Urinalysis CPC Session: Cases for Interpretation Instructor version

Urinalysis CPC: Case 1 Analyte Result Normal Range Color Yellow Clarity Clear Specific gravity 1.018 1.005 – 1.030 pH 5.8 5.0 – 9.0 Protein Negative 0-20 mg/dL Glucose 3+ Ketones 1+ Blood Bilirubin Urobilinogen Weak + 0.2 – 1.0 Nitrite Leukocyte Esterase Epithelial cells Few squamous cells 0-3/HPF Red blood cells (RBCs) 0-2 RBCs/HPF 0-2/HPF White blood cells (WBCs) 0-1 WBCs/HPF Organisms Rare bacteria None Seen HPF Casts 0-1 hyaline casts/LPF 0-3/LPF Crystals None seen Clinical: A 34-year-old woman presents to the clinic with a complaint of chronic fatigue that has been increasing in severity over the past 4 weeks. She has no other specific complaints. A urinalysis is performed with the following results: Macroscopic analysis Chemical analysis Microscopic analysis

Urinalysis CPC: Case 1 Clinical: A 34-year-old woman presents to the clinic with a complaint of chronic fatigue that has been increasing in severity over the past 4 weeks. Urination is normal. A urinalysis is performed with the following results: Analyte Result Normal Range Your thoughts Color Yellow Normal Clarity Clear Specific gravity 1.018 1.005 – 1.030 Mid-range pH 5.8 5.0 – 9.0 Trending acidic Protein Negative 0-20 mg/dL -- Glucose 3+ Markedly increased Ketones 1+ Mildly increased Blood Bilirubin Urobilinogen Weak + 0.2 – 1.0 Nitrite Leukocyte Esterase Epithelial cells Few squamous cells 0-3/HPF Red blood cells (RBCs) 0-2 RBCs/HPF 0-2/HPF White blood cells (WBCs) 0-1 WBCs/HPF Organisms Rare bacteria None Seen HPF Maybe contaminant Casts 0-1 hyaline casts/LPF 0-3/LPF Maybe stress Crystals None seen Interpretation: This patient has glucosuria with mild ketonuria and more acidic urine. Hyaline casts are also present. Summary: In this patient, consider diabetes mellitus, given the clinical history and UA findings.

Urinalysis CPC: Case 2 Clinical: A 55-year-old man presents with burning on urination for 3 days, malaise and fatigue. He has had increased fluid intake and voiding. He is not on diuretics or other medications. A urinalysis is performed with the following results: Analyte Result Normal Range Color Yellow Clarity Hazy Clear Specific gravity 1.004 1.005 – 1.030 pH 6.5 5.0 – 9.0 Protein Trace 0-20 mg/dL Glucose Negative Ketones Blood 1+ Bilirubin Urobilinogen 0.2 0.2 – 1.0 Nitrite Positive Leukocyte Esterase Epithelial cells Few squamous cells 0-3/HPF Red blood cells (RBCs) 1-5 RBCs/HPF 0-2/HPF White blood cells (WBCs) 2-4 WBCs/HPF Organisms Few yeast and bacteria/HPF None Seen HPF Casts None seen 0-3/LPF Crystals

Urinalysis CPC: Case 2 Analyte Result Normal Range Your thoughts Color Yellow -- Clarity Hazy Clear Not specific Specific gravity 1.004 1.005 – 1.030 Dilute pH 6.5 5.0 – 9.0 Mid-range Protein Trace 0-20 Okay Glucose Negative Ketones Blood 1+ Mildly increased Bilirubin Urobilinogen 0.2 0.2 – 1.0 Nitrite Positive Bacteria present Leukocyte Esterase Leukocytes present Epithelial cells Few squamous cells 0-3/HPF Red blood cells (RBCs) 1-5 RBCs/HPF 0-2/HPF Few more than normal White blood cells (WBCs) 2-4 WBCs/HPF Organisms Few yeast and bacteria/HPF None Seen HPF Interesting… Casts None seen 0-3/LPF Crystals Clinical: A 55-year-old man presents with burning on urination for 3 days, malaise and fatigue. He has had increased fluid intake and voiding. He is not on diuretics or other medications. A urinalysis is performed with the following results: Interpretation: This pattern favors infection. The dilute urine fits with his history, so RBCs or WBCs may be underestimated on microscopic (lysed). RBCs likely present due to irritation of GU tract. No WBC casts, so involvement of kidney by infection is less likely. Summary: Urinary tract infection, probably lower tract.

