Chapter 10 1. The functions of the CSF include all of the following except: A. Removal of metabolic wastes B.

Producing an ultrafiltrate of plasma C. Supplying nutrients to the CNS D. Protection of the brain and spinal cord 2. The CSF flows through the A. Choroid plexus B. Pia mater C. Arachnoid space D. Dura mater 3. Substances present in the CSF are contolled by the A. Arachnoid granulations B. Blood-brain barrier C. Presence of one-way valves D. Blood-CSF barrier 4. The CSF tube labeled 3 is sent to: A. The hematology department B. The chemistry department C. The microbiology department D. The serology department 5. The CSF A. Tube B. Tube C. Tube D. Tube tube that should be refrigerated is 1 2 3 4

6. Place the appropriate letter in front of the statement that best describes CS F specimens in these two conditions: A. Traumatic tap B. Intracranial hemorrhage ____Even distribution of blood in all tubes ____Xanthochromic supernatant ____Concentration of blood in tube l is greater than in tube 3 ____Specimen contains clots 7. The presence of xanthochromia can be caused by all of the following except: A. lmmature liver function B. RBC degradation C. A recent hemorrhage D. Elevated CSF protein 8. A web-like pellicle in a refrigerated CSF specimen is indicative of: A. Tubercular meningitis B. Multiple sclerosis C. Primary CNS malignancy D. Viral meningitis 9. Given the following information, calculate the CSF WBC count: cells counted, 80; dilution, 1:10; large Neubauer squares counted, 10. A.8 B.80 C.800

D.8000 10. A CSF WBC count is diluted with: A. Distilled water B. Normal saline C. Acetic acid D. Methylene blue 11. A total CSF cell count on a clear fluid should be: A. Reported as normal B. Not reported C. Diluted with normal saline D. Counted undiluted 12. The purpose of adding albumin to CSF before cytocentrifugation is to: A. Increase the cell yield B. Decrease the cellular distortion C. Improve the cellular staining D. Both A and B 13. The primary concern when pleocytosis of neutrophils and lymphocytes is found in the CSF is: A. Meningitis B. CNS malignancy C. Multiple sclerosis D. Hemorrhage 14. Neutrophils with pyknotic nuclei may be mistaken for: A. Lymphocytes B. Nucleated RBCs C. Malignant cells D. Spindle-shaped cells 15. The presence of which of the following cells is increased when a CNS shunt m alfunctions? A. Neutrophils B. Macrophages C. Eosinophils D. Lymphocytes 16. Macrophages appear in the CSF following: A. Hemorrhage B. Repeated spinal taps C. Diagnostic procedures D. All of the above 17. Nucleated RBCs are seen in the CSF as a result of A. Elevated blood RBCs B. Treatment of anemia C. Severe hemorrhage D. Bone marrow contamination l8. Following a CNS diagnostic procedure, which of the following might be seen i n the CSF? A. Choroidal cells B. Ependymal cells C. Spindle-shaped cells D. All of the above 19. Hemosiderin granules and hematoidin crystals are seen in:

A. B. C. D.

Lymphocytes Macrophages Ependymal cells Neutrophils

20. Myeloblasts are seen in the CSF: A. In bacterial infections B. In conjunction with CNS malignancy C. Following cerebral hemorrhage D. As a complication of acute leukemia 21. Cells resembling large and small lymphocytes with cleaved nuclei represent: A. Lymphoma cells B. Choroid cells C. Melanoma cells D. Medulloblastoma cells 22. The normal value of CSF protein is: A. 6-8 g/dL B. 15-45 g/dL C. 6-8 mg/dL D. 15-45 mg/dL 23. CSF can be differentiated from plasma by the presence of: A. Albumin B. Globulin C. Prealbumin D. Tau transferrin 24. In plasma, the second most prevalent protein is IgG in CSF, the second most prevalent protein is: A. Transferrin B. Prealbumin C. IgA D. Ceruloplasmin 25. Elevated CSF protein values can be caused by all of the following except: A. Meningitis B. Multiple sclerosis C. Fluid leakage D. CNS malignancy 2,6. The integrity of the blood-brain barrier is measured using the: A. CSF/serum albumin index B. CSF/serum globulin ratio C. CSF albumin index D. CSF IgG index 27. Given the following results, calculate the IgG index CSF IgG, 50 mg/dL; serum IgG, 2 gm/dL; CSF albu min, 70 mg/dL; serum albumin, 5 gm/dL. A. 0.6 B. 6.0 C. 1.8 D. 2.8 28. The CSF IgG index calculated in Study Question 27 is indicative of: A. Synthesis of IgG in the CNS B. Damage to the blood~brain barrier

