A

advanced renal disease

244
Q

Casts - broad - formed in?

A

dilated distal tubules & collecting ducts

245
Q

What type of urinary casts are considered “renal failure casts”?

A

broad casts

246
Q

Miscellaneous urine sediment - bacteria - description

A

rods, cocci

247
Q

Miscellaneous urine sediment - bacteria - significance

A

UTI or contaminants

248
Q

Miscellaneous urine sediment - bacteria - what is also present if bacteria are clinically significant?

A

WBCS - unless patient is neutropenic

249
Q

Miscellaneous urine sediment - yeast - description

A

-5-7 um
-ovoid
-colorless
-smooth
-refractile
-may bud & form pseudohyphae

250
Q

Miscellaneous urine sediment - yeast - significance

A

-usually due to vaginal or fecal contamination
-may be due to kidney infection
-often in urine in diabetics

251
Q

Miscellaneous urine sediment - yeast - how to differentiate from RBCs?

A

add 2% acetic acid - RBCs lyse; yeast do not

252
Q

Miscellaneous urine sediment - yeast - pseudohyphae indicate?

A

severe infection

253
Q

Miscellaneous urine sediment - yeast - what are also present in true yeast infections?

254
Q

Miscellaneous urine sediment - sperm - description

A

-4-6 um head
-40-60 um tall

255
Q

Miscellaneous urine sediment - sperm - significance

A

-usually not significant in adults
-may be sign of sexual abuse in child

256
Q

Miscellaneous urine sediment - Trichomonas - description

A

-resembles WBC
-flagella & undulating membrane
-rapid, jerky, non-directional motility

257
Q

Miscellaneous urine sediment - Trichomonas - significance

A

parasitic infection of genital tract

258
Q

Miscellaneous urine sediment - Trichomonas - reporting

A

don’t report unless motile

259
Q

Miscellaneous urine sediment - Mucus - description

A

transparent, long, thin, ribbon-like structure with tapering ends

260
Q

Miscellaneous urine sediment - Mucus - significance

261
Q

Miscellaneous urine sediment - Mucus - may be mistaken for?

A

hyaline casts

262
Q

Renal disorders - acute glomerulonephritis - cause

A

inflammation & damage to glomeruli

263
Q

Renal disorders - acute glomerulonephritis - reagent strip

A

protein, blood

264
Q

Renal disorders - acute glomerulonephritis - sediment

A

-RBCs (some dysmorphic)
-WBCs
-hemoglobin casts

265
Q

Renal disorders - acute glomerulonephritis - frequently follows what type of infection?

A

group A strep infection

266
Q

Renal disorders - nephrotic syndrome - cause

A

increased glomerular permeability

267
Q

Renal disorders - nephrotic syndrome - reagent strip

A

protein (large amount)

268
Q

Renal disorders - nephrotic syndrome - sediment

A

-casts (all kinds)
-free fat & oval fat bodies

269
Q

Renal disorders - nephrotic syndrome - blood

A

-hypoproteinemia
-hyperlipidemia

270
Q

Renal disorders - pyelonephritis - cause

A

kidney infection

271
Q

Renal disorders - pyelonephritis - reagent strip

A

-protein
-LE
-nitrite

272
Q

Renal disorders - pyelonephritis - sediment

A

-WBCs
-WBC casts
-bacteria

273
Q

Renal disorders - cystitis - cause

A

bladder infection

274
Q

Renal disorders - cystitis - reagent strip

A

-LE
-nitrite

275
Q

Renal disorders - cystitis - sediment

A

-WBCs
-bacteria
-possibly RBCs
-NO casts

276
Q

Renal disorders - acute interstitial nephritis - cause

A

allergic reaction to medication

277
Q

Renal disorders - acute interstitial nephritis - reagent strip

A

-LE
-blood
-protein

278
Q

Renal disorders - acute interstitial nephritis - sediment

A

-WBCs
-WBC casts
-RBC casts
-NO bacteria

279
Q

Renal disorders - acute interstitial nephritis - frequently presents with?

