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Clinical Diagnostics (Lab studies)


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rbc's erythrocytes


What is the wbc on the left?
on the right?

hypersegmented neutrophils


When will you see these?
atypical lymphocytes
Mono, viral hepatitis, CMV, toxoplasmosis

What is abnormal about volume/size and color?
microcytic, hypochromic

When is this seen?
hereditary spherocytosis

When are they seen?
Target cells
post splenectomy
Liver Disease

When is it seen?
Basophilic stippling
Seen in Lead poisoning, megaloblastic and refractory anemias, alcoholics, drug exposures

When is it seen?
rouleaux formation
Seen in multiple myeloma

What are they?
When seen?
Howell Jolly body
round, purple staining nuclear fragments of DNA in the red blood cell.
Seen after splenectomy, megaloblastic anemia


What type of anemia?
Iron deficiency

What type of anemia?
Megaloblastic anemia

Sickle Cells

What are these?
What are they indicative of?
Auer rods
Indicative of AML

What Leukemia does this look like?
chronic myelogenous leukemia

What Leukemia?
Chronic lymphocytic leukemia

Plasmodium falciparum
ring form

Plasmodium falciparum

plasmodium malariae

What chromosome abnormality is this showing? What is this indicative of?
Philadelphia Chromosome
(translocation of 9 and 22)
Pathognomic for CML
This tube contains nothing or something to activate clotting
Red top
After centrifuging, the liquid portion of blood is called? How is it different from plasma?
It no longer contains clotting factors
This tube contains EDTA
What tests are done on it?
Purple top
It prevents clotting
Hematology and hgA1C
This tube contains Sodium Citrate
What tests?
Blue top
It prevents clotting and preserves clotting factors
Tests blood's ability to clot
What is the difference between a red top and a tiger top?
both are centrifuged and serum is tested, but tiger has a serum separating gel
What is a gray top tube used for? Why?
Used for glucose tolerance testing. It contains sodium fluoride oxalate, which prevents glycolysis
Yellow top tubes are used for?
blood cultures if bottles not available
Green top - what does it contain, what is it used for?
Contains heparin
Used to test plasma for ammonia and carboxyhemoglobin
Blood Composition?
45% cells (rbcs, wbcs, plts)
55% plasma, 90% of which is water
10% proteins,enzymes, salts cho, lipids
3 components of blood after centrifugation
Top: Serum or plasma
Middle: Buffy Coat: wbcs and plts
Bottom: rbcs
Number of people testing true positive/Number of people who actually have disease
Number of people testing true negative/Number of people who do not have disease
Accuracy vs. Precision
How close you are to the right value vs. how much you can reproduce results (you want both)
Process of blood development and production
All cells are produced from multi-potential stem cells in the ___________.
Bone Marrow
What stimulate stem cells to divide and differentiate?
Colony stimulating factors
The two major stem lines
Is differentiation reversible?
Lymphoid cells form:
B and T cells
2 groups of Leukocytes
Granulocytes include:
neutrophils, eosinophils, basophils
Agranular, mononuclear cells
production of neutrophils, eosinophils, basophils, and monocytes
how long does it take to go from immature "blast" to mature cell?
7-10 days
How does EDTA prevent clotting?
binds to calcium
What happens to WBC count over lifetime?
Highest at birth, then slowly falls
At what age to lymphocytes dominate?
2 wks to 5-7 yrs
PMN's dominate thereafter
How is the # of wbc's reported?
#wbc/mm3 of blood
How is the rbc's reported?
total rbc (millions)/mm3 of blood
How is Hemoglobin (hb) reported?
When is hb higher? lower?
highest at birth
lowest at 3 months
higher in men
lower in preg. women
How is Hematocrit (hct) reported?
What is hemoglobin?
Conjugated protein consisting of globin, protoporphyrin, and iron
What are some normal values for hemoglobin?
males-14-18 g/dl
females-12-16 g/dl
newborns-17-23 g/dl
children 12-14.5 g/dl
What are panic values for hb?
Panic values <8 and >20 g/dl
What does hematocrit measure?
measure of the total blood volume that is made of red cells usually 3x hemoglobin, reported as a %
What is the panic value for hct?
When is hct increased?
polycythemia vera, smokers, high altitudes (hypoxia stimulates RBC production), dehydration(decreased fluid, decreased blood volume, same #RBCs)
When in hct decreased?
in megaloblastic anemia (folate or B12 deficiency), blood loss, drug or alcohol addiction, FE deficiency or sickle cell anemia, pregnancy
Hct normal values
What are the rbc indices?
MCV-mean cell volume, the average volume of red cells
MCV= hematocrit(%)x10 /RBCs (millions)
MCV by age
children have lower MCVs than adults, For every year under 10 years of age subtract one unit from 80. Newborns have high MCVs.
mean cell hemoglobin-the weight of hemoglobin of the average RBC
MCH=hemoglobin x 10/RBCs (millions)
mean cell hemoglobin concentration-the average concentration of hemoglobin in a given volume of red cells
MCHC= hemoglobin x 100/hct
Red cell distribution width-a measure of the degree of anisocytosis (variation in RBC size), measured by automated counters
Normal RDW
RDW is helpful when?
distinguishing uncomplicated thalessemia (low MCV/normal RDW) from iron deficiency anemia (low MCV/high RDW)
RBC's of different sizes
Platelet normal values
Platelet panic values
<50,000 or >1 million
Where are platelets formed?
formed in bone marrow from megakaryocytes
What is the role of platelets in hemostasis?
forming a plug to ensure vascular integrity
How are plts counted?
Manual counts done on Neubauer hemocytometer. These are estimated as part of the differential
What is done for a CBC with differential?
100 WBCs are counted and # representing a percentage is reported. RBC morphology and platelet estimate are also given