C. Cerebral hemorrhage D. Lymphoma infiltration 29. The finding of oligoclonal bands in the CSF and not in the serum is seen wit h: A. Multiple myeloma B. CNS rnalignancy C. Multiple sclerosis D. Viral infections 30. A CSF glucose of 15 mg/dL, WBC count of 5000, 90% neutrophils, and protein o f 80 mg/dL is suggestive of: A. Fungal meningitis B. Viral meningitis C. Tubercular meningitis D. Bacterial meningitis 31. A patient with a blood glucose of 120 mg/dL would have a normal CSF glucose of: A. 20 mg/dL B. 60 mg/dL C. 80 mg/dL D. 120 mg/dL 32. CSF lactate will be more consistantly decreased in: A. Bacterial meningitis B. Viral meningitis C. Fungal meningitis D. Tubercular meningitis 33. Measurement of which of the following can be replaced by CSF glutamine analy sis in children with Reye syndrome? A. Ammonia B. Lactate C. Glucose D. alpha-ketoglutarate 34. Prior to performing a Gram stain on CSE the specimen must be: A. Filtered B. Warmed to 37C C. Centrifuged D. Mixed 35. All of the following statements are true about cryptoccocal meningitis excep t: A. An India Ink preparation is positive B. A starburst pattern is seen on Gram stain C. The WBC count is over 2000 D. A confirmatory immunology test is available 36. The test of choice to detect neurosyphilis is the: A. RPR B. VDRL C. FTA D. FTA-ABS Case Studies 1. Three tubes of CSF containing evenly distributed visible blood are drawn from a 75-year-old disoriented patient and delivered to the laboratory. Initial

test results are as follows: WBC couNT: 250 microliter PROTEIN: 150 mg/dL GLucosE: 70 mg/dL GRAM STAIN: No organisms seen DIFFERENTIAL: Neutrophils, 68%; monocytes, 3%; lymphocytes, 28%; eosinop hils, l% Many macrophages containing ingested RBCs a. What is the most probable condition indicated by these results? State two reasons for your answer. b. Are the elevated WBC count and protein of significance? Explain your answer. c. Are the percentages of the cells in the differential of any significa nce? Explain your answer. d. What two other structures besides RBCs might be contained in the macr ophages? e. If the blood was unevenly distributed and nucleated RBCs and capillar y structures were seen instead of macrophages, what would this indicate? 2. A patient with AIDS is hospitalized with symptoms of high fever and rigi dity of the neck. Routine laboratory tests on the CSF show a 'WBC count of lOO/m icroL with a predominance of lymphocytes and monocytes, glucose of 55 mg/dL (pla sma: 85 mg/dL), and a protein of 70 mg/dL. The Gram stain shows a questionable s tarburst pattern. a. What additional microscopic examination should be performed? b. If the test is positive, what is the patient's diagnosis? c. If the results of the test are questionable, what additional testing can be performed? d. What could cause a false-positive reaction in this test? e. If the tests named in a and c are negative, the glucose level is 35 m g/dL, and a pellicle is observed in the fluid, what additional testing should be performed'? f. If CSF and serum lFE was performed on this patient, what unusual find ings might be present? 3. A 35-year-old woman is admitted to the hospital with symptoms of intermi ttent blurred vision, weakness, and loss of sensation in her legs. A lumbar punc ture is performed with the following results: APPEARANcE: Colorless, clear WBC couNT: 35 cells/microL (90% lymphocytes) GLucosE: 60 mg/dL (plasma: 100 mg/dL) PROTEIN: 60 mg/dL (serum: 8 g/dL) ALBuMiN: 40 mg/dL (serum: 6 g/dL) IGG globulin: 20 mg/dL (serum: 2 g/dL) a. Name and perform the calculation to determine the integrity of the pa tient's blood-brain barrier. b. Does the patient have an intact barrier? c. Name and perform the calculation used to determine if lgG is being sy nthesized within the CNS. d. What does this result indicate? e. Considering the patient's clinical symptoms and the calculation resul ts, what diagnosis is suggested? f. If immunofixation electrophoresis is performed on the patient's serum and CS~ what findings would be expected? . g. What substance in the CSF can be measured to monitor this patient? 4. Mary Howard, age 5, is admitted to the pediatrics ward w

