An Occupational Health Assessment is a medical examination performed by an Occupational Health Physician. Its main aim is to advise employers on the employee’s health and make recommendations on what adjustments could be considered to ensure a safe/healthy working environment for that employee. It can also be an assessment of somebody’s fitness to work.
The JIB’s four approved Occupational Health Assessment Providers will carry out the following industry-specified series of tests as standard:
- Musculoskeletal questionnaire/assessment
- Skin health check
- Respiratory health check
- Audiometry health check
- Blood pressure
- Vision (Keystone test)
- Vibration health check
- Colour vision (Ishihara)
- Mental health/workplace stress assessment
A brief history
The Nordic Musculoskeletal Questionnaire (NMQ) was developed from a project funded by the Nordic Council of Ministers . The aim was to develop and test a standardized questionnaire methodology allowing comparison of low back, neck, shoulder and general complaints for use in epidemiological studies. The tool was not developed for clinical diagnosis.
The NMQ can be used as a questionnaire or as a structured interview. However, significantly higher frequencies of musculoskeletal problems were reported when the questionnaire was administered as part of a focused study on musculoskeletal issues and work factors than when administered as part of a periodic general health examination .
Section 1: a general questionnaire of 40 forced-choice items identifying areas of the body causing musculoskeletal problems. Completion is aided by a body map to indicate nine symptom sites being neck, shoulders, upper back, elbows, low back, wrist/hands, hips/thighs, knees and ankles/feet. Respondents are asked if they have had any musculoskeletal trouble in the last 12 months and last 7 days which has prevented normal activity.
Section 2: additional questions relating to the neck, the shoulders and the lower back further detail relevant issues. Twenty-five forced-choice questions elicit any accidents affecting each area, functional impact at home and work (change of job or duties), duration of the problem, assessment by a health professional and musculoskeletal problems in the last 7 days.
The reliability of the NMQ, using a test–retest methodology, found the number of different answers ranged from 0 to 23%. Validity tested against clinical history and the NMQ found a range of 0 to 20% disagreement. The authors concluded this was acceptable in a screening tool . Further trials identified that the number of different answers between questionnaires ranged from 7 to 26% for annual prevalence and 6 to 19% for weekly prevalence . This research also led to a number of improvements within the questionnaire including changing wording, layout and administration for use in the UK.
Comparing pain in the last 7 days and clinical examination found sensitivity ranged between 66 and 92% and specificity between 71 and 88% . In a further study of outpatients with a range of upper limb disorders, participants completed a Nordic style questionnaire on two occasions 1 week apart. The study identified that symptoms reporting for pain were highly repeatable and in terms of sensitivity, 0.90 for cervical spondylosis, 1.00 for shoulder capsulitis, 0.90 for lateral epicondylitis, 1.00 for carpal tunnel syndrome and 0.78 for Raynaud’s phenomenon . Both papers conclude that the NMQ is repeatable, sensitive and useful as a screening and surveillance tool. However, medical examination is essential to establish a clinical diagnosis.
The NMQ has been applied to a wide range of occupational groups to evaluate musculoskeletal problems, including computer and call centre workers [6,7], car drivers , coopers in the whisky industry , nursing  and forestry workers .
Skin health check
HOW TO CHECK YOUR SKIN
It is important to regularly check your skin to ensure that you are aware of any changes. A great way to remember to complete this regularly is to check it at the start of each season.
Fortunately, performing a skin check is easy if you know what to look out for. Use the ABCDE guide below, and make it a habit to examine your skin, and your partner’s skin, at the beginning of every season.
Follow these five steps to examine your skin.
STEP ONE: TORSO
Examine body front and back in mirror.
Lift your arms to check your face, head, neck, armpits and the sides of your body.
(Women) Lift each breast to check the underside.
With your back to a full length mirror, use a handheld mirror to check the back of the shoulders, back, upper arms and lower back.
STEP TWO: ARMS & HANDS
Look at the hands, both the backs and the palms.
Check between the fingers and under the fingernails.
Bend your elbows. Check wrists and forearms, both the back and front.
Use a large mirror to check all sides of the upper arms, including the underside.
STEP THREE: LEGS & FEET
Check the front of the legs.
Use a full length and a hand mirror to check the legs, backs of the legs, buttocks and feet.
Sit down and crossing one leg over the other to check the front and sides of the legs, ankles feet, between toes and under toenails.
Cross the other leg over and repeat.
Check the soles of the feet
STEP FOUR: FACE, HEAD & NECK
Systematically check your face, nose, lips, mouth and ears.
Use a comb to part your hair and check your scalp.
Use a handheld mirror to check behind your ears and neck.
STEP FIVE: BUTTOCKS & GENITAL AREA
Finally, check your back, buttocks and genital area with a hand mirror.
WHAT TO LOOK FOR: ABCDE
The ABCDE is a simple acronym or classification tool used by dermatologists to distinguish a superficial spreading melanoma from a normal mole: Asymmetry, Borders, Colour, Diameter and Evolving. It provides a simple way to think about what you are looking for. The following information should help you:
Unlike most benign moles, a malignant mole is often asymmetric. This means that if you draw a line through the middle of the mole, the two sides do not mirror one another. An asymmetric mole is a warning sign for melanoma. If you, or your partner, have any concerns about a mole, please see your doctor as soon as possible.
Example of a symmetric benign mole.
Example of an asymmetrical malignant mole.
Benign moles have smooth, even borders. Melanoma lesions often have uneven borders (ragged or notched edges).
An example of a mole with easily identifiable borders.
An example of a mole with difficult to distinguish borders.
Benign moles are usually a single shade – often a single shade of brown – whereas melanomas often contain multiple colours. Colours in melanoma lesions can include brown, black, pink, red, white or purple.
This benign mole is a single shade of brown.
This malignant mole contains multiple colours – a melanoma warning sign.
Benign moles are usually less than 6mm in diameter (<6mm or 1/4”). Melanoma lesions are often more than 6mm in diameter (>6mm or 1/4”).
An example of a mole less than 6mm.
An example of a mole larger than 6mm
When you check your skin, or your partner’s skin, look out for any signs of change in appearance. Benign moles usually do not change over time whereas melanoma lesions often grow in shape or change in height. If you notice a change in shape, colour or height of a mole see your doctor immediately. Other changes to be concerned about include bleeding, itching, or crusting.
