Diurnal variation Diet Tobacco smoking Stress Posture Age

Clinical Specimens

Laboratory Examination

Blood Urine Stool CSF Other BFs

Hematology Chemistry Immunology Microbiology

Kinds: capillary, vein, arterial Time: fasting, ad random, timed (2 hrs pp, serial) Anticoagulant:
Anticoagulant (-) serum Anticoagulant (+) plasma

Stopper color Red

Anticoagula nt None

Specimen type/use

Mechanism of action

Serum N/A (chemistry & serology

Lavender (plastic)
Light blue

K2EDTA (Spray)dried Sodium Citrate

Lithium Heparin

Light green/black

Plasma/Hem Chelates atology (binds) Calcium Plasma/coag Chelates ulation (binds) Calcium Plasma/che Inhibits mistry thrombin formation

Skin puncture Method of choice in pediatric patients (infants) iatrogenic anemia. Adults: extreme obesity, severe burns, thrombotic tendency Geriatric patients skin less thinner, less elastic prevent hematoma

Venipuncture, phlebotomy phlebotomist Complication (in pediatric patients):

Cardiac arrest, hemorrhage, thrombosis, venous constriction (gangrene), damage to organ, infection.

More difficult to perform high pressure difficult to stop bleeding. Preference: radial, brachial, femoral arteries

Ensure valid results procedure Urine testing :

Chemicals Bacteriologic Microscopic (sediment)

Collection:

Container: chemically clean sterile ? Pediatric collection Special collection suprapubic aspiration Urine storage preservation Freshly voided and concentrated urine identify cast, RBC, WBC

Random (first morning voided) Clean catch Timed 24 hrs Catheterized

 Stool : end product of body metabolism Early detection of gastrointestinal bleeding, liver and biliary duct disorders, malabsorption syndromes, & detection parasites Normal: contains bacteria, cellulose & undigested foodstuffs, GI secretions, bile pigments, cells from intestinal walls, electrolytes & water

Clean, dry, widemouth, leakproof, tightfitting lid Not contaminated with urine or water Within 2 hours after collection

Name: Date : Time:

Collection routinely by lumbar puncture between 3rd, 4th or 5th vertebrae Up to 20 mL CSF may normally be moved Collected in 3 sterile tubes:
Tube 1: chemical & serologic tests Tube 2: microbiology Tube 3: cell count & differential

Examination should be performed immediately (<1 hr) Produce 500 ml/day Ultrafiltration and secretion through the choroid plexus Obtained by lumbar puncture, cisternal puncture, lateral cervical puncture or

Functions: Physical support to brain Protect sudden changes in blood pressure Excretory waste Pathway from hypothalamus to midbrain Maintains CNS ionic hemostatic

1. 2.

3.
4.

Meningeal infection Subarachnoid hemorrhage CNS malignancy Demyelinating disease

CSF Examination: 1. Gross examination 2. Microscopic examination 3. Chemical examination

Normal CSF: Turbidity

clear and colorless viscosity similar to water leukocyte >200cells/L, erithrocyte > 400cells/L

Clot formation

traumatic tap, complete spinal block, suppurative and tuberculous meningitis

Viscous

Xanthochromia

metastatic mucin-producing adenomacarcinomas cryptococcal adenocarcinomas

pink, orange or yellow due to RBC lysis or Hb breakdown bilirubin, protein >150mg/dL, carotinoids, melanin, rifampicin therapi, contamination of detergent or methiolate disinfectan

Total Cell Count

Differential Count

Leukocyte: normal 0-5 cells/L, neonates <30 cells/L Use Fuch Rosenthal or Neubauer counting chamber Performed on a Wrights-stained smear Normal: primarily lymphocytes & monocytes adult: lymphocytes : monocytes = 70:30 children: monocytes more prevalent (up to 80%) Neutrophil: e.g bacterial meningitis Lymphocytes: e.g viral & Tb meningitis Eosinophil: e.g parasitic & fungal infections

Total Protein

Derived from plasma, concentration<1% blood level (15-45 mg/dL) elevated CSF protein: Increased permeability of BBB (meningitis, hemorrhage) Decreased resorption at arachnoid villi Mechanical obstruction (tumor) Increase intrathecal immunoglobulin synthesis (Guillain-Barre synd, multiple sclerosis)

Method: Turbidimetric, colorimetric

Glucose derived from blood glucose fasting CSF glucose 50-80mg/dL 60% plasma values Hypoglycorrhacia: bacterial, tuberculous and fungal meningitis

Enzymes 1. Lactate Dehydrogenase (LDH) Normal < 40U/L elevated in bacterial meningitis 2. Creatine Kinase (CK) Normal < 5 U/L elevated in demyelinating disease, seizures, stroke, malignant tumors, meningitis & head injury

Gram stain Bacterial Meningitis group B Streptococcus and Gram negative rods Viral meningitis Enteroviruses (polioviruses) Fungal meningitis Cryptococcus (in AIDS patients) Tuberculous meningitis

Bacterial
WBC count Cell present elevated neutrophil

Viral
elevated

Tubercular Fungal
elevated Elevated

Lymphocytes Lymphocytes Lymphocytes & monocytes & monocytes

Protein elevated
Glucosa

marked
decreased

moderate
normal

Moderate to marked
decreased

Moderate to marked
Normal to decrease

Material cough up from the throat and lung (compare to saliva) Examined to diagnose infection in Upper respiratory tract or lung. Early morning Collected in a wide-mouth glass bottle

Pleural cavity: between mesothelium of visceral and parietal pleura Normal: small amount of fluid Plasma filtrate derived from capillaries of the parietal pleura, reabsorbed through the lympatics and venules of the visceral pleura Effusion: accumulation of fluid Specimen collection: Thoracentesis In EDTA tube: cell counts & differential

