CLINICAL CHEMISTRY COMPREHENSIVE

REVIEW NOTES

IMPORTANT TOPICS:
● QUALITY CONTROL
● CONVERSION FACTORS
● LAB SAFETY (TYPES OF FIRE, FIRE EXTINGUISHER, SAFETY

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DIAMOND, ETC.)
● ANALYTICAL TECHNIQUES (SPECTRO, ETC.)
● SPECIMEN COLLECTION & CONSIDERATION
● CARBOHYDRATES
● PROTEINS & LIPOPROTEINS
● LIPIDS
● LIVER FUNCTION TESTS
● KIDNEY FUNCTION TESTS ● Diagnostic sensitivity - indicates the ability of the test to generate
● ENZYMES more _____________ & few false negative results.
● ELECTROLYTES & TRACE ELEMENTS ● Diagnostic specificity - reflects the ability of the method to detect

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● HORMONES _____________ with very few false positive
● TOXICOLOGY
● ALCOHOL STAGES OF IMPAIRMENT

_______________________________________________________
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INTRODUCTION & QUALITY CONTROL

DEFINITION OF TERMS
● QUALITY CONTROL - A system to monitor the analytical process
and to detect errors that can affect accuracy and precision
● Accuracy – closeness of the measured value to the _____________
● Precision – ability of an analytical method to give _______________
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on the same sample that agree with one another.
● Reliability – ability of an analytical method to maintain accuracy and
precision over an extended period of time
● Sensitivity – ability of an analytical method to measure the
_____________ concentration of the analyte of interest
● Specificity – ability of an analytical method to measure
_____________ of interest
2023 MEDICAL TECHNOLOGY BOARD REVIEW - CLINICAL CHEMISTRY LJUCO2023 1
KINDS OF QUALITY CONTROL
1. Intralab Quality Control (Internal QC) 68-95-99 rule
- Involves the analyses of control samples together with the • Summarizes the relationship between area under a gaussian distribution
_____________ and the SD.
- Important for the daily monitoring of accuracy and precision of • The total area under the gaussian curve is 1.0 or 100%.
analytical methods • Gaussian distributed data – 68% of the data fall between +/-1SD (mean +/-
- Detects both random and systematic errors in a __________ basis 1SD)
2. Interlab Quality Control (External QC) • Gaussian distributed data – 95% of the data fall between +/-2SD (mean +/-
- Involves __________________________ that periodically provide 12D)

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samples of unknown concentrations to participating clinical • Gaussian distributed data – 99% of the data fall between +/-3SD (mean +/-
laboratories 3SD)
- Important for maintaining long-term accuracy of the analytical
method

SOLUTIONS FOR CHECKING ACCURACY AND PRECISION

1. Standard
- A material of known composition available in highly purified form
- Universal color: _____________

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2. Control
- Material with physical and chemical properties closely resembling the
test specimen and containing pre analyzed concentrations of the
substances being measured
- Universal color: _____________
- Either human-based control or bovine-based control
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QUALITY CONTROL CHART - Used to compare results obtained on a high and low control serum
● Used to observe values of control materials over time to determine from different laboratories
reliability of the analytical method
● It is utilized to observe and detect analytic errors such as inaccuracy 3. Shewhart Levey-Jennings Chart
and imprecision - _____________ QC chart in the clinical lab
- Allows the technicians to apply multiple rules without the aid of a
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1. Gaussian Curve (Bell-shaped curve) computer
- It occurs when the data set can be accurately described by - Easily identifies random and systematic errors
the SD and the mean
- Obtained by plotting the values from multiple analyses of a ERRORS WHICH CAN BE OBSERVED IN LJ CHART
sample > Trend
- It occurs when data elements are centered around the mean - 6 consecutive control values continue to increase or decrease
with most elements close to the mean - Main cause : _____________

2023 MEDICAL TECHNOLOGY BOARD REVIEW - CLINICAL CHEMISTRY LJUCO2023 2

> Outlier ADDITIONAL EXAMPLE: 6x
- control values that are far from the main set of values 6 = 6 consecutive values
- caused by random or systematic errors x = one side of the mean
> Shift “6 consecutive values fall
- abrupt change in the mean on one side of the mean”
- Main cause: __________________________

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QUALITY ASSURANCE
● Previously termed as Quality _____________
● Comprehensive set of policies, procedures, and practices followed to
ensure the laboratory’s results are RELIABLE
● _____________ is a part of QA
● Includes all the processes under pre-analytical, analytical and post
analytical phase

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4. Westgard Control Rules
Meaning:
Ex: 1 2s
1 = 1 value
2s = position
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“1 value exceed +/- 2SD”

INTERPRETATION:
● 1 2s = WARNING!
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● The rest= REJECT ● Lean Six Sigma focuses on eliminating _____________.
● In healthcare, a defect can be the difference between life and death.
1 2s ● Use Lean Six Sigma to improve patient safety by eliminating
1 3s life-threatening errors.
R 4s

The rest = SYSTEMATIC

2023 MEDICAL TECHNOLOGY BOARD REVIEW - CLINICAL CHEMISTRY LJUCO2023 3
 ANALYTICAL METHODS

LIGHT ENERGY, WAVELENGTH AND RADIANT ENERGY SPECTRUM

● Wavelength
○ _____________ nm - Visible spectrum
○ _____________ nm - Ultraviolet region (UV)
○ _____________ nm - Infrared region (IR)
○ The relationship between wavelength and energy (E) is
described by Planck’s Formula: E = hv

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● Energy - is transmitted via electromagnetic waves that are
characterized by their frequency and wavelength
● Frequency - is the number of vibrations of wave motion per second
○ The lower the wave frequency, the longer the wavelength
○ The wavelength is _____________ related to frequency and
energy; the shorter the wavelength, the higher the frequency
and energy and vice versa.

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● Lean Six Sigma uses ____________________________________
(DMAIC) – a five-step approach to process improvement.
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SPECTROMETRY/SPECTROPHOTOMETER
● It involves measurement of the light transmitted by a solution to
determine the concentration of the light-absorbing substances in the
solution.
○ SINGLE BEAM
○ DOUBLE BEAM
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 ○ Single beam spectrophotometer 1. Light source
■ It is the _____________ type of absorption 2. Entrance slit
spectrometer. 3. Monochromator
■ It is designed to make one measurement at a time at 4. Exit slit
one specified wavelength. 5. Cuvet
■ The absorption maximum of the analyte must be 6. Photodetector
known in advance when a single-beam instrument is 7. Meter or read-out device
used
1. Light/Radiant source

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○ Double beam spectrophotometer ● It provides polychromatic light and must generate sufficient radiant
■ Is an instrument that splits the monochromatic light energy or power to measure the analyte of interest.
into two components - one beam passes through the ● An intense beam of light is directed through the monochromator and
sample, and the other through a reference solution the sample
or blank. ● To give accurate absorbance measurements throughout its
■ The additional beam corrects for variation in light absorbance range, its response to change in light intensity must be
source intensity. linear
■ In this type of spectrophotometer, the absorbance of ● 2 Types:
the sample can be recorded directly as the electrical a. _____________ - emits radiation that changes in

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output of the sample beam. intensity; widely used in the laboratory.
■ 2 TYPES: Example: tungsten, deuterium and xenon lamps
● DOUBLE-BEAM IN SPACE - w/ ___ ○ Tungsten light bulb is the commonly used light source in the
photodetectors, visible and near infrared region
● DOUBLE BEAM IN TIME - w/ __ ○ Deuterium lamp is routinely used to provide UV radiation in
photodetector analytic spectrometers.
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PARTS OF THE SPECTROPHOTOMETER radiation, which covers both the UV and the visible range.

b. _____________ -emits limited radiation and wavelength.

Examples: mercury and sodium vapor lamps in spectrophotometers
(UV and visible regions), and the hollow cathode lamp
(_____________ - Atomic Absorption Spectro)
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○ Line sources that emit a few discrete lines find wide use in
atomic absorption, molecular, and fluorescent spectroscopy.
○ Light Amplification by Stimulated Emission of Radiation
(LASER) is also used as light sources for spectrophotometry

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 - A narrow light focused on a prism is refracted as it enters the
FACTORS FOR CHOOSING A LIGHT SOURCE more dense glass.
1. Range b. Diffraction gratings
2. Spectral distribution within the range - These are the __________________________; better
3. Source of radiant production resolution than prism.
4. Stability of the radiant energy - These are made by cutting grooves (parallel grooves) or slits
5. Temperature into an aluminized surface of a flat piece of crown -
wavelengths are bent as they pass a sharp corner
c. Filters

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Alternative to tungsten light bulb: - These are __________________________, not precise but
1. Mercury arc (visible and UV) useful.
2. Deuterium lamp (165nm) - UV - These are made by placing semi-transparent silver films on
3. Hydrogen lamp - UV both sides of a dielectric such, as fluoride
4. Xenon lamp - UV - Filters produce monochromatic light based on the principle
5. Merst glower - IR of constructive interference of waves - light waves enter one
6. Globar (silicone carbide) - IR side of the filter and are reflected at the second surface.
- Filters usually pass a wide band of radiant energy and have
a low transmittānce of the selected wavelength.

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d. Holographic grating
2. Entrance slit
● It minimizes unwanted or _____________ and prevents the entrance 4. _____________
of scattered light into the monochromator system. ● It controls the width of light beam (bandpass)- allows only a narrow
● Stray light refers to any wavelengths outside the band transmitted by fraction of the spectrum to reach the sample cuvette.
the monochromator; it does not originate from the polychromatic light ● Bandpass is the total range of wavelengths transmitted.
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source; it causes absorbance error. ● Accurate absorbance measurement requires a bandpass less than
● Stray light limits the maximum absorbance that a spectrophotometer 1/5 the natural bandpass of the spectrophotometer
can achieve.
● Straylight is the most common cause of loss of linearity at 5. Cuvet
high-analyte concentration. ● It is also called __________________________
● It holds the solution/sample whose concentration is to be measured.
3. Monochromator ● KINDS OF CUVETS
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● It isolates specific __________________________ a. _____________ - most commonly used (can be used in
● KINDS OF MONOCHROMATORS: 350-2000nm)
a. Prisms b. Quartz/Plastic - used for measurement of solution/sample
- These are _____________ pieces of glass, quartz or sodium requiring visible and ultraviolet spectra
chloride. c. Borosilicate glass
- These can be rotated, allowing only the desired wavelength d. Soft glass
to pass through an exit slit

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GOOD TO KNOW!:
● Cuvets with scratches on their optical surface scatter light and 7. Meter or read-out device
should be discarded. ● It displays output of the detection system.
● Silica cuvettes transmit light effectively at wavelengths ≥220nm ● Example: galvanometer/ammeter/ light-emitting diode (LED) display
● Alkaline solutions should not be left standing in cuvets for prolonged
periods because alkali slowly dissolves glass producing etching BLANKING TECHNIQUE
● The pathlength of cuvets is 1 cm (10mm), although much smaller ● Blanking technique means the blank contains serum but without the
path lengths are used in automated systems reagent to complete the assay.

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● To increase sensitivity, some cuvets are designed to have path ● Reagent blank corrects absorbance caused by the color of the
lengths of l0 cm, increasing the absorbance for a given solution by a _____________ - the absorbance of reagents is automatically
factor of 10. subtracted from each of unknown reading
● Sample blank measures absorbance of the sample and reagent in
6. Photodetector the absence of the end product, and corrects the measurement for
● It detects and converts transmitted light into _____________ energy. optical interference (like hemoglobin) absorbing the wavelength of
● It detects the amount of light that passes through the sample in the measurement.
cuvet ● A blanking process may not be effective in some cases of turbidity,
● KINDS OF PHOTODETECTORS and ultracentrifugation may be necessary to clear the serum or

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a. _____________/ Photocell/ Photovoltaic cell plasma of chylomicrons.
- it is the _____________ detector; least expensive; ● Lipids interfere mainly by increasing _____________ (turbidity)
temperature-sensitive ● To correct for artifactual absorbance readings, blanking procedures
- It is composed oF Selenium on a plate of iron covered with or dua-wavelength methods may be used
transparent layer of silver.
b. Phototube BEER’S LAW
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- It contains cathode and anode enclosed in a glass case. ● It states that the concentration of the unknown substance is:
- It requires an external voltage tor operation ○ directly proportional to the _____________: (absorbance or
c. __________________________PMT) optical density) and;
- It is the _____________ detector measures visible and UV ○ inversely proportional to the amount of _____________ (%
regions. Transmittance)
- It has excellent sensitivity and has a rapid response -detects ● It mathematically establishes the relationship between concentration
very low levels ot light. and absorbance.
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- It should never be exposed to room light because it will burn ● ABSORBANCE
out. ○ It is the amount of light absorbed
d. Photodiode ○ Is proportional to the inverse log of transmittance
- It is not as sensitive as PMT but with excellent linearity. ○ It is mathematically derived from %T
- It measures light at a multitude of wavelengths- detects less ○ A = 2 - log(%T)
amount of light.
- It is most useful as a __________________________

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 ● PERCENT TRANSMITTANCE ● The amount of light absorbed at a particular wavelength depends on
○ Is the ratio of the radiant energy transmitted (T) divided by molecular and ion types present and may vary with concentration, ph
the radiant energy on the sample (I) or temperature.
● The light path must be kept constant to have absorbance
proportional to concentration.
● Deviations from Beer’s law may be caused by changes in instrument
functions or chemical reactions.
● Instrument deviation is commonly a result of the finite band pass of
the filter or monochromator.

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● Turbidity readings on a spectrophotometer are greater in the blue
region than in the red region of the spectrum.
● An absorbance check is performed using glass filters or solutions
that have known absorbance values for a specific wavelength - the
operator simply measures the absorbance of each solution at à
specified wavelength and compares the results with the stated
values.
● The linearity of a spectrophotometer can be determined using optical
● In actual practice, the light transmitted by a blank is substituted for l0 titers or solutions that have known absorbance values for a given

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wavelength
%T = sample beam signal x 100
/ Blank beam signal FLAME EMISSION PHOTOMETRY
● It measures the light _________ by a single atom burned in a flame
BEER’S LAW SAMPLE CALCULATIONS: ● Principle: _____________ from lower to higher energy state.
● Light source: _____________ [also serves as the cuvette]
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● Internal standard: _____________ -corrects variations in flame and
atomizer characteristics
● It is used for the measurement of excited ions (_____________)
● Flickering light indicates changes in the fuel reading of the
instrument
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ATOMIC ABSORPTION SPECTROPHOTOMETRY
● It measures the light _____________ by atoms dissociated by heat.
● Principle: Element is not excited by merely dissociated from its
chemical bond and place in an unionized, unexcited, ground state.
● Light source: __________________________
● Interferences: chemical, matrix (differences in viscosity) and
ionization
GOOD TO KNOW
2023 MEDICAL TECHNOLOGY BOARD REVIEW - CLINICAL CHEMISTRY LJUCO2023 8
 ● It is used for measurement of unexcited trace metals ● During electrophoresis, proteins are negatively charged (anions) and
(_____________) they move towards the anode.
● It is more sensitive than FEP; it is accurate, precise and very ● Components: Electrical power, support medium, buffer, sample and
specific. detecting system.
● Internal standard is _____ needed - changes in aspiration have ● Factors affecting migration:
little effect on the number of ground state atoms. ○ _____________ of the molecule
● An atomizer (nebulizer/graphite furnace) is used to convert ions to ○ _____________ of molecule
atoms; ○ Electric field strength
● A chopper is used to modulate the light source. ○ Nature of supporting medium

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● Lanthanum or strontium chloride is added to samples to form ○ Temperature of operation
stable complexes, with phosphate ● Molecules migrate towards the _____________ charge
● The gel consists of a permeable matrix, a bit like a sieve, through
TURBIDIMETRY which molecules can travel when an electric current is passed across
● Principle : It determines the amount of light _____________ it.
(reduction of light ) by a particular matter in a turbid solution. ● Supporting medium:
● Depends on _____________ and particle size ○ Paper
● Uses: Protein measurements (CSF & urine); to detect bacterial ○ Cellulose acetate
growth in broth cultures; antimicrobial test (broth method); to detect ■ Separates by molecular size

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clot formation ■ to give sharper bands
■ more easily rendered transparent
NEPHELOMETRY ■ low solvent capacity
● Principle : It determines the amount of scattered light by a ■ enhancing the resolution
particulate matter suspended in a turbid solution. ○ Gels
● Depends on _____________ and particle size ■ most widespread use
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● Uses: measuring the amount of Ag-Ab complexes (proteins) ■ Agarose gel - separates by electrical charge; does
not bind protein
FLUOROMETRY / MOLECULAR LUMINESCENCE ■ Polyacrylamide gel- separates on the basis of
SPECTROPHOTOMETRY charge and molecular size; separates protein in 20
● PRINCIPLE: It determines the amount of light emitted by a molecule fractions and used to study isoenzymes
after excitation by electromagnetic radiation. ● Stains for visualization of fractions (bands)
● Light source: _____________ ○ Amido Black
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● Light detector:PMT or Phototube ○ Ponceau S
● Use:Porphyrins, Mg, Ca, Catecholamines ○ Oil Red O
● Interferences: _____________ - process that reduces the ○ Sudan Black
fluorescence intensity of a given substance (may be due to pH and ○ Fat Red 7B
temp changes, chemical contaminants, UV light changes) ○ Coomasie Blue
ELECTROPHORESIS ○ Gold/Silver stain - Very sensitive even to nanogram
● It is the migration of _____________ particles in an electric field. quantities of proteins

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Note: DENSITOMETRY
● It measure the absorbance of the _____________ - concentration of Stationary Mobile Basis of
Technique
the dye and protein fractions; It scans and quantitates electrophoretic phase phase separation
pattern

● Capillary Electrophoresis Paper solid polarity of

chromatography
liquid
(cellulose) molecules

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Thin layer
solid (silica or polarity of
chromatography liquid
(TLC) alumina) molecules

Liquid column solid (silica or polarity of

chromatography
liquid
alumina) molecules

solid
Size exclusion
chromatography
(microporous liquid size of molecules
beads of silica)

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CHROMATOGRAPHY
● It involves separation of soluble components in a solution by specific solid (cationic
differences in physical and chemical characteristics of the different Ion-exchange ionic charge of
chromatography
or anionic liquid
the molecules
constituents. resin)
● 2 FORMS: PLANAR & COLUMN
● Note: solid (agarose
binding affinity
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○ __________________________- solvent moving through
or porous
of the analyte
glass beads on
the column molecule to the
Affinity to which are
○ __________________________ - -substance that stays chromatography
liquid molecule
immobilized
immobilized on
fixed inside the column molecules like
the stationary
enzymes and
phase
antibodies)

gas (inert gas

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Gas liquid or solid
chromatography
like argon or
support
helium)

GC-MS (GAS CHROMATOGRAPHY-MASS SPECTROSCOPY)

● __________________________ for Drug Testing

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 ● Mass Spectroscopy - based on the fragmentation and ionization of > COULOMETRY
molecules using a suitable source of energy. Before a compound can ● The measurement of the amount of electricity (in coulombs) at a
be detected and quantified by MS, it must be separated by GC. fixed potential.
- Use: _____________ (CSF, serum, sweat)
CHEMILUMINESCENCE
● Principle: The chemical reaction yields an electronically excited > AMPEROMETRY
compound that emits light as it return to its ground state or that ● The measurement of the current flow produced by oxidation reaction.
transfers its energy to another compound which then produces - Use: ___, _______ , chloride, peroxidase determination.
emission.

