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today our topic brings us into
the analysis of urine how important is
this
quite with your analysis we'll take a
look at the general examination
we'll take a take a look at the various
types of dipsticks
yes i said various types of dipsticks
that are important for us to then
measure
whatever metabolite that we're looking
for in the urine is that clear
now i understand that sometimes when you
do a general dipstick
that you may or may not find the
chemical that you're looking for
based on the suspicion of the diagnosis
that you're making for your patient so
how do you know which dipstick to
use the history so all that you're doing
in this section as we go through your
analysis
and the different types of dipsticks it
is important that you understand well
the history comes first and then use
this information
that you're given for your analysis as
either confirmation
or to complement and support the
diagnosis that you've come up with
we'll take a look at the sediments and
the various morphology of that that you
find within the
urine when we analyze now each one of
the terms that we then find in the urine
well you've heard of cast before you've
heard of different types of cells such
as
wbcs and rbcs all this becomes really
important for us
but as i said at first it's about the
pathophysiology
and making sure that you have your
foundation strong before you even take a
look at the urine
let's begin now
this table there are a few tables that
we'll be looking at
in this lecture series and uh it would
behoove you to spend a little bit of
time
and make sure that you understand each
one of the uh statements that i'll be
making
so let me walk you through this first
component of urine
on general examination that you will be
conducting or
you will be given in terms of
information either from
notes from soap notes or perhaps from
your
question will then have you determine or
well how did this occur in terms of
color if it's a dark
yellow maybe concentrated urine so
therefore
tell me about your patient maybe perhaps
dehydrated maybe there was excess
sweating
and remember as to what happens in
excess sweating there's hypotonic loss
of
sodium hypotonic loss of sodium and so
therefore what's your plasma similarity
it's increased if your plasma oscillator
is increased
then now you tell me based on the
lecture series at this point
these should be reflex answers aren't
they if they're not
then maybe perhaps go back and lay down
the foundation
when your plasma osmolarity is increased
then you'll have your awesome receptors
up in the hypothalamus releasing adh
down they come
to the collecting duct and what do they
do they then remove
that fluid and water from your
collecting duct resulting in what kind
of urine
ah concentrated urine what color is this
dark yellow
let's move on what if you found
bilirubin completely different story
isn't it
completely different story in a
patability pathology
we will have done well issues with
jaundice
so therefore we'll take a look at
pre-hepatic hepatic post hepatic
jaundice
and what it means for you to actually
find bilirubin in your urine
now there are different types in
biochemistry
you have already discussed what
bilirubin metabolism means
and what type of bilirubin you should be
finding in your urine versus
that type of bilirubin which then
indicates a pathology
so for example when you get the
bilirubin down in the intestine
at some point you go through various
mechanisms in which you finally form
some of that urobilinogen that
urabilinogen
will then contribute to the pigmentation
of either your stool did you see your
stool this morning what color was it
that was brown
that's circle villain or when you took
urination or you went
pee then what color was your urine oh it
was yellow or
golden and that's a type of eurovillin
isn't it
but ultimately there are other
components
of bilirubin such as conjugated
bilirubin and if that ends up in urine
that is a pathology and that is
something that we have discussed in the
patabiliary
and so therefore the color of that urine
here in fact would be dark
and dark yellow increased ubg
would mean urobilinogen and what that
basically means is say for example
you're not able to proper let me let me
ask you something you ready
now if you get something into the
intestine is that then going to end up
in your urine
once again if you get a substance in
your intestine this is just simple
physiology but this is where students go
wrong if you get something in your
intestine how in the world
is that going to end up in your urine if
it ends up in your intestine it ends up
in your stool i'll give you that
but in order for you to get something in
your kidney and this is important
then you have to reabsorb the substance
from the intestine
into the plasma and then the plasma goes
to the kidney
and then it gets filtered only then will
it end up in your urine
right so whenever you find increased
urobilinogen
it only means that there's excess
amounts of this
in your blood or in your plasma it is
only then
that it gets filtered so maybe perhaps
there was a blockage
blockage of what maybe there was some
kind of hepatic obstruction
and if there's some type of biliary
obstruction then the only method out
from your liver
would be into the plasma keep that in
mind now so this is just one statement
in which there's all this understanding
that took place
prior to you actually examining and