280
Q

Renal disorders - Fanconi syndrome - cause

A

Failure of tubule reabsorption:
-hereditary
-exposure to drugs
-multiple myeloma

281
Q

Renal disorders - Fanconi syndrome - reagent strip

A

-glucose
-protein
-low pH

282
Q

Renal disorders - Fanconi syndrome - plasma glucose

283
Q

Urinalysis correlations - pH/microscopic

A

-check pH when identifying crystals
-RBCs, WBCs, & casts lyse at alkaline pH

284
Q

Urinalysis correlations - pH/nitrite/LE/microscopic

A

Bacterial UTI:
-pos nitrite
-pos LE
-check for bacteria & WBCs
-bacteria convert urea to ammonia, increased pH

285
Q

Urinalysis correlations - protein/microscopic

A

-protein may indicate renal disease
-check for casts

286
Q

Urinalysis correlations - protein/blood/microscopic

A

-large amounts of blood or myoglobin can cause positive protein
-check for RBCs
-present with hematuria, NOT with hemoglobinuria or myoglobinuria

287
Q

Urinalysis correlations - protein/SG

A

-increased SG may cause false positive trace protein
-trace protein is more significant in dilute urine

288
Q

Urinalysis correlations - glucose/ketones

A

ketones present in uncontrolled DM

289
Q

Urinalysis correlations - glucose/microscopic

A

-yeast thrives in increased glucose
-WBCs should be present if true yeast infection

290
Q

Urinalysis correlations - glucose/protein/microscopic

A

-renal disease is common complication of DM
-check for casts

291
Q

Urinalysis correlations - blood/microscopic

A

Pos blood, no RBCs:
-blood reaction could be due to hemoglobin or myoglobin OR
-false pos due to bacterial peroxidase
-check for bacteria

Neg blood, RBCs seen:
-could be false negative blood due to increased ascorbic acid
-yeast or monohydrate calcium oxalate crystals could be misidentified as RBCs

292
Q

Urinalysis correlations - bilirubin/urobilinogen

A

Liver disease:
-bili pos or neg
-urobili increased

Biliary obstruction:
-bili pos
-urobili negative

Hemolytic disorder:
-bili neg
-urobili increased

293
Q

Urinalysis correlations - LE/microscopic

A

-can have pos LE without WBCs (WBCs lysed)
-can have pos LE & WBCs without bacteria (Trichomonas)

294
Q

Urinalysis correlations - Nitrite/LE/microscopic

A

-with Pos nitrite, usually have pos LE, WBCs, & bacteria
-can have pos LE, WBCs, bacteria, & NEG nitrite (non-nitrate-reducing bacteria)

295
Q

Urinalysis correlations - SG/microscopic

A

-RBCs & WBCs lyse in dilute urine
-with increased SG, RBCs & RBCs may crenate, cause false-negative blood & LE

296
Q

CSF - color - normal

297
Q

CSF - color - abnormalities - xanthochromia

A

-slight pink, orange, or yellow due to oxyhemoglobin or bilirubin
-seen in subarachnoid hemorrhage

298
Q

CSF - color - abnormalities - traumatic tap

A

red or pink, decreasing from tube 1-3

299
Q

CSF - color - examine within?

A

1 hour of collection to avoid false positive from lysis of RBCs

300
Q

CSF - clarity - normal

301
Q

CSF - clarity - abnormalities

A

cloudy with infection or bleeding

302
Q

CSF - WBC - normal

A

Adult: 0-5/uL
Newborn: 0-30/uL
(mononuclear)

303
Q

CSF - WBC - abnormalities

A

increased in meningitis

304
Q

CSF - WBC - perform cell count within?

A

30 minutes of collection - cells begin to lyse within 1 hour

305
Q

CSF - WBC - count done in?

A

hemacytometer, following lysis of RBCs with 3% glacial acetic acid

306
Q

CSF - WBC - differential on stained smear following?