An example of change in a malignant melanoma lesion. As you can see, this mole has more than doubled in size over the period it was photographed.
Respiratory health check
What Are Lung Function Tests and Why Are They Done?
Lung function tests (also called pulmonary function tests) include a variety of tests that check how well the lungs work. The most basic test is spirometry. This test measures the amount of air the lungs can hold. The test also measures how forcefully one can empty air from the lungs.
Spirometry is used to screen for diseases that affect lung volumes. It also is used to screen for diseases that affect the airways, such as COPD or asthma.
Lung volume testing is another commonly performed lung function test. It is more precise than spirometry and measures the volume of air in the lungs, including the air that remains at the end of a normal breath. In addition, a diffusing capacity test measures how easily oxygen enters the bloodstream. Exercise testing helps evaluate causes of shortness of breath. There are also tests to find out if asthma is present when the usual breathing test results are normal.
What to Expect
These tests are not painful. They are performed by a pulmonary function technician, who will require you to use maximal effort to blow out and breathe in air. The tests are repeated several times to make sure the results are accurate. When performing the test, keep the following in mind:
- You should take your daily medications prior to testing unless told otherwise.
- Do not smoke for at least six hours prior to testing.
- If you are using a short-acting inhaler that is used only as needed, do not use for six to eight hours prior to testing, if possible.
- Your doctor may give you other instructions regarding medications.
The exercise test will be performed on a bike or treadmill and you should plan to wear loose fitting, comfortable clothing and athletic shoes. You will be attached to a heart monitor and blood pressure machine to monitor your vital signs during the test. You will be given additional instructions about how to prepare for this test at the time it is ordered.
Understanding the Results
After the test, you can return to your normal daily activities. Normal values are calculated based on age, height and gender. If a value is abnormal, a lung problem may be present. Sometimes a patient with normal lungs may have a breathing test value that is abnormal. Your doctor will explain what your test results mean.
What Are the Risks?
You need to understand and follow directions to perform a lung function test. Exercise testing should not be done in those who have had:
- A heart attack or stroke in past three months
- A large aneurysm of a major vessel
- A major head injury
- Recent eye surgery
Special steps are taken to avoid spreading germs between patients who use the same lung function equipment. The technician will change mouthpieces and other equipment between patients. Special filters are also used to prevent the spread of germs. Be sure to ask questions before the test is started.
Audiometry health check
What Is Audiometry?
Hearing loss comes with age but can affect anyone. According to a study in American Family Physician, at least 25 percent of people over 50 experience hearing loss, and 50 percent of people over 80 experience it. One way to test for hearing loss is through the use of audiometry.
An audiometry exam tests how well your hearing functions. It tests both the intensity and the tone of sounds, balance issues, and other issues related to the function of the inner ear. A doctor who specializes in diagnosing and treating hearing loss called an audiologist administers the test.
The unit of measure for sound intensity is the decibel (dB). A healthy human ear can hear quiet sounds such as whispers. These are about 20 dB. A loud sound such as a jet engine is between 140 and 180 dB.
The tone of a sound is measured in cycles per second. The unit of measure for tone is Hertz (Hz). Low bass tones measure around 50 Hz. Humans can hear tones between 20-20,000 Hz. Human speech generally falls in the 500-3,000 Hz range.
Why Audiometry Is Performed
An audiometry test is performed to determine how well you can hear. This may be done as part of a routine screening or in response to a noticeable loss of hearing.
The common causes of hearing loss include:
- birth defects
- chronic ear infections
- inherited conditions, such as otosclerosis, which occurs when an abnormal growth of bone prevents structures within the ear from functioning properly
- an injury to the ear
- inner ear diseases, such as Ménière’s disease or an autoimmune disease that affect the inner ear
- regular exposure to loud noises
- a ruptured eardrum
Damage to the ear or exposure to loud sounds for a long period can cause hearing loss. Sounds louder than 85 dB, such as you hear at a rock concert, can cause hearing loss after only a few hours. It’s good to use hearing protection, such as foam earplugs, if you’re exposed to loud music or industrial noise on a regular basis.
Sensorineural hearing loss occurs when hair cells in the cochlea aren’t working properly. The cochlea is the part of the ear that translates sound vibrations into nerve impulses to be sent to the brain. Sensorineural hearing loss can also occur due to damage to the nerve that carries sound information to the brain or damage to part of the brain that processes this information. This type of hearing loss is usually permanent. It can be mild, moderate, or severe.
The Risks of Audiometry
Audiometry is noninvasive and carries no risk.
How to Prepare for Audiometry
An audiometry exam requires no special preparation. All you have to do is show up to your appointment on time and follow the audiologist’s instructions.
What do your blood pressure numbers mean?
The only way to know if you have high blood pressure (HBP, or hypertension) is to have your blood pressure tested. Understanding your results is key to controlling high blood pressure.
Healthy and unhealthy blood pressure ranges
Learn what’s considered normal, as recommended by the American Heart Association.
|BLOOD PRESSURE CATEGORY||SYSTOLIC mm Hg|
|DIASTOLIC mm Hg|
|NORMAL||LESS THAN 120||and||LESS THAN 80|
|ELEVATED||120 – 129||and||LESS THAN 80|
|HIGH BLOOD PRESSURE|
(HYPERTENSION) STAGE 1
|130 – 139||or||80 – 89|
|HIGH BLOOD PRESSURE|
(HYPERTENSION) STAGE 2
|140 OR HIGHER||or||90 OR HIGHER|
(consult your doctor immediately)
|HIGHER THAN 180||and/or||HIGHER THAN 120|
Note: A diagnosis of high blood pressure must be confirmed with a medical professional. A doctor should also evaluate any unusually low blood pressure readings.
Blood pressure categories
The five blood pressure ranges as recognized by the American Heart Association are:
Blood pressure numbers of less than 120/80 mm Hg are considered within the normal range. If your results fall into this category, stick with heart-healthy habits like following a balanced diet and getting regular exercise.
Elevated blood pressure is when readings consistently range from 120-129 systolic and less than 80 mm Hg diastolic. People with elevated blood pressure are likely to develop high blood pressure unless steps are taken to control the condition.
