Test bank for Urinalysis and Body Fluids 6th Edition by Susan King Strasinger
Test bank for Urinalysis and Body Fluids 6th Edition by Susan King Strasinger
Table of Contents
Front Matter
Dedication
Preface
Reviewers
Acknowledgments
PART ONE Background
CHAPTER 1 Safety and Quality Assessment
LEARNING OBJECTIVES
KEY TERMS
SAFETY
Biologic Hazards
Table 1β1 Types of Safety Hazards
Figure 1β1 Chain of infection and safety practices related to the biohazard symbol.
Personal Protective Equipment
Hand Hygiene
PROCEDURE 1-1 Hand Washing Procedure
Biologic Waste Disposal
Sharp Hazards
Figure 1β2 Biohazard symbol.
Figure 1β3 Technologist disposing of urine (A) sample and (B) container.
Chemical Hazards
Chemical Spills and Exposure
Chemical Handling
Chemical Hygiene Plan
Chemical Labeling
Material Safety Data Sheets
Figure 1β4 Chemical safety aids. A, emergency shower; B, eye wash station.
Radioactive Hazards
Electrical Hazards
Figure 1β5 Chemical hazard symbols.
Fire/Explosive Hazards
Figure 1β6 NFPA hazardous material symbols.
Physical Hazards
Table 1β2 Types of Fires and Fire Extinguishers
QUALITY ASSESSMENT
Urinalysis Procedure Manual
Preexamination Variables
Figure 1β7 Example of procedure review documentation.
Specimen Collection and Handling
Figure 1β8 Cause-and-effect diagram for analyzing urinalysis TAT.
Table 1β3 Policy for Handling Mislabeled Specimens
Table 1β4 Criteria for Urine Specimen Rejection
Examination Variables
Reagents
Instrumentation and Equipment
Testing Procedure
Quality Control
Figure 1β9 Sample of Quality Improvement Follow-up Report form.
Figure 1β10 Sample instrument QC recording sheet.
External Quality Control
Internal Quality Control
Figure 1β11 Levy-Jennings charts showing in-control, shift, and trend results.
Electronic Controls
Proficiency Testing (External Quality Assessment)
Personnel and Facilities
Figure 1β12 βOut-of-controlβ procedures.
Postexamination Variables
Reporting Results
Figure 1β13 Sample standardized urine microscopic reporting format.
Figure 1β14 An example of procedure instructions for reporting critical values in the urinalysis section. A procedure review document similar to that shown in Figure 1β7 would accompany this instruction sheet.
SUMMARY 1-1 Quality Assessment Errors
Preexamination
Examination
Postexamination
Interpreting Results
References
Study Questions
Case Studies and Clinical Situations
CHAPTER 2 Introduction to Urinalysis
LEARNING OBJECTIVES
KEY TERMS
History and Importance
Figure 2β1 Physician examines urine flask.
Figure 2β2 Instruction in urine examination.
Figure 2β3 A chart used for urine analysis.
Urine Formation
Urine Composition
Urine Volume
TECHNICAL TIP
Table 2β1 Primary Components in Normal Urine3
Figure 2β4 Differentiation between diabetes mellitus and diabetes insipidus.
Specimen Collection
Containers
Labels
Requisitions
Specimen Rejection
TECHNICAL TIP
Table 2β2 Changes in Unpreserved Urine
Specimen Handling
Specimen Integrity
Specimen Preservation
TECHNICAL TIP
TECHNICAL TIP
Table 2β3 Urine Preservatives
Types of Specimens
Random Specimen
Table 2β4 Types of Urine Specimens
First Morning Specimen
HISTORICAL NOTE
Glucose Tolerance Specimens
24-Hour (or Timed) Specimen
PROCEDURE 2-1 Sample 24-Hour (Timed) Specimen Collection Procedure
TECHNICAL TIP
Catheterized Specimen
Midstream Clean-Catch Specimen
Suprapubic Aspiration
Prostatitis Specimen
Three-Glass Collection
TECHNICAL TIP
PROCEDURE 2-2 Clean-Catch Specimen Collection: Female Cleansing Procedure2
PROCEDURE 2-3 Clean-Catch Specimen Collection: Male Cleansing Procedure2
Pre- and Post-Massage Test
Pediatric Specimens
HISTORICAL NOTE
Stamey-Mears Test for Prostatitis
TECHNICAL TIP
Drug Specimen Collection
PROCEDURE 2-4 Urine Drug Specimen Collection Procedure
References
Study Questions
Case Studies and Clinical Situations
CHAPTER 3 Renal Function
LEARNING OBJECTIVES
KEY TERMS
Renal Physiology
Figure 3β1 The relationship of the nephron to the kidney and excretory system.
Renal Blood Flow
Figure 3β2 The nephron and its component parts.
Glomerular Filtration
Cellular Structure of the Glomerulus
Glomerular Pressure
TECHNICAL TIP
Figure 3β3 Factors affecting glomerular filtration in the renal corpuscle (A). Inset B, glomerular filtration barrier. Inset C, the shield of negativity.
Renin-Angiotensin-Aldosterone System
Figure 3β4 Close contact of the distal tubule with the afferent arteriole, macula densa, and the juxtaglomerular cells within the juxtaglomerular apparatus. Note the smaller size of the afferent arteriole indicating increased blood pressure.
Figure 3β5 Algorithm of the renin-angiotensin-aldosterone system.
Table 3β1 Actions of the RAAS
Tubular Reabsorption
Reabsorption Mechanisms
Table 3β2 Tubular Reabsorption
TECHNICAL TIP
Tubular Concentration
Collecting Duct Concentration
Figure 3β6 Renal concentration.
Tubular Secretion
Figure 3β7 Summary of movement of substances in the nephron.
AcidβBase Balance
Figure 3β8 Reabsorption of filtered bicarbonate.
Figure 3β9 Excretion of secreted hydrogen ions combined with phosphate.
Figure 3β10 Excretion of secreted hydrogen ions combined with ammonia produced by the tubules.
Renal Function Tests
Figure 3β11 The relationship of nephron areas to renal function tests.
Glomerular Filtration Tests
Clearance Tests
HISTORICAL NOTE
Urea Clearance
HISTORICAL NOTE
Inulin Clearance
Creatinine Clearance
Procedure
EXAMPLE
EXAMPLE
Estimated Glomerular Filtration Rates
Figure 3β12 Creatinine filtration and excretion.
Figure 3β13 A nomogram for determining body surface area.