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● Use: Immunoassays _____________________________________________________________
- Photodetector: PMT
- No monochromators LAB EQUIPMENTS & REAGENT
PREPARATION
ELECTROCHEMISTRY TECHNIQUES
● Involves the measurement of current or voltage generated by the
GLASSWARES PLASTICWARES
activity of a specific ion
- Potentiometry - Kimax/ Pyrex (Borosilicate) - Polystyrene
- Coulometry - Corex (Aluminosilicate) - Polyethylene

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- Amperometry - High silica - Polypropylene
- Voltammetry - Vycor (Acid and Alkali resistant) - Tygon
- Polarography - Low actinic (Amber colored) - Teflon
- Flint (soda lime glass) - Polycarbonate
> POTENTIOMETRY - Polyvinyl chloride
● It is the measurement of electrical potential due to the activity of free
ions-change in voltage indicates activity of each analyte.
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- Measurement differences in voltage at a constant current. > MEASURING MASS - analytical balance, weighing scale, etc.
- Reference electrode: Calomel and silver-silver electrodes > MEASURING VOLUME - pipettes, graduated cylinder, flasks, beaker, etc
- Use: ____, pCO2, electrolytes

> ION-SELECTIVE ELECTRODE

● It is an electrochemical transducer capable of responding to one
given ion
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● Very sensitive and selective for the ion it measures
● ISE membranes
○ Sodium - _____________
○ Potassium - _____________
○ Ca & Li - Liquid _____________

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PIPETTING TECHNIQUE
● Pipettes - These are glass or plastic equipment used to transfer III-A. GRADUATED OR MEASURING PIPETTE
liquids; they may be reusable or disposable. - Are capable of dispensing several different volumes
- Because the graduation lines located on the pipette may vary, they
should indicate on the top of each pipet.
- _____________
● Has a calibration marks to the tip
● The rate of fall of the liquid is much too fast because of
larger orifice.

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● Has an etched ring on the suction piece; generally a blown
out pipet.
- > MOHR
● Calibrated between two marks; no graduation to the tip
● Self-draining pipette but the tip should not be allowed to
touch the vessel wall while draining
- > MICROPIPETTE (<1ml TC pipette)
● TC pipette calibrated with mercury
● Used when small amount of blood or specimen is needed

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III-B. TRANSFER PIPETTE
I. CALIBRATION MARKS OR DESIGN - Dispensing __________________________
1. TO CONTAIN PIPET - > VOLUMETRIC PIPETTE
- Holds a particular volume but does not dispense the exact volume. ● TD and self-draining pipette designed to dispense one
2. TO _____________ PIPET volume without further subdivisions
.J - > OSTWALD FOLIN PIPETTE
- It delivers the exact amount it holds into a container.
● Used with biological fluids having a viscosity greater than
II. DRAINAGE CHARACTERISTICS water (blood)
1. BLOWOUT PIPETTE - > PASTEUR PIPETTE
- It has a _____________ etched rings on top of the pipette ● No calibration marks, used to transfer biological fluids
- Exact volume is obtained when the last drop is blown out without consideration of specific volume
2. SELF DRAINING PIPETTE - > AUTOMATIC PIPETTE (ul) (MACRO>1ML) (MICRO<1ML)
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- _____________ of etched ring ● By far the most routinely used pipette
- Users allow contents of the pipette to drain by _____________. ● Tips (contaminated) are often disposable
● ADVANTAGE: safety, stability, ease to use, increase
precision, lack of required cleaning

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 CHEMICALS USED FOR REAGENT PREPARATION

1. Analytical Reagent Grade

- For quantitative and qualitative analyses, meets or exceeds
the established specifications of American Chemical Society
2. Ultrapure Reagent
- Put through additional purification steps for use in specific
purposes (chromatography, atomic absorption,
immunoassays, etc.)

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3. Chemically Pure or Pure Grade
- Impurity limitations are not stated and that preparation of
these chemicals are not uniform; not recommended for
use by clinical labs.
4. United States Pharmacopeia (USP) & National Formulary (NF)
CENTRIFUGE
used to manufacture drugs.
● Separates on the basis of _____________
5. Technical or Commercial Grade
1. Angle-Head Centrifuge
- used for manufacturing and never used in clinical labs
● With a fixed 25 -52 angle at which the tubes are held during
centrifugation

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WATER SPECIFICATIONS
● Speed: _____________
2. Horizontal Centrifuge
● Aka: __________________________ purified by distillation; remove almost all organic
● Not moving = _____________ materials.
● Moving = _____________
purified by ion exchange; all ions are removed
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● Speed: _____________
3. Ultracentrifuge purified by reverse osmosis; uses pressure to force
● Generates the highest speeds water through a semipermeable membrane.
● Reference method for __________________________
removing particulate water, microorganisms, and any
pyrogens or endotoxins.
Maintenance:
● Disinfection: _____________ destroy bacteria but may leave behind residual products
● Calibration: _____________ - check RPM using tachometer or
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strobe light
● Vibrations & Timer: _____________ - check for unusual vibrations,
braking mechanisms to ensure a smooth, gradual stop, the timer of
the centrifuge using a stopwatch

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REAGENT WATER CATEGORIES AUTOMATION PRINCIPLES & IMPORTANT TERMS
1. Single channel – able to perform only one test with a dedicated
portion of the instrument
PARAMETERS TYPE I TYPE II TYPE III 2. Multi-channel – able to perform a variety of tests at the same time
with separate dedicated instrument components
Max colony ≤10 1000 Not specified 3. Random access – test can be performed in a variety of sequence
count (CFU/mL) 4. Batch analysis – group of samples are analyzed at the same time
for the same test
5. Sequential analysis – performing a set of tests in a particular order

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Silicate (mg/L 0.05 0.1 1.0
SiO2) one after another on given specimen
6. _____________ – can use other manufacturer’s reagent
Resistivity 10 1.0 0.1 7. _____________ - reagents are purchased only from the
(megaohm) manufacturer of the instrument because of unique container or
format
pH N/A N/A 5.0-8.0
APPROACHES TO AUTOMATION
Type of water Ultrapure Deionized RO water
used
liquid is pumped through a system of continuous tubing

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(EX:Autoanalyzer (AA), Technicon (now Siemens) Chem
Use For minimum Analytic process Glassware washing 1)
interference (ex: (ex: reagent prep
Trace metal, iron, and QC materials) most popular and versatile analyzer; random access
enzyme analysis) capability (EX: Abbott ARCHITECT C8000 and C16000
Beckman Coulter UNICEL DXC 6001 and 6801
Ortho-Clinical VITROS 350 and 5,1 FS Roche COBAS
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_____________________________________________________________ 6000 and 8000 Siemens DIMENSION VISTA 500 and
AUTOMATION 1500)

uses acceleration and deceleration of ROTOR to transfer

● Automation – mechanization of the steps in a
the reagents and sample (EX: : Roche COBAS-BIO, IL
procedure. Manufacturers of clinical chemistry Monarch)
analyzers design their instruments to mimic the
manual techniques in an analytical procedure.
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● ADVANTAGES OF AUTOMATION
○
○
○
○
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 PATIENT PREPARATION, SPECIMEN 3. Fasting
COLLECTION & HANDLING ● Fasting requirement is between 8 to 12 hours.
● Fasting specimen:
COMMON FASTING SPECIMENS ______________________________________
● FBS (FASTING BLOOD GLUCOSE) -_____________ ● Fasting for 48 hours may increase serum bilirubin.
● LIPID PROFILE (TAG, Chole, HDL, LDL, VLDL) - _______________ ● Fasting for 72 hours may result to increase of plasma
● BOTH FBS & Lipid Profile - _____________ triglyceride in males while glucose decreases in healthy
● Total Cholesterol - _____________ women to 45 mg/dL.
● __________________________ is early morning blood

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● High density lipoprotein = _____________
● Low density lipoprotein = _____________ collection, 12 hours after the last ingestion of food.
● Basal state collection includes glucose, lipids, lipoproteins
PRE-COLLECTION VARIABLES and electrolytes.
1. Diurnal variation ● Basic metabolic panel: glucose, BUN, creatinine, sodium,
potassium, chloride, CO2 and calcium

DECREASE - CAPAI INCREASE - PTAG

4. Diet
C- P-
A- T- ● Metabolic products of food can increase in venous blood.
P- A- ● High protein diet can increase plasma levels of

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A- G- _____________
I- ● Atkins diet (high protein-low carbo diet) greatly increased
plasma urea and urine ketones.
2. Exercise ● Glucose, lipids and catecholamines may show variation
● Physical activity can have different effects on analyte because of postabsorptive hormonal effects.
concentrations – volume shifts between the vascular and ● _____________ increases concentration of glucose through
.J
interstitial compartments, volume loss by swearing and the release of catecholamines from the adrenal medulla and
changes in hormone concentrations. brain tissue.
● Transient increased: __________________________ ● Increased in obese persons: _________________________
● Long-term increased (skeletal muscle enzymes):
__________________________ 5. Posture or position
● Increased in hormones such as prolactin and growth ● Preferred position during phlebotomy:
hormone, estrogen and testosterone. ________________________________________________
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● Vigorous hand exercise (fist clenching) increases potassium, ● Recommendation: patient should be seated/supine for at
lactate and phosphate. least _____________ before blood collection to prevent
● Elevated levels of proteins in urine (proteinuria) are hemodilution or hemoconcentration (Young, 2007 cited by
observed. Mc Pherson and Pincus, 2017).
● Changing from supine to sitting and standing position causes
constriction of the blood vessels and reduction of plasma
volume: increased levels of albumin, enzymes and calcium

2023 MEDICAL TECHNOLOGY BOARD REVIEW - CLINICAL CHEMISTRY LJUCO2023 15

 ● Changing from sitting to supine causes shifting of water and 8. Alcohol ingestion
electrolytes into tissue causing hemoconcentration: ● It can cause increased plasma levels of urate, lactate, triglyceride
increased levels of proteins, lipids, BUN, iron and calcium and gamma glutamyl transferase (GGT).
● Changing from standing to supine causes extravascular ● It causes _____________ among patients with chronic alcoholism.
water to transfer to the vascular system and dilutes
non-diffusable plasma constituents: decreased levels of
cholesterol, triglycerides and lipoproteins 9. Stress
● Significant elevation of potassium after 30 minutes of ● Increased: catecholamines, cortisol, ACTH, prolactin, albumin,
standing is due to the release of potassium from muscles. glucose and lactate

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● Prolonged bedrest results to decreased plasma albumin due
to fluid retention. 10. Intake of drugs
● Renin plasma level is higher when standing than supine.
● Drugs bound to proteins are affected by postural changes.

6. _____________
● _____________application of tourniquet is recommended.
● Effects of prolonged tourniquet application:
_____________ (venous stasis) and anaerobiosis

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● Increased levels due to prolonged tourniquet application:
potassium, proteins (albumin), enzymes, lactate, cholesterol,
and ammonia
● The pressure from the tourniquet causes biological analytes
to leak from the tissue cells into the blood.
● Prolonged use of a tourniquet with fist exercises can
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increase the serum potassium level by mmol/L.
● For accurate measurement of lactate, tourniquet should not
be applied, and the patient should not clench his fist at the HEMOLYSIS
time of the blood draw. > POSSIBLE CAUSES:
● Tourniquet application and or muscular activity may 1. __________________________
decrease venous pO2 and pH. 2. pulling a syringe plunger back too fast
3. expelling the blood vigorously into a tube
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7. Tobacco smoking (nicotine) 4. shaking or mixing the tubes vigorously
● It can cause elevated hormone levels such as the 5. performing blood collection before the alcohol has dried at the
__________________________ collection site
● Decreased plasma levels of vitamins B12 is also observed.

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 BLOOD COLLECTION TUBES
ANALYTES AFFECTED BY ANALYTES AFFECTED BY
HEMOLYSIS (PMAAAALICCK) LIGHT ● Tube Additives - placed inside evacuated tubes and may function
as anticoagulant, antiglycolytic,clot activators, anti-complement,
P -hosphate _____________ anti-phagocytosis. Some tubes may contain thixotropic gel and
M- agnesiun _____________ antibiotic removing device (ARD)
A - mmonia Vit. A ● Order of draw must be followed to prevent invalid results due to
A - LT (Alanine Aminotransferase) Vit. B6
A - ST (Aspartate aminotransferase) B-Carotene bacterial contamination, tissue fluid contamination and carry over of
A - ________________ Folate one additive/anticoagulant from one tube to another
L - ________________ Porphyrins ● Specimen must be mixed thru _____________

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I - ron
C - athecolamine ● IMPORTANT TO KNOW:
C - K (creatine kinase)
○ Color of the tube
K - ________________
Also: _____, total protein, Albumin, ○ Contents
Cholesterol, Bilirubin, Insulin, TAG, ○ No. of inversions
ALP ○ Tests performed

SPECIMEN COLLECTION FUNCTION: Prevents clotting by chelating Calcium

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● In collection, ensure: - concentration: __________________________
- anticoagulant of choice for hematology cell counts (CBC), cell
○ __________________________
morphology, HBA1C
○ Complete labeling of the specimen - commonly available in _____________ tubes as a liquid or
○ Patient consent and privacy spray-dried dipotassium EDTA (K2EDTA) or tripotassium
○ To follow Chain of custody (Tests that require COC are the ff: EDTA (K3EDTA)
- K2EDTA in plastic is spray-dried
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HIV, Drug Testing, Nucleic Acid Tests, Networking
- K3EDTA in glass is in liquid form
Tests/Send-out tests
- Excess EDTA (underfilled tubes) can cause red blood cells
hemolysis
CRITERIA FOR SPECIMEN REJECTION - PINK spray-dried EDTA for ABO grouping, Rh typing,
1. Hemolysis/ Lipemia Antibody screening and crossmatching
2. Clot present in an anticoagulated specimen - _____________ for molecular diagnostics
3. Non-fasting specimen when test requires fasting
- FUNCTION: Prevents clotting by chelating Calcium
4. Improper Blood Collection Tube
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- available in _____________ tubes containing 0.105M (_____)
5. Short draw, wrong volume or 0.129M (____) Sodium Citrate
6. Improper transport conditions - Blue-top is used in coagulation studies( ex. Prothrombin Time
7. Discrepancies between requisition and specimen label and Activated Partial Thromboplastin Time) because it preserves
8. Unlabeled or mislabeled specimen the labile clotting factors
9. Contaminated specimen or leaking container - Coagulation studies require correct anticoagulant:blood ratio
thus container should be adequately filled (correct
anticoagulant:blood ratio is ______). An insufficient blood

2023 MEDICAL TECHNOLOGY BOARD REVIEW - CLINICAL CHEMISTRY LJUCO2023 17

 volume leads to falsely __________ clotting time - tubes with _____________ (silica, polyester and acrylic gels are
- also available in BLACK-TOP that is generally used in available) which separates the liquid portion and cells of the blood
__________________________ (ESR) with anticoagulant:blood - During centrifugation, blood is forced into a thixotropic gel
ratio of ______ material located at the base of the tube. The gel undergoes a
temporary change in viscosity during centrifugation and lodges
- available in _____________ as Lithium Heparin (LiHep) or between the packed cells and the top serum layer
Sodium Heparin (NaHep)
- FUNCTION: Prevents clotting by binding to Thrombin - available in spray coated silica clot activator for serum or with
- Concentration: _____________ K2EDTA or sodium heparin for plasma
- Does not affect levels of Calcium - used for _____________, trace metal, and nutritional analyses

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- Preferred anticoagulant for :
_______________________________________ - - - contains K2EDTA for _____________
Determination and other routine chemistry tests
- Used especially when a chemistry test is STAT - Two types:
- Do not use LiHep for Lithium and Folate Determination 1. Yellow top with Acid Citrate Dextrose (ACD) - RBC
- Do not use NaHep for Sodium determination; but it can be used preservative used for cellular studies in blood bank, human
for trace elements, Lead, and Toxicology testings leukocyte antigen (HLA) phenotyping, and DNA and paternity
- _____________ is the injectable form used for anticoagulant testing.
therapy 2. Sterile yellow top with Sodium Polyanethol Sulfonate
(SPS) - SPS is an anticoagulant used for _____________; it
- It is NOT an anticoagulant, but a preservative with binds to Calcium to prevent clotting of blood; it is also an

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_____________ property anti-complement, anti-phagocytosis and prevents the action of
- concentration: _____________ certain antibiotics; may contain ARD.
- Prevents glycolysis of glucose for 72 hours
- available in _____________ tube
- If the gray-top tube is labeled with Sodium fluoride only, then it
will yield a _____________ sample
- If plasma sample is needed an anticoagulant must be present in
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the form of _____________ (common), or Na2EDTA. Both
anticoagulants prevent clotting by binding to Calcium.
- Sodium fluoride destroys enzymes. Therefore, do not use this
when performing enzymatic tests (ENZYME POISON)

- Combines Calcium to form insoluble salt

- Conc: _____________
- It interferes with Na, K and most BUN measurements
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- available in _____________ tubes
- NO anticoagulant is present so blood collected from this tube
clots
- can be used for most _____________, blood bank, and
immunology assays
- yields a _____________ sample after a complete clotting of 60
mins.

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 SERUM VS. PLASMA

CHARACTERISTICS SERUM PLASMA

1. Definition The liquid (cell-free) The liquid (cell-free) part

part of the after of the blood that has
coagulation. been treated with
anticoagulant.

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2. Composition Water, albumin, Depending on what
globulins, anticoagulant is used,
Aminoacids, it has lower Calcium
hormones, enzymes, and Magnesiumin
NPNS,gases, higher EDTA and Citrate
in TGF-beta, and plasma. Other
VEGF,IL-8; contents are the same
Fibrinogen is in serum, except,
_____________. FIBRINOGEN IS
_____________.

3. Volume in vivo Serum is not found in 55% of the total blood volu

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vivo. It can be
obtained by allowing
clot.

“Yoko Bumagsak Self, Ready ka na? Go Lang ng Go” 4. Use of

anticoagulants
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Note: Fibrinogen is a protein, specifically a clotting factor (factor I), that is
essential for proper blood clot formation.