Urinalysis CPC: Case 3 Clinical: An 8-year-old girl presents with edema that has been present for 2 weeks. A urinalysis is performed with the following results: Analyte Result Normal Range Color Pale yellow Yellow Clarity Clear Specific gravity 1.007 1.005 – 1.030 pH 6.5 5.0 – 9.0 Protein 4+ 0-20 mg/dL Glucose Negative Ketones Blood Bilirubin Urobilinogen 0.2 0.2 – 1.0 Nitrite Leukocyte Esterase Epithelial cells Few squamous cells 0-3/HPF Red blood cells (RBCs) 0-2 RBCs/HPF 0-2/HPF White blood cells (WBCs) 0-1 WBCs/HPF Organisms None seen None Seen HPF Casts 0-1 fatty casts/LPF 0-3/LPF Crystals

Urinalysis CPC: Case 3 Clinical: An 8-year-old girl presents with edema that has been present for 2 weeks. A urinalysis is performed with the following results: Analyte Result Normal Range Your thoughts Color Pale yellow Yellow -- Clarity Clear Specific gravity 1.007 1.005 – 1.030 Little low pH 6.5 5.0 – 9.0 Mid-range Protein 4+ 0-20 mg/dL Markedly increased Glucose Negative Ketones Blood Bilirubin Urobilinogen 0.2 0.2 – 1.0 Normal Nitrite Leukocyte Esterase Epithelial cells Few squamous cells 0-3/HPF Red blood cells (RBCs) 0-2 RBCs/HPF 0-2/HPF White blood cells (WBCs) 0-1 WBCs/HPF Organisms None seen None Seen HPF Casts 0-1 fatty casts/LPF 0-3/LPF Interesting! Crystals Interpretation: This patient has significant proteinuria with fatty casts. As you will learn later in the block, you might suspect nephrotic syndrome in this patient. Young children don’t normally have significant proteinuria. This may indicate a glomerular problem. Summary: Significant proteinuria with fatty casts. Consider quantification of the amount of proteinuria with a 24-hour urine collection.

Urinalysis CPC: Case 4 Clinical: A 12-year- old boy develops a petechial rash over his legs which has persisted for a month. He also has hypertension and an elevated serum creatinine. A urinalysis is performed with the following results: Analyte Result Normal Range Color Yellow Clarity Hazy Clear Specific gravity 1.012 1.005 – 1.030 pH 7.5 5.0 – 9.0 Protein 2+ 0-20 mg/dL Glucose Negative Ketones Blood 2-3+ Bilirubin Urobilinogen 0.2 0.2 – 1.0 Nitrite Leukocyte Esterase Epithelial cells Few squamous cells 0-3/HPF Red blood cells (RBCs) 20-30 RBCs/HPF 0-2/HPF White blood cells (WBCs) 0-2 WBCs/HPF Organisms None seen None Seen HPF Casts 1-2 RBC casts/LPF 0-3/LPF Crystals

Urinalysis CPC: Case 4 Clinical: A 12-year-old boy develops a petechial rash over his legs which has persisted for a month. He also has hypertension and an elevated serum creatinine. A urinalysis is performed with the following results: Analyte Result Normal Range Your thoughts Color Yellow Okay Clarity Hazy Clear Specific gravity 1.012 1.005 – 1.030 Tending dilute pH 7.5 5.0 – 9.0 Mid-range Protein 2+ 0-20 mg/dL Increased Glucose Negative -- Ketones Blood 2-3+ Bilirubin Urobilinogen 0.2 0.2 – 1.0 Normal Nitrite Leukocyte Esterase Epithelial cells Few squamous cells 0-3/HPF Red blood cells (RBCs) 20-30 RBCs/HPF 0-2/HPF Increased; matches with dipstick + White blood cells (WBCs) 0-2 WBCs/HPF Organisms None seen None Seen HPF Casts 1-2 RBC casts/LPF 0-3/LPF Significant Crystals Interpretation: This patient has proteinuria and hematuria. The microscopic fits with the dipstick findings. The presence of RBC casts is significant. Summary: In this patient with hematuria, proteinuria, and RBC casts, consider renal injury. More specifically, consider glomerular bleeding/injury (nephritic syndrome).