HISTORICAL NOTE
Original MDRD Calculation
Cystatin C
Beta2-Microglobulin
Radionucleotides
Clinical Significance
Tubular Reabsorption Tests
Figure 3β14 The effect of hydration on renal concentration. Notice the decreased specific gravity in the more-hydrated Patient B.
Osmolality
Figure 3β15 Differentiation of neurogenic and nephrogenic diabetes insipidus.
Freezing Point Osmometers
Vapor Pressure Osmometers
Technical Factors
Clinical Significance
TECHNICAL TIP
Free Water Clearance
EXAMPLE
Tubular Secretion and Renal Blood Flow Tests
PAH Test
Titratable Acidity and Urinary Ammonia
HISTORICAL NOTE
Phenolsulfonphthalein Test
References
Study Questions
Case Studies and Clinical Situations
PART TWO Urinalysis
CHAPTER 4 Physical Examination of Urine
LEARNING OBJECTIVES
KEY TERMS
Color
Table 4β1 Laboratory Correlation of Urine Color1
Normal Urine Color
Abnormal Urine Color
Dark Yellow/Amber/Orange
Red/Pink/Brown
Brown/Black
Figure 4β1 Differentiation of red urine testing chemically positive for blood.
Blue/Green
Clarity
Normal Clarity
Table 4β2 Urine Clarity
PROCEDURE 4-1 Urine Color and Clarity Procedure
Nonpathologic Turbidity
Pathologic Turbidity
Table 4β3 Nonpathologic Causes of Urine Turbidity
Specific Gravity
Table 4β4 Pathologic Causes of Urine Turbidity
Refractometer
Box 4-1 Current Urine Specific Gravity Measurements
HISTORICAL NOTE
Urinometry
EXAMPLE
Figure 4β2 Steps in the use of the urine specific gravity refractometer.
Figure 4β3 Calibration of the urine specific gravity refractometer.
Osmolality
HISTORICAL NOTE
Harmonic Oscillation Densitometry
TECHNICAL TIP
Table 4β5 Particle Changes to Colligative Properties
Reagent Strip Specific Gravity
Odor
TECHNICAL TIP
Table 4β6 Possible Causes of Urine Odor1
References
Study Questions
Case Studies and Clinical Situations
CHAPTER 5 Chemical Examination of Urine
LEARNING OBJECTIVES
KEY TERMS
Reagent Strips
Reagent Strip Technique
Errors Caused by Improper Technique
PROCEDURE 5-1 Reagent Strip Technique1,2
Handling and Storing Reagent Strips
Quality Control of Reagent Strips
Confirmatory Testing
pH
Clinical Significance
SUMMARY 5-1 Care of Reagent Strips
Table 5β1 Causes of Acid and Alkaline Urine
TECHNICAL TIP
SUMMARY 5-2 Clinical Significance of Urine pH
Reagent Strip Reactions
TECHNICAL TIP
SUMMARY 5-3 pH Reagent Strip
Protein
Clinical Significance
Prerenal Proteinuria
Bence Jones Protein
Renal Proteinuria
Glomerular Proteinuria
Microalbuminuria
HISTORICAL NOTE
Screening Test for Bence Jones Protein
Orthostatic (Postural) Proteinuria
Tubular Proteinuria
Postrenal Proteinuria
HISTORICAL NOTE
Microalbuminuria Testing
Reagent Strip Reactions
SUMMARY 5-4 Clinical Significance of Urine Protein
Reaction Interference
Sulfosalicylic Acid Precipitation Test
Testing for Microalbuminuria
TECHNICAL TIP
SUMMARY 5-5 Clinical Significance of Urine Protein
PROCEDURE 5-2 Sulfosalicylic Acid Precipitation Test
Table Reporting SSA Turbidity
Albumin: Creatinine Ratio
Reagent Strip Reactions
Albumin
Creatinine
Albumin/Protein: Creatinine Ratio
Glucose
Clinical Significance
Figure 5β1 A protein:creatinine ratio determination chart.
SUMMARY 5-6 Immunologic Tests
SUMMARY 5-7 Clinical Significance of Urine Glucose
Reagent Strip (Glucose Oxidase) Reaction
Reaction Interference
Copper Reduction Test (Clinitest)
SUMMARY 5-8 Glucose Reagent Strip
Clinical Significance of Clinitest
PROCEDURE 5-3 Clinitest Procedure
Ketones
Clinical Significance
TECHNICAL TIP
SUMMARY 5-9 Clinical Significance of Urine Ketones
Reagent Strip Reactions
Reaction Interference
Acetest Tablets
Blood
Figure 5β2 Production of acetone and butyrate from acetoacetic acid.
PROCEDURE 5-4 Acetest Procedure
Clinical Significance
Hematuria
Hemoglobinuria
Myoglobinuria
Reagent Strip Reactions
SUMMARY 5-11 Clinical Significance of a Positive Reaction for Blood
HISTORICAL NOTE
Hemoglobinuria Versus Myoglobinuria
Reaction Interference
SUMMARY 5-12 Blood Reagent Strip
Bilirubin
Bilirubin Production
Clinical Significance
Table 5β2 Urine Bilirubin and Urobilinogen in Jaundice
SUMMARY 5-13 Clinical Significance of Urine Bilirubin
Figure 5β3 Hemoglobin degradation and production of bilirubin and urobilinogen.
Reagent Strip (Diazo) Reactions
Reaction Interference
Ictotest Tablets
SUMMARY 5-14 Bilirubin Reagent Strip
PROCEDURE 5-5 Ictotest Procedure
Urobilinogen
Clinical Significance
Reagent Strip Reactions and Interference
SUMMARY 5-15 Clinical Significance of Urine Urobilinogen
Reaction Interference
Nitrite
Clinical Significance
TECHNICAL TIP
SUMMARY 5-16 Urobilinogen Reagent Strip
Reagent Strip Reactions
Reaction Interference
SUMMARY 5-17 Clinical Significance of Urine Nitrite
SUMMARY 5-18 Nitrite Reagent Strip
Leukocyte Esterase
Clinical Significance
Reagent Strip Reaction
SUMMARY 5-19 Clinical Significance of Urine Leukocytes
Reaction Interference
Specific Gravity
Reagent Strip Reaction
SUMMARY 5-21 Clinical Significance of Urine Specific Gravity
Figure 5β4 Diagram of reagent stripβspecific gravity reaction.
