Clinical Laboratory to Hematology

Clinical Laboratory o Ex. Glucometer measures

A place where SPECIMENS may be: blood sugar levels
(a) Collected, (b) Processed, (c) Has an aspect of ease of access
Examined, (d) Analyzed o POCT are also used in the
OR
Types of Clinical Laboratory Based On Can describe the current situation at
Location that moment
Hospital Laboratory
Free Standing Laboratory Reference Laboratories
Independent labs that stands on its Performs more tests
own (i.e. labs found in malls) Thousands of specimens per day
Reference Laboratory which may come from all over the
country
Hospital Laboratory Offers more specialized procedures
Laboratories that are housed within and testing
the hospital Ex: Bio Reference
Caters to inpatients
Can also be called The Department Types of Clinical Laboratory Based on
of Pathology Function
Medical Technology grads know Clinical Laboratory
how to analyze the results unlike Anatomic Laboratory autopsy
non-MT who only know how to do Forensic Laboratory Crime
the procedure Laboratories what causes unknown
deaths
Hospital Laboratory Tests
Electrolytes (sodium, potassium, Cl) Pathology Department Clinical Pathology
Kidney function tests (urea nitrogen) Clinical Laboratory
Identification of microorganisms and Hematology Laboratory
antibiotic sensitivity testing Immunology Laboratory
Urinalysis and Fecalysis Blood Bank
Coagulation Testing Clinical Microbiology Laboratory
Cardiac Enzyme Assay
Complete Blood Count (CBC) Pathology Department Anatomical
Liver function tests Pathology
Blood typing and cross matching Morgue
*Specialized hospitals may offer Histopathology Laboratory
additional and advanced testing Cytology Laboratory
related to the specialty. Cytogenetic Laboratory
Electron Microscopy Laboratory
POCT Point of Care Testing
Preformed at the patients bedside Clinical Laboratory Categories in the
Uses portable instrument Philippines Accredited by the Department of
Health
 Primary laboratory Tertiary Laboratory
Secondary Laboratory
Point of Primary Laboratory Secondary Lab Tertiary Laboratory
Difference
Examinatio 1. Routine 1. Primary 1. Secondary
ns hematology Laboratory Laboratory
Performed 2. Routine Examinations Examinations
urinalysis 2. Routine 2. Special Chemistry
3. Routine Chemistry 3. Special
fecalysis 3. Blood typing and Hematology
4. Blood Typing crossmatching - 4. Immunology/Serol
HB HB ogy
5. Quantitative 5. Microbiology
Platelet
Determination
- HB
Minimum 10 square meters 20 square meters 30 square meters
Space
Required
Minimum 1. Clinical 1. Primary 1. Secondary
Facilities centrifuge Laboratory Laboratory
Required 2. Hemacytomete equipment/instru equipments/instru
r ments ments
3. Microhematocr 2. Refrigerator 2. Incubator
it centrifuge 3. Photometer or its 3. Trip/Analaytical
4. Microscope equivalent balance
with OIO 4. Water bath or its 4. Rotator
5. Hemoglobino equivalent 5. Serofuge or its
meter or its 5. Timer or its equivalent
equivalent equivalent 6. Autoclave
6. Differential 7. Drying Oven
blood cell 8. Biosafety cabinet
counter or its or its equivalent
equivalent