Urinalysis CPC: Case 5 Clinical: A 30-year-old man is brought to the emergency department following a motorcycle accident. A urinalysis is performed with the following results: Analyte Result Normal Range Color Red-brown Yellow Clarity Hazy Clear Specific gravity 1.025 1.005 – 1.030 pH 7.0 5.0 – 9.0 Protein 2+ 0-20 mg/dL Glucose Trace Negative Ketones Blood 3+ Bilirubin Urobilinogen 0.2 0.2 – 1.0 Nitrite Leukocyte Esterase Epithelial cells Few tubular epithelial cells 0-3/HPF Red blood cells (RBCs) 2-4 RBCs/HPF 0-2/HPF White blood cells (WBCs) Rare Organisms None seen None Seen HPF Casts Few granular casts/LPF 0-3/LPF Crystals

Urinalysis CPC: Case 5 Clinical: A 30-year-old man is brought to the emergency department following a motorcycle accident. A urinalysis is performed with the following results: Analyte Result Normal Range Your thoughts Color Red-brown Yellow Abnormal Clarity Hazy Clear Not specific Specific gravity 1.025 1.005 – 1.030 Upper normal pH 7.0 5.0 – 9.0 Mid-range Protein 2+ 0-20 mg/dL Glucose Trace Negative -- Ketones Blood 3+ Bilirubin Urobilinogen 0.2 0.2 – 1.0 Normal Nitrite Leukocyte Esterase Epithelial cells Few tubular epithelial cells 0-3/HPF ? Tubular damage Red blood cells (RBCs) 2-4 RBCs/HPF 0-2/HPF Abnormal; but differs from dipstick result White blood cells (WBCs) Rare Organisms None seen None Seen HPF Casts Few granular casts/LPF 0-3/LPF ? Stress Crystals Interpretation: Urine is red, which fits with 3+ blood. But, we would expect more RBCs on microscopic. Did RBCs lyse because of dilute urine? No…urine is concentrated…So, consider presence of myoglobin (or hemoglobin), which could turn dipstick positive and account for discrepancy between dipstick blood and microscopic evaluation. Tubular epithelial cells may indicate tubular damage, caused by myoglobin’s toxic effect on tubule epithelium. Protein + may also be due to presence of myoglobin in urine. Summary: Likely hematuria PLUS myoglobinuria due to muscle injury from trauma.

Urinalysis CPC: Case 6 Clinical: A 58-year-old man with severe uncontrolled hypertension presents for evaluation. He is non-compliant with his medications and rarely keeps his scheduled appointments. A urinalysis is performed with the following results: Analyte Result Normal Range Color Amber Yellow Clarity Hazy Clear Specific gravity 1.010 1.005 – 1.030 pH 8.0 5.0 – 9.0 Protein 2+ 0-20 mg/dL Glucose Negative Ketones Blood Bilirubin Urobilinogen 0.2 0.2 – 1.0 Nitrite Leukocyte Esterase Epithelial cells Few squamous cells 0-3/HPF Red blood cells (RBCs) 0-2 RBCs/HPF 0-2/HPF White blood cells (WBCs) 0-2 WBCs/HPF Organisms None seen None Seen HPF Casts 1-2 waxy casts/LPF 0-3/LPF Crystals

Urinalysis CPC: Case 6 Clinical: A 58-year-old man with severe uncontrolled hypertension presents for evaluation. He is non-compliant with his medications and rarely keeps his scheduled appointments. A urinalysis is performed with the following results: Analyte Result Normal Range Your thoughts Color Amber Yellow -- Clarity Hazy Clear Specific gravity 1.010 1.005 – 1.030 Low pH 8.0 5.0 – 9.0 Tending alkaline Protein 2+ 0-20 mg/dL Significant Glucose Negative Ketones Blood Bilirubin Urobilinogen 0.2 0.2 – 1.0 Normal Nitrite Leukocyte Esterase Epithelial cells Few squamous cells 0-3/HPF Red blood cells (RBCs) 0-2 RBCs/HPF 0-2/HPF White blood cells (WBCs) 0-2 WBCs/HPF Organisms None seen None Seen HPF Casts 1-2 waxy casts/LPF 0-3/LPF Crystals Interpretation: This patient has proteinuria and waxy casts, without much else. In a patient with longstanding severe hypertension, this may mean he has chronic kidney disease/chronic renal failure. Summary: Consider chronic renal failure with proteinuria. May want to get a serum creatinine. NOTE: If s.g. is “fixed” on multiple occasions at 1.010, this may also indicate significant renal (tubular) damage.

