Interpretation of information from

clinical pathology

Hartono
Clinical Pathology Department Medicine Faculty
Airlangga University-Soetomo Hospital
Surabaya 2017

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 Laboratory Report steps
Laboratory
Patient
Request
Preanalytic preparation
Specimen Specimen
Collection handling

Analysis / Analytic Internal

Equipments Quaity
control/
Laboratory calibration
Result

References Interferens
value Clinical
Validation symp/sign

Laboratory Postanalytic
Report

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 Specimen collection procedures
Capillary Puncture (Skin Puncture)
Newborn, Infant
POCT
Venipuncture
All of Laboratory test
Arterial Puncture
Blood gass analysis

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 Procedural Alert for Capillary
Puncture (Skin Puncture)
Do not squeeze the site cause alter the
blood composition and invalidates test values.
Warming the extremity or placing it in a
dependent position promote the specimen
collection.

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 Clinical Alert for Venipuncture

Never draw blood (venipuncture):

same extremity being used for IV medications,
fluids, or transfusions.
No site is available, make sure the venipuncture
site is below the IV site.
Avoid areas that are edematous, are paralyzed,
are on the same side as a mastectomy, or skin
condition (infection).

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 Clinical Alert for Arterial Puncture

Normal body temperature (37C), blood gass

value alter quickly (PaO2)
Specimen for BGA (0C/Iced) should stable for
at least 1 hour
Specimen not placed in ice should be tested
within minutes after it is drawn, because of it
decreases PO2.
Leukemia (WBC > 100.000/uL), running
specimen immediatelydecrease PO2
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COMPLETE BLOOD COUNT

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Complete Blood Count

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 Interfering Factors
RBCs (Red Blood Cells)
physiologic variants affect outcomes:
posture,
exercise,
age,
altitude,
pregnancy, and
many drugs.

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 HCT

Hematocrit (HCT)
Physiologic variants affect Hct outcomes:
age,
sex,
and physiologic hydremia of pregnancy

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 HGb

Hemoglobin
Physiologic variations affect test outcomes:
high altitude,
excessive fluid intake,
age, pregnancy, and
many drugs

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 MCHC

MCHC
High values may occur in newborns and infants.
Presence of leukemia or cold agglutinins may
increase levels.
MCHC is falsely elevated with a high blood
concentration of heparin.

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 WBC

WBC Count
Hourly variation,
age,
exercise,
pain,
temperature, and
anesthesia affect test results.

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 Neu and Eo

Neutrophils and Eosinophils

Physiologic conditions: as stress, excitement, exercise,
and obstetric labor increase neutrophil.
The eosinophil count is lowest in the morning and
then rises from noon until after midnight Do repeat
tests at the same time every day.
Stressful states such as burns, postoperative states
decrease the count.
Drugs such as steroids, epinephrine, and thyroxine
affect eosinophil levels.

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 PLT

Platelets
Physiologic factors include high altitudes,
strenuous exercise,
excitement, and
premenstrual and
postpartum effects.
A partially clotted blood specimen affects the test
outcome.

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NORMAL

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MIKROSITOSIS (ANEMIA DEF. BESI)

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MAKROSITOSIS (ANEMIA MEGALOBLASTIK)

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EOSINOPHILIA

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BASOPHILIA

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PANCYTOPENIA

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40

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40

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COAGULATION TEST

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 aPTT
aPTT:
Detect deficiencies in the intrinsic coagulation system
Monitor heparin therapy part of a coagulation panel
workup

Reference Values Normal

aPTT: 21.035.0 seconds
Therapeutic range values (heparin therapy): 22.5 x
normal.