ith a temperature of 105F, lethargy, and cervical rigidity. A lumbar spinal tap i s performed, and three tubes of cloudy CSF are delivered to the laboratory. Prel iminary test results are as follows: APPEARANCE: Hazy WBC couNT: 800 cells/microL DIFFERENTIAL: 80% lymphocytes, 15% monocytes. 5% neutrophils PROTEIN: 65 mg/dL GLucosE: 70 mg/dL GRAM STAIN: No organisms seen a. From these results, what preliminary diagnosis could the physician co nsider? b. Is the Gram stain result of particular significance? Why or why not? c. Are the lymphocytes of significance? Why or why not? d. Would a CSF lactate test be of any value for the diagnosis? Why or wh y not? 5. State possible technical errors that could result in the following discr epancies: a. An unusual number of Gram stains reported as gram-positive cocci fail to be confirmed by positive cultures. b. A physician complains that CSF differentials are being reported only as polynuclear and mononuclear cells. c. Bacteria observed on the cytospin differential cannot be confirmed by Gram stain or culture. d. The majority of CSF specimens sent to the laboratory from the neurolo gy clinic have glucose readings less than 50% of the corresponding blood glucose results performed in the clinic. Chapter 12 1. The functions of synovial fluid include all of the following except: A. Lubrication for the joints B. Removal of cartilage debris C. Cushioning joints during jogging D. Providing nutrients for cartilage 2. The primary function of synoviocytes is to: A. Provide nutrients for the joints B. Secrete hyaluronic acid C. Regulate glucose filtration D. Prevent crystal formation 3. Which of the following is not a frequently performed test on synovial fluid? A. Uric acid B. WBC count C. Crystal examination D. Gram stain 4. The procedure for collection of synovial fluid is called A. Synovialcentesis B. Arthrocentesis C. Joint puncture D. Arteriocentesis 5. Match the following disorders with their appropriate group: A. Noninflammatory

B. Inflammatory C. Septic D. Hemorrhagic ____Gout ____N. gonorrhoeae infection ____Lupus erythematosus ____Osteoarthritis ____Hemophilia ____Rheumatoid arthritis ____Heparin overdose 6. Normal synovial fluid resembles: A. Egg white B. Normal serum C. Dilute urine D. Lipemic serum 7. Powdered anticoagulants should not be used in tubes for synovial fluid testin g because it interferes with: A. Cell counts B. Glucose tests C. Crystal examination D. Differentials 8. Addition of a cloudy, yellow synovial fluid to acetic acid produces a/an: A. Yellow-white precipitate B. Easily dispersed clot C. Solid clot D. Opalescent appearance 9. To A. B. C. D. determine if a fluid is synovial fluid, it should be mixed with: Sodium hydroxide Hypotonic saline Hyaluronidase Acetic acid

10. The highest WBC count can be expected to be seen with: A. Noninflammatory arthritis B. Inflammatory arthritis C. Septic arthritis D. Hernorrhagic arthritis 11. When diluting a synovial fluid WBC count, all of the following are acceptabl e except: A. Acetic acid B. lsotonic saline C. Hypotonic saline D. Saline with saponin 12. The lowest percentage of neutophils would be seen in: A. Noninflammatory arthritis B. Inflammatory arthritis C. Septic arthritis D. Hemorrhagic arthritis 13. All of the following are abnormal when seen in synovial fluid except: A. RA cells B. Reiter cells C. Synovial lining cells

D. Lipid droplets 14. Synovial fluid crystals that occur as a result of purine metabolism or chemo therapy for leukemia are: A. Monosodium urate B. Cholesterol C. Calcium pyrophosphate D. Apatite 15. Synovial fluid crystals associated with inflammation in dialysis patients ar e: A. Calcium pyrophosphate B. Calcium oxalate C. Corticosteroid D. Monosodium urate 16. Crystals associated with pseudogout are: A. Monosodium urate B. Calcium pyrophosphate C. Apatite D. Corticosteroid 17. Synovial fluid for crystal examination should be examined as a/an: A. Wet preparation B. Wright stain C. Gram stain D. Acid-fast stain 18. Crystals that have the ability to polarize light are: A. Corticosteroid B. Monosodium urate C. Calcium oxalate D. All of the above 19. In an examination of synovial fluid under compensated polarized light, rhomb ic-shaped crystals are observed. What color would these crystals be when aligned parallel to the slow vibration A. White B. Yellow C. Blue D. Red 20. If crystals shaped like needles are aligned perpendicular to the slow vibrat ion of compensated polarized light, what color are they? A. White B. Yellow C. Blue D. Red 21. Negative birefringence occurs under compensated polarized light when: A. Slow light is impeded more than fast light B. Slow light is less impeded than fast light C. Fast light runs against the molecular grain of the crystal D. Both B and C 22. Synovial fluid cultures are often plated on chocolate agar to detect the pre sence of: A. Neisseria gonorrhoeae B. Staphylococcus agalactiae C. Streptococcus viridans

