What Is Being Tested?: White Blood Cells

What is being tested?
The complete blood count (CBC) is a test that evaluates the cells that circulate in blood. Blood consists of three types
of cells suspended in fluid called plasma: white blood cells (WBCs), red blood cells (RBCs), and platelets (PLTs).
They are produced and mature primarily in the bone marrow and, under normal circumstances, are released into the
bloodstream as needed.
A CBC is typically performed using an automated instrument that measures various parameters, including counts of
the cells that are present in a person's sample of blood. The results of a CBC can provide information about not only
the number of cell types but also can give an indication of the physical characteristics of some of the cells. A standard
CBC includes the following:
Evaluation of white blood cells: WBC count; may or may not include a WBC differential
Evaluation of red blood cells: RBC count, hemoglobin (Hb), hematocrit (Hct) and RBC indices, which
includes mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), mean corpuscular
hemoglobin concentration (MCHC), and sometimes red cell distribution width (RDW). The RBC evaluation may
or may not include reticulocyte count.
Evaluation of platelets: platelet count; may or may not include mean platelet volume (MPV) and/or platelet
distribution width (PDW)
The three types of cells evaluated by the CBC include:

White Blood Cells
There are five different types of WBCs, also called leukocytes, that the body uses to maintain a healthy state and to
fight infections or other causes of injury. They are neutrophils, lymphocytes, basophils, eosinophils, and monocytes.
They are present in the blood at relatively stable numbers. These numbers may temporarily shift higher or lower
depending on what is going on in the body. For instance, an infection can stimulate the body to produce a higher
number of neutrophils to fight off bacterial infection. With allergies, there may be an increased number of eosinophils.
An increased number of lymphocytes may be produced with a viral infection. In certain disease states, such
as leukemia, abnormal (immature or mature) white cells rapidly multiply, increasing the WBC count.
Red Blood Cells
Red blood cells, also called erythrocytes, are produced in the bone marrow and released into the bloodstream as
they mature. They contain hemoglobin, a protein that transports oxygen throughout the body. The typical lifespan of
an RBC is 120 days; thus the bone marrow must continually produce new RBCs to replace those that age and
disintegrate or are lost through bleeding. A number of conditions can affect the production of new RBCs and/or their
lifespan, in addition to those conditions that may result in significant bleeding. The CBC determines the number of
RBCs and amount of hemoglobin present, the proportion of blood made up of RBCs (hematocrit), and whether the
population of RBCs appears to be normal. RBCs normally are uniform with minimal variations in size and shape;
however, significant variations can occur with conditions such as vitamin B12 and folate deficiencies, iron deficiency,
and with a variety of other conditions. If there are insufficient normal RBCs present, a person is said to
have anemia and may have symptoms such as fatigue and weakness. Much less frequently, there may be too many
RBCs in the blood (erythrocytosis or polycythemia). In extreme cases, this can interfere with the flow of blood through
the small veins and arteries.
Platelets
Platelets, also called thrombocytes, are special cell fragments that play an important role in normal blood clotting. A
person who does not have enough platelets may be at an increased risk of excessive bleeding and bruising. The
CBC measures the number and size of platelets present.
Significant abnormalities in one or more of the blood cell populations can indicate the presence of one or more
conditions. Typically other tests are performed to help determine the cause of abnormal results. Often, this requires
visual confirmation by examining a blood smear under a microscope. A trained laboratorian can evaluate the
appearance and physical characteristics of the blood cells such as size, shape and color, noting any abnormalities
that may be present. Any additional information is noted and reported to the doctor. This information gives the health
practitioner additional clues as to the cause of abnormal CBC results.
How is the sample collected for testing?

A blood sample is obtained by inserting a needle into a vein in the arm or from a fingerstick (for children and adults)
or heelstick (for infants).
NOTE: If undergoing medical tests makes you or someone you care for anxious, embarrassed, or even difficult to
manage, you might consider reading one or more of the following articles: Coping with Test Pain, Discomfort, and
Anxiety, Tips on Blood Testing, Tips to Help Children through Their Medical Tests, and Tips to Help the Elderly
through Their Medical Tests.
How is it used?
The complete blood count (CBC) is often used as a broad screening test to determine an individual's general health
status. It can be used to:
Screen for a wide range of conditions and diseases
Help diagnose various conditions, such as anemia, infection, inflammation, bleeding disorder or leukemia, to
name just a few
Monitor the condition and/or effectiveness of treatment after a diagnosis is established
Monitor treatment that is known to affect blood cells, such as chemotherapy or radiation therapy
A CBC is a panel of tests that evaluates the three types of cells that circulate in the blood and includes the following:
Evaluation of white blood cells, the cells that are part of the body's defense system against infections and
cancer and also play a role in allergies and inflammation:
o
White blood cell (WBC) count is a count of the total number of white blood cells in a person's
sample of blood.
White blood cell differential may or may not be included as part of the panel of tests. It identifies
and counts the number of the various types of white blood cells present. The five types
include neutrophils, lymphocytes,monocytes, eosinophils, and basophils.
Evaluation of red blood cells, the cells that transport oxygen throughout the body:
Red blood cell (RBC) count is a count of the actual number of red blood cells in a person's sample
of blood.
o
Hemoglobin measures the amount of the oxygen-carrying protein in the blood.
Hematocrit measures the percentage of a person's blood that consists of red blood cells.
Red blood cell indices are calculations that provide information on the physical characteristics of
the RBCs:
Mean corpuscular volume (MCV) is a measurement of the average size of RBCs.
Mean corpuscular hemoglobin (MCH) is a calculation of the average amount of oxygencarrying hemoglobin inside a red blood cell.
Mean corpuscular hemoglobin concentration (MCHC) is a calculation of the average
percentage of hemoglobin inside a red cell.

Red cell distribution width (RDW), which may be included in a CBC, is a calculation of the
variation in the size of RBCs.

o
The CBC may also include reticulocyte count, which is a measurement of the absolute count or
percentage of young red blood cells in blood.
Evaluation of platelets, cell fragments that are vital for normal blood clotting:
o
The platelet count is the number of platelets in a person's sample of blood.
Mean platelet volume (MPV) may be reported with a CBC. It is a calculation of the average size of
platelets.
Platelet distribution width (PDW) may also be reported with a CBC. It is a measurement of the
variation of platelet size.
When is it ordered?
The CBC is a very common test. Many people have a CBC performed when they have a routine health examination.
If a person is healthy and has results that are within normal limits, then he or she may not require another CBC until
their health status changes or until their doctor feels that it is necessary.
A CBC may be ordered when a person has any number of signs and symptoms that may be related to disorders that
affect blood cells. When an individual has fatigue or weakness or has an infection, inflammation, bruising, or
bleeding, a doctor may order a CBC to help diagnose the cause and/or determine its severity.
When a person has been diagnosed with a disease known to affect blood cells, a CBC will often be ordered on a
regular basis to monitor their condition. Likewise, if someone is receiving treatment for a blood-related disorder, then
a CBC may be performed frequently to determine if the treatment is effective.
Some therapies, such as chemotherapy, can affect bone marrow production of cells. Some medications can
decreaseWBC counts overall. A CBC may be ordered on a regular basis to monitor these drug treatments.
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What does the test result mean?
A health practitioner typically evaluates and interprets results from the components of the CBC together. Depending
on the purpose of the test, a number of additional or follow-up tests may be ordered for further investigation.
The following tables briefly and generally explain what the result for each component of the CBC may mean.
WBC evaluation
RBC evaluation
Platelet evaluation
For detailed information on each test component, click on the name of the component to go to the specific article.
Components of the CBC
WBC Evaluation
TEST
WBC
FULL NAME
White Blood Cell Count
EXAMPLES OF CAUSES OF A LOW

COUNT
Known as leukopenia
Bone marrow
EXAMPLES OF CAUSES OF A HIGH

COUNT
Known as leukocytosis
disorders or damage
Infection, most
commonly bacterial or viral
Autoimmune conditions
Inflammation
Severe infections
Leukemia, myeloproliferative
(sepsis)
Lymphoma or other
cancer that spread to
disorders
Allergies, asthma
Tissue death (trauma,
the bone marrow
Diseases of immune
system (e.g., HIV)
burns, heart attack)
Intense exercise or severe

stress
TEST
Diff
FULL NAME

COUNT

COUNT
White Blood Cell Differential

(Not always performed; may
be done as part of or in follow
up to CBC)
Neu,
Absolute neutrophil count, %
PMN,
neutrophils
Known as neutropenia
polys
Severe, overwhelming
infection (sepsis)
Autoimmune disorders
Reaction to drugs,
Known as neutrophilia
Acute bacterial infections
Inflammation
Tissue death (necrosis)

caused by trauma, heart attack,
chemotherapy
Immunodeficiency
Myelodysplasia
Bone marrow damage
burns
Physiological (stress,
rigorous exercise)
(e.g., chemotherapy,
Certain leukemias (e.g.,

chronic myeloid leukemia)
radiation therapy)
Cancer that spreads to

the bone marrow
Lymph
Absolute lymphocyte count,

% lymphocytes
Known as lymphocytopenia
Known as lymphocytosis
(e.g., lupus, rheumatoid
(e.g., chicken
arthritis)
pox, cytomegalovirus
Infections (e.g.,
(CMV), Epstein-Barr virus
HIV, viral hepatitis, typhoid

fever, influenza)
(EBV), herpes, rubella)
Bone marrow damage
radiation therapy)
Corticosteroids
Certain bacterial infections

(e.g., pertussis (whooping
(e.g., chemotherapy,
Acute viral infections
cough), tuberculosis (TB))
Toxoplasmosis
Chronic inflammatory
disorder (e.g., ulcerative colitis)
Lymphocytic leukemia,
lymphoma
Stress (acute)
TEST
Mono

COUNT
FULL NAME
Absolute monocyte count, %
Usually, one low count is not
monocytes
medically significant.