Critical Value: aPTT> 70 seconds spontaneous bleeding

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 Coagulation test (aPTT)
Prolonged aPTT :
Congenital deficiencies of intrinsic system coagulation
factors, hemophilia A and hemophilia B
Congenital deficiency of Fitzgeralds factor, Fletchers
factor (prekallikrein)
Heparin therapy, streptokinase, urokinase
Warfarin (Coumadin)-like therapy
Vitamin K deficiency
Hypofibrinogenemia
Liver disease
DIC (chronic or acute)

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 aPTTcont
Shortened aPTT:
Extensive cancer
Immediately after acute hemorrhage
Very early stages of DIC

Interfering Factors
Hemolyzed plasma shortens aPTT
Very increased or decreased Hct
Incorrect ratio of blood to citrate (1:9)

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 PT
PT:
Directly measures extrinsic coagulation system
Analysis of the clotting ability : prothrombin,
fibrinogen, factor V, factor VII, and factor X.
PT is used to evaluate dysfibrinogenemia, the
heparin effect and coumarin effect, liver failure,
and vitamin K deficiency.
Reference Values Normal PT: 11.013.0 seconds (can
vary by laboratory)

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 aPTT and PT
a normal PT and an abnormal aPTT: the
defect lies within the first stage of the clotting
cascade (factor VIII, IX, X, XI, or XII).
a normal PTT with an abnormal PT: a possible
factor VII deficiency.
PT and aPTT are prolonged, a deficiency of
factor I, II, V, or X is suggested.
Used together, aPTT and PT will detect
approximately 95% of coagulation defects.
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URINALYSIS

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 Urine Specific Gravity (SG)
Specific gravity (SG) is a measurement of the
kidneys ability to concentrate urine
Reference Values Normal
Normal hydration and volume: 1.0051.030
(usually between 1.010 and 1.025)
Concentrated urine: 1.025
Dilute urine: 1.0011.010
Infant 2 years old: 1.0011.006

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 Cont

Normal SG:
SG values usually vary inversely with the
amount of urine excreted decreased urine
volume increased SG.
The relationship is not valid in certain conditions:
Diabetesincreased urine volume, increased SG
Hypertensionnormal volume, decreased SG
Early chronic renal diseaseincreased volume,
decreased SG

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 Cont
Hyposthenuria (low SG, 1.001 to 1.010):
Diabetes insipidus (low SG with large urine
volume)
Glomerulonephritis and pyelonephritis
Severe renal damage with disturbance of both
concentrating and diluting abilities of urine The
SG is low (1.010) and fixed (varying little from
specimen to specimen) isosthenuria

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 Cont

Hypersthenuria (increased SG, 1.025 to 1.035)

occurs in the following conditions:
Diabetes mellitus
Nephrosis
Excessive water loss (dehydration, fever, vomiting,
diarrhea)
Increased secretion of ADH and diuretic effects related
to the stress of a surgical procedure
Congestive heart failure
Toxemia of pregnancy

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 Urine pH
The pH is an indicator of the renal tubules ability
to maintain normal hydrogen ion concentration in
the plasma and extracellular fluid
Urine increasingly acidic: sodium and excess acid
retained by the body increases.
Alkaline urine: bicarbonate-carbonic .

Reference Values Normal

The pH of normal urine can vary widely, from 4.6
to 8.0 average pH 6.0 (acidic).

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 Clinical Implications
Acidic urine (pH 7.0) occurs in:
Metabolic acidosis, diabetic ketosis, diarrhea, starvation, uremia
UTIs caused by Escherichia coli
Respiratory acidosis (carbon dioxide retention)
Renal tuberculosis
Pyrexia

Alkaline urine (pH 7.0) occurs in:

UTIs caused by urea-splitting bacteria ( Proteus and Pseudomonas )
Renal tubular acidosis, chronic renal failure
Metabolic acidosis (vomiting)
Respiratory alkalosis involving hyperventilation (blowing off carbon
dioxide)
Potassium depletion

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 Urine Blood or Hemoglobin

Reference Values Normal

Negative ( 0.03 mg free Hb/dL or 10 Ercs/ L)

Clinical Implications Hematuria is found in:

