General Laboratory: Urinalysis: Testing Online Training

Continue Button Continue Untitled Scene Master Template HOOD05162003052540 | Effective Date: 26-Nov-2019 ? Describe how to perform a physical analysis of urine Identify formed elements in urine sediment Explain the purpose and identify the principles of each test strip chemical test Explain the procedure to perform a chemical analysis of urine Urinalysis: Testing Online Training Urinalysis is a reliable laboratory procedure for ruling in or ruling out many medical conditions and diseases. In this course you will learn about the three components of a urinalysis: a physical analysis, a chemical analysis using urinalysis test strips, and a microscopic examination. 1 4 3 2 5 Describe how a microscopic examination of urine is performed Welcome Welcome to the Routine Urinalysis Testing Online Training. Urinalysis is a reliable laboratory procedure for ruling in or ruling out many medical conditions and diseases. In this course, you will learn about the three components of a urinalysis, which include a physical analysis, a chemical analysis using urinalysis test strips, and a microscopic examination. This course will cover the following five learning objectives. For navigation help, select the question mark button located in the lower right corner of each slide. ? Physical Analysis The first component of a routine urinalysis is to perform a physical analysis of the urine. Observing urine color, clarity, odor, and volume can provide useful clues to the presence of many substances. Select the numbered steps below to learn more about observing urine properties. 1 1 1 2 2 2 3 3 3 4 4 4 Physical Analysis The first component of a routine urinalysis is to perform a physical analysis of the urine. Observing urine color, clarity, odor, and volume can provide useful clues that could help rule in or rule out a medical condition or disease, and to the presence of many substances. Color Layer: The pale-yellow color of normal urine is caused by the yellow pigment, urochrome. Pigments produced by particular diseases may cause the urine to change color. Some characteristic urine colors and causes include the following: a dark-yellow color may indicate concentrated urine; bile pigments may produce a yellow-brown or greenish color; hemoglobin gives a reddish color; porphyrins produce a dark brown-red color upon standing; and melanins cause urine to turn a brown-black color upon standing, which is known as alcaptonuria. Clarity Layer: Normal, freshly voided urine is usually clear or transparent. If the specimen is alkaline, it may have a cloudy or turbid appearance due to the presence of phosphates and carbonates. This cloudiness will usually disappear when the urine is acidified. A pinkish turbidity frequently indicates the presence of urates. Abnormal turbidity of urine may occur with urinary tract infections, but this is usually due to the alkalinity rather than the actual number of bacteria or leukocytes present. Some of the new automated urinalysis instruments are also capable of determining urine clarity. Odor Layer: The smell of normal, freshly voided urine is believed to be due to the presence of volatile acids. On the other hand, abnormal urine, such as: urine that has been standing for a long time, urine of people with diabetes mellitus or urine of people with urinary tract infections, may cause a distinct smell. While urine may have many characteristic odors, as a rule these odors are not considered diagnostically significant, although there are exceptions. Volume Layer: The normal volume of urine voided by an adult in a 24-hour period ranges from 750 to 2,000 mL, but averages about 1,500 mL. The amount voided over any period is directly related to fluid intake, temperature and climate, or the amount of perspiration that occurs. Children void somewhat smaller quantities than adults, but the total volume voided is greater in proportion to their body size. Individuals can also produce too much or too little urine: Polyuria refers to an increase in the excretion of urine. It is a physiologic response to: increased fluid intake; the ingestion of diuretic medications; certain diuretic drinks, such as coffee, tea, and alcohol; chilling of the body; nervousness and anxiety; and intravenous infusion of fluids. Polyuria occurs in several disease states, particularly in diabetes mellitus and diabetes insipidus. It is a symptom of chronic kidney disease and has been noted in patients with certain tumors of the brain and spinal cord, as well as acromegaly and myxedema. Polyuria may indicate the loss of concentrating ability by the kidneys. Oliguria refers to decreased urinary output. The extreme form, anuria refers to a total lack of urine. Oliguria occurs when there is excessive loss of body fluids as in vomiting and diarrhea; kidney shutdown through inflammation (nephritis), poisoning, or in cardiac insufficiency; mechanical obstruction of the urinary flow; decreased fluid intake; increased ingestion of salt; and excessive perspiration. Volume 4 Normal volume = 750-2,000 mL Average volume = ~ 1,500 mL Amount voided is directly related to: fluid intake temp and climate amount of perspiration Individuals can also produce too much or too little urine: Polyuria = an increase in the excretion of urine A physiologic response to: increased fluid intake; the ingestion of diuretic medications; certain diuretic drinks, such as coffee, tea, and alcohol; chilling of the body; nervousness and anxiety; and intravenous infusion of fluids Oliguria = decreased urinary output (i.e., less than 200 mL/24 hours) Oliguria occurs when there is excessive loss of body fluids as in vomiting and diarrhea; kidney shutdown through inflammation (nephritis), poisoning, or in cardiac insufficiency; mechanical obstruction of the urinary flow; decreased fluid intake; increased ingestion of salt; and excessive perspiration The extreme form, anuria refers to a total lack of urine Normal Abnormal Odor 3 The smell of normal, freshly voided urine is believed to be due to the presence of volatile acids. Urine that has been standing for a long time develops an ammonia-like odor, which is due to the decomposition of urea by bacteria The urine of people with diabetes mellitus may have a fruity odor due to the presence of ketones The urine of people with urinary tract infections may be foul-smelling, especially when the infecting organism is a coliform bacillus Innate metabolic disorders may also cause distinctive odors in urine including isovaleric acidemia, which produces a "sweaty feet" odor, and maple syrup urine disease, which was named for its odor Certain foods, such as asparagus, may produce a characteristic odor Normal Abnormal Clarity 2 Normal, freshly voided urine is usually clear or transparent. If the specimen is alkaline, it may have a cloudy or turbid appearance due to the presence of phosphates and carbonates A pinkish turbidity frequently indicates the presence of urates Abnormal turbidity of urine may occur with urinary tract infections, but this is usually due to the alkalinity rather than the actual number of bacteria or leukocytes present Note: In about 10% of urine specimens, turbidity formed during refrigeration will not dissolve when the urine is brought to room temperature. Normal Abnormal Color Pale yellow: Color caused by the yellow pigment urochrome Dark yellow: Concentrated Urine Yellow-brown/Yellow-green: Produced by bile pigments Red: Hemoglobin Brown-black: Melanins - Alcaptonuria is identified by urine turning dark brown/black upon standing Dark brown-red: Produced by porphyrins upon standing 