D. Enteroccus faecalis 23. The most frequently performed chemical test on synovial fluid is: A. Total protein B. Uric acid C. Calcium D. Glucose 24. Serologic tests on patients' serum may be performed to detect antibodies cau sing arthritis for all of the following disorders except: A. Pseudogout B. Rheumatoid arthritis C. Lupus erythematosus D. Lyme arthritis 25. Serologic testing of synovial fluid for fibrinogen and C-reactive protein is performed to: A. Determine clot formation B. Determine the amount of inflammation C. Detect osteoarthritis D. Diagnose rheumatoid arthritis Case Studies 1. A 50-year-old man presents in the emergency room with severe pain and sw elling in the right knee. Arthrocentesis is performed and 20 mL of milky synovia l fluid is collected. The physician orders a Gram stain, culture, and crystal ex amination of the fluid, as well as a serum uric acid. He requests that the synov ial fluid be saved for possible additional tests. a.Describe the tubes into which the fluid would be routinely placed. b.If the patient's serum uric acid level is elevated, what type of cryst als and disorder are probable? c. Describe the appearance of these crystals under direct and compensate d polarized light. d. Why were the Gram stain and culture ordered? 2. A medical technology student dilutes a synovial fluid prior to performin g a WBC count. The fluid forms a clot. a.Why did the clot form? b.How can the student perform a correct dilution of the fluid? c.After the correct dilution is made, the WBC count is 100,000/microL. S tate two arthritis classifications that could be considered. d.State two additional tests that could be run to determine the classifi cation. 3. Fluid obtained from the knee of an obese 65-year-old woman being evaluat ed for a possible knee replacement has the following results: APPEARANCE: Pale yellow and hazy WBC couNT: 500 cells/mL GRAM STAIN: Negative GLUCOSE: 110 mg/dL (serum glucose: 115 mg/dL) a. What classification ofjoint disorder do these results suggest? b. Under electron microscopy, what crystals might be detected? c. How does the glucose result aid in the disorder classification? 4. A synovial fluid delivered to the laboratory for a cell count is clotted

. a. What abnormal constituent is present in the fluid? b. What type of tube should be sent to the laboratory for a cell count? c. Could the original tube be used for a Gram stain and culture? Why or why not? Chapter 13 1. The primary purpose of serous fluid is: A. Removal of waste products B. Lowering of capillary pressure C. Lubrication of serous membranes D. Nourishing serous membranes 2. The membrane that lines the wall of a cavity is the: A.Visceral B. Peritoneal C. Pleural D. Parietal 3. During normal production of serous fluid, the slight excess of fluid is: A. Absorbed by the lymphatic system B. Absorbed through the visceral capillaries C. Stored in the mesothelial cells D. Metabolized by the mesothelial cells 4. Production of~ serous fluid is controlled by: A. Capillary oncotic pressure B. Capillary hydrostatic pressure C. Capillary permeability D. All of the above 5. An increase in the amount of serous fluid is called a/an: A.Exudate B. Transudate C. Effusion D. Malignancy 6. Pleural fluid is collected by: A. Pleurocentesis B. Paracentesis C. Pericentesis D. Thoracentesis 7. Place the appropriate letter in front of the following statements describing transudates and exudates. A. Transudate B.Exudate ___Caused by increased capillary permeability ___Caused by increased hydrostatic pressure ___Caused by decreased oncotic pressure ___Caused by congestive heart failure ___Malignancy related ___Tuberculosis related ___Nephrotic syndrome related ___Cloudy appearance 8. Fluid-to-serum protein and lactic dehydrogenase ratios are performed on serou s fluids: A. When malignancy is suspected

