Basic Laboratory Tests

Mohammed Fouad Deek

SDC
November 2013
Objectives
• Introduce basic laboratory tests and their
use in clinical practice
• Discuss normal values and test
interpretation
Complete Blood Count (CBC)
• Provides information on cellular
components of blood
• Includes RBC count, Hemoglobin (Hgb),
Hematocrit (Hct), RBC indices, White
blood cell (WBC) count and differential,
Platelet count
 Total WBCs (leukocytes)
• Measurement of total WBC count
• Consists of total # of WBCs/mm3 of peripheral venous
blood
• Part of “routine” testing
• Useful for evaluation of infection, neoplasm, allergy &
immunosuppression
• Normal: 4,000 – 10,000/mm3
• Critical: < 2,500 or > 30,000/mm3
• ↑ (leukocytosis): infection, malignancy, trauma,
stress, hemorrhage, tissue necrosis, inflammation,
dehydration, thyroid storm
• ↓ (leukopenia): drug toxicity, bone marrow failure,
overwhelming infections, dietary deficiency,
congenital marrow aplasia, bone marrow infiltration,
autoimmune disease, hypersplenism
 Erythrocyte count (RBC)
• Measures # of circulating RBCs/mm3 of peripheral
venous blood
• Direct measure of RBC count
• Part of “routine” testing and anemia evaluation
• Normal: 3.5 – 5.5 x 106/μL
• ↑: erythrocytosis, congenital heart disease, severe
COPD, polycythemia vera, severe dehydration,
hemoglobinopathies
• ↓: anemia, hemoglobinopathy, hemorrhage, bone
marrow failure, renal disease, leukemia, prosthetic
valves, normal pregnancy, multiple myeloma, Hodgkin
disease, lymphoma, dietary deficiency
 Hgb
• Measures total amount of Hgb in blood
• Indirect measure of RBC count
• Part of “routine” testing and anemia evaluation
• Normal: 12 – 15 g/dL
• Critical: < 5 or > 20 g/dL
• ↑: erythrocytosis, congenital heart disease,
severe COPD, polycythemia vera, severe
dehydration
↓: anemia, hemoglobinopathy, hemorrhage, bone
marrow failure, renal disease, leukemia, prosthetic
valves, normal pregnancy, multiple myeloma,
Hodgkin disease, lymphoma, dietary deficiency
 Hct
• Measure of RBC percent of total blood vol
• Indirect measure of RBC # & volume
• Part of “routine” testing and anemia evaluation
• Normal: 36 – 48%
• Critical: < 15% or > 60%
• ↑: erythrocytosis, congenital heart disease,
severe COPD, polycythemia vera, severe
dehydration
• ↓: anemia, hemoglobinopathy, hemorrhage, bone
marrow failure, renal disease, leukemia,
prosthetic valves, normal pregnancy, multiple
myeloma, Hodgkin disease, lymphoma, dietary
deficiency
RBC indices
• Measures size and hgb content of RBCs
• Used to classify anemias
• Includes Mean corpuscular volume (MCV),
mean corpuscular hemoglobin (MCH),
mean corpuscular hemoglobin
concentration (MCHC), red blood cell
distribution width (RDW)
MCV
• Measure of average volume/size of single
RBC
• MCV = Hct (%) x 10/RBC (million/mm3)
• Useful in anemia classification
• Normal: 80 – 100 mm3
• ↑ (macrocytic): pernicious anemia (vit B 12
deficiency), folic acid deficiency, antimetabolic
therapy, alcoholism, chronic liver disease,
hypothyroidism
• Normocytic: bone marrow failure/replacement,
acute blood loss, chronic diseases, hemolytic
anemias
• ↓ (microcytic): Fe deficiency anemia,
thalassemia, anemia of chronic illness
MCH
• Measure of average amount of hgb within
a single RBC
• MCH = Hgb (g/dL) x 10/RBC
(million/mm3)
• Provides little additional info to other
indices
• Normal: 24 – 32 pg
• ↑: macrocytic anemias
• ↓: microcytic anemia, hypochromic
anemia
MCHC
• Measure of average [hgb] within a
single RBC
• MCHC = Hgb (g/dL) x 100/Hct (%)
• 37 g/dL = maximum Hgb able to fit into
