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CHAPTER- 2
CLINICAL PATHOLOGY

INTRODUCTION

Disease is the lack of perfect health. Pathology is the subject that deals with the causes, mechanisms
and alterations in structures and functions in diseases. In brief, it may be said that pathology is the
subject that answers the two questions –Why and how diseases occur.

Why there is a disease? A disease is due to structural and/or functional changes of the body or any of
its constituent parts. The structural changes may be detectable with the naked eye (gross or
anatomical changes) or only with the microscope (histological and cytological changes). Further there
may be changes only at the molecular level of a chemical substance (molecular pathology), e.g.
haemoglobinopathy, inborn errors of metabolism. In terms of biochemistry, a disease is due to change
in certain chemical reaction.

Pathogenesis is the sequence of events in the establishment of the disease from its beginning.

How a disease is caused? The factors or agents which are responsible for diseases are
called-‘Causes’ or ‘Aetiology’.

ERYTHROCYTE SEDIMENTATION RATE (ESR)


1. Definition: When blood mixed with suitable anticoagulant and is allowed to stand in a
vertical position, red blood corpuscles settle down to the bottom. The rate of which this sedimentation
of red cells takes place at the end of 1st hour is known as erythrocyte sedimentation rate (ESR)
2. Normal values: These are two methods available to determine ESR and accordingly the
normal volume of ESR also vary from method to method. These are mentioned below.
a. Westergreen method
(1) Male 0-8 mm in 1st hour.
(2) Female 0-10 mm in 1st hour.
b. Wintrobe method

(1) Male 0-8 mm in 1st hour


(2) Female 0-20 mm in 1st hour.
3. Clinical importance of ESR ESR is a nonspecific supportive test and is useful as a
screening test and in differential diagnosis. ESR is of value in assessing the severity of a disease and
also to follow progress. A normal ESR can not be taken to exclude organic disease. An Increased
value suggests organic disease. A raised ESR is particularly characterized of the acute phase response
to inflammation.
HAEMOGLOBIN
1. Definition Haemoglobin is the main constituent of red cell and is a red globular protein
molecule. The red colour of blood is due to haemoglobin.
2. Types of haemoglobin.

a. Normal haemoglobin
(1) Adult.
(a) Haemoglobin A.
(b) Haemoglobin A2
(2) Foetal.
(a) Haemoglobin F
(b) Haemoglobin Bart’s
(3) Embryonic.
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b (a) Haemoglobin gower I


c (b) Haemoglobin gower II
d (c) Haemoglobin gower III
e (d) Haemoglobin Portland.
b. Abnormal Haemoglobin
(1) Haemoglobin C
(2) Haemoglobin S
(3) Haemoglobin D
An adult has about 90% HbA, 3% HbA2, and 1% HbF. A new born infant has about 70% HbF and
30% HbA.
3. Normal values of haemoglobin Normal values of red cells and haemoglobin are high in
first day after birth. These fall from age of these months to one year, then rise slowly through child
hood to adult value, Such vary of haemoglobin are enumerated below in relation to sex and age of
the patient.
a. Men 15.5 ± 2.5 gm/dl – 14-18 gm%
b. Women 14.0 ± 2.5 gm/dl –11.5-16.5 gm %
c. Infant, full term. Cord blood. 16.5 ± 3.0 gm/dl 13.5 – 19.5 gm %
d. Children 1 year 12.0 ± 1.0 gm/dl 11.0 – 13.0 gm %
e. Children 10-12 Years 13.0 ± 1.5 gm/dl 11.5 – 14.5 gm%

4. Clinical use of Haemoglobin test: Clinically the haemoglobin test is done to asses the
anaemic condition of the patient as well as to follow up or prognosis of the patient in various
systemic diseases after treatment.

