Urine Pt. 1

28 y/o female following MVA, what is appropriate imaging to initially consider?

Cervical Rads

Absent posterior arch → what is the appropriate follow up?

Flexion and extension views

Modic signal changes are associated with

DDD

58 y/o male has considerable neck pain and bilateral arm paresthesia

cervical MRI and X-ray (x-ray over MRI)

What is needed with OPLL

CT and MRI of C spine and ortho neuro consult

What does a patient need relative to a DISH diagnosis?

Fasting blood sugar level

DISH, diabetes and OPLL go together

What does nerve root compression need before treatment?

MRI

Modic Type 1

Low T1 (dark) and high T2 (light)

Inflammatory changes like edema and inflammation

Modic Type 2

high T1 (light) and isointense to High T2 (light)

Fatty changes like fatty marrow replacement

Modic Type 3

Low T1 and T2

Sclerotic changes like bone sclerosis and fibrosis

Endplate destruction =

infection → could be DDD

Typical Chiro Practice (pt.1)

1.) detection of subluxation level by palpation and other tests

2.) special studies such as radiographs, labs, MRI, CT, EKG

3.) Diagnosis or clinical impression including determination of subluxation levels

4.) Develop chiropractic case management plan which MAY consist of concurrent care by another provider

Typical Chiro Practice (pt. 2)

1.) reporting of findings to the patient, including informed consent as mandated by state law or as a part of risk management

2.) if indications of an underlying disease exist, then a second opinion from another health care provider may be necessary for concurrent care

3.) chiros use private, hospital, national reference, or college labs → all governed by the CLIA (clinical laboratory improvement amendments)

Many patients with UTI have

lumbar subluxations

Many patients with liver disease have

T5-T9 subluxations

How Chiro’s use lab tests?

1.) to establish baseline data, to screen (general or target)

2.) to determine diagnosis and prognosis

3.) to monitor patient’s progress and effectiveness of care, both pre and post adjustment

4.) to make decisions regarding a second opinion about follow up care with another health care provider

S/S to order a UA

1.) low back pain, painful urination (dysuria), hematuria

2.) suprapubic pain, urethral or vaginal discharge

3.) frequent urination, inability to urinate, polydipsia

4.) polyphagia, physicals and wellness screenings

Kidneys (1)

1.) have a remarkable ability to select and retain essential substances and excrete end products of metabolism and excess substances from the diet

2.) 25% of cardiac output perfuse the kidneys every minute

Renal disease is responsible for a great deal of

morbidity (millions of cases/year)

Kidneys (2)

1.) play an important role in water balance, acid-base balance and electrolyte balance

2.) involved in the production of erythropoietin and renin

Erythropoietin

hormone that stimulated RBC production

Renin

enzyme for controlling blood pressure

Routing UA

1.) physical properties, chemical properties, microscopic properties

2.) the oldest clinical lab procedure used by Sumerian, Babylonian and Egyptian physicians’

3.) pisse prophets: urine gazers

Urinary system

Consists of 2 kidneys, 2 ureters, urinary bladder, and urethra

Nephron

1.) functional unit of the kidney

2.) consists of the glomerulus, the capillary network of the nephron, proximal convoluted tubule, loop of Henle with a descending and ascending limb, distal tubule, and collecting duct

3.) glomerular filtrate becomes urine after it leaves the distal convoluted tubule

Principle solute of urine

urea, sodium, chloride, potassium, creatinine, uric acid, ammonia

the body excretes 60g of dissolved material/24 hours (1/2 is urea)

Urine formation

1.) result of glomerular filtration, tubular reabsorption, and tubular secretion

2.) composed of 95% of water, and 5% dissolved solids

3.) 1,200-1,500ml daily volume

4.) normal range is 600-2,000mL/day

Polyuria

1.) >2,000mL/24 hours

2.) DM, I, Large fluid intake, diuretics

Oligouria

1.) <500mL/24 hours

2.) renal tubule dysfunction, end stage renal disease, obstruction, edema, dehydration, diarrhea, vomiting, shock

Anuria

Absence of urine

renal failure, obstruction, heart attack

Polydipsia

Excessive water intake

Collecting samples

1.) UA is only as good as the sample collected

2.) Best time in early morning → midstream clean catch on first rising

3.) decomposition begins within 30 minutes at room temperature and within 4 hours if refrigerated

4.) 24 hour sample with a preservative

Random sample

most common and most convenient

testing should be done within 2 hours at room temp

Changes in preserved urine

becomes darker, turbidity increases, foul smelling, pH increases

-Glucose, ketones, bilirubin, and urobilinogen decrease

-Nitrites and bacteria increase

-RBCs lyse

-WBCs and casts disintegrate

Color: Straw to amber

light to dark yellow, considered normal

Color: Red, dark brown

found with excessive hemoglobin, RBC, myoglobin

-menses, UTI, malignancy, prostate

Color: smokey, red, pink, brown

blood

-smoky is yellow urine and red blood

-beets can make it red or pink

Color: orange

dehydration from fever, vomiting, certain foods (rhubarb. vitamin C, carrots), medications