A

concentration (cytocentrifugation)

307
Q

CSF - RBC - normal

308
Q

CSF - RBC - abnormalities

A

increased with subarachnoid hemorrhage, traumatic tap

309
Q

CSF - RBC - diagnostic value

310
Q

CSF - Glucose - normal

A

60-70% of blood glucose

311
Q

CSF - Glucose - abnormalities

A

decreased in bacterial meningitis

312
Q

CSF - Glucose - method

A

blood glucose method

313
Q

CSF - Protein - normal

A

15-45 mg/dL

314
Q

CSF - Protein - abnormalities

A

increased in meningitis & with traumatic tap

315
Q

CSF - Protein - method

A

biuret method is not sensitive enough, use alternative method

316
Q

CSF - cells - normal

A

-lymphocytes
-monocytes
-ependymal cells
-choroid plexus cells

317
Q

CSF - cells - abnormalities

A

-siderophages with subarachnoid hemorrhage
-blasts with leukemia

318
Q

CSF - cells - nucleated RBCs seen?

A

due to bone marrow contamination

319
Q

Differential diagnosis of meningitis:
WBC: increased
Differential: neutrophils
Protein: increased
Glucose: decreased
Lactate: increased
Other: pos gram stain, bacterial antigen

A

bacterial meningitis

320
Q

Differential diagnosis of meningitis:
WBC: increased
Differential: lymphocytes
Protein: increased
Glucose: normal
Lactate: normal

A

viral meningitis

321
Q

Differential diagnosis of meningitis:
WBC: increased
Differential: lymphs, monos
Protein: increased
Glucose: decreased
Lactate: increased
Other: weblike clot or pellicle

A

mycobacterial meningitis

322
Q

Differential diagnosis of meningitis:
WBC: increased
Differential: neutrophils
Protein: increased
Glucose: normal or decreased
Lactate: increased
Other: pos India ink and/or Cryptococcus neoformans antigen test

A

fungal meningitis

323
Q

abnormal accumulation of fluid in body cavity; classified as transudate or exudate

324
Q

fluid contained in pericardial, peritoneal, & pleural cavities

A

serous fluid

325
Q

fluid surrounding heart

A

pericardial fluid (pericardiocentesis fluid)

326
Q

fluid in abdominal cavity

A

peritoneal fluid (abdominal fluid, ascitic fluid)

327
Q

fluid surrounding lungs

A

pleural fluid (chest fluid, thoracentesis fluid, empyema fluid)

328
Q

fluid in joints

A

synovial fluid (joint fluid)

329
Q

Differentiation of transudates and exudates - Transudate - etiology

A

-systemic disorder affecting fluid filtration & reabsorption (CHF, hypoalbuminemia, cirrhosis)
-problem originating outside body cavity

330
Q

Differentiation of transudates and exudates - Transudate - type of process

A

non-inflammatory

331
Q

Differentiation of transudates and exudates - Transudate - color

332
Q

Differentiation of transudates and exudates - Transudate - clarity

333
Q

Differentiation of transudates and exudates - Transudate - SG

334
Q

Differentiation of transudates and exudates - Transudate - protein

335
Q

Differentiation of transudates and exudates - Transudate - fluid-to-serum protein ratio

336
Q

Differentiation of transudates and exudates - Transudate - glucose

A

equal to serum level

337
Q

Differentiation of transudates and exudates - Transudate - spontaneous clotting

338
Q

Differentiation of transudates and exudates - Transudate - lactate dehydrogenase

A

<60% of serum

339
Q

Differentiation of transudates and exudates - Transudate - WBC

340
Q

Differentiation of transudates and exudates - Transudate - differential

A

predominantly mononuclears

341
Q

Differentiation of transudates and exudates - Exudate - etiology

A

condition involving membranes within body cavity (infection, malignancy, inflammation, hemorrhage)