TCEC
1. The abbreviation TC EC designates total circulating eosinophil count. Eosinophil is a granular
leukocyte in the blood, containing coarse reddish granules and two lobed nuclei in their cytoplasm
2. Count The count is done with haemocytometer and WBC pipette. Normal range of
TCEC count in the peripheral blood of normal adult ranges from 60-400/mm 3 (0.04 to 0.4 X 109 ) and
the percentage of eosinophils among blood leucocytes varies, from 1 to 6 percent.
3. Clinical importance of TCEC: When the number of eosinophil in the peripheral blood
increases above the normal range is called eosinophilia. Few common clinical conditions are
mentioned below.
a. Allergic states Asthma, Drug allergy, food sensitivity, Angioneurotic oedema,
articaria, serum sickness, exfoliative dermatitis, Hay fever, erythema multiform
b. Parasitic disease
f (1) Intestinal forms- Ascariasis, Ankylostomiasis, Taeniasis.
g (2) Tissue forms- Trichinellosis, Strongyloidiasis, Filariasis, and Malaria.
c. Skin disorders Scabies, Psoriasis, Pemphigus, Dermatitis Herpetiformis,

d. Drugs Penicillin therapy, streptomycin, chlorpromazine

e. Neoplastic disease Chronic myeloid Leukomia, Eosinophilic leukemia,


polycythaemia, Hodgkin’s disease, Metastasis & necrotic tumors and multiple myeloma.

f. Others Tropical eosinophilia, eosinophilic granulomatosis Eosinophil


syndrome, scarlet fever, Polyarteritis nodosa, Pernicious anaemia, Post splencetomy, Post transfusion
mononucleosis etc.

PLATELETS
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1. The platelets are 2-4 mm in diameter and stain purplish blue in Leishman’s stain. It is
developed from megakaryoblast in the bone marrow. The life span of a platelet in the circulation is
approximately 10 days. Platelet plays a central role in normal haemostasis and thrombosis

2. Normal range of platelet count: The normal range in health is approximately 150-400 X
103 /L (150,000-400,000/mm3) the average values being about 250 X 103 /L (250,000/mm3).

3. Clinical Importance Platelet count is done to assess the bleeding disorders and other
hematological disorders e.g. idiopathic thrombocytopenic purpura, Leukaemia, Aplastic anaemia,
hypersplenism, disseminated intravascular coagulation, secondary carcinoma, multiple myeloma,
malignant lymphoma and myelofibrosis etc.
BT & CT

1. The abbreviation BT stands for Bleeding Time.

2. Definition The time taken for the blood to stop flowing from the wound is known as the
bleeding time. Bleeding time depends upon the number and function of platelets. If the number of
the platelets is reduced below the normal range or they are functionally normal the bleeding time
become prolonged.

3. Method of measuring BT: By two methods.

a. DUKE’s method.
b. IVY’s method.

4. Normal Bleeding time 2-11 Minutes.

5. Clinical interpretation of bleeding time: Prolonged bleeding time commonly occurs in:

a. Thrombocytopenia.
b. Von. Willebrand disease.
c. Platelet function defects.
d. Aspirin ingestion.

CLOTTINNG TIME (CT)

1. Definition The abbreviation CT stands for Coagulation Time. When blood obtained by
venepuncture is put in glass tube clotting mechanisum are activated, soon a clot is formed or in other
words the time interval between the filling the arth blood and the appearance of fibrin thread or clot is
the coagulation time.
2. Method of doing coagulation time: By two methods.
a. Capillary tube method technique
b. Lee and white test tube method.
3. Normal range of coagulation 5-11 minutes

4. Clinical importance of coagulation time test. Whole blood clotting time is an


insensitive and nonspecific test. It will be prolonged only in severe coagulation factor deficiency. The
coagulation factor level may be as low as .1% in case of Christmas disease and hemophilia. So
coagulation time may be prolonged in:

a. Hemophilia.
b. Christmas disease.
c. Anticoagulant therapy particularly heparin.
d. Factor XII, XI, II, V, X and fibrinogen deficiency.

REACTION DUE TO MISMATCHED BLOOD TRANSFUSION


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1. Blood transfusion is a dangerous medicine unless it is properly or safely given to the patient.
So for safe blood transfusion a meticulously survey of the sample properly and cross matching and
screening test procedure of some infectious and transferable disease should be done prior to
transfusion of blood many transfusion reaction due to mismatched blood transfusion may occur
which are described below.

a. Febrile reaction- It is due to presence of white cell antibodies formed by the recipient
blood due to previous transfusion or pregnancy.
b. Haemolytic reaction- Intravascular red cell destruction leading to haemoglobinaemia and
haemoglobinuria. It is due to blood group incompatibility.
c. Circulatory overload- Pulmonary congestion, oedema and acute heart failure. It is the
most common causes of death.
d. Reaction due to infected blood with presence of gram negative bacteria produces
endotoxic shock.
e. Transfusion related diseases
(1) Hepatitis B virus, (HB virus)
(2) Hepatitis C virus (HC virus)
(3) Human immunodeficiency virus (HIV virus)
(4) Malaria
(5) Syphilis

f. Allergic reaction- It is due to lgA and anti lgA antibody.