an RBC (cannot be hyperchromic)
• Normal (normochromic): 32 – 36 g/dL
• ↑: spherocytosis, intravascular
hemolysis, cold agglutinins
• ↓ (hypochromic): Fe deficiency
anemia, thalassemia
Platelet count
• Measurement of platelets (thrombocytes)
• Consists of actual # of platelets/mm3 of peripheral
venous blood
• Part of “routine” testing
• Useful for evaluation of petechiae, spontaneous
bleeding, increasingly heavy menses or
thrombocytopenia
• Useful for monitoring discourse/therapy of
thrombocytopenia/bone marrow failure
• Normal: 150,000 – 400,000/mm3
• Critical: < 50,000 or > 1,000,000/mm3
• ↑ (thrombocytosis): malignant disorders,
polycythemia vera, postsplenectomy syndrome,
rheumatoid arthritis, Fe deficiency anemia
• ↓ (thrombocytopenia): Hypersplenism, hemorrhage,
immune thrombocytopenia, leukemia & other
myelofibrosis disorders, TTP, DIC, SLE,
chemotherapy, pernicious anemia
WBC definitions
• Leukocytosis – abnormally large number
of leukocytes; generally indicated by WBC
count of ≥ 10,000 cells/mm3
• Lymphocytosis – form of actual or relative
leukocytosis due to increase in numbers of
lymphocytes
• Left shift – increase in the number of
immature neutrophils (bands/stabs) found
in the blood
 WBC differential
• Measurement of percentage of each WBC
type in specimen
• Useful for infection, neoplasm, allergy &
immunosuppression evaluations
• Normal: Neutrophils (50 – 70%),
Lymphocytes (20 – 40%), Monocytes (2 –
8%), Eosinophils (0 – 5%), Basophils (0 –
2%)
• ↑: refer to individual cell types on chart
• ↓: refer to individual cell types on chart
Basic Metabolic Panel (BMP)
• Measures electrolytes, chemicals,
metabolic end products & substrates
• Consists of Glucose, Blood Urea Nitrogen
(BUN), Creatinine, Na+, K+, Cl-,
Bicarbonate (HCO3-), Ca2+
 Glucose
• Direct measure of blood glucose
• Commonly used to evaluate diabetic pts
• Part of “routine” testing
• Normal: 70 - 100 mg/dL
• Critical: < 50 and > 400 mg/dL (♂) or < 40 and >
400 mg/dL (♀)
• ↑ (hyperglycemia): DM, acute stress response,
Cushing syndrome, pheochromocytoma, chronic
renal failure, acute pancreatitis, acromegaly,
corticosteroid therapy
• ↓ (hypoglycemia): insulinoma, hypothyroidism,
hypopituitarism, Addison disease, extensive liver
disease, insulin overdose, starvation
BUN
• Measures urea nitrogen in blood
• End product of protein metabolism (produced in
liver)
• Indirect measure of renal function & glomerular
function (excretion)
• Measure of liver metabolic function
• Part of routine labs
• Usually interpreted along with Cr (less accurate
than Cr for renal disease)
• Normal: 6 -21 mg/dL
• Critical: > 100 mg/dL
• ↑: prerenal causes, renal causes, postrenal
azotemia
• ↓: liver failure, overhydration because of
SIADH, neg nitrogen balance, pregnancy,
nephrotic syndrome
 Creatinine
• Measures serum creatinine
• Catabolic product of creatine phosphate (skeletal muscle
contraction)
• Excreted entirely by kidneys → direct measure of renal
function
• Minimally affected by liver function
• Elevation occurs slower than BUN
• Doubling ≈ 50% reduction in GFR
• Normal: 0.44 – 1.03 mg/dL
• Critical: > 4 mg/dL
• ↑: diseases affecting renal function
(glomerulonephritis, pyelonephritis, ATN, urinary
tract obstruction, reduced renal blood flow, diabetic
nephropathy, nephritis), rhabdomyolysis,
acromegaly, gigantism
• ↓: debilitation, decreased muscle mass
 Na+
• Measures serum sodium level
• Major cation in EC space
• Balance between dietary intake and renal
excretion
• Normal: 136 – 146 mEq/L
• Critical: < 120 or > 160 mEq/L
• ↑ (hypernatremia): ↑ Na+ intake, ↓ Na+ loss,
