1.Serum potassium of 45 mmol/L (3.5-5.

0) was
noted on a healthy young man during a check
up at the Clinic.

What is the clinical significance of this serum

potassium result?
⇒ This is lethal and not a possible result. The man would
have cardiac arrhythmia, sweating & shaking.

Explain how it could have happened.

⇒ Haemolysis (breaking of the cell membrane which allows
Potassium to exit the cell). This would have been a bright
red sample
⇒ Transcription error (the number should be 4.5 mmol/L
instead of 45).
⇒ Wrong sample? (maybe used urine instead of serum)
⇒ Contamination with Sodium (tube coated with
anticoagulant) – WRONG tube may have been used
⇒ If it occurred in a hospital, the nurse may have taken the
sample from the same place his IV entered – this would
not have been flushed and would contain higher levels of
electrolytes.

What should you do next?

⇒ Be ANRGY! GRRRRRRRRRRRRR
⇒ Tell someone – find the cause of the problem
⇒ Retest
2.Blood specimens are taken during the
afternoon and evenings at the Clinic. The
specimens were stored in the refrigerator until
shipped to the laboratory making the
measurements at about 11 pm. All the
potassium results were over 6 mmol/L.
(healthy is 3.5-5.0)

Explain these results.

⇒ When samples are stored Potassium leaks out of the
cells. This occurs quicker with refrigeration.

What can be done about it?

⇒ Samples should have been centrifuged before storage
(separate cells from plasma)
⇒ Technical issue: these machines need to be calibrated
3.You send a hair sample to Acme Foothills
Laboratory and also to the Florida Sun
Laboratory.
The Acme laboratory reports that the sample is
deficient in many minerals and vitamins.
The Florida laboratory states that the sample
has high calcium and magnesium content.

Comment on these results.

⇒ Is the hair ‘virgin’ hair? (not dyed)
⇒ How often/when did the hair get washed?
⇒ Is the company selling any products (such as Mg and
Ca?) Is there a conflict of interest?
⇒ What’s in your hair depends on the water in your area.
E.g. Sudbury has lots of nickel
⇒ Hair far from the scalp is different then hair close to the
scalp.

Who is likely to be telling the truth?

⇒ Florida laboratory?

How could you prove it?

⇒ We didn’t cover this in class…

Is this the best sample to use to look for mineral

and vitamin deficiencies?
⇒ NO! Pubic hair is the best if you’re using hair (less
external environment influences)
4.A laboratory is the cheapest in the area, has
the fastest time to report results, and offers
valuable incentives to users of their
services.
Results seem to come back in the middle of
the usual reference ranges.

How likely is that to happen?

⇒ This is a FAKE LAB! They have absolutely no overhead
since the samples are just thrown down the sink and the
results are made up

How can you test the laboratories’ precision

and accuracy?
⇒ ASK who they are certified by
⇒ ASK how they assess their results

Who protects the user from malpractice?

5.A young adult patient is said to have cystic
fibrosis but does not have the usual signs
and symptoms of this disease. You wonder
about misdiagnosis.

What are the expected electrolyte

abnormalities in this disease?
⇒ Increased Salt (NaCl) in sweat
⇒ Glands are filled with mucous

How should you collect a sweat sample to

check for the expected electrolyte
abnormalities in this disease?
⇒ Put electrodes in the area and stimulate it to sweat –
collect with a paper disc
⇒ Best places are forearm, back & thighs

Can a patient have cystic fibrosis and be

“normal”?
⇒ Can have mild forms and many variations of cystic
fibrosis
⇒ This test is not a routine test and there are many daily
abnormalities in sweating
6.A serum specimen is divided into several
portions and two are sent by accident to two
different laboratories. One reports the serum
sodium and chloride as subnormal. The
other as normal.
You send other portions taken at the same
time again to these two laboratories and get
the same results.

How can this be explained?

⇒ 1st sample could have been from only the top portion of
the sample and the 2nd from the bottom only. (Sample
was not mixed properly)
⇒ One lab could measure chloride/water and the other
lab could measure chloride/total volume (this would
give you different results)

What should you do next to find the truth?