g. Air embolism.
h. Thrombophlebitis.
i. Circulatory iron overload due to deposition of iron in vital organs of the body.
j. Post transfusion purpura – Due to dilution of blood volume and cause functional defect of
platelet.
BLOOD GROUP AND ITS TYPES

1. Human red blood cells contain on their surface a series of glycoproteins and glycolipid which
constitute the blood group antigens. The development of their antigens is genetically controlled. They
appear early in foetal life and remain unchanged until death. On the basis of these outguess at best 15
well defined red cell blood group system of wide distribution in most racial groups have been
described. They are the following-

a. The principal blood group.


h (1) ABO system- Based on group specific substance, agglutinogens present
in RBC membrane.
i (2) Rh system- Based on presence or absence of Rh antigen in blood.
j (3) MN system- Used in determining paternity.

b. Others
k (1) Kell blood group
l (2) Daffy blood group.
m (3) Lewis blood group.
n (4) L1 blood group.
o (5) Dombrock blood group.
p (6) Diego blood group.
q (7) Colton system.

2. Clinically important blood group systems are: ABO and Rh system. The ABO system is
divided into four main groups- A, B, AB and O on the presence or absence of the two antigens ; A
and B on the red cells. Group A red cells contain the A antigen, group B cells possess the B antigen,
Group AB cells possess both A and B antigens and group O cells possess neither A nor B cells.
Again, the serum of an individual contains antibodies against the antigens lacking in persons red
cells. Thus group a individual contain anti-B agglutinin, group B individual contain anti-A agglutinin.
Group AB individual contain no antibody, and group O Individuals contain both ant-A and anti-B
antibodies. Group ‘O’ donors were referred to as universal donors and group AB as universal

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recipient. But nowadays it is practically of no value. Whenever possible blood transfusion are to be
given within the same group even after proper and meticulously crosshatch.

3. The Rh system The rhesus blood group system was first demonstrated in human red
cells by the use of antisera prepared by immunizing rabbits with infection of red cells from a Rhesus
monkey. It was found that some human red cells were agglutinated by this serum known as Rh
positive cells while other were not agglutinated known as Rh negative cells. In clinical practice Rh
grouping is performed with anti D serum persons who are D positive are referred to a Rh positive and
those who are D negative as Rh negative.
4. Importance of blood group in Clinical medicine: The importance of blood group lies in
the fact that an antigen in certain circumstances reacts with its corresponding antibody and cause
harmful clinical effects.
SUGAR

1. Sugar is a constituent of any types of food which we eat is as carbohydrate. The term sugar is
used to denote all substances that can reduce benedict solution, The various forms of sugar in the diet
are: Glucose, lactose, pentose, fructose and galactose.
2. Clinical importance These sugar are completely metabolized in a healthy person with
the help of a hormone called insulin which is secreted from the pancreas . When this hormone
(insulin) is deficient or totally absent in the body, then all sugars we eat can not utilized or
metabolized in the body and thus accomodate in the blood and finally through the kidney excreted in
the urine. This high level of sugar above the normal level in the blood is called hyperglycaemia. And
low level of sugar in the blood below the normal level is called hypoglycaemia. Glucose when
excreted in this urine is called glycosuria. Normal fasting level of sugar in the blood is 80-120 mg/dl.
The random blood sugar level is up to 160 mg/dl.
3. The sugar in the wine detected by heated Benedict solution as well as with strip test method.
Sugar in the blood is measured by glucoxidase methods with the help of an instrument called
colorimeter or by analyzer methods.

4. Sugar test is used to assess both hyperglycemia and hypoglycaemia and various systemic
diseased conditions which are enumerated below:
a. Hyperglycaemia (increase in blood sugar level above the normal level of sugar)

(1) Diabetes mellitus.


(2) Hyperactivity of thyroid, pituitary, and adrenal cortex.
(3) Pancreatitis and carcinoma of the pancreas.
(4) Convulsions.
(5) Sepsis.
(6) Infections diseases.
(7) Intracranial disease like meningitis encephalitis etc.
(8) Asphyxia.
(9) Anesthesia.
r
s b. Hypoglycaemia (Decrease in blood sugar level below the normal level) below
2.2 m mol/L

(1) Over dosage with insulin.


