Urinalysis Case Studies

Lab Dx Fall 2008

Case 1: A 28 year old man visits his physician complaining of an intense, sharp pain in
his back and side. In a conversation with his physician, the patient confesses to eating a
diet high in animal proteins such as meat, cheese, and fish. Results of a complete
urinalysis are shown below.

Chemical/Physical Analysis
Color Yellow Glucose Negative Urobilinogen Normal
Appearance Clear Protein Trace Blood Large
Specific Gravity 1.025 Ketones 150mg/dL Nitrite Negative
pH 5.0 Bilirubin Negative Leukocyte Negative

Microscopic Analysis
>100 RBC/hpf
0-3 WBC/hpf
20-30 Bacteria/hpf
0-5 Squamous Epithelial Cells/hpf
Unidentified Crystals

Questions

1. Is the presence of WBCs with bacteria clinically significant?

2. Suggest an explanation for blood in the urine.

3. Below is a photomicrograph from the patient's urine sample:

QuickTimeª and a
TIFF (Uncompressed ) decompressor
are needed to see this pictu re.

**Note: Crystals were soluble in ammonia

What is the cause of the patient's condition?

 a) Uric acid crystals

b) Cystine crystals

c) Triple phosphate crystals

4. What is the diagnosis and treatment for this patient?

a) Cystinuria

b) Urinary tract infection

c) Renal calculi caused by the formation of uric acid crystals

1. No. Ordinarly, bacteria in the presence of WBCs would suggest a urinary tract infection.
However, the 0-3 WBC/hpf is within the reference range and therefore is of no clinical
significance. The relatively low levels of bacteria are also of no clinical significance. Their
presence may be due to contamination.

2. There are two possible ways that blood could get into the urine. First, if the glomerulus was in
some way damaged, its efficiency as a filter may be somewhat compromised. If this was the
case, RBCs, protein, and other larger particles could get into the urine. However, in this case, the
high blood result with only trace amounts of protein suggests that the problem did not occur at the
glomerulus. This leads to the other cause of blood in the urine: damage to the urinary tract. If
any part of the urinary tract is damaged, blood could get into the urine, even if the glomerulus is
working fine. Renal calculi, or kidney stones, could cause damage to the renal tubules as they
flow down the urinary tract. This damage would explain the presence of blood (in the absence of
large amounts of protein).

3. Uric acid crystals are not soluble in ammonia. While triple phosphate crystals may have 6
sides, they are only insoluble in basic urines. This patient's urine is acidic and also it was noted
that these crystals are soluble in alkaline pH. Answer = B

4. Cystinuria is the inability to absorb the amino acid cysteine from the intestines and renal
tubules. Therefore, any cystine that may be present in ones diet (foods high in animal protein)
will be excreted in the urine. Cystine is insoluble in an acidic pH and thus will lead to the
formation of renal calculi in the urinary tract or bladder if the pH environment is acidic. Because
cysteine is not an essential amino acid and can be made from methionine, there are no
physiological consequences resulting from cystinuria. However, a patient with cystinuria will be
susceptible to the pain associated with renal calculi. One option for treatment may be to increase
the urine volume by drinking a lot of fluids. This may prevent stone formation. Another option
is to choose a diet that is free of cystine. A diet high in animal protein, similar to the one this
patient was on, contains large quantities of cystine. Vegetable proteins such as nuts and beans are
low in cystine and should be considered. An additional way of preventing the formation of renal
calculi would be to alkalise the urine. In an alkaline urine, cystine crystals dissolve so renal
calculi will not form. Medications may also be available.
Case 2: A 12 year old boy was examined in the emergency room. his mother said
he was having frequent urination lasting seeral days. he was also compalining of feeling
weak and tired.

Chemical/Physical Analysis
color - pale yellow
Clarity - clear
pH - 6.0
Specific gravity - 1.025
Protein - Trace
Glucose - 1000mg/dl
Ketone - 5mg/dl
Nitrite - neg
Blood - neg
Bilirubin - neg
Urobilinogen - neg
Leukocyte – neg

MICROSCOPIC
Rbc - 0 to 2 per field
Wbc - 0 to 2
Bacteria - few
Epithelial Cells - few

OTHER TESTS
SSA( sulfosalicylic acid test) - trace

QUESTIONS.
1) Which results are outside the normal range?

2) Based on these result, what might be the diagnosis?

3) What is the relationship between the appearance of ketones in urine and carbohydrate
metabolism?

Answers:
Glucose is extremely high, and ketones are abnormal, since they should be 0. However, they are
very low. This would more than likely indicate diabetes (type I).

The presence of ketones in the urine indicates a shift from carbohydrate catabolism to fatty acid
catabolism, since ketones are the end product of the FA pathway.

Glucose should never be present in this amount. The normal renal threshold for glucoe
reabsorption is about 200mg/dL, and when stressed, it can reabsorb 300mG/dL. In cases of severe
hyperglycemia (i.e. type I diabetes), the renal reabsorption threshold is exceeded, and glucose
spills into the urine. This Px probably has a very high blood sugar (600-800 or so), and is
probably ill, with flu-like symptoms.