Tertiary Laboratory Sections Blood Banking Section

Microbiology/Immunology Section
Histopathological Section
Serology and Immunology Section
Microbiology Section
Clinical Chemistry Section
Hematology Section
Clinical Microscopy Section
Laboratory Departments Specimen
Processing
Specimens are sorted, accessioned
into the computer system of the lab.
Labeled for transport to their
respective department
Prepare specimen for transport to
reference lab
Laboratory Departments Hematology
Hematology the scientific study of blood and its components
Red Blood Cells (Erythrocytes)
o Produced in the bone marrow by stem cells
o Consists of hemoglobin, the gas-transporting protein molecule that gives blood its
red color
o Functions:
Transport oxygen from the lungs to different parts of the body
Carry carbon dioxide back to the lungs
o Conditions associated
Anemia low number of RBC
Polycythemia high number of RBC
White Blood Cells (Leukocytes)
o Mobile blood cells
o Produced in the bone marrow by stem cells
Functions:
Defend the body against infection
Types of leukocytes (WBC)
Granulocytes:
o Neutrophils
Most numerous
Protects the body form infection by killing and
ingesting bacteria, fungi, and foreign bodies
o Lymphocytes (25%)
T-cell reorganizes foreign substances and
processes them for removal
B-cell produces antibodies
NK cell kills cancer cells
o Eosinophils (1% - 3%)
Kill parasites
Activates allergic responses
o Basophils (< 1%)
Involved in allergic responses
Monocytes (5% - 10%) ingest bacteria/foreign bodies
o Dendritic cell
Marks out cells that are antigens (foreign bodies)
that need to be destroyed by lymphocytes
o Macrophage
Larger and lives longer than neutrophils
Able to act as an antigen-presenting cell
Platelets (Thrombocytes)
o Cell fragments
o Also produced in the bone marrow by stem cells
 o Functions:
Adhere to the walls of the blood vessels to plug ruptures, thereby
preventing the release of blood
Release chemicals that cause clots in the blood
Plasma
o The clear yellow liquid in blood that is a combination of water, sugar, fat, protein,
and salt solution
o Composes 55% of a normal humans blood volume
o Functions:
Transports the RBC, WBC, and platelets through the blood vessels
Removes the waste products of metabolism
Hematology also includes phlebotomy or the process of blood collection
Phlebotomy refers to the standard procedure of blood collection using lancets and
needles of varying gauges
Types of Phlebotomy
o Skin puncture capillaries
o Venipuncture veins
o Arterial puncture arteries
Blood separation technique refers to the process of centrifuging collected blood to
separate it into three layers: plasma/serum, buffy coat, and packed RBC
Formed elements refer to the cellular components of blood routinely counted in the
hematology section of a laboratory

Note page 183 to 193 in the book.

Laboratory Departments Hematology

Purple Tube contains EDTA
Blue Tube coagulation
Coagulation Testing
o Hemostasis process wherein the final product is clot formation -> coagulation
factors measure of time how long until?
Bleeding Time (BT)
Clotting Time (CT)
These two are done when the patient is about to undergo surgery to
test hemorrhage or excess bleeding
Prothrombin Time (PT)
Activated Partial Thromboplastic Time (APTT)
These two tests monitor if the drugs issued are enough, inadequate
or if its overdosed
Note: fibrinogen the only protein found in plasma and not in serum because it is a clotting
factor. Serum clots, it uses up the fibrinogen.
 CLINICAL CHEMISTRY
- involved in the analysis of biological materials, usually body fluids, to provide diagnostic results
on the state of the human body
- uses plasma or serum
- automated machines
- perform panel tests
- In order to rule out diseases for a specific organ
- Group of tests which are used by physicians to diagnose cardiac problems
- RED TUBE: no anticoagulant
- serum: clear than plasma; any turbidity in the specimen may give false results; has no plasma and
fibrinogen because of the presence of anticoagulant

Routinely Requested Clinical Chemistry Assays

A. Blood Glucose
Diagnosis of diabetic conditions
Hyperglycemia - high sugar level
Hypoglycemia - low sugar level
Diabetes - elevation of blood glucose in a fasting state, lacking insulin (hormone)
Diabetes Mellitus - deficiency in pancreatic hormone insulin
FBS - fasting blood sugar
Carbohydrates
B. Blood Lipid Profile
Lipids - regarded as fat, insoluble in water
Fatty Acids - simplest form of lipids but not routinely measured
Triglycerides - neutral fats consisting of fatty acids and glycerol
Cholesterol - diagnosis of cardiovascular diseases
Phospholipids - most abundant form of lipids but not routinely measured
Lipoproteins - lipid supporters, lipids & proteins; lipids are with proteins to transfer them to the
liver
HDL (high-density lipoprotein)
good cholesterol
high levels of HDL: suggest decreased risk of developing atherosclerosis - hardening and
narrowing of arteries
VLDL (very low-density lipoprotein)
transports endogenous triglycerides to the muscle and adipose cells
LDL (low-density lipoprotein)
bad cholesterol
increased levels: suggest risk of developing atherosclerosis
Chylomicrons
transports exogenous triglycerides to the muscle and adipose cells
C. Kidney (Renal) Function Tests
 NPN: non-protein nitrogen
Creatinine - waste product of muscle metabolism
Blood Urea Nitrogen (BUN) - waste product of protein catabolism
Low BUN levels - during starvation, pregnancy and a low-protein diet
High BUN levels - a high protein diet; after administration of steroids; kidney disease
Glomerular Filtration Rate (GFT) - used to check how well the kidneys are working; measure
how well kidneys are filtering the blood
D. Liver Function Tests
Bilirubin - brownish yellow substance found in the bile; produced when the liver breaks down
old red blood cells
Liver Enzyme Tests
(AST) Aspartate Aminotransferase
(ALT) Alanine Aminotransferase
Note: if there are elevated amounts of both AST and
ALT, then there
most likely liver damage present
(AST/ALT Ratio) De Ritis Ratio identify hepatic disorders
(ALP) Alkaline Phosphate diagnosis of bone and liver diseases
(GGT) Gamma-Glutamyl Transferase diagnosis of chronic
alcoholism
Chloinesterase assessment of insecticide and pesticide poisoning
Total Serum Protein test - measures the total amount of protein in blood
Prothrombin Time (PT) - test of plasma-clotting activity

