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Yapa Wijeratne
MBBS
• Knowledge for everyone.
• Please note that this slides are not complete. I tried my best to give
an general idea of pathology spots in final MBBS.
• Medicine is an ever-changing science. As new research and clinical
experience broaden our knowledge, changes in treatment and drug
therapy are required. I have checked with sources believed to be
reliable to provide information that is complete and generally in
accord with the standards accepted at the time of preparation.
However, in view of the possibility of human error or changes in
medical sciences readers are encouraged to confirm the information
contained herein with other sources.
1
1. Identify this.
2. What is the
measurement
taken?
3. State the ratio of
citrate used in the
investigation
11. Westergen’s tube
2. ESR- Erythrocyte sedimentation rate
3. Tri Sodium citrate : blood = 0.4 : 1.6
(ml)
• Tri Sodium Citrate is the anticoagulant for ESR; for
this 1 volume of citrate is mixed with 4 volumes of
blood.
• Normal ranges
• 0–10mm/h for male 18–65 years.
• 1–20mm/h for female 18–65 years.
• Upper limits of normal increase by 5–10mm/h for
patients >65 years.
• Other factors e.g. Hct influence the ESR.
• Should be regarded as semiquantitative.
• Marked elevations are clinically significant.
• Modest elevations can be more problematic to
interpret
2
• This patient presented with history of fever
& productive cough.
• What is this microscopy slide stain?
– Gram/ Lugol’s iodine
• What is the possible organism?
– Strep pneumonia
• What is the next investigation ?
– Culture & ABST
3
• Patient awaiting liver biopsy. What are the
essential investigations?
– Clotting profile-
• BT/ CT
• PT/INR
– Full blood count
4
• Liver enzyme report
• Total bilirubin
• Direct ↑
• What are the possibilities?
– Obstructive jaundice
5
• Serum electrolyte report
• Na 135.
• K very high 7.
• Why?
– Hemolysed sample.
• Where is the problem?
– Sampling error
6
• Collecting samples
• Urine culture: sterile bottle, midstream
urine following clean meatus
• TB sputum: early morning 3 samples of
sputum for Acid fast bacilli
7
• UFR
– Appearance- mild turbid,
– Protein ++,
– RBC 10-15/hpf,
– Red cell cast +
• Which part of the tract?
– Upper urinary tract
• One disease which can cause this?
– Glomerular nephritis
8
• What is the blood group?
– A negative
• What other investigations you would have
to do if this sample has been taken from a
pregnant mother in 2nd trimester?
– Unexpected antibody level
9
• Interpret
– WBC/DC- 15x109/l
– Neutrophils- 20%
– Lymphocytes- 70%
• Possibilities?
– viral fever
• What anemia: normocytic normochromic
10
• Dengue pt PLT 5x109
• Bottle fully filled.
• Why wrong?
11
• What is the anemia this patient is having
– HB ↓
– MCV ↓
– MCH ↓
– MCHC
– Hypochromic microcytic anemia
• What is the appropriate next investigation?
– Blood picture
• What are the conditions?
– Iron deficiency anemia
– Thalassemia trait
Hypochromic microcytic anaemia
Differential diagnosis
• Iron deficiency anaemia
• Thalassaemia trait
• Anaemia of chronic disorder
• Sideroblastic anaemia
IDA Bthaltrait ACD SA
BP Pencil
shaped
poikilocytes
Irregularly
contracted
cells
Rouloux
formation
NL
Dimorphic
film
MCV Decreased Decreased Decreased Decreased
MCH Decreased Decreased Decreased Decreased
MCHC Decreased Normal
RCC low Increased
Anisocy. +++ No No dimorphic
S.ferritin low normal high Very high
Iron frag neg pos pos increased
Iron
N’blast
neg pos neg sideroblast
12
• CSF report
– Red color gradually disappearing
• Interpret
– Traumatic tap
• What sample is sent for sugar, culture
• What other sample needed at the time of
lumbar puncture? RBS
• If the sample is blood stained due to traumatic tap
• Use the least blood stained specimen for full protein and
cell analysis.
• Use more blood stained samples for other analysis.