Summary picture of cell types

example of cbc smear
More mature neutrophils are called?
Segs (segmented)
there are more lobulations of the nuclei
More immature neutrophils are called?
bands or stabs
refers to the release of less mature forms, it is defined as when more than 10-12% bands are seen or when the total PMN count (segs plus bands) is greater than 80.
Left shift
When is a left shift seen?
can occur in infection or inflammation/ hemorrhage.
hypersegmented neutrophils can be seen in megaloblastic anemias and liver disease
Right Shift
increase in absolute number of neutrophils in response to invading organisms or tumor cells.
Children respond to infection with a ______ degree of neutrophilia than adults.
may be due to decreased production, excess stored in blood vessel margin, or too many called into action and used up
eosinophils are capable of?
phagocytosis of ag-ab complexes
When do eosinophils become active?
later stages of inflammation
eosinophils respond to what type of conditions?
allergic and parasitic
when are eosinophil counts lower?
in the am
What is the normal amount of eosinophils?
Eosinophilia Mnemonics:
Neoplasm, Allergy, Addison’s Disease, Collagen –vascular disease, and Parasites.
Pulmonary Infiltrate Eosinophilia
What is eosinopenia due to?
increased adrenal steroids (Cushing’s), drugs- ACTH, epi, prostaglandins, stressful situations, burns, labor, postop states.
phagocytic, are called mast cells when found in tissues. They contain heparin, histamine, and serotonin.
Normal amount of basophils
Basophilia is seen in?
CML, Hodgkin’s disease.
Basopenia is seen in?
hyperthyroidism, acute phase of infection, stress.
Largest cell of normal blood
How do monocytes help with infection?
are mobile via pseudopods-remove injured or dead cells, microorganisms, and insoluble particles from circulating blood.
Migrate to the tissues where they become macrophages.
normal amount of monocytes?
Monocytosis is seen with?
recovery state of acute infection, TB, subacute endocarditis
Monocytopenia is seen with?
prednisone treatment, RA, hairy cell leukemia
Lymphocytes are a source of?
serum immunoglobulins
B cell Lymphocytes are involved in?
antibody response to antigens
T cells are involved in?
cell mediated immunity - helper, killer, suppressor cells
T cells mature in?
Thymus gland
Normal amt of lymphocytes
Lymphocytosis, aka
when is it seen?
inverted or reversed diff- more lymphs than neutrophils,( normal in a child), ALL, CLL, viral infection.
Lymphopenia is seen in?
chemo, radiation, normal in 22% of population
Platelets are important in?
Important in hemostasis, may be normal in count but not in function.
How to assess abnormalities in plt function?
Abnormalities in platelet function can be assessed with a bleeding time.
Thrombocytosis - seen when?
sudden exercise, post trauma, post-surgical esp. after splenectomy
Thrombocytopenia - seen when?
Thrombocytopenia-ITP, TTP, DIC, burns, snakes and insect bites, marrow suppressants-chemo radiation, alcohol addiction
rbc production in the bone marrow, controlled by erythropoietin (Procrit) produced in the kidneys. Cells develop through four stages of mitosis, taking 4-5 days.
