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![Interpretation
• Blue solution – Negative
• Green color - Traces [<0.5gm/dL]
• Green ppt - + [0.5 - 1%]
• yellow ppt - ++ [1 – 1.5%]
• Orange ppt - +++ [1.5 - 2%]
• Brick red ppt - ++++ [>2.0gm/dL]
• FALSE POSITIVE TEST
– Other sugars except sucrose
– Nonsugar subs - Creatine, Uric acid, urates,
Ascorbic Acid & Glucuronides
– Drugs- Salicylates, Cephalosporins,
Streptomycin](https://image.slidesharecdn.com/urinephysicalexam-190722132436/75/examination-of-urine-unani-36-2048.jpg)
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examination of urine (unani)
- 1. EXAMINATION OF URINE Dr. Neelofer AssistantProfessor Department of Mahiyatul amraz (Pathology) Rajputan Unani Medicial College Jaipur (Rajisthan) India
- 2. URINALYSIS COLLECTION OF SPECIMEN PRESERVATION OF SPECIMEN EXAMINATION PHYSICAL EXAMINATION CHEMICAL EXAMINATION MICROSCOPIC EXAMINATION OF SEDIMENT
- 3. COLLECTION OF SPECIMEN •CLEAN CATCH MIDSTREAM SAMPLE Specimen of choice (Routine+bacteriologic ex) •CATHETERIZATION of bladder in pts with difficult voiding but S/E infection •SUPRAPUBIC ASPIRATION Infants & small children •If single specimen submitted for multiple measurements Do bacteriologic exam FIRST
- 4. TIMING FOR COLLECTION •Random sample sufficient But 1st morning sample – specimen of choice (more conc) • For glycosuria – 2-3 hours after meals • For urobilinogen – early afternoon sample • For quantitative analysis – 24 hr sample(nephrotic synd) – Empty bladder & discard urine at 8 am – Collect all urine for next 24 hrs including 8am sample of next day – Keep specimen in refrigerator during entire collection period
- 5. PRESERVATION Ideal – fresh(10-20 ml), best to examine within 2 hr Refrigerate ,if delayed At room temperature urea splitting bacteria Urea NH3 + H+ NH4 + pH decomposition of casts and pus cells used by bacteria Glucose in urine false –ve for glycosuria
- 6. PRESERVATIVES Toluene –2ml/100ml urine Good for chem tests not effective against bacterial contamination Floats on surface – difficult to separate Formalin – 1 drop/30ml urine S/E if incr conc Ppt protein False +ve for reducing subs Thymol s/e interferes with acid ppt test for proteins & bile salts Preservative tablets – 1 tablet / 30 ml urine Release formaldehyde s/e false +ve test for reducing subs at high conc, incr sp gravity by 0.005 / tablet/30ml sample Chloroform obsolete. Interferes with cellular sediment
- 7. REAGENT STRIP Aplastic strip containing pads incorporated with reagents for a chemical reaction leading to the detection of certain substance Urine is added for reaction by dipping the plastic strip into it & then slowly withdrawing. The subsequent colorimetric reactions are timed to an endpoint Extent of ~ level of substance color formation to be detected The colors are read manually by comparison with color charts or with the use of automated reflectance meters.