CAPILLARY PUNCTURE
Order of Collection
1. Capillary blood gases
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2. Blood smear
3. EDTA tubes
4. Other anticoagulated tubes
5. Serum tubes

POINT OF CARE TESTING (POCT)

2023 MEDICAL TECHNOLOGY BOARD REVIEW - CLINICAL CHEMISTRY LJUCO2023 19

 ● Point-of-care testing (POCT) is defined as medical testing at or near ● CARBOHYDRATES - sugar
the site of patient care. ● The term carbohydrate originally referred to “hydrates of carbon”.
● The driving notion behind POCT is to bring the test conveniently and ● Composition: _______ (Carbon, Hydrogen, Oxygen)
immediately to the patient. ● Function: function mainly as a source of chemical energy for
● This increases the likelihood that the patient, physician, and care generating ATP needed to drive metabolic reactions.
team will receive the results quicker, which allows for immediate
clinical management decisions to be made.
Major Carbohydrate Groups
● POCT includes: _________________________________________
_______________________________________________________

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Monosaccharide Glucose- the main blood sugar
_______________________________________________________ _____________ (aka: Levulose) - fruits
_______________________________________________________ Galactose- in milk sugar
Deoxyribose- in DNA
ANALYTES THAT REQUIRES CHILLING Ribose- in RNA
● _____________
● _____________ Disaccharide Sucrose- table sugar= glucose + fructose
● Catecholamines Lactose- milk sugar= glucose + galactose
Maltose- glucose + glucose
● Gastrin
● Lactic acid

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● Renin Polysaccharide Glycogen- stored form of carbohydrates
● PTH Starch
● Pyruvate Cellulose

ADDITIONAL NOTES: QUICK FACTS:

● Specimen for electrolyte analysis - __________________________ ● Whole blood glucose is _____ lower than serum/plasma
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● Specimen for HBA1C - __________________________ ● Serum must be separated within __________
● Anticoagulant for Lipoprotein - _____________ ● Fasting: _______
● Anticoagulant for Blood gas studies - ________________________ ● CSF: _______ of plasma glucose
● Whole blood glucose is ___________ than serum
● 10% contamination with 5% dextrose - INCREASES GLUCOSE BY
_____________
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CARBOHYDRATES GLUCOSE METABOLISM

2023 MEDICAL TECHNOLOGY BOARD REVIEW - CLINICAL CHEMISTRY LJUCO2023 20
 ● Grading
GLUCOSE ○ 50 – 65 mg/dL – observable symptoms appear
LEVEL ○ <60 mg/dL – strongly suggest hypoglycemia
○ 65 – 75 mg/dL – glucagon and hyperglycemic hormones are
released into the circulation
GLYCOLYSIS - breakdown of glucose
● Diagnoses by Whipple’s triad
○ ____ blood glucose concentration
GLUCONEOGENESIS - Formation of glucose from
non-CHO sources (ex: Fatty ○ Typical symptoms appear
○ Symptoms alleviated by glucose administration

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acid, Amino acids)
● Associated with:
GLYCOGENESIS - Formation of glycogen ○ Alcohol intake
○ Renal, hepatic and cardiac failure
○ Hormonal deficiency
GLYCOGENOLYSIS - Breakdown of glycogen ○ Leukemia
○ GSD, Reye’s syndrome
○ Reactive – 4 hours after a meal
LIPOGENESIS - Formation of lipid
HYPERGLYCEMIA

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● FBS level =_____________
LIPOLYSIS - Breakdown of lipid ● Causes: stress, dehydration, pancreatectomy, insulin deficiency,
hemochromatosis, abnormal insulin receptor
● In healthy patients, during a hyperglycemia state, insulin is secreted
by the β cells of the pancreatic islet of Langerhans.
● Insulin enhances membrane permeability to cells in the liver, muscle
.J and adipose tissue. It also alters the glucose metabolism pathway.
● Hyperglycemia or increased plasma glucose levels, is caused an
imbalance of hormones

DIABETES MELLITUS
● It is a group of metabolic disorders characterized by hyperglycemia
resulting from defects in INSULIN SECRETION, INSULIN
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RECEPTORS, or both.
● FBS = ≥ 126 mg/dL on more than one testing
● Glucosuria occurs when the plasma glucose level exceeds 180
mg/dL with normal renal function.
● Renal threshold for glucose = _____________

HYPOGLYCEMIA CATEGORIES OF DIABETES

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 • Type 1 diabetes ● After childbirth, the individual generally returns to normal
• Type 2 diabetes metabolism. However, there is an increased chance that type 2
• Other specific types of diabetes diabetes mellitus may develop later in life.
• Gestational Diabetes Mellitus (GDM) Large % of patients develop DM within 5-10
years
DIAGNOSTIC CRITERIA FOR DIABETES MELLITUS ● Screening performed between 24 – 48
● RBS = ≥ _____________with symptoms of DM) weeks of gestation
● FBS = ≥ _____________ ● Diagnostic Criteria:
● 2 hours post glucose load = ≥ 200 mg/dl ○ 1. FBS > 92 mg/dL

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● HBA1C (Glycosylated Hemoglobin) = ≥6.5% (using NGSP-certified ○ 2. 1hr GTT > 180 mg/dL
method) ○ 3. 2hr GTT > 153 mg/dL

CLASSIFICATION OF DIABETES MELLITUS GLUCOSE METHODOLOGIES

● NOTE! If specimen is left at:
○ __________________________(20-25˚C): 7 mg/dl / hour
○ __________________________(4˚C) : 2 mg/dl / hour

> Chemical Method

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● Oxidation reduction method
1. Alkaline Copper Reduction
● Folin Wu Method
● Nelson Somogyi
● Neocuproine
● Benedict’s
.J 2. Alkaline Ferric Reduction (Hagedorn Jensen)

Note: Autoantibodies ● Condensation method

> GAD65 - __________________ ○ Ortho-toluidine (Dubowski method)
> Insulin AutoAb - __________________
> Enzymatic Method
Type 1 DM aka: Type 2 DM aka:
● _____________ ● _____________
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● Juvenile Diabetes ● Adult type/Maturity Onset DM
● Brittle Diabetes ● Stable Diabetes
● Ketosis Prone Diabetes ● Ketosis-Resistant Diabetes
● Receptor-Deficient DM
NOTE: Adult ages 45 and older – screened for diabetes every _________
GESTATIONAL DIABETES MELLITUS
OXIDATION REDUCTION
● GDM is the onset of diabetes mellitus during _____________.
2023 MEDICAL TECHNOLOGY BOARD REVIEW - CLINICAL CHEMISTRY LJUCO2023 22
I. ALKALINE COPPER REDUCTION ● 2 Most Commonly Used Chromogen
● Folin Wu method ○ 3-methyl,2-benzothiazolinone hydrazine
○ Cuprous Ions + Phosphomolybdate 🡪__________________ ○ N-dimethylaniline

● Nelson-Somogyi Method 2. Polarographic glucose oxidase

○ Cuprous Ions + Arsenomolybdate 🡪 ___________________ ● Principle: Rate of consumption of _____________
● Oxygen consumption is proportional to glucose
● Neocuproine Method concentration
○ Reagent: 2, 9 dimethyl 1,10 Phenantroline Hydrochloride

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○ Color: Yellow / Yellow orange ● HEXOKINASE
○ __________________________ for glucose determination
● BENEDICT’S TEST ○ Measures NADPH at 340 nm
○ AKA : _____________ ○ Affected by hemoglobin (hemolyzed sample)
○ Detects and quantitates reducing substances in body fluids Glucose + ATP –hexokinase-> Glucose-6-phosphate + ADP
like blood and urine G6P + NADP –G6PD-> 6-phosphogluconolactone + NADPH
○ Stabilizing agents : _____________
● GLUCOSE DEHYDROGENASE
II. ALKALINE FERRIC REDUCTION ______________________________) ○ Mutarotase is added to shorten the time necessary to reach

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● INVERSE COLORIMETRY equilibrium
● Converts ferricyanide to ferrocyanide

CONDENSATION METHOD DEXTROSTICS (cellular strip)

● Ortho-toluidene (Dubowski Method) ● Capillary blood glucose of > 140 mg/dL, should be rescreened with:
a. Fasting plasma glucose
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Glucose + Aromatic Amine 🡪 Glycosyl Amine + Schiff’s Base b. HbA1c
c. OGTT
_____________________________________________________________
SAMPLES FOR GLUCOSE MEASUREMENT
ENZYMATIC METHODS ● 2 HPPBS
● GLUCOSE OXIDASE ● RBS
○ _____________ for ß-D-glucose ● FBS
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○ Disadvantages: ● OGCT
False + - ____________ ● OGTT
False - - Ascorbic acid, uric acid, glutathione, creatinine,
dopamine and methyldopa

1. Colorimetric glucose oxidase (Trinder rxn) LABORATORY TESTS USED TO ASSESS GLUCOSE METABOLISM

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 I. OGTT
SUMMARY OF REFERENCE VALUES
- must be _____________
- CHO intake in 3 days before the test (_____________/day) Criteria for Fasting Plasma Glucose
- refrain from exercise, eating, drinking, smoking 1. Non-diabetic (Pre-diabetes) - <100 mg/dl
- 75 g ; 1.75 g / kg (children, max of 75 g) 2. Impaired Plasma Glucose – 100-125 mg/dl
a. Janney-Isaacson Method (Single Dose Method) – most common 3. Diabetes Mellitus - ≥ 126 mg/dl
b. Exton Rose Method (Divided Oral Dose or Double Dose Method)
Categories of Oral Glucose Tolerance Test
1. Normal/Non-Diabetic – 2-hr plasma glucose (PG) <140 mg/dL
- Intravenous Glucose Tolerance Test (IVGTT)* 2. Impaired GTT – 2-hr PG 140-199 mg/dl

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● it is used for DM patients with gastrointestinal disorders. 3. Diabetes Mellitus – 2-hr PG ≥ 200 mg/dl
● fasting blood sample is also required
● Glucose load: 0.5 g of glucose /kg body weight (given within Diagnostic Criteria for Diabetes Mellitus
minutes) administered intravenously 1. RBS - ≥ 200 mg/dl
2. FBS - ≥ 126 mg/dl
● The second blood collection is after 5 minutes of IV glucose
3. 2 hour post glucose load - ≥ 200 mg/dl
4. HBA1C - ≥ 6.5 %
II. Glycosylated Hemoglobin (HBA1C)
- Determined once in _____________
- Reliable method for _____________ glucose monitoring

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- NV: 4-6% GLYCOGEN STORAGE DISEASE
III. Glycosylated Albumin (Fructosamine) ● This disease is a consequence of inherited deficiencies of enzymes
- Once in _____________ that control the synthesis or breakdown of glycogen
- Reliable method for _____________ glucose monitoring ● Abnormal quality or quantity of glycogen is found in these disorders
- Monitoring diabetic individuals with chronic hemolytic anemia and
hemoglobin variants – decreased RBC lifespan
- NV: 205-285 µmol/L
.J Type of GSD Synonym Enzyme Deficient

↑ HbA1c in Non-diabetics ↓ HbA1c I Von Gierkes Glucose-6-Phosphatase

1. IDA 1. Hemolytic Anemia
2. Splenectomy 2. Chronic blood loss II Pompe 1,4-Glucosidase
3. Alcohol toxicity 3. Pregnancy
4. Lead toxicity 4. Chronic renal failure III Cori-Forbes Debrancher
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IV Andersen Brancher

V Mc Ardle Muscle Phosphorylase

VI Hers Liver Phosphorylase

2023 MEDICAL TECHNOLOGY BOARD REVIEW - CLINICAL CHEMISTRY LJUCO2023 24

 VII Tarui Phosphofructokinase

VIII ------ Adenyl kinase

IX ------- Phosphorylase

O ------- Glycogen synthase

TRIGLYCERIDES

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XI Fanconi-Bickel Glucose-transporter 2
● It contain three _____________ molecules attached to one molecule
*Causes Muscle Defects: V, VII of glycerol by ester bonds.
*Causes Liver Damage: The Rest - Very hydrophobic
*Affects both Liver and Muscles: Type III and IX - Neutral lipids
- Requires _______ hurs fasting
_____________________________________________________________

LIPIDS & LIPOPROTEINS

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LIPIDS
METHODS FOR TAG DETERMINATION
● Commonly referred to as fats, composed mostly of carbon-hydrogen
● Van Handel & Zilversmith – _____________ method
bonds
● Hantzsch Condensation – _____________ method
● They require special transport mechanisms (lipoproteins) for
● Glycerol kinase Method - Disappearance of NADH is measured at
circulation in the blood.
.J 340nm; Interference: Glycerol
● Major lipids: Phospholipids, Cholesterol, Triglycerides, fatty Acid and
● CDC Reference Method – Modified Van Handel and Zilversmith
Fat Soluble Vitamins (_________)
(Saponification (alcoholic KOH) extraction (chloroform) treated with
silicic acid -> pink end color)
FATTY ACIDS
● A linear chains of C–H bonds that terminate with a carboxyl group TAG VALUES in mg/dL
(–COOH).
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● Saturated VS Unsaturated Fatty acids
<150 Normal

150-199 Borderline High

200-499 High

> 500 Very High

2023 MEDICAL TECHNOLOGY BOARD REVIEW - CLINICAL CHEMISTRY LJUCO2023 25

 ↑ Cholesterol ↓ Cholesterol
TAKE NOTE:
1. Hyperlipoproteinemia I, III, V 1. Severe hepatocellular disease
● 400 mg/dL – Serum is LIPEMIC when TAG exceeds __ 2. Biliary cirrhosis 2. Malnutrition
● <200 mg/dL – TAG level if plasma is CLEAR 3. Nephrotic syndrome 3. Severe burns
● >300 mg/dL – TAG level that causes hazy/turbid plasma 4. Poorly controlled DM 4. Malabsorption syndrome
● >600 mg/dL – TAG level that causes MILKY PLASMA 5. Alcoholism 5. Hyperthyroidism
6. Primary hypothyroidism
PHOSPHOLIPIDS
● Most abundant lipids

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● Importance: Phospholipids allow the _____________ to remain open METHODS FOR CHOLESTEROL DETERMINATION
during respiration NOTE: Cholesterol can be assayed from _____________blood samples-
● _____________ fasting has little effect on total cholesterol.
- only phospholipid in membranes that is not derived from
glycerol but from an amino alcohol called sphingosine ● Liebermann Burchardt reaction
- it accumulates in the liver and spleen of patients suffering ○ End product: Cholestadienyl Monosulfonic Acid (green end
from Niemann-Pick Disease color)
(lipid storage disorder) ● Salkowski reaction
● Fetal Lung Maturity ○ End product: Cholestadienyl Disulfonic Acid (red end color)

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- Reference method:
_____________
- _____________ – measured for
alveolar activity
- _____________ – reference General Methods:
material ONLY/ control (due to
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constant production)
ONE STEP C Pearson, Stern, and mac Gavack /
- L/S ratio is measured using TLC Boyle’s
- NV: ≥ ______
TWO STEP C+

CHOLESTEROL THREE STEP

● Clinical significance:
FOUR STEP
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○ Evaluates the risk for _____________, myocardial infarction,
and coronary arterial occlusions. * C = Colorimetry ; E = Extraction ; S = Saponification ; P = Precipitation
○ There is a direct relationship between elevated serum
cholesterol and myocardial infarction > routine lab analysis: Cholesterol oxidase method - can detect sterol
○ It is also used to monitor effectiveness of lifestyle changes > reference method: GC-MS / Modified Abell Kendall method
and stress management.

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Cut-off points for Serum Cholesterol (Risk for Cardiovascular Problem) METHODS FOR LIPOPROTEIN ANALYSIS
1. Ultracentrifugation: based on _____________________
2. Electrophoresis
Age group Moderate Risk High Risk
3. Standing Plasma Test – to differentiate VLDL from chylomicrons;
2-19 store at 4C , do not agitate
a. Chylomicrons – ______________________
20-29 b. VLDL – homogenous turbidity
30-39

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40 and above Lipids & lipoprotein reference ranges

LIPOPROTEINS
● These are large macromolecular complexes of lipids with specialized
proteins known as apolipoproteins
● _____________
○ helps to keep the lipids in solution (solubility) during
circulation through the bloodstream

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○ it interacts with specific cell-surface receptors and direct the
lipids to the correct target organs and tissues in the body.
.J Formula for LDL-C

VLDL = TAG / 5 (mg/dL)

VLDL = TAG / 2.2 (mmol/L)

SAMPLE COMPUTATION:
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2023 MEDICAL TECHNOLOGY BOARD REVIEW - CLINICAL CHEMISTRY LJUCO2023 27

MINOR LIPOPROTEIN ACCEPTABLE COEFFICIENT OF VARIATION
● Intermediate Density Lipoprotein
○ a product of VLDL catabolism – _____________
○ Major apolipoprotein: _____________

● Lp (a)
○ known as “__________________________”
○ increased levels may indicate premature coronary heart

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disease and stroke

● Lipoprotein X ADDITIONAL NOTES FOR LIPIDS & LIPOPROTEINS

○ It is an abnormal lipoprotein present in _____________ & ● HDL – Good Cholesterol, Reverse Cholesterol Transport, Highest
LCAT deficiency CHON content
● LDL - Bad Cholesterol
● _____________ ● VLDL – Endogenous TAG
○ It is known as “abnormally migrating β-VLDL” and “Floating ● Chylomicron – Exogenous/Dietary TAG, Highest TAG content
Beta Lipoprotein” ● Minor Lipoprotein – IDL, Lp (a)

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○ Has the density of VLDL by ultracentrifugation but migrates ● Sinking Pre-beta Lipoprotein – Lp (a)
with LDL in the β region during electrophoresis ● Floating Beta Lipoprotein - ________ ; also present in TYPE III
○ It is found in type 3 Dysbetalipoprotenemia Familial Dysbetalipoproteinemia
Fredrickson’s Classification of Dyslipoproteinemias ● _____ - Lipoprotein in Obstructive Jaundice
_____________________________________________________________
Type Name Elevated Lipoprotein
.J PROTEINS
I Familial LPL Deficiency Chylomicron ● Composed of carbon, hydrogen, oxygen and _____________
● The nitrogen content of serum protein is approximately 16%.
IIa Familial Hypercholesterolemia LDL ● Amphoteric: Proteins can yield a positive or negative charge making
them a good buffer
IIb Familial Combined LDL, VLDL
● Synthesized by the liver except for _____________
Hyperlipidemia
● Amino acids are the basic structural units of proteins
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III Familial IDL , (+) B-VLDL
Dysbetalipoproteinemia
PROTEIN STRUCTURE
IV Familial Hypertriglyceridemia VLDL ● PRIMARY STRUCTURE – represents the number and types of
amino acids in the specific amino acid sequence.
V Endogenous CM, VLDL
Hypertriglyceridemia
2023 MEDICAL TECHNOLOGY BOARD REVIEW - CLINICAL CHEMISTRY LJUCO2023 28
 ● SECONDARY STRUCTURE – regularly repeating structures
stabilized by hydrogen bonds between the amino acids within the
protein.
● TERTIARY STRUCTURE – overall shape, or confirmation of the
protein molecule.
○ Confirmation – is the fold.
● QUATERNARY STRUCTURE – shape or structure that results from
the interaction of more than one protein molecule, pr protein
subunits, held together by noncovalent forces.