Reaction Interference
SUMMARY 5-22 Urine Specific Gravity Reagent Strip
References
Study Questions
Case Studies and Clinical Situations
CHAPTER 6 Microscopic Examination of Urine
LEARNING OBJECTIVES
KEY TERMS
Macroscopic Screening
Table 6β1 Macroscopic Screening and Microscopic Correlations
Specimen Preparation
Specimen Volume
Centrifugation
Sediment Preparation
Volume of Sediment Examined
Commercial Systems
Examining the Sediment
Reporting the Microscopic Examination
EXAMPLE
Correlating Results
HISTORICAL NOTE
Addis Count
Table 6β2 Routine Urinalysis Correlations
Sediment Examination Techniques
Sediment Stains
Table 6β3 Urine Sediment Stain Characteristics
Table 6β4 Expected Staining Reactions of Urine Sediment Constituents
Lipid Stains
Gram Stain
Hansel Stain
Prussian Blue Stain
Cytodiagnostic Urine Testing
Microscopy
The Microscope
Table 6β5 Urinalysis Microscopic Techniques
Figure 6β1 Parts of the binocular microscope.
PROCEDURE 6-1 Care of the Microscope
KΓΆhler Illumination
Figure 6β2 Centering the condenser and KΓΆhler illumination.
Types of Microscopy
Bright-Field Microscopy
Phase-Contrast Microscopy
Polarizing Microscopy
Figure 6β3 Phase-contrast ring adjustment.
Interference-Contrast Microscopy
Figure 6β4 Diagram of polarized light.
Dark-Field Microscopy
Figure 6β5 Differential interference-contrast (Nomarski) microscopy.
Fluorescence Microscopy
Figure 6β6 Dark-field microscopy.
Urine Sediment Constituents
Red Blood Cells
Figure 6β7 Fluorescent microscopy.
Figure 6β8 Normal RBCs (Γ400).
Figure 6β9 Microcytic and crenated RBCs (Γ100).
Figure 6β10 Yeast. The presence of budding forms aid in distinguishing from RBCs (Γ400).
Figure 6β11 KOVA-stained squamous epithelial cells and oil droplets (Γ400). Notice how the oil droplet (arrow) resembles an RBC.
Figure 6β12 Air bubble. Notice no formed elements are in focus (Γ100).
Clinical Significance
Figure 6β13 Dysmorphic RBCs (Γ400). Notice the smaller size and fragmentation.
White Blood Cells
SUMMARY 6-1 Microscopic RBCs
Figure 6β14 RBCs and one WBC (Γ400). Notice the larger size and granules in the WBC.
Figure 6β15 WBCs. A. One segmented and one nonsegmented WBC (Γ400). B. Notice the multilobed nucleoli (Γ400).
Eosinophils
Figure 6β16 Glitter cells (Γ400). Observe the very noticeable granules.
Figure 6β17 Hansel-stained eosinophils (Γ400).
Mononuclear Cells
Figure 6β18 WBCs with acetic acid nuclear enhancement. Notice the ameboid shape in some of the WBCs.
Epithelial Cells
SUMMARY 6-2 Microscopic WBCs
Squamous Epithelial Cells
Figure 6β19 Sediment-containing squamous, caudate transitional, and RTE cells (Γ400).
Figure 6β20 A. Squamous epithelial cells identifiable under low power (Γ100). B. KOVA-stained squamous epithelial cells (Γ400). Compare the size of the nucleus with the RBCs in Figure 6β8.
Figure 6β21 Phenazopyridine-stained sediment showing squamous epithelial cells and phenazopyridine crystals formed following refrigeration (Γ400).
Figure 6β22 Clump of squamous epithelial cells (Γ400).
Figure 6β23 Clump of squamous epithelial cells with folded forms (Γ400).
Transitional Epithelial (Urothelial) Cells
Figure 6β24 Transitional epithelial cells.
Figure 6β25 KOVA-stained spherical transitional epithelial cells (Γ400).
Figure 6β26 Caudate transitional epithelial cells (Γ400).
Figure 6β27 Syncytia of transitional epithelial cells from catheterized specimen (Γ400).
Renal Tubular Epithelial Cells
Figure 6β28 RTE cell. Columnar proximal convoluted tubule cell with granules and attached fat globules (Γ400). N, nucleus.
Figure 6β29 RTE cells. Oval distal convoluted tubule cells. Notice the eccentrically placed nuclei (Γ400).
Figure 6β30 RTE cells, cuboidal from the collecting duct (Γ400).
Figure 6β31 Fragment of RTE cells from the collecting duct under phase microscopy (Γ400).
Clinical Significance
Figure 6β32 Prussian blueβstained hemosiderin granules.
Oval Fat Bodies
Figure 6β33 Oval fat body (Γ400).
Figure 6β34 Sudan III-stained oval fat body (Γ400).
Figure 6β35 Oval fat body under bright-field (left) and polarized (right) microscopy. Notice the Maltese cross formation (arrow) (Γ400).
Bacteria
SUMMARY 6-3 Epithelial Cells
Figure 6β36 A. Rod-shaped bacteria often seen in urinary tract infections. B. KOVA-stained bacteria and WBC (Γ400).
Yeast
Figure 6β37 A. Budding yeast B. Yeast showing mycelial forms (Γ400).
Parasites
Figure 6β38 Trichomonas vaginalis. Notice the flagella and undulating membrane.
Spermatozoa
Figure 6β39 Schistosoma haematobium ova (Γ300). Eggs are often contained in the last few drops of urine expelled from the bladder.
Figure 6β40 A. Enterobius vermicularis ova (Γ100) B. Enterobius vermicularis ova (Γ400).
Figure 6β41 Spermatozoa (Γ400).
Mucus
Casts
Figure 6β42 A. Mucus threads (Γ400). B. Mucus clump (Γ400).
SUMMARY 6-4 Miscellaneous Structures
Cast Composition and Formation
Hyaline Casts
Figure 6β43 Hyaline casts under low power (Γ100).
Figure 6β44 Hyaline cast (A) and amorphous urates (B) attached to mucus pseudocast (Γ100).
Figure 6β45 A. Hyaline cast (Γ400). B. Hyaline cast under phase microscopy (Γ400).
Figure 6β46 Convoluted hyaline cast (Γ400).
RBC Casts
Figure 6β47 Hyaline cast containing occasional granules (Γ400).
Figure 6β48 RBC cast (Γ400).
Figure 6β49 KOVA-stained RBC cast under phase microscopy (Γ400).
Figure 6β50 Disintegrating RBC cast. Notice the presence of free RBCs (arrows) to confirm identification.
Figure 6β51 Cast containing hemoglobin pigment. A comparison of RBCs (A) and yeast (B) also can be made (Γ400).