B. To classify transudates and exudates C. To determine the type of serous fluid D. When a traumatic tap has occurred 9. Which of the following requires the most additional testing? A. Transudate B.Exudate 10. An additional test performed on pleural fluid to classify the fluid as a tra nsudate or exudate is the: A. WBC count B. RBC count C. Fluid-to-cholesterol ratio D. Fluid-to-serum protein gradient 11. A milky-appearing pleural fluid is indicative of: A. Thoracic duct leakage B. Chronic inflammation C. Microbial infection D. Both A and B 12. Which of A. Blood B. Blood C. Blood D. Blood the following best represents a hemothorax? HCT: 42 Fluid HCT: 15 HCT: 42 Fluid HCT: 10 HCT: 30 Fluid HCT: 10 HCT: 30 Fluid HCT: 20

13. All of the following are normal cells seen in pleural fluid except: A. Mesothelial cells B. Neutrophils C. Lymphocytes D. Mesothelioma cells 14. A differential observation of pleural fluid associated with tuberculosis is: A. Increased neutrophils B. Decreased lymphocytes C. Decreased mesothelial cells D. Increased mesothelial cells 15. All of the following are characteristics of malignant cells except: A. Cytoplasmic molding B. Absence of nucleoli C. Mucin-containing vacuoles D. Increased N:C ratio 16. A pleural fluid pH of 6.0 is indicative of: A. Esophageal rupture B. Mesothelioma C. Malignancy D. Rheumatoid effusion 17. A mesothelioma cell seen in pleural fluid indicates: A. Bacterial endocarditis B. Primary rnalignancy C. Metastatic lung malignancy D. Tuberculosis infection 18. Another name for a peritoneal effusion is A. Peritonitis B. Lavage

C. Ascites D. Cirrhosis 19. The test performed on peritoneal lavage fluid is: A. WBC count B. RBC count C. Absolute neutrophil count D. Amylase 20. The recommended test for determining if peritoneal fluid is a transudate or an exudate is the A. Fluid-to-serum albumin ratio B. Serum ascites albumin gradient C. Fluid-to-serum lactic dehydrogenase ratio D. Absolute neutrophil count 21. Given serum serum fluid the following results, classify this peritoneal fluid: albumin, 2.2 g/dL; protein, 6.0 g/dL; albumin, 1.6 gldL.

A. Transudate B. Exudate 22. Differentiation between bacterial peritonitis and cirrhosis is done by perfo rming a/an: A. WBC count B. Differential C. Absolute neutrophil count D. Absolute lymphocyte count 23. Detection of the CA 125 tumor marker in peritoneal fluid is indicative of: A. Colon cancer B. Ovarian cancer C. Gastric malignancy D. Prostate cancer 24. Chemical tests primarily performed on peritoneal fluid include all of the following except: A. Lactose dehydrogenase B. Glucose C. Alkaline phosphatase D. Amylase 25. Cultures of peritoneal fluid are incubated A. Aerobically B. Anaerobically C. At 37C and 42C D. Both A and B Case Studies 1. Fluid from a patient with congestive heart failure is collected by thoracente sis and sent to the laboratory for testing. It appears clear and pale yellow and has a WBC count of 450/mL, fluid:serum protein ratio of 035, and fluid:serum LD ratio of 0.46. a. What type of fluid was collected? b. Based on the laboratory results, would this fluid be considered a transuda te or an exudate? Why?

c. List two other tests that could be performed to aid in classifying this fl uid. 2. A cloudy pleural fluid has a glucose level of 30 mg/dL (serum glucose level i s 100 mg/dL) and a pH of 6.8. a. What condition do these results indicate? b. What additional treatment might the patient receive based on these results ? 3. The following results were obtained on a peritoneal fluid: serum albumin, 2.8 g/dL; fluid albumin, 1.2 g/dL. a. Calculate the SAAG. b. Is this a transudate or an exudate? Why? c. What is the most probable cause of the effusion? 4. Paracentesis is performed on a patient with ascites. The fluid appears turbid and has an elevated WBC count. Additional tests ordered include an absolute gra nulocyte count, amylase, creatinine, CEA, and CA 125. a. What is the purpose for the absolute granulocvte count? If it is less than 250 cells/mL, what condition is indicated? b. If the amylase level is elevated, what is its significance? State an addit ional test that might be ordered. c. Explain the significance of an elevated creatinine level. d. What is the purpose of the CEA and CA 125 tests? 5. Describe a situation in which paracentesis might be performed on a patient wh o does not have ascites. If the RBC count is 300.000/mL. what does this indicate ? 6. Microscopic examination of an ascitic fluid shows many cells with nuclear and cytoplasmic irregularities containing Psammoma bodies. The CEA test result is n ormal. What additional test would be helpful?