Penalaran Klinis

Natural History of Disease

Perjalanan Alamiah Penyakit

dr. Erlina Marfianti, MSc, SpPD

Internal Medicine Department
Medical Faculty
UII
 Tujuan Belajar
• Menjelaskan Perjalanan alamiah Penyakit
• Menjelaskan Perjalanan alamiah Penyakit
infeksi dan non infeksi
• Menggunakan perjalanan alamiah penyakit
untuk untuk melakukan keputusan klinis
• Menjelaskan dan mengaplikasikan
penalaran klinis dalam melakukan tindakan
klinis
 Natural History of Disease
(Perjalanan Alamiah Penyakit)
• The progress of a disease process in
an individual over time, in the
absence of intervention.
• The process begins with exposure to
or accumulation of factors capable
of causing disease.
• Without medical intervention, the
process ends with recovery
,disability, or death

3
Natural History of Disease
What is ‘clinical reasoning’?
Clinical reasoning describes
the thinking and
decision-making processes
associated with clinical
practice
 It is a clinician’s ability to …
a) make decisions based on the available clinical
information that includes history, clinical
examination and (sometimes) test results –
often against a backdrop of clinical
uncertainty
b) formulate and communicate these effectively
with the patient and/or their carers
Information from Natural
History of Disease

• Incubation period, Latent period

• Symptomp
• Time and Place 🡪 frequency
• Biologic Aspect of Pathogent
NHD , Is it Important ?

TECHNOL
Clinical
OGY
reasoning

PREVENTIF CONTROL
DIAGNOSIS SURVEILANCE
MANAGEMENT PROGRAM
THERAPY
PROGNOSIS

(COMMUNITY)
Natural History of Disease
TECHNOLO
GY

Exposure to Agent
Symptom
Development

Pre-exposure
Stage: Preclinical
Stage:
Factors present
Exposure to Clinical Stage: Resolution Stage:
leading to
problem causative Symptoms Problem resolved.
development agent: no present Returned to health
symptoms or chronic state or
present death

Primary Prevention Secondary Tertiary

Prevention Prevention

13
 Clinical skills (history,
examination,
communication)

Shared Use and

decision interpretation of
diagnostic tests
making

Clinical
reasoning

Patient centred
Understanding
evidence-based
cognitive biases and
medicine
human factors

Critical thinking
(metacognition)
Causes of diagnostic error
• No fault errors
• System failures
• Human cognitive error

1. Knowledge gaps
2. Misinterpretation of diagnostic tests
3. Cognitive errors and biases
Infection Disease
Communicable disease :
TBC, Malaria, HIV
Non Communicable disease:
Degenerative Disease/Chronic
Disease : DM, Heart Disease
Malignancy
Others
 Epidemiologic Triad

Disease is the result of

forces within a dynamic
system consisting of:

• agent of
infection
• host
Stage

•PREPATHOGENESIS
•PATHOGENESIS
•PASCAPATHOGENESIS
Prepathogenesis
Agent – Host Interaction
No disease
Immunity factor
Healthy person
Pathogenesis
Incubation period
Subclinical Stage of disease
(early disease)
Clinical Stage of disease
Pasca/PostPathogenesis
Death
Disability
Chronic
Carrier
Cure, Recovery
 RIWAYAT ALAMIAH PENYAKIT

MASA PRE- MASA

PASCA
PATHOGENESIS PATHOGENESIS PATHOGENESIS

Masa Meninggal
Masa Masa
lanjut Kronis
awal penyembuha
Sakit
sakit n Cacat
H
A
Sembuh
H A HORIZON KLINIS

A
H Awal terjadi
EE E
Sakit Waktu
Tempat
Keseimbangan
Pergeseran Orang
Interaksi
keseimbangan
 NATURAL HISTORY OF
DISEASE

• Generally
(Pre-Pathogenesis-Post)
• SPESIFIC (/ disease)
• Some disease 🡪 have similar
• Different in incubation period, etc
 ‘Good doctors are not those who don’t make
mistakes; good doctors are those who expect to
make mistakes and act on that expectation.’

James Reason
NATURAL HISTORY OF
INFECTION DISEASE
Trias

Disea disebabkan adanya interaksi antara agen penyebab penyakit dengan manusia
yang rentan dan didukung oleh keadaan lingkungan yang sesuai
 Factors Influencing Disease

Agent Environment
• Infectivity • Weather
• Pathogenicity • Housing
DISEASE

• Virulence • Geography
• Immunogenicity • Occupational
setting
• Antigenic stability
• Age • Air quality
• Survival Host
• Sex • Food
• Genotype
• Behaviour (www)
• Infectivity refers to the proportion of
Naturalpersons
exposed Historywhoandbecome
Spectrum of
infected.
Disease
• Pathogenicity refers to the proportion of
infected persons who develop clinical
disease.
• Virulence refers to the proportion of
persons with clinical disease who become
severely ill or die
 Timeline for Infection

Infection
Dynamics of Latent Infectious Non-infectious
infectiousness period period