1 Normal Abnormal ? Chemical Analysis The second component of a routine urinalysis is to run a series of chemical tests. Most of the chemical tests performed during a urinalysis involve using chemically impregnated reagent strips or urinalysis test strips. Test strips allow laboratories to perform a single test and obtain results for a number of different test parameters. The strip is dipped into fresh urine, and then the underside of the strip is dragged along the inside of the container to remove excess urine Chemical Analysis After noting the physical characteristics of a urine specimen, the second component of a routine urinalysis is to run a series of chemical tests. Urinalysis test strips allow laboratories to perform a single test and obtain results for a number of different test parameters. ? Visually Reading a Test Strip Note: This procedure represents the general procedure used. To obtain reliable results, follow the procedure listed on the package insert or in the manufacturers manual exactly. Collect a fresh urine specimen in a clean, dry container; Mix well immediately before testing Remove one strip from the bottle and replace the cap Completely immerse the reagent areas of the strip into the urine and remove immediately (tip the container if needed) Start timing Remove the strip from the urine container, run the edge of the strip against the rim of the container to remove excess urine Hold the strip in a horizontal position to prevent possible mixing of chemicals from adjacent reagent areas and/or contaminating the hands with urine Compare the reagent areas to the corresponding color chart on the bottle label at the times specified Visually Reading a Test Strip Standardized results can be achieved by processing the reacted urinalysis test strips with special instrumentation, although you can also read test strips visually. The procedure listed represents the general procedure used. However, to obtain reliable results the procedure listed on the package insert or in the manufacturer's manual must be followed exactly. First, collect a fresh urine specimen in a clean, dry container. Mix the sample well immediately before testing. Next, remove one strip from the bottle and replace the cap. Completely immerse the reagent areas of the strip into the urine and remove immediately to avoid dissolving out the reagents. If there is insufficient urine available to completely immerse all of the reagent pads, tip the container so that the urine reaches a sufficiently high level to be able to wet all reagent areas. After immersing the strip, start the timer. While removing the strip from the urine container, run the edge of the strip against the rim of the urine container to remove excess urine. Hold the strip in a horizontal position to prevent possible mixing of chemicals from adjacent reagent areas and/or contaminating the hands with urine. Finally, compare the reagent areas to the corresponding color chart on the bottle label at the times specified. Hold the strip close to the color blocks and match carefully. Avoid laying the strip directly on the color chart, as this will result in the urine soiling the color chart. ? Types of Chemical Tests A:C Ratio Glucose Ketones Bilirubin Blood Nitrite Leukocyte Esterase Urobilinogen Specific Gravity pH Osmolality Protein Albumin Creatanine P:C Ratio Types of Chemical Tests In this section you will: review how tests typically included in a chemical analysis of urine provide clinicians with valuable information to help detect metabolic and kidney disorders and learn about the chemical reactions that occur in the reagent areas on urinalysis test strips. Select each arrow to learn more about the types of chemical tests. Urobilinogen Determination of urinary urobilinogen is a useful procedure in routine urinalysis since it serves as a guide in detecting/ differentiating liver disease, hemolytic disease, and biliary obstruction. Sequential determinations also assist in evaluating progress of the disease and response to therapy Test Method Principle: The urobilinogen reagent area of test strip is impregnated with para-diethylaminobenzaldehyde and an acid buffer solution. It reacts with urinary urobilinogen, porphobilinogen, and para-aminosalicylic acid to form colored compounds. Dip test strip into fresh, uncentrifuged urine, without preservatives Wait exactly 60 seconds The color reaction is compared to the urinalysis color chart The 5 color blocks provided on the chart range from peach to pink (representing 0.2-8 mg/dL) Table with 2 columns and 7 rows Concentration Levels 0 mg/dL absent 0.2 mg/dL normal 1 mg/dL normal 2 mg/dL elevated 4 mg/dL elevated 8 mg/dL elevated Sample Collection & Inhibitors A freshly voided urine specimen is necessary for the test, preferably a sample collected over a two-hour period in the early afternoon when urinary urobilinogen excretion is thought to be at the highest rate for the day. Formaldehyde, which may be used as a preservative, can inhibit this reaction, causing falsely lowered results. No other substances are known to clearly inhibit the reaction. Drugs containing azo dyes will have a masking effect on the urobilinogen area. Leukocyte Esterase The leuckocyte esterase test detects esterase released from the granules of neutrophilic leukocytes (type of WBC) into the urine. Indicates bacteriuria Indirect test for urinary tract infections When WBCs are found in the urine sediment (pyuria), experienced technologists will look harder to find bacteria and correlate other indications of urinary tract infections (high pH or positive nitrite tests). Usually, the combination of positive results for both nitrite and leukocyte esterase leads directly to confirmation of bacteriuria by microbiological culture testing. The principle of the reaction is that the enzyme splits an ester to form a pyrrole compound that reacts with a diazo reagent to form a highly colored azo dye. The intensity of color is proportional to the amount of enzyme in the urine and, in turn, proportional to the number of white blood cells in the urine. Test Strip Method: Nitrite The nitrite test provides an indirect method for early detection of significant bacteriuria. The most common infecting organism of the urinary tract is Eschericia Coli, and less common are Klebsiella, Proteus, and Pseudomonas. These infecting organisms contain reductase enzymes that reduce nitrate in the urine to nitrite. Nitrite converters are generally gram-negative bacteria and gram-positive organisms may not be detected. Test Method Principle: The nitrite area of urinalysis test strips has a chemical compound, para-arsanilic acid, impregnated into the strip. This reagent forms a diazonium compound with nitrite which, in turn, couples with a tetrahydro quinoline derivative to produce a pink-colored compound. Blood Blood in urine is also a sign of damage to the kidney or urinary tract. Blood may appear as: intact red blood cells (hematuria) free hemoglobin (hemoglobinuria) Test Method Principle: The urinalysis test strip method is the simplest and most direct test for the presence of blood in urine. The blood reagent area on test strip is impregnated with tetramethylbenzidine and buffered organic peroxide The composition forms a green to dark blue compound when hemoglobin catalyzes the oxidation reaction of tetramethylbenzidine with a peroxide Compare the test strip with a color chart 60 seconds after the strip is dipped into the urine The color ranges from orange through green, indicating negative, non-hemolyzed trace, non-hemolyzed moderate, hemolyzed trace, small (1+), moderate (2+), and large (3+) amounts of blood Occult Blood Most urinalysis test strips with four or more reagent areas include a test for occult blood. The test is usually capable of detecting 0.015 to 0.062 mg/dL of free hemoglobin, which is equivalent to 5 to 20 intact red blood cells per microliter of urine. Bilirubin Bilirubin in the urine is a sign of hepatocellular disease or intra- or extra-hepatic biliary obstruction. Indirect Bilirubin + Direct Bilirubin Bilirubin is formed by the breakdown of hemoglobin in the reticuloendothelial cells of the spleen and bone marrow. Indirect bilirubin is linked to albumin in the bloodstream and transported to the liver, where it is converted into direct bilirubin that can be excreted by the kidneys. Normally its level in the blood is not high enough to cause significant amounts to appear in the urine. Test Strip Method: Determination of bilirubin: Dip the test strip into uncentrifuged urine Tap the strip to remove excess urine Wait 30 seconds Compare to the color chart on the test strip bottle The reagent area is impregnated with stabilized, diazotized 2, 4-dichloroaniline which reacts with bilirubin in urine to form a brownish-to-purplish-colored azobilirubin compound. All positive reactions, or atypical reactions, need to be confirmed by using Ictotest® Reagent Tablets. Ketones The excretion of abnormally large amounts of ketone bodies in the urine, is known as ketonuria: Diabetes mellitus Accompanies the restricted carbohydrate intake that occurs in association with fevers, anorexia, gastrointestinal disturbances, fasting, starvation, cyclic vomiting, pernicious vomiting of pregnancy, and cachexia Occurs following anesthesia and as a result of certain neurological disorders Test Strip Method The ketone reagent area on the urinalysis test strip is impregnated with sodium nitroprusside and alkaline buffers. After exactly 15 seconds, the reagent pad color is compared to the color chart, which has six color blocks ranging in color from buff to lavender and maroon and indicating: The test is sensitive only to acetoacetic acid (does NOT) react with beta-hydroxybutyric acid or acetone) Compounds that contain sulfhydryl groups may cause false positive results or atypical reaction Table with 2 columns and 6 rows Concentration Trace 5 mg/dL negative 15 mg/dL small 40 mg/dL moderate 80 mg/dL large 160 mg/dL significant Glucose The presence of detectable amounts of glucose in urine is known as glycosuria. Diabetes mellitus is the chief cause of glycosuria, although the condition may be either benign or pathological Test Strip Method: Enzymatic tests based on the action of glucose oxidase on glucose is used for urinalysis test strips. Glucose oxidase catalyzes the oxidation of glucose → gluconic acid + hydrogen peroxide The peroxide, in the presence of peroxidase, oxidizes an indicator that produces a color change The color is compared to a six-block color chart ranging from blue (indicating less than 0.1% concentration of glucose) to brown (indicating 2.0% or more) Table with 3 columns and 5 rows Sugar Detected by: Identified by: Galactose reagent tablets paper chromatography galactose oxidase test Lactose reagent tablets paper chromatography Fructose reagent tablets paper chromatography Selivanoff's test Pentose reagent tablets paper chromatography Detecting Non-Glucose-Reducing Sugars Other sugars, such as lactose, fructose, galactose, and pentose, are not substrates for glucose oxidase and, therefore, do not react with this test. Albumin:Creatinine Ratio The A:C ratio test permits the estimation of the 24-hour albumin excretion. Testing for the A:C ratio on random urine samples has been found to be as valid an indicator of microalbuminuria as a timed 24-hour sampling. The A:C ratio detects very low levels of albumin in the urine (microalbuminuria), and is therefore most appropriate for detecting early kidney damage in people with diabetes. Test Method Principle: A creatinine test pad on urinalysis test strips is used to calculate A:C ratio as a means of improving strip result correlation to actual analyte excretion rates. The ratio allows for the use of single-void specimens in the discrimination of normal and abnormal levels of protein The A:C ratio is calculated from the albumin and creatinine results Urine chemistry analyzers calculate the results automatically Note: Accurately timed 24-hour urine specimens have also been used to express protein excretion in units of g/min. However, 24-hour urine specimens are difficult to accurately collect, necessitating a means to correct for urine concentration and/or volume when the collection accuracy is in doubt. Protein:Creatinine Ratio The P:C ratio test permits the estimation of the 24-hour protein excretion. Testing for proteinuria and obtaining a P:C ratio result is a useful tool for the early detection of kidney disease. Note: Accurately timed 24-hour urine specimens have also been used to express protein excretion in units of g/min. However, 24-hour urine specimens are difficult to accurately collect, necessitating a means to correct for urine concentration and/or volume when the collection accuracy is in doubt. Test Method Principle: A creatinine test pad on urinalysis test strips allows for semi-quantitative measurement of the P:C ratio as a means of improving strip result correlation to actual analyte excretion rates. The ratio allows for the use of single-void specimens in the discrimination of normal and abnormal levels of protein The P:C ratio is calculated from the protein and creatinine results Chemistry analyzers calculate the results automatically Both methods provide clinicians with a convenient and efficient manner to obtain all results simultaneously Creatinine The value of the creatinine test is that it can be used to calculate P:C and A:C ratios that correct for varying urine concentrations. Test Strip Method: The urinalysis test strip is based on the peroxidase-like activity of copper-creatinine complexes. With TMB and DBDH, the peroxidase-like activity of copper-creatinine complexes is measured Creatinine is derived from the non-enzymatic dehydration of creatine in skeletal muscle. The amount of creatine per unit of muscle mass is constant → the breakdown of creatine:creatinine is constant. This enables creatinine to be used to correct for urine concentration and/or volume when the collection accuracy of a 24-hour urine specimen for protein excretion is in question. Albumin As kidney function declines, the amount of albumin in the urine increases. In disease states, smaller proteins, such as albumin, are excreted into the urine more readily than larger proteins. Albumin constitutes between 60% and 90% of protein excreted in most disease states. In patients with diabetes, microalbuminuria (low levels of albumin in the urine) is one of the first signs of deteriorating kidney function. The flow chart shown here by the American Diabetes Association can be used as a guide to microalbuminuria testing. Protein Urine protein testing is used to assess kidney function and to help detect and diagnose early kidney damage and disease. Proteinuria refers to serum proteins that leak into the urine when kidney glomeruli are damaged, may also reflect urinary tract or physiological conditions Certain diseases are characterized by the excretion of specific globulins rather than by a diffuse proteinuria The urine of people with multiple myeloma contains increased amounts of a low molecular weight globulin (Bence Jones protein) Test Strip Method: The colorimetric reagent strip test is based on the ability of proteins to alter the color of some