COUNT
tuberculosis, fungal infection)
Repeated low counts can
Bone marrow damage
Collagen vascular diseases

(e.g., lupus, scleroderma,
or failure
Infection within the heart

(bacterial endocarditis)
indicate:
Chronic infections (e.g.,
rheumatoid arthritis,vasculitis)
Hairy cell leukemia
Monocytic or myelomonocytic
leukemia (acute or chronic)
Eos
Absolute eosinophil count, %
Numbers are normally low in the
eosinophils
blood. One or an occasional low
Asthma, allergies such as

hay fever
number is usually not medically
Drug reactions
significant
Parasitic infections
Inflammatory disorders
(celiac disease, inflammatory
bowel disease)
Some cancers, leukemias or

lymphomas
Baso
Absolute basophil count, %
As with eosinophils, numbers are
basophils
normally low in the blood; usually
Rare allergic reactions

(hives, food allergy)
not medically significant
Inflammation (rheumatoid
arthritis, ulcerative colitis)
Some leukemias
RBC Evaluation
TEST
RBC
FULL NAME
Red Blood Cell

Count
EXAMPLES OF CAUSES OF LOW RESULT
Known as anemia
EXAMPLES OF CAUSES OF HIGH RESULT
Known as polycythemia
Acute or chronic bleeding
Dehydration
RBC destruction
Lung (pulmonary) disease
Kidney or other tumor that
(e.g., hemolytic anemia, etc.)
Nutritional deficiency (e.g.,
produces excess erythropoietin
TEST
FULL NAME
iron deficiency, vitamin B12 or
Smoking
folate deficiency)
Genetic causes (altered
Bone marrow disorders or
oxygen sensing, abnormality in
damage
Hb
Hemoglobin
Chronic inflammatory disease
Kidney failure
Usually mirrors RBC results, provides
hemoglobin oxygen release)
Polycythemia veraa rare

disease
Usually mirrors RBC results
added information
Hct
Hematocrit
Usually mirrors RBC results
Usually mirrors RBC results; most

common cause is dehydration
RBC indices
MCV
MCH
Mean
Indicates RBCs are smaller than
Indicates RBCs are larger than normal
Corpuscular
normal (microcytic); caused by iron
(macrocytic), for example in anemia
Volume
deficiency anemia or thalassemias, for
caused by vitamin B12 or folate
example.
deficiency
Mean
Mirrors MCV results; small red cells
Mirrors MCV results; macrocytic RBCs
Corpuscular
would have a lower value.
are large so tend to have a higher
Hemoglobin
MCHC
MCH.
Mean
May be low when MCV is low;
Increased MCHC values
Corpuscular
decreased MCHC values
(hyperchromia) are seen in conditions
Hemoglobin
(hypochromia) are seen in conditions
where the hemoglobin is more
Concentration
such as iron deficiency anemia and
concentrated inside the red cells, such
thalassemia.
as autoimmune hemolytic anemia, in

burn patients, and hereditary
spherocytosis, a rare congenital
disorder.
RDW (Not
RBC
Low value indicates uniformity in size
Indicates mixed population of small and
always
Distribution
of RBCs
large RBCs; immature RBCs tend to be
reported)
Width
larger. For example, in iron deficiency

anemia or pernicious anemia, there is
high variation (anisocytosis) in RBC
size (along with variation in shape
poikilocytosis), causing an increase in
TEST
FULL NAME
the RDW.
Reticulocyte
Reticulocytes
In the setting of anemia, a low
In the setting of anemia, a high
Count (Not
(absolute count
reticulocyte count indicates a condition reticulocyte count generally indicates
always done)
or %)
is affecting the production of red blood
peripheral cause, such as bleeding
cells, such as bone marrow disorder or orhemolysis, or response to treatment

damage, or a nutritional deficiency
(e.g., iron supplementation for iron
(iron, B12 or folate)
deficiency anemia)
Platelet Evaluation
TEST
Plt
FULL NAME
Platelet
Count
Known as thrombocytopenia:
Viral infection
Know as thrombocytosis:
(mononucleosis, measles, hepatitis)
Rocky mountain spotted fever
Platelet autoantibody
Drugs (acetaminophen,
quinidine, sulfa drugs)
Cancer (lung,
gastrointestinal, breast, ovarian,
lymphoma)
Rheumatoid arthritis, inflammatory

bowel disease, lupus
Iron deficiency anemia
Cirrhosis
Hemolytic anemia
Myeloproliferative disorder (e.g.,
Sepsis
Leukemia, lymphoma
Myelodysplasia
Chemo or radiation therapy
essential thrombocythemia)
MPV (Not
Mean
Indicates average size of platelets is
Indicates a high number of larger, younger
always
Platelet
small; older platelets are generally
platelets in the blood; this may be due to the
reported)
Volume
smaller than younger ones and a low
bone marrow producing and releasing
MPV may mean that a condition is
platelets rapidly into circulation.
affecting the production of platelets by

the bone marrow.
PDW (Not
Platelet
Indicates uniformity in size of platelets
Indicates increased variation in the size of
always
Distribution
the platelets, which may mean that a
reported)
Width
condition is present that is affecting platelets
Is there anything I can do to improve results of my CBC?

People who have a keen interest in their own health care frequently want to know what they can do to change their
WBCs, RBCs, and platelets. Unlike "good and "bad" cholesterol, cell populations are not generally affected by
lifestyle changes unless the individual has an underlying deficiency (such as vitamin B12 or folate deficiency or iron
deficiency). There is no way that a person can directly raise the number of his WBCs or change the size or shape of
his RBCs. Addressing any underlying diseases or conditions and following a healthy lifestyle will help optimize your
body's cell production, and your body will take care of the rest.
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2. If I have an abnormal result on my CBC, what other tests might my doctor order as follow up?
It depends on the results that are abnormal and the suspected cause as well as your medical history and findings
from your physical examination. Your doctor may request that a blood smear examination be done. Other general
tests to check your health and to look for possible causes may include a comprehensive metabolic panel (CMP). A
few other general examples include:
Abnormal results for WBCs may be followed by a culture of the affected area (e.g., blood culture, urine
culture, sputum culture), a strep test or tests for viruses such as mononucleosis or EBV. If inflammation is suspected,
then a CRP or ESR test may be done.
Abnormal RBC results may prompt a reticulocyte count, iron studies, tests for vitamin B12 and folate, G6PD,
orhemoglobinopathy evaluation to help make a diagnosis.
An abnormal platelet count may be followed by tests that further evaluate platelets, such as platelet function
tests or HIT antibody. Additional tests may be done to check for bleeding disorders or excessive clotting
disorders such as PT, PTT,von Willebrand factor or coagulation factors.
When a serious condition such as leukemia, myelodysplasia or another bone marrow disorder is suspected, then
a bone marrow biopsy and examination may be necessary. Numerous other tests specific for certain conditions may
be needed to establish a diagnosis. Talk to your doctor about the results of your CBC, whether additional tests are
necessary, and why.
DEFINITIONPOTTS DISEASE
Potts disease also known as tuberculous spondylitis is a presentation of extra
pulmonary tuberculosis that affects the spine
, a kind of tuberculous arthritis of the intervertebral joints. Scientifically, it is called
tuberculous spondylitis. Potts disease is the most common site of
bone infection in TB; hips and knees are also often affected. The lower thoracic and
upper lumbar vertebrae are the areas of the spine mostoften affected. Pott's
disease, which is also kno
wn as Potts caries, David's disease, and Pott's curvature, is a medical condition of
the spine.
Individuals suffering from Pott's disease typically experience back pain, night
sweats, fever, weight loss, and anorexia. They may alsodevelop a spinal mass,
which results in tingling, numbness, or a general feeling of weakness in the leg
muscles. Often, the pain associated
with Pott's disease causes the sufferer to walk in an upright and stiff position. Potts
disease is caused when the vertebrae
become soft andcollapse as the result of caries or osteitis. Typically, this is caused
by mycobacterium tuberculosis. As a result, a person with Pott's disease
often develops kyphosis, which results in a hunchback. This is often referred to as
Potts curvature. In som
e cases, a person with Pott's
disease may also develop paralysis, referred to as Potts paraplegia, when the spinal
nerves become affected by the curvature
. The diseaseprogresses slowly. Signs and symptoms include: back pain, fever, night
sweats, anorexia, weight loss, and easy fatigability. Diagnosis isbased on: blood
tests - elevated ESR, skin tests, radiographs of the spine , bone scan, CT of the
spine , and bone biopsy. Gibbus formationis the pathognomonic sign of this disease.
Gibbus formation refers to a sharply angled curvature of the backbone, resulting
from collapse of a vertebra or simply a hunchback. Approximately 1-2% of total
tuberculosis cases are attributable to Pottdisease. The incidence rate here in the
Philippines is approximately20-30% of all the patient diagnosed to have
Tuberculosis. Most of the cases of the Pott's disease in the Philippines is caused by
the non-compliance of the treatment regimen of TB. Internationally, between 1993
and 2001, tuberculosis of the bone and joints accounted for 3.5%of all tuberculosis
cases (0.2-1.1% in patients of European origin and 2.3-6.3% in patients of non-
European origin. 21 nursing problems

according to Faye Glenn Abdellah could be best adapted on this kind of case. She
defined nursing as broadly grouped into the 21nursingproblem areas to guide care
and promote the use of nursing judgment. She also said that nursing is a service
that is based on the art andscience and aims to help people, sick or well, cope with
their health needs. The said disease could lead to different problems that
thepatients can experience. It is the responsibility of the nurse to meet the different
needs of the client to achieve the optimum level of functioning. The researcher
chose to discuss Pott's disease as one of the requirement in the rotation. This study
will help the researcher toanalyze and dig deeper and see a clearer picture, in
response to our roles as future registered nurses. ANATOMY AND PHYSIOLOGY The
spinal cord is the largest nerve in the body, and it is comprised of the nerves which
act as the communication system for the body. Thenerve fibers within the spinal
cord carry messages to and from the brain to other parts of the body. The spinal
cord is surrounded byprotective bone segments, called the vertebral column. The
vertebral column is comprised of seven cervical vertebrae, twelve
thoracicvertebrae, five lumbar vertebrae and five sacral vertebrae. The vertebral
column also provides attachment points for muscles of the back and ribs. The
vertebral disks serve as shock absorbers during activities such as walking, running
and jumping, they also allow the spine toflex and extend.
DIAGNOSTIC PROCEDURES1. TUBERCULINE SKIN TEST (Purified Protein Derivative
[PPD])Results are positive in 84-95% of patients with Potts disease who are not
infected with HIV. A standard dose of 5 Tuberculin units (0.1 mL)(The standard
Mantoux test in the UK consists of an intradermal injection of 2TU of Statens Serum
Institute (SSI) tuberculin RT23 in 0.1mlsolution for injection.) Injected intradermally
(between the layers of dermis) and read 48 to 72 hours later. This intradermal
injection istermed the mantoux technique. A person who has been exposed to the
bacteria is expected to mount an immune response in the skin containing the
bacterial proteins. The reaction is read by measuring the diameter of in duration
(palpable raised hardened area) across theforearm (perpendicular to the long axis)
in millimeters. If there is no in duration, the result should be recorded as "0 mm".
Erythema(redness) should not be measured. If a person has had a history of a
positive tuberculin skin test, or has not had a recent tuberculin skintest (within one
year), another skin test may be needed.
2. THE ERYTHROCYTE SEDIMENTATION RATE (ESR) may be markedly elevated
(>100mm/h)ESR stands for erythrocyte sedimentation rate. It is a test that
indirectly measures show much inflammation is in the body. However, itrarely leads
directly to a specific diagnosis. This test can be used to monitor inflammatory or
cancerous diseases. It is a screening test, whichmeans it cannot be used to
diagnose a specific disorder. However, it is useful in detecting and monitoring
tuberculosis, tissue death, andcertain forms of arthritis, autoimmune disorders, and
inflammatory diseases that cause vague symptoms.
3. RADIOGRAPHY Radiographic changes associated with Pott disease present
relatively late. The following are radiographic changes characteristic of spinal
tuberculosis on plain radiography: visibly seen curvature of the spine or visible bone
lesions on different levels
Why Get Tested?