• If only one sample is available for analysis
• First do culture and ABST (to avoid contamination) and
smear
• Do protein and cells
• If no sample is collected into a S bottle inform the lab
and send the sample immediately to the lab so they will
process the specimen quickly for sugar analysis
• CSF microscopy of patient found
unconscious.
• Red cells are seen
• Diagnosis?
– SAH
13
• Calculate BT
14
• Child with facial puffiness. Urine
sulphosalicylic test result is as follows
• Interpret
– Heavy proteinuria +4
• 2 conditions
– Nephrotic syndrome
– UTI
– Pre-eclampsia
– Diabetic nephropathy
15
• Name the container for following
investigations
• FBC
• Liver enzymes
• Electrolytes
• APTT
• What are the sample collection methods
for following tests
1. PT
2. APTT
3. Serum Ca
• PT – blood drained in one reaction
– Sodium citrate : Blood = 0.2ml :1.8ml
• APTT – plastic container ( glass – reduce APTT)
– Sodium citrate : Blood = 0.2ml :1.8ml
• Serum Ca – plane bottle immersed on HCl
overnight & dry, no tourniquet.
16
• State the method of delivering the sample
1. Pap smear-
1. 95% alcohol
2. Muscle biopsy-
1. fresh sample covering with a gauze. NO
preservatives. Immediately to the path lab
3. Solitary thyroid nodule:
1. 23 G 10cc in 95% alcohol
17
• Blood sample for sugar was collected to a
plain tube.
• Identify the abnormality
• What is the cause?
18
• Alcoholic patient. Low prn & Ca+2.
• Interpret his FBC
• How to treat?
1. What is the likely
diagnosis? Give
with reasons
2. What are the other
tests can be done
to confirm the
diagnosis?
Thalassaemia major
• Hb Low
• Blood picture: Target cells, normoblasts,
irregularly contracted cells, poikylocytosis
• Haemoglobin electrophoresis: Increased
Hb F
• Both parents are carriers
• Alkali denaturation test: increased Hb F
β thalassaemia major: note bizarre red cells with
marked anisopoikilocytosis
CML
• 27 year old male presented
with WB Anaemia, weight loss,
night sweats &
Splenomegaly.Blood picture
shown. His WBC/DC was very
high.
• What is the
diagnosis?
Peripheral blood film in CML: note large numbers of
granulocytic cells at all stages
of differentiation.
1.Identify three
types of cells in
the slide?
2.Identify the
parasite
precisely?
37
38
39
40
41
temperature°c
1 2 3 4 5
Following temperature chart belongs to a patient who has the blood
picture shown.
What is the diagnosis?
in pus
in culture media
A & B are two smears taken
from pus & culture media from
same organism.
1. Identify the stain?
2. Identify the possible organism?
A
B
Following ova in microscope given.
1. Identify?
2. What is the stain
used?
Fertilized egg-round shape,
corticated outer shell
Embryonated egg -less
pronounced cortication of outer
shell, mature embryo
Ascaris lumbricoides eggs
1. Identify?
2. State the mode of
transmission.
• Know the eggs of
• Ascaris
• Trichuris
• Pin worm
• Hook worm
• Ascaris- slide stain- iodine
• This is a blood picture of a 8 yrs old male child
treated with nitrofurantoin for UTI who developed
haematuria after the treatment.
1. What is the diagnosis?
2. What are the tests available for confirm the
diagnosis?
Blood film:
chronic renal
failure with burr
(irregular
shaped) cells.
• Blood film of a 17
year old female
patient.
• What is the
diagnosis?
– Iron deficiency
anaemia:
• Give reasons
– Pale red cells with
pencil cell (top left).
• Blood picture of megaloblastic anemia
• Temperature chart of
a surgical patient is
given with regular
spikes.
• List two causes.
