INTERNSHIP: VISIT TO PATHOLOGY LAB - Khyati kansagra - SNK

Dates

Time

12th November2012 16th November2012 17th November2012 19th November2012 21st November2012

9:30-12:00 11:00-1:00 10:45-1:15 9:30-12:00 10:20-12:40

We started our internship on 12th November 2012 at 10.45 A.M. Throughout our internship we were guided by Ms. Rupa Chande and Mr. Ashish Kothari. On the very first day we learnt the different sections of Pathology lab, i.e. haematology, clinical pathology, Bio chemistry, Immunology and Microbiology. CLINICAL PATHOLOGY: As the pathology lab is on 6th floor, blood, urine or other samples are collected on the ground floor as per doctors prescription. Later these samples are sent to pathology lab for tests. Urine containers are used to collect urine samples. Sputums are used for collecting cough samples. Stool samples are collected in plain container. Blood samples are collected in specific vacutainer (viles). Different viles are used for collection of blood samples depending on the requirement. Every different vile has

different chemicals present in it. These are used because it creates vacuum and for accurate measurement. It also prevents clotting of blood.

Colours of viles:
Colour Purple Chemical K2 EDTA (ethylene diamide tetra acetic acid. Clot activator Use Works as an anticoagulant Tests the serums which are extracted from blood clots For coagulation determination For glucose determination Plasma separation For coagulation determination

Yellow

Blue

Grey Green Black

Sodium citrate (3.2% concentrated) Sodium fluoride Heparin Sodium citrate

Procedure of sample collection:

1) Consultation of the doctor. 2) Investigation form. 3) Diagnostic Reception: Pay the charge of test. 4) Sample collection of patient.

5) Phlebotomist (person who collects samples) enters bar code of patient with unique Id in the system. 6) Bar codes are stuck on the viles or other containers whoch are used for sample collection. 7) Collects the sample. 8) Housekeeping staff sends the samples to lab. 9) In lab, samples are distributed according to the test to be performed. 10) After the tests are done, reports are generated.

URINE TESTS:
Urine test is performed in 3 main steps. They are 1) Physical examination: Colour, quantity, turbidity (for eg: If pus, urine is turbid), pH, specific gravity. For all these above factors multi parameter urine strips are used which give accurate and fast results. With urine strips we can test the pH, blood, specific gravity, proteins, glucose of urine. We have to dip it in the sample, after 30 seconds, put it in the strip reader (machine which reads this strip) will give the results. Chemical examination: under this we perform sugar, proteins, bile salts, bile pigments, acetone tests. Bile salts and bile pigment tests are done only when the urine is strong yellow in colour.

2)

3)

Microscopic examination

For urine, 5 minutes centrifugation is must.

Centrifugation table:
Specimen used Speed (in rpm) Time

Heparinized whole blood

3500 (+/300) Blood for serum separation 3500 (+/300) Citrated blood 3500 (+/300) Blood for lymphocyte 2500 (+/separation 200) Body fluids 3500 (+/300) Blood for QBC(instrument) 10,000 (+/500) Urine for routine micro exam 2500 (+/200) Urine for AFB (Acid Fast 3500 (+/Bacilli) 300) BAL specimen 2500 (+/200)
IMMUNOLOGY:

6 mins 6 mins 10 mins 30 mins 10 mins 10 mins 5 mins 30 mins 15 mins

Tests which are performed in immunology section: HIV HBSAG (Hepatitis B) HCV (Hepatitis C Virus) Troponin T (heart related test) PCT Dengue HAEMATOLOGY: This section is mainly for CBC (Complete Blood Count) Test. [platelets, RBCs, WBCs, Haemoglobin). CBC test is done in a machine called cell counter. This machine is of two types: 1)5 part cell counter: All 5 WBCs is detected in this machine. 2)3 part cell counter: Only 3 things are detected in this machine, i.e. granulocytes, lymphocytes and mixed. ESR (Erythrocyte Sedimentation Rate): It is the time taken by RBCs to settle down. In normal patient RBC settle slowly. CBC: 1) Haemoglobin: -If less, then anaemia

-if more, then dehydration 2) Leucocytes: -If less, then immunity problems, viral infection, malaria, dengue -If more, then pus, infection in intestine 3) Platelets: -If less, clotting factor reduces. BIO CHEMISTRY: Various tests are performed in the bio-chemistry section. 1) One of the main tests which is performed in this section is dry chemistry test which includes the following tests: Glucose diabetes related test Urea
Kidney related test

Creatinine Sodium, potassium, chloride, Calcium bones related test Phosphorus- kidney and bones related test Cholesterol Triglycerides Direct HDLC
Heart related test