Urinalysis CPC: Case 7 Analyte Result Normal Range Color Dark brown Yellow Clarity Cloudy Clear Specific gravity 1.025 1.005 – 1.030 pH 7.0 5.0 – 9.0 Protein 2+ 0-20 mg/dL Glucose Negative Ketones 1+ Blood 3+ Bilirubin Urobilinogen 2.0 (2+) 0.2 – 1.0 Nitrite Leukocyte Esterase Epithelial cells Rare squamous cells 0-3/HPF Red blood cells (RBCs) 1-5 RBCs/HPF 0-2/HPF White blood cells (WBCs) 0-2 WBCs/HPF Organisms None seen None Seen HPF Casts 1-2 granular casts and 1-2 hemoglobin casts/LPF 0-3/LPF Crystals Clinical: A 24-year-old soldier has recently returned from service in Africa. He was not stationed in a country where Ebola virus is prominent. He recently developed a severe chill and fever. A urinalysis is performed with the following results:

Urinalysis CPC: Case 7 Analyte Result Normal Range Your thoughts Color Dark brown Yellow Blood ? Hemoglobin ? Clarity Cloudy Clear Okay Specific gravity 1.025 1.005 – 1.030 Relatively concentrated pH 7.0 5.0 – 9.0 Mid-range Protein 2+ 0-20 mg/dL Moderately increased Glucose Negative -- Ketones 1+ Mildly increased Blood 3+ Markedly increased Bilirubin Urobilinogen 2.0 (2+) 0.2 – 1.0 Elevated Nitrite Leukocyte Esterase Epithelial cells Rare squamous cells 0-3/HPF Red blood cells (RBCs) 1-5 RBCs/HPF 0-2/HPF Elevated, but doesn’t fit with dipstick (3+) White blood cells (WBCs) 0-2 WBCs/HPF Organisms None seen None Seen HPF Casts 1-2 granular casts and 1-2 hemoglobin casts/LPF 0-3/LPF Granular = stress; hemoglobin significant Crystals Clinical: A 24-year-old soldier has recently returned from service in Africa. He was not stationed in a country where Ebola virus is prominent. He recently developed a severe chill and fever. A urinalysis is performed with the following results: Interpretation: Dark brown color fits with dipstick blood 3+, but microscopic doesn’t correlate. RBCs probably didn’t lyse because urine isn’t dilute. So, consider presence of hemoglobin or myoglobin that turns dipstick positive (fits with hemoglobin casts). Increased urobilinogen suggests increased bilirubin excretion into GI tract. Summary: Clinical history & UA results suggest acute hemolysis. Consider malaria, given recent travel history.

Urinalysis CPC: Case 8 Clinical: A 50-year-old man who is undergoing chemotherapy for lung cancer develops intense right-sided flank pain radiating down to his right groin. He has a history of diabetes mellitus and hypertension. A urinalysis is performed with the following results: Analyte Result Normal Range Color Light pink to yellow Yellow Clarity Cloudy Clear Specific gravity 1.025 1.005 – 1.030 pH 5.0 5.0 – 9.0 Protein 1+ 0-20 mg/dL Glucose Trace Negative Ketones Blood 2+ Bilirubin Urobilinogen 0.2 0.2 – 1.0 Nitrite Leukocyte Esterase Positive Epithelial cells Few squamous cells 0-3/HPF Red blood cells (RBCs) 15-20 RBCs/HPF 0-2/HPF White blood cells (WBCs) 5-10 WBCs/HPF Organisms None seen None Seen HPF Casts 0-3/LPF Crystals Abundant needle-like crystals