• A –ve
• Investigate cord blood for,
1. Hb%
2. Retic count
3. Bilirubin
4. Grouping & DT
5. Coomb’s test - Direct
Acid base balance
• Normal
blood gas
values
PH 7.34-7.44
PCo2
4.4-5.8kpa
35-45 mmHg
Po2
10-13.3kpa
80-100mmHg
HCo3 20-30mmol/l
SBC 20-30mmol/l
ABE/SBE -2.5-2.5mmol/
Sat 95-98%
TCo2 22-32mmol/l
Hb 12.5-17.5g/100ml
Simple scheme for interpretation
• Look at pH-acidosis or alkalosis
• Look at PCo2 – determine the respiratory
component
• Look at standard bicarbonate /BE –
determine the metabolic component
• Look at Hb
• Look at Po2 and Fio2
Interpret following blood gas analysis
• Hb 18.2
• PH 7.275
• PCo2 12.98 ( 45)
• Po2 4.44 (33)
• HCO3 44
• SBC 33.9
• ABE 11.4
• SBE 15.8
• Sat 55.1%
• Compensatory respiratory acidosis
Interpret following blood gas analysis
• Hb 13.2
• PH 7.081
• PCo2 2.76 ( 20.7)
• Po2 14.10(105.7)
• HCO3 5.9
• SBC 8.4
• ABE -23.5
• SBE -22.4
• Sat 95%
• metabolic acidosis with respiratory compensation
• Diabetic ketoacidosis
Interpret following blood gas analysis
• Hb 9.7
• PH 7.532
• PCo2 3.83( 28.7)
• Po2 4.44(33)
• HCO3 23.7
• SBC 25.7
• ABE 2.0
• SBE 1.4
• Sat 67.2%
• Acute respiratory alkalosis & low po2- hypoxia
Interpret following blood gas analysis
• Hb 8.0
• PH 7.46
• PCo2 2.59 ( 19.42)
• Po2 13.49(101)
• HCO3 13.8
• SBC 17.2
• ABE -8.9
• SBE -9.3
• Sat 98%
• Metabolic alkalosis with respiratory compensation
• Aspirin overdose ?
• Urine microscopy. Identify
– Granular cast
• What other investigation would you
request?
– U culture + ABST
• What is this investigation?
– Rothera’s test
• What does it indicate?
– Urine ketone body positive
• What are the conditions that gives above
result?
– DKA/ ketotic hypoglycemia
– Hyperemesis
– Starvation
• What is this investigation?
– Benedict’s test
• How do you perform?
– 2.5ml of Benedicts reagent + 4 drops of urine
• What does it indicate?
– Urine reducing substances positive
• What are the conditions that gives above
result?
– Glucose
– Aspirin
– Nalidixic acid
– Cephalosporins
• How do you collect urine for specific
gravity?
– Early morning, mid stream
• Name 2 instances urinary specific gravity
increase?
• Urine bottles. What are the uses?
– Can with acetic acid: 24 hour collection-
• Protein excretion
• Wilson’s disease- 24 hour urinary excretion of
copper
– Early morning sample- specific gravity
(orthostatic proteinuria, TB
– Culture- mid stream
• Urine sample of a 45
year old man was tested
are following substances
were observed.
1. Identify the substances?
2. Give a diagnosis?
Fouchet’s Earlich’s
• Urine sample of a 25
year old man was tested
are following substances
were observed.
1. Identify the substances?
2. Fouchet’s- bilirubin + if
greenish blue (normal-
colorless)
3. Ehrlich- urobilinogen + if
distinct red color
(normal- pink)
4. Give a diagnosis?
Fouchet’s Earlich’s
• Urine electrophoresis results were given.
1. Identify A & B diseases
2. List two other investigations for each disease
+ +
A B
• Electrophoresis film of a patient who came with chronic
back pain. What is the diagnosis?
– Multiple myeloma
• What type of paper is used?
– Cellulose acetate
• What other 2 investigations would you request?
– Skeletal survey ( skull+ mandible, CXR, pelvis, long
bones)
– Urine Bence Jones Protein
• Path form filling. What are the must?
• For blood picture- pallor, LNE,
hepatosplenomegaly
• Advices for
• SFA
• Stool for occult blood testing?
– No meat diet for 3 days
• MI diagnosis
• Troponin I levels
• Histopathology report forms
• Bone marrow biopsy-
• What are those large cells?