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- 10. PHYSICAL EXAMINATION VOLUME COLOR ODOUR APPEARANCE/ TURBIDITY SPECIFIC GRAVITY
- 11. VOLUME • Normal –1.5 – 2.5 L/ 24 hrs • Min 500 ml required to eliminate waste products of normal metabolism • Oliguria < 500 ml / 24 hrs – Prerenal –dehydration, edema, shock – Renal – AGN – Post renal – obstruction • Anuria < 100 ml / 24 hrs – ATN, shock, Hg poisoning, total obstruction
- 12. VOLUME • Polyuria >2.5L / 24hrs – Physiological – pregnancy, caffeine, alcohol, diuretics, high protein diet, polydipsia – Pathological – DM (sp gravity high), DI (sp gravity low), CRF, tubular damage • Diurnal variation – amount during day – Day : night ratio = 100 : 26-60 – Nocturia • renal failure ( 1st sign) • Disturbance in intestinal absorption • Addison’s disease
- 13. COLOUR Normal – paleyellow / straw colored due to urochrome, urobilin, uroerythrin. Urochrome syn increases in fever,thyrotoxicosis &starv Low specific gravity – pale High specific gravity – dark Acidic urine darker than alkaline
- 14. COLOUR PATH. CAUSENON PATH. CAUSE Pale yellow to dark amber Normal Yellow orange Bilirubin, urobilin Acriflavin, azogantricin, B complex, pyridium, nitrofurantoin, sulfa, quinacrine, carrots Milky white Pus, chyle Phosphate, carbonate Pink – red Hb, Myoglobin, RBCs, porphyrin, porphobilirubin Beets, Rifampicin, aminopyrin, diphenyl hydantoin, M Dopa, bromosulphthaline, phenacetin, pyridium COLOUR
- 15. COLOUR PATH. CAUSESNON PATH. CAUSES Red brown Porphobilinogen, uroporphyrin Smoky Microscopic hematuria Brown black Bilirubin, homogentisic acid (alkaptonuria), melanin, indican, Meth Hb, Myoglobin Chloroquin, hydroquinone, iron Rx, resorcinol, M Dopa, L Dopa, nitrofurantoin, Blue green Biliverdin, pseudomonas infection Acriflavin, amitryptiline, azure A, methylene blue, B complex
- 16. ODOUR Odour Condition Sweet/ fruityKetones Pungent Bacteria (NH3 produc) Foul smelling Bacterial infection Maple syrup Maple syrup urine ds Musty /mousy Phenylketonuria Sweaty feet Isovaleric acidemia Rancid butter/ fishy hypermethioninemia No smell ATN (ARF) NORMAL – aromatic – organic acids
- 17. APPEARANCE/ TURBIDITY • Turbidityevaluated by holding the specimen in front of a line of printed material • Normal – clear • Graded as – clear – slightly cloudy – cloudy – turbid
- 18. APPEARANCE CAUSES Clear Normal CloudyLeukocytes, bacteria, epithelial cells, amorphous phosphate (alkaline urine), amorphous urates (acidic urine) White ppt Amorphous phosphate Amorphous pink ppt Amorphous urate Hazy Mucus Smoky Microscopic hematuria Milky Fat, chyle APPEARANCE
- 19. SPECIFIC GRAVITY WEIGHT/ VOLUME : WEIGHT / VOLUME OF URINE OF WATER N – 1.003 – 1.035 (RANDOM SPECIMEN) - 1.015 – 1.025 (24 HR SPECIMEN) INDICATES CONC OF DISSOLVED MATERIAL DEPENDS UPON NUMBER OF PARTICLES WEIGHT OF PARTICLES MEASURES CONCENTRATING & DILUTING POWER OF KIDNEY
- 20. SPECIFIC GRAVITY MEASUREMENT METHODS Urinometer Refractometer Reagent strip Sp gravity beads Falling drop method By weighing
- 21. • HYPERSTHENURIA –high specific gravity (>1.035) – Dehydration - Proteinuria (nephrotic synd) – Glycosuria - Eclampsia – Lipoid nephrosis – False incr (dextran, radiographic dye) • HYPOSTHENURIA – low sp gravity (<1.007) – Collagen diseases - Pyelonephritis – HT - Protein malnutrition – Polydipsia - DI – Diuretics - Coffee, alcohol (natural diuretics) • ISOSTHENURIA – fixed sp gravity of 1.010 – Total loss of concentrating power of kidney - Poor tubular reabsorption.Sp gravity of urine & of plasma ultrafiltrate becomes the same.