E. Cardiac Function Tests

Troponin Test - most sensitive and specific test for myocardial damage
Myoglobin - ordered as a cardiac biomarker to help diagnose or rule out a heart attack
Cardiac Enzymes
CK-MB (Creatine Kinase)
AST (Aspartate Aminotransferase)
LDH (Lactate Dehydrogenase)

F. Special Chemistry Tests: Tumor Markers

Tumor marker is a biomarker indicative of an inherent cancerous condition:
AFP (Alpha-fetoprotein) - hepatocellular carcinoma
CEA (Carcinoembryonic antigen) - gastrointestinal cancer
PSA (Prostate-specific antigen) - prostate cancer
hCG (Human chorionic gonadotropin) - gestational
trophoblastic disease
NSE (Neuron specific enolase) - neuroendocrine tumor
CA 125 - ovarian cancer
CA 19-9 - pancreatic cancer
CA 15-3 - breast cancer
Calcitonin - medullary thyroid carcinoma
Desmin - smooth muscle sarcoma
 SEROLOGY - IMMUNOLOGY
- identifying and quantifying antigens (substance capable of stimulating an immune response) and
antibodies (proteins made by plasma cells in response to an antigen)
- investigating problems or disorders with the immune system
- determining organ, tissue and fluid compatibility for transplantation

IMMUNOLOGY
immune system
deals with the response of an organism to antigenic challenge
the disease is already there
SEROLOGY
Involves detection and measurement of antigen and antibody

Antibody Titer - concentration of antibody; measures the presence and amount of antibodies in
blood
Pregnancy test
HIV test
Dengue duo test - presence of virus
HBsAG rapid test - hepatitis
Test if positive for hepa-B antigen
Bacterial agglutination tests - detect bacterial infections associated w/ persistent fever
Observing agglutination (Clumping of cells)
Widal test - specific test for typhoid fever
Weil-Felix test - non-specific test for typhus fever

IMMUNOHEMATOLOGY/BLOOD BANKING
- focuses on the presence of antigens and antibodies on cells/plasma
Blood Typing
Antibody Screening
Crossmatching - for transfusions (compatibility test)
blood is compatible with donor
adverse reaction
Antigens and antibodies
In the case of the ABO blood groups, the antigens are present on the surface of the red blood cell,
while the antibodies are in the serum
Rh - either positive or negative
- Karl Landsteiner - developed the ABO blood group

ABO Blood Type Antigen on RBC Antibody in Serum/Plasma

A A-antigen Anti-B
 B B-antigen Anti-A

AB A-antigen/B-antigen No Anti-A & Anti-B

O No antigen Anti-A and Anti-B

**Anti-B - yellow; Anti-A - blue; Anti-AB white

- Test Tube Method of ABO Grouping

Cell typing/grouping (direct/forward typing)
- Determine what antigens are present on the surface of red blood cell with known Anti A & B
- Most common
Serum typing/grouping (backward, reverse and indirect typing)
- Determine what antibodies are present in the serum or plasma with A & B cells
- Anti-A + Blood Type A = agglutination