acid-base indicators without altering the pH, known as the "protein error of indicators" principle In visual reading, protein is determined simply by dipping the strip into well-mixed uncentrifuged urine and comparing the resulting color with the chart provided on the reagent strip bottle Other Test Methods: Specific methods are used for the detection and quantification of albumin, globulins, Bence Jones protein, and others. The majority of these methods, with the notable exception of the simple colorimetric reagent strip test, depend on the precipitation of protein as the basis for quantitative determinations. Osmolality Urine osmolality is important for understanding the concentrating ability of the kidney. Useful for: Determining the differential diagnosis of hypernatraemia or hyponatraemia Differentiating pre-renal from renal kidney failure For identifying and diagnosing diabetes insipidus pH Test Strip Method: The pH portion of urinalysis test strips is impregnated with two separate indicators: methyl red and bromthymol blue. The indicators provide a wide spectrum of color changes, from orange to green to blue, which is compared to a standardized color chart on the bottle label, which shows the pH values ranging from 5 through 8.5. Note: When more exact determinations are needed, a pH meter should be used. The accurate measurement of pH can only be done on freshly voided specimens, as urine may become alkaline upon standing. Urine samples that will not be tested within one hour should be refrigerated. Secretion of an acid or alkaline urine by the kidneys is one of the most important mechanisms the body uses to maintain a constant body pH. To maintain acid-base balance, the acidity of urine increases as the amount of sodium retained by the body increases. The alkalinity of urine increases if there is an excess of base or alkali in the body Specific Gravity Test Strip Method: Specific gravity reflects the relative degree of concentration or dilution of the specimen, which correlates to the concentrating and diluting abilities of the kidney. Specific gravity of urine indicates the density by measuring the total solids. The principle of the colorimetric reaction is based on a pKa change of pre-treated polyelectrolytes in relation to the ionic concentration: In the specific gravity reagent area of the test strips – the polyelectrolyte is sensitive to the # of ions in the urine specimen When the concentration of the electrolytes increases (high specific gravity) in the urine → the pKa of the polyelectrolyte in the urinalysis test strip decreases (pH decreases) The bromthymol blue indicator changes color from blue-green to green to yellow-green, indicating the pH change caused by increasing ionic strength (increasing specific gravity) and is empirically related to specific gravity Some laboratories screen urine samples. ? Microscopic Examination Perform a microscopic examination of urine sediment to detect elements, such as cells, casts, crystals, bacteria, parasites, and artifacts. This information can provide: Evidence of kidney disease as opposed to lower urinary tract infection Indication of the type and activity of a kidney lesion or disease condition Sample Preparation Sample Examination Screening Urine Samples Only cloudy urine specimens or specimens that show positive strip results for blood (RBCs), white blood cells (WBCs), nitrite, or protein are the most likely to show anything significant with the microscopic examination. Some laboratories have reduced the number of microscopic urine sediment examinations performed by first evaluating the urine appearance and urinalysis test strip results. These clinicians have determined that urine specimens may not require further testing unless an abnormal result is obtained for one or more of several urinalysis test strip parameters, such as blood, protein, leukocytes, nitrite, or clarity. This concept is often referred to as a "screen" or "sieve." This procedure is intended to eliminate the performance of labor-intensive microscopic examinations on specimens that tend to have a low yield of abnormal microscopic findings. Of course, clinicians must ultimately determine whether this testing protocol is appropriate for their particular laboratory situation and patient population. Microscopic Examination The third component of a routine urinalysis is to perform a microscopic analysis, if necessary. The examination of centrifuged sediment under the microscope is performed to detect elements, such as cells, casts, crystals, bacteria, and parasites. In some circumstances, microscopic examination can also serve as a confirmatory test. The microscopic results and urine chemistry results should be checked against each other. Discrepancies should be explained before reports are issued. Select each tab to learn about sample preparation and examination. Sample Examination One way to standardize the microscopic examination is by using a complete test system that has special test slides that come complete with cover slips, and a grid pattern on the slide so that the number of cells/µL of urine can be reported. Example of a standardized procedure: Start with the same volume of fresh urine to be concentrated (12 mL) Centrifuge for a constant time (5 minutes), at a constant relative centrifugal force (RCF) of 400 G Decant or aspirate the supernatant to leave a standard volume of concentrate (0.5 mL) Examine a standardized volume of urine in a standardized slide chamber with a set depth, first under low power and then high power magnification Report the number of elements/µL of urine, based on a factor established for the specific test system Note: When it is not a standardized determination, the actual number of cells counted should be interpreted with caution. Sample Preparation While the first-morning specimen is usually the preferred specimen, other specimens can be used The urine specimen should be examined as soon as possible (less than two hours after collection), as the formed elements (cells, casts, etc.) begin to lyse upon standing If the specimen cannot be examined within two hours, it must be refrigerated or otherwise preserved Refrigeration may cause the precipitation of amorphous urates or phosphates that can make it hard to see formed elements in the microscopic examination Warming of the urine specimen to room temp will re-dissolve the amorphous urates The amorphous phosphates require the addition of a weak acid for them to go back into solution ? Microscopic Techniques Most microscopic examinations of urine sediment are made under Brightfield Illumination. Other techniques include: Brightfield Illumination Phase Contrast Interference Contrast Polarized Light Automated Systems Hover over each box to learn more about each techniques. Microscopic Techniques Most microscopic examinations of urine sediment are made under what is called Brightfield Illumination. Other techniques include using Phase Contrast Microscopy, Interference Contrast Illumination, and Polarized Light. There are also instrument systems on the market that automate sediment analysis of formed elements. Hover over each type of microscopic technique to learn more. Instrument systems that automate sediment analysis of formed elements work on principles of flow imaging or flow cytometry to identify and quantify cells and other formed elements. Certain specimens with casts, crystals, or a large number of formed elements are appropriately flagged for visual review and/or the microscope. Plain or compensated polarized light is ideal for assisting in the identification of crystals, starch, fat, and fibers. This