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METHODS FOR PROTEIN DETERMINATION

1. Biuret Method – measures the amount of _____________ present;

needs at least_____________
Reagent in Biuret Method:
R –____________ (aka:_SODIUM POTASSIUM TARTRATE_)

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A- ____________
N – ____________
K - ____________

2. Kjeldahl Method – measures the _____________ content of protein

Steps in Kjehldahl Method
.J
P – ________________________
A – ________________________ (H2SO4)
M – ________________________

3. SERUM PROTEIN ELECTROPHORESIS

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SUMMARY OF SIGNIFICANT PROTEINS NORMAL:

2023 MEDICAL TECHNOLOGY BOARD REVIEW - CLINICAL CHEMISTRY LJUCO2023 29

SUMMARY OF PROTEIN MIGRATION

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ABNORMAL ELECTROPHORETIC PATTERNS

Beta-gamma bridging, Increased IgA

Polyclonal gammopathy (Gamma spike) CHRONIC INFLAMMATION

(RA, Malignancy)

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4. Folin-Ciocalteu (Lowry) Method
Monoclonal gammopathy (Gamma spike) ● Highest analytical sensitivity
● Principle: oxidation of phenolic compounds such as tyrosine,
Increased alpha 1 and 2 tryptophan and histidine to give a deep blue color
● Main reagent: Phosphotungstic acid-molybdic acid or phenol
reagent
Alpha-2 globulin spike
.J NEPHROTIC SYNDROME
● Color enhance: Biuret reagent
Increased a2 macroglobulin

5. Dye-binding
Decreased alpha-1 EMPHYSEMA, ALPHA-1 ● Albumin binds to dye which causes shift in absorption maximum
ANTITRYPSIN DEFICIENCY a. Bromcresol green – _____________ (630nm)
b. Bromcresol purple – most specific
c. Methyl orange - nonspecific
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d. Hydroxyazobenzene benzoic acid – many interferences
(salicylates, bilirubin)

6. Ultraviolet Adsorption Method

● Protein absorbs light at 280nm (tryptophan, tyrosine, phenylalanine)
and at 210nm

2023 MEDICAL TECHNOLOGY BOARD REVIEW - CLINICAL CHEMISTRY LJUCO2023 30

 7. Salt Fractionation TEST FOR GFR
● Globulins can be separated from albumin by salting-out procedures ● GLOMERULAR FILTRATION - _____________ tests (used to
using sodium salts evaluate glomerular filtration)
_____________________________________________________________ ● Examples:
> _____________ - old
NON-PROTEIN NITROGEN > _____________ = MOST COMMON
> _____________ = GOLD STANDARD/REFERENCE METHOD
KIDNEY FUNCTION TESTS > Beta2-microglobulin
> Radioisotopes

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> Cystatin C
SYNTHESIS

METABOLISM > Inactivation of aldosterone, glucagon and insulin

> Activation of Vitamin D, formation of creatine

EXCRETION Ammonia, urea, uric acid, several minerals, toxic

substances

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CLINICALLY SIGNIFICANT NON PROTEIN NITROGEN COMPOUNDS
FORMULA:
Where:
Ccr = Creatinine Clearance
U = Urine Creatinine (mg/dl)
V = Urine volume (ml/min)
.J P = Plasma creatinine
A = Body surface area

● Creatinine is the end product of _____________ derived from

CREATINE
● Most commonly used endogenous substance in the clinical
assessment of GFR
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Normal Values:
THREE MAJOR GROUPS OF KIDNEY FUNCTION TESTS - Men: 107 – 139 ml/min
A. TESTS MEASURING GLOMERULAR FILTRATION RATE (GFR) - Women : 87 – 107 ml/min
B. TESTS MEASURING RENAL BLOOD FLOW ● Creatinine clearance is a measure of the completeness of a
C. TESTS MEASURING TUBULAR FUNCTION _______________________________________

2023 MEDICAL TECHNOLOGY BOARD REVIEW - CLINICAL CHEMISTRY LJUCO2023 31

SAMPLE COMPUTATION: ● Methods:
○ Colorimetric: diacetyl (inexpensive, lacks specificity)
○ Enzymatic: NH3 formation (more expensive, greater
specificity)
○ IDMS: _____________ for NPNs (urea)
● Measurement of urea is used to evaluate renal function, to assess
hydration status, to determine nitrogen balance, to aid in the
diagnosis of renal disease, and to verify adequacy of dialysis.
● Urea concentration may be measured in plasma, serum, or urine.

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○ INCREASE: __________________________________
○ DECREASE: _________________________________
● Reference value: 8 – 23mg/dL

● Categories of Azotemia
TESTS MEASURING RENAL BLOOD FLOW ○ Azotemia - defined as an elevation of _____________ (&
● The principal substances included among the NPN compounds are creatinine) concentration in the blood
urea, amino acids, uric acid, creatinine, creatine and ammonia. Of ■ Very high plasma urea concentration accompanied
these compounds, urea is present in the plasma in the greatest by renal failure is called uremia or the uremic

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concentration, comprising approximately 45% of the syndrome
nonprotein-nitrogen fraction.
● NOTE: Plasma contains 20 – 35 mg/dL of NPN Prerenal Azotemia Renal Azotemia Postrenal Azotemia
○ _____________ 45%
○ Amino acid 20% Reduced renal blood flow Acute & chronic renal Urinary tract obstruction
○ Uric acid 20% Congestive heart failure failure Renal calculi
○ Creatinine 5%
.J Shock, hemorrhage, Renal diseases Bladder or prostate
○ Creatine 1 – 2% dehydration tumors
○ _____________ 0.2% Increased protein catabolism Severe UTI
High protein diet
BLOOD UREA NITROGEN (BUN)
● The NPN compound present in highest concentration in the blood is CREATININE
urea. ● Creatinine is formed from creatine and creatine phosphate in
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● 1st metabolite to elevate in _____________ disease muscle and is excreted into the plasma at a constant rate related to
● Urea is the major excretory product of protein metabolism. It is muscle mass.
formed in the liver from amino group (−NH2) and free ammonia ● Methods:
generated during protein catabolism. ○ Chemical method/ Direct Jaffe method
● To obtain concentration of urea from BUN ■ Most frequently used method
○ a. 2.14 X BUN (mmol/L) ■ a. Saturated picric acid
○ b. 0.357 X BUN (mg/dL) ■ b. 10% sodium hydroxide

2023 MEDICAL TECHNOLOGY BOARD REVIEW - CLINICAL CHEMISTRY LJUCO2023 32

 ○ Lloyd or Fuller’s Earth Method Conversion Factors:
■ Most sensitive and specific BUN CU to SI - 0.357
■ Adsorbent (removes interferences): Urea to BUN - 0.467
1. _____________ - sodium aluminum silicate BUN to Urea - 2.14
2. _____________ – aluminum magnesium silicate N to Protein - 6.25
○ IDMS - REFERENCE METHOD
○ Clinical Significance: Measurement of creatinine
concentration is used to determine the sufficiency of kidney AMMONIA
function, to determine the severity of kidney damage, and to ● Ammonia is produced in the _____________ of amino acids during

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monitor the progression of kidney disease. protein metabolism.
● It is removed from the circulation and converted to _____________
● INCREASE: Impaired renal function, Chronic nephritis, CHF, in the liver. Free ammonia is toxic; however, ammonia is present in
Muscular dystrophies, _____________ the plasma in low concentrations.
● DECREASE: Decrease muscle mass, Severe liver disease, ● Specimen: __________________________
Pregnancy, __________________________ ● Should be chilled and tested immediately
● Cigarette smoking can _____________ plasma ammonia
BLOOD URIC ACID (BUA) ● Methods:
● Uric acid is the product of catabolism of the _____________ ○ Enzymatic (Glutamate dehydrogenase) – most common

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(guanine & adenine) nucleic acids. ● Measurement of ammonia
● Uric acid is relatively insoluble in plasma and, at high concentrations, 1. Nesslerization Reaction
can be deposited in the joints and tissue (TOPHI), causing painful ○ Yellow end color – nitrogen low to moderate
inflammation. ○ Orange-brown – nitrogen is high
● Methods: 2. Berthelot Reaction
○ Colorimetric:Phosphotungstic acid (Problems with turbidity; ○ NH3 + Phenol + hypochlorite – Sodium Nitroprusside
.J
several common drug interferences) Indophenol blue
○ Enzymatic UV: Uses _____________ enzyme (specific ○ Specimen of Choice: Arterial blood (Heparin/EDTA)
method) to convert uric acid to Allantoin (285 nm); requires ○ Plasma/serum kept in ice water immediately
mercury arc vapor lamp
○ Enzymatic H2O2 production: interference by reducing
substances
○ IDMS : _____________
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● Clinical significance: Uric acid is measured to confirm diagnosis
and monitor treatment of _____________, to prevent uric acid
nephropathy during _____________, to assess inherited disorders of
purine metabolism (Leisch Nyhan Syndrome), to detect kidney
dysfunction, and to assist in the diagnosis of renal calculi

ADDITIONAL NOTES:

2023 MEDICAL TECHNOLOGY BOARD REVIEW - CLINICAL CHEMISTRY LJUCO2023 33

 BILIRUBIN

● __________is the chief metabolic organ in the body and is the

largest internal organ of the body. The liver has the following
biochemical functions:
1. Synthetic function
2. Conjugation function
3. Detoxification function and Drug metabolism
4. Excretory and Secretory function

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5. Storage function

● Several laboratory tests are performed to assess the different

functions of the liver, example is Bilirubin which is useful in assessing
the conjugation and excretory function of the liver.

● __________is the end product of hemoglobin metabolism and the

principal pigment in bile.
○ There are two types of bilirubin, unconjugated and

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conjugated.
○ It is important to take note that the conjugation of bilirubin
takes place in the presence of the enzyme uridyl
diphosphate glucuronyl transferase (UDPGT).
.J
NORMAL VALUES:
● Total bilirubin = __________
● Conjugated bilirubin (Direct bilirubin) = __________
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● Unconjugated bilirubin (Indirect bilirubin)= __________
Conversion Factor:__________

2023 MEDICAL TECHNOLOGY BOARD REVIEW - CLINICAL CHEMISTRY LJUCO2023 34

CLINICAL SIGNIFICANCE INTERPRETATION EVELYN MALLOY JENDRASSIK
GROF
Disease Description B1 B2
pH

Dissociating Agent
Prehepatic Problem causing jaundice
Jaundice occurs prior to liver Diazo Product
(Hemolytic metabolism
Anemia)

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● In order to measure the total bilirubin, the indirect bilirubin must also
Hepatic Impaired bilirubin excretion
be measured by adding methanol or caffeine sodium benzoate.
(Cirrhosis,
Viral The measurement is repeated after 5 minutes to measure the total
hepatitis) bilirubin. The color produced is directly proportional to the
concentration of total bilirubin in the sample.
Post Hepatic Intrinsic liver defect or disease
(Obstructive due to disorders of bilirubin
metabolism and transport defects ● Indirect bilirubin is calculated as the difference between total and
jaundice)
or due to diseases resulting in direct bilirubin.(INDIRECT BILI = TOTAL BILI - DIRECT BILI)
hepatocellular injury

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METHODS FOR BILIRUBIN DETERMINATION
● The determination of bilirubin involves the principle of
____________________
● In this reaction, the direct-reacting bilirubin reacts with the Diazo
.J
reagent and sodium nitrite to produce colored azobilirubin complex in
aqueous solution. The color is directly proportional to the
concentration of direct bilirubin in the sample.

Note: normal serum yields

__________Van den Bergh reaction
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2023 MEDICAL TECHNOLOGY BOARD REVIEW - CLINICAL CHEMISTRY LJUCO2023 35

INTERPRETATION OF VAN DEN BERGH REACTION
Defective uptake of Bili

1. DIRECT POSITIVE
● Reagent + B2 = purple color immediately (around 30 secs) Defective in excretion of Bili
● Related to cases of ____________________
2. INDIRECT POSITIVE
● Addition of __________(or alcohol) dissolves B1 & gives ___________________________________________________________
positive reaction (around 30 mins)
● Related to ____________________

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ENZYMES
3. __________ ● These are proteins produced by living cells that hastens chemical
● If serum contains high conc of B1 & B2, reactions in organic matter.
● Purple color produced immediately (direct) & this is further ● They are measured in terms of their activity and not in terms of
intensified by the addition of alcohol (indirect) their absolute value.
● Related to hepatic jaundice
IMPORTANT TERMS
SPECIMEN CONSIDERATIONS FOR BILIRUBIN DETERMINATION
1. After blood collection, the sample should be protected from light Active site Where substrate interacts with particular charged amino acids
due to the reason that Bilirubin is oxidized when exposed to light. residues

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The sample can be wrapped by aluminum foil or carbon paper.
2. Hemolyzed, icteric, and lipemic samples should be avoided. Allosteric site Site other than the active site; may bind regulator molecules
3. The specimen should be processed within 2 hours of collection
and the serum should be separated from the red cells after Holoenzyme Whole enzyme molecule; apoenzyme + cofactor
centrifugation.
Apoenzyme Protein portion of the enzyme
NOTES TO REMEMBER
.J
Effect of cigarette smoking on ammonia Cofactor Non-protein portion of the enzyme; can be organic
(__________) or inorganic (__________)
Bilirubin covalently attached to albumin
Zymogens Inactive form of enzymes

Danger of kernicterus at bilirubin levels Isoenzymes Enzymes with the same activity but different in genetic origin
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Accelerator used in Jendrassik-Grof

method

Deficiency of UDPGT

2023 MEDICAL TECHNOLOGY BOARD REVIEW - CLINICAL CHEMISTRY LJUCO2023 36

CLASSIFICATION OF ENZYMES ○ __________= Should be high enough to saturate all
enzymes (Addition of substrate concentration will lead to
increase in the rate of reaction - FIRST ORDER KINETICS)
CLASS FUNCTION EXAMPLES
● Cofactors – non-protein entities that must bind to particular
Oxidoreductas Catalyze the removal or LDH, G6PD, GDH, MDH enzymes before a reaction occurs.
es addition of electrons (redox Ex: ends w/
○ Coenzymes(ORGANIC) – NAD and flavine, Pyridoxal PO4
reaction). -____________________
○ Activators(INORGANIC) – ___________________________
○ Metalloenzymes – ex: Catalase, Cytochrome oxidase

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Transferases Catalyze the transfer of a AST, ALT, CK, GGT, PK
chemical group other than Ex: ends w/
● Inhibitors – enzymatic reactions may not progress if an inhibitor
hydrogen from one substrate to ____________________
another. interferes with the reaction.
○ Competitive Inhibitor
Hydrolases Catalyze hydrolysis or splitting Esterase: ALP, ACP ○ Non-Competitive Inhibitor
of a bond by the addition of Peptidase: Trypsin, Pepsin, ○ Uncompetitive Inhibitor
water (hydrophobic reactions). LAP
Glycosidase: AMS,
Galactosidase

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Lyases Catalyze the removal of groups Glutamate decarboxylase,
from substrates without Pyruvate decarboxylase,
hydrolysis. Product contains Aldolase
double bonds. Ex: ends
____________________

Isomerases
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Catalyze the intramolecular Triosephosphate isomerase
arrangement of the substrate Ex: ends w/ __________
compound.

Ligases Catalyze the joining of two Glutathione __________

substrate molecules. Synthase
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FACTORS AFFECTING ENZYMATIC REACTIONS
● Enzyme Concentration & Substrate Concentration
○ Enzyme = Directly proportional to the reaction (If the reaction
rate depends on __________concentration - ZERO ORDER ● Isoenzymes – enzymes having the same catalytic reactions but
KINETICS) slightly different molecular structure

● Temperature – Optimum temp: ______

2023 MEDICAL TECHNOLOGY BOARD REVIEW - CLINICAL CHEMISTRY LJUCO2023 37

 ○ The rate of denaturation is significant at 40 – 50C
○ 60 – 65C may cause inactivation of enzymes

● Hydrogen Ion Concentration or pH

● Storage
○ -20˚C = ideal temp for preservation of enzymes (longer
period of time)
○ 2-8˚C = ideal for substrates and coenzymes

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○ 22˚C or Room temp = ideal for LDH (LD4 and LD5)

● Hemolysis - ______ enzyme conc.

● Latescence or milky specimen – decrease enzyme conc.

ENZYME THEORY

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.J MEASUREMENT OF ENZYME ACTIVITY
1. Fixed-time / Endpoint Method
● A final measurement is taken to measure the total amount of
substrate/products
● Reaction proceeds for a designated time
● Weak acid is added to stop reaction

2. Continuous Monitoring / Kinetic Assay

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● Multiple measurements are taken over the course of the reaction
by using continuously recording spectrophotometer

2023 MEDICAL TECHNOLOGY BOARD REVIEW - CLINICAL CHEMISTRY LJUCO2023 38

ENZYMATIC METHODS ● FLIPPED PATTERN: ____________________________________

AST/ALT LDH CK PRONOUNCED MODERATE SLIGHT ELEVATION

ELEVATION ELEVATION (up to 3x)
(5x or more) (3-5x)
Karmen Wacker - FORWARD Tanzer Gilvarg -
Reitman Frankel Wrobleuski Ladue - Forward
● __________ ● Myocardial ● Most liver disease
REVERSE Oliver Rosalki -
● Hepatic metastases infarction ● Nephrotic
Reverse
● Systemic shock ● Pulmonary syndrome

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and hypoxia infarction ● Hypothyroidism
ACP ALP AMS ● Hemolytic ● Cholangitis
● Hepatitis
● Renal infarction conditions
Gutman Bodansky King & Armstrong Saccharogenic ● Leukemias
Babson & Read Shinowara Bessy, Lowry & Brock Amyloclastic
Jones Bowers & McComb ● IM
Shinowara Reinhart Huggins & Talalay Chromogenic ● Delirium tremens
Phillips Moss Klein, Babson & Read Coupled-enzyme ● Muscular
Roy Hillman dystrophy

LACTATE DEHYDROGENASE METHODS

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Coenzyme Tissue Methods Normal ● Wacker (8.3-8.9)
Lactate + NAD ----🡪 ________ + NADH + H
Sources Values

_______ Wacker 125-220 U/L ● Wroblewski Ladue (7.1-7.4)

Liver Wroblewski Pyruvate + NADH + H ---🡪 ________ + NAD
Muscle Ladue
Kidney
.J Wroblewski ● Note:
RBC Cabud ○ Sources of error: any degree of hemolysis, instability in any
Brain Berger Broida
temperature

ISOENZYMES:
● LD1 - HHHH -
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● LD2 - HHHM -
● LD3 - HHMM -
● LD4 - HMMM -
● LD5 – MMMM -
● LD6 - ALCOHOLIC DEHYDROGENASE(arteriosclerotic
cardiovascular failure)
● NORMAL PATTERN: __________________________________

2023 MEDICAL TECHNOLOGY BOARD REVIEW - CLINICAL CHEMISTRY LJUCO2023 39

G6PD (GLUCOSE 6 PHOSPHATE DEHYDROGENASE) AST: KARMEN METHOD
Tissue Sources Clinical Normal value
Significance Aspartate + Alpha-ketoglutarate —------> Oxaloacetate + Glutamate

