Holistic Diagnosis Report

Diabetes Mellitus Type II With Complication Of

Diabetic Ulcus and Diabetic Neuropathy In the Elderly By Internal Risk Aspects
Through Family Medicine Approach

Arranged by:
Shafira Herowati Febriyanti 1102017213
Lecturer:
dr. Maya Trisiswati, MKM

Family Medicine Department Of Public Health

Faculty Of Medicine Yarsi University Period 26 September – 03 December 2022
 Patient’s Identity

1. Name : Mr. M 7. Religion : Islam

2. Age : 65 years old 8. Ethnic : Betawi

3. Sex : Male 9. Profession : Retired

4. Marital Status : Married 10. Examination date : 11 November 2022

5. Address : Menteng Sukabumi 11. Home Visit date : 15&17 November 2022

6. Education : Senior High School

Chief Complaint à Pain in the left instep since 6 months ago.
Current Medical History
Mr. M, 65 years old, came to the
Menteng Health Center with
complaints of pain in the left instep
since 6 months ago.
The patient also complained of
reduced touch sensation on the back
of his left leg, tingling on the tips of
his toes and since the last 3 months the
patient has felt weak and gets tired
quickly.
Initially there is a bubble
filled with fluid on the The wound is getting
instep of the left leg then wider and there is pus.
burst.
When examined the Then the doctor at the
patient's fasting blood puskesmas referred the
sugar was 324.2 mg/dl patient to Menteng Mitra
Afia Hospital, where the
patient admitted that the
wound had been cleaned and
sewn up.
Current Medical History
He was diagnosed with Diabetes Melitus since 17 years ago. His first symptom was feeling
weak all day and feeling like hungry all the time so he tend to eat a lot and got hungry easily, at
night he used to woke up every night to urinated. The patient felt like something wasn’t right, so he
cheked his symptoms to nearest doctor and turned out his blood sugar level reached 300 mg/dL. The
doctor gave the patient Metformin 3x500mg. Fortunately, the patient wants to recover and did a
rutine control and took medication regularly. But, two years ago, he often to forget to take his
medicine and rarely came to the health center to do check his health condition. He felt bored
because he had to took medicine every day and had his food controlled by his family. Also he has a
thought that the drugs could damage his kidney. The patient’s family has reminded the patient but
the patient tend not to listen.
 Past Medical History
§ The patient was diagnosed with
Diabetes Mellitus type 2 in 2005.
§ History of hypertension, cholesterol,
stroke, heart disease, and allergies
was denied.
§ History of medication Metformin
3x500 mg.
Family Medical History
§ History of diabetes mellitus : Father
and older sister of the patient.
§ History of hypertension : mother and
younger brother of the patient.
§ History of cholesterol, stroke, heart
disease, and allergies in the family
was denied.
 Social Personal History
The patient is the 2nd child of 4 siblings. The patient is married and has
one son. His child is married and currently the patient lives with his wife, children,
daughter-in-law, and his grandchild. He has a good relationship with his family
and easily socializes with anyone. His last education is senior high school.

Every day, he wakes up at 04.00 A.M to morning prayer. The patient is

rarely physically active. His routine daily activities are helping to clean the house
by sweeping. After that he will watch television and take a nap. In the afternoon,
the patient left the house and chatted with neighbors. Before experiencing leg pain, the
patient regularly attends routine recitation events and usually sleep at 21.00 P.M.
 Social Personal History
Before being diagnosed with DM type 2, he had an irregular eating
pattern, the patient ate four to five times a day. The food cooked by the patient's
wife or daughter-in-law and sometimes bought outside. The patient's daily food is
like rice, chicken, fish, eggs, or tempeh, tofu. He also likes to eat sweet such as
cakes, chocolate, 2 bottles of packaged sweet tea a day, and food made with
coconut milk and rarely eats fruits and vegetables. The patient never exercised and
never took part in elderly gymnastics held at the nearest Posyandu. The patient does
not consume alcohol or smoke.
Patient income comes from retired patients as civil servants, namely Rp.
1,300,000 /month, plus a little help from his son who works as a employee, namely
Rp. 3,000,000 /month. Patients and his family can meet their daily needs by living
simply.
 System Review
§ The patient has been diagnosed with DM Type 2 since 2005. Patients often have routine monthly visits
to the health center and take Metformin 3x500 mg regularly, however, in the last 2 years, patients often
forget to take their medication and rarely go to the puskesmas.
§ Since 6 months ago the patient complained of pain in the back of the left leg, The wound is getting
wider and there is pus. The patient also complained of reduced touch sensation on the back of his left
leg, tingling on the tips of his toes and since the last 3 months the patient has felt weak and gets tired
quickly.
§ The patient never exercised and had an irregular eating pattern. The patient is at risk of developing
hypertension, because the patient's mother and younger brother have a history of the disease.

a. Neurological System : (+), Diabetic Neuropathy

b. Dermatomuscular system : (+), diabetic ulcus
c. Endocrinology System : (+), DM type II
 Illness Experience
§ The patient was diagnosed with DM type 2 since 2005.