Figure 6β52 Granular, dirty, brown cast (Γ400).
WBC Casts
Figure 6β53 WBC cast. Notice the free WBCs to aid in identification.
Figure 6β54 KOVA-stained WBC cast (Γ400).
Figure 6β55 Disintegrating WBC cast (Γ400).
Bacterial Casts
Figure 6β56 WBC clump. Notice the absence of a cast matrix.
Epithelial Cell Casts
Fatty Casts
Figure 6β57 RTE cell cast (Γ400).
Figure 6β58 A. KOVA-stained RTE cell cast (Γ400). B. KOVA-stained RTE cell cast under phase microscopy (Γ400).
Figure 6β59 RTE cast with bilirubin-stained cells (Γ400).
Mixed Cellular Casts
Figure 6β60 Fatty cast showing adherence of fat droplets (arrows) to cast matrix (Γ400).
Figure 6β61 Fatty cast (Γ400).
Figure 6β62 Fatty cast under phase microscopy (Γ400).
Granular Casts
Figure 6β63 Finely granular cast (A) and uric acid crystals (B) (Γ400).
Figure 6β64 Granular cast formed at a tubular bend (Γ400).
Figure 6β65 Granular disintegrating cellular cast (Γ400).
Figure 6β66 Coarsely granular cast (A), squamous epithelial cell (B), and mucus (C) (Γ400).
Waxy Casts
Figure 6β67 Granular cast degenerating into waxy cast (Γ400).
Figure 6β68 KOVA-stained waxy casts (Γ100).
Figure 6β69 KOVA-stained waxy casts (Γ200).
Figure 6β70 KOVA-stained waxy cast (Γ400).
Broad Casts
Urinary Crystals
Figure 6β71 KOVA-stained broad waxy cast (Γ400).
Figure 6β72 Broad granular cast becoming waxy (Γ400).
Figure 6β73 Broad bile-stained waxy cast (Γ400).
Crystal Formation
General Identification Techniques
SUMMARY 6-5 Urine Casts
Normal Crystals Seen in Acidic Urine
Table 6β6 Major Characteristics of Normal Urinary Crystals
Figure 6β74 Amorphous urates (Γ400).
Figure 6β75 Amorphous urates attached to a fiber.
Figure 6β76 Uric acid crystals (Γ400).
Figure 6β77 Clump of uric acid crystals (Γ400). Notice the whetstone, not hexagonal, shape that differentiates uric acid crystals from cystine crystals.
Figure 6β78 A. Uric acid crystals under polarized light (Γ100). B. Uric acid crystals under polarized light (Γ400).
Figure 6β79 Classic dihydrate calcium oxalate crystals (Γ400).
Figure 6β80 Classic dihydrate calcium oxalate crystals under phase microscopy (Γ400).
Figure 6β81 Attached classic dihydrate calcium oxalate crystals (Γ400).
Figure 6β82 Monohydrate calcium oxalate crystals (Γ400).
Normal Crystals Seen in Alkaline Urine
Figure 6β83 Amorphous phosphates (Γ400). Urine pH 7.0.
Figure 6β84 Amorphous phosphates (Γ400).
Figure 6β85 Triple phosphate crystal (Γ400).
Figure 6β86 Triple phosphate crystals (arrow) and amorphous phosphates (Γ400).
Figure 6β87 Calcium carbonate crystals (Γ400).
Figure 6β88 Ammonium biurate crystals (Γ400). Notice the βthorny appleβ appearance.
Figure 6β89 Ammonium biurate crystals A. Ammonium biurate and triple phosphate crystals (Γ100). Note thorn (arrow). B. Ammonium biurate and triple phosphate crystals (Γ400).
Figure 6β90 Ammonium biurate crystals (Γ400). Note thorns (arrow).
Abnormal Urine Crystals
Cystine Crystals
Cholesterol Crystals
Table 6β7 Major Characteristics of Abnormal Urinary Crystals
Figure 6β91 Cystine crystals (Γ400).
Radiographic Dye Crystals
Crystals Associated With Liver Disorders
Figure 6β92 Clump of cystine crystals (Γ400). Notice the hexagonal shape still visible.
Figure 6β93 Cholesterol crystals. Notice the notched corners (Γ400).
Figure 6β94 Cholesterol crystals under polarized light (Γ400).
Figure 6β95 Tyrosine crystals in fine needle clumps (Γ400).
Figure 6β96 Tyrosine crystals in rosette forms (Γ400).
Figure 6β97 Leucine crystals (Γ400). Notice the concentric circles.
Figure 6β98 Bilirubin crystals. Notice the classic bright yellow color (Γ400).
Sulfonamide Crystals
Ampicillin Crystals
Figure 6β99 Sulfa crystals in rosette form (Γ400).
Figure 6β100 Sulfa crystals, WBCs, and bacteria seen in UTI (Γ400).
Figure 6β101 Ampicillin crystals. A. Nonrefrigerated ampicillin crystals. (Γ400). B. Ampicillin crystals after refrigeration (Γ400).
Urinary Sediment Artifacts
Figure 6β102 Starch granules. Notice the dimpled center (Γ400).
Figure 6β103 Fecal material and oil artifacts (Γ400).
Figure 6β104 Pollen grain. Notice the concentric circles (Γ400).
Figure 6β105 Fiber and squamous epithelial cell (Γ400).
Figure 6β106 Fiber under polarized light (Γ100).
Figure 6β107 Diaper fiber resembling a cast. Notice the refractility (Γ400).
Figure 6β108 Vegetable fiber resembling waxy cast (Γ400).