Acute UTI (cystitis)
Lupus nephritis
Urinary tract or renal tumors
Urinary calculi (intermittent hematuria)
Malignant hypertension
Glomerulonephritis (acute or chronic)

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 Clinical Implications Hemoglobinuria

a. Extensive burns
b. Transfusion reactions (incompatible blood products)
C. Malaria
f. Bleeding resulting from operative procedures on the prostate
g. Hemolytic disorders: sickle cell anemia, thalassemia, and glucose-6-
phosphate dehydrogenase deficiency
h. Paroxysmal hemoglobinuria
j. Hemolysis occurring while the urine is in the urinary tract (RBC lysis from
hypotonic urine or alkaline urine)
K. Disseminated intravascular coagulation (DIC)
m. Strenuous exercise (march hemoglobinuria)

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 Interfering Factors
1. Drugs causing a positive result for blood or hemoglobin include:
a. Drugs toxic to the kidneys (e.g., bacitracin, amphotericin)
b. Drugs alter blood clotting (warfarin [Coumadin])
c. Drugs that cause hemolysis of RBCs (aspirin)
d. Drugs a false-positive result (bromides, copper, iodides,
oxidizing agents)
2. High doses of ascorbic acid or vitamin Ca false-negative result.
3. High SG or elevated protein reduces sensitivity.
4. Myoglobin produces a false-positive result.
5. Hypochlorites or bleach used to clean urine containers false-
positive results.
6. Menstrual blood contaminate the specimenalter results.
7. Prostatic infections may cause false-positive results.

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Reference Values Normal

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Urinalysis using dipstick

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 Urine Glucose (Sugar)

Reference Values Normal

Random specimen: Negative
24-hour specimen: 115 mg/dL (60830
mol/L) or 0.5 g/24 hours ( 2.8 mmol/day)

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 Clinical Implications
Increased glucose occurs in:
Diabetes mellitus
Endocrine disorders (thyrotoxicosis, Cushings
syndrome, acromegaly)
Liver and pancreatic disease
Central nervous system disorders (brain injury, stroke)
Impaired tubular reabsorption
Advanced renal tubular disease
Pregnancy with possible latent diabetes (gestational
diabetes)

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 Cont
Increase of other sugars (react only with
reduction tests, not dipstick tests):
Lactosepregnancy, lactation, lactose intolerance
Galactosehereditary galactosuria (severe
enzyme deficiency in infants; must be treated
promptly)
Xyloseexcessive ingestion of fruit
Fructosehereditary fructose intolerance, hepatic
disorders
Pentosecertain drug therapies and rare
hereditary conditions
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 Interfering Factors
1. Interfering factors for reduction test (false-positive results):
a. Presence of nonsugar-reducing substances such as ascorbic acid, homogentisic
acid,creatinine
b. Tyrosine
c. Nalidixic acid, cephalosporins, probenecid, and penicillin
d. Large amounts of urine protein (slows reaction)
2. Interfering factors for dipstick enzyme tests:
a. Ascorbic acid (in large amounts) may cause a false-negative result.
b. Large amount of ketones may cause a false-negative result.
c. Peroxide or strong oxidizing agents may cause a false-positive result.
3. Stress, excitement, myocardial infarction, testing after a heavy meal, and
testing soon after the administration of intravenous glucose false-
positive results or most frequently trace reactions.
4. Contamination of the urine sample with bleach or hydrogen peroxide
invalidate results.
5. False-negative urine is left to sit at room temperature for an extended
period.

