MANUAL DIFFERENTIAL.doc

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Laboratory 10Manual Differential

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Laboratory #10: MANUAL DIFFERENTIAL

Skills= 20

Obj!ti"s:

1. To determine the relative number of each type of white cell present in the blood

by performing differential cell counts on normal and abnormal blood smears.

2. Calculate absolute white blood cell counts when given the total WBC count and

the relative (% number of each type of WBC.

!. To determine within one "ualitative unit the red cell# white cell# and platelet

morphology of each of the blood smears.

$. To determine within !&% accuracy an estimate of the white cell counts and the

platelet counts of each of the blood smears.

'. To calculate the corrected automated WBC count for nucleated red blood cells.

ri$!i%l:

stained smear is e)amined in order to determine the percentage of each type of

leu*ocyte present and assess the erythrocyte and platelet morphology. +ncreases in

any of the normal leu*ocyte types or the presence of immature leu*ocytes or

erythrocytes in peripheral blood are important diagnostically in a wide variety of

inflammatory disorders and leu*emia (see ,BC -orphology ab# CBC/01 Correlation

ab# and the WBC 2 0T 3stimates/+nclusions abs for e)amples. 3rythrocyte

abnormalities are clinically important in various anemias. 0latelet si4e irregularities

are suggestive of particular thrombocyte disorders.

The WBC count is verified by estimating the count in the e)amination area of the

blood smear. well made blood smear with proper distribution of WBCs

throughout e)amination area and feather edge is essential for WBC estimation (see

Blood 1mear 0reparation ab.

The platelet count is verified by estimating the number platelets on the blood

smear as well. The tube must be chec*ed for clumps. +f visible clots are observed#

the specimen is 56CC30TB3. 37T induced platelet satellitism falsely

decreases platelet counts. 6a Citrate specimen can be used for the platelet

count in this circumstance. ,efer to the WBC 2 0T 3stimates/+nclusions ab for

corrective action and the calculation.

S%!i&$:

0eripheral blood smear made from 37T8anticoagulated blood. mears should be

made within $ hours of blood collection from 37T specimens stored at room

temperature to avoid distortion of cell morphology. 5nstained smears can be stored


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for indefinite periods in a dry environment# but stained smears gradually fade

unless coverslipped.

Ra'$ts( s)%%lis( a$* +)i%&$t:

1. 0repared slides

2. -anual cell counter designed for differential counts

!. -icroscope#

$. +mmersion oil

'. ens paper

,)ality -o$trol:

Training and e)perience in e)amining immature and abnormal cell morphology are

essential. +n the clinical environment# a set of reference slides with established

parameters should be established to assess the competence of an individual to

perform differential and morphological identification of leu*ocytes and

erythrocytes. 0articipation in a "uality assurance program continues to document

the e)pertise of the hematologist in microscopy. 9uestionable or abnormal smears

should be referred to a supervisor or pathologist for verification.

ro!*)r:

1. :ocus the microscope on the 1&; ob


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appropriate area# count the number of platelets on .successive fields# and then

apply the formula found in the WBC 2 0T 3stimates/+nclusions ab. This

number should be within !&% of the actual platelet count. +f it is not within

this range# the estimation should be repeated. +f platelets are clumped# include

an appropriate comment from the 0latelet table in the WBC 2 0T

3stimates/+nclusions abto the report form.

'. To perform the differential# choose the portion of the smear where '&% of the

,BCs are slightly overlapping and '&% are individually spaced. The ,BCs should

have a central pallor. @ou should use the 1&& ; ob


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1&. ll abnormal morphology (,BC# WBC# or 0T is reported in the -orphology

section of the report form for each patient/slide. +f you do not observe

abnormal morphology# write InormalJ in this section.

MANUAL DIFFERENTIAL SUMMAR4

1. 1&) scan

2. '&; WBC estimate

!. 1&&; 0T estimate

$. 1&&; 0T morphology

'. 1&&; WBC differential

?. 1&&; WBC morphology

A. 1&&; ,BC morphology

R5r$! "al)svary depending on age. :or this e)ercise# the following values will be

used (inside cover of te)tD

-ll Ty% irt/ 6 &o 7yr 17 yrs a$*

)%

Total WBC )

1&!/K

>8!& ?81 $.'81!.' $.'811.&

6eutrophils % '&8?& 2'8!' !'8$' $&8&

ymphocyte % 2'8!' ''8?' '&8?' 2'8!'

-onocyte % 281& 281& 281& 281&

3osinophil % &8' &8' &8' &8'Basophil % &81 &81 &81 &81

ro!*)ral Nots

1. well8made and well8stained smear is essential to the accuracy of the

differential count. The *nowledge and ability of the cell morphologist is critical

to high8"uality results.