To screen for metabolic and kidney disorders and for urinary tract infections (UTIs)
When to Get Tested?

During a routine physical or when you have symptoms of a UTI, such as abdominal
pain, back pain, frequent or painful urination; as part of a pregnancy check-up, a
hospital admission, or a pre-surgical work-up
Sample Required?
One to two ounces of urine; first morning sample is most valuable.
Test Preparation Needed?

None
The Test Sample

A urinalysis is a group of chemical and microscopic tests. They detect the byproducts of normal and
abnormalmetabolism, cells, cellular fragments, and bacteria in urine. Urine is produced by the kidneys, two fist-sized
organs located on either side of the spine at the bottom of the ribcage. The kidneys filter wastes out of the blood, help
regulate the amount of water in the body, and conserve proteins, electrolytes, and other compounds that the body
can reuse. Anything that is not needed is excreted in the urine, traveling from the kidneys through ureters to the
bladder and then through the urethra and out of the body. Urine is generally yellow and relatively clear, but each time
someone urinates, the color, quantity, concentration, and content of the urine will be slightly different because of
varying constituents.
Many disorders can be diagnosed in their early stages by detecting abnormalities in the urine. Abnormalities include
increased concentrations of constituents that are not usually found in significant quantities in the urine, such as:
glucose, protein, bilirubin, red blood cells, white blood cells, crystals, and bacteria. They may be present because:
1.
There are elevated concentrations of the substance in the blood and the body is trying to decrease blood
levels by "dumping" them in the urine.
2.
Kidney disease has made the kidneys less effective at filtering.
3.
There is a urinary tract infection present, as in the case of bacteria and white blood cells.
A complete urinalysis consists of three distinct testing phases:

1.
Visual examination, which evaluates the urine's color, clarity, and concentration.
2.
Chemical examination, which tests chemically for about 9 substances that provide valuable information
about health and disease.
3.
Microscopic examination, which identifies and counts the type of cells, casts, crystals, and other
components, such as bacteria and mucus, that can be present in urine.
The first two phases of urinalysis may be completed in the laboratory or doctor's office. A microscopic examination is
then performed if there is an abnormal finding on the visual or chemical examination, or if the doctor specifically
orders it.

Urine for a urinalysis can be collected at any time. The first morning sample is considered the most valuable because
it is more concentrated and more likely to yield abnormalities if present. It is important to clean the genitalia before
collecting urine. Bacteria and cells from the surrounding skin can contaminate the sample and interfere with the
interpretation of test results. With women, menstrual blood and vaginal secretions can also be a source of
contamination. Women should spread the labia of the vagina and clean from front to back; men should wipe the tip of
the penis. Start to urinate, let some urine fall into the toilet, then collect one to two ounces of urine in the container
provided, then void the rest into the toilet. This type of collection is called a "midstream collection" or a "clean catch."
A urine sample will only be useful for a urinalysis if taken to the doctor's office or laboratory for processing within a
short period of time. If it will be longer than an hour between collection and transport time, then the urine should be
refrigerated or a preservative may be added.
Another article, Follow That Sample, provides a glimpse at the collection and processing of a blood sample and throat
culture.
Is any test preparation needed to ensure the quality of the sample?

No advance test preparation is needed. However, at the time of sample collection, follow instructions for a clean catch
urine sample as stated above.
How is it used?
The urinalysis is used as a screening and/or diagnostic tool because it can help detect substances or cellular material
in the urine associated with different metabolic and kidney disorders. It is ordered widely and routinely to detect any
abnormalities that require follow up. Often, substances such as protein or glucose will begin to appear in the urine
before people are aware that they may have a problem. It is used to detect urinary tract infections (UTIs) and other
disorders of the urinary tract. In those with acute or chronic conditions, such as kidney disease, the urinalysis may be
ordered at intervals as a rapid method to help monitor organ function, status, and response to treatment.
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When is it ordered?
A routine urinalysis may be done when someone is admitted to the hospital. It may also be part of a wellness exam, a
newpregnancy evaluation, or a work-up for a planned surgery. A urinalysis will most likely be performed when a
person sees a health care provider complaining of symptoms of a UTI or other urinary system problem such
as kidney disease. Somesigns and symptoms may include:
Abdominal pain
Back pain
Painful or frequent urination
Blood in the urine
This test can also be useful when monitoring certain conditions over time.
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Urinalysis results can have many interpretations. Abnormal findings are a warning that something may be wrong and
should be evaluated further. Generally, the greater the concentration of the atypical substance, such as greatly
increased amounts of glucose, protein, or red blood cells, the more likely it is that there is a problem that needs to be
addressed. But the results do not tell the doctor exactly what the cause of the finding is or whether it is a temporary
or chronic condition.
A normal urinalysis does not guarantee that there is no illness. Some people will not release elevated amounts of a
substance early in a disease process, and some will release them sporadically during the day, which means that they
may be missed by a single urine sample. In very dilute urine, small quantities of chemicals may be undetectable.
For additional details on what certain results may mean, click on the links below:
Visual examination
Chemical examination
Microscopic examination
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Is there anything else I should know?

The urinalysis is a set of screening tests that can provide a general overview of a person's health. A doctor must
correlate the urinalysis results with a person's symptoms and clinical findings and search for the causes of abnormal
findings with other targeted tests, such as a comprehensive metabolic panel (CMP), complete blood count (CBC),
or urine culture (to look for a urinary tract infection).
Common Questions
1.
2.
Is the time of day a factor when collecting a urine sample?

Are there home test kits available?
1. Is the time of day a factor when collecting a urine sample?

Because this is a general screening test, time of collection is usually not important, although a first morning void is
usually preferred because it is more concentrated. However, if your doctor is looking for a specific finding, he or she
may ask that you collect a sample at a specific time. For example, if the doctor is looking for the excretion of glucose,
it may be better to collect a specimen after a meal.
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2. Are there home test kits available?
Kits to perform a full urinalysis are not available because the test requires special equipment and technical skills.
However, some commercial testing strips can be purchased at a pharmacy to perform part of the chemical
examination, such as urine pH, urine glucose, and urine ketones. See the article on Home Tests for more information.
BUN
Why Get Tested?
To evaluate kidney function; to monitor the effectiveness of dialysis and other treatments related to kidney disease or
damage
When to Get Tested?

As part of a routine comprehensive or basic metabolic panel or when you are acutely or chronically ill with a condition
that may cause or be worsened by kidney dysfunction
Sample Required?
A blood sample drawn from a vein in your arm

None

This test measures the amount of urea nitrogen in the blood. Urea is produced in the liver when protein is broken into
its component parts (amino acids) and metabolized. This process produces ammonia, which is then converted into
the less toxic waste product urea.
Nitrogen is a component of both ammonia and urea. Urea and urea nitrogen are referred to somewhat
interchangeably because urea contains nitrogen and because urea/urea nitrogen is the "transport method" used by
the body to rid itself of excess nitrogen. Urea is released by the liver into the bloodstream and is carried to the
kidneys, where it is filtered out of the blood and excreted in the urine. Since this is an ongoing process, there is
usually a small but stable amount of urea nitrogen in the blood.
Most diseases or conditions that affect the kidneys or liver have the potential to affect the amount of urea present in
the blood. If increased amounts of urea are produced by the liver or decreased amounts are excreted by the kidneys,
then urea concentrations will rise. If significant liver damage or disease inhibits the production of urea, then BUN
concentrations may fall.

A blood sample is drawn from a vein in the arm.
culture.

No test preparation is needed.
How is it used?
The blood urea nitrogen or BUN test is primarily used, along with the creatinine test, to evaluate kidney function in a
wide range of circumstances, to help diagnose kidney disease, and to monitor people with acute or chronic kidney
dysfunction or failure. It also may be used to evaluate a person's general health status when ordered as part of
a basic metabolic panel (BMP) or comprehensive metabolic panel (CMP).
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When is it ordered?
BUN is part of both the BMP and CMP, groups of tests that are widely used:
When someone has non-specific complaints
As part of a routine testing panel
To check how the kidneys are functioning before starting to take certain drug therapies
When an acutely ill person comes to the emergency room and/or is admitted to the hospital
During a hospital stay
BUN is often ordered with creatinine when kidney problems are suspected. Some signs and symptoms of kidney
dysfunction include:
Fatigue, lack of concentration, poor appetite, or trouble sleeping
Swelling or puffiness (edema), particularly around the eyes or in the face, wrists, abdomen, thighs, or ankles
Urine that is foamy, bloody, or coffee-colored
A decrease in the amount of urine
Problems urinating, such as a burning feeling or abnormal discharge during urination, or a change in the
frequency of urination, especially at night
Mid-back pain (flank), below the ribs, near where the kidneys are located
High blood pressure
BUN also may be ordered:
At regular intervals to monitor kidney function in those with chronic diseases or conditions such
as diabetes,congestive heart failure, and myocardial infarction (heart attack)
At regular intervals to monitor kidney function and treatment in people with known kidney disease
Prior to and during certain drug treatments to monitor kidney function
At regular intervals to monitor the effectiveness of dialysis

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Increased BUN levels suggest impaired kidney function. This may be due to acuteor chronic kidney disease, damage,
or failure. It may also be due to a condition that results in decreased blood flow to the kidneys, such as congestive
heart failure, shock, stress, recent heart attack, or severe burns, to conditions that cause obstruction of urine flow, or
to dehydration.
BUN concentrations may be elevated when there is excessive protein breakdown (catabolism), significantly increased
protein in the diet, or gastrointestinal bleeding (because of the proteins present in the blood).
Low BUN levels are not common and are not usually a cause for concern. They may be seen in severe liver
disease,malnutrition, and sometimes when a person is overhydrated (too much fluid volume), but the BUN test is not
usually used to diagnose or monitor these conditions.
Both decreased and increased BUN concentrations may be seen during a normal pregnancy.
If one kidney is fully functional, BUN concentrations may be normal even when significant dysfunction is present in
the other kidney.
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BUN levels can increase with the amount of protein in the diet. High-protein diets may cause abnormally high BUN
levels while very low-protein diets can cause an abnormally low BUN.
A wide variety of drugs can cause an increase in BUN. Drugs that can decrease BUN include Chloramphenicol and
Streptomycin. Inform your health care provider of any mediations you are taking.
Common Questions
1.
2.
3.
What other tests are used with BUN to check how my kidneys are functioning?
How does BUN change with age?
What is a BUN/Creatinine ratio?
1. What other tests are used with BUN to check how my kidneys are functioning?
BUN and creatinine are the primary tests used to check how well the kidneys are able to filter waste products from
your blood. Your doctor may also order electrolyte tests, such as sodium and potassium, or calcium to help
understand how your kidneys are functioning.
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2. How does BUN change with age?