__________ G6PD deficiency Up to 0.18 U/L Oxaloacetate + NADH + H —--------> Malate + NAD
Adrenal cortex Hemolytic anemia
Spleen AMI
ALT (ALANINE AMINOTRANSFERASE)
Thymus Primaquine
Lymph nodes Megaloblastic Coenzyme Tissue Methods Normal

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Lactating mammary anemia Sources Value
glands

● Specimen: Whole blood; uses hemolysate; EDTA for G6PD Reitman-Frankel 7-45 U/L
Method
Deficiency and HA ; serum for AMI

AST (ASPARTATE AMINOTRANSFERASE) ● Previously known as: SGPT (Serum Glutamic

__________Transaminase)
Coenzyme Tissue Sources Methods Normal Value
● In acute hepatocellular injury, in < 24 hours
○ AST > ALT

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Cardiac Muscle Karmen 5-35 U/L
● In 24 – 48 hours following onset of injury
Liver Method
Skeletal Muscle ○ ALT > AST
Kidney
Pancreas Alanine + Alpha-ketoglutarate —---------> Pyruvate + Glutamate
RBC
.J Pyruvate + NADH + H —-------------> Lactate + NAD
● Previously known as: SGOT (Serum Glutamic
__________Transaminase) CK (CREATINE KINASE)
● Sources of error: Hemolysis, stable in serum for 3-4 days at 2-8’C Activators Tissue Clinical Methods Normal
sources Significance Values
AST ISOENZYMES
1. Cytoplasmic / Extramitochondrial AST Brain Muscle Tanzer- M: 15-160 U/L
Cardiac Dystrophy Gilvarg F: 15-130 U/L
● More predominant in plasma or serum
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muscle AMI Oliver
● Half-life 17 hours Skeletal Rhabdomyolysis Rosalki
Muscle Nerve
2. Mitochondrial AST Degeneration
● Cause of tissue necrosis Stroke
● Half-life 87 hours Seizures
CNS Shock

2023 MEDICAL TECHNOLOGY BOARD REVIEW - CLINICAL CHEMISTRY LJUCO2023 40

CK ISOENZYMES ● Possible sources of error:
○ Hemolysis
● CK 1 – BB - __________ ○ Instability of CK
● CK 2 – MB - __________ ○ ____________________
● CK 3 – MM - __________(Most ○ Physically well trained patients
predominant)
GGT (GAMMA GLUTAMYL TRANSFERASE)
● NOTE: Tissue Clinical Methods Normal
○ CK-1 – most anodal and labile

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Source Significance Value
isoenzyme (CK-BB)
○ CK-3 – least anodal and major Liver Chronic Szasz M: 6-55 U/L
isoenzyme (CK-MM) Kidney Alcoholism Rosalki & Tarrow F: 5-38 U/L
Brain Hepatobiliary Orlowski
Prostate Disorder
Pancreas Drugs
Highest elevation of CK is seen in: DM
AMI
● Atypical CK Isoenzyme
○ Mitochondrial CK (CK-Mi) Gamma glutamyl p-nitroanilide + glycylglycine → p-nitroaniline

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■ bound to the exterior surface of the inner
mitochondrial membranes of muscle, brain, and liver ● Most sensitive enzyme of __________
migrate cathodal to CK-MM ● Not affected by hemolysis
■ 0.8%-1.7%
■ indicator of severe illness, tx damage, and detected ALP (ALKALINE PHOSPHATASE)
.J
in cases of malignant tumor and cardiac Activator Tissue Methods Normal Value
abnormalities Sources
○ Macro CK
■ migrate midway CK-MM and CK-MB L- 1. Bessey, Lowry M: 53-128 U/L
■ comprised of CK-MM complexed with IgG, some IgA & Brock F: 42-98 U/L
B- 2. Bower-McCom
or complexes of lipoproteins with CK-MM
■ age and sex related
P- b
3. King-Armstrong
I-
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■ 0.8%-1.6% 4. Sinowara,
Jones &
CK METHODS Reinhart
1. TANZER-GILBARG (pH = 9.0) 5. Huggins &
● Creatine -> Creatine phosphate Talalay
6. Moss
2. OLIVER ROSALKI (pH = 6.8)
● Creatine phosphate -> Creatine

2023 MEDICAL TECHNOLOGY BOARD REVIEW - CLINICAL CHEMISTRY LJUCO2023 41

ALP ISOENZYMES ALP METHODS
> Major Isoenzymes 1. Electrophoresis – L (most anodal) (____________________)
● ALP1 - Liver 2. Heat Stability - P (most heat stable (____________________)
● ALP2 - Bone ● 56C for 10 minutes P (same as carcinoplacental
● ALP3 - Placenta isoenzymes) ILB
● ALP4 - Intestine ● 65C for 30 minutes (Placental ALP resists denaturation at
this temp)
> Abnormal/Atypical Isoenzyme - Carcinoplacental Isoenzymes 3. Chemical Inhibition
● __________- ectopic production of an enzyme by malignant tissue; ● All are inhibited by phenylalanine

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detected in various carcinomas like lung, breast, ovarian, and colon ● Liver and bone – inhibited by Levamisole reagent
(highest in ovarian and gynecologic cancers); used for monitoring ● Bone – inhibited by 3M urea
treatment because it disappears upon successful therapy. 4. Requires a pH of 9 - 10
● __________- detected in metastatic carcinoma of pleural surfaces
and in adenocarcinoma of the pancreas and bile duct SUMMARY OF ALP METHODS

PRONOUNCED MODERATE SLIGHT Method Substrate Comments

ELEVATION (5x or ELEVATION ELEVATION
more) (3-5x) (Up to 3x) Shinowara-Jones-Reinhart Beta-glycerophosphate Long incubation time;

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↑ blank values
● Biliary cirrhosis ● Granulomatous ● Viral hepatitis Bodansky
● _____________ or infiltrative ● Cirrhosis
disease of liver Bessy, Lowry, and Brock P-nitrophenylphosphate Endpt or kinetic, rapid
___________ ● Pregnancy
● Infectious ● Normal
● Bile duct mononucleosis King-Armstrong Phenylphosphate Endpt, requires protein
obstruction growth removal
● Metastatic bone pattern in
● Hyperparathyroi
.J carcinoma children Uses phosphate -
dism Bowers-McComb
● Metabolic bone ● Healing accepting buffer;
● Osteogenic disease reference method
sarcoma fractures
(rickets,osteomala
cia) Huggins and Talalay Phenolphthalein diphosphate Phenolphthalein red

Moss Alpha-naphthol phosphate Alpha-naphthol

Additional Notes (Sources of errors):
● Intestinal ALP may increase after consumption of fatty meal in group Klein, Bobson and Read Buffered Free phenolphthalein
L
phenolphthalein
______________________________ phosphate
● 25% higher values after high fatty meal ingestion
● Hemolysis (ALP is 6x more concentrated in RBCs than in serum)
● Delayed analysis (activity in serum increases approximately 3-10%
on standing at 25°C or 4°C for several hours)

2023 MEDICAL TECHNOLOGY BOARD REVIEW - CLINICAL CHEMISTRY LJUCO2023 42

ACP (ACID PHOSPHATASE) Less sensitive,
Bobson and Reed Alpha-naphthylphosphate
Tissue Clinical Methods Normal complicated
Sources Significance Value (continuous
monitoring)
___________ Prostate Hudson M: 2.5-11.7
Bone carcinoma Babson & Reed U/L Hudson PNPP Nonspecific, rapid
Liver Roy F: 0.3-9.2 U/L
Spleen Rape Bodansky ROY MORE SPECIFIC
Kidney Gutzman, King FOR PROSTATIC
RBC FORM (endpt

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Paget’s Disease & Armstrong
monitoring)
Platelets
Reitz, Guilbault 4- methylumbelliferone Fluorescent, some
phosphate improved sensitivity

AMS (AMYLASE)

ACP ISOENZYMES Activator Tissue Clinical Methods NV

Source Significance
● ACP 1 – Prostate (inhibited by tartrate)
● ACP 2 & 4 – Granulocytes Pancreas ___________ Amyloclastic 28-100

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● ACP 3 – Erythrocytes (ACINAR Mumps U/L
● ACP 5 – Osteoblasts (tartrate resistant) CELLS) Saccharogenic
- Reference
SOURCES OF ERROR Salivary Method
glands
● Delay in separation of serum from red cells (ACP from RC and
Skeletal Chromogenic
platelet may leaked) muscle
.J
● Instability of ACP (activity decreases within 1-2 hours at RT without Fallopian Continous
preservative) due to CO2 in the serum resulting to an elevated pH. If Tubes
not assayed immediately, serum must be frozen or acidified to a pH ● AMS is considered as the smallest enzyme in size
<6.5 (stable for 2 days upon acidification at RT)
● Hemolysis (erythrocytic ACP) AMS ISOENZYMES
● S-type (Salivary) = __________________ (fastest)
SUMMARY OF ACP METHODS ○ predominates in serum
L
Method Substrate Comments
● P-type (Pancreatic) = __________________ (slowest)
Bodansky Beta-glycerophosphate Length assay, nonpecific ○ predominates in urine

Gutman, Phenylphosphate Nonspecific

S-type AMS is inhibited by wheat germ lectin. To measure S-AMS and
King-Armstrong
P-AMS, determine the T-AMS in the presence and absence of lectin.

2023 MEDICAL TECHNOLOGY BOARD REVIEW - CLINICAL CHEMISTRY LJUCO2023 43

AMYLASE METHODS ● Tietz and Fiereck

● Peroxidase coupling – most commonly used method; does not use

Note:Substrate for all the methods is __________________
50% olive oil

● Saccharogenic - classic reference method expressed in Somogyi SOURCES OF ERRORS:

units ● Hemolysis inhibits the activity of serum LPS and may falsely
● Amyloclastic – follows the decrease in substrate concentration decreased the level of activity
● Chromogenic – measures amylase activity by the increase in color ● LPS activity is stable in serum (negligible loss for 1 week at RT or 3

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intensity weeks at 4°C), but more than that, LPS may decompose.
● Coupled-enzyme – measures amylase activity by a
continuous-monitoring technique PANCREATIC ENZYMES
RISE PEAK NORMALIZE
SOURCES OF ERRORS:
WITHIN:
● Acute pancreatitis with hyperlipemia (TG inhibits AMS)
● Morphine and other opiates for pain relief may falsely elevate AMS
Amylase 24 hours 3-5 days
● saliva contamination
(Sensitive)
● Oxalates and citrates may falsely decrease the level of AMS
because of enzyme inactivation

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Lipase 24 hours 8-14 days
(Specific)
LPS (LIPASE)
Tissue Clinical Method Normal
ALDOLASE
Sources Significance Value
● Isoenzymes:
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Pancreas Pancreatitis Cherry-Crandall 0-1 IU/mL ○ Aldolase B – WBC, liver, kidney
Small intestine ○ Aldolase C – brain
Stomach Tietz- Fierck ● Significance: ↑ skeletal muscle disease, leukemia, hemolytic
anemia, and hepatic cancer
Peroxidase Coupling
5’ NUCLEOTIDASE
● isoenzymes: L1, L2, L3 (__________________ is the most clinically ● Tissue: Liver, associated with canaliculi membrane; widely
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specific and sensitive) distributed
● Significance:
LIPASE METHODS ○ ↑ hepatobiliary disease
● Cherry-Crandall ○ NORMAL in pregnancy and bone disorders
○ reference method ○ Bone Disease : __ ALP , __ 5NT
○ substrate: __________________ (now: Triolein) ○ Liver Disease: __ ALP , __ 5NT

2023 MEDICAL TECHNOLOGY BOARD REVIEW - CLINICAL CHEMISTRY LJUCO2023 44

PSEUDOCHOLINESTERASE SUMMARY OF LIVER ENZYMES
● Tissue source: Liver, myocardium, pancreas ● LDH
● Pathological levels are __________________ from the normal values ● AST
by as much as 80 – 90% ● ALT
● Significance: ● GGT
1. Reflects synthetic function of the liver rather than injury ● ALP
2. Marker for__________________ which are cholinesterase inhibitors ● 5 NT
(organic phosphates, carbamates) ● Bone Disease : ↑ ALP , N’ 5NT
3. Monitor the effects of muscle relaxants (succinylcholine) ● Liver Disease: ↑ ALP , ↑ 5NT

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● Methods:
○ Michel Method (Electrometric method) SUMMARY OF CARDIAC ENZYMES
○ Manometric method - liberation of CO2 MARKER ONSET OF PEAK DURATION
○ Ellman technique (Photometric enzyme reaction) - most ELEVATION OF
widely used ELEVATION

ORNITHINE CARBAMOYL TRANSFERASE (OCT) Myoglobin 1- 3 hrs 5-12 hours 18-30 hrs
● Catalyzes the reversible conversion of ornithine to citrulline
Troponin I 3-6 hrs 12-18 hours 5-10 days
(synthesis of urea)

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● Tissue source: __________________ CK-MB 4-6 hrs 12-24 hours 48-72 hrs
● Diagnostic significance:
○ Increased: acute viral hepatitis, obstructive jaundice, AST 6-8 hrs 24 hrs 5 days
cirrhosis, metastatic carcinoma, heart failure, delirium
tremens, cholecystitis LDH 12-24 hrs 48-72 hours 10-14 days
● METHODS:
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○ Reichard and Reichard * Trop T 3-4 hrs 10-24 hrs 7 days
○ Colorimetric method
ENZYME SPECIFICITY
LEUCINE AMINOPEPTIDASE (LAP)
● Catalyzes the hydrolysis of N-terminal residues from certain peptides High specificity Prostate, RBC
Liver
and amides containing free amino groups Pancreas
● Tissue source: urine, serum, bile Pancreas & salivary gland
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● Diagnostic significance:
○ Increased: hepatobiliary diseases like hepatitis, cirrhosis, Moderate Liver , Heart, Skeletal muscle
obstructive jaundice, metastatic carcinoma of the liver, specificity Brain, Heart, Skeletal muscle
pancreatitis
● LAP METHOD: Low specificity Liver, Bone, Kidney
All tissues
○ Goldbarg and Rutenberg

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NOTES dissociates to form a bicarbonate ion (HCO3− ) and a hydrogen ion
● All enzymes tend to __________________ as a result of tissue (H+).
destruction ● Any excess acid or base introduced to the system is
● Most enzymes are clinically significant when its level elevates neutralized by shifting the equation to left or right.
except for __________________ __________________ (decreases in
Pesticide poisoning)
● Most specific liver enzyme: __________________
● Most sensitive liver enzyme: __________________

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● Most sensitive for acute pancreatitis: __________________
● Most specific for acute pancreatitis: __________________

_______________________________________________________

BLOOD GAS ANALYSIS

ACID BASE BALANCE 2. Phosphate buffer

● ACID: a substance that can yield a hydrogen ion or hydronium

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● Uses HPO4 and H2PO4- to minimize changes in plasma and
ion when dissolved in water erythrocytes.
○ An increase in [H+] __________________ the pH ● Primary buffer in urine
○ A decrease in [H+] __________________ the pH 3. Plasma protein buffers
● BASE: substance that can yield hydroxyl ions 4. Hemoglobin buffer
● BUFFER: combination of a weak acid or a weak base and its
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salt; a system that resists changes in pH ORGANS INVOLVED IN ACID-BASE BALANCE
● pH = negative or inverse log of the hydrogen ion concentration ● Two organs that help maintain blood pH are __________________
[pH = -log (H+)] and __________________ .
● If blood pH is too low (ACIDOSIS)
BUFFER SYSTEMS - respiration increases to
1. Bicarbonate-Carbonic Acid buffer system remove more CO2 kidneys
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● Most important buffer system in the bod excrete more H+/bicarbonate
● The bicarbonate buffer system in involves the balance of ions
○ carbonic acid (H2CO3) ● If blood pH is too high (alkalosis)
○ bicarbonate ions (HCO3-), and - respiration decreases to
○ carbon dioxide (CO2) remove less CO kidneys
in order to maintain pH in the blood around Carbon dioxide (CO2) excrete less H+/bicarbonate
reacts with water (H2O) to form carbonic acid (H2CO3), which rapidly ions
2023 MEDICAL TECHNOLOGY BOARD REVIEW - CLINICAL CHEMISTRY LJUCO2023 46
HENDERSON HASSELBALCH EQUATION BLOOD GAS PARAMETERS
● pH is directly proportional to ______________ Parameter Measurement of Derivation Reference value
○ increase in bicarbonate causes increase in pH and vice
versa pH [H+] pH electrode on blood gas 7.35-7.45
analyzer
● pH is inversely proportional to ______________
pCO2 Partial pressure of pCO2 electrode on blood 35-45 mmHg
CO2 gas analyzer
○ increase in pCO2 causes a decrease in pH and vice
versa pO2 Partial pressure of pO2 electrode on blood gas 81-110 mmHg

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O2 analyzer

HCO3- Bicarbonate Calculated value on blood 21-28 mmol/L

gas analyzer

Total CO2 Bicarbonate + Calculated value on blood 23-27 mmol/L

carbonic gas analyzer
FORMULAS TO REMEMBER
H2CO3 Carbonic acid Calculated by pCO2 x 0.03 1.05-1.35
mmol/L

Oxygen Amount of Measured by oximeter >95%

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saturation oxygenated
hemoglobin
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SAMPLE COMPUTATION
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CLINICAL SIGNIFICANCE SPECIMEN CONSIDERATIONS FOR ABG
Disturbance Organ Primary cause Organ to EFFECT
compensate
defective
1. Prolonged standing of
Acidosis Respiratory Lungs Hypoventilation Kidneys
the specimen
<7.35 pH
Metabolic Kidneys Bicarbonate Lungs 2. Specimen should be
excretion chilled during transport

Alkalosis Respiratory Lungs Hyperventilation Kidneys 3. Glycolysis

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>7.45 pH
4. Avoid excess heparin - most
Metabolic Kidneys Bicarbonate Lungs
reabsorption
common source of preanalytic
error
5. Lower temperature
BLOOD GAS ANALYSIS
● The term “________________” (BGA) is used for laboratory testing 6. Exposure to room air
that relates to acid-base balance and oxygenation status of a patient
● SPECIMEN COLLECTION
● SPECIMEN: Arterial blood COMMON ERRORS IN COLLECTION & HANDLING

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● ANTICOAGULANT:_________________ 1. Form and concentration of anticoagulant
● __________________________ 2. Speed of syringe filling
● Usual sites of arterial puncture are radial, brachial or femoral artery 3. Maintenance of anaerobiosis
● Syringe and needle for arterial blood collection must be 4. Mixing of samples
pre-heparinized by drawing up heparin into the syringe to wet its 5. Collection device Transport and Storage time
interior; any excess should be expelled before analysis
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● Butterfly infusion sets is NOT recommended
METHODS FOR BLOOD GAS ANALYSIS
BGA SPECIMEN COLLECTION > Gasometer
● Any air trapped in the syringe during collection should be ● Van Slyke - The instrument liberated and isolated "the desired gas
immediately expelled at the completion of draw. contained in a known volume of solution, and recording in
● ___________________________________ millimeters of mercury the pressure of that gas at a known fixed
● Following air-bubbles expulsion, homogenization of the sample with volume"
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the anticoagulant should be done to avoid formation of the clots. ● Natelson
● Rolling of the syringe between the palms, and then inverting it ○ Mercury - ______________
vertically (or mixing in figure of 8) ○ Caprylic alcohol - ____________
● The best method for blood gas collection in the newborn is by ○ Lactic acid
___________________________ ○ NaOH and NaHSO3
● A capillary blood sample can be considered as an adequate
substitute for the arterial blood in neonatal and paediatric units.