(2) Insulinoma.
(3) Starvation.
(4) Myxoedema.
(5) Simmond’s disease.
(6) Addison’s disease.
(7) New born infants (first two days).
(8) Severe exercise.
t (9) Glycogen storage disease.
u (10) Post prandial hypoglycaemia .
v (11) Alcohol ingestion.
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UREA

1. Urea is the derivative product of amino acid formed in the liver and lost as excretory product
in the urine and some portion of it is reabsorbed to be recycled through kidneys. Total blood urea
formed per day is 25-30 g. and all of it is excreted through urine. Blood urea reference range is 3.3-
6.7 mmol/L and a minimum of 500 ml of urine per day is essential for its excretion.

2. Clinical importance of urea: When kidney function is impaired, then urea and others
can not excrete in the urine and accomodate in the blood which is called uremia. Therefore uraemia
can be defined as a syndrome characterized by biochemical and clinical changes due to profound loss
of functional nephrone mass. (Nephrone is the functional unit of kidney)

3. Causes of raised urea level


a. Prerenal causes

(1) Hypovolumic shock- occur due to haemorrhage, burn and uncontrolled


gastroenteritis
(2) Mismatched blood transfusion.
(3) Cardiogenic shock due to myocardial infarction or pulmonary embolism.
(4) Acute poisoning.
(5) Multiple myeloma.
(6) Homograft rejection.
(7) Renal artery stenosis.

b. Renal cause

(1) Acute glomerulonephritis- due to post streptococcal infection.


(2) Diabetic nephropathy.
(3) Hypertensive nephropathy.
(4) Acute tubular necrosis.
(5) Various nephrotoxic drugs. Like Gentamycin, heavy metals, Kanamycin may
damage the kidney resulting in uremia.
(6) Transplant rejection.
(7) Disseminated intravascular coagulation.

c. Post renal causes

(1) Ureteric obstruction due to stones or strictures.


(2) Urethral obstruction due to enlarged prostrate or stricture ( mainly post
gonococcal)

4. Determination of urea in the laboratory Common methods is use for the determination
of blood urea is:

a. Urease Nesslerization method.


b. Urease Berthelot reaction.
c. Diacetyl inonoxime method.
d. Xanthydrol reaction method
e. Urostrat method.

CREATININE

1. Creatinine is the metabolic end product of muscle creatine. Between 1-2% of muscle
creatinine is converted to creatinine daily. The creatinine is excreted through the kidneys. In the
absence of kidney disease the excretion rate of creatinine (creatinine clearance) and plasma level of
clearance relatively constant. Normal range of serum creatinine: 0.5-1.5 mg/dl (53 – 133 m mol/L)

2. Clinical importance: In all conditions in which there is poor glomerular function, the
level of serum creatinine rises above the normal level and is parallel with the degree of renal failure.
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ELECTROLYTES

1. The serum electrolytes refer to a solution of charged particles or ions will conduct an
electrical current. The particles may be positively charged (cations). The common cations in the body
are sodium, potassium, calcium and magnesium. The common anions are chloride, bicarbonate,
phosphate, sulphate and organic acids. The proportion of cations and anions is so balanced that
electrical neutrality is preserved. Clinically common electrolytes estimated are sodium, potassium
and chloride.

2. Sodium

a. Normal value: 132 to 144 m mol/L serum

b. Clinical importance

(1) Hypernatraemia Pathological increase of sodium is hypernatraemia.


Causes are enumerated below:

(a) Severe dehydration.


(b) Hyperadrenalism.
(c) Diabetic coma- treatment with insulin as some sodium in cell is
replaced by potassium.
(d) Nasogastric feeding of patients with solution containing a high
concentration of proteins without sufficient fluid intake.
(e) Diabetes insipidus (deficiency of anti diuretic hormone) without
sufficient intake of water to cover the fluid loss.

(2) Hyponatroemia Pathological decrease of sodium is called


hyponatraemia. Causes are enumerated below.

(a) A large loss of gastrointestinal secretions occurring with –


i. Diarrhoea.
ii. Intestinal fistula.
iii. Severe gastrointestinal disorder.
iv. Hyponatraemia occurs when replaement is made with water
only.