Excessive free body H2O loss
• ↓ (hyponatremia): ↓ Na+ intake, ↑ Na+ loss,
↑ free body H2O
 K+
• Measures serum potassium level
• Major cation within cell
• Normal: 3.4 – 5.2 mEq/L
• Critical: < 2.5 or > 6.5 mEq/L
• ↑ (hyperkalemia): excessive intake,
acidosis, acute/chronic renal failure,
Addison disease, hypoaldosteronism,
infection, dehydration
• ↓ (hypokalemia): deficient intake, burns,
hyperaldosteronism, Cushing syndrome,
RTA, licorice ingestion, alkalosis, renal
artery stenosis
 Cl-
• Measures serum chloride level
• Major anion in EC space
• Helps maintain electrical neutrality; follows sodium
• Normal: 98 – 108 mEq/L
• Critical: < 80 or > 115 mEq/L
• ↑ (hyperchloremia): dehydration, metabolic
acidosis, RTA, Cushing syndrome, renal
dysfunction, respiratory alkalosis,
hyperparathyroidism
• ↓ (hypochloremia): overhydration, SIADH, CHF,
chronic respiratory acidosis, metabolic alkalosis,
Addison disease, Aldosteronism,
vomiting/prolonged gastric suction, hypokalemia
HCO3-
• Measures CO2 content of blood
• Major role in acid-base balance
• Regulated by kidneys
• Used to evaluate pt pH status & electrolytes
• Normal: 22 – 32 mEq/L
• Critical: < 6 mEq/L
• ↑: severe vomiting, high-volume gastric
suction, aldosteronism, mercurial diuretic
use, COPD, metabolic alkalosis
• ↓: chronic diarrhea, chronic loop diuretic
use, renal failure, DKA, starvation,
metabolic acidosis, shock
Ca2+
• Measures serum calcium level
• Direct measurement
• Used to evaluate parathyroid function & Ca
metabolism
• Used to monitor renal failure, renal transplantation,
hyperparathyroidism, various malignancies, & Ca level
when giving large-volume blood transfusions
• Normal: Total = 8.3 – 10.3 mg/dL, Ionized = 4.5 –
5.6 mg/dL
• Critical: Total < 6 or > 13 mg/dL, Ionized < 2.2 or > 7
mg/dL
• ↑ (hypercalcemia): hyperparathyroidism, bone
mets, Paget disease of bone, prolonged
immobilization, milk-alkali syndrome, vit D
intoxication, hyperthyroidism
• ↓ (hypocalcemia): hypoparathyroidism, renal failure,
rickets, vit D deficiency, osteomalacia, pancreatitis,
alkalosis, malabsorption, fat embolism
Comprehensive Metabolic
Panel (CMP)
• Includes all components of BMP plus
Albumin, Total protein, Alkaline
phosphatase (ALP), Alanine
aminotransferase (ALT), Aspartate
aminotransferase (AST) and Bilirubin
Albumin
• Measures amount of albumin in blood
• Formed within liver & comprises 60% of total protein
in blood
• Maintains colloidal osmotic pressure & transports
blood constituents
• Measure of both hepatic function and nutritional
state
• Normal: 3.5 – 5 g/dL
• ↑: dehydration
• ↓: malnutrition, pregnancy, liver disease,
protein-losing enteropathies, protein-losing
nephropathies, 3rd space losses,
overhydration, ↑ capillary permeability,
inflammatory disease, familial idiopathic
dysproteinemia
Total Protein
• Measures total protein in blood
• Combination of prealbumin, albumin &
globulins
• Normal: 6.4 – 8.3 g/dL
 ALP
• Measures serum ALP concentration
• Detect & monitor liver and bone disease
• Normal: 30 -120 units/L
• ↑: 1° cirrhosis, intrahepatic/extrahepatic
biliary obstruction, 1°/metastic liver tumor,
hyperparathyroidism, Paget disease,
normal growing bones in children, bone
mets, RA, MI, sarcoidosis, healing fracture,
normal pregnancy, intestinal ischemia or
infarction
• ↓: hypophosphatemia, malnutrition, milk-
alkali syndrome, pernicious anemia, scurvy
 ALT
• Found predominantly in liver
• Injury/disease to parenchyma → release into blood
• ID & monitor hepatocellular diseases of liver