References
Study Questions
Case Studies and Clinical Situations
CHAPTER 7 Renal Disease
LEARNING OBJECTIVES
KEY TERMS
Glomerular Disorders
Glomerulonephritis
Acute Poststreptococcal Glomerulonephritis
Rapidly Progressive (Crescentic) Glomerulonephritis
Goodpasture Syndrome
Wegener Granulomatosis
Henoch-SchΓΆnlein Purpura
Membranous Glomerulonephritis
Membranoproliferative Glomerulonephritis
Chronic Glomerulonephritis
Immunoglobulin A Nephropathy
Nephrotic Syndrome
Minimal Change Disease
Focal Segmental Glomerulosclerosis
Tubular Disorders
Acute Tubular Necrosis
Table 7β1 Laboratory Testing in Glomerular Disorders
Table 7β2 Clinical Information Associated With Glomerular Disorders
Hereditary and Metabolic Tubular Disorders
Fanconi Syndrome
Alport Syndrome
Uromodulin-Associated Kidney Disease
Diabetic Nephropathy
Nephrogenic Diabetes Insipidus
TECHNICAL TIP
Renal Glycosuria
Interstitial Disorders
Table 7β3 Laboratory Testing in Metabolic and Hereditary Tubular Disorders
Table 7β4 Clinical Information Associated With Metabolic and Tubular Disorders
Acute Pyelonephritis
Chronic Pyelonephritis
TECHNICAL TIP
Acute Interstitial Nephritis
Renal Failure
Table 7β5 Laboratory Results in Interstitial Disorders
Table 7β6 Clinical Information Associated With Interstitial Disorders
Table 7β7 Causes of Acute Renal Failure
Renal Lithiasis
References
Study Questions
Case Studies and Clinical Situations
CHAPTER 8 Urine Screening for Metabolic Disorders
LEARNING OBJECTIVES
KEY TERMS
Overflow Versus Renal Disorders
Table 8β1 Abnormal Metabolic Constituents or Conditions Detected in the Routine Urinalysis
Newborn Screening Tests
Table 8β2 Major Disorders of Protein and Carbohydrate Metabolism Associated With Abnormal Urinary Constituents, Classified by Functional Defect
Figure 8β1 Specimen collection form for MS/MS newborn screening test.
Amino Acid Disorders
Phenylalanine-Tyrosine Disorders
Phenylketonuria
Figure 8β2 Phenylalanine and tyrosine metabolic pathway including the normal pathway (blue), enzymes (yellow), and disorders caused by failure to inherit particular enzymes (green).
Tyrosyluria
PROCEDURE 8-1
Melanuria
PROCEDURE 8-2 Nitroso-Naphthol Test for Tyrosine
Alkaptonuria
TECHNICAL TIP
TECHNICAL TIP
PROCEDURE 8-3 Homogentisic Acid Test
TECHNICAL TIP
Branched-Chain Amino Acid Disorders
Maple Syrup Urine Disease
Figure 8β3 Ξ±-Alpha amino acid and branched chain amino acid structures. A. Structure of an Ξ±-amino acid. B. Structure of the branched chain amino acid leucine.
Organic Acidemias
Tryptophan Disorders
PROCEDURE 8-4
Indicanuria
5-Hydroxyindoleacetic Acid
Figure 8β4 Tryptophan metabolism.
Cystine Disorders
PROCEDURE 8-5
Cystinuria
PROCEDURE 8-6 Silver Nitroprusside Test for Homocystine
Cystinosis
Homocystinuria
Porphyrin Disorders
PROCEDURE 8-7
Figure 8β5 Pathway of heme formation, including normal pathway (green), enzymes (orange), and stages affected by the major disorders (yellow) of porphyrin metabolism.
Table 8β3 Common Porphyrias
HISTORICAL NOTE
Vampires in Old Europe
Mucopolysaccharide Disorders
PROCEDURE 8-8 Watson-Schwartz Differentiation Test
PROCEDURE 8-9 Watson-Schwartz reactions.
PROCEDURE 8-10
Purine Disorders
Carbohydrate Disorders
PROCEDURE 8-11
TECHNICAL TIP
References
Study Questions
Case Studies and Clinical Situations
PART THREE Other Body Fluids
CHAPTER 9 Cerebrospinal Fluid
LEARNING OBJECTIVES
KEY TERMS
Formation and Physiology
Figure 9β1 The layers of the meninges. A, the layers of the meninges in the brain. B, the layers of the meninges in the spinal cord.
Specimen Collection and Handling
Figure 9β2 The flow of CSF through the brain and spinal column.
Appearance
Figure 9β3 CSF specimen collection tubes.
TECHNICAL TIP
TECHNICAL TIP
Figure 9β4 Tubes of CSF. Appearance left to right is normal, xanthochromic, hemolyzed, and cloudy.
Traumatic Collection (Tap)
Uneven Blood Distribution
Table 9β1 Clinical Significance of CSF Appearance
Clot Formation
Xanthochromic Supernatant
Cell Count
Methodology
Figure 9β5 Neubauer counting chamber depicting the nine large square counting areas.
Calculating CSF Cell Counts
EXAMPLE
Total Cell Count
WBC Count
Quality Control of CSF and Other Body Fluid Cell Counts
Differential Count on a CSF Specimen
Cytocentrifugation
Figure 9β6 Cytospin 3 cytocentrifuge specimen processing assembly
CSF Cellular Constituents
Table 9β2 Cytocentrifuge Recovery Chart7
Figure 9β7 Normal lymphocytes. Some cytocentrifuge distortion of cytoplasm (x1000).
Figure 9β8 Normal lymphocytes and monocytes (x500).
Neutrophils
Table 9β3 Predominant Cells Seen in CSF
Figure 9β9 Neutrophils with cytoplasmic vacuoles resulting from cytocentrifugation (x500).
Figure 9β10 Neutrophils with intracellular bacteria (x1000).
Figure 9β11 Neutrophils with intracellular and extracellular bacteria (x1000).
Figure 9β12 Neutrophils with pyknotic nuclei. Notice the cell with a single nucleus in the center (x1000).
Figure 9β13 Nucleated RBCs seen with bone marrow contamination (x1000).
Lymphocytes and Monocytes
Figure 9β14 Bone marrow contamination (x1000). Notice the immature RBCs and granulocytes.
Figure 9β15 Capillary and tissue fragments from a traumatic tap (x100).
Figure 9β16 Broad spectrum of lymphocytes and monocytes in viral meningitis (x1000).
Eosinophils
Macrophages
Nonpathologically Significant Cells
Figure 9β17 Eosinophils (x1000). Notice cytocentrifuge distortion.
Figure 9β18 Macrophages. Notice the large amount of cytoplasm and vacuoles (x500).
Figure 9β19 Macrophages showing erythrophagocytosis (x500).
Figure 9β20 Macrophage with RBC remnants (x500).
Figure 9β21 Macrophage with aggregated hemosiderin granules (x500).
Figure 9β22 Macrophage containing hemosiderin stained with Prussian blue (x250).
Figure 9β23 Macrophage with coarse hemosiderin granules (x500).
Figure 9β24 Macrophage containing hemosiderin and hematoidin crystals (x500).
Figure 9β25 Macrophages with hemosiderin and hematoidin (x250). Notice the bright yellow color.
Figure 9β26 Choroidal cells showing distinct cell borders and nuclear uniformity (x500).
Figure 9β27 Ependymal cells. Notice the nucleoli and less distinct cell borders (x1000).