⇒ Check samples for (all labs):
 Hemolysis
 Lipemia
 jaundive
 7.A salesman suggests that saliva chemistries
are the coming trend. Samples are less
invasive to collect and less painful to get for
the patient. Also he has a cheap machine to
buy and operate that measures salivary
electrolytes that he can sell to the Clinic for
your use.

Can these samples be used in a clinically useful

way to assess electrolytes?
⇒ Yes, as long as the tests/conditions are standardized
⇒ Saliva is an ultrafiltrate of serum
⇒ Also a secretion – glands add to saliva
⇒ Saliva has free, unbound & active proteins/hormones

What problems do you anticipate?

⇒ Problems with standardization because the test is
dependant on what you eat
 Possibly rinse mouth out before the test and give
them something rubber to chew on
 8.A salesman says that ionized calcium and
magnesium measurements are better than
total calcium and magnesium
measurements for diagnostic and prognostic
purposes.

Is this likely to be true?

⇒ YES!

What are the technical problems with this

approach?
⇒ Depends on the way the blood sample is taken – need
blood gas (which requires special machines)
⇒ This is only done in the operating room – not routine yet
9. What are seasonal variations in electrolytes
and why do they happen?

10. What is the optimal use of laboratory

services?

How do you know that this is optimal?

11. Suppose you have hepatitis C How can you

protect the patient from you?

12. You are in charge of shipping specimens

from your clinic to the reference laboratories.

How should you ship the sample at about

4oC?
How should you ship the sample at – 20oC?
How should you ship the sample at –70OC?
If the sample is known to be very infectious?

Where do you find rules on how to do this?

Who sets the rules?

 13.A reputable test for iron deficiency anemia
is serum ferritin. The reference range for an
adult woman is said to be 10-120 ug/L and
for an adult man it is 20-250 ug/L.

Why the difference between the ranges for men

and women?
⇒ MENSES!

Why not just measure serum irons for iron

deficiency?
⇒ Want to measure stores
⇒ Iron in the body depends on what you’re eating (or if
you’re fasting)
⇒ Diurnal variation – iron fluctuates throughout the day in a
circadian rhythm

One of your patients looks as though she might

have iron deficiency anemia. Her serum ferritin
is 30 ug/L.

What is the significance of the value? How do

you know?
⇒ You don’t know. Your clinical impression is probably true.
⇒ This has to do with PROBABILITY – the probability of the
‘healthy range’ overlapping with the ‘disease range’
⇒ Check the internet for these ranges

What is the “gold” standard test for this disease?

 ⇒ Gold standard is bone marrow test – iliac crest

14. A school girl thinks that she might be

pregnant and buys a self testing kit from the
corner drug store.
She does the test and finds she is pregnant.
She tells her mother and they went to the local
laboratory and the girl was tested again. The
results are negative.
After a month or so her clothes do not fit and
she is tested again.
She is positive by the pregnancy test.

What happened?
⇒ Drugs can give false negatives or false positives (eg
diuretics)
⇒ Certain tumors can produce hCG (cancers)
⇒ Home urine test (urine) vs. lab (blood?!)
⇒ The kits could have been different!
 Have to look at the lower unit used to pick up the
hormone levels (sensitivity) – “how low can you go”
 The lab could have missed it
 hCG doubles every day for first 3 months
 all kits are not equal!
⇒ Have to look at following instructions – most people don’t
do it properly at home
⇒ Time of day the test was taken is also important –
morning sample is best because it’s the most
concentrated
 2nd test (lab) could have been taken in the
afternoon…
 15.One of your older colleagues believes that
serum lactate dehydrogenase is a good
test for diagnosing myocardial infarctions,
heart attacks.