Urinalysis CPC: Case 8 Analyte Result Normal Range Your thoughts Color Light pink to yellow Yellow Pink…? Blood ? Clarity Cloudy Clear Why? Specific gravity 1.025 1.005 – 1.030 Little concentrated pH 5.0 5.0 – 9.0 Acidic Protein 1+ 0-20 mg/dL Mildly elevated Glucose Trace Negative -- Ketones Blood 2+ Increased Bilirubin Urobilinogen 0.2 0.2 – 1.0 Normal Nitrite Leukocyte Esterase Positive Leukocytes present Epithelial cells Few squamous cells 0-3/HPF Red blood cells (RBCs) 15-20 RBCs/HPF 0-2/HPF Increased; fits with dipstick result White blood cells (WBCs) 5-10 WBCs/HPF Organisms None seen None Seen HPF Casts 0-3/LPF Crystals Abundant needle-like crystals What type? Clinical: A 50-year-old man who is undergoing chemotherapy for lung cancer develops intense right-sided flank pain radiating down to his right groin. He has a history of diabetes mellitus and hypertension. A urinalysis is performed with the following results: Interpretation: The clinical history suggests stone passage. Pink color could indicate the presence of blood…Certain crystals/stones tend to form in acidic urine. Blood and WBCs could be due to stone/crystal trauma and inflammation. Needle-like crystals could be uric acid. Summary: Clinical history and UA findings consistent with passage of uric acid stone. Chemotherapy can cause rapid lysis of tumor cells, which results in excess uric acid in system. This can lead to uric acid stone formation. Now, efforts are taken to reduce the incidence of uric acid stone formation in this setting.

Urinalysis CPC: Case 9 Clinical: A 27-year-old prisoner complains of fever, recent weight loss, back pain, nausea, vomiting, malaise and fatigue. He has a history of substance abuse and was recently incarcerated for burglary. A urinalysis is performed with the following results: Analyte Result Normal Range Color Green-yellow Yellow Clarity Cloudy Clear Specific gravity 1.025 1.005 – 1.030 pH 8.5 5.0 – 9.0 Protein 1+ 0-20 mg/dL Glucose Trace Negative Ketones Blood Bilirubin 2+ Urobilinogen 0.2 (+) 0.2 – 1.0 Nitrite Positive Leukocyte Esterase Epithelial cells Few squamous cells 0-3/HPF Red blood cells (RBCs) 12-15 RBCs/HPF 0-2/HPF White blood cells (WBCs) 20-40 WBCs/HPF Organisms 1+ Trichomonas, bacteria present None Seen HPF Casts 0-1 granular casts and 1-2 WBC casts/LPF 0-3/LPF Crystals None seen

Urinalysis CPC: Case 9 Analyte Result Normal Range Your thoughts Color Green-yellow Bilirubin ? Clarity Cloudy Crystals or infection ? Specific gravity 1.025 1.005 – 1.030 Relatively concentrated pH 8.5 5.0 – 9.0 Alkaline Protein 1+ 0-20 mg/dL Mildly elevated Glucose Trace A little Ketones Blood Bilirubin 2+ Increased Urobilinogen 0.2 (+) 0.2 – 1.0 Normal Nitrite Positive Bacteria present Leukocyte Esterase Leukocytes present Epithelial cells Few squamous cells Red blood cells (RBCs) 12-15 RBCs/HPF 0-2/HPF Confirms Blood on dipstick White blood cells (WBCs) 20-40 WBCs/HPF Confirms leukocytes on dipstick Organisms 1+ Trichomonas; bacteria present Infection Casts 0-1 granular casts and 1-2 WBC casts/LPF WBC casts = kidney inflammation Crystals None seen Clinical: A 27-year-old prisoner complains of fever, recent weight loss, back pain, nausea, vomiting, malaise and fatigue. He has a history of substance abuse and was recently incarcerated for burglary. A urinalysis is performed with the following results: Interpretation: Green color and bilirubin fit together, so he possibly has a liver problem. It’s not bile duct obstruction, because urobilinogen is positive. Alkaline urine with nitrite, LE and WBCs and WBC casts point to kidney infection. RBCs probably present due to irritation & infection. Summary: Consider liver disease, renal infection, STIs.

Urinalysis Patterns to Recognize “Normal” Non-specific “stress” changes (UA Case 1 from Case Study lecture) Dehydration with/without ketosis (UA Case 2 from Case Study lecture) Biliary tract obstruction (UA Case 3 from Case Study lecture) Pyelonephritis – Upper Urinary Tract Infection (UA Case 4 from Case Study lecture)

More Urinalysis Patterns to Recognize Diabetes mellitus (CPC Case 1) Lower urinary tract infection (CPC Case 2) Heavy proteinuria (CPC Case 3) Glomerular bleeding/injury (CPC Case 4) Hematuria/Myoglobinuria (CPC Case 5) Chronic renal disease (CPC Case 6) Hemolysis (CPC Case 7) Stone passage (CPC Case 8, also tumor lysis) Liver disease (CPC Case 9, other things included)