Malignant Cells of Hematologic Origin
Figure 9β28 Cluster of spindle-shaped cells (x500).
Figure 9β29 Lymphoblasts from acute lymphocytic leukemia (x500).
Figure 9β30 Myeloblasts from acute myelocytic leukemia (x500).
Figure 9β31 Monoblasts and two lymphocytes (x1000). Notice the prominent nucleoli.
Figure 9β32 Cleaved and noncleaved lymphoma cells (x1000).
Figure 9β33 Lymphoma cells with nucleoli (x500).
Malignant Cells of Nonhematologic Origin
Figure 9β34 Burkitt lymphoma. Notice characteristic vacuoles (x500).
Figure 9β35 Medulloblastoma (x1000). Notice cellular clustering, nuclear irregularities, and rosette formation.
Chemistry Tests
Cerebrospinal Protein
Clinical Significance of Elevated Protein Values
Methodology
Protein Fractions
Table 9β4 Clinical Causes of Abnormal CSF Protein Values*
Electrophoresis and Immunophoretic Techniques
Figure 9β36 Normal and abnormal oligoclonal banding.
Myelin Basic Protein
CSF Glucose
CSF Lactate
CSF Glutamine
Microbiology Tests
Table 9β5 CSF Chemistry Tests
Gram Stain
Table 9β6 Major Laboratory Results for Differential Diagnosis of Meningitis
Figure 9β37 India ink preparation of C. neoformans (x400). Notice budding yeast form.
Figure 9β38 Gram stain of C. neoformans showing starburst pattern (x1000).
Serologic Testing
Figure 9β39 Naegleria fowleri trophozoite.
References
Study Questions
Case Studies and Clinical Situations
CHAPTER 10 Semen
LEARNING OBJECTIVES
KEY TERMS
Physiology
Table 10β1 Semen Composition
Figure 10β1 The male genitalia. Top, sagittal view; bottom, anterior view.
Specimen Collection
SUMMARY 10-1 Semen Production
TECHNICAL TIP
Specimen Handling
Semen Analysis
Appearance
Table 10β2 Reference Values for Semen Analysis5
Liquefaction
Volume
Viscosity
PROCEDURE 10-1
PROCEDURE 10-2
TECHNICAL TIP
pH
Sperm Concentration and Sperm Count
Figure 10β2 Areas of the Neubauer counting chamber used for red and white blood cell counts. W, typical WBC counting area; R, typical RBC counting area.
Calculating Sperm Concentration and Sperm Count
EXAMPLES
Sperm Motility
Table 10β3 Sperm Motility Grading
Table 10β4 Alternative Sperm Motility Grading Criteria1
Sperm Morphology
TECHNICAL TIP
Figure 10β3 Normal spermatozoon structure.
Figure 10β4 Spermatozoon with double head, hematoxylin-eosin (Γ1000).
Figure 10β5 Spermatozoon with amorphous head, hematoxylin-eosin (Γ1000).
Figure 10β6 Spermatozoon with double tail, hematoxylin-eosin (Γ1000).
Calculating Round Cells
Additional Testing
Figure 10β7 Common abnormalities of sperm heads and tails.
Figure 10β8 Spermatozoon with bent neck and spermatid, hematoxylin-eosin (Γ1000).
Figure 10β9 Immature spermatozoa, hematoxylin-eosin (Γ1000).
Sperm Vitality
Seminal Fluid Fructose
Table 10β5 Additional Testing for Abnormal Semen Analysis
Figure 10β10 Nonviable spermatozoa demonstrated by the eosin-nigrosin stain (Γ1000).
PROCEDURE 10-3
Antisperm Antibodies
Microbial and Chemical Testing
Table 10β6 Reference Semen Chemical Values1
Postvasectomy Semen Analysis
Sperm Function Tests
Semen Analysis Quality Control
TECHNICAL TIP
Table 10β7 Sperm Function Tests
References
Study Questions
Case Studies and Clinical Situations
CHAPTER 11 Synovial Fluid
LEARNING OBJECTIVES
KEY TERMS
Physiology
Figure 11β1 A synovial joint.
Table 11β1 Normal Synovial Fluid Values2
Specimen Collection and Handling
Table 11β2 Classification and Pathologic Significance of Joint Disorders
Table 11β3 Laboratory Findings in Joint Disorders3
Table 11β4 Required Tube Types for Synovial Fluid Tests
TECHNICAL TIP
Color and Clarity
Viscosity
Cell Counts
Differential Count
Table 11β5 Cells and Inclusions Seen in Synovial Fluid
Crystal Identification
Types of Crystals
Table 11β6 Characteristics of Synovial Fluid Crystals
Slide Preparation
Crystal Polarization
Figure 11β2 Unstained wet prep of MSU crystals (Γ400). Notice the characteristic yellow-brown of the urate crystals.
Figure 11β3 Wright’s-stained neutrophils containing CPPD crystals (Γ1000).
Figure 11β4 Strongly birefringent MSU crystals under polarized light (Γ500).
Figure 11β5 Weakly birefringent CPPD crystals under polarized light (Γ1000).
Figure 11β6 Extracellular MSU crystals under compensated polarized light. Notice the change in color with crystal alignment (Γ100).
Figure 11β7 MSU crystals under compensated polarized light. The yellow crystal is aligned with the slow vibration (Γ500).
Figure 11β8 CPPD crystals under compensated polarized light. The blue crystal is aligned with the slow vibration (Γ1000).
Chemistry Tests
Figure 11β9 Negative and positive birefringence in MSU and CPPD crystals. (A) MSU crystal with grain running parallel to the long axis. The slow ray passes with the grain, producing negative (yellow) birefringence. (B) CPPD crystal with grain running perpendicular to the long axis. The slow ray passes against the grain and is retarded, producing positive (blue) birefringence.
TECHNICAL TIP
Microbiologic Tests
Serologic Tests
References
Study Questions
Case Studies and Clinical Situations
CHAPTER 12 Serous Fluid
LEARNING OBJECTIVES
KEY TERMS
Formation
Specimen Collection and Handling
Figure 12β1 The body areas and membranes where serous fluid is produced.
Figure 12β2 The normal formation and absorption of pleural fluid.
Table 12β1 Pathologic Causes of Effusions
Transudates and Exudates
General Laboratory Procedures
Table 12β2 Laboratory Differentiation of Transudates and Exudates
Pleural Fluid
Appearance
Table 12β3 Correlation of Pleural Fluid Appearance and Disease5
Hematology Tests
Table 12β4 Differentiation Between Chylous and Pseudochylous Pleural Effusions
Table 12β5 Significance of Cells Seen in Pleural Fluid
Figure 12β3 Systemic lupus erythematosus cell in pleural fluid. Notice the ingested βround bodyβ (Γ1000).