342
Q

Differentiation of transudates and exudates - Exudate - type of process

A

inflammatory

343
Q

Differentiation of transudates and exudates - Exudate - color

A

yellow, brown, red, green

344
Q

Differentiation of transudates and exudates - Exudate - clarity

345
Q

Differentiation of transudates and exudates - Exudate - SG

346
Q

Differentiation of transudates and exudates - Exudate - protein

347
Q

Differentiation of transudates and exudates - Exudate - fluid-to-serum protein ratio

348
Q

Differentiation of transudates and exudates - Exudate - glucose

A

30 mg or more < than serum level

349
Q

Differentiation of transudates and exudates - Exudate - spontaneous clotting

350
Q

Differentiation of transudates and exudates - Exudate - lactate dehydrogenase

A

> 60% of serum

351
Q

Differentiation of transudates and exudates - Exudate - WBC

A

> 1,000/uL

352
Q

Differentiation of transudates and exudates - Exudate - differential

A

predominantly neutrophils

353
Q

Synovial fluid - normal - color

A

pale yellow to colorless

354
Q

Synovial fluid - normal - clarity

355
Q

Synovial fluid - normal - viscosity

356
Q

Synovial fluid - normal - WBcs/uL

357
Q

Synovial fluid - normal - Polys

358
Q

Synovial fluid - non-inflammatory - etiology

A

degenerative joint disease

359
Q

Synovial fluid - non-inflammatory - color

360
Q

Synovial fluid - non-inflammatory - clarity

361
Q

Synovial fluid - non-inflammatory - viscosity

362
Q

Synovial fluid - non-inflammatory - WBCs/uL

363
Q

Synovial fluid - non-inflammatory - Polys

364
Q

Synovial fluid - inflammatory - etiology

A

-rheumatoid arthritis
-lupus erythematosus
-gout
-pseudogout

365
Q

Synovial fluid - inflammatory - color

366
Q

Synovial fluid - inflammatory - clarity

A

cloudy, turbid

367
Q

Synovial fluid - inflammatory - viscosity

368
Q

Synovial fluid - inflammatory - WBCs/uL

A

2,00-100,000

369
Q

Synovial fluid - inflammatory - Polys

370
Q

Synovial fluid - infectious - etiology

A

bacterial infection

371
Q

Synovial fluid - infectious - color

A

yellow-green

372
Q

Synovial fluid - infectious - clarity

A

cloudy, turbid

373
Q

Synovial fluid - infectious - viscosity

374
Q

Synovial fluid - infectious - WBCs/uL

A

50,000-200,000

375
Q

Synovial fluid - infectious - Polys

376
Q

Synovial fluid - infectious - other

A

positive culture (S. aureus, N. gonorrhoeae, most common)

377
Q

Synovial fluid - crystal induced - etiology

A

gout, pseudogout

378
Q

Synovial fluid - crystal induced - color

A

yellow, white

379
Q

Synovial fluid - crystal induced - clarity

A

cloudy, milky

380
Q

Synovial fluid - crystal induced - viscosity

381
Q

Synovial fluid - crystal induced - WBCs/uL

A

500-200,000

382
Q

Synovial fluid - crystal induced - Polys

383
Q

Synovial fluid - hemorrhagic - etiology

A

trauma, coagulation abnormality

384
Q

Synovial fluid - hemorrhagic - etiology

A

trauma, coagulation abnormality

385
Q

Synovial fluid - hemorrhagic - color

A

pink, red, red-brown

386
Q

Synovial fluid - hemorrhagic - clarity

387
Q

Synovial fluid - hemorrhagic - viscosity

388
Q

Synovial fluid - hemorrhagic - WBCs/uL

389
Q

Synovial fluid - hemorrhagic - Polys

390
Q

Synovial fluid crystals - monosodium urate - description

A

-1-30 um long needles
-intra- or extracellular
-strongly birefringent
-yellow when long axis of crystal is parallel to slow wave of red compensator; blue when perpendicular