BUN levels increase with age. BUN levels in very young babies are about 2/3 of the levels found in healthy young
adults, while levels in adults over 60 years of age are slightly higher than younger adults. Levels are also slightly
higher in men than women.
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3. What is a BUN/Creatinine ratio?

Occasionally, a doctor will look at the ratio between a persons BUN and blood creatinine to help them determine
what is causing these concentrations to be higher than normal. The ratio of BUN to creatinine is usually between 10:1
and 20:1. An increased ratio may be due to a condition that causes a decrease in the flow of blood to the kidneys,
such as congestive heart failure or dehydration. It may also be seen with increased protein, from gastrointestinal
bleeding, or increased protein in the diet. The ratio may be decreased with liver disease (due to decrease in the
formation of urea) andmalnutrition.
CREATININE
Why Get Tested?
To determine if your kidneys are functioning normally and to monitor treatment for kidney disease
When to Get Tested?
Routinely as part of a comprehensive or basic metabolic panel; when your doctor suspects that you are suffering from
kidney dysfunction or when you are acutely or chronically ill with a condition that may affect your kidneys and/or be
worsened by kidney dysfunction; at intervals to monitor treatment for kidney disease or kidney function while on
certain medications
Sample Required?
A blood sample drawn from a vein in your arm and/or a 24-hour urine sample

You may be instructed to fast overnight or refrain from eating cooked meat; some studies have shown that eating
cooked meat prior to testing can temporarily increase the level of creatinine.

This test measures the amount of creatinine in the blood and/or urine. Creatinine is a waste product produced by
muscles from the breakdown of a compound called creatine. Creatine is part of the cycle that produces energy
needed to contract muscles. Both creatine and creatinine are produced by the body at a relatively constant rate.
Almost all creatinine is excreted by the kidneys, so blood levels are usually a good indicator of how well the kidneys
are working. The quantity produced depends on the size of the person and their muscle mass. For this reason,
creatinine concentrations will be slightly higher in men than in women and children.
Results from a blood creatinine test and a 24-hour urine creatinine test may be used to calculate creatinine
clearance.

A blood sample is drawn from a vein in the arm. A 24-hour urine sample may also be collected. The doctor or
laboratory will provide a large container and instructions for proper sample collection. Typically, the first morning urine
sample is not collected, but the time is recorded and used as the start time for the 24-hour collection. All urine
produced during the next 24 hours is saved.
culture.

You may be instructed to fast overnight or refrain from eating cooked meat; some studies have shown that eating
cooked meat prior to testing can temporarily increase the level of creatinine. If a 24-hour urine sample is being
collected, it is important to save all of the urine produced during that time period.
How is it used?
The creatinine blood test is used along with a BUN (blood urea nitrogen) test to assess kidney function. Both are
frequently ordered as part of a basic or comprehensive metabolic panel (BMP or CMP), groups of tests that are
performed to evaluate the function of the bodys major organs. BMP or CMP tests are used to screen healthy people
during routine physical exams and to help evaluate acutely or chronically ill people in the emergency room and/or
hospital. If the creatinine and BUN tests are found to be abnormal or if someone has an underlying disease, such
as diabetes, that is known to affect the kidneys, then these two tests may be used to monitor the progress of kidney
dysfunction and the effectiveness of treatment. Blood creatinine and BUN tests may also be ordered to evaluate
kidney function prior to some procedures, such as a CT (computed tomography) scan, that may require the use of
drugs that can damage the kidneys.
A combination of blood and urine creatinine levels may be used to calculate a creatinine clearance. This test
measures how effectively the kidneys are filtering small molecules like creatinine out of the blood.
Urine creatinine may also be used with a variety of other urine tests as a correction factor. Since it is produced and
removed at a relatively constant rate, the amount of urine creatinine can be compared to the amount of another
substance being measured. This stable excretion rate is useful when evaluating both 24-hour urine
samples and random urine samples. Examples of this are when creatinine is measured with protein to calculate
a urine protein/creatinine ratio (UP/CR) and when it is measured with microalbumin to calculate a
microalbumin/creatinine ratio.
The microalbumin/creatinine ratio is calculated to help determine how much albumin is escaping from the kidneys into
the urine. People who have consistently detectable amounts of albumin in their urine (microalbuminuria) have an
increased risk of developing progressive kidney failure and cardiovascular disease in the future.
Serum creatinine measurements (along with age, weight, and sex) also are used to calculate the estimated
glomerular filtration rate (eGFR), which is used as a screening test to look for evidence of kidney damage.
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When is it ordered?
Creatinine may be ordered routinely as part of a comprehensive or basic metabolic panel, during a health
examination. It may be ordered when a person has non-specific health complaints, when someone is acutely ill,
and/or when a doctor suspects that a person's kidneys are not working properly. Some signs and symptoms of kidney
dysfunction include:
Fatigue, lack of concentration, poor appetite, or trouble sleeping
Swelling or puffiness, particularly around the eyes or in the face, wrists, abdomen, thighs or ankles
Urine that is foamy, bloody, or coffee-colored
A decrease in the amount of urine
Problems urinating, such as a burning feeling or abnormal discharge during urination, or a change in the
frequency of urination, especially at night
Mid-back pain (flank), below the ribs, near where the kidneys are located
High blood pressure
The creatinine blood test may be ordered, along with BUN test and microalbumin, at regular intervals when someone
has a known kidney disorder or has a disease that may affect kidney function or be exacerbated by dysfunction. Both
BUN and creatinine may be ordered when a CT scan is planned, prior to and during certain drug therapies, and
before and afterdialysis to monitor the effectiveness of treatments.
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Increased creatinine levels in the blood suggest diseases or conditions that affect kidney function. These can include:
Damage to or swelling of blood vessels in the kidneys (glomerulonephritis) caused by, for example, infection
orautoimmune diseases
Bacterial infection of the kidneys (pyelonephritis)
Death of cells in the kidneys' small tubes (acute tubular necrosis) caused by, for example, drugs or toxins
Prostate disease, kidney stone, or other causes of urinary tract obstruction
Reduced blood flow to the kidney due to shock, dehydration, congestive heart failure, atherosclerosis, or
complications of diabetes
Creatinine blood levels can also increase temporarily as a result of muscle injury and are generally slightly lower
duringpregnancy.
Low blood levels of creatinine are not common, but they are also not usually a cause for concern. They can be seen
with conditions that result in decreased muscle mass.
Levels of 24-hour urine creatinine are evaluated with blood levels as part of a creatinine clearance test.
Random urine creatinine levels have no standard reference ranges. They are usually used with other tests to
reference levels of other substances measured in the urine. Some examples include the microalbumin test and
microalbumin/creatinine ratio and the urine protein test.
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Some drugs may cause increased creatinine levels. Inform your health care provider of any drugs you are taking.
Common Questions
1.
2.
3.
4.
5.
Will exercise affect my creatinine levels?

How does diet affect creatinine levels?
What is creatine? If I take creatine, will my creatinine levels go up?
Do creatinine levels change with age?
What is a BUN/Creatinine ratio?
1. Will exercise affect my creatinine levels?

In general, moderate exercise will not affect your creatinine levels. As you continue to exercise and build muscle
mass, your creatinine levels may increase slightly but not to abnormal levels.
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2. How does diet affect creatinine levels?

In general, creatinine levels will not vary with a normal diet. Creatinine levels may be 10%-30% higher in people who
eat a diet that is very high in meat.
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3. What is creatine? If I take creatine, will my creatinine levels go up?
Creatine is a compound that is made primarily in the liver and then transported to your muscles, where it is used as
an energy source for muscle activity. Once in the muscle, some of the creatine is spontaneously converted to
creatinine. The amount of both creatine and creatinine depend on muscle mass, so men usually have higher levels
than women. Creatine is now available as a dietary supplement. If you take creatine, your creatinine levels may be
higher than when you do not take the supplement. You should tell your health care provider about all of the dietary
supplements you are taking to help in the evaluation of your lab results.
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4. Do creatinine levels change with age?

Creatinine levels relate to both muscle mass and to kidney function. As you age, your muscle mass decreases but
your kidneys tend to function less effectively. The net result is not much change in creatinine levels in the blood as
you get older.
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5. What is a BUN/Creatinine ratio?

Occasionally, a doctor will look at the ratio between a persons BUN and blood creatinine to help them determine
what is causing these concentrations to be higher than normal. The ratio of BUN to creatinine is usually between 10:1
and 20:1. An increased ratio may be due to a condition that causes a decrease in the flow of blood to the kidneys,
such as congestive heart failure or dehydration. It may also be seen with increased protein, from gastrointestinal
bleeding, or increased protein in the diet. The ratio may be decreased with liver disease (due to decrease in the
formation of urea) andmalnutrition.
SODIUM
Why Get Tested?
To determine whether your sodium concentration is within normal limits and to help evaluate electrolyte balance and
kidney function; to monitor chronic or acute hypernatremia or hyponatremia
When to Get Tested?

If you are experiencing dehydration or edema; also to monitor certain chronic conditions, like high or low blood
pressure
Sample Required?
A blood sample drawn from a vein in the arm or, in some cases, a 24-hour urine sample

None

This test measures the level of sodium in the blood. Sodium is an electrolyte that is vital to normal body processes,
including nerve and muscle function. Sodium, along with other electrolytes such as potassium, chloride,
and bicarbonate (or total CO2), helps cells function normally and helps regulate the amount of fluid in the body.
Sodium is present in all body fluids but is found in the highest concentration in the blood and in the fluid outside of the
bodys cells. This extracellular sodium, as well as all body water, is regulated by the kidney.
We get sodium in our diet, from table salt (sodium chloride or NaCl), and to some degree from most of the foods that
we eat. Most people have an adequate intake of sodium. The body uses what it requires and the kidneys excrete the
rest in the urine to maintain the sodium concentration in blood within a very narrow range. It does this by:
Producing hormones that can increase (natriuretic peptides) or decrease (aldosterone) sodium losses in
urine
Producing a hormone that prevents water losses (antidiuretic hormone, ADH)
Controlling thirst; even a 1% increase in blood sodium will make you thirsty and cause you to drink water,
returning your sodium level to normal.
Abnormal blood sodium is usually due to some problem with one of these control systems. When the level of sodium
in the blood changes, the water content in the body also changes. These changes can be associated
with dehydration oredema, especially in the legs.