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> Spectrophotometric Determination of Oxygen Saturation > Modern Blood Gas Analyzers
(CO-Oximetry) ● Routinely contain ________
● The actual percent oxyhemoglobin (O2Hb) can be determined ● Rapid, accurate and direct measurement of:
spectrophotometrically using a CO-oximeter designed to directly ○ pH
measure the various hemoglobin species. ○ pCO2
● At a minimum, instruments should have four wavelengths for ○ pO2
measurements of HHb, O2Hb, and the two most common
dyshemoglobins, COHb and MetHb. > Continuous monitoring for pO2
● Uses transcutaneous(TC) electrodes placed directly on the skins of

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>Blood Gas Analyzers: pH, pCO2, and pO2 the patient
● Blood gas analyzers use electrodes (macroelectrochemical or ● Commonly used for:____________________
microelectrochemical sensors) as sensing devices to measure ● Non-invasive procedure
_________________
● The blood gas analyzer can also calculate several additional FACTORS AFFECTING BLOOD GAS & pH
parameters: ____________________________________ MEASUREMENT
1. TEMPERATURE (37 degrees Celsius +/-
Blood Gas Analyzers: Measurement of pO2 0.1’) - MOST IMPORTANT FACTOR
● Principle: ____________________ - For every 1 degree Celsius

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● Electrode: ____________________ increase in fever
● Factors to consider: 3% ______ pCO2
● pO2 test is affected by build up of proteins on 7% ______ pO2
the surface of the membrane 2. Elevated plasma protein concentration -
● Bacterial contamination pO2 is mostly affected
3. Bacterial contamination - pO2 is mostly affected
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Blood Gas Analyzers: Measurement of pH 4. Improper transport of blood specimen
● Principle: ____________________ ● Blood sample not transported on ______: pO2 changes
● Electrodes: rapidly than pH and pCO2
1. ● Samples should be kept at room temperature and analyzed
2. immediately after blood collection
3. QUALITY CONTROL
● QC minimum requirement:
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Blood Gas Analyzers: Measurement of pCO2 ○ ______ ; and
● Principle:____________________ ○ _________________
● Electrode:____________________ ● Calibration:
● It has an outer semipermeable membrane that allows CO2 to ○ Each analyzer has recommended calibration protocols that
diffuse and dissolve into an internal layer of electrolyte, usually a include specific calibration materials and frequency
bicarbonate buffer. ○ Normally, two different gas mixtures with known pCO2 and
pO2 levels are used.

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PROFICIENCY TESTING
Regulation of adenosine Mg
● Participating in external, interlaboratory surveys or proficiency triphosphatase (ATPase) ion
testing programs is another essential component of ensuring the pumps
quality of blood gas Measurements.
● Ongoing comparisons of results through proficiency testing help Acid–base balance HCO3, K, Cl
ensure that systematic (accuracy) errors do not slowly increase and
go undetected by internal QC procedures.
● National reference lab for CC :_________________________ Blood coagulation Ca, Mg

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GOOD TO KNOW Neuromuscular excitability K, Ca, Mg
● Blood gas results are affected by gas mixture the patient is
breathing and by patient’s body temperature Production and use of ATP Mg, PO4
● The total CO2 in arterial blood (plasma or serum) is equal to HCO3 from glucose
in arterial blood
● Calculations of base excess uses pH and pCO2 values
● Blood gas results should be back to the physician preferably within
10 minutes after draw to obtain maximum benefit from them
SODIUM
● Most abundant cation in the extracellular space;

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_____________________________________________________________
● Largely determines the ______________ of the plasma.
ELECTROLYTES ● Concentration gradient is regulated by Na+/K+ -ATPase ion pump
● Ions capable of carrying an electrical charge; classified either as (active transport)
anions or cations ● 3 Na+ OUT, 2 K+ IN
● Plasma concentration is affected by
.J ○ Intake of water
IMPORTANCE OF ELECTROLYTES ○ Excretion of water
○ Blood volume status
Volume and osmotic ● Hormone control: _______________
regulation

Myocardial rhythm and ↑ (HYPERNATREMIA) ↓ (HYPONATREMIA)

contractility
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● Hyperaldosteronism ● heart failure,
Cofactors in enzyme Mg, Ca, Zn ● ingestion of sodium ● liver disease,
activation ● excessive sweating ● nephrotic syndrome,
● Burns ● renal failure,
● DI ● SIADH,
● hypoaldosteronism

2023 MEDICAL TECHNOLOGY BOARD REVIEW - CLINICAL CHEMISTRY LJUCO2023 50

SODIUM METHODS CHLORIDE
● Sodium normal value:__________________ ● Major extracellular anion
● Spx: serum, plasma, 24-hour urine, sweat ● It is involved in maintaining osmolality, blood volume, and electric
neutrality.
1. Flame Emission Spectrophotometry - ______________ ● ______________OF SODIUM (it is the major anion that
2. Chemical methods counterbalances the major cation, Na+)
3. Atomic Absorption Spectrophotometry (AAS) ● Reciprocal relationship with HCO3
4. Ion Selective Electrode (______________) - most routinely ○ Chloride In, HCO3 out

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used.
↑ (HYPERCHLOREMIA) ↓ (HYPOCHLOREMIA)
POTASSIUM
● Major intracellular cation
● prolonged diarrhea ● prolonged vomiting
● Major effect on skeletal and cardiac muscle contraction ● renal tubular disease ● burns
● ECG patterns - can be affected in the event of abnormal levels ● Dehydration ● salt-losing renal diseases
● hyperparathyroidism
↑ (HYPERKALEMIA) ↓ (HYPOKALEMIA)
CHLORIDE METHODS
● Acidosis ● Alkalosis

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● Chloride normal value:_________________
● Crush injuries ● Increased insulin, ● Specimen: Serum, heparinized plasma, 24-hour urine, sweat
● Tissue hypoxia ● Increased GI or urine loss
● Insulin deficiency 1. Ion Selective Electrode (ISE) - an ion-exchange membrane is
used to selectively bind Cl− ions
2. Amperometric-Coulometric Titration - uses the principle Cotlove
.J Chloridometer
3. Mercuric Titration - uses the principle Schales & Schales &
POTASSIUM METHODS Whitehorn
● Potassium normal value:______________ 4. Colorimetry method
● Specimen: Serum, Plasma, 24-hour urine
● ______________ BICARBONATE
● Second most abundant anion in ECF; account for more than 90%
1. Flame Emission Spectrophotometry - ______________
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of total CO2;
2. Chemical methods ● Methods:
3. Atomic Absorption Spectrophotometry (AAS) ○ ISE
4. Ion Selective Electrode (______________) - most routinely use ○ Enzymatic - converts CO2 to HCO3
● ↑ metabolic alkalosis (severe vomiting, hypokalemia, excessive
alkali intake)
● ↓ metabolic acidosis

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MAGNESIUM CALCIUM
● It is the fourth most abundant cation in the body and second most ● 99% of calcium is found in bones and teeth
abundant intracellular ion ● 1% is found in the blood
● Similar to Ca2+, it is the free ion that is physiologically active in the ● Exists in three forms in the blood
body ○ Free calcium (ionized) = 50%
● Mg2+ regulation appears to be related to that of Ca2+ and Na+ ○ Complexed calcium = 10%
● Functions ○ Protein Bound = 40%
○ Contributor to bone structure ● Controlled by parathyroid hormone, calcitonin and vitamin D
○ For muscle contraction and heart rhythm ○ PTH = ↑ calcium and ↓ phosphate

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○ Activator to enzymatic reactions ○ Calcitonin = ↓ calcium
○ Vitamin D = ↑ calcium and ↑ phosphate
● HYPERMAGNESEMIA:observed less frequently than is ● RECIPROCAL OR INVERSE RELATIONSHIP WITH ___________
hypomagnesemia.

↑ (HYPERCALCEMIA) ↓ (HYPOCALCEMIA)

● Primary hyperparathyroidism - ● Primary hypoparathyroidism -

adenoma or glandular glandular aplasia, destruction
hyperplasia or removal

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● Benign familial hypocalciuria ● Hypomagnesemia
● HYPOMAGNESEMIA ● Malignancy ● Hypermagnesemia
● Multiple myeloma ● Hypoalbuminemia (total
● IncreasedVitamin D calcium only, ionized calcium
● Thiazide diuretics not affected)
● Prolonged immobilization ● Acute pancreatitis
●
.J Vitamin D deficiency
● Renal disease
● Rhabdomyolysis
● Pseudohypoparathyroidism - is
a rare hereditary disorder in
which PTH target tissue
response is decreased (end
MAGNESIUM METHODS organ resistance).
● Mg normal value: ______________
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● SPECIMEN: Serum, urine
CALCIUM METHODS
● METHODS:
● CALCIUM NORMAL VALUE:
○ Total Calcium ______________
1. Calmagite method
○ Ionized Calcium______________
2. Formazan dye method
● SPECIMEN: Serum, plasma, urine
3. Methylthymol blue method
1. Orthocresolphthalein complexone (colorimetric method)
4. AAS - reference method
2023 MEDICAL TECHNOLOGY BOARD REVIEW - CLINICAL CHEMISTRY LJUCO2023 52
 a. Dye: Arzeno III ● INCREASED LEVEL: Uremia, renal failure, ketoacidosis, alcohol
b. Mg2+ inhibitor: 8-hydroxyquinoline (chelator) and salicylate poisoning, lactic acidosis, hypernatremia.
2. Atomic absorption spectrophotometry (AAS) – reference method ● DECREASED LEVEL: Hypoalbuminemia, severe hypercalcemia.
a. Lanthanum binds phosphate that might instead bind the
calcium and cause falsely low result ● NV: 7 to 16 mmol/L - WITHOUT K
3. Clark Collip Precipitation method ● NV: 10 to 20 mmol/L
4. Ferro Ham Chloroanilic acid Precipitation method
5. Ion-selective electrode – uses a liquid-membrane electrode with an _____________________________________________________________
ion-selective carrier such as dioctyphenyl phosphate

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VITAMINS & MINERALS
PHOSPHATE/INORGANIC PHOSPHORUS
● HORMONE CONTROL: PTH, Calcitonin, Vitamin D VITAMINS
● INVERSE relation with ______________ ● Formerly called as “accessory food factors”
● METHOD: ● coined by Casimir Funk in 1912
○ Fiske-Subbarow method (Ammonium molybdate method) – ● “vita”=necessary for life; “amines”= because vitamins were originally
Uses molybdate reagent thought to contain amino acids
● Organic compounds occurring in natural foods.
● NV: 0.78-1.42 mmol/L ● TWO MAJOR GROUPS:

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○ Water-soluble (vitamins B complex, vitamin C, etc.)
○ Fat-souble (____________________________)
ANION GAP
● Routine measurement of electrolytes usually involves only Na+, K+,
Vitamins Chemical Name Clinical Deficiency
Cl−, and HCO3− (as total CO2). These values may be used to
approximate the anion gap (AG). A1 Night Blindness, growth
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● Difference between unmeasured anions and unmeasured cation. retardation, dermatitis
● AG is useful in indicating an increase in one or more of the
unmeasured anions in the serum and also as a form of quality E Tocopherol RBC fragility
control for the analyzer used to measure these electrolytes.
D Cholecalciferol Rickets, Osteomalacia

K Phylloquinones
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B1 Thiamine ______________,
Wernicke-Korsakoff

B2 Riboflavin Cheilosis, Angular stomatitis,

Glossitis

B3 Niacin Pellagra

2023 MEDICAL TECHNOLOGY BOARD REVIEW - CLINICAL CHEMISTRY LJUCO2023 53

 B5 Panthotenic acid Paresthesia/Muscle weakness 3. Acid-base equilibrium.
4. Primary component of some tissues.
5. Component of some physiological compounds.
B6 Pyridoxine Seborrheic dermatitis 6. Enzymatic reactions.

B9 Folic Acid

B12 Cyanocobalamin Megaloblastic anemia,

neurologic abnormalities

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C Ascorbic Acid

ADDITIONAL NOTES:

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MINERALS
● Elements which are major components of body molecules.
● Nutritionally important (Ca, P, Mg, Na, K, and Cl)
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● Essential trace elements (Cr, Co,Cu, I, Fe, Mn, Mo, Zn, Se)
● Required but no known essential functions (As, Cd, Ni, Si, Sn, V)
● Toxic (Pd, Hg)

FUNCTIONS
1. Needed to provide a suitable medium for protoplasmic activity.
2. Play primary role in osmotic phenomena.

2023 MEDICAL TECHNOLOGY BOARD REVIEW - CLINICAL CHEMISTRY LJUCO2023 54

 COPPER
● Function: cellular respiration, neurotransmitter regulation, collagen
synthesis, development of vascular and skeletal structures and
CNS, protection from free radical damage
● Transported by: ______________
● TOXICITY_____________
● DEFICIENCY: Malnutrition, _____________ (kinky hair)

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IRON
● Fourth most abundant element in the earth’s crust
● Stored as ferritin (soluble) and hemosiderin (insoluble)
● Transported by _____________
● Diurnal variation: higher in the morning
● Deficiency:_____________ (microcytic, hypochromic RBCs)
_____________________________________________________________ ○ _ iron ; _ transferrin
● Overload state: HEMOCHROMATOSIS
TRACE ELEMENTS
ZINC

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> ESSENTIAL TRACE ELEMENTS ● Cofactor for >300 enzymes
● Essential trace elements are important for maintenance of normal
health, tissue and organ functions. CHROMIUM
● The most commonly used instrumentation for trace and toxic metal ● Important component of __________________________(Cr III)
analysis has been the atomic absorption spectrometer, either with ● Recognized allergen, respiratory tract irritant (Cr VI and carcinogen)
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flame (FAAS) or flameless (i.e., graphite furnace, GFAAS) ● Function:
atomization. ○ potentiates insulin action
● Atomic emission spectrometry is also useful for some elements, ○ Glucose and lipid metabolism
particularly if used in the form of inductively coupled plasma atomic
emission spectroscopy (ICP- AES) for atomization and excitation. IODINE
● Recently, inductively coupled plasma mass spectrometry (ICP-MS) is ● Function: synthesis of thyroid hormones
becoming more widely used because of its sensitivity, wide range of ● TOXICITY: Thyrotoxicosis
● DEFICIENCY: _____________, hypothyroidism, cretinism,
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elements covered, and relative freedom from interferences.
● Essential trace elements: Copper, Zinc, Iron myxedema
● Essential ultratrace elements: Chromium, Cobalt, Iodine,
Manganese, Molybdenum, Selenium

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 TUMOR MARKERS
NMP, BTA CFHrp, Basic fetoprotein Urinary bladder cancer
(BFP)
● Substances synthesized and released by a tumor OR produced by
host in response to a tumor. Prostatic specific antigen (PSA)
● Found in circulation, body cavity fluids, including blood and urine; cell
membranes or cytoplasm/nucleus of a cell.
● Used in diagnosing, determining disease progression, choosing _____________________________________________________________
therapeutic drugs, monitoring response to therapy, and detecting
recurrence. ENDOCRINOLOGY

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● Note: most common use is monitoring for tumor recurrence. ● Refers to the study of the different glands that regulate the system
● Ideally, tumor markers must be specific, sensitive and absent in of the body. In response to the changing environment.
healthy individuals
Endocrine System
SUMMARY OF TUMOR MARKERS ● Is a network of ductless glands of internal secretions
● It is considered to be the regulatory system of the body
Adrenocorticotropic hormone (ACTH) Small cell lung cancer ● It is regulated by means of control of hormone synthesis rather than
by degradation.
Hepatocellular and testicular cancer
● _____________serve as chemical messenger in the body to

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produce biochemical changes
Bence-Jones protein (BJP) Multiple myeloma

CA125 , HE4

_____________ , CA 549, Breast cancer

HER-2-/neu, Cathepsin G
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CA 19-9 Gastric, coloni and pancreatic
adenocarcinoma

Calcitonin Familiary medullary thyroid

carcinoma
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Carcinoembryonic antigen (CEA) Breast, lung colorectal and stomach
cancer

CYFRA 21-1 Lung cancer and breast cancer

(&bladder cancer)
ENDOCRINE SYSTEM FUNCTIONS
Human chorionic gonadotropin (hCG) Choriocarcinoma, testicular cancer ● Maintain Internal Homeostasis
● Support Cell Growth
2023 MEDICAL TECHNOLOGY BOARD REVIEW - CLINICAL CHEMISTRY LJUCO2023 56
 ● Coordinate Development Hormone secretion can be stimulated and inhibited by:
● Coordinate Reproduction ● Other hormones (stimulating- or releasing-hormones)
● Facilitate Responses to External Stimuli ● Plasma concentrations of ions or nutrients, as well as binding
globulins
WHAT ARE THE ELEMENTS OF AN ENDOCRINE SYSTEM ● Neurons and mental activity
● Sender = Sending Cell ● Environmental changes, e.g., of light or temperature
● Signal = Hormone
● Nondestructive Medium = Serum & Hormone Binders TYPES OF HORMONE ACTION
● Selective Receiver = Receptor Protein 1. Endocrine – secreted in one location and release into blood

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● Transducer = Transducer Proteins & 2º Messengers circulation; binds to specific receptor to elicit physiological response
● Amplifier = Transducer/Effector Enzymes 2. Paracrine – secreted in endocrine cells and release into interstitial
● Effector = Effector Proteins space; binds into specific receptor in adjacent cell and affects its
● Response = Cellular Response (2º Hormones) function
3. Autocrine – secreted in endocrine cells and sometimes release into
HORMONES interstitial space; binds into specific receptor on cell of origin
● Secretory products literary means to excite or to arouse into activity. resulting to self-regulation of its function
● Produced by a specific endocrine gland 4. Juxtacrine – secreted in endocrine cells and remains in relation to
● They are chemical signals produced by specialized cells secreted plasma membrane; acts on immediately adjacent cell by direct

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into the bloodstream and carried to a target site of action as free cell-to-cell contact
hormone or bound to transport protein 5. Exocrine – secreted in endocrine cells and released into lumen of
● They play an important role in the growth and development of an gut; it affects their function
organism 6. Neurocrine – secreted in neurons and released into extracellular
space; binds to receptor in nearby cell and affects its function
REGULATION OF HORMONES 7. Neuroendocrine – secreted in neurons and released from nerve
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● Hormones are regulated by the metabolic activity either positive or endings; interacts with receptor of cells at distant site
negative feedback mechanism
CLASSIFICATION OF HORMONES ACCORDING TO COMPOSITION &
1. __________________________ – an STRUCTURE
increased in the product also increases
Classification Comments Example
the activity of the system and the
production rate
Peptides and proteins cannot cross the cell Glycoprotein: FSH,
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Ex. Gonadal, thyroid and adrenocortical
> Glycoprotein membrane and thus, TSH, hCG, EPO, LH
hormones > Polypeptides produce their effects in
the outer surface of the Polypeptide: ACTH,
2. __________________________ – an cell; WATER ADH, GH, Angiotensin,
increased in the product decreases the activity of the system and the SOLUBLE; NOT Calcitonin,
bound to carrier protein Cholecystokinin,
production rate
Gastrin, Glucagon,

