Unit 4. Physical Examination of Urine

10-15 ml

In the lab, how many mL of urine sample is used for physical exam?

400 RCF

4 mins

0.5-1 ml

To concentrate formed elements in the urine, centrifuge the urine sample at ____ for ___, then decant the supernatant, only leaving ____ of sediment.

20 µL

How many urine sample is needed for microscopic exam?

• Color

• Clarity

• Specific gravity

• pH (actually under chemical exam)

• Odor (not actually part of the exam, but is clinically helpful)

Parameters under Physical Exam

PHYSICAL EXAMINATION

through investigation and documentation of urine’s physical characteristics

a crucial step in routine analysis procedure; provides preliminary information about the patient’s health status

confirm/explain findings in the chemical and microscopic exams

hydration status.

The urine volume of a certain person reflects his/her _

600-2000 ml

Normal urine volume excreted by a healthy adult in a day

• fluid intake,

• fluid loss from nonrenal sources,

• variations in ADH and

• necessity to excrete dissolved substance.

Enumerate several factors that affect urine volume.

T

T or F

When the body loses more water through sweat, the kidneys conserve water by producing less urine to maintain the body's fluid balance.

↑ Sweating = ↓ Urination

_ Sweating = _ Urination

↑ Hydration = ↓ ADH production

_ Hydration = _ ADH production

150 mL

_ of blood enter the tubule within 24 hrs

2 liters

From 150 mL of water > Tubular reabsorption > only ___ of urine is produced

Glycosuria = presence of glucose in urine

Mellituria = presence of other reducing sugars in urine

Glycosuria vs. Mellituria

Hyperglycemia-Associated Glycosuria

• ↑ glucose in blood/plasma (renal threshold met)

• normal, functional kidneys

• need to excrete glucose thru urination

Renal-associated glycosuria

• ↑ glucose in urine

• glucose leaks from the GFB

• abnormal, nonfunctional kidneys

Differentiate Hyperglycemia-Associated Glycosuria from Renal-associated glycosuria

• Hyperglycemia-Associated Glycosuria = (+) glucose (-) proteins

• Renal-associated glycosuria = (+) glucose (+) proteins

• Hyperglycemia-Associated Glycosuria = __ glucose __ proteins

• Renal-associated glycosuria = __ glucose __ proteins

Oliguria

It is related to an abnormal decrease in urine output.

It is always accompanied by hypersthenuria (1.030).

a. state of hydration as a result of excessive water loss from vomiting, diarrhea, perspiration, severe burns

b. obstruction due to renal calculi (renal stones) & tumor of the kidney (carcinomas)

Oliguria can be due to?

Infants: < 1ml/kg/hr

Urine output of infants experiencing Oliguria

Children: <0.5 ml/kg/hr

Urine output of children experiencing Oliguria

Adults: <400 ml/day

Urine output of adults experiencing Oliguria

ANURIA

cessation of urine flow

any serious damage to the kidneys, or from a decrease in the flow of blood to the kidneys

• End stage renal disease

• functional nephrons are gone/depleted

complete obstruction (renal stones, carcinoma)

toxic agents

Nocturia

It is related to the excretion of more than 500 ml urine at night.

always accompanied by isosthenuria or low urine specific gravity which indicates loss of concentrating ability of the tubules.

diabetes mellitus & diabetes insipidus

Nocturia & Polyuria is a common symptom assoc. with __ and __

Polyuria

increase in daily urine volume

It is because of persistent production of more than 2000-3000ml of urine in 24 hours.

ADH

Polyuria may be induced artificially by diuretics, caffeine, or alcohol which suppress __

Children: >3 ml/kg/day

Urine output of children experiencing Oliguria

Adults: >2.5 L/day

Urine output of adults experiencing Polyuria

elevated (abnormal)

HbA1c

If FBS is __, the nephrologist may request _ to confirm DIABETES MELLITUS.

normal

Total Prostate-Specific Antigen (PSA)

If FBS is _, the nephrologist may request _ to confirm PROSTATITIS.

Urine odor

• not routinely reported in the lab

• should be notified to the attending physicians for consideration of metabolic disorders or aminoaciduria

aromatic

Normal urine odor

Bacterial decomposition

Urinary Tract Infection (UTI)

Cause of urine odor that is Foul, ammonia-like

Ketones (diabetes mellitus, starvation, vomiting)

Cause of urine odor that is Fruity, sweet

Maple syrup urine disease

Cause of urine odor that is Maple syrup, Burnt sugar

Phenylketonuria

Cause of urine odor that is Mousy

Tyrosinemia

Cause of urine odor that is Rancid

Isovaleric/Glutaric acidemia

Cause of urine odor that is Sweaty feet

Methionine malabsorption

Cause of urine odor that is Cabbage, Hops

Contamination

Cause of urine odor that is Bleach

Trimethylaminuria

Cause of urine odor that is Rotten fish

Hawkinsinuria

Cause of urine odor that is Chlorine, swimming pool

Cystinuria

Cause of urine odor that is Rotten egg, sulfur-like

Urine color

one parameter used in urinalysis to predict urine concentration and probable dissolved substances present in it

a. Normal metabolic functions

b. Physical activity

c. Ingested materials

d. Pathologic condition

e. Abnormal variations caused by bleeding

f. Liver disease g. Infection

Normal variations in urine color are caused by:

1. Urochrome

2. Uroerythrin

3. Urobilin

3 URINE PIGMENTS

urochrome

3 URINE PIGMENTS

• product of endogenous metabolism, and under normal conditions, the body produces it at a constant rate

urochrome

3 URINE PIGMENTS

• gives the normal yellow coloration of urine

• provides an estimate of body hydration

• thyroid conditions

• fasting states

• standing at room temp

Urochrome is increased in what conditions

Uroerythrin

3 URINE PIGMENTS

• a pink pigment, is most evident in specimens that have been refrigerated, resulting in the precipitation of amorphous urates in an acid urine.