- 22. URINOMETER / HYDROMETER Floating instrument calibrated at 200C Measures sp gravity at fixed temp (200C) Principle of buoyancy Urinometer floats higher in urine (denser than water) Fill 15ml urine in cylinder (decant any turbid material) Put urinometer in jar by spinning (do not let it touch side of cylinder) Read lower meniscus
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- 24. CHEMICAL EXAMINATION pH Reducing substances Protein Ketone bodies Blood Bile salts and bile pigments Miscellaneous
- 25. Measured by GradedpH Paper (reagent test strip) • impregnated with methyl red & bromothymol blue • pH reflected by color change from orange (acid) to green to blue (alkaline) •Covers pH range 5 – 9 Litmus paper,pH meter & titration of acidity.
- 26. PROTEIN • Screening testsbased on – protein error of indicators principle or on ability of protein to be precipitated by acid or heat • False +ve – contamination with vaginal discharge, semen, heavy mucus, pus, blood • False –ve – very dilute urine therefore always correlate with specific gravity • Confirm positive screening by quantitative procedures & / or electrophoretic, immunoelectrophoretic, immunodiffusion & ultracentrifugation studies.
- 27. TESTS FOR PROTEINS Qualitativetests Heat Precipitation test Sulphosalicylic acid test Heller’s method Reagent strip ( Albustix) Quantitative tests Esbach’s Albuminometer Electrophoresis • Biuret method
- 28. PROTEINURIA • Normal valuesupto 150 mg/ 24 hours • Functional proteinuria – dehydration, fever, cold exposure, heavy exercise • Postural proteinuria (orthostatic) – proteinuria during day due to exaggerated lordotic position leading to renal congestion & ischemia because of compression of abnormal vasculature
- 29. Causes of Proteinuria Accordingto site of lesion Prerenal Renal Post renal According to amount of protein excreted Mild Moderate Severe
- 30. Mild Proteinuria (<0.5 g/day) •Orthostatic • Chronic Pyelonephritis • Interstitial nephritis • Nephrosclerosis • Polycystic kidney disease • Inactive glomerular disease Moderate Proteinuria (0.5-3.5g/day) • Glomerulonephritis • Multiple myeloma • Nephrosclerosis • Toxic / Radiation nephritis • Pre eclampsia • Tubulointerstitial disease • Hypertension • Fanconi’s syndrome
- 31. Heavy Proteinuria (>3.5g/day) • Nephrotic syndrome • Minimal change disease • DM • SLE • RPGN • Malignant HTN • Eclampsia • Sickle cell disease • Amyloidosis • Renal transplant rejection • APLA syndrome • Heavy metal toxicity (Au, Hg), penicillamine
- 32. PRERENAL CAUSES Dehydration CHF Ascitis Fever Severe anemia Drugs Postural POSTRENALCAUSES Obstruction Tumors of: pelvis bladder prostate • RENAL CAUSES • GLOMERULAR : • GN • SLE • HT • DM • Amyloidosis • Nephrosclerosis • TUBULAR : • RTA • Fanconi’s syndrome • Cystinosis • Transplant rejection
- 33. REDUCING SUBSTANCES Various testsdone are:- • Benedict’s copper reduction test • Fehling’s test • Reagent strip ( Glucose – oxidase test )
- 34. Benedict’s Test Semi quantitativetest Detects the presence of reducing substance in urine Non specific test for reducing substances Principle cupric hydroxide reducing subs cuprous oxide (colored ppt)
- 35. Procedure 5 ml ofBenedict’s reagent in test tube Boil if color changes - DISCARD 8 drops of urine Boil for 5 minutes note color of precipitate
- 36. Interpretation • Blue solution– Negative • Green color - Traces [<0.5gm/dL] • Green ppt - + [0.5 - 1%] • yellow ppt - ++ [1 – 1.5%] • Orange ppt - +++ [1.5 - 2%] • Brick red ppt - ++++ [>2.0gm/dL] • FALSE POSITIVE TEST – Other sugars except sucrose – Nonsugar subs - Creatine, Uric acid, urates, Ascorbic Acid & Glucuronides – Drugs- Salicylates, Cephalosporins, Streptomycin