analyzing urine
for urobilinogen what about vitamins
well as far as vitamins are concerned
what kind of uh
substance or what kind of characteristic
does a vitamin have to have
for it to be in your urine it has to be
conjugated
it has to be water soluble doesn't it
and so that then becomes important in
terms of let's say that you take vitamin
c
or vitamin b vitamins some of those are
water soluble could they then end up in
your urine
quite quite a bit actually so all those
vitamins that you end up taking
remember a lot of those if you don't
require it they end up in your urine
gets reabsorbed into your plasma and
then it gets filtered
dark dark yellow color number one
a second type of color red or pink
what's this mean the urine
actually looks red for example you wake
up in the morning and
uh that first mctuition that first
mcdericion passing of urine
oh my god it's red how did that happen
it's kind of scary for the patient isn't
it how did how in the world did you end
up getting blood in your urine
well that one that i just gave you where
you wake up in the morning well what
happened at night perhaps
your respirator rate increased or
decreased well let me walk you through
this
decreased respiratory rate huh you're
holding on to
carbon dioxide so for that moment at
night
then what is your ph a little bit
decreased it's called
respiratory acidosis so at night
you go through respiratory acidosis and
then all of a sudden the rbcs are
undergoing severe
intravascular hemolysis so all of this
comes into simple pathophysiology well
not so much simple but you're strong
the time that you spent understanding a
condition called proximal
nocturnal hemoglobin area and proxismo
and octo hemoglobin area
the problem is genetically in which the
complement system
ends up destroying your rbcs
intervascularly
in conditions that are acidotic welcome
to nocturnal
at night you wake up in the morning what
do you find your urine to be
well that's the patient that's a patient
himself or herself
that ends up seeing red urine hematuria
is what this is
and then we have hemoglobinuria what
does that mean to you well this is
something like intravascular molasses
in which you are literally losing
hemoglobin through your glomerulus
and this is an example that i gave you
such as pnh
proxismo nocturnal hemoglobinuria all
i'm doing you all i'm doing at this
point is giving a little bit of history
based on some of the findings that you
have uh based on the color of the urine
what if it was myoglobulia how do you
think about this or how should you be
thinking about this
myoglobin is the hemoglobin for the
muscle hence myo right
and so therefore say that you get into a
crush injury and if there's a crush
injury
literally there's a damage to the
skeletal muscle in which you are then
releasing myoglobin into the urine
or excuse me into the plasma and that
then ends up in the urine what do we
call this
myoglobinuria what color might this then
give you urine
red or pink drugs such as finazza
pyridine
or urinary anesthetics possibility
and then porphyrias the big one here you
might have heard of acute intermittent
porphyria
acute intermittent porphyria at the
porphyria in which
many of the symptoms and signs that you
find with aip
would begin with the letter p meaning to
say that you would end up having
pink urine there would be abdominal pain
there is p psychosis okay at least take
three p's right now for acute
intermittent porphyria
one of them being pink urine do you see
the significance of urine analysis thus
far
you thought that you can just go through
this and memorize that you know me well
enough
where that's not what we're going to do
it's about you looking at this
seeing this hearing this and truly
coming up with
a few differentials in your head as to
well what's going on with your patients
continue
what if it was smoky colored urine acid
ph
urine converts the hemoglobin into
what's called hematin
at the common finding in nephritic okay
and if you're dealing with nephretic you
should be thinking something along the
lines of
perhaps ij nephropathy why did i say aj
nephropathy
because that would be the most common
type of glomerulonephritis
so nephritic what does that mean to you
you pay attention letter h
and a lecture series that we have
together in which we talk about
glomerulonephritis
and we talk about nephritic syndrome i
will have you highlight in your head
the letter h for nephritic
y that h means hypertension hematuria
it could mean that you have smoky
colored urine
hematin is what you're paying attention
to what if it was black urine
that's crazy isn't it could you imagine
urinating urinating and then upon
exposure to oxygen in the environment it
turns black
what's your diagnosis well this would be
something like acaptanuria
autosomal recessive disorder with the
deficiency and you must memorize
and you have memorized in biochemistry
the enzyme called
homogeneity oxidase so homogeneitisate
oxidase is the enzyme that's deficient
in a condition called
alcaptanuria now that that you find
as being black is what happens take a
look
it's a homogeneity acid in the urine and
therefore
upon exposure to light as soon as it
comes out into the world the urine does
it then turns black and some of this
black substance may also accumulate
within your cartilage and such
ochronosis
continue we'll talk about clarity so one
major component that we just completed
our discussion
is color what about clarity what if it