2. When in the clinical world# before reporting significant abnormalities such as

blasts# malaria or other significant finding on a patientLs differential# as* a moree)perienced tech to review the smear for confirmation. +n clinical settings

where a pathologist or hematologist is present# the smear is set aside for

0athologist ,eview. R"i8 t/ 30- 9 #LT Esti&ats2I$!l)sio$s Lab a$*

R0- Mor%/olo'y Lab 5or A-- o%rati$' %ro!*)r 5or r%orti$' %ri%/ral

s&ar 5i$*i$'s


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; Absol)t -o)$ts

+t is also helpful to *now the actual number of each white cell type per K of

blood. This is referred to as the absol)t !o)$t +f not reported by the

instrument# absolute counts can be calculated easily using the automated WBC

count and calculated as followsD

Absol)t # o5 !lls.

!. eton -edical Center Pematology 0rocedure -anual

$. -c*en4ie# hirlyn# Clinical aboratory Pematology#2nd edition# pp.AA28AA!.


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MLAB 1415: Hematology Laboratory #

Manual Different

-anual 7ifferential ,eport :orm

*illsD 2& pts.

tudent 6ameDRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRR 7ateDRRRRRRRRRRRRRRRRRRRRRRRRRRRRR

ati$t Na&a$* ID or

Sli* N)&br

3- Esti&at LT Esti&at N)tro%/il > Ly&%/o!yt>

Mo$o!yt>

Eosi$o%/il>

aso%/il>

Ot/rs>

# $R-

3

0roD typD

-yeloD

-etaD ymph

BandD Mor%/olo'y

egD Total:

Total:

0roD typD

-yeloD

-etaD ymph

BandD Mor%/olo'y

egD Total:

Total:


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MLAB 1415: Hematology Laboratory#10

Manual Differential

STUD4 ,UESTIONS

(you may need to reference other labs to answer these "uestions

;7 %oi$ts

6ame RRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRR7ate RRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRR

' pt 1. ist the normal adult ranges for each cell type.

Cell Type ,elative ,eference ,ange in %

egmented 6eutrophil

ymphocyte

-onocyte

3osinophil

Basophil

2 pts 2. 7escribe the procedure for estimating the white count.

2 pts !. 7escribe the procedure for estimating the platelet count.

2pts. '. Calculate the neutrophil absolute count for the following differentialD

Total WBC H 1$.2 ) 1&!/K

A&% segs

!% band

2&% lymphs

!% monos

$% eos

2 pts. ?. When performing a manual differential# you see 12 6,BCs. Pow do you

report themS

!pts. A. Calculate the corrected WBC given the following results.

WBC H !2.& ) 1&!/K

6,BC/1&& WBC H 2&


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Manual Differential

2 pt . 7escribe the proper area where you should begin your WBC differential.

2 pt >. 7raw a diagram of a blood smear and illustrate the path you would ta*e in

performing a manual differential.

2 pt 1&. 5pon scanning a stained peripheral smear# you notice clumped platelets. There

appear to be a very high number of platelets because on a!/ 5il*you observe at least ?&

platelets in multiple clumps. What would you doS

2pt 11. Fiven the following WBC count and differential# calculate the bsolute

lymphocyte count.

utomated WBC countD A. ; 1&>/

egsD $?%

ymphsD 2$%

-onosD 12%

3osD 1'%

BasosD !%

2pt 12. patientLs automated platelet count is 1!2 ; 1&!/G. 5pon slide review# the

patientLs sample has rosettes of platelets surrounding the segmented neutrophils. 6a

Citrate tube is collected on the patient. The technician gets a 1>A ; 1&!/G platelet count

on the 6a citrate tube. What is the correct platelet count to report to the physicianS


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Manual Differential

pts

1!. +n the blan* ne)t to the term# write the number of the corresponding description(found below.

RRRR. to)ic granulation

RRRRB. 7hle bodies

RRRRC. hypersegmentation

RRRR7. auer rod

RRRR3. smudge cell

RRRR:. 0elger8Puet anomaly

RRRRF. platelet satellitism

RRRRP. 0y*notic neutrophil

1. ight blue oval inclusions composed of ,ough 3,

2. ,eddish8blue staining inclusions found in myeloblasts

!. Cell with ruptured cytoplasm

$. egmented neutrophil with 2 lobes

'. egmented neutrophil with ? lobes

?. egmented neutrophil with degenerating nucleus

A. 6eutrophil with pieces of mega*aryocyte cytoplasm encircling it

. bnormally large primary granules of neutrophils

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