CASE 1A 23-year old mother of two children (a 6 year old girl and an 8 year old boy) submitted a midstream clean-catch urine specimen for a routine urinalysis. She is presently in the sixth month of pregnancy for her third baby. She is being seen by her OB-Gyne because of back pain, fever, chills, and vomiting.

Urinalysis Results:Physical Appearance:color: yellowclarity: cloudy

Chemical Screening:pH 6.0specific gravity 1.010protein (strip) 100 mg/dL protein (SSA) 2+blood negativenitrite positiveleukocyte esterase positiveglucose negativeketones negativebilirubin negativeurobilinogen normal

Microscopic:red blood cells 0-2/hpfwhite blood cells 25-50/hpf {glitter cells present}casts 5-10 granular/lpf

2-5 cellular/lpfepithelial cells few transitional

few squamousbacteria many {rods}

1. What urinalysis findings are abnormal or discrepant?2. Are these findings consistent with an upper or a lower urinary tract infection? Explain.3. In this case the white cells are most likely to consist of what cell type? Explain.4. The cellular casts are most likely to consist of what type of cells? Explain.5. The disease-exhibited by this patient is acute pyelonephritis. What portion of the kidney

does this disease affect? (choose one)a. glomerulusb. interstitium

CASE 2From a rural hospital in Barangay Ilang-Ilang, this 71-year old woman was transferred to a tertiary hospital complaining of shortness of breath and showing evidence of pulmonary edema. There was no history of chest pains, nausea, vomiting or diaphoresis. Her admission diagnosis was Congestive Heart failure (acute exacerbation), Myocardial Infarction (subendocardial), DM and HTN. Medications included Lasix, morphine, nitroglycerin, and Procardia. Laboratory tests were significant for increased CK, 544 U/L (21-215) with a CKMB of 29.2 ng/mL (0-4), which is a relative index of 54. During the first few days of her hospital stay, blood glucose ranged from 201 to 365 mg/dL (70-110); creatinine ranged from 1.9 to 3.7 mg/dL (0.6-1.0); and BUN ranged from 31 to 46 mg/dL (5-25). Admission urinalysis was significant for: glucose 100 mg/dL; blood moderate; protein >300 mg/dL (<90); WBCs 2-5/hpf; RBCs 10-20/hpf; epithelials/lpf few squamous, few renal; casts/lpf 5-10 granular, 0-1 WBC. After aggressive treatment of the. She received intravenous nitroglycerin and insulin. The discharge diagnosis was status postsubendocardial MI, triple-vessel cardiac disease, CHF, renal insufficiency, HTN, and DM. She was scheduled to return to the hospital eventually for a triple vessel coronary bypass. What renal condition do the urinalysis data suggest? Explain. Do the analyses on blood correlate with this? Explain. What is the pathophysiology behind the renal condition in the first question? Explain.

CASE 3 This patient, a 46-year old man, was admitted complaining of diarrhea (experienced during the entire previous month) and jaundice, together with gas and nausea for the previous 3 weeks. Because of a long history of alcoholism, his admission diagnosis was “probable cirrhosis”, but further work showed a large, infiltrating mass in the liver that turned out to be hepatocellular carcinoma. The porta hepatis was entirely blocked, causing severe obstructive jaundice. The admission urinalysis showed bilirubin large; color amber; casts/lpf 1-5 granular and 1-5 WBC; Ictotest positive. Blood chemistries showed total bilirubin 32.1 mg/dL (0-1.5); conjugated bilirubin 22.2 mg/dL (0-0.4); ALP 299 U/L (37-107); AST 302 U/L (8-42); ALT 46 U/L (3-96); total protein 4.9 g/dL (6.4-8.2); albumin 2.1 m/dL (3.4-5.0); and LD 272 U/L (100-190). What urine results correlate with the diagnosis? Explain. How do the blood analyses correlate with this? Explain.