was cloud d
urine this is alkaline ph so what does
this mean to you
normal finding most often due to
phosphates
cloudy what if it was cloudy urine with
acid ph
normal finding most often due to uric
acid
so you want to be familiar as to what
the ph of
urine is in great detail in general it
tends to be
on the acidic side but if it's a little
bit more acidic say that it's below
four and then you start thinking about
uric acid if it's on the higher side
maybe 5.5 it may be six then you're
thinking along the lines of phosphate
depending
as to what the physiologic needs the
patient is then you have others
others in terms of clarity bacteria wbcs
we will be focusing upon these
as we progress further through urine
analysis do you see now as to how we've
created a picture of a table
and the more number of times that you're
able to give a clinical tags
and one and let me let me give you a
tidbit of advice here
it is not imperative at this point for
you to go through every single detail
and don't get frustrated that you're not
if you're not able to come up with the
differential immediately
at least pick one or two components
of each one of these characteristics if
it's dark yellow for at this point
if all that you remember is bilirubin
okay it's fantastic that's okay at least
you give yourself one tag of a
differential right
if the only thing that you can at this
point remember with pink
as being oh something like myoglobinuria
that's okay
and you keep coming back you keep coming
back every time you come back
you give a clinical tag you give a
clinical correlation with each one of
these findings
and before you know it you have a whole
host of differentials you do that
throughout medicine with me and you will
be in fantastic
shape when it comes to pathology another
component will be specific gravity
what's this mean literally the gravity
that the urine is exhibiting
evaluates urine concentration and
dilution now before we move on
if your urine is concentrated what color
is it
dark yellow next if your urine is
concentrated
what do you expect the gravity to be use
common sense here
obviously it'll be increased let's take
a look
if your specific ready is above now this
you want to memorize
1.023 the usual limit of specific
gravity is usually about 10 10
and what i mean by that is 1.0 100
use 10 10. 1.010
how would you say that layman terms say
1010 make your life easier
now here we have something as greater
than 1.023
that's high specific gravity next well
okay that sounds good but what does that
actually mean because
you're responsible to do what you're
responsible to actually interpret labs
in your hands maybe on a computer screen
what have you
and you should be able to take a look at
urine osmolarity take a look what's in
the parentheses here
urine osmolarity at 900 ml
osmos let me ask you something
what's normal plasma similarity normal
approximately
300 when you get this plasma into the
bowmen space
and the proximal portion of your pct
what's your urinal similarity
approximately
300 ah what's my point
if you start moving down the descending
limb you start raising your nose
molarity
doesn't 900 seem a lot more dramatically
increased than 300
it is is 900 concentrated or diluted
urine please it's concentrated urine
what's your specific gravity higher
understand the concept first
then you put in the values indicates
urine concentration
and excludes intrinsic renal disease
excludes it why that means that adh
has had an opportunity to remove the
water and thus
increase concentration let's continue so
we have hypotonic urine
has a specific gravity of 1.015
what does this mean don't memorize this
either understand the concept first
hypotonic urine what kind of urine is
this it's a diluted urine
did adh work yet um probably not
because you created diluted urine so
you're an osmolarity take a look at this
what's normal plasma similarity
plasma osmolarity approximately 300
and then you get it into the bowman
space what is the urine osmolarity there
approximately 300 take a look at the
urine osmolarity in the parentheses what
does that say
220 in the urine what does that mean to
you hypotonic urine
what do you call that in layman terms
diluting urine
what is a specific gravity decreased
understand the concept
then you memorize less than one point
zero one five
let's move on urine osmolarity is the
best indicator of urine concentration or
dilution
we just went through examples here of
showcasing that
next what if it was a fixed specific
gravity okay so then we have here
let's say that it's fixed at
approximately normal and we'll use 10
10.
1.0 one o ten ten correlation with
uranosmia lack of concentration
and dilution um this
indicates chronic renal failure i want
you to come back up and take a look at
the second row here
and where we talked about specific
gravity being greater than 1.023
that is concentrated urine what does
that do that excludes
intrinsic renal disease but if your
urine osmolarity is fixed
throughout the nephron do you understand
the concept nothing is
changing why because a kidney is
dying do you understand how important
this is
example chronic renal failure how
important is this
ridiculously important how often does
this occur you've heard of diabetic
nephropathy
it occurs more often than one would
think huh specific gravity spend a
little bit of time here
understand the concepts and put in the
values
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you