391
Q

Synovial fluid crystals - monosodium urate - significance

392
Q

Synovial fluid crystals - calcium pyrophosphate - description

A

-1-20 um long, 4 um wide
-rod-shaped, rectangular, or rhomboid
-intracellular
-weakly birefringent
-blue when long axis of crystal is parallel to slow wave of red compensator; yellow when perpendicular

393
Q

Synovial fluid crystals - calcium pyrophosphate - significance

A

pseudogout

394
Q

Synovial fluid crystals - cholesterol - description

A

-large rectangle with notched-out corner
-extracellular

395
Q

Synovial fluid crystals - cholesterol - significance

A

extracellular

396
Q

Semen analysis - fertility testing - specimen collection

A

-collect in sterile container, without condom, after 3-day abstinence
-keep at RT
-deliver to lab within 1 hour of collection

397
Q

Semen analysis - fertility testing - liquefaction

A

don’t analyze until specimen is liquefied (normally within 30 minutes of collection)

398
Q

Semen analysis - fertility testing - volume

A

Normal: 2-5 mL

399
Q

Semen analysis - fertility testing - motility

A

-observe within 3 hours of collection
-50-60% of sperm should show at least fair motility

400
Q

Semen analysis - fertility testing - cell count

A

-dilute & count in Neubauer hemacytometer
-Normal: >20 million per mL

401
Q

Semen analysis - fertility testing - morphology

A

-stain & examine at least 200 cells
-Normal: oval head (3 x 5 um) with long tapering tail
-Abnormalities: double heads, giant heads, amorphous heads, pinheads, tapering heads, constricted heads, double tails, coiled tails, large numbers of spermatids (immature forms)
-NORMAL: <=30% abnormal forms

402
Q

Semen analysis - fertility testing - pH

403
Q

Semen analysis - post-vasectomy - specimen collection

A

-condom can be used
-time & temp not critical
-test monthly beginning 2 months after vasectomy
-continue until 2 consecutive specimens are without sperm

404
Q

Semen analysis - post-vasectomy - liquefaction

A

don’t analyze until specimen is liquefied

405
Q

Semen analysis - post-vasectomy - cell count

A

-examine undiluted & following centrifugation
-even 1 sperm is significant

406
Q

Amniotic fluid tests - Lecithin-to-sphingomyelin (L/S) ratio - assessment/diagnosis of

A

fetal lung maturity

407
Q

Amniotic fluid tests - Lecithin-to-sphingomyelin (L/S) ratio - method

A

thin-layer chromatography

408
Q

Amniotic fluid tests - Lecithin-to-sphingomyelin (L/S) ratio - ratio that signal maturity

409
Q

Amniotic fluid tests - Lecithin-to-sphingomyelin (L/S) ratio - false increases

A

blood or meconium contamination

410
Q

Amniotic fluid tests - Phosphatidylglycerol (PG) - assessment/diagnosis of

A

fetal lung maturity

411
Q

Amniotic fluid tests - Phosphatidylglycerol (PG) - assessment/diagnosis of

A

fetal lung maturity

412
Q

Amniotic fluid tests - Phosphatidylglycerol (PG) - method

A

immunologic agglutination

413
Q

Amniotic fluid tests - Phosphatidylglycerol (PG) - affected by presence of blood or meconium?

414
Q

What is the last surfactant to rise (fetal lung maturity)?

A

phosphatidylglycerol

415
Q

Amniotic fluid tests - Foam stability index (shake test) - assessment/diagnosis of

A

fetal lung maturity

416
Q

Amniotic fluid tests - Foam stability index (shake test) - method

A

shake with increasing amounts of 95% ethanol

417
Q

Amniotic fluid tests - Foam stability index (shake test) - index is?

A

highest concentration of ethanol that supports ring of foam after shaking

418
Q

Amniotic fluid tests - Foam stability index (shake test) - what index is comparable to L/S ratio of 2.0?

419
Q

Amniotic fluid tests - Foam stability index (shake test) - does blood and meconium interfere?