CASE 4Jessica is a 20-year old woman admitted to R/O appendicitis, pancreatitis, pyelonephritis, abdominal abscess, or ruptured viscus. She came to the ER complaining of severe abdominal pain or what is called an “acute abdomen”. Because she was 36 weeks’ (estimated) IUP, a low C-section was performed and the child was delivered. Her appendix was found to be ruptured and it was removed at the same time. Blood cultures were positive for E.coli, sensitive to Cefotan (cefotetan disodium) and to gentamicin, which she was given. The urinalysis, obtained two days postsurgery, was as follows: glucose negative, bilirubin small; ketones 40 mg/dL; specific gravity 1.025; blood negative; pH 6.5; protein 30 mg/dL; urobilinogen 1.0 EU/dL; nitrite negative; leucocyte esterase trace; color orange; WBCs 5-10/hpf; RBCs 0-2/hpf; epithelial cells 1+/hpf; bacteria 1+/hpf; bacteria 1+; casts 1-5 granular. Ictotest negative. C&S was not

requested on this urine. What aspects of the urinalysis do you find significant? What pathophysiologic aspects of this case are illustrated by the urine microscopic examination?

CASE 5An 82-year old woman with a history of HTN treated with Vasotec (enalapril maleate), and of NIDDM, was seen in the outpatient clinic complaining of a blister on her lower lip that she said had been developing slowly over a year. The blister wasw diagnosed as a mucocele (a mucus cyst), and an appointment was made to have it biopsied and excised at a future date. In the course of her examination, a routine urinalysis (without the microscopic) was requested and the urine was found to be significant for nitrite positive; and leukocyte esterase moderate. The results prompted the request for a urine C&S. The urine C&S subsequently indicated a colony greater than 100,000 CFU/mL with an identification of E.coli. What aspects of the urine sediment do you find significant? What diagnosis would you give this case? What type of treatment do you think this patient was given for the condition shown here? What results will be expected upon performing the microscopic examination of the patient’s urine? CASE 6With a medical history of HTN, IDDM and CHF, this 57-year old woman was attending a social event until the early morning hours, had been walking around complaining of shortness of breath, and suddenly collapsed with a blood-tinged discharge coming from her mouth. She was rushed to the ER in a private car and on arrival was unresponsive to verbal or painful stimuli, and showed agonal respirations with a weak radial pulse. The impression was respiratory arrest, acute pulmonary edema, R/O MI. Subsequent laboratory work did not support the diagnosis of acute MI, suggesting instead acute pulmonary edema. Her admission urinalysis produced the following results: glucose 250 mg/dL; bilirubin and ketones negative; specific gravity 1.010; blood small; pH 5.5; protein 100 mg/dL; urobilinogen normal; nitrite and leukocyte esterase negative; color amber; appearance hazy; WBCs 20-50/hpf; RBCs 0-2/hpf; epithelials few/hpf; bacteria 1+/hpf; casts TNTC granular/lpf. What urinalysis results do you find significant? What pathophysiology of this case is most closely related to the urinary sediment findings?

CASE 7This 49-year old man presented to the ER complaining of bilateral low abdominal pain that he had experienced for the preceeding 5 months (on and off) and worsening over the last 2 days. The pain was described as a “hot poker going through my abdomen” and associated with the abdominal pain was nausea, vomiting, and some coughing (non-productive). The patient did not have diarrhea or any changes in appetite or weight. The patient had been diagnosed with AIDS the previous year and has disseminated tuberculosis. In the ER it was noticed that he also had a crusted, slightly erythematous rash on the toes of both feet. On admission he was taking INH, rifampin, Bactrim DS, Megace, Flucon, MS Contin and morphine elixir. The patient had been an intravenous drug abuser for many years but denies homosexuality. On initial presentation, the patient’s chest x-ray study did not show any significant infiltrate. However,