Transudates: increased capillary hydrostatic pressure or decreased plasma oncotic pressure Congestive heart faillure Hepatic cirrhosis Hypoproteinemia Exudates: Increase capillary permeability or decreased lymphatic resorption Infections: Tb, bacterial, viral pneumonia Neoplasms: metastatic Ca Extrapleural sources: pancreatitis, ruptured esophagus

Color Turbidity Odor Clot

Transudates Pale yellow to straw Clear -

Exudates

Turbid/milky/ bloody Fecalent: anaerobic inf +

Transudates Cell counting Differential count : Mesothelial cell

Neutrophilia

Exudates > 1000/L

< 1000/L

negative

Tb,

(>50%)
(>50%)

10%

case
case

Lymphocytosis

30%

Eosinophilic

(>10%)

Cong

heart failure, trauma

empiema, rheumatoid Bacterial pneu, pancreatitis Tb, viral inf, malignancy, SLE parasitic/fungal inf, drug rx, rheumato

Protein Glucose LDH Amylase pH

Transudates <3.0 g/dL = serum PF/S <0.6 <200 IU/L serum >7.4

Exudates >3.0 g/dL < 60mg/dL : purulent PF/S >0.6 >200 IU/L serum >/<7.3


1. 2. 3. 1. 2. 3.

Immunologic: Rheumatoid Factor ANA titers Complement levels

Microbiological: Grams stain Acid-fast stain culture

Fluid in the joint cavities Arthrocentesis Anticoagulant 3 tubes

Arthrocentesis Steril, disposable needles and plastic syringe Specimen:

1. 2. 3. EDTA: cell count & diff count Na-Heparinized : chemical & immunologic test Plain: microbiologic test & crystal examination Oxalate, Li-heparin and EDTA avoided (?)

Color evaluated in a clear glass tube against a white background Normal: colorless to pale yellow noninflammatory/ inflammatory dis: straw to yellow (xanthochromia) Septic: yellow, brown, green

Clarity Related to the number and type of particles within synovia Normal: transparent Translucent: leukocytes Opaque: massive crystals Milky opalescent: abundance of cholesterol crystal

Total Cell Count 1 hour after arthrocentesis Hemacytometer or automated cell counter Incubated with hyaluronidase Normal: <150-200/ L

Differential Count Normal: Neutrophils 20% Lymphocytes 15% Monocytes & macrophages 65% Eosinophilia 2% Elevated: Neutrophils: inflammatory, Gout & RA Lymphocytes: early RA, chronic infection Monocytes: viral arthritis Eosinophilia: RA, metastatic carcinoma, parasitic inf

Crystal Examination Gout: crystal deposition in articular tissue 1. monosodium urate monohydrate (MSU) 2. calcium pyrophosphate dihydrate (CPPD) 3. apatite 4. basic calcium phosphate (BCP) Polarized light microscope 1. MSU: Gout, septic arthritis 2. CPPD: degenerative arthritis, hypo-Mg, hemochromatosis

Crystal
Monosodium urate

Shape
Needles

Ca pyrophosphate

Rods

cholesterol

Notched rhombic plates

apatite
coricosteroid

Small needles
Flat, variable shape plates

Mucin clot test: add acetic acid Glucose: Normal <10 mg/dL Protein: Normal 1.38 g/dL Lipids: 1. cholesterol-rich psedochylous: chronic RA 2. lipid droplets: trauma 3. chylous effusion: RA, SLE, filariasis, pancreatitis, trauma

1.

Immunologic studies Rheumatoid Factor (RF) Complement Microbiological Examination Grams stin Ziehl-Neelson Culture

2.

Infection of upper respiratory tract (bird flu) Sterile swab sterile test tube or transport medium

Peritoneocentesis Ultrafiltrate of plasma Peritoneal effusion: ascites Normal: <50mL Specimen collection:EDTA Gross Examination Transudates: pale yellow & clear Exudates: cloudy/ turbid Acute pancreatitis & cholecystitis: green Malignancy & TB: bloody Chylous & pseudochylous: milky fluid Microscopic Examination Bacterial peritonitis: leukocyte >500/L, >50% neutrophil Eosinophilia (>10%): chronic inflammatory process

Chemical Analysis Protein: little value Low glucose: TB peritonitis & malignancy Elevated amylase: pancreatitis, gastrointestinal perforation Elevated alkaline phosphatase: intestinal perforation Elevated urea/ creatinine: ruptured bladder

Normal: 10-50 mL Produced by transudative process Effusion: Inflammatory, malignant, hemorrhagic processes Obtained: pericardiotomy, pericardiocentesis

Gross Examination Normal: pale yellow and clear Infection: turbid effusion Uremia: clear & straw colored effusion Chylous effusion: milky appearance Microscopic Examination Leukocyte count: >10 000/L: bacterial, TB, malignant

Chemical Analysis

Protein >3.0g/dL: exudates Glucose <40mg/dL: bacterial, TB, malignant pH <7.10: rheumatic & purulent condition 7.20-7.40: malignant, uremia, TB Enzymes LD >300U/dL & fluid/serum LD ratio>0.6: exudates

1.

2. 3.

Clinical Diagnosis and Management by Laboratory Methods.Henry JB. 20th ed. 2001. WB Saunders co: Philadelphia London Urinalysis and Body Fluid. Strasinger SK. 2nd ed.1989. F.A. Davis Co: Philadelphia Basic Medical Laboratory Techniques. Estridge BH, Reynolds AP, Walters NJ. 4th ed. 2000. Delmar: Africa Australia