Erythrocyte avg size and shape
7-8 um in size, biconcave disc, capable of altering shape
Normal life span of erythrocyte
120 days
7-8 microns
seen when?
<7 microns, MCV <80
Fe def anemia, thalessemias, children
seen when?
>8 microns, MCV >101
liver disease, B12/folate def., newborns
variation in shape of RBC
Spherocytes, describe
no central area of pallor, no biconcavity, MCHC >36%, osmotic fragility, can easily burst; breakdown of RBCs can develop gallstones. hereditary spherocytosis, hemolytic anemia, ABO transfusion reactions
ovalocytes, describe
ovalocytes-oval shaped RBC with white area in the center, hereditary ovalocytosis, sickle cell, Fe def, thalessemia, megaloblastic anemia
Target cells, describe
aka(leptocytes)-small clump of Hgb in center surrounded by area of pallor, a thin rim of Hgb. Cell appears slightly larger since it is flatter than normal. Liver disease, thalessemias, hemoglobinopathies, post-splenectomy
-fragmented or pieces of cell, prosthetic heart valves
Burr cells (Acanthocytes)
RBCs with evenly placed blunt or rounded projections. Severe liver disease, uremia, DIC, TTP, carcinoma. Acanthocytes have more thorny projections and can be seen in anorexia, severe burns and hypothroidism
Tear drop cells
tennis racket, “Patient crying for a bone marrow”, fibrotic bone marrow, ineffective erythropoesis
-“smiley cells”-slitlike areas of central pallor. -liver disease, artifact, lupus
Helmet cells
“bite cells”, “Pac Man”, G6PD crisis, DIC, pulmonary emboli
Heinz bodies
denatured or precipitated protein seen in G6PD Deficiency, drug-induced hemolytic anemia
rouleaux formation
stack of coins, due to abnormal proteins found in blood such as in multiple myeloma
last stage of development prior to becoming a mature RBC, retics have remnant of RNA and circulate for approx. 24 hours, reflects responsiveness and potential of bone marrow (erythropoietic activity).
reticulocytes are suggested by?
basophilia or polychromasia on Wright's Stain
How is retic count reported?
What are normal values?
Normal ranges-0.5-2.0% for adults, 2.5-6.5% for children
Corrected retic count = ?
(aka retic index)
What should it equal?
reported count x patient’s HCT/normal HCT
Should = 1.0
What may happen to retic ct. after adequate iron dosage for fe def. anemia. What does this indicate?
rise over 20%
Indicates good response to tx.
What is the retic count measuring clinically?
the ability of bone marrow to react to anemia and make rbc's.
Erythrocyte sedimentation rate
The rate at which RBCs settle out of anticoagulated blood in one hour.
What to inflammatory and necrotic processes do the the esr?
cause an alteration in blood proteins resulting in the aggregation of red cells. They become heavier and fall more rapidly leading to a higher ESR.
When is the esr most useful?
polymyalgia rheumatica and temporal arteritis
causes esr to increase
increased in infection, inflammation, multiple myeloma, macrocytic disorders, acute MI
causes esr to decrease
decreased in microcytic disorders, polycythemia vera, hereditary spherocytosis, sickle cell anemia, hemoglobin C disease
normal esr
normal in allergies, viral infections, cirrhosis, malaria

