SYNOVIAL FLUID Flashcards
(123 cards)
1
Q
Other term is “JOINT FLUID”
A
SYNOVIAL FLUID
2
Q
Specifically, for the movable type of joints
A
SYNOVIAL FLUID
3
Q
SF Came from the Latin word “synovial” which is the term for?
A
Egg
4
Q
Why egg?
A
the viscosity of the egg white resembles the same as the synovial fluid
5
Q
These are specialized cell in the synovial membrane that secretes Hyaluronic acid and small amounts of protein
A
SYNOVIOCYTES
6
Q
is the joint that connect the 3 Bones (which are the Femur, Tibia, and Patella).
A
Synovial joint
7
Q
This type of cartilage provides a big support for the joints so that your bones won’t tear apart
A
Articular cartilage
8
Q
What part of the synovial joint will be aspirated during specimen collection?
A
Synovial cavity
9
Q
(3) MAIN FUNCTION OF SYNOVIAL FLUID
A
→ Reduce friction between the bones during joint movement by providing lubrication
→ Provides nutrients to articulating cartilages
→ Lessen shock of joint compression during activities (Walking/Jogging) or any leg movements
10
Q
is the main support system of the bones
A
articulating cartilages
11
Q
T or F
only the Medtech’s are the one who collects the synovial fluid.
A
F
only the doctors are the one who collects the synovial fluid. MedTech only receive the sample.
12
Q
what do doctors use for aspiration of SF?
A
syringe
13
Q
The special characteristic of the syringe used for aspiration
A
is that there is a Moistening the barrel of syringe with heparin.
14
Q
Why Moistening? And not powder?
A
because if you’ll be using powdered, you’re anticoagulant being applied in the barrel, it can interfere during microscopic examinations.
15
Q
During microscopic examinations for SF, we will do what procedure?
A
differential count
we will also seek for the presence of elements (especially crystals)
16
Q
If powder is being used, there is a greater chance for?
A
False Positive for presence of crystals.
17
Q
On aspiration, what will doctors feel first before they will estimate on where they will hit and aspirate.
A
Patella
18
Q
2 disorders that are related when we’re talking about Synovial fluid
A
Osteoarthritis and Rheumatoid Arthritis
(they are arthritic joints)
19
Q
This is the “wear and tear” of your joints. Usually this happens to old people (tigulang), elder patients which ages >60.
A
Osteoarthritis.
20
Q
This is arthritis that cause Autoimmune disorder. This are the cells inside your body that attack your synovial cells or synoviocytes.
A
Rheumatoid Arthritis
21
Q
DISTRIBUTION
Basaha lang
A
After collection, plastar them in the coagulated tube even if they are being moisted with heparin (barrel) in the initial collection, proceed to Anticoagulated tubes (IF you’re going to laboratory examination).
22
Q
5 Common laboratory examination being done for synovial fluid would be
A
WBC count
Differential count
Gram Staining
Culture and Sensitivity
microscopic examination
23
Q
Every fluid must undergo _________ beforehand.
A
Macroscopic examination
24
Q
4 specific tubes for SF to be transferred
A
Gram stain and culture - Heparinized tube/Green top(sterile)
Cell counts - heparin or EDTA
Non-anticoagulated tube for other tests - Non anticoagulated tube or Red top or Yellow top.