What are the interpretive problems with this

approach?
⇒ Every test has sensitivity and specificity
⇒ We know there are better tests but lactate dehydrogenase
(LD) is still used
⇒ Problem: specificity (lumphoma, leukemia, and other
diseases come out positive for LD)

What can you tell him about the newer

enzyme methods for this?
⇒ Newer methods such as creatine kinase and myoglobin
decrease a few hours after the heart attack
⇒ LD stays elevated for 1 week (can go back to see if there
was a heart attack)
16.You think a patient might be worth carrying
out an erythrocyte sedimentation test on
his blood.
How should you set this up?
⇒ Set up standard conditions (such as temperature)
What are the problems with it?
⇒ Not specific
What does it mean?
⇒ Means there could be chronic disease (inflammation)
17.What do you need to know about the
patient before you order a complete blood
count?

⇒ Look at drugs taken (herbals too)

⇒ Exercise
 Changes coagulation time (PT test). Blood thins
so that it circulates quickly
 Changes differential (WBC) count – flush
monocytes/neutrophils out of spleen
⇒ Travel – high altitude, malaria, hookworm
⇒ Recent infection
⇒ Family history
⇒ Recent blood donation (decreases hemoglobin)
18.A person proven by culture and sensitivity
to have a urinary tract infection came into
the clinic. You decided to check the urine
for urinary tract infection by the urinalysis
dip stick method.
The results came back negative.
Explain this.
⇒ Vitamin C? (false negative)
⇒ Starvation – no nitrate (most nitrates come from
vegetables)
⇒ Old urine?
⇒ Was the urine less than 4 hours in the bladder (the
amount of time needed for the bugs to convert nitrate
to nitrite)
⇒ Type of bacteria (only some do the conversion) –
nature of the bug. It’s a good test, but only on certain
bacteria. Brilliant if everyone has E. coli
⇒ ***he made many references to this being on the exam
19.A middle aged man with low back pain
gives you a urine sample and you find a
small amount of protein in the urine by the
dip stick method. Out of interest you carry
out a simple method for protein using a mix
of urine and sulfosalicylic acid. The finding
is that there is a large amount of protein in
his urine.
Explain this.
⇒ Abnormal protein is present: he could have a spinal
cord disease: multiple myeloma. Bence-Jones protein.
This is not measured by dipstick = NOT albumin
⇒ There was talk about other diseases for back pain, but
they wouldn’t show this protein abnormality
20.A long distance runner is concerned that
after a long hard run his urine appears dark
red.
Explain this.
⇒ Protein is not red coloured. One is: myoglobin
⇒ Beetroot juice
⇒ Could be blood – from pounding due to bladder friction
when running (joggers get bleeding ulcers)
21.A strict vegetarian is in your office. What
abnormalities do you expect from a vegan
type of diet?
⇒ Alkaline urine
⇒ Vitamin C would be abnormally high
⇒ Smell
⇒ Crystals – lots of oxalates.
 22.Is there any point in reporting crystals in
urine? (Some laboratories do not)
What are the conditions if you want to know
about the crystal content of urine?
⇒ Could mean gout or kidney stones
⇒ If they are abnormal (weird), you have a problem

Extra class notes:

⇒ For St. Patrick’s day, how do you get green urine?
 Drink something blue?! He didn’t really answer this
⇒ How do you preserve urine?
 Put it in the fridge! Cells gone in a few hours…
 You can buy preservatives for either dipstick and forget
about cells/casts (or vice versa). Have to pick one.
Formaldeyde preserves the cells (only). There are many
products out there for dipstick.
⇒ Doper’s Urine – how do we avoid being caught?
 Buy urine online
 Can you confuse the test/negate it?
• Alkaline urine (it is illegal to have alkaline urine
because it masks steroids). Bicarbonate is banned
because it makes urine alkaline.
• Apologize to vegans?! ha
 Use old urine – lab could tell
 Dilute your urine. Take diuretics.
 Can filter your urine
 If supervised: put urine in a condom (up there for women),
then break it with your fingernails when you’re under
supervision.
• If it is hidden ON your body it fails a temperature
check.
⇒ Marion Jones. 1st test positive for erythropoietin. 2nd negative.
SAME sample.
 Second lab – was it corrupt? This was investigated…
 Put in protease to digest the chemical and then digest itself!!
Protease will digest all proteins.
 Took longer time to get to the 2nd lab so it worked!
70 questions on the test!! 2 hours. All multiple choice. One or two definitions and
the rest are situational!!