Hypertension Stage 1
Hypertension Stage 1 is when blood pressure consistently ranges from 130-139 systolic or 80-89 mm Hg diastolic. At this stage of high blood pressure, doctors are likely to prescribe lifestyle changes and may consider adding blood pressure medication based on your risk of atherosclerotic cardiovascular disease (ASCVD), such as heart attack or stroke.
Hypertension Stage 2
Hypertension Stage 2 is when blood pressure consistently ranges at 140/90 mm Hg or higher. At this stage of high blood pressure, doctors are likely to prescribe a combination of blood pressure medications and lifestyle changes.
This stage of high blood pressure requires medical attention. If your blood pressure readings suddenly exceed 180/120 mm Hg, wait five minutes and then test your blood pressure again. If your readings are still unusually high, contact your doctor immediately. You could be experiencing a hypertensive crisis.
If your blood pressure is higher than 180/120 mm Hg and you are experiencing signs of possible organ damage such as chest pain, shortness of breath, back pain, numbness/weakness, change in vision or difficulty speaking, do not wait to see if your pressure comes down on its own. Call 911.
Your blood pressure numbers and what they mean
Your blood pressure is recorded as two numbers:
- Systolic blood pressure (the first number) – indicates how much pressure your blood is exerting against your artery walls when the heart beats.
- Diastolic blood pressure (the second number) – indicates how much pressure your blood is exerting against your artery walls while the heart is resting between beats.
Which number is more important?
Typically, more attention is given to systolic blood pressure (the first number) as a major risk factor for cardiovascular disease for people over 50. In most people, systolic blood pressure rises steadily with age due to the increasing stiffness of large arteries, long-term buildup of plaque and an increased incidence of cardiac and vascular disease.
However, either an elevated systolic or an elevated diastolic blood pressure reading may be used to make a diagnosis of high blood pressure. According to recent studies, the risk of death from ischemic heart disease and stroke doubles with every 20 mm Hg systolic or 10 mm Hg diastolic increase among people from age 40 to 89.
Why blood pressure is measured in mm Hg
The abbreviation mm Hg means millimeters of mercury. Mercury was used in the first accurate pressure gauges and is still used in medicine today as the standard unit of measurement for pressure.
Taking your pulse versus checking your blood pressure
While both are indications of health, blood pressure and heart rate (pulse) are two separate measurements. Learn more about the difference between blood pressure and heart rate.
Vision (Keystone test)
Comprehensive Screening Tests
Substandard vision need not penalise most otherwise healthy persons. People with deficient sight skills can attain adequate vision if professional eye care is obtained when needed. This is why Vision Screening is playing an important role in industry.
In industry, a comprehensive screening programme can provide a general overview of employee’s visual disorders, detecting those where corrective action should be taken. Vision Screening Tests are a means of identifying individuals with defective vision who need a full eyesight test. Using the Keystone VS-II, we carry out fourteen tests of nine visual functions, not just visual acuity alone.
Screening Tests Can Indicate
Who Should be Screened?
- Display Screen Equipment users in accordance with the Health & Safety (Display Screen Equipment) Regulations 1992
- Van Drivers
- Fork Lift Truck Drivers
- Company Car Drivers
- Close Inspection Workers
- Occupations where ‘normal’ colour vision is desirable or essential
Vision Screening Process
After completing a vision screening questionnaire, the Vision Screening Test will be carried out using the Keystone VS-II. Results will be discussed with the employee and if necessary referrals to an optician will be advised. A report of the results will be forwarded to the employer. Screening can be carried out at Nuffield House or on Company premises. Each test takes approximately 15 minutes.
Vision screening is advisable at Initial Medical Assessment and then 2-yearly thereafter.
Vibration health check
What are the health effects of hand-arm vibration?
Vibration induced health conditions progress slowly. In the beginning it usually starts as a pain. As the vibration exposure continues, the pain may develop into an injury or disease. Pain is the first health condition that is noticed and should be addressed in order to stop the injury.
Vibration-induced white finger (VWF) is the most common condition among the operators of hand-held vibrating tools. The symptoms of VWF are aggravated when the hands are exposed to cold.
Vibration can cause changes in tendons, muscles, bones and joints, and can affect the nervous system. Collectively, these effects are known as Hand-Arm Vibration Syndrome (HAVS). Workers affected by HAVS commonly report:
- attacks of whitening (blanching) of one or more fingers when exposed to cold
- tingling and loss of sensation in the fingers
- loss of light touch
- pain and cold sensations between periodic white finger attacks
- loss of grip strength
- bone cysts in fingers and wrists
The development of HAVS is gradual and increases in severity over time. It may take a few months to several years for the symptoms of HAVS to become clinically noticeable.
What are the symptoms of hand-arm vibration syndrome (HAVS)?
Hand-arm vibration exposure affects the blood flow (vascular effect) and causes loss of touch sensation (neurological effect) in fingers.
A common method that is used to classify VWF is the Stockholm Workshop classification scale.
The Stockholm Workshop classification scale
for cold-induced peripheral vascular and sensorineural symptoms
(a) Vascular assessment
|1||Mild||Occasional attacks affecting only the tips of one or more fingers|
|2||Moderate||Occasional attacks affecting finger tips and middle of the finger (distal and middle phalanges), and also rarely affects the parts of the finger close to the palm (proximal phalanges)|
|3||Severe||Frequent attacks affecting all parts of most fingers (all phalanges)|
|4||Very Severe||Same symptoms as in stage 3 with skin changes in the finger tips.|
|(b) Sensorineural assessment|
|OSN||Exposed to vibration but no symptoms|
|1SN||Intermittent numbness, with or without tingling|
|2SN||Intermittent or persistent numbness, reduced sensory perception|
|3SN||Intermittent or persistent numbness, reduced tactile discrimination and/or manipulative dexterity|
Source: Gemne, G., et al. Scandinavian Journal of Work, Environment and Health. Vol. 13, no. 4 (1987). p. 275-278. And: American Conference of Governmental Industrial Hygienists (ACGIH). 2016 TLVs® and BEIs®. p. 190-194 and 198-204.
The severity of hand-arm vibration syndrome depends on several other factors, such as the characteristics of vibration exposure, work practice, personal history and habits. Table 2 summarizes these factors.