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 Urine Ketones (Acetone; Ketone Bodies)
Indications for Ketone Testing
1. General: Screening for ketonuria hospitalized patients, presurgical
patients,pregnant women, children, and persons with diabetes.
2. Glycosuria (diabetes):
a. Testing for ketones indicated in any patient elevated urine and blood
sugars.
b. Treatmentswitched from insulin to oral hypoglycemic agents ketonuria
within 24 hours after withdrawal of insulin--_indicates a poor response
c. Ketone testingdifferentiate between diabetic comapositive ketones and
insulin shocknegative ketones.
3. Acidosis:
a. Ketone testing used to judge the severity of acidosis response to
treatment.
b. Urine ketone measurement frequently provides a more reliable indicator of
acidosis than blood testing (emergency situations).
c. Ketones appear in the urine before there is any significant increase of ketones in
the blood.
4. Pregnancy: During pregnancy, the early detection of ketones is essential because
ketoacidosis is a prominent factor

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 Clinical Implications

a. Metabolic conditions
(1) Diabetes mellitus (diabetic acidosis)
(2) Renal glycosuria
(3) Glycogen storage disease (von Gierkes disease)

b. Dietary conditions
(1) Starvation, fasting
(2) High-fat diets
(3) Prolonged vomiting, diarrhea
(4) Anorexia
(5) Low-carbohydrate diet
(6) Eclampsia

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 Clinical Implications
c. Increased metabolic states caused by:
(1) Hyperthyroidism
(2) Fever
(3) Pregnancy or lactation

d. Nondiabetic persons ketonuria frequently during acute illness, severe

stress, or strenuous exercise.
e. 15% of hospitalized patients ketones in their urine
f. Ketonuria occurs after anesthesia (ether or chloroform).

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 Interfering Factors
1. Drugs false-positive result:
a. Levodopa
b. Phenothiazines
c. Ether
d. Insulin
e. Isopropyl alcohol
f. Metformin
g. Penicillamine
h. Phenazopyridine (Pyridium)
i. Captopril
2. False-negative resultsurine stands too long

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 Clinical Implications
1. Under the light microscope, the presence of 20 bacteria per
high-power field (hpf) indicate a UTI.
2. A positive nitrite test bacteriuria performing urine
culture.
4. A negative result should never be interpreted as indicating
absence of bacteriuria
a. may not have been enough time the nitrate to convert to
nitrite in the bladder.
b. Some UTIs caused by organisms that do not convert nitrate
to nitrite (e.g., staphylococci,streptococci).

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 Interfering Factors
1. False-positive results
a. Vaginal discharge, parasites, histocytes
b. Drug therapies (e.g., ampicillin, kanamycin)
c. Salicylate toxicity
d. Strenuous exercise
2. False-negative results
a. Large amounts of glucose or protein
b. High specific gravity
c. Certain drugs (e.g., tetracycline)

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 Urine Urobilinogen
Reference Values Normal
Random specimen: 0.11 Ehrlich U/dL or 1
mg/dL
2-hour specimen: 0.11.0 Ehrlich U/2 hours or
1 mg/2 hours
24-hour specimen: 0.54.0 Ehrlich U/24 hours
or 0.54.0 mg/day

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 Clinical Implications
1. Urine urobilinogen is increased:
a. Increased destruction of RBCs
(1) Hemolytic anemias
(2) Pernicious anemia (megaloblastic)
(3) Malaria

b. Hemorrhage into tissues

(1) Pulmonary infarction
(2) Excessive bruising

c. Hepatic damage
(1) Biliary disease
(2) Cirrhosis (viral and chemical)
(3) Acute hepatitis

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 Clinical Implications

2 Decreased urinary urobilinogen is associated

with:
a. Cholelithiasis
b. Severe inflammation of the biliary ducts
c. Cancer of the head of the pancreas

3. Antibiotic therapy suppression of normal gut

flora prevent the breakdown of bilirubin to
urobilinogen decreased or absent.

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 Interfering Factors
1. Drugs affect urobilinogen levels
2. Peak excretionnoon to 4:00 p.m. (1600)
diurnal variation.
3. Strongly alkaline urine higher urobilinogen
level and strongly acidic urine lower
urobilinogen level.
4. Drugs cause hemolysis increased
urobilinogen
5. Urine is highly colored the strip will be
difficult to read.
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