Rh Blood Group System

- determine the presence and absence of the D antigen on the surface of the red blood cells

a. Rh positive - presence of the D antigen; agglutination w/ anti-D

b. Rh negative - absence of the D antigen; no agglutination w/ anti-D

**Can you transfer RA+ and RA-?

- YES
- no reaction
- effect: develop antibody to antigen
- complication: second transfusion

CLINICAL MICROSCOPY
Urinalysis
- Physical appearance of urine
- Chemical and microscopic analysis
Semen Analysis
Cerebrospinal Fluid (CSF)
Stone Analysis - kidney stones; gall bladder stone
Pleural fluid - lungs
Sputum - a mixture of saliva and mucus
Stool examination
Abdominal
Pericardial - heart
Synovial - joints
Amniotic fluid - protective liquid contained by the amniotic sac of a pregnant female

Physical Appearance of Urine

A. Color
- Attributed to the presence of three coloring pigments: urochrome, urobilin and uroerythrin
- Rough indication of the state of hydration of an individual
- light yellow to yellow (there is a standard container for objectivity)
- Urines should be placed in a same colored container to prevent errors
B. Transparency
- Clear, hazy, turbid
- Must be checked in a black background
C. Volume
- indicates balance between fluid ingestion and water lost from lungs, sweat and intestines
- 1000-2000 mL of urine per day
D. Specific Gravity
- amount of solute present in the solvent
Refractometer - measurement of an index of refraction
Urinometer - used for measuring the specific gravity of urine
Dipstick - basic diagnostic tool used to determine pathological changes in a patient's urine in
standard urinalysis (spg, pH, protein, sugar); for qualitative; it may have 3 or 10 parameters
- Greater RBC, greater solute
E. pH
- measures the acidity and alkalinity

Chemical Examination - Qualitative: presence/absence

*if present = might have a disease
Protein
Glucose
Blood
WBC - pus cells - disintegration of WBC
Nitrite - presence of bacteria
Bilirubin - breakdown product of RBC - detoxification product
Ketones - breakdown of fatty acids
*qualitative - presence and absence
*quantitative - amount present
*qualitative tests first before quantitative

Microscopic Examination
RBC: hematuria
- #/HPO
- Range: (1-2)
WBC: pyuria
- #/HPO
- Range: (0-1)
Epithelial cells
- cells found on the lining of nephrons and urinary tract
- squamous cells (large and flat), renal epithelial cells (round and uninucleate), transitional bladder
EC (urothelial cells)
- Occasional/rare
Bacteria
- Presence of infection - UTI (nitrite + WBC)
Casts: cylinduria or cylindroiduria
- Types: hyaline, granular (coarse and fine), and cellular (RBC, WBC, EC, waxy cast, fatty cast)
Crystals: crystalluria
- Indicates starting of stone formation depending on pH level
- acidic or alkaline
- Calcium oxalate crystals, uric acid crystals
*scanner (not all microscopes) LPO (10x) HPO (40x) Oil immersion (100x)
Process:
1. Measure urine sample
2. Observe and take note of qualitative characteristics
3. Place dipstick into the urine sample
4. Place in a centrifuge
5. Pour out supernatant
6. Mix sediment
7. Pour 1 drop of sediment on a glass slide
8. Cover with coverslip
9. View under microscope

MICROBIOLOGY/PARASITOLOGY
- identification of pathogenic microorganism
- antibiotic sensitivity testing cultivate bacteria
- identification of parasites

Branches of Microbiology
Protozoology - protozoa: single-cell
Mycology - fungi
Bacteriology - bacteria
Rickettsiology - rickettsiae
Virology - virus

Direct Fecal Smear (Routine Procedure)

1. Add 1 drop of NSS - Normal Saline Solution
2. Mix and cover
3. Observe under microscope
Stool Examination
A. Color
B. Consistency
Formed
Soft
Mushy
Watery
Mucoid - presence of amoeba
*Microns - measure word of microorganisms

Antibiotic Sensitivity Testing Process

1. Place specimen on an agar plate
2. Allow to grow for 14 hours
3. Identify bacteria through biochemical test
4. Create sensitivity discs
5. Incubate for 24 hours and observe bacterial growth around each disc