A blood sample is taken by needle from the arm. In some cases, a 24-hour urine sample may be required.
culture.

How is it used?
Blood sodium testing is used to detect abnormal concentrations of sodium, termed hyponatremia (low sodium)
andhypernatremia (high sodium). A doctor may order this test, along with other electrolytes, to identify an electrolyte
imbalance. It may be ordered to determine if a disease or condition involving the brain, lungs, liver, heart, kidney,
thyroid, or adrenal glands is causing or being exacerbated by a sodium deficiency or excess. In patients with a known
electrolyte imbalance, a blood sodium test may be ordered at regular intervals to monitor the effectiveness of
treatment. It may also be ordered to monitor patients taking medications that can affect sodium levels, such
as diuretics.
Urine sodium levels are typically tested in patients who have abnormal blood sodium levels to help determine
whether an imbalance is from, for example, taking in too much sodium or losing too much sodium. Urine sodium
testing is also used to see if a person with high blood pressure is eating too much salt. It is often used in persons with
abnormal kidney tests to help the doctor determine the cause of kidney damage, which can help guide treatment.
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When is it ordered?
Sodium testing is a part of the routine lab evaluation of most patients. It is one of the blood electrolytes, which are
often ordered as a group. The most common group of blood electrolytes is sodium, potassium, chloride,
and bicarbonate (total CO2). These electrolytes are also included in the basic metabolic panel, a larger group of tests
widely used when someone has non-specific health complaints. Electrolytes are also measured when monitoring
treatment involving IVfluids or when there is a possibility of developing dehydration. Electrolyte panels and basic
metabolic panels are also commonly used to monitor treatment of certain conditions, including high blood
pressure, heart failure, and liver andkidney disease.
A blood sodium test may be ordered when a person has symptoms of hyponatremia, such as weakness, confusion,
and lethargy, or symptoms of hypernatremia, such as thirst, decreased urinary output, muscle twitching, and/or
agitation.
A urine sodium test may be ordered when a blood sodium test result is abnormal, to help determine the cause of the
imbalance, or to monitor treatment.
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A low level of blood sodium is usually due to loss of too much sodium, too much water intake or retention, or to
excess fluid accumulation in the body (edema). If the sodium level falls quickly, the person may feel weak and
fatigued; in severe cases, he may experience confusion or even fall into a coma. When the sodium level falls slowly,
however, there may be no symptoms. That is why sodium levels are often checked even if someone has no
symptoms.
Hyponatremia is rarely due to decreased sodium intake (deficient dietary intake or deficient sodium in IV fluids). Most
commonly, it is due to sodium loss from conditions such as Addison's disease, diarrhea, diuretic administration,
or kidney disease. In some cases, it may be due to excessive water consumption as might occur during exercise or
excessive fluid accumulation as might occur in heart failure, cirrhosis, and kidney diseases that cause protein loss
(nephrotic syndrome). In other cases (particularly diseases involving the brain and the lungs, many kinds of cancer,
and in response to some drugs), the body makes too much anti-diuretic hormone (ADH), causing a person to keep
too much water in their body.
A high blood sodium level is almost always due to inadequate water intake and dehydration. Symptoms include dry
mucous membranes, thirst, agitation, restlessness, acting irrationally, and coma or convulsions if the sodium level
rises to extremely high concentrations. In rare cases, hypernatremia may be due to Cushing syndrome or a condition
caused by too little ADH called diabetes insipidus.
Sodium urine concentrations must be evaluated in association with blood levels. The body normally excretes excess
sodium, so the concentration in the urine may be elevated because it is elevated in the blood. It may also be elevated
in the urine when the body is losing too much sodium; in this case, the blood level would be normal to low. If blood
sodium levels are low due to insufficient intake, then urine concentrations will also be low.
Decreased urinary sodium levels may indicate dehydration, congestive heart failure, liver disease, or
nephrotic syndrome.
Increased urinary sodium levels may indicate diuretic use or Addison's disease.
Sodium levels are often evaluated in relation to other electrolytes and can be used to calculate a quantity
termed anion gap. The anion gap is useful in identifying the presence of unknown substances such as toxins in the
blood.
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Certain drugs such as anabolic steroids, antibiotics, corticosteroids, laxatives, cough medicines, and oral
contraceptives may cause increased levels of sodium. Other drugs such as ACE inhibitors, diuretics, carbamazepine,
heparin, and tricyclic antidepressants may cause decreased levels of sodium.
1. What is the recommended dietary salt intake?

The Food and Nutrition Board recommends a sodium intake of less than 2300 mg per day for adults. People normally
obtain adequate amounts of sodium in their daily diet, but it is important not to exceed this recommended maximum
amount.
Common dietary sources of sodium are often processed food to which salt is added during preparation, such as
cheeses, soups, pickles, and pretzels. Additionally, other processed, commercially prepared, or restaurant foods are
generally high in sodium.
For people who are sodium-sensitive or have hypertension, reducing sodium intake can lead to markedly beneficial
health effects. But even if you don't have high blood pressure, limiting sodium as part of a healthy diet may decrease
your risk of developing blood pressure problems and heart disease.
Your taste for salt is both acquired and reversible. As you use less salt, your preference for it will lessen.
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2. Is anyone at particular risk for low or high sodium levels?

Yes. People who have diarrhea, profuse sweating, burns, vomiting, Addison's disease, kidney disease, or congestive
heart failure may have low sodium levels. People with dehydration, diuretic use, Cushing syndrome, cystic fibrosis,
neurological disorders, hypothyroidism, or renal failure may have high sodium levels.
POTASSIUM
Why Get Tested?
To determine whether your potassium level is within normal limits and to help evaluate an electrolyte imbalance; to
monitor chronic or acute hyperkalemia or hypokalemia
When to Get Tested?

As part of a routine medical exam, when you have symptoms such as weakness and/or cardiac arrhythmia, or when
an electrolyte imbalance is suspected; at regular intervals when you are taking a medication and/or have a disease or
condition, such as high blood pressure (hypertension) or kidney disease, that can affect your potassium level
Sample Required?
A blood sample drawn from a vein in the arm

None

This test measures the amount of potassium in the blood. Potassium is an electrolyte that is vital to
cell metabolism and muscle function. Potassium, along with other electrolytes such as sodium, chloride,
and bicarbonate (total CO2), helps regulate the amount of fluid in the body, stimulates muscle contraction, and
maintains a stable acid-base balance. Potassium is present in all body fluids, but most potassium is found within your
cells. Only about 2% is present in fluids outside the cells and in the liquid part of the blood (called serum or plasma).
Because the blood concentration of potassium is so small, minor changes can have significant consequences. If
potassium levels are too low or too high, there can be serious health consequences; a person may be at risk for
developing shock, respiratory failure, or heart rhythm disturbances. An abnormal potassium level can alter the
function of neuromuscular tissue; for example, the heart muscle may lose its ability to contract.

A blood sample is taken by needle from a vein in the arm.
culture.

How is it used?
Potassium testing is frequently ordered, along with other electrolytes, as part of a routine physical. It is used to detect
concentrations that are too high (hyperkalemia) or too low (hypokalemia). The most common cause of hyperkalemia
iskidney disease, but many drugs can decrease potassium excretion from the body and result in this condition.
Hypokalemia can occur if someone has diarrhea and vomiting or if is sweating excessively. Potassium can be lost
through the kidneys in urine; in rare cases, potassium may be low because someone is not getting enough in their
diet.
The potassium test may be ordered at regular intervals to monitor effects of drugs that can cause the kidneys to lose
potassium, particularly diuretics. Monitoring may also be done if someone has a condition or disease, such
as acute orchronic kidney failure, that can be associated with abnormal potassium levels.
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When is it ordered?
Serum or plasma tests for potassium levels are routinely performed in most patients when they are investigated for
any type of serious illness. Also, because potassium is so important to heart function, it is usually ordered (along with
otherelectrolytes) during all complete routine evaluations, especially in those who take diuretics or blood pressure or
heart medications. Potassium testing is ordered when a doctor is diagnosing and evaluating high blood pressure
(hypertension) and kidney disease and when monitoring a patient receiving dialysis, diuretic therapy, or intravenous
therapy.
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Increased potassium levels are seen in the following conditions:
Acute or chronic kidney failure
Addison's disease
Hypoaldosteronism (see Aldosterone)
Injury to tissue
Infection
Diabetes
Dehydration
Excessive dietary potassium intake (for example, fruits are particularly high in potassium, so excessive
intake of fruits or juices may contribute to high potassium)
Excessive intravenous potassium intake
Certain drugs can also cause hyperkalemia in a small percent of patients; among them are non-steroidal
anti-inflammatory drugs, ACE inhibitors, beta blockers (such as propanolol and atenolol), angiotensin-converting
enzyme inhibitors (such as captopril, enalapril, and lisinopril), and potassium-sparing diuretics (such as
triamterene, amiloride, and spironolactone).
Decreased levels of potassium may be seen in the following conditions:
Gastrointestinal disorders associated with diarrhea and vomiting
Hyperaldosteronism (see Aldosterone)
Deficient potassium intake (rare)
As a complication of acetaminophen overdose
In diabetes, the potassium level may fall after someone takes insulin, particularly if the person has not
managed their diabetes well.
Low potassium is commonly due to "water pills" (potassium-wasting diuretics); if someone is taking these,
their doctor will check their potassium level regularly.
Additionally, certain drugs such as corticosteroids, beta-adrenergic agonists such as isoproterenol, alphaadrenergic antagonists such as clonidine, antibiotics such as gentamicin and carbenicillin, and the antifungal
agent amphotericin B can cause loss of potassium.
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Physicians question elevated potassium results when the numbers do not fit the patient's clinical condition.
Potassium levels can be falsely elevated by a variety of circumstances surrounding specimen collection and
specimen processing. For example, if a patient is clenching and relaxing his fist, the potassium level in his blood may
increase. If blood samples are delayed in getting to the lab or if the blood tubes are subjected to vigorous shaking or
rough handling in transit, pottasium may leak from red blood cells and falsely elevate the potassium in the serum.
If there are any questions as to how your blood was collected, your doctor may request that the test be repeated to
verify results.
1. What are some good dietary sources of potassium?