method is not widely used, but it offers the benefits of phase contrast, plus showing the elements in 3D. This type of microscopy is particularly useful in identifying hyaline casts, mucus, cells, and bacteria that may be difficult to see using Brightfield Illumination. This standard examination should start with examination under "low power" magnification (10x objective and 10x eyepiece [100-x]), with contrast achieved by varying the opening of the iris diaphragm. This permits the observation of larger elements such as casts, especially hyaline casts, mucus, and some cells The specimen is then examined with a 40x objective and 10x eye piece (400x or high power) ? Supravital Stains A variety of stains can be used to assist in the identification of various elements. These stains can include: Supravital stains – such as Sternheimer-Malbin or toluidine blue Lipid stains – such as the Sudan group Gram stain (to identify bacteria) Table with 2 columns and 9 rows Elements in urine sediment take on the following characteristics when stained using a supravital stain: Leukocytes may appear unstained initially OR the nucleus may appear red-blue with red cytoplasm after prolonged period of time Hyaline Casts stain bright blue Finely Granular Casts stain bright red Coarsely Granular & “Waxy” Casts stain reddish violet RBC Casts outlined in shades of pink Hemoglobin Casts appear rust-brown Miscellaneous Substances (such as oval fat bodies and yeast) will not stain Trichomonas will not stain OR may appear bluish Supravital Stains A variety of stains can be used to assist in the identification of various elements, such as supravital stains, lipid stains, and the Gram stain. ? Identifying Formed Elements What do you observe in normal urine sediment? Normal urine sediment may contain a limited number of formed elements, such as: The presence of one or two blood cells, one or two leukocytes, and a few epithelial cells An occasional hyaline cast The urine of mature females may normally contain large numbers of squamous epithelial cells from the vaginal walls Abnormal urine sediment, however, may contain many cells or casts that indicate a disease process. Select the tab arrows to learn more about formed elements in urine sediment. Casts Cells Crystals Organisms & Contaminants Identifying Formed Elements Normal urine sediment is not free of cells or casts, but contains a limited number of formed elements. Abnormal urine sediment, however, may contain many cells or casts that indicate a disease process. In this section, you will learn the significance of formed elements that may appear in urine sediment and how to identify them microscopically. Select each tab to learn more about formed elements in urine sediment. ? Casts Cast formation usually occurs in the distal convoluted tubule of the nephron. Casts may also occur in the ascending loop of Henle or the collecting duct Requirements for cast formation are an acid condition, high salt concentration, reduced urine flow, and protein Casts are named according to the inclusions contained in them, such as RBC cast, WBC cast, etc. Microscopic Identification: The appearance, size, and inclusion of a cast will offer incontrovertible evidence of the condition of at least one nephron of one kidney just prior to passage of the urine. Practically all casts have a hyaline matrix that may or may not contain inclusions, such as desquamated cells from the lining of tubules, white blood cells, or red blood cells. Hover over each box to learn more about each techniques. Casts Waxy and fatty casts are associated with tubular inflammation and degeneration. The broad, waxy cast is formed in the collecting tubules when the urine flow through them is reduced. Both waxy and fatty casts are found in chronic kidney disease. Waxy casts are composed of a homogeneous, yellowish material. They are relatively broad, have a highly refractile outline, and appear very brittle. They are irregularly shaped, show characteristic clefts, and occasionally may have a "corkscrew" appearance. Broad casts (kidney failure casts) are two to six times as wide as ordinary casts. They are usually waxy, granular, or cellular. They are thought to appear in the collecting tubules as a result of markedly decreased urinary output, presumably due to severe kidney disease. When describing granular casts, the terms "coarsely granular" and "finely granular" are used to indicate the degree of degeneration that has occurred in the cellular inclusion, i.e., whether the cells have been broken down into coarse or fine particles. While an occasional granular cast may be found in normal individuals, numbers beyond occasional may indicate pyelonephritis. Granular casts are also found in chronic lead intoxication. Coarse granular casts contain homogeneous, coarsely granular material. They are clear, colorless, and appear very dense. Coarse granular casts may represent the initial stages of degeneration of epithelial cell casts. These casts further degenerate into fine granular casts and terminate as waxy casts or fatty casts. Fine granular casts are differentiated from coarse granular casts by the presence of fine granular material. Hyaline casts, formed of the gel of Tamm-Horsfall protein, may imply damage to the glomerular capillary membrane, permitting leakage of proteins through the glomerular filter. Such damage may be permanent or transient as a result of fever or the effects of posture (orthostatic, lordotic), emotional stress, or strenuous exercise. If a person exercises strenuously, the blood flow to the kidneys is reduced, as it is re-directed to the muscles. During this period, hyaline casts may be formed. When the exercise is over and the blood flow returns to normal, there is a "flushing out" of these casts into the urine. This "shower of casts" is usually non-pathological. Hyaline casts are pale, colorless, occasionally refractile "cylinders." They are best seen when the intensity of the light is sharply reduced. These casts are formed from the gel of proteins that have presumably traversed the glomerular capillary membrane. Epithelial cell casts are formed by fused desquamated tubular cells. Since the tubule is a living membrane, it is always replacing itself. Thus, the finding of an occasional kidney epithelial cell or clump is not unusual. However, in any disease producing damage to the tubular epithelium, the appearance of many epithelial casts may indicate excessive desquamation such as may occur in nephrosis, eclampsia, amyloidosis, and in the presence of poisoning with heavy metals and a variety of other toxins. Epithelial cell casts are formed by fused desquamated tubular cells. The degeneration of the discrete cellular casts into coarsely and finely granular material is purely a function of age and permits the inference that there has been stasis in the nephron. White blood cell casts may be found in the urine of people with acute glomerulonephritis, nephrotic syndrome, or pyelonephritis. Since pyelonephritis may remain completely asymptomatic even though it is progressively destroying kidney tissue, careful examination of the urinary sediment for leukocyte casts is important. In some cases, it may be the only significant laboratory finding in an asymptomatic situation. White blood cell casts are usually composed of many leukocytes in a cylindrical encasement and indicate kidney origin. Red blood cell casts indicate the presence of an acute inflammatory or vascular disorder in the glomerulus, causing kidney hematuria. They should always be regarded as pathological and may be the only manifestation of acute glomerulonephritis, kidney