ZONE OF INHIBITION
- indicates the extent of the test organisms inability to survive in the presence of the test antibiotic
- sensitive to the antibiotic
NO ZONE OF INHIBITION
- indicates resistance of the bacteria to the test antibiotic
7. Histology/Pathology/Cytology
Histopathology - Tissues samples are processed
o Tissues a group of cells part of your organ
Examine for presence/absence of carcinogen cells or abnormal cells
o Biopsy surgical procedure to take a part of an organ
Then the specimen submits it to a lab the lab only processes and stains
the specimen the physician/pathologist examines it for abnormal cells
o Different Processes
Fixation
Dehydration
Infiltration
Examined for abnormal function and form
Examination for various specimen for abnormal cells and chromosomal studies
Pap smears method of screening for cervical cancer
o Vaginal wall cells specimen
o The cells are smeared on a slide and then studied

Routine and Special Tests in Anatomic Pathology

1. Routine Histopathological Examinations
a. Numbering process of recording tissue
b. Fixation preserving the tissue specimen
c. Dehydration process of removing water from the specimen
d. Clearing process of removing excess alcohol
e. Infiltration process of filling up tissue spaces or cavities using melted paraffin
f. Embedding/Molding placing the infiltrated tissue in a mold
g. Trimming process of removing excess paraffin
h. Sectioning/Microtomy the tissue is cut into thin slices via microtome
i. Staining the use of hematoxylin and eosin dyes to differentiate the cells
j. Mounting the process of putting the cover slip on the stained tissue
k. Labeling the means of identifying the specimen
2. Fine Needle Aspiration Biopsy (FNAB)
a. A diagnostic technique used to investigate superficial (under the skin) masses or
lumps
3. Papanicolau Smear (PAP Smear)
a. A method ofscreening for cervical cancer and pre-cancerous changes in the
cervix.
 b. Also detects Sexually Transmitted Diseases (STDs) such as Trichomoniasis,
Candidiasis, and Human Papilomavirus (HPV) Infections
4. Cytopathological Techniques
a. Cell Block a paraffin-embedded specimen prepared from dried mucus, sputum,
and debris found in pleural fluids, pericardial fluids, and other sites that cannot be
processed in the usual fashion (routine histopathological procedures)
b. Cytospin a cytological technique specifically designed to concentrate cells on a
slide in a uniform monolayer using a high speed centrifuge. The monolayer
distribution improves the morphological appearance of the cells present
5. Frozen Section (Cyrosection) Technique
a. Performed when an immediate or rapid microscopic analysis of a specimens
needed
6. Brest Panel
a. Consists of biomarkers that are important in the genetic testing for breast cancer
7. Special Staining (Histochemistry)
a. Use of special stains to determine the chemical compounds and their distribution
within and in between the biological cells of the body.
8. Immunohistochemical Staining
a. The process of detecting antigens (proteins) in the cells of tissue sections by using
the principle of antibodies binding to specific antigens
9. Post-mortem Examinations (Autopsy or Necropsy)
a. A highly specialized surgical procedure that consists of a thorough examination of
a dead body to determine the cause of death

Why is Laboratory Testing Performed?

To assign a diagnosis
o Confirm clinical diagnosis the signs and symptoms need to match
o To establish an appropriate plan of action
Prevention of early detection of diseases through screening tests
Ongoing assessment of the patients progress and treatment
o Follow up on a treatment to see if its effective
Cancer: to see if a treatment (i.e. chemotherapy) is effective
Diabetes: to see if the medicine is working via glucose monitoring

Information Flow in a Clinical Laboratory

Laboratory requisition
o A form used by physician to document the tests that are to be performed on
patients
o Contains the following
Patients Demographic Info: name, address, birthday
Patients Birthday used to differentiate patients with similar names
Test Selection should be marked clearly
Additional comments i.e. patients diagnosis
Important points to remember of specimen collection and handling:
o Proper identification of patients mistaken identity is common for inpatients
 Check hospital tag, ask for their name dont tell them their names
o Correct patient preparation
i.e. if the patient needs fasting 6-8 hours for glucose, 12 hours for
triglycerides/cholesterol
o Correct use of collection tubes used the correct color tube
o Correct anticoagulants use the correct color tube
o Correct order of Draw
Yellow (Bacteriological) -> Light Blue (Coagulation) -> Red (Clinical
Chemistry) -> Purple (Hematology)
o Use of preservatives

Laboratory Report Inclusions

Date and time of specimen collection
Name and identification number of the patients
Date and time of test analyses was done
Results of the tests performed w/ reference range (aka normal range)