heinz bodies


describe 1, 2, and 3 by color

see picture

ID 1,2,and 3 based on shape

see image

ID 1,2,and 3 based on shape

see image
The most common cause of microcytic anemia
Fe deficiency
signs and symptoms of Fe deficiency anemia
fatigue, doe, pica – hallmark of Fe def., may crave ice or complain of a sore mouth.
signs: pallor, epithelial cell shedding-atrophic glossitis, cheilitis, spooning of nails
Lab studies in Fe def anemia
microcytic, hypochromic anemia, increased RDW, retic monitors response to treatment, ferritin, TIBC, serum Fe, % saturation.
What does ferritin do?
stores iron
Tmt of Fe def anemia
iron replacement (Slow FE, Feosol) given between meals for better absorption, stools remain black, may be constipating- consider Colace for better tolerability, consider transfusing packed RBCs if Hgb is < 6 gms/dl
B12 deficiency causes?
Pernicious Anemia
What is pathophys of pernicious anemia?
atrophy of gastric mucosa (parietal cell) leads to lack of intrinsic factor and HCL secretion. B12 needs intrinsic factor for absorption. Impaired DNA synthesis results in RBCs with immature chromatin and appears enlarged or megaloblastic
What is avg age for pernicious anemia?
Risk factors for pernicious anemia
alcoholism, ascorbic acid, cimetedine (Tagamet), oral contraceptives, strict vegens who avoid dairy, gastric bypass
Labs for pernicious anemia
MCV > 95, decreased retics, hypersegmented neutrophils, Howell-Jolly bodies (DNA remnant
Schilling test
radioactive B12 is given orally and then measure the amount excreted in the urine. If no IF, no B12 is absorbed and none is excreted. Then give exogenous IF- if normalized excretion you have the diagnosis of pernicious anemia. If not excreted then consider intestinal cause of B12 malabsorption.
Treatment for Pernicious Anemia
IM or SC B12 (cyanocobalamin) once weekly for eight weeks, then one monthly lifelong.

Sickle cells

What anemia may cause this?
Sickle cell disease



What are they pathognomic for?
Reed-Sternberg cells
Pathognomic for Hodgkin's
How do you streak a plate?

see image

describe type of bacteria
give example
gram positive cocci, cluster
eg: staph

Describe type of bacteria
Give example
Gram positive cocci, chain
eg: strep

describe type
gram neg rods

What type of stain
give example of bacteria
Acid fast stain
acid fast bact: mycobacteria

Treponema pallidum (syphillis)
Dark field microscopy

What type of plate
What is pink?
What is clear?
MacConkey Plate
Pink: lactose positive
Clear: Lactose negative

What type of plate
Is this pos or neg?
Hektoin plate
This is neg
pos would be bluish-green

What phenomenon?
What species?
Proteus species

Describe this lactose plate, what species may it be?
Lactose positive, mucoid
Klebsiella species

What species?

What species?
What is this called?
Strep hemolysis

Beta hemolysis with halos

What's happening at 1 and 2?
1 - alpha hemolysis
2 - optochin sensitive

What test is this?
Which one is positive?
Give example of pos bact
Catalase test
the one one L is pos, (gas bubbles)
eg staph

Which is pos, which is neg?
bact that is pos?
L - pos
R - neg
staph aureus is pos, other staph's are not

What is this?
What does it indicate?
“P” (optochin) disc – three way streak for “lawn” of bacteria, incubated at 35 degrees Celsius for 24 hrs. (CO2 will enhance the growth but will decrease the zone size) 14 mm in diameter zone of inhibition is indicative of Strep pneumoniae ) Old Quelling reaction for capsular swelling

candida albicans

neutrophils with gram negative coccobacillary

what does this show?

What test is this showing?
is it pos or neg?
oxidase positive

H. Influenza

What's being measured?
Zone of inhibition

What does this kid probably have?
Group A strep

What are these?
What do they indicate
Clue cells, indicating bacterial vaginitis

trichomonas vaginitis

Trichomonas vaginalis

N. gonorrhea

ID 1,2 and 3
Epithelial cells
Calcium oxalate crystals

Type of cast
Hyaline Cast

Type of cast
what are the different types of this, what are they caused by?
cellular cast
WBC cast- pyelonephritis, glomerulonephritis, inflammatory nephritis
RBC casts- glomerulonephritis, interstitial nephritis pyelonephritis, renal trauma/tumor, acute necrosis
Epithelial casts- glomerulonephritis

Caused by?
Fatty casts/lipids
Nephrotic syndrome/ nephrosis

Granular cast
Can be fine or coarse- disintegration of WBC or epithelial cast

What are waxy casts from?
Associated with renal failure and CRI- further degeneration of cellular casts

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