Figure 12β4 Normal pleural fluid mesothelial cells, lymphocytes, and monocytes (Γ250).
Figure 12β5 Normal mesothelial cell (Γ500).
Figure 12β6 Reactive mesothelial cells showing eccentric nuclei and vacuolated cytoplasm (Γ500).
Figure 12β7 One normal and two reactive mesothelial cells with a multinucleated form (Γ500).
Figure 12β8 Pleural fluid plasma cells seen in a case of tuberculosis. Notice the absence of mesothelial cells (Γ1000).
Figure 12β9 Pleural fluid adenocarcinoma showing cytoplasmic molding (Γ250).
Figure 12β10 Pleural fluid adenocarcinoma showing nuclear and cytoplasmic molding and vacuolated cytoplasm (Γ1000).
Figure 12β11 Enhancement of nuclear irregularities using a toluidine blue stain (Γ250).
Figure 12β12 Poorly differentiated pleural fluid adenocarcinoma showing nuclear irregularities and cytoplasmic vacuoles (Γ500).
Figure 12β13 Pleural fluid small cell carcinoma showing nuclear molding (Γ250).
Chemistry Tests
Figure 12β14 Metastatic breast carcinoma cells in pleural fluid. Notice the hyperchromatic nucleoli (Γ1000).
Table 12β6 Characteristics of Malignant Cells
Table 12β7 Significance of Chemical Testing of Pleural Fluid
Microbiologic and Serologic Tests
Pericardial Fluid
Figure 12β15 Algorithm of pleural fluid testing.
Table 12β8 Significance of Pericardial Fluid Testing
Appearance
Laboratory Tests
Figure 12β16 Malignant pericardial effusion showing giant mesothelioma cell with cytoplasmic molding and hyperchromatic nucleoli (Γ1000).
Peritoneal Fluid
Transudates Versus Exudates
Table 12β9 Significance of Peritoneal Fluid Testing
EXAMPLE
Appearance
Laboratory Tests
Cellular Examination
Figure 12β17 Lipophages (macrophages containing fat droplets) in peritoneal fluid (Γ500).
Figure 12β18 Budding yeast in peritoneal fluid (Γ400).
Figure 12β19 Ovarian carcinoma showing community borders, nuclear irregularity, and hyperchromatic nucleoli (Γ500).
Figure 12β20 Ovarian carcinoma cells with large mucin-containing vacuoles (Γ500).
Figure 12β21 Adenocarcinoma of the prostate showing cytoplasmic vacuoles, community borders, and hyperchromatic nucleoli (Γ500).
Figure 12β22 Colon carcinoma cells containing mucin vacuoles and nuclear irregularities (Γ400).
Figure 12β23 Psammoma bodies exhibiting concentric striations (Γ500).
Chemical Testing
Microbiology Tests
Serologic Tests
References
Study Questions
Case Studies and Clinical Situations
CHAPTER 13 Amniotic Fluid
LEARNING OBJECTIVES
KEY TERMS
Physiology
Function
Volume
Table 13β1 Tests for Fetal Well-Being and Maturity
Figure 13β1 Fetus in amniotic sac.
Chemical Composition
Differentiating Maternal Urine From Amniotic Fluid
Specimen Collection
Indications for Amniocentesis
Table 13β2 Indications for Performing Amniocentesis
Collection
Specimen Handling and Processing
Color and Appearance
Tests for Fetal Distress
Hemolytic Disease of the Newborn
Table 13β3 Amniotic Fluid Color
Figure 13β2 Rh antibodies crossing the placenta.
Figure 13β3 Spectrophotometric bilirubin scan showing bilirubin and oxyhemoglobin peaks.
Neural Tube Defects
Figure 13β4 Example of a Liley graph.
Tests for Fetal Maturity
Fetal Lung Maturity
Lecithin-Sphingomyelin Ratio
Phosphatidyl Glycerol
Foam Stability Index
Lamellar Bodies
PROCEDURE 13-1 Foam Shake Test
PROCEDURE 13-2 Foam Stability Index
HISTORICAL NOTE
Microviscosity: Fluorescence Polarization Assay
Lamellar Body Count
PROCEDURE 13-3 Lamellar Body Count18
References
Study Questions
Case Studies and Clinical Situations
CHAPTER 14 Fecal Analysis
LEARNING OBJECTIVES
KEY TERMS
Physiology
Figure 14β1 Fluid regulation in the gastrointestinal tract.
Diarrhea and Steatorrhea
Diarrhea
Secretory Diarrhea
TECHNICAL TIP
Osmotic Diarrhea
Table 14β1 Common Fecal Tests for Diarrhea
Table 14β2 Differential Features for Diarrhea
Altered Motility
Steatorrhea
Specimen Collection
Macroscopic Screening
Color
Appearance
Table 14β3 Macroscopic Stool Characteristics12,26
Microscopic Examination of Feces
Fecal Leukocytes
Muscle Fibers
PROCEDURE 14-1 Methylene Blue Stain for Fecal Leukocytes
Qualitative Fecal Fats
Figure 14β2 Meat fibers present in fecal emulsion specimen using brightfield microscopy examination (Γ400).
Figure 14β3 Note striations on meat fiber present in a fecal emulsion specimen (Γ1000).
PROCEDURE 14-2 Muscle Fibers
Figure 14β4 Several orange-red neutral fat globules present in a fecal suspension stained with Sudan III (Γ400).
PROCEDURE 14-3 Neutral Fat Stain
PROCEDURE 14-4 Split Fat Stain
Chemical Testing of Feces
Occult Blood
Guaiac-Based Fecal Occult Blood Tests
Immunochemical Fecal Occult Blood Test
Porphyrin-Based Fecal Occult Blood Test
Quantitative Fecal Fat Testing
TECHNICAL TIP
SUMMARY 14-1 gFOBT Interference
False-Positive
False-Negative
PROCEDURE 14-5 Acid Steatocrit
APT Test (Fetal Hemoglobin)
Table 14β4 Tests, Materials, and Instrumentation for Fecal Fat Analysis19
PROCEDURE 14-6 APT Test
Fecal Enzymes
HISTORICAL NOTE
Screening Test for Fecal Trypsin
Carbohydrates
Table 14β5 Fecal Screening Tests
References
Study Questions
Case Studies and Clinical Situations
CHAPTER 15 Vaginal Secretions
LEARNING OBJECTIVES
KEY TERMS
Specimen Collection and Handling
Table 15β1 Clinical Features and Laboratory Findings in Vaginitis2
Color and Appearance
Diagnostic Tests
pH
Table 15β2 Normal Findings in Vaginal Secretions
Microscopic Procedures
PROCEDURE 15-1 pH Test
Wet Mount Examination
Squamous Epithelial Cells
Table 15β3 Quantitation Scheme for Microscopic Examinations2
Figure 15β1 Squamous epithelial cells identifiable under low power (Γ100).