420
Q

Amniotic fluid tests - lamellar body count - assessment/diagnosis of

A

fetal lung maturity

421
Q

Amniotic fluid tests - lamellar body count - method

A

count in platelet channel of hematology analyzers

422
Q

Amniotic fluid tests - lamellar body count - number correlates with?

A

amount of phospholipid present in fetal lungs

423
Q

Amniotic fluid tests - lamellar body count - sample must be free of?

A

blood or meconium

424
Q

Amniotic fluid tests - amniotic fluid bilirubin - assessment/diagnosis of

A

hemolytic disease of the newborn/fetus

425
Q

Amniotic fluid tests - amniotic fluid bilirubin - method

A

direct spectrophotometric scan from 365-550 nm

426
Q

Amniotic fluid tests - amniotic fluid bilirubin - peak absorbance

427
Q

Amniotic fluid tests - amniotic fluid bilirubin - determine severity of disease by?

A

deltaA450 compared to gestational age

428
Q

Amniotic fluid tests - amniotic fluid bilirubin - specimen must be protected from?

429
Q

Amniotic fluid tests - amniotic fluid bilirubin - do blood and meconium interfere?

430
Q

Amniotic fluid tests - alpha-fetoprotein (AFP) - assessment/diagnosis of

A

neural tube defects

431
Q

Amniotic fluid tests - alpha-fetoprotein (AFP) - method

A

immunologic method

432
Q

Amniotic fluid tests - alpha-fetoprotein (AFP) - high levels with?

A

-anencephaly
-spina bifida

433
Q

Amniotic fluid tests - alpha-fetoprotein (AFP) - confirm with?

A

ultrasound

434
Q

A first morning urine specimen is best for screening and for routine urinalysis because it:

A. Is produced when the body is in a resting state
B. Is more concentrated
C. Is not affected by diurnal variation
D. Will be the most acidic

A

B. Is more concentrated

435
Q

Which of the following “color of urine: cause” is a correct match?

A. Red: concentrated specimen
B. Black: bilirubin
C. Green: Pseudomonas infection
D. Pink or red: homogentisic acid

A

C. Green: Pseudomonas infection

436
Q

Which of the following cells found in the urine sediment is indicative of tubular damage or necrosis?

A. WBC
B. Epithelial cell
C. Renal tubular epithelial cell
D. Transitional epithelial cell

A

C. Renal tubular epithelial cell

437
Q

In a patient with severe liver disease, which of the following crystals would be anticipated upon examination of their urine sediment?

A. leucine
B. tyrosine
C. bilirubin
D. all of the above

A

D. all of the above

438
Q

Large amounts of protein (proteinuria) are most frequently found associated with which of the following renal diseases?

A. Nephrotic syndrome
B. Acute glomerulonephritis
C. Acute interstitial nephritis
D. Cystitis

A

A. Nephrotic syndrome

439
Q

In which of the following conditions would a positive leukocyte esterase reagent strip in the absence of bacteria is most likely?

A. Acute pyelonephritis
B. Trichomonas infection
C. Cystitis
D. All of the above

A

B. Trichomonas infection

440
Q

Which of the following characterizes a subarachnoid hemorrhage rather than a traumatic spinal tap?

A. Increase in protein
B. Clear supernatant after centrifugation
C. Xanthochromia
D. Presence of bacteria

A

C. Xanthochromia

441
Q

Which of the following laboratory results is characteristic of an exudate fluid?

A. Clear and colorless
B. Total protein = 2.5 g/dL
C. Fluid/serum protein ratio = 0.3
D. Specific gravity = 1.021

A

D. Specific gravity = 1.021

442
Q

In which form of meningitis is a normal CSF glucose value most often observed?

A. Bacteria
B. Fungal
C. Viral
D. Mycobacterial

443
Q

Which of the following amniotic fluid tests is utilized for the diagnosis of open neural tube defect?

A. Lamellar body count
B. AFP
C. Bilirubin
D. Phosphatidylglycerol

AMT MT Exam (12 decks)

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