Clinical Pathology

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CLINICAL PATHOLOGY INSIDE     

Blood glucose report Kidney function report Liver function report Blood report Urine report

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Blood glucose report Fasting blood glucose Normal Diabetes milletus

70-110 mg/dl 126 mg/dl

2 hours postprandial blood glucose Up to 120 mg/dl >200 mg/dl

Glucose tolerance curve

250 200 150

renal threshold normal

100

diabetic

50 diabetic normal

0

renal threshold 2 hours

In diabetic: ascends above 200 mg/dl after meal & descends slowly but not to normal value

N.B - No impaired glucose tolerance (‫)مش هيجيلك‬ - No D.D , only say o o

D.M Normal blood glucose

-Take rapid look on glucose tolerance curve

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kidney function report Normal kidney function Normal 0.4-1.4 mg/dl Normal 15-45 mg/dl

Serum creatinine level Blood urea level

Renal failue High High

D.D if you find  

One value is high The other is normal

High serum creatinine Prerenal causes(only one value is elevated)

    

Renal causes(both values are elevated)

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 Post renal causes(both values are elevated)

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Subject with large muscle mass High protein intake Transient increase after vigorous exercise Using non-specific analytical methods Some drugs as o Salicylates o Cimetedine

High blood urea 

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Decreased renal perfusion o Shock o Haemorrhage o Burns o Severe vomiting o Congestive heart failure After high protein diet Increased protein catabolism o Trauma o Major surgery o Extreme starvation o Haemorrhage into GIT

Impaired renal perfusion o Reduced blood o Fluid depletion o Renal artery stenosis Diseases lead to loss of functioning nephrons o Acute glomerulonephritis o Chronic glomerulonephritis Urinary tract obstruction o Enlarged prostate o Stones or casts

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Liver function tests Normal total bilirubin level : 0.3-1 mg% Jaundice

Direct bilirubin (up to 0.2 mg%) Indirect bilirubib (up to 0.8 mg%) Alkaline phosphatase (3-13 KAU) SGPT(ALT) (5-30 U/L) SGOT(AST) (8-40 U/L) Albumin (4-5 gm%)

Haemolytic −

Hepatocellular ↑

Obstructive ↑

↑

↑

−

−

−

↑

−

↑

−

−

↑

−

−

↓

−

D.D of hypoalbuminemia (with chronic diseases only) 

 



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Decreased intake o Malnutrition o Malabsorption Decreased synthesis o Severe liver failure Increased loss o Nephritic syndrome o Severe burn Increased catabolism o Infection o Thyrotoxicosis o Cushing syndrome Haemodilution o Late stages of pregnancy o During I.V therapy

Increased With acute diseases

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Total protein Normal 6-8 gm%

Decreased With chronic diseases

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D.D of hyperproteinemia  Dehydration  Artifactual(staisis during venepuncture)  Paraproteinemia→ multiple myeloma  Chronic diseases (immunoglobulins)  Liver cirrhosis  Autoimmune diseases

D.D of hypoproteinemia  Over hydration  Artifactual(drip arm)  Excessive protein loss o Nephritic syndrome o Severe burns  Decreased synthesis o Protein deficiency o Liver disease o malabsorption

Summary ↑direct bilirubin + ↑alkaline phosphatase = obstructive jaundice ↑direct & indirect bilirubin + ↑ALT,AST + ↓albumin = hepatocellular jaundice only abnormality in protein - ↑total protein →D.D of hyperprotenemia - ↓total protein →D.D of hypoprotenemia - ↓total albumin →D.D of hypoalbuminemia

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Blood report Includes o Type of anemia o D.D o Investigations required 1- type

if Hb is decreased : anemia microcyic hypochromic

↓MCH

↓MCV

normocytic normochromic

macrocytic normochromic

normal MCH

↑MCH

normal MCV

↑MCV

Microcytic hypochromic anemia

Normal reticulocytic count

Reticulocytosis

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Microcytic hypochromic anemia D.D  Iron deficiency anemia  Anemia of chronic disease  Sideroblastic anemia



Thalassemia

Investigations  Serum iron  Total iron binding capacity  Serum ferritin  Transferring saturation  Iron store  Serum soluble transferrin receptor  Serum indirecr bilirubin  Serum LDH  Serum haptoglobin  Direct Coomb’s test  Osmotic fragility

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Hb electrophoresis

Macrocytic normochromic anemia Macrocytic normochromic anemia D.D With thrombocytopenia and leucopenia(pancytopenia)

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Megaloblastic anemia o ↓Vit. B12 o ↓folate

Normal thrombocytic & leucocytic count

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Macrocytic Non megaloblastic anemia due to: o Haemolytic anemia & post haemorrhagic anemia (reticulocytosis) o Anemia due to bone marrow infiltration or replacement:  Myelosclerosis  2ry carcinoma of bone  Multiple myeloma  Malignant lymphoma o Leukemia especially acute o Liver disease o scurvy o myxoedema & hypopituitarism

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Investigations Serum B12 Serum folate RBCs folate Schilling test