infarction, collagen disease, or kidney involvement in subacute bacterial endocarditis. Red blood cell casts form in 3 stages: Presence of free red blood cells Degenerating cells within a protein matrix Homogeneous blood casts Any disease that alters the integrity of the glomerulus will alter the composition of the urine. Disease of injury to the glomerulus usually results in a leakage of RBCs and protein. ? Cells More than 2-3 RBCs per high power field is an abnormal condition, as it can indicate a variety of kidney and systemic diseases, including trauma to the kidney. Hematuria occurs with: pyelonephritis tuberculosis of the genitourinary tract cystatitis prostatitis kidney calculi kidney tumors/other malignancies of the urinary tract hemorrhagic diseases (e.g. hemophilia) RBCs may also appear following traumatic catheterization, passage of stones, contamination from menstrual blood, and strenuous exercise Note: RBCs tend to lyse or dissolve in alkaline or dilute urine. Red Blood Cells Red Blood Cells Red Blood Cells White Blood Cells White Blood Cells Epithelial Cells Epithelial Cells Microscopic Identification: Red blood cells usually look like pale, light-refractive, bi-concave discs when viewed under high power magnification. They have no nuclei. Red blood cells seen in fresh, unstained sediment are pale in color In urine that is not fresh, they are colorless "shadow cells" In concentrated urine, the red blood cells may be small and crenated In dilute urine, they are often large and swollen, and sometimes rupture to produce "ghost" cells Select the marker to learn about the microscopic identification of red blood cells. Cells Squamous epithelial cells frequently appear in normal urine. Large numbers of kidney epithelial cells, which are common in the urine of people with acute necrosis and necrotizing papillitis, may indicate active tubular degeneration. Microscopic Identification: Due to the osmotic, pH, and traumatic changes the cells undergo during passage through the genitourinary system, various epithelial cells in urine rarely retain their original shape. Epithelial Cells Select the markers to learn about the microscopic identification of various types of epithelial cells. Kidney Tubular Epithelial Cells: are round and slightly larger than leukocytes. Each contains a single large nucleus. Bladder Epithelial Cells: are larger than kidney tubular epithelial cells. They range in shape from flat to cuboidal or columnar. Squamous Epithelial Cells: are large flat cells with single small nuclei and a large cytoplasm. The majority of these cells are contaminants from the vagina or vulva, but some originate in the urethra. The presence of large numbers of white cells or leukocytes (pyuria) usually indicates bacterial infection in the urinary tract. Pyuria may also be seen in acute glomerulonephritis. The cells are segmented neutrophils or polys. Large numbers of mononuclear cells (lymphs) in a patient with a kidney transplant may indicate early tissue rejection. White Blood Cells Microscopic Identification: The predominant type of leukocyte appearing in the urine is the polymorphonuclear leukocyte: have segmented nuclei are usually granular are approximately 1x as large as red blood cells Certain neutrophils are larger than the usual leukocytes, and their cytoplasmic granules show Brownian movement. These cells are called granular motility or "glitter" cells. Originally they were thought to be pathognomic of pyelonephritis but are now thought to be a result of hypotonic urine. With white blood cells in the sediment, the urine should give a positive chemical test for leukocyte esterase. Select the marker to learn about the microscopic identification of white blood cells. ? Crystals A variety of crystals may appear in the urine. The type and quantity of crystalline precipitate vary with the pH of the urine. Amorphous material is of little importance. While most crystals are non-pathological, some do indicate pathology. Crystals form in normal urine as the specimen cools Crystals can be identified by their specific appearances and solubility characteristics Hover over each box to learn more about each techniques. Crystals Leucine and tyrosine are abnormal crystals occasionally seen in urine of people with liver problems. When there are severe liver problems, these amino acids are not metabolized. Tyrosine crystals appear as colorless fine needles and are usually grouped in clusters. Uric acid crystals may appear in the urine in a variety of shapes and colors. They may appear as a result of pathology or metabolism. Uric acid may appear as needles, hexagonal shapes, rosette shapes, "whetstone form," or as rhombic plates. The crystals may appear colorless, yellow, or brown. Increased uric acid denotes increased purine metabolism. Uric acid crystals may be found in cases of fever, leukemia, some kidney tubular diseases, and gout. Cystine crystals indicate cystinuria, a condition in which cystine stones form in the kidney and cystinosis, an innate metabolic disorder in which cystine crystals are found in the urine, reticuloendothelial system, spleen, and eyes. ? Organisms and Contaminants Bacteria may be seen in the sediment as a result of either urinary tract infection or contamination of the specimen. The two causes cannot usually be distinguished by examination of the specimen, although the presence of large numbers of leukocytes, a positive nitrite test, and/or a positive leukocyte esterase test is suggestive of urinary tract infection. Bacteria Bacteria Bacteria Parasites Parasites Yeast Yeast Spermatozoa Spermatozoa Contaminants Contaminants Bacilli are more easily recognized than cocci, which may be mistaken for amorphous crystals. A culture on a clean-catch specimen should be performed when in doubt. Organisms and Contaminants Cotton threads and starch granules shown here as well as hair, wood and wool fibers, and other contaminants must be recognized to ascertain that these substances do not represent any significant finding in the urinary sediment. Select the markers to identify the type of contaminants in the images. Contaminants Cotton threads Starch granules Spermatozoa are frequently seen in the urine following nocturnal emissions or sexual intercourse. Spermatozoa have oval bodies with long delicate tails. They may be mobile or stationary. Spermatozoa Yeast cells may be seen in the urinary sediment. Yeast cells (Candida albicans) may be indicative of urinary candidiasis, especially in people with diabetes mellitus. Frequently, yeast appears as a contaminant in the urine of females with vaginal candidiasis. Large numbers of yeast with hyphae are suggestive of vaginitis. Yeast Yeast cells are sometimes confused with red blood cells. They differ by being ovoid (rather than round), colorless, and variable in size. They may also frequently show budding. If in doubt, the addition of acetic acid to the sediment on the slide will lyse red blood cells but leave yeast cells intact. The majority of parasites observed in urine are contaminants from fecal or vaginal material. A urinary tract parasite infestation may be associated with the presence of red blood cells, e.g., Schistosoma haematobium. Trichomonas vaginalis is the most frequently seen parasite in urine. It is a unicellular organism with anterior flagellae and an undulating membrane. The parasites may resemble flattened, ovoid epithelial cells, but are usually recognized by their swimming motions through the sediment, the movements of their flagellae, and the characteristic undulating membrane. Parasites ? Urine Chemistry Analyzers Urine