(b) Acidosis of diabetes mallitus before the coma stage.


(c) Renal disease with malformation of tubular on exchange
(d) Addison disease with depressed secretion of aldosterone and
corticosteroid.
w (e) Diabetes insipidus with compensatory intake of water.

3. Potassium

a. Normal value 3.8-5.0 m mol/L serum.

b. Clinical importance: Pathological increase of potassium is called hyperkalaemia such


conditions are: uremic, coma, oliguria, intestinal obstruction, and Addison’s disease.
Pathological decrease of potassium is called hypokalaemia such condition is:-

(1). Sever vomiting.


x (2) Diarrhoea.
y (3) During treatment of diabetic coma with insulin
z (4) Cushing syndrome.
aa (5) Familial periodic paralysis during the attack.

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4. Chloride

a. Normal value 95 to 105 mmol/L serum


Urine: 170-250 m mol/ 24 hours, or 6-8.8g/ 24 hours

b. Clinical importance Pathological increase causes in the following reasons.

bb (1) Dehydration.
cc (2) Certain types of renal tubular acidosis.
dd (3) Respiratory alkalosis that stimulate respiratory center and causes over
breathing

c. Pathological decrease of chloride Held due to the following causes.

(1) Metabolic acidosis (with high anion gap)


(2) Uncontrolled diabetes mallitus
(3) In renal disease.
(4) Pyloric stenosis.
(5) Intestinal obstruction.
(6) Salt losing nephritis.

LIVER FUNCTION TEST (LFT)

1. Certain tests commonly used in the investigation of actual or suspected liver dysfunction.
Since the function of the liver are almost innumerable. Its reserve capacity is enormous and its ability
to resture and regenerate are quite phenomenal, no one test is capable of measuring the degree or
nature of its dysfunction. For this reason multiple test are commonly employed though the good
clinician will often be judicious in his selection of investigations. A chalk of such liver function test
is noted below:
a. Biochemical test
ee (1) Bilirubin.
(a) Blood – increased bilirubin is called hyperbilirubinaemia and cause
founding normal blood bilirubin 0.2 to 1.0 mg/dl
(b) Urine test for bilirubin and urobilinogen
(2) Enzymes
ff (a) Aminotransferase.
i Alanine aminotransferase (ALT) normal range 10-35 U/L
gg ii. Aspartate aminotransferase (AST) normal range 10 – 35
U/L
hh (b) Alkaline phosphate- normal range 98-279 U/L
ii (3) Serum protein: Total serum protein, albumin & globulin.
jj (4) Coagulation factor- Prothrombin test.
kk (5) Other determinations – Ferritin, Iron binding capacity saturation,
Alpha 1- antitrypsin, Alpha fetoprotein, Ceruloplasmin, and Copper
b. Serological tests

ll (1) Viral antigens and antibodies


mm (2) Autoantibodies.
c. Uses of liver function test

nn (1) Differential diagnosis and prognosis of jaundice.


oo (2) To assess the extent of liver disease.
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pp (3) To follow the progress of liver damage.

LIPID PROFILES

1. Lipids are an essential element of the body tissue and play an important role in all aspects of
biological life. The main constituents of total serum lipids are cholesterol, cholesterol esters,
phospholipid and triglycerides.

2. In the body, lipids are complexed with certain protein which keeps them soluble in the
plasma. This complex of lipids with protein (apolipoprotein) is called lipoprotein. When body level
of this lipid fraction are increased above the normal level , then saturation occur and get deposited in
the blood vessels and other vital organs of the body and then cause slow streaming of blood
circulation resulting lack of blood supply in the organs with dynamic changes and other organic
dysfunction
3. Some clinically important plasma lipid fractions with their normal values are noted below:
qq a. Serum cholesterol: Normal range –150-250 mg/dl
rr b. Serum triglyceride: 60-150 mg/dl
ss c. Serum high density lipoprotein(HDL): Normal range->35 mg/dl in male and
->45 mg/dl in female
tt d. Serum low density lipoprotin : Normal range : <130 mg/dl

PROCEDURE OF COLLECTION OF VARIOUS SPECIMEN AND PRECAUTIONARY


MEASURES

a. The collection of various specimens for different tests, their transport and storage until
they are tested are the most important steps for any laboratory investigations. Any mistake at
this level renders all the labour fruitless. The test report becomes doubtful or insignificant
therefore all necessary precautions must be taken at this step.