- 37. Specific tests forother sugars • Fructose - Seliwanoff’s test – ( Fructosuria- intake of grapes and citrus fruits) • Pentose - Bial’s test • Lactose - Methylamine test – ( Lactosuria- late pregnancy, lactating women) • Glucose - Glucose oxidase test (Enzymatic method)
- 38. Glycosuria Glycosuria withhyperglycemia 1) Temporary – Stress, Infection, Surg, MI, Burns, fractures, preg 2) Permanent DM, Pancreatitis, Glucagon secreting tumors Genetic Diseases( Glycogen storage Ds, Cystic fibrosis, Hemachromatosis) Endocrinopathies( Acromegaly, Thyrotoxicosis, Cushings Syndrome, Hyperaldosteronism, pheochromocytoma) Drugs- Salisylates, OCP’s, propanalol, thiazides Chronic Diseases- CRF, Chr Liver Ds, Brain Tumor
- 39. Alimentary Glycosuria • aftermeals • Increased blood glucose crosses renal threshold Glycosuria • Blood glucose returns to normal in 2 hrs glycosuria disappears • Causes - large Carbohydrate intake
- 40. KETONE BODIES • Productsof incomplete fat metabolism • three discrete but metabolically related chemicals: • acetoacetic acid (20%) • β-hydroxybutyric acid (78%) • Acetone (2%) • Acetoacetic acid acetone + CO2 reduction β-hydroxy butyric acid • β-hydroxy butyric acid lacks ketone group • Normal blood contains 3-4 mg/dl of ketone bodies • Urine contains traces of ketone bodies
- 41. Ketone bodies…Tests donefor ketones bodies:- • Rothera’s test • Gerhardt’s test • Harts test • Reagent strip / Ketostix / Ames test
- 42. BLOOD • HEMATURIA • HEMOGLOBINURIA •MYOGLOBINURIA • HEMOSIDERINURIA • CORRELATE WITH MICROSCOPIC EXAMINATION
- 43. HEMATURIA +nce ofintact RBCs in urine Microhematuria – no change in color of urine Gross hematuria – smoky urine Lyse in alkaline/acidic, dilute urine – ghost cells Causes : Membranous nephropathy, IgA nephropathy, mesangioproliferative GN, FSGS, giant cell arteritis Trauma, calculi, tumors SABE, malignant HT Bleeding disorders, anticoagulant usage Cyclophosphamide Excessive exercise (marathon runners)
- 44. HEMOGLOBINURIA • +nce offree Hb in urine(no RBCs) • Colors urine due to formation of acid hematin • Indicates intravascular hemolysis • Hb appears in urine when capacity of haptoglobin to bind with it gets saturated. • Causes : – PNH, PCH, transfusion mismatch, March hemoglobinuria, autoimmune hemolytic anemia RBC enzyme deficiencies (G6PD), unstable Hb – Severe burns, Erythrocyte trauma – malaria (black water fever), bartonella, clostridium welchii ; brown recluse spider bite ; drug exposure (sulfonamides, nitrofurantoin)
- 45. MYOGLOBINURIA • Heme proteinof striated muscle • Result of acute destruction of muscle fibres (crush injury)- rhabdomyolysis • Other Causes : – Strenous exercise, heat stroke, electric shock, – dermatomyositis, polymyositis, defect in muscle phosphofructokinase – Snake bite,hyperthermia • H/O muscle tenderness & cramps followed by red brown urine within 1-2 days after exertion • D/D hemoglobinuria • Confirmatory Dx - immunochemistry
- 46. Hematuria Hemoglobinuria Myoglobinuria Plasmacolor Normal Pink Normal Plasma haptoglobin Normal Low Normal S.Creatine kinase Normal normal Marked increase S.Aldolase Normal normal Increased Urine color normal/ smoky/ pink/ red/ brown Pink/red/brown Red/brown Urine RBCs Many Occasional Occasional Casts RBC casts Pigment Dense brown
