The Role of GP In Laboratory Medicine

Health care delivery involves many different disciplines and specialities diagnostic evaluation/services laboratory test.

Human body
Consist of many systems System is : a set or series of interconnected or interdependent parts or entities (organs), that function together in a common purpose or produce results impossible of achievement by one of them acting or operating alone.

System consist of many organs Organ consist of tissues Tissue consist of cells

 E.g :
Neurobehaviour system Respiratory system Cardiovascular system Gastrointestinal system Genitourinary system Reproductive system Dermato musculoskeletal system etc

Respiratory system
Organs: nose, throat, trachea, bronchus, bronchioles, lung, etc. Tissues: muscle, connective Cells: epithel

 Systems work properly healthy human System(s) work improperly unhealthy (sick/ill) : Signs & symptoms (e.g fever/febris) Asymptomatic (e.g increase of blood glucose level/Diabetes Mellitus).

4 aspects of disease
1. Causes (disease agent, etiology) 2. Mechanism of its development (pathogenesis, pathophysiology) 3. Morphologic changes 4. Clinical significance

Sign
Definition :
An indication of the existence of something Any objective evidence of disease such evidence as is perceptible to the examining physician

Examples :
Anemic conjunctiva or icteric sclera

Symptom
Definition : any subjective evidence of disease or of patients condition. Examples : Fatigue, nausea

 Healthy people could become ill by one or another reasons called etiology. Mechanism of diseases is called pathophysiology/pathogenesis

Etiology
The study or theory of the factors that cause disease and the method of their introduction to the host the cause of disease.

Pathophysiology/pathogenesis
Pathophysiology : the physiology of disordered function. Pathogenesis : the development of morbid conditions or disease; more specifically, the cellular events and reactions and other pathologic mechanisms occurring in the development of disease.

Pathology
Branch of medicine which treats of the essential nature of disease, especially of the structural and functional changes in tissues and organs of the body which cause or are caused by disease. Cellular and Clinical Pathology

 Cellular (Anatomical Pathology): Regards the cells as a starting points of the phenomena of disease and that every cell descends from some preexisting cell.
Clinical Pathology: Pathology applied to the solution of clinical problems, especially the use of laboratory methods in clinical diagnosis.

Clinical Pathology

Basic biological & physical sciences

-Modern equipment

Medical principles

-Reagents
-IT -Industry/Vendor

 Disease : disruption of normal body function Anything which disrupts homeostasis may be viewed as a disease agent (etiology). Disease agents :
Infectious agents Physical and chemical agents Inherited genetic alterations Acquired mutation and cancer Malnutrition Inflammation and autoimmunity

Etiology

Healthy Human

Pathophysiology

Sick/ill

- Symptoms

- Signs
- Lab.evaluations

S.typhi

Etiology

Healthy Human
Pathophysiology
Endotoxin

Sick/ill

- Symptoms : fever, headache

- Signs : fever
- Lab.evaluations : leukopenia,
culture (+), Widal (+)

Diagnosis : Typhoid fever

Clinical Pathology
Clinical Hematology Clinical Chemistry

Samples :

Blood Blood Urine

Clinical Microbiology
Clinical Immunology

Stool
CSF Trans/Exudate etc blood

Clinical Hematology
Parameters to be evaluated : Hemoglobin Leucocyte count

Manually

Platelet count
Hematocrit etc

Automatically

Automatic Hematology Analyzer

Clinical Chemistry
Blood Parameters to be evaluated Glucose, protein, bilirubin, pregnancy test, etc Glucose, cholesterol, triglyceride, cardiac enzyme, etc

Urine

Clinical Microbiology

Blood Parameters to be evaluated

Blood cultures of microorganisms

Swab

Direct preparation of microorganisms

Clinical Immunology
Blood

Parameters to be evaluated

Hepatitis markers (A, B)

TORCH
HIV Dengue Typhoid etc

Purposes of Laboratory Tests

1. Screening 2. To confirm a diagnosis 3. To monitor patients disease status

The purpose and function of Clinical Pathology

1. Screening 2. Confirming or rejecting diagnosis 3. Monitoring:

Response to treatment (providing guidelines in patient management) Respons to drug (level) Measure progression or regression of a disease

4. Establishing a prognosis

Screening
1. Mass screening:
Phenylketonuria in newborn Hepatitis V in blood transfusion donor

2. Screening asymptomatic patients:

Blood glucose, cholesterol in mediecal check up

3. Screening symptomatic patients:

Symptomatic patients
1. Non-specific complaints 2. Specific problem already identified

Non-specific complaints
1. Battery of chemistry tests 2. Complete Blood Count (CBC) 3. Routine urinalysis Problem: positive test false positive results

Solution: repeat abnormal test on a different sample

Detecting disease through case finding or screening

Screening of the donors for Hepatitis B Virus : HBsAg : HBsAg : (+) Donors rejected (case findings)

HBsAg : (-)

Donors accepted (screening healthy subjects)

Specific complaint (problem)

Defined set of differential diagnosis

Screening test to spare down differential diagnosis (high sensitivity for a disease)

Test negative disease excluded Test positive True positive False positive use test(s) with high specificity