b. When a patient comes for a laboratory test he usually brings a test request form. This
form should be checked for its completion particularly in respect of patient identification.
Then the tests requested should be noted. If there is any difficulty in reading or understanding,
it should be clarified from a qualified person or the patient’s doctor before proceeding any
further. One must know what specimen is required and what time for a particular test
requested. Then the patient should be appropriately registered and should be allotted a
laboratory identification number.

c. Before collecting specimens all containers must be labeled properly giving full details
of patient identification. The practice of labeling after collection of specimen may lead to
change in specimens particularly at rush hours. It is justifiable that the patient and his sample
should also be identified by a laboratory number in addition to his own identification data like
number, age, sex, ward, hospital and bed number.

d. There are a number of specimens which are required for different test but most
commonly required are those of blood urine and faeces. Some special specimens like swabs,
aspirates and smears are best collected by examining doctors. A short account of specimen
collection in various wing of the hospital laboratory or pathology department are narrated
below.

(1) Clinical pathology

(a) Urine for routine examine: The container should absolutely dry,
clean and dust free. The collected sample should be sent to the laboratory
within ½ an hour to 1 hour of collection. If delayed it should be refrigerated.

(b) Stool for routine examination: The container should be properly


a glass container or a plastic container which should be absolutely dry, clean
and dust free.
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(c) Sputum for routine or tuberculosis bacilli examination Specimen


of sputum should be of 24 hours collection and must be collected in a plastic or
glass container with a close lid. If delayed to send in the laboratory of should
be refrigerated

(d) Any aspiration fluid for routine examination: Several test tube
(5-6 test tubes) should filled and send to the laboratory without delay. The
cultural or microbiological sample of the aspirated fluid should be collected in
an autoclaved dry and dust free test tubes.

(e) 24 hours urine for total protein estimation: 24 hours urine for
total protein estimation is collected in a big container containing 10 ml toubne
as preservative.

(f) Semen analysis: A dry clean and dust free test tube for collection
is given to the patient.

(2) Biochemistry

uu (a) Blood sugar estimation About 2 ml fresh blood is


collected in a bottle containing 100 ml sodium flouride and EDTA 200ml.
vv
(b) For urea, electrolytes, creatinine, liver function test, lipid profiles,
Bilirubin cardiac enzymes, calcium, serum. Iron, TLBC and protein profiles
about 5-10 freshly drawn blood should be collected and immediately sent to
the Biochemistry department.

ww (3) For serology

(a) Prothrombin time (PT), Activated partial Thromboplastin test (APTT),


fibrinogen and fibrinogen degradation product (FDP) test 1.8 ml blood should
be collected in a clean dry container containing 3.2 % trisodium citrate of 0.02
ml or 200 ml.
(b) For VDRL, TPHA, RA test, ASO Titer, CRP, HBsAg, HIV test Anti
HCV or any serological test. About 5-10 cc freshly drawn blood should be
collected in a dry clean and dust free test tube.
(c) Urine for pregnancy test Preferably morning sample of urine
should be collected in a clean dry & dust free test tube and immediately to be
sent to the department within half an hour after collection.

(4) Bacteriology

(a) Any specimen for culture sensitivity test should be collected in on


autoclaved or sterilized container which will be easily available in some of the
bacteriological department.

(5) Hematology

(a) Blood for TC, DC, ESR and Hb %. About 2 ml blood should be
collected in a dry clean container. 0.2 ml Ethylene diamine tetra acetic acid
(EDTA) as anticoagulant
(b) Blood for malarial parasites one thin and one thick film should be
prepared in two dry microscopic glass slide and dried in the air and then to be
sent to the hematology department. .
(c) For Blood grouping and Rh factor- About 2 ml blood to be collected in
an EDTA bottle. Collections are to be sent to the hematology department.
(d) For blood grouping and crossmatching – About 5-7 ml blood is
collected in a dry, clean and dust free plain test tube and then to be sent to the
transfusion wing of the hematology department.
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(6) Histopathology

(a) The ready made container containing 10% formal saline solution is
available in the pathology department. The disputed tissue is just put into such
containers which will preserve the tissues for at least 4 weeks.

(7) Biopsy

(a) A jar containing Ethyl alcohol is made ready. After needle aspiration
the fluid is spread into several microscopic glass slides and then these slides
are immerged into the jar containing ethyl alcohol and kept up to 30 minutes
for proper fixation.