Factors that influence the effect of vibration on the hand
|Physical Factors||Biodynamic Factors||Individual Factors|
|Acceleration of vibration||Grip forces – how hard the worker grasps the vibrating equipment||Operator’s control of tool|
|Frequency of vibration||Surface area, location, and mass of parts of the hand in contact with the source of vibration||Ability to change or vary the work rate of the machine|
|Duration of exposure each workday||Hardness of the material being contacted by the hand-held tools, for example metal in grinding and chipping||Skill and productivity|
|Years of employment involving vibration exposure||Position of the hand and arm relative to the body||Individual susceptibility to vibration|
|State of tool maintenance||Texture of handle-soft and compliant versus rigid material||Smoking and use of drugs.Exposure to other physical and chemical agents.|
|Protective practices and equipment including gloves, boots, work-rest periods.||Medical history of injury to fingers and hands, particularly frostbite||Disease or prior injury to the fingers or hands|
Is Raynaud’s phenomenon of occupational origin?
Hand-arm vibration syndrome is also known as Raynaud’s phenomenon of occupational origin. Vibration is just one cause of Raynaud’s phenomenon. Other causes are connective tissue diseases, tissue injury, diseases of the blood vessels in the fingers, exposure to vinyl chloride, and the use of certain drugs. The resulting reduced blood flow can produce white fingers in cold environments.
What are the health effects of whole-body vibration?
Whole-body vibration can cause fatigue, stomach problems, headache, loss of balance and “shakiness” shortly after or during exposure. The symptoms are similar to those that many people experience after a long car or boat trip. After daily exposure over a number of years, whole-body vibration can affect the entire body and result in a number of health disorders. Studies of bus and truck drivers found that occupational exposure to whole-body vibration could have contributed to a number of circulatory, bowel, respiratory, muscular and back disorders. The combined effects of body posture, postural fatigue, dietary habits and whole-body vibration are the possible causes for these disorders.
Many studies have reported decreased performance in workers exposed to whole-body vibration.
How much vibration exposure has to accumulate before people are affected?
As in all occupational exposures, individual sensitivity to vibration varies from person to person.
Three important factors affect the health effects that can result from exposure to vibration:
- the threshold value or the amount of vibration exposure that results in no adverse health effects
- the dose-response relationship (how the severity of the ill health effects is related to the amount of exposure)
- latent period (time from first exposure to appearance of symptoms)
The threshold value of vibration is the level below which there is no risk of vibration syndrome. In other words, it is the maximum intensity of vibration to which most healthy workers can be exposed every workday for their entire full-time employment without developing numbness, paleness or chill of fingers. Workers will not be likely to develop vibration-related injuries or disease if their exposure to vibration is maintained at sufficiently low levels.
What has been observed is that the number of affected people increases as the intensity and duration of vibration exposure increases. This type of exposure-response relationship indicates a possible link between health effects and the total amount of vibration energy entering the hands or body. Depending on the intensity of exposure, the symptoms may appear months or years after the start of the exposure.
Are there any studies about the combined effect of noise and vibration?
Since most vibrating machines and tools produce noise, a vibration-exposed worker is likely to be exposed to noise at the same time. Studies of hearing loss revealed that, for equal noise exposure, those with vibration-induced white finger (VWF) had greater hearing loss than those without VWF. The reason for this effect is not clear.
Are there laws regarding vibration exposure at work?
Canada, British Columbia, Saskatchewan, Manitoba, Quebec, New Brunswick, Yukon, Northwest Territories, and Nunavut are the jurisdictions in Canada that have specifically mentioned vibration exposure within their occupational health and safety regulations in terms of worker health or musculoskeletal effects. Most jurisdictions do not regulate a specific limit to exposure, but rather state that workplaces must control for vibration where it can cause health or musculoskeletal effects.
The American Conference of Governmental Industrial Hygienists (ACGIH) has published exposure recommendations for prevention of hand-arm and whole body vibration.Document last updated on February 1, 2017
Colour vision (Ishihara)
Ishihara 38 Plates CVD Test
The original Ishihara color blindness test was introduced in early last century and since then, it is by far the most well known color vision deficiency test all around the world. Dr. Shinobu Ishihara from Japan produced three different test sets which are widely used and which all based on the same pseudoisochromatic plates.
This test is actually designed to be used in a booklet and is usually executed by an eye doctor.But I have made an onlince version of the test, available right here on Colblindor.
The online test is based on the 38 plates edition and will give you a little feedback at the end of the test.
As this test is only made to check for red-green color blindness, any other form of CVD can not be detected. And at the end—if you like—you can even share your test result with your friends.This way they can see how you performed and try the test themselves if they like to.
At a Glance
Why Get Tested?
To screen for, help diagnose and/or monitor several diseases and conditions, such as kidney disorders or urinary tract infections (UTIs)
When To Get Tested?
When you have symptoms, such as abdominal pain, back pain, frequent or painful urination; sometimes as part of a health examination, pregnancy check-up, hospital admission, or pre-surgical work-up
One to two ounces of urine—a sufficient sample is required for accurate results; sometimes you may be directed to collect a sample using a “clean-catch” technique: women should spread the labia of the vagina and clean from front to back; men should wipe the tip of the penis. Start to urinate, let some urine fall into the toilet, then collect one to two ounces of urine in the container provided, then void the rest into the toilet.
Test Preparation Needed?
What is being tested?
A urinalysis is a group of physical, chemical, and microscopic tests. The tests detect and/or measure several substances in the urine, such as byproducts of normal and abnormal metabolism, cells, cellular fragments, and bacteria.
Urine is produced by the kidneys, two fist-sized organs located on either side of the spine at the bottom of the ribcage. The kidneys filter wastes out of the blood, help regulate the amount of water in the body, and conserve proteins, electrolytes, and other compounds that the body can reuse. Anything that is not needed is eliminated in the urine, traveling from the kidneys through ureters to the bladder and then through the urethra and out of the body. Urine is generally yellow and relatively clear, but each time a person urinates, the color, quantity, concentration, and content of the urine will be slightly different because of varying constituents.
Many disorders may be detected in their early stages by identifying substances that are not normally present in the urine and/or by measuring abnormal levels of certain substances. Some examples include glucose, protein, bilirubin, red blood cells, white blood cells, crystals, and bacteria. They may be present because:
- There is an elevated level of the substance in the blood and the body responds by trying to eliminate the excess in the urine.
- Kidney disease is present.
- There is a urinary tract infection present, as in the case of bacteria and white blood cells.