Colorless

Diabetes insipidus or overhydration associated with low SpG

diabetes insipidus is associated with decreased pituitary ADH

Brownish yellow/green

found with liver problems → check bilirubin and urobilinogen

may also be referred to as dark yellow, may se jaundice of the skin and sclera and other findings possible for hepatitis/liver disease (SGOT, SGPT, RUQ pain)

Milk

associated with hyperlipidemia (risk factor for heart disease)

Turbidity: Clear is normal when held up to the light

1.) slightly hazy: usually normal (check sediment, if negative then it is insignificant)

2.) need to microscopically look at urinary sediment

3.) urine sediment contributes to turbidity

Turbidity: Cloudy

if associated with crystals usually insignificant, although may be pus, bacteria, RBCs, spermatozoa

-due to infection

Specific gravity

1.) evaluates kidneys ability to concentrate the urine, inability to concentrate the urine can be an early sign of renal disease

2.) 1.015-1.035 is normal range in adult

3.) weight of urine compared to distilled water (specific gravity of water is 1.000)

4.) urinometer/refractometer of dipstick

hyposthenuria

low specific gravity

Hypersthenuria

high SpG

isosthenuria

fixed SpG at 1.010 same as protein free plasma and signifies the end stage of renal failure

Sugar and protein are

heavy molecules

Increased specific gravity

1.) indicated a concentrated urine (proteinuria, glucosuria)

2.) dehydration (fever, vomiting, diarrhea)

3.) Decreased renal blood flow (heart failure, renal artery stenosis)

Decreased specific gravity → indicates dilute urine

1.) decreased concentration, overhydration (polyuria, blood casts)

2.) pyelonephritis, diabetes insipidus, renal failure

Odor: not reported unless abnormal

1.) diabetes mellitus/ketosis: fruity, sweet

2.) asparagus, enterobladder fistula: feces odor

Urinalysis chemical characteristics

substances present in excess amounts are filtered through the kidney and appear in the urine

-dipsticks are utilized, a plastic strip with pads impregnated with various chemicals

-precise timing is essential

pH

indicates the acid-base balance of the pt → often an indicator of renal or lung disease

-pH hormonal range is 4.5-7.5

Acidic pH

1.) <7 → diets high in animal products and cranberries

2.) respiratory acidosis (emphysema), metabolic acidosis (sugars…diabetic ketoacidosis)

3.) diabetes mellitus, associated with xanthine, cysteine, uric acid stones

3.) should be kept alkaline

Neutral pH

7

Alkaline pH

1.) >7

2.) diets high in citrus fruits and veggies, respiratory alkalosis (hyperventilation)

3.) Metabolic alkalosis

4.) UTI (e. coli, bacillus proteus)

5.) associated with calcium carbonate, calcium and magnesium phosphate stones and should be kept acidic

6.) helpful in identifying crystals

Urine becomes alkaline as it stands due to

bacterial growth and breakdown of urea

blood pH 7.35-7.45 (more critical)

Changes in pH may first appear in urine and it maintains normal pH primarily through reabsorption of sodium and secretion of hydrogen and ammonium ions

Protein/albumin (1/3 is albumin) (1)

1.) white and frothy urine, reported as negative, trace (1+, 2+, 3+, 4+)

2.) normal is negative although it is normal to excrete some, however negative implies non-measurable (trace amounts 150mg/day)

3.) albuminuria is used synonymously with proteinuria

4.) normally the glomerulus prevents proteins entering the glomerular filtrate

5.) ALWAYS investigate proteinuria since it may be primary indicator of renal disease

Protein/albumin (2)

1.) Screening test is the dipstick → positive needs to be confirmed with SSA

2.) centrifuge the urine, heavy stuff (WBC, RBC) to the bottom, fluid above

3.) SSA sulfosalicylic acid (3%) detects all proteins (stay suspended)

4.) glomerular filter is leaking proteins

Protein/albumin (3)

1.) tech checks for amount of turbidity, proteinuria because of kidney disease usually indicates an upper UTI/UUT problem

2.) diabetes (affects kidneys, proteins can leak)

3.) glomerulonephritis, nephrotic syndrome, preeclampsia

4.) trauma, strenuous exercise (physiological proteinuria) → do not take lightly may be a sign of early renal disease, if in doubt rerun UA

5.) exposure to cold, large abdomen, pregnancy increases abdominal pressure

6.) dehydration, febrile illness

Orthostatic proteinuria

1.) normal urine when supine and displays proteinuria when standing → lie down for 1 hour and recheck urine

2.) may be associated with exaggerated lumbar lordosis (renal congestion)