ROUTINE EXAMINATION OF URINE TEST

1. Physical examination

a. Quantity: The total urinary out put 700 to 2500 ml in 24 hours.

b. Colour: The normal urine is straw coloured due to the presence of urochrome &
urobilinogen due to drugs- yellow. It is red or dark brown due to blood pigments, yellow,
orange or green due to bilirubin, excess of urobilinogen & milky due to chyluria.

c. Appearance The normal urine is clear & transparent. It is smoky due to presence
of blood. It is hazy or turbid due to presence of deposits.

d. Sediment: The mucus may settle as whorly deposit. There may be unorganized
and organized deposits.

e. Specific gravity: The normal specific gravity in between 1’010 to 1’020. It is


high when the urine is concentrated or contains substance like sugar, protein, calcium oxalate
crystal or urates. It is low when urine is dilated as in chronic nephritis or after large intake of
fluid. It is also low in diabetes insipidus
2. Chemical examination:
a. Reaction (PH): The normal urine is always acidic. It is alkaline when the diet is
mainly of vegetables and it is decomposed.
b. Protein (Albumin: In normal urine, it is always absent. It may be present due to
organic disease, such as:
(1) Nephrotic syndrome.
(2) Chronic glomerulonephritis.
(3) Renal infections.
(4) Acute tubular necrosis.
(5) Toxaemia of pregnancy.
c. Reducing substance: In the normal urine it is always absent. The reducing
substances are sugar, glucose, fructose, lactose, pentose and glactose etc.
d. Blood: The presence of blood in the urine may be evident due to haematuria.
e. Bile salts: They are absent in normal urine and present in obstructive jaundice.
f. Bile pigments: In normal urine bilirubin is absent which is soluble in water.
3. Microscopic examination:

a. The urinary deposits may be unorganized or organized substances.

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(1) Unorganized deposits: These are mostly in the form of crystal


substances.

xx (a) Calcium oxalate crystal.


yy (b). Uric acid crystal or sulphonamide crystal etc.
(2) Organized deposit These may be cellular cast of spermatozoa such as :
zz (a) Leucocytes.
aaa (b) Erythrocytes.
bbb (c) Epithelial cell.
ccc (d) WBC cast.
ddd (e) RBC cast.
eee (f) Hyaline cast.

ROUTINE EXAMINATION OF STOOL

1. General examination of stool should be a part of routine investigation. The routine


examination comprises
a. Naked eye examination.
b. Chemical examination &
c. Microscopic examination.
2. Naked eye examination
a. Amount: The amount of stool is increased in condition associated with
diminished intestinal absorption.
b. Consistency: A normal sample of stool is formed and semisolid in consistency.
Unformed and fluid stools indicate hypermotility of the intestine. Hard stool indicates
constipation.
c. Colour: A normal sample of stool is brown in colour. A green stool is seen in
infantile diarrhoea. The stool may be black due to melaena or ingestion of iron bismuth.
d. Odour: The odour may be offensive if the exudate of a dysenteric stool is
decomposed.
e. Mucus: A trace of mucus may be present in the normal stool. Presence of
mucus more than trace is indicative of dysentery.
f. Blood: Fresh blood is present in stool when it comes from the lower part of the
alimentary canal or from the upper part without any alternation by the digestive fragments.
This may be from bleeding piles, ulcerative colitis.

3. Chemical examination of stool:

a. Reaction: The reaction is normally slightly alkaline

b. Occult blood test: The test is done for detection of altered blood or trace of blood
which is not visible with the naked eye.

4. Microscopic examination of stool:

fff a. Intestinal protozoa


(1) Entameoeba histolytica
(2) Giardia.

b. Helminths

ggg (1) Taenia saginata.


hhh (2) Hymenolepsis nana.
iii (3) Ascaris lumbricoides.
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jjj (4) Enterobius vermicularis.


kkk (5) Strongaloides stercoralis.
lll (6) Trichuris trichiura.

c. Fat: Droplets of fat may appear in incomplete digestion.

5. Microscopic examination of stool:

a. Vegetable cells: May be present in normal stool.


b. Pus cells: Presence of pus cells indicates the presence of an inflammation.
c. RBC: Presence of red cells indicates an inflammatory or other bleeding condition
in intestine.
d. Macrophages: These are large phagocytic cells often showing small projection
of pseudopodia.