Clue Cells
White Blood Cells
Figure 15β2 Clump of squamous epithelial cells (Γ400).
Figure 15β3 Clue cells (Γ400).
Figure 15β4 White blood cells. Notice the multilobed nucleoli (Γ400).
Red Blood Cells
Parabasal Cells
Figure 15β5 Normal red blood cells (Γ400).
Figure 15β6 Parabasal cell surrounded by epithelial cells (Γ400).
Basal Cells
Bacteria
Trichomonas vaginalis
Figure 15β7 Bacteria. A, Large rods characteristic of Lactobacilli, the predominant bacteria in normal vaginal secretions (Γ400). B, Bacteria with white blood cells (Γ400).
Yeast Cells
Figure 15β8 Trichomonas vaginalis.
Figure 15β9 Trichomonas vaginalis in wet mount.
KOH Preparation and Amine Test
Figure 15β10 Budding yeast cells (Γ400).
Figure 15β11 Yeast cells showing mycelial forms (Γ400).
Other Diagnostic Tests
Gram Stain
PROCEDURE 15-2 Saline Wet Mount2
PROCEDURE 15-3 KOH Preparation2
PROCEDURE 15-4 Amine (Whiff) Test
Table 15β4 Nugent’s Gram Stain Criteria to Diagnose Bacterial Vaginosis
Culture
DNA Testing
Point of Care Tests
Vaginal Disorders
Bacterial Vaginosis
Trichomoniasis
Candidiasis
Desquamative Inflammatory Vaginitis
Atrophic Vaginitis
Additional Vaginal Secretion Procedures
Fetal Fibronectin Test
AmniSure Test
References
Study Questions
Case Studies and Clinical Situations
Back Matter
APPENDIX A Urine and Body Fluid Analysis Automation
Urinalysis Automation
Table Aβ1 Measurement Technology Methods in Automated Urinalysis
Semi-Automated Urine Chemistry Analyzers
Table Aβ2 Urinalysis Automation
Fully Automated Urine Chemistry Analyzers
Figure Aβ1 DiaScreen50 semi-automated urine chemistry analyzer.
Figure Aβ2 Cobas u 411 urine chemistry analyzer.
Figure Aβ3 Urisys 1100 semi-automated urine chemistry analyzer.
Figure Aβ4 Clintek Status + Analyzer. A, Clinitek Status Connect with Barcode Stand. B, Clinitek Status with test strip.
Figure Aβ5 Clinitek Advantus semi-automated urine chemistry analyzer.
Figure Aβ6 iChem 100 semi-automated urine chemistry analyzer.
Automated Microscopy
Figure Aβ7 Urisys 2400 automated urine chemistry analyzer.
Figure Aβ8 Clinitek Atlas automated urine chemistry analyzer.
Sysmex UF-1000i
Figure Aβ9 Aution Max AX-4030 fully automated urine chemistry analyzer.
Figure Aβ10 iChem Velocity automated urine chemistry analyzer.
Figure Aβ11 Sysmex UF 1000i urine chemistry analyzer.
Figure Aβ12 Diagram of urine particle analysis in the Sysmex UF1000i.
Figure Aβ13 Staining elements for the Sysmex UF1000i.
Figure Aβ14 UF1000i signal waveform for cells.
iQ 200
Figure Aβ15 Scattergram showing Sysmex UF1000i microscopy results.
Figure Aβ16 iQ 200 microscopy analyzer.
Figure Aβ17 Diagram of the iQ 200 digital flow capture process.
Figure Aβ18 Auto-Particle Recognition (APR) process.
Figure Aβ19 iQ 200 urinalysis results display, showing particle categories available for analysis or counting.
Automated Urinalysis Systems
Figure Aβ20 AUWi, a fully automated urinalysis system that combines the Siemens Clinitek Atlas Chemistry analyzer and the Sysmex UF-1000i particle analyzer.
Figure Aβ21 iRICELL3000, a fully automated Urinalysis System that combines the iChem Velocity urine chemistry analyzer and the iQ 200 microscopy analyzer.
Body Fluid Analysis Automation
References
Additional Information Sources
APPENDIX B Bronchoalveolar Lavage
White and Red Blood Cell Counts
Leukocytes
Figure Bβ1 Bronchoalveolar lavage: Normal macrophages and lymphocytes (Γ1000).
Erythrocytes
Epithelial Cells
Figure Bβ2 Bronchoalveolar lavage: Ciliated bronchial epithelial cells; notice the eosinophilic bar (Γ1000).
Fungi, Viruses, and Bacteria
Figure Bβ3 Bronchoalveolar lavage: Amorphous material associated with P. carinii when examined under low power (Γ100).
Figure Bβ4 Bronchoalveolar lavage: Characteristic cup-shaped organisms indicating P. carinii (Γ1000).
Cytology
References
Answers to Study Questions and Case Studies and Clinical Situations
Chapter 1
Study Questions
Case Studies and Clinical Situations
Chapter 2
Study Questions
Case Studies and Clinical Situations
Chapter 3
Study Questions
Case Studies and Clinical Situations
Chapter 4
Study Questions
Case Studies and Clinical Situations
Chapter 5
Study Questions
Case Studies and Clinical Situations
Chapter 6
Study Questions
Case Studies and Clinical Situations
Chapter 7
Study Questions
Case Studies and Clinical Situations
Chapter 8
Study Questions
Case Studies and Clinical Situations
Chapter 9
Study Questions
Case Studies and Clinical Situations
Chapter 10
Study Questions
Case Studies and Clinical Situations
Chapter 11
Study Questions
Case Studies and Clinical Situations
Chapter 12
Study Questions
Case Studies and Clinical Situations
Chapter 13
Study Questions
Case Studies and Clinical Situations
Chapter 14
Study Questions
Case Studies and Clinical Situations
Chapter 15
Study Questions
Case Studies and Clinical Situations
Abbreviations
Glossary
Index
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