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 Insulin, MSH, Oxytocin,
PTH, Prolactin,
Somatostatin

Steroids lipid molecules that have Aldosterone, Cortisol,

cholesterol as a common Estrogen, Progesterone,
precursor; WATER Testosterone, Vitamin D
INSOLUBLE; BOUND
to carrier protein

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Amines Derived from amino Epinephrine,
acid and they are Norepinephrine, T3, T4,
intermediary between Serotonin
steroid and protein
hormones

Fatty acid derivatives Prostaglandins

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HORMONAL INTERACTION
● Antagonist reaction – the effect of one hormone is against the
action of another
● Synergistic reaction – the effect of one hormone is the same as the
action of the other
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● Potentiation reaction – the presence of one hormone increase the
action of another
● Permissive reaction – the presence of one hormone is necessary in
order to bring about the effects of the other
● Stimulatory reaction – the presence of one hormone stimulates the
secretion of another
● Inhibitory reaction – the presence of one hormone inhibits the
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secretion of another

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HORMONE CASCADE HYPOTHALAMUS
● Part of the CNS
● The pituitary stalk connects the hypothalamus and pituitary gland

HYPOTHALAMUS ANTERIOR TARGET ORGAN

PITUITARY

GnRH Testes & Ovaries

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TRH Thyroid

CRH Adrenal gland

GhRH Liver and peripheral tissues

PRP Mammary gland

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PITUITARY GLAND (HYPOPHYSIS)
● AKA: “Master gland”, “Spit mucus”
● Hypophysis(growth beneath the hypothalamus)
● Activity of thyroid gland, adrenal cortex, and gonads is controlled by
.J feedback effects of their circulating hormones on the
hypothalamic-pituitary axis.
> Anterior pituitary (_____________)
> Posterior pituitary (_____________)

ANTERIOR PITUITARY
● “True Endocrine Gland”
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● The hormones secreted are either peptides or glycoproteins
● 5 Types of cells by Immunochemical Tests:
○ Somatotropes – secrete GH
○ Lactotropes – secrete prolactin
○ Thyrotropes – secrete TSH
○ Gonadotropes – secrete LH and FSH
○ Corticotropes – secrete ACTH

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GROWTH HORMONE / SOMATOTROPIN ● Specimen requirement: blood should be collected 3-4 hours after
● Most abundant of all pituitary hormones the individual has awakened; fasting sample
● It stimulates growth and cell reproduction and regeneration in
humans and other animals
INCREASE PROLACTIN DECREASE PROLACTIN
● Controlled by GHRH and Somatostatin (decrease)
● Structurally similar to prolactin and human placental lactogen
● Markedly elevated during sleep (deep sleep) ● Hyperprolactinaemia is the ● Bulimia
● Patient preparation: complete rest 30 minutes before blood term given to having too-high ● Excess dopamine
levels of prolactin in the
collection

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blood.
● Specimen : _____________ ● Prolactinoma
● Excess thyrotropin-releasing
A. HYPERSECRETION hormone (TRH), usually in
> GIGANTISM primary hypothyroidism
- GH-producing tumor before epiphyseal closure (________) ● Many anti-psychotic
> ACROMEGALY medications
- GH-producing tumor after epiphyseal closure (__________) ; ● Emotional stress
bony and soft tissue overgrowth ● Pregnancy and Lactation.
LAB DIAGNOSIS:

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● Screening test: Somatomedic C or Insulin-like Growth Factor I
● Confirmatory test: OGTT (75g oral glucose load)

B. HYPOSECRETION
TSH (THYROID STIMULATING HORMONE)
> PITUITARY DWARFISM
- may be due to tumors or inevitable consequence of aging ● Also known as thyrotropin is a peptide hormone synthesized and
secreted by thyrotrope cells in the anterior pituitary gland which
LAB DIAGNOSIS:
.J regulates the endocrine function of the thyroid gland.
● Screening test: Exercise test ● TSH DISORDERS
● Confirmatory test:
○ HYPERSECRETION:
(1) Insulin Tolerance test (gold standard)
(2) Arginine Stimulation test (2nd confirmatory test) ■ Thyrotoxicosis/ Grave’s disease - can be due to
hyper activity of thyroid gland or pituitary gland
○ HYPOSECRETION:
PROLACTIN / LACTOGENIC HORMONE ■ Cretinism - _____________
● Also known as Luteotropic hormone (LTH) is a peptide hormone
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■ Myxedema - _____________
primarily associated with lactation.
● In breastfeeding, the act of an infant suckling the nipple stimulates
ACTH(ADENOCORTICOTROPIC HORMONE)
the production of prolactin, which fills the breast with milk via a
● Produced in response to low serum cortisol
process called lactogenesis, in preparation for the next feed.
● Regulate androgen synthesis
Oxytocin, another hormone, is also released, which triggers milk
● Deficiency causes to the atrophy of Zona glomerula and Zona
let-down.
reticularis ( layers of the Adrenal Cortex)
● _____________is its main inhibitory factor
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 ● Highest level is between 6:00-8:00AM ● Vasopressin and ADH is synthesized by the ______________ and
● Lowest level between 6:00 pm to 11:00PM stored & released by the posterior pituitary.
● Specimen consideration:
○ Collection of blood into pre-chilled polysterene (plastic) VASOPRESSIN
EDTA tubes to prevent degradation of ACTH - ACTH ● Arginine vasopressin (AVP), also known as vasopressin, argipressin
adheres to glass and will result to false decrease of values) or antidiuretic hormone (ADH)
○ BEST TIME of COLLECTION :_____________ ● Derived from a preprohormone precursor that is synthesized in the
hypothalamus and stored in vesicles at the posterior pituitary. Most
FSH (FOLLICLE STIMULATING HORMONE) of it is stored in the posterior pituitary to be released into the

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● Considered as a gonadotropin together with LH bloodstream; however, some of it is also released directly into the
● It regulates the development, growth, pubertal maturation, and brain.
reproductive processes of the human body. FSH and Luteinizing ● It acts on the DCT and collecting tubule of the nephron
hormone (LH) act synergistically in reproduction. ● It decreases the production of urine by promoting the reabsorption of
● An important markers in diagnosing fertility and menstrual cycle water by the renal tubules (maintains water homeostasis)
disorders ● A decreased in blood volume or blood pressure will stimulate ADH
● Aids in spermatogenesis, ovulation and final follicular growth release
● One of the most important roles of AVP is to regulate the body's
LH (LUTEINIZING HORMONE) retention of water; it is released when the body is dehydrated and

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● Also known as lutropin is a hormone produced by the anterior causes the kidneys to conserve water, thus concentrating the urine,
pituitary gland. and reducing urine volume.
● Female = an acute rise of LH – the LH surge – triggers ovulation. ● In high concentrations, it also raises blood pressure by inducing
Also helps corpus luteum to produce estrogen moderate vasoconstriction.
● Male = where LH had also been called Interstitial Cell Stimulating ● HYPERSECRETION: Syndrome of Inappropriate ADH secretion
Hormone (ICSH), it stimulates Leydig cell production of testosterone. (SIADH)
.J
● Important markers in diagnosing fertility and menstrual cycle ○ Diagnosis: _____________
disorders ● HYPOSECRETION: Diabetes insipidus
○ Diagnosis: _____________
MSH (MELANOCYTE STIMULATING HORMONE)
● Also called _____________or melanotropin DIABETES INSIPIDUS
● Stimulates melanocytes in the epidermis and hair follicles to release
NEUROGENIC DI NEPHROGENIC DI
melanin pigment
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● Hypersecretion: may cause abnormally dark skin pigment
● Hyposecretion: may cause abnormally light skin pigment ● True Diabetes insipidus ● Normal ADH but
(Hypothalamic/Neurogenic/ abnormal ADH receptor
Cranial/Central Diabetes ● Failure of the kidney to
POSTERIOR PITUITARY
Insipidus) respond to normal or
● Capable of releasing hormone but NOT capable of producing it. ● Deficiency of ADH with elevated ADH levels
● Hormones: Vasopressin, ADH normal ADH receptor

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 THYROID HORMONES
● Failure of the pituitary gland
to secrete ADH T3 T4
● There is large volume of
urine excreted (3-20 L/day) ● _____________(T3) ● _____________(T4)
● Also known as the 3,5,3’ ● Also known as 3,5,3’5’
triiodothyronine tetraiodothyronine
● It has the most active thyroid ● Principal secretory product
OXYTOCIN
hormonal activity ● A prohormone for T3
● Hormone that also acts as a neurotransmitter in the brain ● Almost 80% is produced from production

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● It is best known for its roles in female reproduction: the tissue deiodination of T4 ● All circulating T4 originates in
○ it is released in large amounts after distension of the cervix ● The principal application of the thyroid gland
and vagina during labor, and this hormone is in diagnosing ● The amount of serum T4 is a
○ after stimulation of the nipples, facilitating birth and T3 thyrotoxicosis good indicator of the thyroid
breastfeeding secretory rate

Thyroid Hormone Binding Proteins:

THYROID GLAND 1. Thyroxine-Binding Globin (TBG)
● Butterfly-shaped gland ● Transports 70-75% of total T4
● It is consists of two lobes (one on

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● Transports majority of T3
either side of the trachea) located ● Affinity for T3 is lower than T4
in the lower part of the neck just
below the larynx (voicebox) 2. Thyroxine-Binding Prealbumin (Transthyretin)
● The lobes are connected by a ● Transports 15-20% of total T4
narrow band called isthmus ● T3 has no affinity for prealbumin
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● By 11 weeks of gestation, the
gland begins to produce 3. Thyroxine-Binding Albumin
measurable amounts of hormone ● Transports most of the T3
● FOLLICLE – is the fundamental structural unit of the thyroid gland ● Transports 10% of total T4
○ Follicular cells (_____________)
○ Parafolllicular cells or C cells (_____________) REGULATION OF THYROID HORMONES
● Functions of Thyroid Hormones: ● TRH (Thyrotropin Releasing Hormone)
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○ For tissue growth ○ Synthesized by the hypothalamus to release ______
○ Form development of the CN ● TSH (Thyroid Stimulating Hormone)
○ Elevated heat production ○ Circulates to thyroid gland and increases production and
○ Increased oxygen consumption release of _____________

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DISORDERS OF THYROID THYROID HORMONES TEST
> HYPERSECRETION
TSH ● Most useful
1. THYROTOXICOSIS
● Hypothyroidism → _____________TSH
● Caused by excessive thyroid hormone in the circulation
● Hyperthyroidism → _____________TSH
● Due to pituitary tumors, excessive TSH secretion, thyroid ● 2nd & 3rd generation assays used in hormone replacement
carcinoma, and toxic multinodular goiter therapy & to screen for hyper & hypothyroidism
● ↑ T3 and T4; ↓ TSH and TRH
2. GRAVE’S DISEASE Serum T4 ● Measured by RIA or chemiluminometric assay
● Autoimmune disorder in which immunoglobulins are ● Low T4 - may indicate hypothyroidism

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produced that activate the TSH receptor ● High T4 - may indicate hyperthyroidism
3. Riedel’s thyroiditis
● The thyroid turns into a woody or stony-hard mass Serum T3 ● Measured by RIA or chemiluminometric assay
4. Subclinical hyperthyroidism ● Low T4 - may indicate hypothyroidism
● Showing no clinical symptoms but TSH is low and FT3 and ● High T3 - may indicate hyperthyroidism
FT4 are normal
5. Secondary (pituitary) hyperthyroidism FT4(Free T4) ● method of measuring T4 that eliminates the effect of
● Increased TSH and FT4 proteins that naturally bind T4 and may prevent accurate
measurement
6. Subacute granulomatous/Subacute nonsuppurative

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thyroiditis/De Quervain’s thyroiditis (painful thyroiditis)
FT3(Free T3) ● method of measuring T3 that eliminates the effect of
● Associated with neck pain, low grade fever and swings in proteins that naturally bind T3 and may prevent accurate
thyroid function testsThyroidal peroxidaxe (TPO) antibodies measurement
are absent, ESR and thyroblobulin levels are elevated
Thyroglobulin ● An ideal tumor marker for thyroid cancer patients
> HYPOSECRETION
.J
- Results in CRETINISM (congenital hypothyroidism) in children and Thyroid ● Detects antibodies directed at thyroid tissue
MYXEDEMA in adults autoimmunity
1. PRIMARY HYPOTHYROIDISM - Inadequate secretion of thyroid
hormones Other thyroid ● PBI (Protein Bound Iodine)
2. SECONDARY HYPOTHYROIDISM - Decrease in production of TSH fxn tests ● Total T4
leading to low serum levels of thyroid hormones ∙ ↓ TSH ; ↓ T3 and ● Total T3
T4 ; compensatory mechanism: ↑ TRH ● Resin T3 uptake test - indirect measure of TBG binding
capacity
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3. TERTIARY HYPOTHYROIDISM - Hypothalamic failure leading to a
● Thyroid releasing hormone stimulation
lack of TRH production ↓ TRH ; ↓ TSH ↓ T3 and T4 ● RAIU (Radioactive Iodine Uptake test)
4. CHRONIC IMMUNE THYROIDITIS (_____________
THYROIDITIS)
● Caused by a genetic abnormality in the immune system.
Involves massive infiltration of the thyroid gland by
lymphocytes. Same symptoms with hypothyroidism

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 T3 T4 TSH ADRENAL GLANDS
● Also known as suprarenal glands are endocrine glands that sit atop
1° the kidneys; in humans, the right suprarenal gland is triangular
HYPERthyroidism shaped, while the left suprarenal gland is semilunar shaped
● They are chiefly responsible for releasing hormones in response to
1°
stress through the synthesis of corticosteroids such as cortisol and
HYPOthyroidism
catecholamines such as epinephrine.
2°
HYPERthyroidism

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2°
HYPOthyroidism
Subclinical normal normal
Hyperthyroidism

Subclinical normal normal

Hypothyroidism

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CALCITONIN
● Hormone that is produced in humans primarily by the parafollicular
cells (also known as C-cells) of the thyroid, and in many other
animals in the ultimobranchial body. ADRENAL CORTEX
● Outer region of the adrenal gland secreting the steroid hormone
● It acts to _____________blood calcium (Ca2+), opposing the
● Major site of steroid hormone production
effects of parathyroid hormone (PTH).
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PARATHYROID GLAND
● It is located on or near the thyroid capsule (region of the thyroid
gland) sometimes within the thyroid gland
● It may also be found outside their normal anatomic site – between
the hyoid bone in the neck and mediastinum
ALDOSTERONE
● Most people have 4 parathyroid glands but some have 8 or as few as
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● From Zona _____________
2
● Primary mineralocorticoid
● _____________endocrine gland in the body
● Regulated by RAAS which is activated by:
● Secretes parathyroid hormones (PTH) – _____________
○ ↓ Plasma osmolality
● Parathyroid hormone – involved in the metabolism of both calcium
○ ↓ Sodium concentration in the blood
and phosphorus by the kidneys and bones
○ ↓ Circulating blood volume
● In bone – increases bone resorption of calcium into serum
○ ↓ Blood pressure
● In kidneys – increases renal reabsorption of calcium
2023 MEDICAL TECHNOLOGY BOARD REVIEW - CLINICAL CHEMISTRY LJUCO2023 64
 ● Reabsorption on sodium
HYPERSECRETION HYPOSECRETION
● Excretion of potassium
● Excretion of hydrogen ions
Cushing’s syndrome - caused by excess Addison’s disease or Adrenal
Clinical Disorders: glucocorticoid production or Insufficiency – caused by primary
prolonged exogenous steroid use adrenal problem or ACTH deficiency
1. Primary hyperaldosteronism (_____________)
● Caused by Aldosterone-secreting adrenal adenoma
● Symptoms: HPN, hypokalemia, mild hypernatremia and ANDROGENS
metabolic alkalosis ● From Zona reticularis

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2. Secondary hyperaldosteronism ● The most important androgens include:
● Occurs as a result of excessive production of rennin ○ Testosterone: a hormone with a wide variety of effects,
○ Liddle’s syndrome (pseudohyperaldosteronism) – ranging from enhancing muscle mass and stimulation of cell
resembles primary aldosteronism clinically but growth to the development of the secondary sex
aldosterone level is low and absence of HPN characteristics.
○ Bartter’s syndrome (Bumetanide-sensitive chloride ○ Dihydrotestosterone (DHT): a metabolite of testosterone,
channel mutation) – elevated concentrations of and a more potent androgen than testosterone in that it
Aldosterone and rennin binds more strongly to androgen receptors.
○ Gitelman’s syndrome (Thiazide-sensitive ○ Androstenedione (Andro): an androgenic steroid produced

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transporter mutation) – increased aldosterone by the testes, adrenal cortex, and ovaries. While
androstenediones are converted metabolically to
3. Hypoaldosteronism testosterone and other androgens, they are also the parent
● Due to destruction of the adrenal glands and deficiency of structure of estrone
glucocorticoid ○ Dehydroepiandrosterone (DHEA): It is the primary
● It is also associated with enzyme 21-hydroxylase deficiency precursor of natural estrogens. DHEA is also called
.J
● Symptoms: hyperkalemia and metabolic acidosis dehydroisoandrosterone or dehydroandrosterone. The
reticularis also produces DHEA-sulfate due to the actions of
CORTISOL a sulfotransferase, SULT2A1
● From Zona _____________
● Primary _____________ ADRENAL MEDULLA
● Critical to hemodynamic and glucose homeostasis ● The adrenal medulla is part of the adrenal gland. It is located
● Maintain blood glucose by inducing lipolysis and amino acid release at the center of the gland, being surrounded by the adrenal
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from muscle breakdown for conversion into glucose cortex.
(gluconeogenesis) and storage as liver glycogen ∙ ● It is the innermost part of the adrenal gland, consisting of
● Secretion is diurnal and is associated with a person’s sleep-wake cells that secrete epinephrine (adrenaline), norepinephrine
cycle
(noradrenaline), and a small amount of dopamine in response
● High level in the early morning (6-8AM) and lowest at night
to stimulation by sympathetic preganglionic neurons
(10PM-12AM)

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CATECHOLAMINES CATECHOLAMINES CLINICAL SIGNIFICANCE
> EPINEPHRINE (__________________________) ● Urine and Plasma catecholamines
● Is a hormone and a neurotransmitter. 1. _______________________(catecholamine-producing tumor)
● Most abundant medullary hormone ● Diagnosis:
● Called the “flight and fright hormone” because it is released in ○ Fractionated metanephrines & catecholamines: best
response to physiologic (injuries) or psychological (stress, test for diagnosis in a 24-hour collection
anxiety) threats ○ Total plasma catecholamines & urine metanephrines:
● Any form of stress that increases cortisol levels stimulates its most sensitive screening profile