Susceptible

Time
Infection

Dynamics of Incubation Symptomatic Non-diseased

disease period period

Susceptible

Time

(www)
 “Iceberg” concept of infectious disease
in populations

DEATH

CLINICAL
DISEASE
SEVERE
DISEASE

SUB CLINICAL MILD ILLNESS

DISEASE

INFECTION WITHOUT
CLINICAL ILLNESS

EXPOSURE WITHOUT INFECTION

31
LEVEL OF PREVENTION

1. Primordial Prevention
2. Primary Prevention
3. Secondary Prevention
4. Tertiary Prevention
 Natural history of disease
Interrelation of Agent , Host and Reaction of the host to the stimulus
Environmental Factor
Production of stimulus Early Discernible Advance Convalescence
pathogenesis early lesions disease
Pre-pathogenesis period Period of Pathogenesis
Health Promotion Specific protection Early diagnosis & Disability Rehabilitation
prompt treatment limitation
•Health Education •Use of specific •Case finding measures •Adequate •Provision of hospital
•Good standard of immunization individual & mass treatment to & community
nutrition adjusted to •Attention to personal •Screening surveys arrest the facilities for
developmental phases hygiene disease retaining &
•Selective examinations process and to education for
of life •Use of environmental objectives prevent further maximum use of
•Attention of personality sanitation To cure & prevent complications remaining capacities
development •Protection against disease process
•Education of public
•Provision of adequate occupational hazards To prevent the spread of
•Provision of & industry the
housing recreation & •Protection from a communicable diseases rehabilitated
facilities to
agreeable working accidents To prevent complications limit disability •As full employment
cond. & sequel
•Use of specific nutrients and to prevent as possible
•Marriage counseling To shorten period of death
ang sex education •Protection of disability •Selective placement
carcinogens •Work therapy in
•Genetics
•Avoidance of allergens hospitals
•Periodic selective
examination •Use of shelter
colony
Primary prevention Secondary Prevention Tertiary prevention
Natural History Of Chronic
Disease

HEART DISEASE
DIABETES MELLITUS
CHD Pathology: Coronary Artery
Sections
Normal Artery
Muscle Wall

Endothelium

Open Lumen

Atheroma Plaque
Then plaque ruptures
& triggers clotting

Thrombus
The LONG Natural History of CHD

HD
ofC
e
urs
al Co
tur
Na

↑ Atheroma

Atheroma &
Thrombosis
Hanlon, Capewell et al 1997
CHD starts early, presents later
✞
✞✞
HD
ofC
e
urs
al Co
tur
Na

↑ Atheroma

Inflammation &
Thrombosis
CHD starts early, presents later
✞
✞✞
HD
ofC
e
urs
al Co
tur ✞✞✞
Na

↑ Atheroma

Atheroma &
Thrombosis
CHD Prevention options

HD
ofC
e
urs
al Co
tur
Na
CHD Prevention options

HD
ofC
e
urs
al Co
tur
Na
CHD Prevention options

HD
e of C
ours
al C
r
N atu
 CVD
Risk Factor
Paradigm:
solid
evidence
base

IMPLEMENT THE DIET ACTION PLAN NOW

Population CVD
Biological Combined
Policies & Patient OUTPUTS
Risk Factors CVD Risk
Behaviours Groups
Diabete
s NO
SUD
Physic N-S
or S
al UDS
IGT Unstable Chronic
Activity
Obesit Angina Angina
y CHD
(BMI)
Death
Cholester
Diet
ol

Combined
CVD Risk
LDL
Acut Early From
(& HDL) e Heart any
MI State
Failure
Re
Blood
Smoking cu
Pressu
rre Severe
re
nt Heart

MI Failure Non-CHD
MI
survivors
Death
Deprivati
on Additional
CVD Stroke

Risk PAD

Factors etc

Populations: UK>E&W>Regions>PCTs

Outputs: Population-based incidence, prevalence; Deaths prevented; Life-Years; Life expectancy; Costs; Cost-effectiveness ratios
 International Diabetes Federation Definition:

Abdominal obesity plus two other components: elevated BP, low

HDL, elevated TG, or impaired fasting glucose
Case 1
• Seorang Laki-laki 26 tahun datang ke
Puskesmas, keluhan demam 1 hari,
pusing, demam terus menerus,
Dokter meminta melakukan
pemeriksaan darah lengkap.
Case 2
• Seorang wanita 18 tahun datang ke
Dokter dengan keluhan kuning, ada
mual dan sedikit demam sekitar 1
minggu. Riwayat teman kosnya
punya riwayat sama. Belum pernah
sakit kuning, riwayat tranfusi (-).
Kemudian diminta periksa lengkap
marker untuk HVB, HCV.
Case 3
• Seorang laki-laki 20 tahun datang
karena diare kronis selama 3 bulan.
Riwayat menggunakan narkoba. BB
turun, sering demam, dan ada
banyak sariawan di mulutnya.
Datang ke dokter, kemudian dokter
merencanakan untuk endoskopi.
Case 4
• Pasien penderita DM selama 20
tahun, selama ini dengan terapi
insulin dan metformin. Sebelumnya
terapi rutin dengan glimepirid dan
metformin. Akhir akhir ini muncul
bengkak di kaki, dan wajah kalau
bangun tidur. Dokter tetap memberi
obat rutin tersebut
ALHAMDULILLAH