CAUSATIVE ORGANISM OF VARIOUS DISEASES

a. Bacillary dysentery = Shigella.


b. Measles = Paramyxo virus/Measles virus.
c. Enteric fever = Salmonella typhi & Salmonella paratyphi.
d. Gonorrhoea = Neisseria Gonorrhoeae
e. Dengue fever = Flavi virus
f. Syphilis = Treponema Pallidum
g. Malaria = Protozoa of genus plasmodium
h. Tetanus = Clostridium Tetani.
j. Chicken pox = Varicella Zoster Virus
k. Cholera = Vibrio cholerae
l. Typhoid = Salmonella Typhi
m. Mumps = Paramyxo virus/Mumps virus.
n. Diphtheria = Corynebacterium diphtheriae.
p. Tuberculosis (TB) = Mycobacterium Tuberculosis.
q. Influenza = Influenza viruses A, B, C.
r. Anthrax = Bacillus Anthracis.
s. Plague = Pasteurella pestis.
t. Poliomyelitis = Polio virus.
u. Rabies = Rabies virus.
v. AIDS = HIV (Human Immunodeficiency Virus)
w. Chancroid = Haemophilus ducreyi
x. Hepatitis B = Hepatitis B virus
y. Trichomonas Leucorrhoea= Trichomonas Vaginalies
z. Scabis = Sarcoptes scabie
aa. Vaginal Candidiasis = Candia alvicans
ab. Fungus = Tinea
ac. Leprosy = Mycobacterium Leprae
ad. Filariasis = Wuchereria Bancroftia

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NORMAL RANGE

a. CP (Complete picture) =
1. Haemoglobin (Hb%)
Men - 13.5 – 18.0 g/dl
Women - 11.5 – 16.0 g/dl
Child - 11.5 – 14.5 g/dl
Infant - 13.5 – 18.0 g/dl
2. TLC (Total Leucocytes Count)
Adult - 4000 – 11000/cmm
Child - 6000-18000/cmm
Infant - 10000 – 25000/cmm
3. DLC (Differential Leucocytes Count)-
Neutrophil - 45 – 75%
Eosinophil - 01 – 06%
Basophil - 0 – 01%
Lymphocyte - 25 – 45%
Monocyte - 02 – 10%
4. ESR =
Westergren method
Men - 0 to 8 mm in 1st hour.
Women - 0 to 10 mm in 1st hour.
Wintrobe method
Men - 0 to 9 mm in 1st hour
Women - 0 to 20 mm in 1st hour
b. Blood Glucose (F) - 4.20 – 6.40 mmol/L.
Blood Glucose (R) - < 7.8 mmol/L.
c. S. bilirubin - 0.2 – 1.0 mg/dl.
d. S. urea - 15 – 45 mg/dl.
e. S. Calcium - 8.4 – 10.4 mg/dl
f. S. Creatinine - Male - 0.7 – 1.4 mg/dl
Female – 0.6 – 1.1 mg/dl
g. S. uric acid - Men 3.4 – 7.2 mg/dl
Women 2.6 – 6.0 mg/dl
h. S. Cholesterol - Up to 200 mg/dl
j. Serum amylase - Up to 90 U/L.
k. S. CPK - Male – 25 – 193 U/L
Female – 25 – 174 U/L
l. Platelets count - 1,50,000 – 4,50,000/cmm
m. S. Electrolytes - Na – 136 – 148 mmol/litre
K - 3.8 – 5.2 mmol/litre
NaCl 95 – 105 mmol/litre
n. BT (Bleeding time) - 2 -11 minutes
CT(Coagulation time) - 5 – 11 minutes
p. Cardiac enzyme - CPK - 24-174 Unit/L
LDH - 80-285 Unit/L
SGOT - <38 Unit/L
q. Lipid profile - Serum Cholesterol - Upto 200 mg/dl
Serum triglyceride - Men -40-160 mg/dl
Women -35-135 mg/dl.
Serum HDL(High Density Lipoprotein)
- Men > 35 mg/dl
Women > 45 mg/dl
Serum LDL (Low Density Lipoprotein) - < 130 mg/dl
r. LFT - Serum Bilirubin - 0.2 - 1.0 mg/dl
Serum SGPT - Upto 38 U/L
Serum Alkaline Phosphate- 09-35 U/L

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