• If jaundiced, implicates liver rather than RBC hemolysis
• Normal: 4 – 36 international units/L @ 37°C
• Sig ↑: hepatitis, hepatic necrosis, hepatic ischemia
• Mod ↑: cirrhosis, cholestasis, hepatic tumor,
hepatotoxic drugs, obstructive jaundice, severe
burns, trauma to striated muscle
• Mild ↑: myositis, pancreatitis, MI, infectious mono,
shock
 AST
• Found in highly metabolic tissue (cardiac &
skeletal muscle, liver cells)
• Disease/injury → lysing of cells & release into
blood
• Elevation proportional to # of cells injured
• Used for evaluation of suspected coronary
artery disease or hepatocellular disease
• Normal: 0 – 35 units/L
• ↑: heart diseases, liver diseases, skeletal
muscle diseases
• ↓: acute renal disease, beriberi, DKA,
pregnancy, chronic renal dialysis
 Bilirubin
• Measures level of total bilirubin in blood
• End product of RBC metabolism (RBCs → Hgb
→ Heme (+ globin) → Biliverdin → Bilirubin
(unconjugated/indirect) → Bilirubin
(conjugated/direct)
• Component of bile
• Consists of conjugated (direct) & unconjugated
(indirect) bilirubin
• Used to evaluate liver function; hemolytic
anemia workup in adults & jaundice in newborns
• Jaundice occurs when total bilirubin > 2.5 mg/dL
• Normal: 0.3 – 1 mg/dL
• Critical: > 12 mg/dL
Unconjugated bilirubin
• Measures level of indirect bilirubin in blood
• Normal: 0.2 – 0.8 mg/dL
• ↑: erythroblastosis fetalis, transfusion rxn,
sickle cell anemia, hemolytic jaundice,
hemolytic anemia, pernicious anemia,
large-volume blood transfusion, large
hematoma resolution, hepatitis, cirrhosis,
sepsis, neonatal hyperbilirubinemia,
Crigler-Najjar syndrome, Gilbert syndrome
Conjugated bilirubin
• Measures level of direct bilirubin in blood
• Produced by conjugating glucuronide w/
unconjugated/indirect bilirubin in liver
• Normal: 0.1 – 0.3 mg/dL
• ↑: gallstones, extrahepatic duct
obstruction, extensive liver mets,
cholestasis from drugs, Dubin-Johnson
syndrome, Rotor syndrome
Urinary Analysis (UA)
• Provides information about kidneys &
other metabolic processes
• Used for diagnosis, screening &
monitoring
• Frequently used to test for urinary tract
infections (UTIs)
UA Normal Values
• Appearance: clear
• Color: amber yellow
• Odor: aromatic
• pH: 4.6 – 8
• Protein: 0 – 8 mg/dL
• Specific gravity: 1.005 – 1.030
• Leukocyte esterase: negative
• Nitrites: none
• Ketones: none
UA Normal Values cont.
• Bilirubin: none
• Urobilinogen: 0.01 – 1 Ehrlich unit/mL
• Crystals: none
• Casts: none
• Glucose: negative
• White Blood Cells: 0 – 4/low-power
field
• WBC casts: none
• Red Blood Cells (RBCs): ≤ 2
• RBC casts: none
Urinary Protein
• Used to monitor kidney function
• Normally not present in normal kidney
due to size barrier in glomerulous
• Normally tested by dipstick method,
quantification requires 24-hour urine
collection
• Presence (proteinuria) can indicate
nephrotic syndrome, multiple
myeloma or complications of DM,
glomerulonephritis, amyloidosis
Urinary Glucose
• Glucosuria – presence of glucose in urine
• Reflection of serum glucose levels
• Helpful in monitoring DM therapy
• Renal glucose reabsorption threshold = 180 mg/dL
(in proximal renal tubules)
• Not always abnormal
• Can occur after a high-carbohydrate meal or IV
dextrose fluids
• Can occur in diseases affecting renal tubules;
genetic defects of metabolism & glucose excretion
• ↑: DM & other causes of hyperglycemia,
pregnancy, renal glycosuria, Fanconi
syndrome, Hereditary defects in metabolism
of other reducing substances, ↑ ICP,
nephrotoxic chemicals
Urinary Leukocyte esterase
• Screen to detect leukocytes in urine