A complete urinalysis consists of three distinct testing phases:
- Visual examination, which evaluates the urine’s color and clarity
- Chemical examination, which tests chemically for about 9 substances that provide valuable information about health and disease and determines the concentration of the urine
- Microscopic examination, which identifies and counts the type of cells, casts, crystals, and other components such as bacteria and mucus that can be present in urine
See below for details on each of these examinations.
A microscopic examination is typically performed when there is an abnormal finding on the visual or chemical examination, or if a healthcare practitioner specifically orders it.
Abnormal findings on a urinalysis may prompt repeat testing to see if the results are still abnormal and/or may be followed by additional urine and blood tests to help establish a diagnosis.
How is the sample collected for testing?
One to two ounces of urine is collected in a clean container. A sufficient sample is required for accurate results.
Urine for a urinalysis can be collected at any time. In some cases, a first morning sample may be requested because it is more concentrated and more likely to detect abnormalities.
Sometimes, you may be asked to collect a “clean-catch” urine sample. For this, it is important to clean the genital area before collecting the urine. Bacteria and cells from the surrounding skin can contaminate the sample and interfere with the interpretation of test results. With women, menstrual blood and vaginal secretions can also be a source of contamination. Women should spread the labia of the vagina and clean from front to back; men should wipe the tip of the penis. Start to urinate, let some urine fall into the toilet, then collect one to two ounces of urine in the container provided, then void the rest into the toilet.
A urine sample will only be useful for a urinalysis if taken to the healthcare provider’s office or laboratory for processing within a short period of time. If it will be longer than an hour between collection and transport time, then the urine should be refrigerated or a preservative may be added.
Is any test preparation needed to ensure the quality of the sample?
No advance test preparation is needed.
How is the test used?
The urinalysis is a set of screening tests that can detect some common diseases. It may be used to screen for and/or help diagnose conditions such as a urinary tract infections, kidney disorders, liver problems, diabetes or other metabolic conditions, to name a few.
A urinalysis is comprised of several chemical, microscopic and visual examinations used to detect cells, cell fragments and substances such as crystals or casts in the urine associated with the various conditions listed above. It can detect abnormalities that might require follow-up investigation and additional testing. Often, substances such as protein or glucose will begin to appear in the urine before people are aware that they may have a problem.
In people diagnosed with diseases or conditions, such as kidney disease or diabetes, the urinalysis may be used in conjunction with other tests, such as urine albumin, to follow treatment
When is it ordered?
A urinalysis may sometimes be ordered when a person has a routine wellness exam, is admitted to the hospital, or will undergo surgery, or when a woman has a pregnancy checkup.
A urinalysis will likely be ordered when a person sees a healthcare practitioner complaining of symptoms of a urinary tract infection or other urinary system problem, such as kidney disease. Some signs and symptoms may include:
- Abdominal pain
- Back pain
- Painful or frequent urination
- Blood in the urine
Testing may also be ordered at regular intervals when monitoring certain conditions over time
What does the test result mean?
Urinalysis results can have many interpretations. Abnormal findings are a warning that something may be wrong and should be evaluated further. A healthcare practitioner must correlate the urinalysis results with a person’s symptoms and clinical findings and search for the causes of abnormal findings with other targeted tests, such as a comprehensive metabolic panel (CMP), complete blood count (CBC), renal panel, liver panel, or urine culture (for urinary tract infection).
Generally, the greater the concentration of the atypical substance, such as greatly increased amounts of glucose, protein, or red blood cells, the more likely it is that there is a problem that needs to be addressed. However, the results do not tell the healthcare practitioner exactly what the cause of the finding is or whether it is a temporary or chronic condition.
A normal urinalysis does not guarantee that there is no illness. Some people will not release elevated amounts of a substance early in a disease process, and some will release them sporadically during the day, which means that they may be missed by a single urine sample. In very dilute urine, small quantities of chemicals may be undetectable.
For additional details on what specific results may mean, see the sections below on:
- Visual examination
- Chemical examination
- Microscopic examination
Is there anything else I should know?
There are many factors that can affect or interfere with the tests that comprise a urinalysis. If instructed to do so, it is important to follow the directions carefully for a “clean-catch” sample. Give a complete history to your healthcare practitioner, including any prescribed or over-the-counter medications or supplements you may be taking. If you are a women, be sure to tell your healthcare practitioner whether you are menstruating.
Is the time of day a factor when collecting a urine sample?
Because this is a general screening test, time of collection is usually not important, although a first morning void may be preferred because it is more concentrated. However, if your healthcare provider is looking for a specific finding, you may be asked to collect a sample at a specific time.
See below for details on each of these examinations.
A microscopic examination is typically performed when there is an abnormal finding on the visual or chemical examination, or if a healthcare practitioner specifically orders it.
Abnormal findings on a urinalysis may prompt repeat testing to see if the results are still abnormal and/or may be followed by additional urine and blood tests to help establish a diagnosis.
During the visual examination of the urine, the laboratorian observes the urine’s color and clarity. These can be signs of what substances may be present in the urine. They are interpreted in conjunction with results obtained during the chemical and microscopic examinations to confirm what substances are present. (See The Chemical Examination and The Microscopic Examination for details)
Urine can be a variety of colors, most often shades of yellow, from very pale or colorless to very dark or amber. Unusual or abnormal urine colors can be the result of a disease process, several medications (e.g., multivitamins can turn urine bright yellow), or the result of eating certain foods. For example, some people can have red-colored urine after eating beets; the color is from the natural pigment of beets and is not a cause for worry. However, red-colored urine can also occur when blood is present in the urine and can be an indicator of disease or damage to some part of the urinary system. Another example is yellow-brown or greenish-brown urine that may be a sign of bilirubin in the urine (see The Chemical Examination section).
Urine clarity refers to how clear the urine is. Usually, laboratorians report the clarity of the urine using one of the following terms: clear, slightly cloudy, cloudy, or turbid. “Normal” urine can be clear or cloudy. Substances that cause cloudiness but that are not considered unhealthy include mucus, sperm and prostatic fluid, cells from the skin, normal urine crystals, and contaminants such as body lotions and powders. Other substances that can make urine cloudy, like red blood cells, white blood cells, or bacteria, indicate a condition that requires attention
To perform the chemical examination, most clinical laboratories use commercially prepared test strips with test pads that have chemicals impregnated into them. The laboratorian dips the strip into urine, chemical reactions change the colors of the pads within seconds to minutes, and the laboratorian determines the result for each test. To reduce timing errors and eliminate variations in color interpretation, automated instruments are frequently used to “read” the results of the test strip.