Low levels of potassium can be a result of increased urinary loss due to certain heart medications that lower sodium
levels and prevent water retention. To make up for this loss of potassium, doctors often suggest eating more foods
high in potassium. A number of fruits and vegetables (bananas, cantaloupe, grapefruit, oranges, tomatoes, honeydew
melons, squash, potatoes, legumes) and other foods such as nuts and seeds are good sources of potassium.
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2. Is there an over-the-counter test I can use to check my potassium level?

No. Electrolyte tests are performed by trained laboratorians using highly sensitive instruments.
ESR
Why Get Tested?
To detect the presence of inflammation caused by one or more conditions such as infections, tumors or autoimmune
diseases; to help diagnose and monitor specific conditions such as temporal arteritis, systemic vasculitis, polymyalgia
rheumatica, or rheumatoid arthritis
When to Get Tested?

When your health practitioner thinks that you might have a condition causing inflammation; when you have signs and
symptoms associated with temporal arteritis, systemic vasculitis, polymyalgia rheumatica, or rheumatoid arthritis such
as headaches, neck or shoulder pain, pelvic pain, anemia, poor appetite, unexplained weight loss, and joint stiffness
Sample Required?
A blood sample drawn from a vein in your arm

None
The Test Sample

Erythrocyte sedimentation rate (ESR or sed rate) is a test that indirectly measures the degree of inflammation present
in the body. The test actually measures the rate of fall (sedimentation) of erythrocytes (red blood cells) in a sample of
blood that has been placed into a tall, thin, vertical tube. Results are reported as the millimeters of clear fluid (plasma)
that are present at the top portion of the tube after one hour.
When a sample of blood is placed in a tube, the red blood cells normally settle out relatively slowly, leaving little clear
plasma. The red cells settle at a faster rate in the presence of an increased level of proteins, particularly proteins
calledacute phase reactants. The level of acute phase reactants such as C-reactive protein
(CRP) and fibrinogen increases in the blood in response to inflammation.
Inflammation is part of the body's immune response. It can be acute, developing rapidly after trauma, injury or
infection, for example, or can occur over an extended time (chronic) with conditions such as autoimmune diseases or
cancer.
The ESR is not diagnostic; it is a non-specific test that may be elevated in a number of these different conditions. It
provides general information about the presence or absence of an inflammatory condition.
There have been questions about the usefulness of the ESR in light of newer tests that have come into use that are
more specific. However, ESR test is typically indicated for the diagnosis and monitoring of temporal arteritis, systemic
vasculitisand polymyalgia rheumatica. Extremely elevated ESR is useful in developing a rheumatic disease
differential diagnosis. In addition, ESR may still be a good option in some situations, when, for example, the newer
tests are not available in areas with limited resources or when monitoring the course of a disease.

A blood sample is obtained by inserting a needle into a vein in the arm.
culture.

How is it used?
The erythrocyte sedimentation rate (ESR or sed rate) is a relatively simple, inexpensive, non-specific test that has
been used for many years to help detect inflammation associated with conditions such as infections, cancers,
and autoimmune diseases.
ESR is said to be a non-specific test because an elevated result often indicates the presence of inflammation but
does not tell the health practitioner exactly where the inflammation is in the body or what is causing it. An ESR can be
affected by other conditions besides inflammation. For this reason, the ESR is typically used in conjunction with other
tests, such asC-reactive protein.
ESR is used to help diagnose certain specific inflammatory diseases, temporal arteritis, systemic
vasculitis andpolymyalgia rheumatica. A significantly elevated ESR is one of the main test results used to support the
diagnosis.
This test may also be used to monitor disease activity and response to therapy in both of the above diseases as well
as some others, such as systemic lupus erythematosus (SLE).
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When is it ordered?
An ESR may be ordered when a condition or disease is suspected of causing inflammation somewhere in the body.
There are numerous inflammatory conditions that may be detected using this test. For example, it may be ordered
when arthritisis suspected of causing inflammation and pain in the joints or when digestive symptoms are suspected
to be caused byinflammatory bowel disease.
A health practitioner may order an ESR when an individual has symptoms that suggest polymyalgia
rheumatica, systemic vasculitis, or temporal arteritis, such as headaches, neck or shoulder pain, pelvic pain, anemia,
poor appetite, unexplained weight loss, and joint stiffness. The ESR may also be ordered at regular intervals to assist
in monitoring the course of these diseases.
Before doing an extensive workup looking for disease, a health practitioner may want to repeat the ESR.
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The result of an ESR is reported as the millimeters of clear fluid (plasma) that are present at the top portion of the
tube after one hour (mm/hr).
Since ESR is a non-specific marker of inflammation and is affected by other factors, the results must be used along
with other clinical findings, the individual's health history, and results from other laboratory tests. If the ESR and
clinical findings match, the health practitioner may be able to confirm or rule out a suspected diagnosis.
A single elevated ESR, without any symptoms of a specific disease, will usually not give enough information to make
a medical decision. Furthermore, a normal result does not rule out inflammation or disease.
Moderately elevated ESR occurs with inflammation but also with anemia, infection, pregnancy, and with aging.
A very high ESR usually has an obvious cause, such as a severe infection, marked by an increase
in globulins,polymyalgia rheumatica or temporal arteritis. A health practitioner will typically use other follow-up tests,
such as blood cultures, depending on the person's symptoms. People with multiple myeloma or Waldenstrom's
macroglobulinemia (tumors that make large amounts of immunoglobulins) typically have very high ESRs even if they
don't have inflammation.
When monitoring a condition over time, rising ESRs may indicate increasing inflammation or a poor response to a
therapy; normal or decreasing ESRs may indicate an appropriate response to treatment.
^ Back to top

A low ESR can be seen with conditions that inhibit the normal sedimentation of red blood cells, such as a high red
blood cell count (polycythemia), significantly high white blood cell count (leukocytosis), and some protein
abnormalities. Some changes in red cell shape (such as sickle cells in sickle cell anemia) also lower the ESR.
ESR and C-reactive protein (CRP) are both markers of inflammation. Generally, ESR does not change as rapidly as
does CRP, either at the start of inflammation or as it resolves. CRP is not affected by as many other factors as is
ESR, making it a better marker of inflammation. However, because ESR is an easily performed test, many health
practitioners still use ESR as an initial test when they think a patient has inflammation.
If the ESR is elevated, it is typically a result of two types of proteins, globulins or fibrinogen. Depending on the tested
person's medical history, signs, symptoms and what the health practitioner suspects is the cause, he or she may then
order a fibrinogen level (a clotting protein that is another marker of inflammation) and a serum protein
electrophoresis to determine which of these (or both) is causing the elevated ESR.
Women tend to have a higher ESR, and menstruation and pregnancy can cause temporary elevations.
In a pediatric setting, the ESR test is used for the diagnosis and monitoring of children with rheumatoid arthritis or
Kawasaki disease.
Drugs such as dextran, methyldopa, oral contraceptives, penicillamine procainamide, theophylline, and vitamin A can
increase ESR, while aspirin, cortisone, and quinine may decrease it.
There is a commercial rapid test available that performs the ESR in 4 minutes by a centrifugal method. It is being
used more widely to shorten waiting times for patients, particularly in emergency departments.
1. Should everyone have an ESR done?
No. The ESR is not a specific test it does not point to any one condition or disease and can be affected by
many different factors other than inflammation. As such, it is not recommended for use in screening people without
symptoms or apparently healthy people.
^ Back to top
2. What other tests might my doctor order besides ESR?

Your health practitioner may order the C-reactive protein (CRP) test as well as other general tests, such as
acomprehensive metabolic panel (CMP) or a complete blood count (CBC), at the same time as the ESR. Additional
tests that may be ordered based on your symptoms include antinuclear antibody (ANA), rheumatoid factor
(RF), fibrinogen orserum protein electrophoresis.
^ Back to top
3. What do changes in my ESR mean?

Changes in the ESR may indicate the presence or abatement of infection or inflammation. If you have a chronic
inflammatory disease, the ESR may fluctuate with the degree of severity or clinical course of your condition.
PTT
Why Get Tested?
As part of an investigation of a possible bleeding disorder or thrombotic episode; to monitor unfractionated (standard)
heparin anticoagulant therapy
When to Get Tested?

When you have unexplained bleeding or blood clotting; when you are on unfractionated (standard) heparin
anticoagulant therapy; sometimes as part of a pre-surgical screen
Sample Required?
A blood sample drawn by needle from a vein in the arm

None

The partial thromboplastin time (PTT) is a screening test that helps evaluate a person's ability to form blood clots
appropriately by measuring the time it takes (in seconds) for a clot to form in a test tube when specific substances
(reagents) are added to a sample of plasma. By measuring the time it takes to form the clot, the PTT assesses the
amount as well as the function of certain coagulation factors that are part of hemostasis.
When body tissue(s) or blood vessel walls are injured, bleeding occurs and a process called hemostasis is initiated.
Small, sticky cell fragments called platelets adhere to and then aggregate at the injury site. This begins the activation
of thecoagulation cascade system, the components of which are known as coagulation factors. Through the
activation of a series of other factors, fibrinogen (Factor I) is converted to fibrin, a thread-like material that crosslinks
together to form a fibrin net that adheres to the injury site. This fibrin net, along with platelets, produces a stable blood
clot. Blood clots are formed by this process to seal off injuries to blood vessels, to prevent further blood loss, and to
give the damaged areas time to heal.
Each component of the hemostatic process must function properly and be present in sufficient quantity for normal
blood clot formation. If there is a deficiency in one or more of these factors, or if the factors function abnormally, then
a stable clot may not form and bleeding continues. Excessive bleeding, whether external or internal, will lead to
serious and possibly life-threatening episodes.
With a PTT, a person's sample is compared to a normal reference interval. When a person's PTT takes longer than
normal to clot, the PTT is said to be "prolonged." A prolonged PTT may be due to a condition that causes a decrease
in the amount of one or more coagulation factors, inhibition by certain antibodies, or dysfunction of one or more
coagulation factors. When used to investigate bleeding or clotting episodes, a PTT is often ordered in conjunction
with a prothrombin time (PT) test. A doctor will evaluate the results of the two tests together to help determine the
cause of bleeding or clotting episode(s).
It is now understood that coagulation tests such as the PT and PTT are based on what happens artificially in the test
setting (in vitro) and thus do not necessarily reflect what actually happens in the body (in vivo). Nevertheless, they
can be used to evaluate certain components of the hemostasis system. The PTT specifically evaluates the
coagulation factors that are often referred to as the intrinsic coagulation and common pathways while the PT
evaluates those coagulation factors that are part of the extrinsic and common pathways. (For more on this, see the
explanation of the coagulation cascade).

A blood sample is obtained by inserting a needle into a vein in the arm.
culture.