Sodium fluoride - Gray top (sodium fluoride)
25
NORMAL LIMITS OF SYNOVIAL FLUID
Volume
<3.5 ml
26
NORMAL LIMITS OF SYNOVIAL FLUID
Color
Colorless to pale yellow
(Supposed to be, no color pigments involved)
27
NORMAL LIMITS OF SYNOVIAL FLUID
Clarity
Clear
28
NORMAL LIMITS OF SYNOVIAL FLUID
Viscosity
Able to form a string 4 to 6 cm long
(During bedside collection)
(normal: same like egg white)
29
NORMAL LIMITS OF SYNOVIAL FLUID
Leukocyte count
<200 cells/ul
30
NORMAL LIMITS OF SYNOVIAL FLUID
Neutrophil
<25% of the differential
31
NORMAL LIMITS OF SYNOVIAL FLUID
Crystals
None present
32
NORMAL LIMITS OF SYNOVIAL FLUID
Glucose-Plasma difference
<10 mg/dl lower than the blood glucose level
(Remember: that synovial fluid is an ultrafiltrate of your plasma. Meaning, the chemical constituents are very similar to current plasma value that is why there is glucose-plasma difference)
33
NORMAL LIMITS OF SYNOVIAL FLUID
Total Protein
3 g/dL
34
Routine Laboratory testing
WBC, Differential count, Gram staining and culture, Microscopic examination for presence of crystals
35
4 Groups of Classification of SF specimen
Noninflammatory
Inflammatory
Septic
Hemorrhagic
36
Identify the Groups Classification of SF specimen regarding with these pathologies;
Degenerative joint disorders, osteoarthritis
Noninflammatory
37
Identify the Groups Classification of SF specimen regarding with these pathologies;
Immunologic disorders, rheumatoid arthritis, lupus erythemato-sus, scleroderma, polymyositis, anklylosing spondylitis, rheumatic fever, and Lyme arthritis Crystal-induced gout and pseudogout
Inflammatory
38
Identify the Groups Classification of SF specimen regarding with these pathologies;
Microbial infection
Septic
39
Identify the Groups Classification of SF specimen regarding with these pathologies;
Traumatic injury, tumors, hemo-philia, other coagulation disorders, Anticoagulant overdose
Hemorrhagic
40
Group Classification of SF specimen where it is usually colored green synovial fluid
septic
41
What causes the green color SF in septic?
Commonly caused by Pseudomonas aeruginosa, with the presence of pigment called Cyanine.
42
Group Classification of SF specimen where it is usually colored red
Hemorrhagic
43
Group Classification of SF specimen where it is usually increased in WBC count
Inflammatory
44
Identify the Groups Classification of SF specimen regarding with these laboratory findings;
Clear, yellow fluid
Good viscosity
WBCs <1000 pL
Neutrophils 30%
Normal glucose (similar to blood glucose)
Noninflammatory
45
Identify the Groups Classification of SF specimen regarding with these laboratory findings;
Cloudy, yellow fluid
Poor viscosity
WBCs 2000-75,000 pL
Neutrophils =50%
Decreased glucose level
Possible autoantibodies present
45
Identify the Groups Classification of SF specimen regarding with these laboratory findings;
Cloudy, yellow fluid
Poor viscosity
WBCs 2000-75,000 pL
Neutrophils =50%
Decreased glucose level
Possible autoantibodies present
Inflammatory IMMUNOLOGIC ORIGIN
46
Identify the Groups Classification of SF specimen regarding with these laboratory findings;
Cloudy or milky fluid
Low viscosity
WBCs up to 100,000 pL
Neutrophils <70%
Decreased glucose level
Crystals present
Inflammatory CRYSTAL-INDUCED ORIGIN
47
Identify the Groups Classification of SF specimen regarding with these laboratory findings;
Cloudy, yellow-green fluid
Variable viscosity
WBCs 50,000-100,000 ML
Neutrophils >75%
Decreased glucose level
Positive culture and Gram stain
Septic
48
Identify the Groups Classification of SF specimen regarding with these laboratory findings;
Cloudy, red fluid
Low viscosity
WBCs equal to blood
Neutrophils equal to blood
Normal glucose level
Hemorrhagic
49
Group Classification of SF specimen
you can proceed to glucose testing and cultures since this relates to bacterial infection. This is also performed in the microbiology section.
Septic
50
COLOR AND CLARITY
Normal
colorless to pale yellow
51
COLOR AND CLARITY
Non-inflammatory and inflammatory
deeper yellow
52
COLOR AND CLARITY
Septic
greenish tinge
53
COLOR AND CLARITY
Hemorrhagic
presence of blood
(Determine if from traumatic tap – Nasayop ug tusok)
54
T or F
traumatic tap is considered to be clinically significant
F
In traumatic tap, we do not consider that as clinically significant since it is faulty error during collection. If compared to venipuncture, that is being hemolyzed.
55
Know the clarity
you can also read it against the newsprint. Same reading as the urine which we have Clear, cloudy and turbid.
56
if MILKY synovial fluid this may indicate?
a sign with the presence of crystals. More or less abnorma
57
comes from the polymerization of the hyaluronic acid and is essential for the proper lubrication of the joints
VISCOSITY
58
How to observe the viscosity of the SF
Observe the ability of the fluid to form a string from the tip of a syringe, and can be done at the bedside
String test – press the plunger slowly and observe
59
Normal length of the string test for viscosity?