The degree of color change on a test pad can give an estimate of the amount of substance present. For example, a slight color change in the test pad for protein may indicate a small amount of protein present in the urine whereas a deep color change may indicate a large amount.
The chemical examination is often done in conjunction with or may be followed by a microscopic examination of the urine if there are any abnormal results. Results from both sets of tests are then considered together for interpretation. Abnormal findings may be followed by additional urine and/or blood tests.
The most frequently performed chemical tests using reagent test strips are described below
Urine specific gravity is a measure of urine concentration. This test simply indicates how concentrated the urine is. Specific gravity measurements are a comparison of the amount of substances dissolved in urine as compared to pure water. If there were no substances present, the specific gravity of the urine would be 1.000 (the same as pure water). Since all urine has some substances in it, a urine SG of 1.000 is not possible. If a person drinks excessive quantities of water in a short period of time or gets an intravenous (IV) infusion of large volumes of fluid, then the urine specific gravity may be very close to that of water. The upper limit of the test pad, a specific gravity of 1.035, indicates concentrated urine, one with many substances in a limited amount of water.
Knowing the urine concentration helps healthcare practitioners understand whether a urine specimen they are evaluating is the best one to detect a particular substance. For example, if they are looking for very small amounts of protein, a concentrated morning urine specimen would be the best sample
As with specific gravity, there are typical but not “abnormal” urine pH values. The urine is usually slightly acidic, about pH 6, but can range from 4.5-8. The kidneys play an important role in maintaining the acid-base balance of the body. Therefore, any condition that produces acids or bases in the body, such as acidosis or alkalosis, or the ingestion of acidic or basic foods can directly affect urine pH.
Some of the substances dissolved in urine will precipitate out to form crystals when the urine is acidic; others will form crystals when the urine is basic. If crystals form while the urine is being produced in the kidneys, a kidney stone or “calculus” can develop. By modifying urine pH through diet or medications, the formation of these crystals can be reduced or eliminated. (For additional information, see the articles on Kidney Stone Analysis and Kidney Stone Risk Panel.)
This test screens for bilirubin in the urine. Bilirubin is not present in the urine of normal, healthy individuals. It is a waste product that is produced by the liver from the hemoglobin of RBCs that are broken down and removed from circulation. It becomes a component of bile, a fluid that is released into the intestines to aid in food digestion.
In certain liver diseases, such as biliary obstruction or hepatitis, excess bilirubin can build up in the blood and is eliminated in urine. The presence of bilirubin in urine is an early indicator of liver disease and can occur before clinical symptoms such as jaundice develop.
The results of this test will be considered along with the result of urobilinogen (below). If positive, the healthcare practitioner will likely follow up with other laboratory tests, such as a liver panel, to help establish a diagnosis.
For more information, see the articles on Bilirubin and Liver Disease
This test screens for urobilinogen in the urine. The results are considered along with those for urine bilirubin (above).
Urobilinogen is normally present in urine in low concentrations. It is formed in the intestine from bilirubin, and a portion of it is absorbed back into the blood. Positive test results may indicate liver diseases such as viral hepatitis, cirrhosis, liver damage due to drugs or toxic substances, or conditions associated with increased RBC destruction (hemolytic anemia). When urine urobilinogen is low or absent in a person with urine bilirubin and/or signs of liver dysfunction, it can indicate the presence of hepatic or biliary obstruction
The protein test pad provides a rough estimate of the amount of albumin in the urine. Albumin makes up about 60% of the total protein in the blood. Normally, there will be no protein or a small amount of protein in the urine. When urine protein is elevated, a person has a condition called proteinuria.
Proteinuria may occasionally be seen in healthy individuals. Healthy people can have temporary or persistent proteinuria due to stress, exercise, fever, aspirin therapy, or exposure to cold, for example. Repeat testing may be done once these conditions have resolved to determine whether the proteinuria is persistent.
If trace amounts of protein are detected, and depending on the person’s signs, symptoms and medical history, a repeat urinalysis and dipstick protein may be performed at a later time to see if there is still protein in the urine or if it has dropped back to undetectable levels.
If a large amount of protein is detected on a urinalysis and/or if the protein persists in repeated tests, a 24-hour urine protein test may be used as a follow-up test. Since the dipstick primarily measures albumin, the 24-hour urine protein test also may be ordered if a healthcare practitioner suspects that proteins other than albumin are being released into the urine.
Protein in the urine may be a sign of kidney disease. Small amounts of albumin may be found in the urine when kidney dysfunction begins to develop. A different test called a urine albumin test detects and measures small amounts of albumin in the urine. The urine albumin test is more sensitive than a dipstick urinalysis and is routinely used to screen people with chronic conditions that put them at risk for kidney disease, such as diabetes and high blood pressure. (See the article on Urine Albumin.)
Proteinuria may also be associated with many other diseases and conditions. A healthcare practitioner may order other types of follow-up tests to help determine the cause of protein in the urine. For more information, see the articles on Proteinuria and Kidney Disease
Glucose is normally not present in urine. When glucose is present, the condition is called glucosuria. It results from either:
- An excessively high glucose level in the blood, such as may be seen with people who have uncontrolled diabetes
- A reduction in the “renal threshold;” when blood glucose levels reach a certain concentration, the kidneys begin to eliminate glucose into the urine to decrease blood concentrations. Sometimes the threshold concentration is reduced and glucose enters the urine sooner, at a lower blood glucose concentration.
Some other conditions that can cause glucosuria include hormonal disorders, liver disease, medications, and pregnancy. When glucosuria occurs, other tests such as a fasting blood glucose are usually performed to further identify the specific cause
Ketones are not normally found in the urine. They are intermediate products of fat metabolism. They are produced when glucose is not available to the body’s cells as an energy source. They can form when a person does not eat enough carbohydrates (for example, in cases of fasting, starvation, or high-protein diets) or when a person’s body cannot use carbohydrates properly. When carbohydrates are not available, the body metabolizes fat instead to get the energy it needs to keep functioning. Strenuous exercise, exposure to cold, frequent, prolonged vomiting, and several digestive system diseases can also increase fat metabolism, resulting in ketonuria.