Confirming or rejecting diagnosis

Patient with fever Differential diagnosis: Dengue

Typhoid Laboratory results:

Dengue (-) Typhoid (+)

Final diagnosis:
Dengue reject Typhoid confirm

Providing guidelines in patient management

Patients with Diabetes Mellitus

2HPP* Blood glucose levels :

Mr.A : still high (300 mg/dL)

Mrs.B : normal (110 mg/dL)

Increase Oral Anti Diabetic dose

Maintain Oral Anti Diabetic dose

*2HPP : 2 hours post prandial (after meal)

Establishing prognosis
Patients with acute viral hepatitis

Cellular liver enzymes : ALT* level

Mr.X : high (400 IU)

Mrs.Y: very high (1400 IU)

Prognosis : good
*ALT : Alanine aminotransferase

Prognosis : bad

Monitoring follow up therapy

Patient with urinary tract infection

After finished 1 cured dosage of certain antibiotic

Urine culture still (+)

Change antibiotic with the sensitive one

Order of testing
From cheap to costly From less to more risky From simple to more complex
Within the constrains of time, risk, and cost, try to do the test or procedure with the most efficiency as soon as possible highest: sensitivity, specificity and predictive value

Perfect Test
1. 2. 3. 4. 5. 6. 7. Accurate (teliti) Precise (keterulangan tinggi) Discriminating ( kemampuan membedakan) Pain free (tidak menyakitkan) Risk free (risiko kecil) Inexpensive (murah) Useful (bermanfaat)

Phases of the Test

1. Pretest 2. Intratest 3. Posttest
Elements of:
Safe Effective Informative

Interpreting Laboratory Result

Reference Intervals (value) Sensitivity & specificity Interpreting & correlating abnormal laboratory values Quality Control & Quality Assurance

Reference intervals
A set of values of a certain type of quantity obtainable from a single individual or a group of individuals corresponding to a stated description (Dybkaer)

This description must be spelled out and available if others are to used the reference values

For each type of quantity, a series of reference group will be necessary, taking into consideration : age, sex, ras, menstruation, previous diet and exercise, posture etc.
Example : Hemoglobin level (new born baby, infant, children, female adult, male adult, elderly)

Example : Mean Hemoglobin level (g/dL)

Newborn 1-3 days 1 week 2 weeks 1 month 2 months 3-6 months 0.5-2 years 2-6 6-12 12-18 Female Male 18-49 Female Male : 16.5 : 18.5 : 17.5 : 16.5 : 14 : 11.5 : 11.5 : 12 : 12.5 : 13.5 : 14 : 14.5 : 14 : 15.5

Sensitivity & Specificity

Sensitivity :

indicates the frequency of positive test results in

patients with particular diseases. Its positivity in disease expressed as percent Example : The sensitivity of HIV test with 3rd generation of ELISA is 99.9 %.

Sensitivity & Specificity

Specificity :

indicates the frequency of negative test results

in patients without the diseases. Its negativity in health or absence of a particular disease expressed as percent Example : The specifitivity of HIV test with 3rd generation of ELISA is 98.5 %.

Interpreting & Correlating

Abnormal Laboratory Values
Major purpose of performing laboratory determination aids in the diagnosis & management of : patients with disease
individual in health assessment

Doctor has to :
1. Explain abnormal lab.value (esp.those that do not seem correlate with one another. 2. Recommended/order lab.test that may lead to correct diagnosis. 3. Reveal the occurrence of laboratory error

Fundamental Principles in
Interpretation of Values

Never rely on a single (out of reference range) value to make a diagnosis. It is vital to establish a trend in values.

Example :
Single Sodium values of 30 mEq/L does not necessarily indicate hyponatremia. It maybe spurious and may reflect such factors as : - improper phlebotomy technique - laboratory variability

Oslers Rule
Especially if the patient is under the age of 60 years, try to attribute all abnormal lab.findings to a single cause. Only if there is no possible way to correlate all abnormal findings, should the possibility of multiple diagnosis be entertained.

Thank you for your attention

Sequence of Tests
Depends on many situation: 1. Critical test with the highest yield is done, even though there maybe some risks. 2. Time-lower risk yield, less risky procedure done first

Elements of Safe, Effective and Informed care

PRETEST PHASE Basic knowledge & ness.skill Testing environments History & assessment Reimbursement for d/ service Methodology of testing Interfering factors Avoiding errors Proper preparation Patient education Testing Protocols Patient independence Test results Laboratory reports INTRATEST PHASE Basic knowledge & ness.skill Infection control Collaborative approaches Risk management Specimens and procedures Equipment and supplies Family presence Positioning for procedure Administr of drug & solution Management of environment Latex sensitivity & allergy Pain control, comfort measuRes, & patient Monitoring POSTTEST PHASE Basic knowledge & ness.skill Abnormal test results Follow-up councelling Monitoring for complications & sedation effect Test results availability Integration Reverral & Treatments Follow-up care Documentation, Record Keeping & Reporting Guidelines for disclosure Patient responses to d/

Margins of error
Ethics and the law Patients bill of right & respon

Sedation & analgesia

Expected & unex/ outcomes

Cultural sensitivity