No test preparation is needed; however, a high fat meal prior to the blood draw may cause interference with the test
and should be avoided.
How is it used?
The PTT test is used to investigate unexplained bleeding or clotting. It may be ordered along with a PT (Prothrombin
Time) test to evaluate hemostasis, the process that the body uses to form blood clots to help stop bleeding. The PTT
evaluates the coagulation factors XII, XI, IX, VIII, X, V, II (prothrombin), and I (fibrinogen) as well as prekallikrein (PK)
and high molecular weight kininogen (HK). A PT test evaluates the coagulation factors VII, X, V, II, and I (fibrinogen).
By evaluating the results of the two tests together, a doctor can gain clues as to what bleeding or clotting disorder
may be present.
A PTT is often used to monitor standard (unfractionated, UF) heparin anticoagulant therapy. Heparin is a drug that is
givenintravenously (IV) or by injection to prevent and to treat thromboemboli. When it is administered for therapeutic
purposes, it must be closely monitored. If too much is given, the treated person may bleed excessively; with too little,
the treated person may continue to clot.
If the PTT is prolonged and the cause is not anticoagulant therapy or heparin contamination, then a second PTT test
is performed by mixing the patient's plasma with pooled normal plasma (a collection of plasma from a number of
normal donors). If the PTT time returns to normal ("corrects"), it suggests a deficiency of one or more of the
coagulation factors in the patient's plasma. If the time remains prolonged, then the problem may be due to the
presence of an abnormal factorinhibitor (autoantibody). Further studies can then be performed to identify what factors
may be deficient or determine if an inhibitor is present in the blood. Nonspecific inhibitors, such as lupus
anticoagulant and anticardiolipin antibodies, are associated with clotting episodes and with recurrent miscarriages,
especially those that occur in the second or third trimester. For this reason, PTT testing may be performed to help
investigate recurrent miscarriages.
Based on carefully obtained patient histories, the PTT and PT tests are sometimes selectively performed as presurgical procedures to screen for potential bleeding tendencies.
Other testing that may be done along with a PTT includes:
Platelet counts should always be monitored during heparin therapy to promptly detect any heparininducedthrombocytopenia
Thrombin time testing sometimes ordered to help rule out heparin contamination
Fibrinogen testing may be done to rule out hypofibrinogenemia as a cause of PTT prolongation
^ Back to top
When is it ordered?
The PTT may be ordered along with other tests such as a PT when a person presents with unexplained bleeding or
bruising, a thromboembolism, an acute condition such as disseminated intravascular coagulation (DIC) that may
cause both bleeding and clotting as factors are used up at a rapid rate, or with a chronic condition such as liver
disease. When someone has had a thrombotic episode or recurrent miscarriages, the PTT may be ordered as part of
an evaluation forlupus anticoagulant or anticardiolipin antibodies.
When a person is on intravenous (IV) or injection heparin therapy, the PTT is often ordered at regular intervals to
monitor the degree of anticoagulation. When someone is switched from heparin therapy to longer-term warfarin
(COUMADIN) therapy, the two are overlapped and both the PTT and PT are monitored until the person has
stabilized.
A PTT may be ordered as part of a pre-surgical evaluation for bleeding tendencies, especially if the surgery carries an
increased risk of blood loss and/or if the person has a clinical history of bleeding, such as frequent or excessive
nosebleeds and easy bruising, which may indicate the presence of a clotting disorder.
^ Back to top

PTT results that fall within the reference interval as established by each laboratory usually indicate normal clotting
function; however, mild to moderate deficiencies of a single coagulation factor may still exist. The PTT may not be
prolonged until the factor levels have decreased to 30% to 40% of normal. Also lupus anticoagulant may be present
but may not prolong the PTT result. If the lupus anticoagulant (LA) is suspected, an LA-sensitive PTT or a Dilute
Russell Viper Venom Time can be used to test for it.
A prolonged PTT means that clotting is taking longer to occur than expected and may be due to a variety of causes.
Often, this suggests that there may be a coagulation factor deficiency or a specific or nonspecific inhibitor affecting
the body's clotting ability. Coagulation factor deficiencies may be acquired or inherited.
Prolonged PTT tests may be due to:
Inherited or acquired factor deficiencies. Prolonged PTTs due to a factor deficiency usually "correct" after
being mixed with pooled normal plasma. The PTT may be prolonged in von Willebrand disease, the most
common, inheritedbleeding disorder, which affects platelet function due to decreased von Willebrand factor.
Hemophilia A and Hemophilia B (Christmas disease) are two other inherited bleeding disorders resulting from a
decrease in factors VIII and IX, respectively. Deficiencies of other coagulation factors are rare but may also
adversely impact PTT results.
An example of an acquired deficiency is one due to lack of vitamin K. Vitamin K, found in various leafy green
vegetables and produced by certain gastrointestinal bacteria, is a key component to proper blood
coagulation. Vitamin K deficiencies are rare but can occur due to an extremely poor diet, malabsorption
disorders, or prolonged use of certain antibiotics. Most coagulation factors, including the vitamin K-dependent
ones, are manufactured by the liver, thus liver disease may cause prolonged PT and PTT. With liver disease
and vitamin K deficiency, PT is more likely to be prolonged than is PTT.
A nonspecific inhibitor. Nonspecific inhibitors, such as the lupus anticoagulant (LA) and cardiolipin
antibodies, bind to chemicals called phospholipids found on the surface of platelets. Since phospholipids assist
in the clotting process, and since the PTT test reagents contain phospholipids, such antibodies may prolong the
PTT, suggesting a bleeding problem. In fact, the presence of these inhibitors is usually associated
with thrombosis instead of bleeding in the body. If the lupus anticoagulant does prolong the PTT or LA sensitive
PTT, it will not correct with normal plasma mixing, but it will usually correct if an excess of phospholipid is added
to the sample. The Dilute Russell Viper Venom Time (dRVVT) is more sensitive than the PTT in detecting lupus
anticoagulants.
A specific inhibitor. Although relatively rare, these are antibodies that specifically target certain coagulation
factors, such as Factor VIII antibodies. They may develop in someone with a bleeding disorder who is receiving
factor replacements (such as Factor VIII, which is used to treat hemophilia A) or spontaneously as an
autoantibody. The specific inhibitor will prolong the PTT and it will not correct with mixing studies. Factor-specific
inhibitors can cause severe bleeding.
Heparin. Will prolong a PTT, either as a contaminant of the sample or as part of anticoagulation therapy. For
anticoagulant therapy, the target PTT is often about 1.5 to 2.5 times longer than a person's pretreatment level.
Warfarin (COUMADIN) anticoagulation therapy. The PTT is not used to monitor warfarin therapy, but it may
be affected by it. Typically, the PT is used to monitor warfarin therapy.
Prolonged PTT levels may also be seen with leukemia, excessive bleeding in pregnant women prior to or
after giving birth, or recurrent miscarriages.
Results of the PTT are often interpreted with that of the PT in determining what condition may be present.
Interpretation of PT and PTT in Patients with a Bleeding or Clotting Syndrome
PT
RESULT
PTT RESULT
COMMON CONDITION PRESENT
Prolonged Normal
Liver disease, decreased vitamin K, decreased or defective factor VII
Normal
Decreased or defective factor VIII, IX, or XI, von Willebrand disease, or lupus
Prolonged
anticoagulant present
Prolonged Prolonged
Decreased or defective factor I, II, V or X, severe liver disease, disseminated

intravascular coagulation (DIC)
Normal
Normal or
May indicate normal hemostasis; however PT and PTT can be normal in conditions
slightly
such as mild deficiencies in other factors and mild form of von Willebrand disease.
prolonged
Further testing may be required to diagnose these conditions.
A shortened PTT may result when coagulation factor VIII is elevated. This may occur during an acute phase reaction,
a condition causing pronounced tissue inflammation or trauma. This is usually a temporary change that is not
monitored with a PTT test. When the condition causing the acute phase reaction is resolved, the PTT will return to
normal.
^ Back to top

Two anticoagulants often used, low molecular weight heparin (LMWH) and danaparoid, may not prolong the PTT and,
if indicated, should be monitored using the heparin anti-factor Xa assay.
Several factors can affect results of a PTT and the interpretation of test results:
Insufficient sample there must be enough blood collected. The anticoagulant-to-blood ratio must be 9:1 in
the collection tube.
People with high hematocrit levels may have prolonged PTTs.
Heparin contamination this is the most common problem, especially when blood is collected from
intravenous lines that are being kept "open" with heparin washes.
Clotted blood samples the clotting process uses up some of the factors.
People should avoid high-fat meals prior to having their blood drawn for a PTT.
In some cases, heparin can unintentionally decrease a person's platelet count in a complication called
heparin-induced thrombocytopenia. When this occurs, substitute anticoagulants such as hirudin or argatroban
may be given. The PTT test is also used to monitor these therapies. It does not directly measure the
anticoagulants used but measures their effect on blood clotting.
1. Is the PTT always used to monitor heparin therapy?

In a few situations, it is not.
1.
When very high doses of heparin are used, as may occur during open heart surgery, the PTT loses its
sensitivity; it will not clot. At this intense level of anticoagulation, the Activated Clotting Time (ACT) is used as a
monitoring tool.
2.
Some doctors and laboratories now monitor standard (unfractionated) heparin therapy using the anti-factor
Xa test.
3.
Low molecular weight heparin (LMWH) is a fast-acting form of heparin often used in the treatment of
conditions such as deep vein thrombosis prevention. Though generally not requiring monitoring, it must be
monitored using the anti-factor Xa test.
4.
For patients with lupus anticoagulant and clotting and who are being treated with heparin, the PTT is not
reliable; thus the anti-factor Xa assay must be used to monitor their heparin therapy.
^ Back to top
2. Should everyone have their PTT checked?

This is not usually necessary. The PTT is not used as a routine screening test but is ordered when someone has
symptoms or a family history of abnormal bleeding or clotting. Asymptomatic people are occasionally screened prior
to a surgery if their doctor feels that it will help evaluate their risk of excessive bleeding during the procedure.
^ Back to top
3. How can I change my PTT?

The PTT is not something you can change through lifestyle changes (unless you have a vitamin K deficiency). It is a
reflection of the integrity of your clotting system. If your PTT is prolonged due to acquired factor deficiencies, then
addressing the underlying condition may bring the results to near normal levels. If they are prolonged due to a
temporary oracute condition, they should return to normal on their own when the acute condition is resolved. Inherited
coagulation abnormalities or deficiencies must be routinely monitored and may be treated with frequent replacement
infusions of the missing clotting factor.
^ Back to top
4. What is an LA-sensitive PTT and how does it differ from regular PTT?
The LA-sensitive PTT (LA-PTT or PTT-LA) is a variation of the PTT using a low phospholipid reagent that has been
optimized in detecting lupus anticoagulants. This type of PTT is based on the principle that lupus anticoagulant binds
to the phospholipids that are used as one of the reagents in the PTT test. Any lupus anticoagulant that is present in a
test sample will bind to the phospholipid reagent, causing an abnormally prolonged PTT. When low levels of
phosopholipids are used in the test, most or all of the phospholipids are bound by any lupus anticoagulant present,
producing abnormally prolonged results. For more on this, see the article on Lupus Anticoagulant.
PT
Why Get Tested?
To check how well the blood-thinning medication (anticoagulant) warfarin (COUMADIN) is working to prevent blood
clots; to help detect and diagnose a bleeding disorder
When to Get Tested?