(dipstick method)
• Presence indicates UTI
• 90% accurate
Urinary Ketones
• End products of fatty acid catabolism
• Examples: β-hydroxybutyric acid,
acetoacetic acid, acetone
• Associated with poorly controlled diabetes
• Used to evaluate ketoacidosis associated
w/ alcoholism, fasting, starvation, high-
protein diets, isopropanol ingestion
Urinary Nitrites
• Screen for UTI (dipstick method)
• Test based on chemical rxn by bacterial
reductase (reduces nitrate to nitrite)
• 50% accurate
• Enhances leukocyte esterase sensitivity
 Urinary Casts
• Hyaline – conglomerations of protein;
indicative of proteinuria; few = normal
especially after exercise
• Cellular – conglomerations of
degenerated cells
• Granular – glomerular disease
• Fatty – nephrotic syndrome
• Waxy – chronic renal disease
• Epithelial cells & casts (renal tubular casts)
• WBCs & casts – acute pyelonephritis
• RBCs & casts – glomerular diseases
Cerebral Spinal Fluid
(CSF) Analysis
• Collected via lumbar puncture (LP)
• Useful for the diagnosis of 1° or metastatic
brain/spinal cord neoplasm, cerebral
hemorrhage, meningitis, encephalitis,
degenerative brain disease, autoimmune
diseases w/ CNS involvement,
neurosyphilis, demyelinating diseases
CSF analysis Normal Values
• Opening pressure: <20 cm H2O
• Color: clear & colorless
• Blood: none
• RBCs: 0
• WBCs: 0 – 5 cells/μL
• Neutrophils: 0 – 6%
• Lymphocytes: 40 – 80%
• Monocytes: 15 – 45%
CSF analysis Normal
Values cont.
• Protein: 15 – 45 mg/dL
• Glucose: 50 – 75 mg/dL or 60 – 70% of
blood glucose level
CSF WBC count
• Pleocytosis – turbidity of CSF due to
increased #s of cells
CSF PMNs
• Causes of ↑ PMNs: bacterial meningitis,
tubercular meningitis, cerebral abscess,
subarachnoid bleeding, tumor
CSF Lymphs
• Causes of ↑ lymphs/plasma cells: viral,
tubercular, fungal or syphilitic meningitis;
multiple sclerosis (MS), Guillain-Barré
syndrome
CSF Monos
• Causes of ↑ monos: tubercular or fungal
meningitis, hemorrhage, brain infarction
CSF Profile
RBCs/ WBCs/ Glucose Protein Opening Appearan γ-globulin
mm3 mm3 (mg/dL) (mg/dL) pressure ce (%
(cm H2O) protein)
Bacterial ↑ (> 1,000 ↓ (< 45 ↑ (> 250 ↑ Cloudy
meningitis PNMs) mg/dL) mg/dL)
Viral ↑
meningitis (lymphs/m
onos)
Aseptic ↑
meningitis
SAH ↑↑ ↑ ↑

Guillain- ↑↑
Barré
syndrome
MS Normal in ↑↑
2/3 pts; >
15 in < 5%
of pts
Pseudotu ↑↑↑
mor
cerebri
References
• Pagana, K.D. & Pagna, T.J. (2006).
Mosby’s Manual of Diagnostic and
Laboratory Tests. St. Louis: Mosby
Elsevier.
• 27th edition (2000). Stedman’s Medical
Dictionary. Baltimore: Lippincott Williams
& Wilkins.
• UpToDate. Retrieved July 26, 2009, from
http://www.uptodateonline.com
• Urinalysis. Retrieved July 17, 2009, from
http://library.med.utah.edu/WebPath/TUTO
RIAL/URINE/URINE.html
• Vital Signs. Retrieved July 17, 2009, from
http://www.healthsystem.virginia.edu/uvah
ealth/adult_nontrauma/vital.cfm
Additional Resources

• Corbett, J.V. (2008). Laboratory Tests and

Diagnostic Procedures with Nursing Diagnoses 7th
Edition. Upper Saddle River: Prentice Hall.
• Fischbach, F.T. & Dunning, M.B. (2008). A Manual
of Laboratory & Diagnostic Tests 8th Edition.
Philadelphia: Lippincott Williams & Wilkins.
• Jacobs, D.S., De Mott, W.R. & Oxley, D.K. (2001).
Jacobs & DeMott Laboratory Test Handbook with
Key Word Index 5th Edition. Hudson: Lexi Comp,
Inc.
• Wu, A. (2006). Tietz Clinical Guide to Laboratory
Tests 4th Edition. St. Louis: Saunders Elsevier.
• Young, R.H. & Hicks, J. (2002). Directory of Rare
Analyses 2000-2002. St. Louis: AACC Press.
• http://www.labtestsonline.org/