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- 48. BILE SALTS • Naand K glycocholates and taurocholates • Normally not present in urine • Present in obstructive jaundice & hepatocellular jaundice • Decrease surface tension of urine – surfactant action • Test – Hay’s Sulphur test 20 ml of urine in a beaker sprinkle sulphur powder watch for 5 min If it sinks to the bottom—Bile salts are present • Dissociated jaundice – conjugated bilirubin + in urine but bile salt absent d/t diminished synthesis in liver & exhaustive conjugation with bilirubin. Seen in some cases of hepatocellular jaundice
- 49. UROBILINOGEN • Normal excretion2-4 mg/24 hrs (colorless) decomposes to Urobilin on exposure to sunlight (Yellow to orange color),so collection should be in dark bottle. • Causes of increased urobilinogen – Hemolytic anemias – Pre-icteric phase of infective hepatitis • Causes of decreased or absent urobilinogen – Obstructive Jaundice
- 50. BILIRUBIN • Breakdown productof Hb. • (N) no detectable Bilirubin in urine • whenever there is some Intra/ Extra hepatic obstruction---spillage into blood urine • ANY BILIRUBIN IN URINE (CONJUGATED) • Causes - Obstructive Jaundice Hepatocellular Jaundice • Tests – Fouchet’s test / Harrison spot test – Foam test – Icto test – Strip test – Smith iodine test – Gmelin’s test
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- 52. MICROSCOPIC EXAMINATION OFURINE To detect those cellular & noncellular elements in urine which do not give distinct chemical reactions. Fresh morning sample – best concentrated & acidic (RBCs & casts dissolve in alkaline urine, low sp gravity) Examine as soon as possible Refrigerate for only few hours Centrifuged urine sediment contains insoluble material (formed elements)
- 53. PROCEDURE First morning midstream Sample Centrifuge @ 1500 rpm X 5 min Discard supernatant 1 drop resuspended sediment on glass slide Place a coverslip (avoid air bubbles) Examine immediately LP & HP, condenser low Put on slide Examine
- 54. LOOK FOR… • CELLS- No / HPF • CASTS – No / LPF – TYPING - HP • CRYSTALS • PARASITES • MISCELLANEOUS STRUCTURES • ARTIFACTS
- 55. CELLS • ERYTHROCYES (RBCS) •LEUKOCYTES (WBCS) • EPITHELIAL CELLS – from urinary tract contaminants from genital tract
- 56. ERYTHROCYTES• Fresh –normal, pale or yellowish, smooth biconcave discs without nuclei. Hour glass appearance on side view • Dilute/hypotonic & alkaline urine – cells swell up – lyse – release Hb. • Lysed cells – ghost or shadow cells (faint circles – empty cell membranes). • Hypertonic urine – crenation of RBCS • Normal – 1-2 RBCs/HPF
- 57. If the RBCshave their typical shape & color - hematuria associated with lower urinary tract disease. Dysmorphic RBCs indicate glomerular hematuria. characterized by a great variation in the size of the cells (anisocytosis) & many ghost cells
- 58. LEUKOCYTES • Spherical, dullgrey or greenish yellow. • Single or as clumps. • Mostly neutrophils, identified by characteristic granules or nuclear lobulations • Larger than RBCS but smaller than renal epithelial cells
- 59. •Nuclei accentuated by2% acetic acid •Hypotonic urine – cells expand & granules exhibit brownian movement – “glitter cells” •Normal – 0-2 cells/ hpf •Increased in inflammation at or near urinary tract (>20/hpf or clumps)
- 60. EPITHELIAL CELLS • Origin– any site from proximal convoluted tubule to urethra or from vagina • Three main types • Tubular • Transitional • Squamous
- 61. Renal tubular epithelialcells • Flat / cuboidal / columnar cells slightly larger than leukocytes with large round nucleus • Increased no. suggests tubular damage – pyelonephritis, ATN, salicylate toxicity, transplant rejection, ac interstitial nephritis
- 62. simply load the samplerrack and press START URINALYSERS AUTOMATING THE ENTIRE ANALYTICAL PROCESS
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