• Megakaryocytes

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Clinical pathology spots for final MBBS

  • 2. • Knowledge for everyone. • Please note that this slides are not complete. I tried my best to give an general idea of pathology spots in final MBBS. • Medicine is an ever-changing science. As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy are required. I have checked with sources believed to be reliable to provide information that is complete and generally in accord with the standards accepted at the time of preparation. However, in view of the possibility of human error or changes in medical sciences readers are encouraged to confirm the information contained herein with other sources.
  • 3. 1 1. Identify this. 2. What is the measurement taken? 3. State the ratio of citrate used in the investigation
  • 4. 11. Westergen’s tube 2. ESR- Erythrocyte sedimentation rate 3. Tri Sodium citrate : blood = 0.4 : 1.6 (ml) • Tri Sodium Citrate is the anticoagulant for ESR; for this 1 volume of citrate is mixed with 4 volumes of blood. • Normal ranges • 0–10mm/h for male 18–65 years. • 1–20mm/h for female 18–65 years. • Upper limits of normal increase by 5–10mm/h for patients >65 years. • Other factors e.g. Hct influence the ESR. • Should be regarded as semiquantitative. • Marked elevations are clinically significant. • Modest elevations can be more problematic to interpret
  • 5. 2 • This patient presented with history of fever & productive cough.
  • 6. • What is this microscopy slide stain? – Gram/ Lugol’s iodine • What is the possible organism? – Strep pneumonia • What is the next investigation ? – Culture & ABST
  • 7. 3 • Patient awaiting liver biopsy. What are the essential investigations? – Clotting profile- • BT/ CT • PT/INR – Full blood count
  • 8. 4 • Liver enzyme report • Total bilirubin • Direct ↑ • What are the possibilities? – Obstructive jaundice
  • 9. 5 • Serum electrolyte report • Na 135. • K very high 7. • Why? – Hemolysed sample. • Where is the problem? – Sampling error
  • 10. 6 • Collecting samples • Urine culture: sterile bottle, midstream urine following clean meatus • TB sputum: early morning 3 samples of sputum for Acid fast bacilli
  • 11. 7 • UFR – Appearance- mild turbid, – Protein ++, – RBC 10-15/hpf, – Red cell cast + • Which part of the tract? – Upper urinary tract • One disease which can cause this? – Glomerular nephritis
  • 12. 8 • What is the blood group? – A negative • What other investigations you would have to do if this sample has been taken from a pregnant mother in 2nd trimester? – Unexpected antibody level
  • 13.
  • 14.
  • 15. 9 • Interpret – WBC/DC- 15x109/l – Neutrophils- 20% – Lymphocytes- 70% • Possibilities? – viral fever • What anemia: normocytic normochromic
  • 16. 10 • Dengue pt PLT 5x109 • Bottle fully filled. • Why wrong?
  • 17. 11 • What is the anemia this patient is having – HB ↓ – MCV ↓ – MCH ↓ – MCHC – Hypochromic microcytic anemia • What is the appropriate next investigation? – Blood picture • What are the conditions? – Iron deficiency anemia – Thalassemia trait
  • 18. Hypochromic microcytic anaemia Differential diagnosis • Iron deficiency anaemia • Thalassaemia trait • Anaemia of chronic disorder • Sideroblastic anaemia
  • 19. IDA Bthaltrait ACD SA BP Pencil shaped poikilocytes Irregularly contracted cells Rouloux formation NL Dimorphic film MCV Decreased Decreased Decreased Decreased MCH Decreased Decreased Decreased Decreased MCHC Decreased Normal RCC low Increased Anisocy. +++ No No dimorphic S.ferritin low normal high Very high Iron frag neg pos pos increased Iron N’blast neg pos neg sideroblast
  • 20. 12 • CSF report – Red color gradually disappearing • Interpret – Traumatic tap • What sample is sent for sugar, culture • What other sample needed at the time of lumbar puncture? RBS
  • 21. • If the sample is blood stained due to traumatic tap • Use the least blood stained specimen for full protein and cell analysis. • Use more blood stained samples for other analysis. • If only one sample is available for analysis • First do culture and ABST (to avoid contamination) and smear • Do protein and cells • If no sample is collected into a S bottle inform the lab and send the sample immediately to the lab so they will process the specimen quickly for sugar analysis
  • 22. • CSF microscopy of patient found unconscious. • Red cells are seen • Diagnosis? – SAH
  • 24. 14 • Child with facial puffiness. Urine sulphosalicylic test result is as follows • Interpret – Heavy proteinuria +4 • 2 conditions – Nephrotic syndrome – UTI – Pre-eclampsia – Diabetic nephropathy
  • 25. 15 • Name the container for following investigations • FBC • Liver enzymes • Electrolytes • APTT
  • 26.