Other things to consider in diabetes: polyuria, polydipsia, polyphagia. Parents will say "he eats
and eats and seems to be losing weight". Generally these Px present to the doctor in DKA, so
proper management is imperative.

Nugget: Na+ is normally the major osmotic attractant of serum, but in extreme hyperglycmeic
cases, glucose takes over, and the Px will look like they are hyponatremic. A calculation can be
done to correct for this, and serum Na+ is usually elevated, due to the dehydrated state of the
body.

Diabetes insipidus also presents with polyuria and glucosuria, but NO KETONES.

The following cases do not have answers, so discuss away!

Case 3: Patient A is an 8 year old European American girl who woke up one morning
with a fever and complaining of back pain on the right side just above her waist. At the
physician’s office later that morning on a clean catch, midstream urine sample, the
following results were obtained.

Chemical/Physical Analysis
Color yellow
Clarity cloudy
SG 1.019
pH 6.0
Protein 1+
Glucose neg
Ketones neg
Blood 1+
Bilirubin neg
Urobilinogen 0.1
Nitrite pos
Leukocyte esterase 2+

Microscopic examination
40-60 WBC/hpf
0-8 RBC/hpf
few squamous/lpf
rare renal epithelial cell/hpf
3-6 WBC casts/hpf
moderate bacteria

1. Are there any inconsistencies between the macroscopic, chemical and microscopic
findings that need to be explained? If so, what might explain them?
2. What condition is indicated by this constellation of findings and which particular
findings support this diagnosis?

3. Is any additional testing indicated for this patient? If yes, what test and what is its
principle?

4. What is the source of the positive protein finding in this condition?

5. What is the purpose of assessing specific gravity in urine? Why is it important to know
that the specific gravity was measured with a dipstik?

Case 4: Patient B is a 14 year old African American boy who had a sore throat about
two weeks ago but that is now gone. His mother has taken him to an urgent care facility
because his ankles and hands seems very swollen and his urine is dark. The following
results are on a clean catch, midstream sample collected at the urgent care facility.

Chemical/Physical Analysis

Color brown
Clarity cloudy
SG 1.026
pH 6.0
Protein 3+
Glucose negative
Ketones negative
Blood 3+
Bilirubin negative
Urobilinogen 0.1
Nitrite negative
Leukocyte esterase negative

Microscopic examination
40-50 rbc/hpf
3-10 WBC/hpf
0-5 hyaline casts/lpf
0-2 rbc casts/lpf
1-3 granular casts/lpf
few sq. epi/hpf

1. Are there any inconsistencies between the macroscopic, chemical and microscopic
findings that need to be explained? If so, what might explain them?

2. What condition is indicated by this constellation of findings and which particular

findings support this diagnosis?

3. Is any additional testing indicated for this patient? If yes, what test and what is its
principle?

4. What is the source of the positive protein finding in this condition?

5. Why are the patient’s ankles swelling?

6. What is the relationship of the patient’s prior sore throat to his present condition?

7. Why is the microscopic examination negative for bacteria?

Case 6: Patient C is an 18 year European American female who sought treatment at the
university health center complaining of frequent urination with burning. She reported that
she had sexual intercourse two days previous to this visit and had no recent history
illness. She was instructed to collect a clean catch, midstream sample that was tested with
the following results.

Chemical/Physical Analysis
Color yellow
Clarity cloudy
SG 1.012
pH 5.5
Protein 1+
Glucose negative
Ketones negative
Blood 1+
Bilirubin negative
Urobilinogen 0.1
Nitrite negative
Leukocyte esterase 2+

Microscopic examination
50-75 WBC/lpf some in clumps
15-20 rbc/lpf
many sq epi/lpf
1+ mucous
many bacteria

1. Are there any inconsistencies between the macroscopic, chemical and microscopic
findings that need to be explained? If so, what might explain them?
2. What condition is indicated by this constellation of findings and which particular
findings support this diagnosis?

3. Is any additional testing indicated for this patient? If yes, what test and what is its
principle?

Case 6: Kenji is a 56 year old Asian American man who has been experiencing a sharp
but intermittent pain in his back for some time. His wife has been pressing him to see a
doctor but he has resisted until today because the pain has become more severe and
persistent. Below are the results of a routine urinalysis on a clean catch midstream sample
collected and tested in the physician office.

Chemical/Physical Analysis
Color yellow
Clarity clear
SG 1.009
pH 6.0
Protein negative
Glucose negative
Ketones negative
Blood trace
Bilirubin negative
Urobilinogen 0.1
Nitrite negative
Leukocyte esterase negative

Microscopic examination
0-2 sq epi/lpf
2-5 rbc/hpf
0-1 WBC/hpf

1. Is the sample acceptable for evaluation? Explain your conclusion.

2. Are there any inconsistencies between the macroscopic, chemical and microscopic
findings that need to be explained? If so, what might explain them?

3. What condition is suggested by this constellation of findings and which particular

findings support this diagnosis?