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production ○ Plasma metanephrines: touted as most specific &
● It increases glucose concentration (glycogenolysis) sensitive diagnostic test; measured by HPLC or RIA
● Functions: ○ Urine metanephrines: possibly most sensitive urine test
○ increases heart rate ○ Serum chromogranin A & plasma catecholamines
○ constricts blood vessels ○ Clonidine suppression test
○ dilates air passages and participates in the ○ Radiologic localization: CT, MRI, PET scanning
fight-or-flight response of the sympathetic nervous
system GONADS (TESTES & OVARIES)
TESTES

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> NOREPINEPHRINE (__________________________) ● Predominant hormone: _____________
● Is a catecholamine with multiple roles including as a hormone ● Controlled by pituitary hormones:
and a neurotransmitter. ○ Follicle-Stimulating hormone (FSH) – acts primarily on
● Areas of the body that produce or are affected by germinal stem cell
norepinephrine are described as noradrenergic. ○ Luteinizing hormone (LH) – acts primarily on Leydig
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● One of the most important functions of norepinephrine is its cells, located in the testicular interstitium; synthesize
role as the neurotransmitter released from the sympathetic testosterone
neurons affecting the heart. An increase in norepinephrine ● Reflects the parallel rhythms of FSH and LH levels
from the sympathetic nervous system increases the rate of ● Highest level is found at about 8am
contractions ● Lowest level is found at about 8pm
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>DOPAMINE
● A cathecolamine produced in the body by the decarboxylation
of 3,4-dihydroxyphenylalanine (DOPA)
● Present in highest concentration in the regions of the brain
● It plays a role as a “reward center” and in many body
functions, including memory, movement, motivation, mood,
attention and more.
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DISORDERS OF TESTICULAR HYPOFUNCTION
Kallmann’s ● X-linked recessive trait
Syndrome that manifests as
Hypogonadotropic hypogonadism during
DISORDER Comments hypogonadism puberty
- Low ● Anosmia (inability to
Klinefelter’s testosterone smell)
● Most common karyotype:
Syndrome levels with low ● Midline defects (cleft
47, XXY
(Primary or palate and lip)
● Physical manifestations:
Hypogonadism) inappropriately ● Certain men also have
small and firm testicles,

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normal FSH or red-green color blindness,
gynecomastia,
LH levels congenital deafness and
azoospermia – sterility
cerebellar dysfunction

Testicular ● Most severe form of Age & Pituitary diseases

Feminization androgen resistance
Syndrome syndrome
Hypergonadotropic ● Physical development OVARIES
hypogonadism pursues the female type
- Low > ESTROGEN
testosterone, ● Estrogens are produced primarily by developing follicles in the

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elevated FSH ovaries, the corpus luteum, and the placenta.
and LH, and 5-Reductase ● Reduction in the levels of ● Luteinizing hormone (LH) stimulates the production of estrogen in
impaired sperm Deficiency 5-reductase – decreased the ovaries.
production testosterone level
● Some estrogens are also produced in smaller amounts by other
tissues such as the liver, adrenal glands, and the breasts. These
Myotonic Dystrophy ● Testicular failure typically
presents in the fourth secondary sources of estrogens are especially important in
.J decade of life postmenopausal women. Fat cells also produce estrogen, potentially
the reason why being underweight or overweight are risk factors for
Sertoli Cell – Only ● Lack of germ cells infertility.
Syndrome ● Men present with a small ● Estrogen is essential for the growth, development, and maintenance
testes – azoospermia but of female sex organs.
with normal testosterone
levels A. ESTRONE (E1)
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● most abundant estrogen in _____________
Testicular injury & infection B. ESTRADIOL (E2)
● most potent estrogen secreted by the ovary
● most abundant estrogen in the_____________
● serves a negative feedback for FSH
● it us used in assessing ovarian function

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C. ESTRIOL (E3) > RELAXIN
● metabolite of estradiol ● In the female, it is produced by the corpus luteum of the ovary, the
● the estrogen found in the_____________ breast and, during pregnancy, also by the placenta, chorion, and
● major estrogen secreted in the placenta decidua
● used to assess the fetoplacental unit, post date gestations and intra ● In the male, it is produced in the prostate and is present in human
uterine retardation semen.
● used as marker for Down Syndrome (together with AFP and hCG) ● In males, relaxin enhances motility of sperm in semen.

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> PROGESTERONE GASTROINTESTINAL MUCOSA
● Produced by the corpus luteum ● GASTRIN - The mucosa of the pyloric area of the stomach secretes
● Readying the endometrium for embryo implantation the hormone gastrin, which stimulates the production of gastric acid
● Dominant hormone responsible for the luteal phase for digestion.
● Deficiency would lead to failure of implantation of embryo, thickening ○ Highest elevation is seen in Zollinger-Ellison Syndrome
of cervical mucus and reduction of uterine contractions
● Fertility and ovulation marker ● SECRETIN - The mucosa of the duodenum and jejunum secretes
the hormone secretin, which stimulates pancreatic juice, bile, and
intestinal secretion.

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KIDNEYS
1. Renin
- Initial component of renin-angiotensin-aldosterone system
- Produced by the juxtagromerular cells of the renal medulla
- Responds to decreased extracellular fluid volume and low blood
.J pressure
2. Erythropoietin
- Production by cells close to proximal tubules
- Production is regulated by blood oxygen levels – hypoxia prodces
increased serum concentration within 2 hours
- Acts on the erythroid precursors in the bone marrow
- Decreased EPO: Chronic renal insufficiency and anemia
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3. 1, 25-dihydroxy Vitamin D3
- Active form of vitamin D
- Determine phosphate and calcium balance
- Bone calcification in the human body
- Osteomalacia – inadequate bone calcification; adult form of rickets –
distortion of normal vitamin D metabolism

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4. Prostaglandins TOXICOLOGY
- ↑ Renal blood flow
- ↑ Sodium and water excretion ● The study of substance toxic to the body. Common substances
- ↑ Renin release causing acute toxicity include alcohol, acetaminophen, salicylate,
abuse substance and carbon monoxide.
ENDOCRINE DISORDERS: SUMMARY OF SCREENING & ● IMPORTANT TERMS:
CONFIRMATORY TESTS
TD50 Is the dose that would be predicted to produce a toxic response in
50% of the population.

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LD50 Is the does that would predict death in 50% of the population

ED50 Is the does that would be predicted to be effective of

have a therapeutic benefit in 50% of the population

Toxic Agents Notes

Mercury - Binds with proteins and also an enzyme inhibitor; Method

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for testing: Reinsch test - Nicknamed “quicksilver”, this
is the only metal that assumes a liquid form under ordinary
conditions
- Erethism, appropriately described as being "mad as a
hatter" refers to an insidious change in mood to shyness,
withdrawal and depression along with explosive anger or
blushing is associated with it
.J
Lead - Component seen in household paints and potent enzyme
inhibitor
- Interferes with mitochondrial oxidative phosphorylation
(accelerated cell death and apoptosis), ATPases, calcium
dependent messengers; enhances oxidation - Characteristic
“wrist drop or foot drop” manifestation
- Whole blood for quantitative testing; urine for assessment
of recent lead exposure
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Ethanol - Most common drug of abuse; Methods for testing:
enzymatic, GC and osmometry

Methanol - Commonly used solvent and a contaminant of homemade

liquors
- Converted first to formaldehyde, the to formic acid in the
liver
2023 MEDICAL TECHNOLOGY BOARD REVIEW - CLINICAL CHEMISTRY LJUCO2023 69
 Carbon - Indicator of toxicity: “cherry red” color of Barbiturates Sedative hypnotics
monoxide the face; and it causes hypoxic state - Colorless,
odorless and tasteless gas Benzodiazepines Sedative hypnotics
- Inhibits cellular respiration and electron transport
Cannabinoids Derived from marijuana plant
Cyanide - Characteristic “odor of bitter almonds” Cannabis sativa; Most extensively
- Component of insecticides and rodenticides; common
abused drug in the world;
suicide agent
tetrahydrocannabinol (THC) is the
Arsenic - Characteristic “odor of garlic” and “metallic taste” most potent component

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- Use of hair and nails as specimens are important in the
evaluation of long-term exposure with the use of ion Opiates Derived from poppy plant Papaver
emission spectroscopy; Use blood and urine specimens for somniferum
short-term exposure; Method for testing: Atomic Medically used to relive moderate
absorption spectrophotometer to severe chronic pain
Cadmium - Utilized in electroplating and galvanizing; a significant Cocaine Alkaloid found in a plant,
environmental pollutant Erythroxylon coca; benzoylecgonine
is the primary metabolite;
DRUGS OF ABUSE AND ITS METABOLITES Medically used as a local
anesthesia; CNS stimulant

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● Specimen for drugs of abuse → urine is often used.
● Screening (immunoassays); confirmatory (GC-MS) Lysergic acid drugs Structurally similar to
Drug/Hormone Metabolite serotonin; synthesized
from a fungus- Claviceps
Norepinephrine/Epinephrine VMA purpurea Psychedelic drug,
Dopamine HVA hallucinogenic
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Serotonin 5-HIAA Amphetamines Ecstasy (MDMA-
methylenedioxymethamphetamine)
Heroin Morphine
Cocaine Benzoylecgonine Phencyclidine Aka: angel dust or angel hair

*CANNABIS THC
Procainamide NAPA
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Amitriptyline Nortryptyline
Primidone Phenobarbital

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STAGES OF ALCOHOL IMPAIRMENT
level to half of its initial value

0.01-0.05 No obvious impairement Peak concentration Is the highest concentration of a drug

obtained in the dosing interval
0.03-0.12 Mild Euphoria
Pharmacodynamics Is the relationship between the drug
0.09-0.25 Decreased CRIM: concentration and response of the
Critical Judgement, Reaction Time, tissues
Inhibitions, Memory
Pharmacogenomics Refers to the study of genes that

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0.18-0.30 Confusion, Dizziness, Slurred Speech
affect the performance of a drug in an
0.27-0.40 Cannot Stand, Vomit, IMPAIRED individual.
CONSCIOUSNESS
Pharmacokinetics Mathematical expression of the
0.35-0.50 Coma, Death relationship between drug dose and
drug blood level

THERAPEUTIC DRUG MONITORING

● Involves the analysis, assessment and evaluation of circulating SPECIMEN CONSIDERATIONS
concentrations of drugs in serum, plasma or whole blood. It allows

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Peak concentrations 1 hour after drug is orally or intramuscularly
for the safe use of drugs that would otherwise be potentially toxic. administered; 30 minutes if drug is intravenously
given.
IMPORTANT TERMS
Trough concentrations Blood sample should be drawn right before next dose
is administered.
Bioavailable fractions Is the fraction of the dose that reaches
.J the blood Specimen of choice Serum or plasma (do not use separator tubes)

Vd of the drug Represents the dilution of the drug Single most important Timing of specimen
after it has been distributed to the factor
body

First-pass hepatic metabolism Drugs that are transported to the

liver lost a fraction of its
bioavailability before reaching
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circulation

First-order elimination Represents linear relationship

between the amount of drug
eliminated per hour and the blood
level of drug

Half-life The time required to reduce a drug

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EXAMPLES OF DRUGS ● Healthcare-acquired infection (HAI) - an infection acquired by a
patient as the result of a health-care procedure that may or may not
Class Drugs
require a hospital stay.
Antibiotics Aminoglycosides, Vancomycin,
Chloramphenicol, Trimethoprim lactate STANDARD PRECAUTION FOR INFECTION CONTROL
● Standard precautions are work practices required to achieve a basic
Bronchodilators Theophylline level of infection control. This mainly includes:
Anti-neoplastic Methotrexate, Busulfan ○ Hand Hygiene
○ Use of gloves, eye protection, gown, mask (PPEs)

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Immunosuppressive Cyclophosphamide, Cyclosporine, ○ Prevention of needlestick Injuries
Leflunomide, Mycophenolate mofetil ○ Respiratory hygiene & Cough etiquette
○ Proper handling of linens
Anticonvulsants Phenobarbital, Phenytoin, Valproic acid
○ Environmental cleaning & Waste disposal
Anti-inflammatory Acetylsalicylic acid, acetaminophen ○ Proper use of patient care equipment

Anti-psychotic Phenothiazines HAND HYGIENE

● HAND CONTACT is the primary method of infection transmission.
Antidepressants Lithium, Imipramine ● _____________is the best way to break the chain of infection.

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Cardioactive Amiodarone, Digitoxin, Lidocaine
“When hands are visibly soiled, wash hands with soap and
water.
_____________________________________________________________ When hands are not visibly soiled, apply alcohol based
hand-rub (ex: hand sanitizers )”
MISCELLANEOUS TOPICS
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CHAIN OF INFECTION HANDWASHING PROCEDURE
● Wet hands with warm water.
● Apply antimicrobial soap.
● Rub to form a lather, create friction, and loosen debris.
● Thoroughly clean between fingers, including thumbs, under
fingernails and rings, and up to the wrist for at least 15-20 seconds.
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● Rinse hands in a__________________________
● Dry with a paper towel.
● Nosocomial Infection – an ● Turn off faucets with a clean paper towel to prevent recontamination.
infection acquired by a
patient during a hospital stay ● AND DON’T FORGET THE HANDWASHING SONG (TWICE)
○ #1 cause of Nosocomial infection:_________________

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 DONNING OF PPE:

DOFFING OF PPE:

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ENVIRONMENTAL CLEANING & WASTE DISPOSAL
● Use adequate procedures for the routine cleaning and
disinfection of environmental and other frequently
touched surfaces.

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● Ensure safe waste management.
● Treat waste contaminated with blood, body fluids,
secretions and excretions as clinical waste, in
accordance with local regulations.
● Human tissues and laboratory waste that is directly
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associated with specimen processing should also be
treated as clinical waste.
● Discard single use items properly. CHEMICAL HAZARDS
● Phlebotomists may come in contact with chemicals
while accessioning or processing samples in the laboratory
and preparing containers for urine samples that require
preservatives.
● General rules for safe handling of chemicals include:
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1. Taking precautions to avoid getting chemicals on the body,
clothes, and work area.
2. Wearing PPE, such as safety goggles when pouring
chemicals.
3. Observing strict labeling practices.
4. Carefully following instructions.

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 ● All chemicals and reagents containing hazardous ingredients in a ELECTRICAL HAZARD
concentration greater than 1% are required to have a Material ● When drawing blood or performing other
Safety Data Sheet (MSDS) on file in the work area. procedures, phlebotomists should avoid contact
with electrical equipment in the patient’s room
because current from improperly grounded
equipment can pass through the phlebotomist and
metal needle to the patient.

● When a situation involving electrical shock occurs, it is important to

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remove the electrical source immediately. This must be done without
touching the person or the equipment because the current will pass
on to you. ____________________ and moving the equipment using
a nonconductive glass or wood object are safe procedures to follow.
The victim should receive immediate medical assistance following
discontinuation of the electricity.

PHYSICAL HAZARDS
● General precautions that phlebotomists should observe include:

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1. Avoid running in rooms and hallways.
2. Be alert for wet floors.
3. Bend the knees when lifting heavy objects or
patients.
4. Keep long hair tied back and remove dangling
.J jewelry to avoid contact with equipment and patients.
5. Wear comfortable, closed-toe shoes with nonskid
soles that provide maximum support.
6. Maintain a clean, organized work area.
NOTE: DEGREE OF HAZARDS!!! (HAZARD INDEX)
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0 = No/Minimal Hazard
1 = Slight Hazard
2 = Moderate Hazard
3 = Serious Hazard
4 = Extreme/Severe Hazard

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 TYPES OF FIRE

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FIRE TYPE COMPOSITION TYPE OF EXTINGUISHI
OF FIRE FIRE NG MATERIAL
EXTINGUI
SHER

Class A Wood, paper, or Class A Water

clothing
.J Class B Liquid flammable org Class B Dry chemicals,
materials carbon
dioxide, foam, or Halon

Class C Electrical Class C Dry chemicals,

carbon
dioxide, or Halon

Class D Combustible mater Class A, B, C Dry chemicals or Sand or

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dry powder

Class K Grease, oils, Class K Liquid designed to prev

fats splashing and cool the f

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 LABORATORY MATH SOLUTIONS
● A solution is a homogenous mixture that contains small particles.
UNITS OF MEASURE Liquid solutions are transparent
● System Internationale d’ Unites (SI) is preferred in scientific ● Solutions consist of two parts:
literature and clinical laboratories and is the only system employed in ○ The _________ is the substance present in a lesser amount.
many countries. The SI system units (referred as SI units) are based ○ The _________ is the substance present in a larger amount.
on the metric system. Several sub-classifications exist within the SI An aqueous solution has water as the solvent.
system, one of which is the basic unit.

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SOLUBILITY
● Solubility is the amount of solute that dissolves in a given amount of
solvent.
● Solubility is usually reported in grams of solute per 100mL of solution
(g/100mL)
● Solubility can be summed up as “like dissolves like.”
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CONCENTRATION
● Concentration – how much solute is dissolved in a given amount of
solution
● Concentration can be measured in several ways that use mass,
volume, or moles.
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Percent Concentration
a. Weight/volume percent concentration, (w/v) %, is the number of
grams of solute dissolved in 100 mL of solution.

2023 MEDICAL TECHNOLOGY BOARD REVIEW - CLINICAL CHEMISTRY LJUCO2023 76

 c. Weight/weight percent concentration, (w/w) % is the mass of
Weight/volume percent concentration, (w/v) %
EXAMPLE: solute in grams contained in 100g of solution

Weight/weight percent concentration, (w/w) %

EXAMPLE:

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b. Volume/Volume percent concentration, (v/v) % is the number of
milliliters of solute dissolved in 100 mL of solution

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Parts per million
● When a solution contains a very small concentration of solute, it is
often expressed in parts per million.
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Volume/Volume percent concentration, (v/v) %
EXAMPLE:
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2023 MEDICAL TECHNOLOGY BOARD REVIEW - CLINICAL CHEMISTRY LJUCO2023 77

 NORMALITY
Parts per million
EXAMPLE: ● number of gram equivalent weight per liter of solution
● It has often been used in acid-base calculations
● GEW/L or mEq/mL

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MOLARITY
● Molarity is the number of moles of solute per liter of solution,
abbreviated as M. Normality Example:

Molarity Example:

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To prepare a normal solution of solids:
Grams of solute = GEW x Normality x Volume (L)
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2023 MEDICAL TECHNOLOGY BOARD REVIEW - CLINICAL CHEMISTRY LJUCO2023 78

MOLALITY DILUTION
● It is the amount of solute per 1 kilogram of solvent. It is expressed in ● Dilution is the addition of solvent to decrease the concentration of
terms of w/w or moles per kilogram solute. The solution volume changes, but the amount of solute is
constant.

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Dilution Example:

Molality Example:

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2023 MEDICAL TECHNOLOGY BOARD REVIEW - CLINICAL CHEMISTRY LJUCO2023 79