Uroerythrin

3 URINE PIGMENTS

• It attaches itself on amorphous crystals’ surface creating a brick dust appearance especially on amorphous urates.

Urobilin

3 URINE PIGMENTS

• It provides orange-brown color in older (unpreserved) urine specimens.

Urobilin

3 URINE PIGMENTS

• an oxidation product of the normal urinary constituent urobilinogen.

protoporphyrins

RBC

Urobilin is a derivative of __ that come from _ catabolism

pink precipitate

white precipitate

amorphous urate = acidic = ___

amorphous phosphate = alkaline = ___

pH

• amorphous urate = acidic

• amorphous phosphate = alkaline

amorphous urate and amorphous phosphate is differentiated by __

Alkaptonuria

a metabolic disorder, most common in infants, wherein an acidic urine > alakaline > black colored urine due to homogentisic acid

phenindione

an acidic urine turning alkaline and appearing as orange is usually due to medication _

Triple phosphate crystal

coffin-lid crystal ; manila city hall crystal

(-) Chemical test for blood

(+) Watson-Schwartz screening test

A red or port-wine urine due to porphyrin/ phorphobilinogen will be negative for ___ and positive for ___

Rhabdomyolysis

breakdown of skeletal muscle fibers, causing muscle cell contents (especially myoglobin) to leak into the bloodstream.

leiomyolysis

he degeneration or dissolution (breakdown) of smooth muscle cells.

Hemoglobinuria

What disease is being described:

• red urine

• clear

• no intact RBCs (lysed)

• red plasma

myoglobinuria

What disease is being described:

• red urine

• clear

• no intact RBCs (lysed)

• clear plasma

microscopic hematuria

What disease is being described:

• red urine

• clear

• MANY intact RBCs in the microscopic exam

Macroscopic hematuria

What disease is being described:

• Red urine

• Cloudy

• MANY intact RBCs in the microscopic exam

hemoglobin

myoglobin

iron

These proteins, __ and __, are toxic to the glomerulus due to the presence of ___

Blondheim's Plasma Test (ammonium sulfate precipitation test)

a test is used to differentiate hemoglobinuria from myoglobinuria

red

golden yellow (clear)

Blondheim’s Test results

• Hemoglobinuria = __ plasma

• Myoglobinuria = __ plasma

5 mL

2.8 g ammonium sulfate

5 mins

Blondheim’s Plasma test:

__ urine sample > add _______ > incubate for ____ > centrifuge > filter > observe the color of sample/plasma

myoglobinuria

Total creatinine kinase is markedly increased in ____

hemoglobinuria

LD1 & LD2 is increased in ___

myoglobinuria

LD4 & LD5 is increased in ___

TRANSPARENCY

It pertains to the clarity or turbidity of a urine specimen

one of the criteria considered in determining the necessity of performing a microsco[pic examination

↑ Clarity/↓Turbidity = ↓ Specific Gravity

Relationship of Clarity/Turbidity with Specific gravity

Clear

CLARITY wherein there’s No visible particulates; transparent

Hazy (slightly cloudy)

CLARITY wherein there’s few particulate; print easily seen

Cloudy

CLARITY wherein there’s Many particulates; print blurred through urine

Turbid

CLARITY wherein Print cannot be seen through urine

Milky

CLARITY wherein there’s Presence of suspended solid in urine; May precipitate or be clotted

manual

If spx is cloudy/turbid use ___ method

automated

If spx is clear/hazy use ___ method

NON PATHOLOGIC TURBIDITY

Pathologic or Non-Pathologic turbidity?

Hazy female specimens with squamous epithelial cells and mucus

NON PATHOLOGIC TURBIDITY

Pathologic or Non-Pathologic turbidity?

Bacterial growth in unpreserved specimens

NON PATHOLOGIC TURBIDITY

Pathologic or Non-Pathologic turbidity?

Refrigerated specimens with precipitated amorphous phosphates and urates

NON PATHOLOGIC TURBIDITY

Pathologic or Non-Pathologic turbidity?

Contamination; fecal talc, semen, vaginal creams, IV contrast media

PATHOLOGIC TURBIDITY

Pathologic or Non-Pathologic turbidity?

RBCs, WBCs, bacteria (most common)

PATHOLOGIC TURBIDITY

Pathologic or Non-Pathologic turbidity?

Nonsquamous epithelial cells, yeast

PATHOLOGIC TURBIDITY

Pathologic or Non-Pathologic turbidity?

Abnormal crystals

PATHOLOGIC TURBIDITY

Pathologic or Non-Pathologic turbidity?

Lymph fluid

PATHOLOGIC TURBIDITY

Pathologic or Non-Pathologic turbidity?

Lipid

1.040

SG of radiographic contrast media (RCM)

Renal Tubular Epithelial (RTE) cells

cells that line the tubule of nephrons

significant cell in urinalysis

suggestive of renal disease

Elephantiasis caused by Wuchereria bancrofti

this caused the presence of lymph fluid in urine

Nephrotic Syndrome

Increased glomerular permeability → protein loss

↑ Hyperlipidemia and lipiduria

Nephritic Syndrome

Inflammation of the glomeruli → bleeding and reduced filtration

Usually normal blood lipid level

Urine pH

determined by the concentration of free H+ ion present in urine sample.

kidneys

lungs

Basically, the _ and the _work in an orchestrated manner to maintain acid - base balance in the body.

carbon dioxide

respiration

To maintain acid base balance, the lung excretes __ through _

bicarbonate

ammonium ions

To maintain acid base balance, while the kidney reclaims and generates _ and secretes _