4. Is any additional testing indicated for this patient? If yes, what test and what is its
principle?

Case 7: Obrian is an 8 year old African American boy who was hospitalized with
pneumonia following a cold. He was treated with antibiotics and within a day of
beginning treatment, his urine turned dark. The results below are the from the second
urine sample after the dark urine was discovered. A CBC collected shortly after the dark
urine was reported showed an elevated white blood count with a left shift and toxic
changes; normochromic, normocytic anemia with an occasional helmet cell and
shistocyte; and normal platelet count and morphology.

Chemical/Physical Analysis
Color red-brown
Clarity clear
SG 1.015
pH 5.5
Protein trace
Glucose negative
Ketones negative
Blood 4+
Bilirubin negative
Urobilinogen negative
Nitrite negative
Leukocyte esterase negative

1. Is the sample acceptable for evaluation? Explain your conclusion.

2. Are there any inconsistencies between the macroscopic, chemical and microscopic
findings that need to be explained? If so, what might explain them?

3. What condition is suggested by this constellation of findings and which particular

findings support this diagnosis?

4. Is any additional testing indicated for this patient? If yes, what test and what is its
principle?

5. What changes to the results of the urinalysis would be expected in the next few days?
What is the principle of the test on the stik that will detect these changes?

Case 8: Bobby Mcgee, a 56 year old white male, had some basic tests performed as part
of an insurance policy screening. The urine sample was collected at the patient’s home
and then delivered to a laboratory for testing and reporting. The sample was a random
void without directions to collect it midstream or clean catch.

Chemical/Physical Analysis
Color yellow
Clarity hazy
SG 1.012
pH 6.0
Protein negative
Glucose negative
Ketones negative
Blood negative
Bilirubin negative
Urobilinogen 0.1
Nitrite negative
Leukocyte esterase negative

Microscopic examination:
moderate calcium oxalate crystals
few bacteria

1. Is the sample acceptable for evaluation? Explain your conclusion.

2. Are there any inconsistencies between the macroscopic, chemical and microscopic
findings that need to be explained? If so, what might explain them?

3. What condition is suggested by this constellation of findings and which particular

findings support this diagnosis?

4. Is any additional testing indicated for this patient? If yes, what test and what is its
principle?

5. Under what conditions are crystals seen in urine? Which crystals are considered
normal?

Case 9: Harriet is a 40 year old African American woman who has been experiencing
sharp pains under her ribs on the right side for several months. She seems to think that it
is related to eating heavy meals. She has finally decided to see her physician because this
morning when she woke up she noticed that her eyeballs had turned yellow and this was
pretty scary to her. A urine sample collected in the physician’s office showed the results
below.

Chemical/Physical Analysis
Color dark yellow
Clarity hazy
SG 1.020
pH 5.5
Protein negative
Glucose negative
Ketones negative
Blood negative
Bilirubin positive
Urobilinogen negative
Nitrite negative
Leukocyte esterase negative

Microscopic examination
moderate sq. epi/hpf

1. Is the sample acceptable for evaluation? Explain your conclusion.

2. Are there any inconsistencies between the macroscopic, chemical and microscopic
findings that need to be explained? If so, what might explain them?

3. What condition is suggested by this constellation of findings and which particular

findings support this diagnosis?

4. Is any additional testing indicated for this patient? If yes, what test and what is its
principle?

Case 10: Bret is 18 month old European American boy seen in the doctor’s office for a
routine well-child visit. The urine sample was collected with one of the pediatric bags.

Chemical/Physical Analysis
Color yellow
Clarity hazy
SG 1.013
pH 6.5
Protein negative
Glucose negative
Ketones negative
Blood negative
Bilirubin negative
Urobilinogen 0.1
Nitrite negative
Leukocyte esterase negative

Microscopic examination
15-20 sq epis/lpf
few uric acid crystals/lpf

1. Is the sample acceptable for evaluation? Explain your conclusion.

2. Which results are outside reference ranges or acceptable limits?

3. Are there any inconsistencies between the macroscopic, chemical and microscopic
findings that need to be explained? If so, what might explain them?
4. What condition is suggested by this constellation of findings and which particular
findings support this diagnosis?

5. Is any additional testing indicated for this patient? If yes, what test and what is its
principle?

Case 11: Lilia, a 35 year old Mexican American woman, provided the urine sample
whose results are below during a routine physical examination. She was instructed to
provide a mid-stream sample. Her weight was down approximately 10 pounds from the
prior year and she said she had been working out and eating more healthfully. She was
found to be healthy.

Chemical/Physical Analysis
Color straw
Clarity clear
SG 1.007
pH 5.5
Protein negative
Glucose negative
Ketones 1+
Blood negative
Bilirubin negative
Urobilinogen 0.1-1.0 EU
Nitrite negative
Leukocyte esterase negative

Microscopic examination
0-2 sq epis/lpf

1. Is the sample acceptable for evaluation? Explain your conclusion.

2. Are there any inconsistencies between the macroscopic, chemical and microscopic
findings that need to be explained? If so, what might explain them?

3. What condition is suggested by this constellation of findings and which particular

findings support this diagnosis?

4. Is any additional testing indicated for this patient? If yes, what test and what is its
principle?