4 to 6 cm
60
If you want more chemically incline viscosity test:
Ropes or mucin clot test
61
Measurement of the amount of hyaluronate polymerization
Ropes or mucin clot test
(Normal synovial fluid forms a solid clot surrounded by clear fluid)
62
Used solution for Ropes or mucin clot test
- added to 2% to 5% acetic acid
63
Reporting of Ropes or mucin clot test
▪ good (solid clot)
▪ fair (soft clot)
▪ low (friable clot)
▪ poor (no clot)
64
To prevent cellular disintegration, counts should be performed ___________ or the specimen should be ________
as soon as possible, refrigerated RESPECTIVELY
65
T or F
If you’re using the specimen for the presence of crystals in the examination, you can always refrigerate it for preservation
you should not try to refrigerate it because it can cause insignificant debris or artifact
66
Very viscous fluid may need to be pretreated by adding a pinch of?
hyaluronidase to 0.5 mL of fluid or one drop of 0.05% hyaluronidase in phosphate buffer per milliliter of fluid
67
hyaluronidase penetration to the viscous fluid should be incubated at what temp? At what time?
incubate at 37⁰C for 5 minutes
68
T or F
Manual counts using the Neubauer counting chamber is the same manner as cerebrospinal fluid counts
T
69
Basaha lang ah
Clear fluids can usually be counted undiluted, but dilutions are necessary when fluids are turbid or bloody
70
T or F
traditional WBC diluting fluid cannot be used
T
71
(2) Differential counts for SF should be performed on
cytocentrifuged preparations
thinly smeared slides
72
ALWAYS DO THIS STEP PRIOR TO SLIDE PREPARATION
Fluid should be incubated with hyaluronidase prior to slide preparation.
(Specially for very viscous fluid)
73
(2) Primary cells found on Diff. count of SF
Mononuclear cells (monocytes, macrophages) and synovial tissue cells
74
Normal range of your WBCs of the differential count
<25 percent
75
This is described through your neutrophil containing cell. It looks like a macrophage in a way that neutrophil characteristic with ingested round body. It is big and its lobes are on the side, its cytoplasm covers the whole. Just look for the round body ingestion.
LE cells – Lupus erythematosus cells
76
These are vacuolated macrophages containing neutrophil.
Reiter Cells
77
These cells are considered normal when you see during differentiation counts. Very similar to your Macrophages but they are multinucleated. Sizes are big. It can be mistaken as neutrophil but these doesn’t have segments.
Synovial Lining Cell
78
These are neutrophil-like characteristic with dark cytoplasmic granules. These granules contain immune complexes specifically immunoglobulins and antibodies inside.
Medical condition: Rheumatoid arthritis and Immunologic disorders
Ragocyte, also known as RA cells
79
(4) Causes of Crystal formation:
1. Metabolic disorders
2. Decreased renal excretion that produce elevated blood levels of crystallizing chemicals
3. Degeneration of cartilage and bone
4. Injection of medications, such as corticosteroids into a joint
80
2 Primary crystals seen in synovial fluid
Monosodium urate (uric acid) (MSU) - gout, very common condition
Calcium pyrophosphate (CPPD) - seen with pseudogout
81
(4) Other crystals found in SF
1. Apatite (basic calcium phosphate)
2. Cholesterol crystals
3. Corticosteroids
4. Calcium oxalate crystals
82
Other crystals found in SF
associated with calcified cartilage degeneration
Apatite (basic calcium phosphate)
83
Other crystals found in SF
associated with chronic inflammation
Cholesterol crystals
84
Other crystals found in SF
following injections
Corticosteroids
85
Other crystals found in SF
in renal dialysis patients
86
pabalik balik nga note basta crystals in SF
When talking crystals, do not use powdered anticoagulants during specimen collection since it can contribute to False positive presence of crystals.