the abdominal x-ray study showed multiple air-fluid levels in the small bowel. The general impression on admission was ileus, probably related to narcotic abuse, including the morphine and MS Contin; AIDS; disseminated tuberculosis and skin rash. The patient was admitted for observation and also for treatment of ileus with nasograstric tube and administration of GoLYTGELY. He continued to receive TB medications and his pain was controlled by the narcotic, Toradol. His condition improved continuously and after 3 days he was discharged in stable condition with Bactrim DS, Diflucan (for fungal dermatitis), INH and rifampin. His admission urinalysis (microscopic not requested) was glucose, bilirubin, ketones, negative; specific gravity 1.020; blood negative; pH 7.0; protein 30 mg/dL; urobilinogen normal; nitrite and leukocyte esterase negative; color amber. A C&S was not requested. Are there any significant findings in the urinalysis? How would you characterize the casts and cells that may be observed in the urine if microscopic analysis was performed? What pathophysiologic picture is illustrated by the urinalysis in this case?

CASE 8A urine specimen is obtained from a 14-year-old boy with a history of a sore throat. Three weeks ago he was cultured and treated for a streptococcal throat infection with a single intramuscular dose of penicillin. Two weeks after his initial visit, he showed no abnormal physical findings; however, his urinalysis revealed microscopic hematuria and he was told to rest. Currently he has weakness and anorexia. He woke up with a headache and puffy eyelids and says his urine is dark and there is very little of it.

Urinalysis Results: Physical Appearance color: red (red-brown) clarity: cloudy

Chemical Screening pH 6.0 specific gravity 1.025protein (strip) 300 mg/dL protein (SSA) 3+ blood large nitrite negative leukocyte esterase negative glucose negativeketones negative bilirubin negativeurobilinogen 0.5 EU/dl

Microscopicred blood cells 10-25/hpf (dysmorphic forms present)white blood cells 0-2/hpf casts 2-5 red blood cell casts/lpf crystals few amorphous urates

1. What urinalysis findings are abnormal or discrepant?2. What is the significance of dysmorphic red cells in the urine sediment of this patient?3. Proteinuria is an important indication of renal disease. Match the following protein tests (a and b) with the proteins they measure.

a. Reagent strip test for protein?b. Sulfosalicylic acid test for protein?___albumin___Tamm-Horsfall glycoprotein___plasma globulins

4. What is the significance of red blood cell casts in this patient?5. Why don't you see bacteria in the microscopic examination of the sediment in this patient?

6. What is the likely diagnosis for this patient?

CASE 9A urine specimen is collected from a 7-year-old girl with a history of several recent infections. She is seen because of lethargy, pallor, and facial edema and is found to have generalized edema. The urine specimen is pale but noticeably foamy.

Urinalysis Results:Physical Appearance:color: paleclarity: hazyfoam: large quantity, white

Chemical Screening:pH 6.0specific gravity 1.010protein (strip) >2000 mg/dL protein (SSA) 4+blood negativenitrite negativeleukocyte esterase negativeglucose negativeketones negativebilirubin negativeurobilinogen 0.5 EU/dL

Microscopic:red blood cells 0-2/hpfwhite blood cells 0-2/hpfcasts 2-5 fatty casts/lpf

5-10 hyaline casts/lpfepithelial cells few renal

few squamousother moderate fat globules

1. What urinalysis findings are abnormal or discrepant?2. What is causing the large amount of white foam in this urine specimen?3. Explain the edema exhibited by this patient in terms of the urinalysis findings.4. What are oval fat bodies and what do they signify in this patient?5. What is the name of the syndrome exhibited by this patient?

CASE 10A 32-year old woman with a long history of IDDM has been checking her blood sugar at home daily and administering her own insulin. On a rainy Sunday night, she was admitted through the ER after 2 days of vomiting, upper abdominal pain, and right jaw pain. Her admission diagnosis was Diabetic Ketoacidosis and dehydration. The admission urinalysis (no microscopic) was significant for glucose >1000 mg/dL and ketones >80 mg/dL. Her condition was resolved with fluid and electrolyte therapy and insulin drip. What urinalysis results correlate with the diagnosis of DKA? Explain. What results should be expected from the microscopic examination?