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Normocytic normochromic anemia

normocytic normochromic anemia

reticulocytic count

reticulocytosi s

WBCs & platelets

pancytopenia

chronic haemolytic anemia

normail reticulocytic count

reticulocytop enia

aplastic anemia

↑WBC

pancytopenia

↓platelets

normocytic normochromic anemia, leucocy -tosis & thrombocytopenia

aplastic anemia BM infiltration preleukemia hyper splenism

Investigations -

Pancytopenia→ BM aspiration Thalassemia → mentioned before Normocytic normochromic anemia , leucocytosis & thrombocytopenia  According to differencial leukocytic count Blast cells

D.D

Acute lymphoblastic leukemia(ALL)

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↑Basophils ↑Myelocytes ↑Segmented cells ↑Metamyelocytes Chronic myeloid leukemia(CML)

↑lymphocytes

Chronic lymphocytic leukemia

Medicalexcel.com Acute myeloblastic leukemia(AML) B.M aspiration Cytochemistry Immunephenotyping Cytogenetics

Investigations

Lymphoma B.M aspiration NAP score Philadelphia chromosome

Urine report 1- volume normally: 600-2400 cc/day increased → polyurea due to o

drugs  caffeine  alcohol  thiazide diuretics o pathologic  D.M  Diabetes incipidus  Chronic renal failure Decreased →oligurea due to o Dehydration (severe diarrhea or vomiting) o Renal ischemia (heart failure, shock) o Oligurea stage of chronic nephritis o Acute tubular necrosis o Acute glomerulonephritis o Obstruction of urinary tract : may lead to anurea

2- Aspect Normally: clear and yellow or transparent Turbid urine due to o o o o o

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Phosphate precipitation Urate precipitation Presence of pus cells Bacterial growth Mucus

B.M aspiration L.N biopsy

Medicalexcel.com o o

Red cells Chylurea

3- Colour Normally: amber yellow (urobilin & uroerythrin, small amount) Abnormal may be: o Watery o Diabetes incipidus o Diuretics o Excess fluid intake o Red urine o After eating beets o Haemoglobinurea o Haematurea o Porphrinurea o Yellow brown or green brown o Bile pigment (as obestructivejaundice) o Orange red o Excess urobilin →oxidized →urobilinogen o Dark brown or black urine o Alkaptonurea o Melanurea o Drugs o Milk urine o Presence of lymph and chylmicrons(due to rupture of lymphatics into urinary tract) o Foamy (frothy) urine o Proteinurea o Bile salts o Concentrated urine o haematurea

Drugs that change the color of urine Drugs causing dark brown urine o o o o o

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2m methyldopa , metronidazole 2n nitrate , nitrofurantoin F ferrous salts S sulphonamides C chloroquine

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Q quinine

Drugs causing blue- blue green urine o o o

2m methylene blue , methocarbamol Amitryptylene Triametrine

Drugs causing red – pink urine o o o o

3p phenothiazine , Phenylbutazone , Phenytoin Salicylates Rifampicin Heparin

4- Sugar Normally very small amount of glucose Sugar in urine Glucosurea Indicates : o Presence of glucose in urine o Its serum level is > 180 mg/dl (renal threshold) If fructose , pentose , galactose & lactose are present o D.M o certain poisons: CO , morphine o increased ingestion of sugar or carbohydrates (aliemientary glucosurea) renal glucosurea o glucose in urine o normal bl. Glucose level o due to incomplete reabsorption of glucose by renal tubules

5- protein normally < 150 mg/day proteinurea orthostatic (postural) o

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increased by upright position

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recumbency (urine of early morning)

functional (transient) o o o o o

fevers severe exercise heat stroke severe cold atmosphere congestive heart failure

disease of the kidney o o o o

acute & chronic glomerulonephritis nephritic syndrome pyelonephritis miscellaneous o renal TB o tumours

diseases of urinary tract o o

calculi infection

6- specific gravity normally : 1015 -1025 increased in o D.M o Nephritic syndrome Decreased in o 1010→ renal failure o Other→ diabetes incipidis

7- RBCs Normally: o In male→ 0-3/hpf o In female→ 1-5/hpf Increased in: o Trauma o Pyelonephritis

8- Pus cells (WBCs) Normally : 0-4/hpf

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Medicalexcel.com Increased in o Urinary Tract infection o TB o Renal tumours o Acute glomerulonephritis o Interstitial nephritis o Analgesic abuse o Steril pyorea o TB o Analgesic nephropathy o Interstitial nephritis o Nonspecific inflammation of the bladder

9- Casts Hyaline casts o Benign hypertension o Nephritic syndrome o After exercise Red cell casts o Acute glomerulonephritis o Lupus nephritis o Subacute bacterial endocarditis o Good pasture’s disease (immune disease of the kidney) o After streptococcal infection o Malignant hypertension WBCs casts o Pyelonephritis Epithelial casts o Tubular damage o Nephrotoxins o Viraemia Granular casts o Acute tubular necrosis Waxy casts o Severe chronic disease o Amyloidosis Fatty casts o Nephritic syndrome o D.M

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