  • 27. • What are the sample collection methods for following tests 1. PT 2. APTT 3. Serum Ca
  • 28. • PT – blood drained in one reaction – Sodium citrate : Blood = 0.2ml :1.8ml • APTT – plastic container ( glass – reduce APTT) – Sodium citrate : Blood = 0.2ml :1.8ml • Serum Ca – plane bottle immersed on HCl overnight & dry, no tourniquet.
  • 29. 16 • State the method of delivering the sample 1. Pap smear- 1. 95% alcohol 2. Muscle biopsy- 1. fresh sample covering with a gauze. NO preservatives. Immediately to the path lab 3. Solitary thyroid nodule: 1. 23 G 10cc in 95% alcohol
  • 30. 17 • Blood sample for sugar was collected to a plain tube. • Identify the abnormality • What is the cause?
  • 31. 18 • Alcoholic patient. Low prn & Ca+2. • Interpret his FBC • How to treat?
  • 32. 1. What is the likely diagnosis? Give with reasons 2. What are the other tests can be done to confirm the diagnosis?
  • 33. Thalassaemia major • Hb Low • Blood picture: Target cells, normoblasts, irregularly contracted cells, poikylocytosis • Haemoglobin electrophoresis: Increased Hb F • Both parents are carriers • Alkali denaturation test: increased Hb F
  • 34. β thalassaemia major: note bizarre red cells with marked anisopoikilocytosis
  • 35. CML • 27 year old male presented with WB Anaemia, weight loss, night sweats & Splenomegaly.Blood picture shown. His WBC/DC was very high. • What is the diagnosis?
  • 36. Peripheral blood film in CML: note large numbers of granulocytic cells at all stages of differentiation.
  • 37. 1.Identify three types of cells in the slide? 2.Identify the parasite precisely?
  • 38.
  • 39. 37 38 39 40 41 temperature°c 1 2 3 4 5 Following temperature chart belongs to a patient who has the blood picture shown. What is the diagnosis?
  • 40.
  • 41. in pus in culture media A & B are two smears taken from pus & culture media from same organism. 1. Identify the stain? 2. Identify the possible organism? A B
  • 42. Following ova in microscope given. 1. Identify? 2. What is the stain used?
  • 43. Fertilized egg-round shape, corticated outer shell Embryonated egg -less pronounced cortication of outer shell, mature embryo Ascaris lumbricoides eggs
  • 44. 1. Identify? 2. State the mode of transmission.
  • 45. • Know the eggs of • Ascaris • Trichuris • Pin worm • Hook worm • Ascaris- slide stain- iodine
  • 46. • This is a blood picture of a 8 yrs old male child treated with nitrofurantoin for UTI who developed haematuria after the treatment. 1. What is the diagnosis? 2. What are the tests available for confirm the diagnosis?
  • 47. Blood film: chronic renal failure with burr (irregular shaped) cells.
  • 48.
  • 49.
  • 50. • Blood film of a 17 year old female patient. • What is the diagnosis? – Iron deficiency anaemia: • Give reasons – Pale red cells with pencil cell (top left).
  • 51. • Blood picture of megaloblastic anemia
  • 52.
  • 53. • Temperature chart of a surgical patient is given with regular spikes. • List two causes.
  • 54. • A –ve • Investigate cord blood for, 1. Hb% 2. Retic count 3. Bilirubin 4. Grouping & DT 5. Coomb’s test - Direct
  • 55.
