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 shellEmbryonated 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

PCo24.4-5.8kpa

35-45 mmHg

Po210-13.3kpa

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