87
(4) In microscopic examination, we cannot deny that we can see some artifacts. In synovial fluid, artifacts include:
1. Talcum powder- use this to smoothen the pain
2. Starch from gloves- Due to specimen handling or collection
3. Precipitated anticoagulants
4. Dust
5. Scratches on slides and coverslips
88
T or F
Crystal examination should be performed soon after fluid collection to ensure that crystals are not affected by changes in temperature and pH
T
89
T or F
Both MSU and CPPD crystals are reported as being located extracellularly and intracellularly (within Synoviocytes)
F
Both MSU and CPPD crystals are reported as being located extracellularly and intracellularly (within NEUTROPHILS)
90
T or F
Fluid must be examined prior to WBC disintegration
T
91
Identify what type of Crystal
Appear as needle-shaped crystals
* crystals lyse phagosome membranes and therefore do not appear in vacuoles
* Clinical Significane: Gout
MSU CRYSTALS
92
Identify what type of Crystal
* may be extracellular or located within the cytoplasm of neutrophils
* are frequently seen sticking through the cytoplasm of the cell
MSU CRYSTALS
93
Detection of MSU CRYSTALS
Drop of synovial fluid and then Microscope examination
94
Identify what type of Crystal
* appear rhombic-shaped or square but may appear as short rods
* usually located within vacuoles of the neutrophils (intracellularly)
CPPD CRYSTALS
95
To avoid misidentification of CPPD crystals, the classic rhomboid shape should be observed and confirmed with?
compensated polarized microscopy
96
Best microscope used for identification of CPPD crystals
Polarized Microscope
97
presence of the crystals has been determined using?
direct polarization
98
positive identification of crystals is made using
compensated polarized light
99
A control slide for the polarization properties of MSU can be prepared using?
betamethasone acetate corticosteroid
100
T or F
MSU and CPPD crystals have the ability to polarize light
T
101
T or F
CPPD is more highly birefringent and appears brighter against the dark background
F
It should be MSU
102
when Compensated polarized light is used, a _____ compensator is placed in the microscope between the crystal and the analyzer
red compensator
103
Red compensator principle
separates the light ray into slow-moving and fast-moving vibrations and produces a red background
104
3 Crystals that exhibit birefringence
1. Cholesterol - negative
2. Oxalate - negative
3. Corticosteroids crystals- negative and positive (cuz sa meds mostly)
105
A crystal that does not exhibit birefringence
Apatite crystals
(Medical condition: Osteoarthritis)
106
T or F
Chemistry test values are approximately the same as serum values
T
(but note that Chemistry tests are just back-up tests)
107
The most frequently requested chemisty test is?
as markedly decreased values are indicative of inflammatory (group 2) or septic (group 3) disorders
glucose determination
108
Simultaneous blood and synovial fluid samples should be obtained, preferably after the patient has fasted for __ hours to allow equilibration between the two fluids
8 hours
109
Normal synovial fluid glucose should not be more than? ____ (mg/dL) lower than the blood value
specimens should be analyzed within ___ hour or preserved with????
10 mg/dL
1 hour
sodium fluoride (gray top tube)
110
(2) Other chemistry tests that may be requested are the:
1. Total protein
2. Uric acid determinations
111
Normal synovial fluid contains ____ (g/dL) of protein
3 g/dL of protein (approximately one third of the serum value)
112
Increased levels of Protein in SF Indicates?
inflammatory and hemorrhagic disorders
113
-elevation of serum uric acid
GOUT
114
demonstration of an elevated synovial fluid _________ may be used to confirm the diagnosis when the presence of crystals cannot be demonstrated in the fluid
uric acid level
115
Measurement of serum uric acid is often performed as a _____ evaluation of suspected cases of gout
first
116
(3) MICROBIOLOGIC TESTS
* Gram stains and cultures
* Bacterial infections are most frequently seen; however, fungal, tubercular, and viral infections also can occur
* Routine bacterial cultures should include an enrichment medium, such as chocolate agar
117
MICROBIOLOGIC TESTS
4 Organisms that infect synovial fluid
1. Staphylococcus
2. Streptococcus
3. Haemophilus species
4. N. gonorrhoeae
(Note: Anything any fluid that are greenish-blue is more or less related to Pseudomonas)
118
uses Non-anticoagulant tube or red top tube. This is to assess autoimmune diseases.
SEROLOGIC TESTS
119
The 2 autoimmune diseases
1. Rheumatoid arthritis
2. Lupus erythematosus
120
_________is a frequent complication of Lyme disease = demonstration of antibodies to the causative agent ______________in the patient’s serum can confirm the cause of the arthritis
Arthritis
Borrelia burgdorferi
121
The extent of inflammation can be determined through measurement of the concentration of?
acute phase reactants
- For detection and early signs of inflammation
122
2 acute phase reactants
1. Fibrinogen
2. C-reactive protein