In a person who has diabetes, ketones in urine may also be an early indication of insufficient insulin. With insufficient insulin, a diabetic cannot process glucose and instead metabolizes fat. This can cause ketones to build up in the blood, resulting first in ketosis and then progressing to ketoacidosis, a form of metabolic acidosis. Excess ketones and glucose are dumped into the urine by the kidneys in an effort to flush them from the body. This condition, called diabetic ketoacidosis (DKA), is most frequently seen with uncontrolled type 1 diabetes and can be a medical emergency. (See the articles on Ketones and Diabetes.)
Blood (Hemoglobin) and Myoglobin
This test is used to detect hemoglobin in the urine (hemoglobinuria). Hemoglobin is an oxygen-transporting protein found inside red blood cells (RBCs). Its presence in the urine indicates blood in the urine (known as hematuria).A small number of RBCs are normally present in urine and usually result in a “negative” chemical test. An increased amount of hemoglobin and/or increased number of RBCs are detected as a “positive” chemical test result. Results of this test are typically interpreted along with those from the microscopic examination of the urine to determine whether RBCs are present in the urine. A positive result on this test with no RBCs present may indicate the presence of hemoglobin in the urine (which can occur when RBCs have broken apart) or myoglobin from muscle injury. (See the article on Myoglobin.)Blood in the urine is not a normal finding, but it is not uncommon and not necessarily a cause for alarm. Your healthcare practitioner will investigate further to try to determine the source and underlying cause of the blood and may request repeat testing to determine whether the blood is persistent.See “The Microscopic Exam: Red Blood Cells” below and the article on Hematuria for more information.
Leukocyte esterase is an enzyme present in most white blood cells (WBCs). A few white blood cells are normally present in urine and usually give a negative chemical test result. When the number of WBCs in urine increases significantly, this screening test will become positive. Results of this test will be considered along with a microscopic examination for WBCs in the urine.
When this test is positive and/or the WBC count in urine is high, it may indicate that there is inflammation in the urinary tract or kidneys. The most common cause for WBCs in urine (leukocyturia) is a bacterial urinary tract infection (UTI), such as a bladder or kidney infection. In addition to WBCs, bacteria and RBCs may also be seen in the microscopic examination. If bacteria are present, the chemical test for nitrite may also be positive (see below).
This test detects nitrite and is based upon the fact that many bacteria can convert nitrate (a normal substance in urine) to nitrite. Normally, the urinary tract and urine are free of bacteria and nitrite. When bacteria enter the urinary tract, they can cause a urinary tract infection. A positive nitrite test result can indicate a UTI. However, since not all bacteria are capable of converting nitrate to nitrite, someone can still have a UTI despite a negative nitrite test. The results of this test will be considered along with the leukocyte esterase (above) and a microscopic examination
Ascorbic Acid (Vitamin C)
Occasionally, people taking vitamin C or multivitamins may have large amounts of ascorbic acid in their urine. When this is suspected to be the case, a laboratorian may test the sample for ascorbic acid (vitamin C) because it has been known to interfere with the accuracy of some of the results of the chemical test strip, causing them to be falsely low or falsely negative. Examples of tests that may be affected include the urine dipstick tests for glucose, blood, bilirubin, nitrite, and leukocyte esterase
A microscopic examination may or may not be performed as part of a routine urinalysis. It will typically be done when there are abnormal findings on the physical or chemical examination and the results from all will be taken into account for interpretation.
The microscopic exam is performed on urine sediment – urine that has been centrifuged to concentrate the substances in it at the bottom of a tube. The fluid at the top of the tube is then discarded and the drops of fluid remaining are examined under a microscope. Cells, crystals, and other substances are counted and reported either as the number observed “per low power field” (LPF) or “per high power field” (HPF). In addition, some entities, if present, are estimated as “few,” “moderate,” or “many,” such as epithelial cells, bacteria, and crystals. Cells and other substances that may be seen are listed below
Normally, a few RBCs are present in urine sediment (0-5 RBCs per high power field, HPF). A positive chemical test for hemoglobin and an increase in the number of RBCs seen under the microscope indicates that there is blood in the urine. However, this test cannot be used to identify where the blood is coming from. For instance, contamination of urine with blood from hemorrhoids or vaginal bleeding cannot be distinguished from a bleed in the urinary tract. This is why it is important to collect a urine specimen correctly and for women to tell their healthcare provider that they are menstruating when asked to collect a urine specimen.
Blood in the urine is not a normal finding, but it is not uncommon and is not necessarily a cause for alarm. Hematuria is a sign or an indicator that prompts a healthcare practitioner to investigate further to try to determine the underlying cause of the blood. As part of the investigation, a healthcare practitioner will evaluate an individual’s medical history, physical examination, and accompanying signs and symptoms. Additional urine and blood tests may be done to help determine the source.
Some of the underlying causes of hematuria are benign, temporary states that do no lasting harm and resolve with little or no specific treatment. If there is blood in the urine along with white blood cells and bacteria, it may be caused by a urinary tract infection that can be easily treated with antibiotics. Some causes of hematuria, however, may be critical conditions or represent a chronic condition that requires treatment and monitoring.
For more detailed information on causes and tests, read the article on Hematuria
White blood cells (WBCs)
The number of WBCs in urine sediment is normally low (0-5 WBCs per high power field, HPF). WBCs can be a contaminant, such as those from vaginal secretions.
An increased number of WBCs seen in the urine under a microscope and/or positive test for leukocyte esterase may indicate an infection or inflammation somewhere in the urinary tract. If also seen with bacteria (see below), they indicate a likely urinary tract infection
Epithelial cells are usually reported as “few,” “moderate,” or “many” present per low power field (LPF). Normally, in men and women, a few epithelial cells can be found in the urine sediment. In urinary tract conditions such as infections, inflammation, and malignancies, an increased number of epithelial cells are present. Determining the kinds of cells present may sometimes help to identify certain conditions. For example, epithelial cells containing large amounts of broken-down hemoglobin (called hemosiderin) may indicate that there were red blood cells or hemoglobin in the urine recently, even if there are none now
Bacteria, yeast and parasites
In healthy people, the urinary tract is sterile and, if the urine sample is collected as a “clean-catch” sample, there will be no microbes seen in the urine sediment under the microscope. Special care must be taken during specimen collection, particularly in women, to prevent bacteria that normally live on the skin or in vaginal secretions from contaminating the urine sample.