chemistry analyzers can be used in: Point-of-care settings, such as doctor offices, clinics, and hospital wards Laboratory settings, such as hospitals or private laboratories In most cases, these systems also interface with the Laboratory Information System (LIS) for data management and reporting. Urine Chemistry Analyzers Point of care and laboratory analyzers automate the reading of urinalysis test strips. These analyzers are common in busy laboratories and many physician offices because they help standardize testing by eliminating operator-to-operator variability, as well as improve laboratory efficiency because read rates are as fast as seven seconds per test strip. In most cases, these systems also interface with the Laboratory Information System (LIS) for data management and reporting. ? Course Review Congratulations. You have completed the Urinalysis: Testing course. Select the numbered buttons below to review the material before proceeding to the final assessment. Explain the procedure to perform a chemical analysis of urine Describe how to perform a physical analysis of urine Describe how a microscopic examination of urine is performed Identify formed elements in urine sediment 1 1 1 3 3 3 2 2 2 4 4 4 5 5 5 Explain the purpose and identify the principles of each test strip chemical test Course Review Identify formed elements in urine sediment Table with 4 columns and 2 rows Casts Cells Crystals Organisms & Contaminants Red Blood Cell White Blood Cell Epithelial Cell Hyaline Granular Waxy Red Blood Cells White Blood Cells Epithelial Cells Cystine Uric Acid Leucine/Tyrosine Bacteria Parasites Yeast Spermatozoa Contaminants Describe how a microscopic examination of urine is performed Sample Prep and Exam The first-morning specimen is usually the preferred specimen The urine specimen should be examined as soon as possible (less than 2 hours after collection) If specimen cannot be examined within 2 hours, it must be refrigerated, or otherwise preserved, then brought back to room temp for examination One way to standardize the microscopic examination is by using a complete test system that has special test slides with cover slips, and a grid pattern on the slide so that the number of cells/µL of urine can be reported Most microscopic examinations of urine sediment are made under Brightfield Illumination. Other techniques: Phase Contrast Interference Contrast Polarized Light Automated Systems A variety of stains can be used to assist in the identification of various elements. Supravital stains Lipid stains Gram stain Explain the purpose & identify the principles of each test strip chemical test Specific gravity – correlates to the concentrating/diluting abilities of the kidney Based on a pKa change of pre-treated polyelectrolytes in relation to the ionic concentration pH – high acidity of urine reflect excess sodium, alkalinity reflects excess base or alkali Impregnated with 2 indicators (methyl red, bromthymol blue) Osmolality – important for understanding the concentrating ability of the kidney Protein – detect and diagnose early kidney damage/disease "Protein error of indicators" principle Albumin – as kidney function declines, amount of albumin in the urine increases Creatinine – used to calculate P:C and A:C ratios Based on the peroxidase-like activity of copper-creatinine complexes P:C Ratio – testing for proteinuria and obtaining a P:C ratio result is useful for the early detection of kidney disease A:C Ratio – detects very low levels of albumin, therefore most appropriate for detecting early kidney damage in diabetics Glucose – presence of detectable amounts of glucose in urine is known as glycosuria, cause by diabetes mellitus Based on the action of glucose oxidase on glucose Ketones – excretion of abnormally large amounts of ketone bodies in the urine, known as ketonuria Impregnated with sodium nitroprusside and alkaline buffers Bilirubin – sign of hepatocellular disease or intra- or extra-hepatic biliary obstruction Impregnated with stabilized, diazotized 2, 4-dichloroaniline, reacts with bilirubin in urine Blood – sign of damage to kidney/urinary tract Impregnated with TMB and buffered organic peroxide, hemoglobin catalyzes oxidation reaction Nitrite – provides indirect method for early detection of significant bacteriuria Impregnated with para-arsanilic acid Leukocyte Esterase – detects esterase released from WBCs, indicates bacteriuria (indirect UTI test) Enzyme splits an ester to form a pyrrole compound that reacts with a diazo reagent Urobilinogen – guide in detecting/differentiating liver disease, hemolytic disease, biliary obstruction Impregnated with para-diethylaminobenzaldehyde and acid buffer solution Explain the procedure to perform a chemical analysis of urine Visually Reading a Test Strip Collect a fresh urine specimen in a clean, dry container; Mix well immediately before testing Remove one strip from the bottle and replace the cap Completely immerse the reagent areas of the strip into the urine and remove immediately (tip the container if needed) Start timing Remove the strip from the urine container, run the edge of the strip against the rim of the container to remove excess urine Hold the strip in a horizontal position to prevent possible mixing of chemicals from adjacent reagent areas and/or contaminating the hands with urine Compare the reagent areas to the corresponding color chart on the bottle label at the times specified Describe how to perform a physical analysis of urine Color Normal → pale yellow Abnormal → dark yellow, yellow-brown, yellow-green, red, dark brown-red, brown black Clarity Normal → clear/transparent Abnormal → cloudy, turbid, pinkish turbidity Odor Normal → odor due to volatile acids Abnormal → ammonia like odor, fruity odor, foul-smelling odor, “sweaty feet” odor Volume Normal → 750-2,000 mL Abnormal → polyuria > 2,000 mL oliguria < 200 mL/24 hrs anuria – lack of urine Disclaimer Please note that the learning material is for training purposes only! For the proper use of the software or hardware, please always use the Operator Manual or Instructions for Use (hereinafter collectively “Operator Manual”) issued by Siemens Healthineers. This material is to be used as training material only and shall by no means substitute the Operator Manual. Any material used in this training will not be updated on a regular basis and does not necessarily reflect the latest version of the software and hardware available at the time of the training. The Operator's Manual shall be used as your main reference, in particular for relevant safety information like warnings and cautions. Note: Some functions shown in this material are optional and might not be part of your system. Certain products, product related claims or functionalities (hereinafter collectively “Functionality”) may not (yet) be commercially available in your country. Due to regulatory requirements, the future availability of said Functionalities in any specific country is not guaranteed. Please contact your local Siemens Healthineers sales representative for the most current information. The reproduction, transmission or distribution of this training or its contents is not permitted without express written authority. Offenders will be liable for damages. All names and data of patients, parameters and configuration dependent designations are fictional and examples only. All rights, including rights created by patent grant or registration of a utility model or design, are reserved. Copyright © Siemens Healthcare GmbH 2022 Siemens Healthineers Headquarters\Siemens Healthcare GmbH\Henkestr. 