  • 56. Acid base balance • Normal blood gas values PH 7.34-7.44 PCo2 4.4-5.8kpa 35-45 mmHg Po2 10-13.3kpa 80-100mmHg HCo3 20-30mmol/l SBC 20-30mmol/l ABE/SBE -2.5-2.5mmol/ Sat 95-98% TCo2 22-32mmol/l Hb 12.5-17.5g/100ml
  • 57. Simple scheme for interpretation • Look at pH-acidosis or alkalosis • Look at PCo2 – determine the respiratory component • Look at standard bicarbonate /BE – determine the metabolic component • Look at Hb • Look at Po2 and Fio2
  • 58. Interpret following blood gas analysis • Hb 18.2 • PH 7.275 • PCo2 12.98 ( 45) • Po2 4.44 (33) • HCO3 44 • SBC 33.9 • ABE 11.4 • SBE 15.8 • Sat 55.1% • Compensatory respiratory acidosis
  • 59.
  • 60. Interpret following blood gas analysis • Hb 13.2 • PH 7.081 • PCo2 2.76 ( 20.7) • Po2 14.10(105.7) • HCO3 5.9 • SBC 8.4 • ABE -23.5 • SBE -22.4 • Sat 95% • metabolic acidosis with respiratory compensation • Diabetic ketoacidosis
  • 61. Interpret following blood gas analysis • Hb 9.7 • PH 7.532 • PCo2 3.83( 28.7) • Po2 4.44(33) • HCO3 23.7 • SBC 25.7 • ABE 2.0 • SBE 1.4 • Sat 67.2% • Acute respiratory alkalosis & low po2- hypoxia
  • 62. Interpret following blood gas analysis • Hb 8.0 • PH 7.46 • PCo2 2.59 ( 19.42) • Po2 13.49(101) • HCO3 13.8 • SBC 17.2 • ABE -8.9 • SBE -9.3 • Sat 98% • Metabolic alkalosis with respiratory compensation • Aspirin overdose ?
  • 63. • Urine microscopy. Identify – Granular cast • What other investigation would you request? – U culture + ABST
  • 64.
  • 65.
  • 66. • What is this investigation? – Rothera’s test • What does it indicate? – Urine ketone body positive • What are the conditions that gives above result? – DKA/ ketotic hypoglycemia – Hyperemesis – Starvation
  • 67.
  • 68. • What is this investigation? – Benedict’s test • How do you perform? – 2.5ml of Benedicts reagent + 4 drops of urine • What does it indicate? – Urine reducing substances positive • What are the conditions that gives above result? – Glucose – Aspirin – Nalidixic acid – Cephalosporins
  • 69.
  • 70. • How do you collect urine for specific gravity? – Early morning, mid stream • Name 2 instances urinary specific gravity increase?
  • 71. • Urine bottles. What are the uses? – Can with acetic acid: 24 hour collection- • Protein excretion • Wilson’s disease- 24 hour urinary excretion of copper – Early morning sample- specific gravity (orthostatic proteinuria, TB – Culture- mid stream
  • 72. • Urine sample of a 45 year old man was tested are following substances were observed. 1. Identify the substances? 2. Give a diagnosis? Fouchet’s Earlich’s
  • 73. • Urine sample of a 25 year old man was tested are following substances were observed. 1. Identify the substances? 2. Fouchet’s- bilirubin + if greenish blue (normal- colorless) 3. Ehrlich- urobilinogen + if distinct red color (normal- pink) 4. Give a diagnosis? Fouchet’s Earlich’s
  • 74. • Urine electrophoresis results were given. 1. Identify A & B diseases 2. List two other investigations for each disease + + A B
  • 75.
  • 76.
  • 77. • Electrophoresis film of a patient who came with chronic back pain. What is the diagnosis? – Multiple myeloma • What type of paper is used? – Cellulose acetate • What other 2 investigations would you request? – Skeletal survey ( skull+ mandible, CXR, pelvis, long bones) – Urine Bence Jones Protein
  • 78. • Path form filling. What are the must? • For blood picture- pallor, LNE, hepatosplenomegaly
  • 79. • Advices for • SFA • Stool for occult blood testing? – No meat diet for 3 days
  • 80. • MI diagnosis • Troponin I levels
  • 81. • Histopathology report forms • Bone marrow biopsy- • What are those large cells? • Megakaryocytes