Uric acid- joints related test Total protein: albumin and globulin test A/G ratio (Albumin: Globulin)- Kidney and liver related test AST (SGOT) ALT (SGPT)
These are the enzymes in liver. These are used in jaundice treatment

ALKP- alkaline phosphate Liver test GGT- Gamma GT- Possible test for liver Total bile Unconjugated bile Direct bile LDL VLDL CHOL/ dHDL CPK (enzyme) CPKMB Troponin T Serum proteins- liver related test
Heart related test

2) Another important test in this section is thyroid function test:

Thyroid function test TSH (thyroid stimulating hormone) -Hyperthyrodism -hypothyrodism

T3

T4

3) Other test of this section is PSA (Prostate specific antigen) Test: Normal count- Normal patient Increased count- Cancer possibilities 4) PT (Prothrombin time) and APTT (Activated PTT) test: PT test is done for proper circulation of blood for patients undergoing heart surgery. They are provided with medicines. This test helps to regulate the thickness of the blood. MICROBIOLOGY: In microbiology section, the entire test is performed in 3 basic steps. These steps are 1) Primary microscopic examination

2) Culture preparation and examination 3) Antibiotic sensitivity a)Primary microscopic examination: 1) 2) KOH test: Dissolves mucus, kills bacteria, shows fungus clearly Gram stain test: It is based on physic-chemical composition cell wall. Gram positive: In cell wall lipid content is less. Purple staining (due to more staining) Gram negative: In cell wall lipid content is more. Pink staining (due to less staining) Acid fastness test: It is the ability to retain the colour in presence of strong acids. Done to test whether micro bacteria are present or not. Usually done for TB patients. Reddish pink staining.

3)

b)Culture preparation and examination: Media selection is done on the basis of samples. Different types of media with their examples are: 1) 2) Ordinary media: All types of organisms grow. E.g.: Nutrient agar Selective media: Inhibits the growth of gram+, only gram- grows. E.g.: MacConkey Agar, it has bile salts, crystal violet and NACL.

3)

Enrichment media: It is the media which is used to favour one specific organism without inhibiting the others. E.g.: Alkaline peptone water. 4) Enriched media: In this it is necessary to know which organism we are growing as we add a particular nutrient to support the growth of specific organism. E.g.: Blood agar, chocolate agar. 5) Transport media: Used for transportation to far off places. It keeps the microbial count constant. Doesnt increase or decrease the count of microbes. Two types of techniques to make a culture is spreading the sample and streeking it with a nichrome wire which results into a colony. Then this colony is examined physically on the following factors: opacity, size, shape, texture, margin, elevation, pigmentation and mucosity. After physical examination of colony bio chemical test is done which includes either of sugar fermentation, urea hydrolysis, IMVIC (Indol; methyl red; VP test; citrate test), cholera rate reaction (ricy water like sample), TSI (Triple Sugar Iron) test (slant) Triple sugars are: Glucose, sucrose and lactose. This test is done to detect the following: Sugar fermentation done or not CO2 gas formation took place or not H2S production done or not

c) Antibiotic sensitivity: Two factors affecting anti-biotic sensitivity are: 1) 2) Turbidity compared to McFarlands standard. Medium thickness if more thickness then less diffusion will take place if less thickness then more diffusion will take place

*Mueller Hinton Agar: Used specifically for antibiotic sensitivity. It helps in equal distribution of all antibiotics. *Sabourand Dextrose Agar with chloramphenicol prevents the growth of bacteria. It is an example of selective media. All tests of micro biology are performed in a machine called Safety cabinet machine. It is of three types depending upon the facilities it provides. They are: -Class 1 cabinet machine -Class 2 cabinet machines -Class 3 cabinet machines *Benefits of this machine are: -Provides sterile environment -UV light kills microbes

Automated blood culture system: It is used for sensitive samples like brain samples. *Benefits of this machine are: - Closed system so prevents contamination - Gelatine particles are used which helps in surface tension reduction.

An unusual experience: When we went to observe how the blood samples are collected, we were taken to emergency ward. There were 6 patients of the same house who met with an accident. All of them were aged. There, in absence of staff, I was asked to hold the wrist of one grandma as her blood was to be collected. She was completely blood loaded. That was an unusual experience for me as I never saw someone so blood loaded and moreover I had to hold her wrist to take her blood. I was scared and was literally shaking out of fear.

Photo gallery:

Automated blood culture system

Gall bladder

Spleen

Chemicals Tool used for streaking method

Culture with antibiotics

Streaking method