127\ 91052 Erlangen, Germany\Telephone: +49 9131 84-0\siemens-healthineers.com ? Disclaimer Assessment This assessment will test your retention of the presented content. A passing score of 80% or higher is required to complete the course and earn your certificate. You may repeat the assessment as many times as needed. Start ? Assessment Select the best answer. ? Question 1 of 10 Pigments produced by particular diseases may also cause the urine to change color. Which of the following could be the cause of a yellow-brown or greenish color? Concentrated urine Hemoglobin Bile pigments Melanins Multiple Choice Incorrect Melanins cause urine to turn a brown-black color upon standing. Correct Bile pigments may produce a yellow-brown or greenish color. Incorrect Hemoglobin gives a reddish-brown color. Incorrect A dark color may indicate concentrated urine. Select the best answer. ? Question 2 of 10 The urine of people with diabetes mellitus may have a fruity odor due to the presence of __________. Ketones Volatile acids Crystals Bacteria or leukocytes Multiple Choice Incorrect A fruity odor in urine is not due to bacteria or leukocytes. Incorrect A fruity odor in urine is not due to crystals. Incorrect The smell of normal, freshly voided urine is believed to be due to the presence of volatile acids. Correct The urine of people with diabetes mellitus may have a fruity odor due to the presence of ketones. Select the best answer. ? Question 3 of 10 On average, what is the normal volume of urine voided by an adult in a 24-hour period? Less than 750 mL per day 1,500 mL per day Greater than 2,000 mL per day Greater than 4,000 mL per day Multiple Choice Incorrect The normal volume of urine voided by an adult in a 24-hour period is less than 4,000 mL per day. Incorrect The average volume of urine voided by an adult in a 24-hour period is less than 2,000 mL per day. Correct The normal volume of urine voided by an adult in a 24-hour period ranges from 750 to 2,000 mL, but averages about 1,500 mL. Incorrect The normal volume of urine voided by an adult in a 24-hour period is greater than 750 mL per day. Select the best answer. ? Question 4 of 10 Which of the following would you expect to see in a patient with excessive loss of body fluids, as in vomiting or diarrhea? Anuria Polyuria Oliguria No change Multiple Choice Incorrect There will be decreased urinary output in a patient with excessive loss of body fluids. Correct Oliguria refers to decreased urinary output (i.e., less than 200 mL/24 hours). Oliguria occurs when there is excessive loss of body fluids Incorrect Polyuria refers to an increase in the excretion of urine. Incorrect Anuria refers to a total lack of urine. Select the best answer. ? Question 5 of 10 Which urinalysis test correlates to the concentrating and diluting abilities of the kidney? Specific gravity Nitrite Protein Albumin Multiple Choice Incorrect As kidney function declines, the amount of albumin in the urine increases. Incorrect Urine protein testing is used to assess kidney function and to help detect and diagnose early kidney damage and disease. Incorrect The nitrite test provides an indirect method for early detection of significant bacteriuria. Incorrect Specific gravity measurements reflect the relative degree of concentration or dilution of the specimen, which, under normal circumstances, correlate to the concentrating and diluting abilities of the kidney. Select the best answer. ? Question 6 of 10 Which urinalysis test allows physicians to detect early signs of deteriorating kidney function in patients with diabetes? Bilirubin Protein Albumin Specific gravity Multiple Choice Incorrect Specific gravity measurements reflect the relative degree of concentration or dilution of the specimen, which, under normal circumstances, correlate to the concentrating and diluting abilities of the kidney. Correct In patients with diabetes, microalbuminuria (low levels of albumin in the urine) is one of the first signs of deteriorating kidney function. Incorrect In disease states, smaller proteins, such as albumin, are excreted into the urine more readily than larger proteins. In patients with diabetes, microalbuminuria (low levels of albumin in the urine) is one of the first signs of deteriorating kidney function. Incorrect In patients with diabetes, microalbuminuria (low levels of albumin in the urine) is one of the first signs of deteriorating kidney function. Select the best answer. ? Question 7 of 10 What formed elements do you observe here? RBCs Uric acid crystals Yeast cells Epithelial cells Multiple Choice Incorrect These are not epithelial cells. Correct Incorrect These are not uric acid crystals. Incorrect These are not RBCs. Select the best answer. ? Question 8 of 10 Which of the following statements about crystals is FALSE? Type and quantity of crystalline precipitate vary with the pH of urine The presence of crystals indicates a pathologic process Crystals will form in normal urine if the specimen cools Crystals can appear in acidic, neutral, and alkaline urine Multiple Choice Incorrect Some crystals indicate pathology but most crystals are non-pathological. Incorrect Some crystals indicate pathology but most crystals are non-pathological. Incorrect Some crystals indicate pathology but most crystals are non-pathological. Incorrect Some crystals indicate pathology but most crystals are non-pathological. Select the best answer. ? Question 9 of 10 Urinalysis test strips use glucose oxidase to test for the presence of what? Glucose Lactose Fructose Pentose Multiple Choice Incorrect Glucose oxidase is NOT used to test for pentose. Incorrect Glucose oxidase is NOT used to test for fructose. Incorrect Glucose oxidase is NOT used to test for lactose. Correct Select the best answer. ? Question 10 of 10 What formed elements do you observe here? WBC casts Uric acid crystals RBC casts Yeast cells Multiple Choice Incorrect These are not yeast cells. Incorrect These are not RBC casts. Incorrect These are not uric acid crystals. Correct Assessment Results YOUR SCORE: PASSING SCORE: Review Retry Retry Continue Continue Continue %Results.ScorePercent%% %Results.PassPercent%% ? Assessment Results You did not pass the course. Take time to review the assessment then select Retry to continue. Congratulations. You passed the course.. Exit To access your Certificate of Completion, select the Launch button drop down on the course overview page. You can also access the certificate from your PEPconnect transcript. ? You have completed the [Product Name] [Topic] Online Training. Completion Navigation Help Select the icon above to open the table of contents. Click Next to continue. Next Welcome Slide The timeline displays the slide progression. Slide the orange bar backwards to rewind the timeline. Click Next to continue. Next Timeline Select the CC icon to display closed captioning (subtitles). Click Next to continue. Next Caption Icon add subtitles Select the buttons to learn more about a topic. Be sure to review all topics before navigating to the next slide. Click Next to continue. Next Tab Arrow Slide Select the X to close the pop-up. Click Next to continue. Next Layer Slide Select Submit to record your response. Click the X in the upper right corner to exit the navigation help. Assessment Slide Question Bank 1 HILS2271 | Effective Date: 16-Mar-2022 1.1 Welcome 1.2 Physical Analysis 1.3 Chemical Analysis 1.4 Visually Reading a Test Strip 1.5 Types of Chemical Tests 1.6 Microscopic Examination 1.7 Microscopic Techniques 1.8 Supravital Stains 1.9 Identifying Formed Elements 1.14 Urine Chemistry Analyzers 1.15 Course Review 1.16 Disclaimer 1.17 Assessment