Preeclampsia

1.) toxemia associated with pregnancy especially 3rd trimester

2.) proteinuria and increased BP are associated signs if mild

3.) may become severe with headache, visual changes, liver enlargement, severe proteinuria, intrauterine growth retardation, convulsions, coma

Heart conditions

1.) cardiac enzymes present on UA → CNS lesions, blood disorders, drug therapy, systemic disorders (diabetes), collagen disease (systemic lupus, scleroderma), septicemia (microorganism in blood)

Nephrotic syndrome

1.) massive proteinuria that shows up 4+ protein, losing large amounts of protein (several grams a day)

2.) severe edema around eyes, associated with toxins, bee stings, severe infections and polycystic kidney

Bence Jones Proteins → should be run on all patients with 4+ protein

1.) should be considered when the following are suspected

-multiple myeloma (50-80%) chief complaint is usually back pain, may have lytic changes (rain drop skull)

Multiple myeloma

malignant proliferation of plasma cells (B lymphocytes)

more common in older population and are at risk of fx from weakened bones

Immunoglobulins

2 long (heavy) chains and 2 shorter (light) chains

sometimes kidneys excrete pieces of the M protein into the urine (part of light chain)

-Not detected by routine UA (needs boil, chemicals, electrophoresis or immunoelectrophoresis)

Urine protein electrophoresis (UPEP) and urine Immunofixation

test for monoclonal immunoglobulin in urine

Immunoglobulins (2)

Lymphomas, leukemia

urinary erection of increased amount of kappa or lambda light chains → suggestive of positive sulfosalicylic acid test with negative dipstick test, presence of globulins

Nausea, confusion, polyuria

hypercalcemia renal insufficiency

Fatigue

anemia and renal insufficiency

Bone pain

boney lysis and pathological fx

Bleeding

thrombocytopenia

infections

immune deficiency

Neurological complaints

pathological fx

Confusion, dizziness, blurred vision

hyperviscosity

patient with suspected multiple myeloma needs

a 24 hours urinalysis with protein electrophoresis to determine the presence of bence jones proteinuria

CRAB

calcium (elevated)

renal failure/dysfunction

anemia

bone lesions

Looks like lytic mets

bone scan for hot spots → MRI → biopsy

Looks like MM

PEP (urine and blood) for M spike → skeletal survey → MRI → Biopsy >10% plasma cells

bone scan is not indicated with MM

Immunization electrophoresis

1.) usually ordered when PEP shows the presence of abnormal protein band that may be immunoglobulin

2.) when MM is suspected, it is important to test for the M protein in both serum and urine by PEP and immunofixation

Urinalysis chemical characteristics

1.) Dipstick test is qualitative for glucose

2.) Clinitest is a confirmation test (quantitative) for any reducing sugar glucose, fructose, galactose (not typically done) 

3.) If positive, need a fasting blood sugar (FBS), and correlate to history (family history, overweight, >40, polyuria, polydipsia, etc)

Sugar/Glucose (1)

1.) glucose is filtered by glomeruli and reabsorbed in proximal tubules

2.) Renal threshold value (RTV) or blood threshold value (BTV) beyond the threshold glucose spills over into the urine (glycosuria or glucosuria)

3.) 140-180 mg/dl is RTV

4.) Diabetics may demonstrate a higher than normal RTV (maybe 220-240)

Sugar/glucose (2)

1.) Glycosuria is not always abnormal and may be seen immediately after eating a high carbohydrate meal 

-May also be seen with kidney disease affecting the renal tubules which may lower RTV (renal glycosuria), Diabetes mellitus (classic), Endocrine disorders (acromegaly)

-Pancreatic problems (tumor, pancreatitis), Adrenal disorders (Cushing's syndrome), Hyperthyroidism (oily hair/skin, inc B/P hyperactivity, increase metabolism)

-Pregnancy (gestational diabetes), Stress (fight or flight), CNS disorders, tumor, hemorrhage, stroke

-Disturbances of metabolism such as burns, infections, MI, obesity, Liver disease, Exercise, Certain drugs

Ketones

1.) due to lack of available sugar getting to the cells due to lack of insulin

2.) byproduct of fat metabolism, reported as negative, trace, small, moderate or large amounts (1+, 2+, 3+, 4+

3.) negative is normal

Ketones (2)

1.) acetone, beta hydroxybutryic acid, acetoacetic acid

2.) usually associated with poorly controlled diabetes mellitus and may warn of impending diabetic coma, fasting and starvation

3.) low carb/high protein diet start the body of carbs and ketones from fat storage are broken down

4.) dehydration (nausea, vomiting), electrolytic imbalance, alcoholism, babies and children with fever

Diabetic patients

Ketonuria suggests inadequately controlled disease

Nondiabetic patient

ketonuria suggests reduced carb metabolism and excessive fat metabolism

Diabetes mellitus positive labs

ketones and sugars, possible fruity odor of urine