When you are taking warfarin or when your doctor suspects that you may have a bleeding disorder
Sample Required?
A blood sample drawn from a vein in the arm; sometimes blood from a fingerstick

None needed, although if you are receiving anticoagulant therapy, the specimen should be collected before
taking your daily dose.

The prothrombin time (PT) test measures how long it takes for a clot to form in a sample of blood. In the body, the
clotting process involves a series of sequential chemical reactions called the coagulation cascade, in which
coagulation or "clotting" factors are activated one after another and result in the formation of a clot. There must be a
sufficient quantity of each coagulation factor, and each must function properly, in order for normal clotting to occur.
Too little can lead to excessive bleeding; too much may lead to excessive clotting.
In a test tube, there are two "pathways" that can initiate clotting, the so-called extrinsic and intrinsic pathways. Both of
these then merge into a common pathway (like the shape of a "Y") to complete the clotting process. In one of the final
steps of the clotting cascade, prothrombin (also called Factor II) is converted into thrombin, but this factor and step is
not the sole focus of the PT test.
The PT test evaluates how well all of the coagulation factors in the extrinsic and common pathways of the coagulation
cascade work together. Included are: Factors I (Fibrinogen), II (Prothrombin), V, VII and X. The PT test evaluates the
overall ability to produce a clot in a reasonable amount of time and, if any of these factors are deficient or
dysfunctional, the PT will be prolonged.
The PT test is usually measured in seconds and is compared to a normal range that reflects PT values in healthy
individuals. Because the reagents used to perform the PT test vary from one laboratory to another and even within
the same laboratory over time, the normal ranges also will fluctuate. To standardize results across the U.S. and the
world, a World Health Organization (WHO) committee developed and recommended the use of the Internationalized
Normalized Ratio (INR) with the PT test for people who are receiving the anticoagulant warfarin (COUMADIN).
The INR is a calculation that adjusts for changes in the PT reagents and allows for results from different laboratories
to be compared. Most laboratories are now reporting both PT and INR values whenever a PT test is performed. The
INR is only applicable, however, for those taking the blood-thinning medication warfarin.

A blood sample is obtained by inserting a needle into a vein in the arm or, sometimes, from a fingerstick.
culture.

No test preparation is needed. If a person is receiving anticoagulant therapy, the specimen should be collected before
the daily dose is taken.
How is it used?
The prothrombin time (PT) test is ordered to help diagnose unexplained bleeding, often along with a partial
thromboplastin time (PTT) test. The PT test evaluates the extrinsic and common pathways of the coagulation
cascade, while the PTT test evaluates the intrinsic and common pathways. Using both examines the integrated
function of all of the coagulation factors.
Occasionally, the tests may be used to screen people for any previously undetected bleeding problems prior to
surgical procedures.
The PT and INR are used to monitor the effectiveness of the anticoagulant warfarin (COUMADIN). This drug affects
the function of the coagulation cascade and helps inhibit the formation of blood clots. It is prescribed on a long-term
basis to people who have experienced recurrent inappropriate blood clotting. Common clinical indications for warfarin
use are atrial fibrillation, the presence of artificial heart valves, deep venous thrombosis, and
pulmonary embolism (where the embolized clots first form in veins). Warfarin is also used in antiphospholipid
syndrome, and occasionally in heart attacks. The goal with warfarin therapy is to maintain a balance between
preventing clots and causing excessive bleeding. This balance requires careful monitoring, typically by PT/INR.
^ Back to top
When is it ordered?
When a person is taking the anticoagulant drug warfarin, the doctor will order periodic PT/INR tests to ensure that the
prescription is working properly and that the PT/INR is appropriately prolonged. There is no set frequency for doing
the test. A doctor will order them often enough to make sure that the drug is producing the desired effect - that it is
increasing the person's clotting time to a therapeutic level without causing excessive bleeding or bruising.
The PT may be ordered when a person who is not taking anticoagulant drugs has signs or symptoms of a bleeding
disorder, which can range from nosebleeds, bleeding gums, bruising, heavy menstrual periods, blood in the stool
and/or urine to arthritic-type symptoms (damage from bleeding into joints), loss of vision, and chronic anemia.
PT, along with PTT, is routinely ordered when a person is to undergo an invasive medical procedure, such as surgery,
to ensure normal clotting ability.
^ Back to top
Most laboratories report PT results that have been adjusted to the INR for people on warfarin. These people should
have an INR of 2.0 to 3.0 for basic "blood-thinning" needs. For some who have a high risk of clot formation, the INR
needs to be higher - about 2.5 to 3.5. The doctor will use the INR to adjust a person's drug dosage to get the PT into
the desired range that is right for the person and their condition.
The test result for a PT depends on the method used, with results measured in seconds and compared to the normal
range established and maintained by the laboratory that performs the test. This normal range represents an average
value of healthy people who live in that area and will vary somewhat from region to region and may vary over time.
So someone who is not taking warfarin would compare their PT test result to the normal range provided with the test
result.
A prolonged PT means that the blood is taking too long to form a clot. This may be caused by conditions such as liver
disease, vitamin K deficiency, or a coagulation factor deficiency. The PT result is often interpreted with that of
the PTT in determining what condition may be present.
Interpretation of PT and PTT in Patients with a Bleeding or Clotting Syndrome

PT RESULT
PTT RESULT
Prolonged Normal
EXAMPLES OF CONDITIONS THAT MAY BE PRESENT
Liver disease, decreased vitamin K, decreased or defective factor VII, chronic lowgradedisseminated intravascular coagulation (DIC), anticoagulation drug (warfarin)
therapy
Normal
Prolonged
Decreased or defective factor VIII, IX, or XI, von Willebrand disease (severe type),
presence of lupus anticoagulant
Prolonged Prolonged
Decreased or defective factor I, II, V or X, severe liver disease, acute DIC
Normal
Normal or
May indicate normal hemostasis; however, PT and PTT can be normal in conditions
slightly
such as mild deficiencies in other factors and mild form of von Willebrand disease.
prolonged
Further testing may be required to diagnose these conditions.
^ Back to top
Some consumed substances, such as alcohol, can affect the PT/INR test. Some antibiotics can increase the PT/INR.
Barbiturates, oral contraceptives and hormone-replacement therapy (HRT), and vitamin K (either in a multivitamin or
liquid nutrition supplement) can decrease PT. Certain foods, such as beef and pork liver, green tea, broccoli,
chickpeas, kale, turnip greens, and soybean products, contain large amounts of vitamin K and can alter PT results. It
is important that a doctor knows about all of the drugs, supplements, and foods that a person has ingested recently
so that the PT/INR results are interpreted and used correctly.
Some laboratories will report a PT as a percentage of normal, although this is not as common as reporting the results
in seconds.
1. Can I do this test at home?

Yes, if you will be taking warfarin for an extended period of time. The Food and Drug Administration has approved
several home PT/INR testing systems. However, home testing is usually done in the context of a home-based
coagulation management program that involves patient training and defined response and management protocols.
For more on this, see the article on Home Testing.
^ Back to top
2. Should I have it done at the same time of day?
It is not generally necessary to have your PT/INR measured at a particular time of day. It is, however, important that
you take your warfarin medication at the same time each day to maintain a continuous level. If your doctor increases
or decreases your dosage, she may want you to have your blood rechecked in a day or so to judge the effect of the
dosage change on your PT/INR (it is not an immediate effect).
^ Back to top
3. My PT results vary sometimes, yet my doctor doesnt change my prescription. Why?

Illness, change in diet, and some medications (as mentioned above) can alter PT results. Certain foods, such as beef
and pork liver, green tea, broccoli, chickpeas, kale, turnip greens, and soybean products contain large amounts of
vitamin K and can alter PT results. The blood collection technique and the difficulty in obtaining the blood sample can
also affect test results. If your doctor has concerns about the stability of your PT/INR, he may test your blood more
frequently.

What Is Being Tested?: White Blood Cells

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What Is Being Tested?: White Blood Cells

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What is being tested?

The three types of cells evaluated by the CBC include:

How is the sample collected for testing?

Screen for a wide range of conditions and diseases

Monitor the condition and/or effectiveness of treatment after a diagnosis is established

Hemoglobin measures the amount of the oxygen-carrying protein in the blood.

Mean corpuscular volume (MCV) is a measurement of the average size of RBCs.

percentage of hemoglobin inside a red cell.

variation in the size of RBCs.

The platelet count is the number of platelets in a person's sample of blood.

What does the test result mean?

White Blood Cell Count

EXAMPLES OF CAUSES OF A LOW

EXAMPLES OF CAUSES OF A HIGH

Tissue death (trauma,

the bone marrow

burns, heart attack)

Intense exercise or severe

EXAMPLES OF CAUSES OF A LOW

EXAMPLES OF CAUSES OF A HIGH

White Blood Cell Differential

Absolute neutrophil count, %

Acute bacterial infections

Tissue death (necrosis)

Bone marrow damage

Certain leukemias (e.g.,

Cancer that spreads to

Absolute lymphocyte count,

(e.g., lupus, rheumatoid

(CMV), Epstein-Barr virus

HIV, viral hepatitis, typhoid

(EBV), herpes, rubella)

Bone marrow damage

Certain bacterial infections

Acute viral infections

cough), tuberculosis (TB))

EXAMPLES OF CAUSES OF A LOW

Absolute monocyte count, %

Usually, one low count is not

EXAMPLES OF CAUSES OF A HIGH

tuberculosis, fungal infection)

Repeated low counts can

Bone marrow damage

Collagen vascular diseases

Infection within the heart

Chronic infections (e.g.,

Hairy cell leukemia

Absolute eosinophil count, %

Numbers are normally low in the

blood. One or an occasional low

Asthma, allergies such as

number is usually not medically

Some cancers, leukemias or

Absolute basophil count, %

As with eosinophils, numbers are

normally low in the blood; usually

Rare allergic reactions

not medically significant

Red Blood Cell

EXAMPLES OF CAUSES OF LOW RESULT

EXAMPLES OF CAUSES OF HIGH RESULT

Acute or chronic bleeding

Lung (pulmonary) disease