If microbes are seen, they are usually reported as “few,” “moderate,” or “many” present per high power field (HPF).
- Bacteria from the surrounding skin can enter the urinary tract at the urethra and move up to the bladder, causing a urinary tract infection (UTI). If the infection is not treated, it can eventually move to the kidneys and cause kidney infection (pyelonephritis). If a person has an uncomplicated lower urinary tract infection, then the person may be treated without need for a urine culture. However, if the person has had recurrent UTIs, suspected complicated infection, or is hospitalized, a urine culture and susceptibility testing may be performed to help guide treatment. (See the article on Urine Culture for details.)
- In women (and rarely in men), yeast can also be present in urine. They are most often present in women who have a vaginal yeast infection because the urine has been contaminated with vaginal secretions during collection. If yeast are observed in urine, then the person may be treated for a yeast infection.
- Trichomonas vaginalis is a parasite that may be found in the urine of women, or rarely, men. As with yeast, T. vaginalisinfects the vaginal canal and their presence in urine is due to contamination during sample collection. If these are found during a urinalysis, then Trichomonas testing may be performed to look for a vaginal infection.
Casts are cylindrical particles sometimes found in urine that are formed from coagulated protein released by kidney cells. They are formed in the long, thin, hollow tubes of the kidneys known as tubules and usually take the shape of the tubule (hence the name). Under the microscope, they often look like the shape of a “hot dog” and in healthy people they appear nearly clear. This type of cast is called a “hyaline” cast. Normally, healthy people may have a few (0–5) hyaline casts per low power field (LPF). After strenuous exercise, more hyaline casts may be detected.
Other types of casts are associated with different kidney diseases, and the type of casts found in the urine may give clues as to which disorder is affecting the kidney. Cellular casts, such as red blood cell and white blood cell casts, indicate a kidney disorder. Some other examples of types of casts include granular casts, fatty casts, and waxy casts. When a disease process is present in the kidney, cells or other substances can become trapped in the protein as the cast is formed. When this happens, the cast is identified by the substances inside it, for example, as a red blood cell cast or white blood cell cast.
For more on the types of conditions and disorders that can affect kidneys, read the article on Kidney Disease.
Urine contains many dissolved substances (solutes) – waste chemicals that the body needs to eliminate. These solutes can form crystals, solid forms of a particular substance, in the urine if:
- The urine pH is increasingly acidic or basic;
- The concentration of dissolved substances is increased; and
- The urine temperature promotes their formation.
Crystals are identified by their shape, color, and by the urine pH. They may be small, sand-like particles with no specific shape (amorphous) or have specific shapes, such as needle-like. Crystals are considered “normal” if they are from solutes that are typically found in the urine; these usually form as urine cools after collection and were not present in the body. Some examples of crystals that can be found in the urine of healthy individuals include:
- Amorphous urates
- Crystalline uric acid
- Calcium oxalates
- Amorphous phosphates
If the crystals are from substances that are not normally in the urine, they are considered “abnormal.” Abnormal crystals may indicate an abnormal metabolic process. Some of these include:
- Calcium carbonate
Normal or abnormal crystals can form within the kidneys as urine is being made and may group together to form kidney “stones” or calculi. These stones can become lodged in the kidney itself or in the ureters, tubes that pass the urine from kidney to the bladder, causing extreme pain. For more details, read Kidney Stone Analysis and Kidney Stone Risk Panel.
Medications, drugs, and x-ray dye can also crystallize in urine. Therefore, the laboratorian must be familiar with and trained in the identification of urine crystals.
Mental health/workplace stress assessment
For most people, work can be both challenging and demanding. Meeting challenges can promote growth and increase resiliency for employees and organizations. However, demands and challenges may also result in high stress, which can be costly.
Why is addressing stress important for employers?
Excessive workplace stress causes a staggering 120,000 deaths and results in nearly $190 billion in health care costs each year.1 This represents 5% to 8% of national health care spending, derived primarily from high demands at work ($48 billion), lack of insurance ($40 billion), and work-family conflict ($24 billion).
These are some of the harmful health effects from excessive stress:
- Damage to key brain structures and circuitry,2 reduced ability to cope with future stress and increased anxiety and chronic depression;3
- The onset of post-traumatic stress disorder (PTSD);4
- Reduced immune system functioning;5 and
- Increased inflammation and depression.6
High on-the-job demands and insufficient resources contribute to stress.7 In addition, an effort-rewards imbalance with perceptions of high effort and low compensation or recognition can also contribute to work stress.8 Goals perceived as exceedingly difficult, rather than achievable challenges, are also factors in excessive stress, anger, and anxiety.9
What can employers do?
Employers can address and reduce excessive workplace stress by focusing their efforts at the following three levels:10, 11
- Prevention level: by developing organization-wide policies and practices in the following key areas:12
- Training for leaders and supervisors on effective ways to reduce stress;
- Working with employees to create challenging but realistic goals for optimal performance;
- Communicating clearly and managing conflicts respectfully;
- Identifying and using employees’ strengths and skills for career advancement;
- Compensating fairly;
- Ensuring safe work conditions;
- Modeling work-life balance;
- Building in opportunities to formally recognize individual and team goal achievement;
- Creating a work climate that encourages social support and connectedness; and
- Developing ways to reflect on positive daily workplace events and accomplishments.
Adopting effective stress reduction strategies also holds promise in preventing depression13 which can be costly to employers.
- Targeted early identification and intervention level : offer employees the following options:
- Stress screenings and information on stress reduction and the early warning signs of mental health conditions;
- Effective intervention programs like cognitive-behavioral therapy for stress management;
- Programs that effectively address stress like mindfulness, relaxation, yoga and tai chi and encourage exercise, emphasizing the value to mental and physical health; and
- Programs that improve resiliency.
Web-based and mobile stress management programs offer employers cost-effective options for reducing workplace stress.15
- Intensive individualized support level:
- Assist employees in accessing effective care and supports;
- Initiate active outreach to employees out on disability;
- Support employees in remaining engaged with supervisors and co-workers;
- Develop effective transition and return to work policies and practices; and
- Consider ADA accommodations that help employees stay on the job.
Workplace stress can significantly impact the bottom line, however can also be managed to improve productivity, employee health and to create a more positive workplace climate and culture.