§ After knowing the disease, the patient wants to recover, so he often has routine monthly
controls at the health care and takes medication regularly, but in the last 2 years patients
often forget to take their medicine and rarely have control at the health care.

§ The patient admits that sometimes the patient feels bored because every day he takes the
drug and his food pattern is irregular and the patient also feels worried if he takes the drug
continuously on a regular basis, the patient thinks that the drug can damage the patient's
kidneys, so the patient does not take the medicine regularly .
 Illness Experience
§ The patient's family has reminded the patient to manage their eating patterns and manage
food portions, but the patient still has difficulty controlling their eating patterns and
portions. After experiencing an injury to his leg, the patient regretted not taking medicine
regularly and not controlling his eating patterns and portions.

§ The patient is worried that there will be a more severe condition that the patient will
experience in the future. The patient hopes that his illness will improve soon and no more
complaints will arise.

Patient’s Religious Perception

Total score is 116, which means good
 Home Condition

§ The patient lives in his own house measuring

10x5 m.

§ The patient's house consists of 1 living room

measuring 5x4 m, 2 bedrooms each measuring
4x3 m and 3x3 m, 1 bathroom inside the house
measuring 2x1 m and 1 kitchen measuring 2x2
m.

§ The patient's house has windows and ventilation,

but they are rarely opened.

§ The patient’s house doesn’t meet the criteria for a

healthy home with a total value of 1325
 Home Surroundings
§ The location is densely populated.
§ The patient's household waste is immediately disposed of
into a closed drain and smells bad.
§ The patient has a trash can in the house, which is then
dumped into a public garbage collection center every day,
where the garbage will be picked up by a garbage
collector 3 times a week.
§ The patient's house is adjacent to the patient's neighbor's
house which is on the right or left, and the distance
between the patient's house and neighbors is very close.
Work Environment
§ The patient is a retired civil servant with a
workload that is not too heavy.
§ The patient socializes well with co-workers.
§ During daily work, the patient sits more, to
reduce the feeling of soreness, sometimes
the patient stretches for 1 minute, but this is
rarely done.
 PHBS Indicator

Indicator of PHBS is good because it meets 7 indicators, but the

indicators for eradicating mosquito nests, consume vegetables and fruit every day
and carrying out physical activities or sports are not fulfilled.
 Family Genogram

Family Structure Stages of the Family Life Cycle

three generation family. at stage VI
 Family Map
Legenda:

Family APGAR
The family is highly functional, with a total score of 10.
 SCREEM Strength Weakness
Aspect
F
Social Patient’s can social interaction and maintain good relations -
A
with family and neighbors at home. M
Cultural The patient’s is from Betawi ethnicity and his ethnicity is not - I
related to his illness.
L
Religious The patient’s family are Muslim. The total value of Family -
Religious Perception is 19 which meant sufficient. Patients
Y
also routinely perform worship such as praying 5 times at
home, dhikr, and reading the Al-Qur’an. S
Educational The patient's last education is senior high school. The patient -
C
understands the disease he is experiencing.

Economic The family's economic stability is good and sufficient to meet -

R
the daily needs of the family. E
Medical Access to health facilities from the patient’s home is close to Patients rarely check up to the puskesmas E
many health facilities. M
 Family Life Line

Graduate From High School Diagnosed with DM Type 2

1975 1985 2005 2022

Patient Got Married Diagnosed with Diabetic

Ulcer and Diabetic
Neuropathy
Family Religion Reception
The value of family religious perception is 19 which indicates
family religious perception is sufficient.
Vital Sign Anthropometry
§ General condition : Good § Height : 169 cm
§ Awareness : ComposMentis § Weight : 70 kg
§ Blood Pressure : 120/80 mmHg § BMI : 24,5 kg/m2
§ Heart Rate : 90 x/mnt § Waist-Hip-Ratio : 0.94 (moderate risk factor)
§ Respiration : 20 x/mnt § Status : Normal
§ Temperature : 36,3°C
§ SpO2 : 98%
PHYSICAL FINDING
General Examination Laboratory Examination
( November 11, 2022)
§ Examination of the head, neck ,heart,
lungs, abdomen, and genitals within
§ Fasting Blood Sugar à 324.2 mg/dl
normal limits
§ Extremities superior dextra, superior
sinistra, Inferior dextra within normal
limits
§ Extremities inferior sinistra : Ulcus (+)
Localist Status
Left Pedis Region
Inspection: There is a 2x3 cm wound with a depth of
0.5 cm on the left dorsum pedis, edema (+), pus (+),
the edges of the wound are irregular, the skin color
around the wound is hyperpigmented.
Palpation: Rough surface, tenderness (+), felt hot (-)
 Upper Extremity Lower Extremity
Right Left Right Left
Motoric
Strength 5/5 5/5 5/5 5/5
tone (+) (+) (+) (+)
Atrophy (-) (-) (-) (-)
Biceps Physiological Reflex (+) (+) (+) (+)
Triceps Physiological Reflex (+) (+) (+) (+)
Hoffman's Pathological (-) (-) - -
Reflex
Trommer's Pathological (-) (-) - -
Neurological Status
Reflex
Sensory
Smooth Touch (+) (+) (+) (+)
decrease decrease
Painful (+) (+) (+) (+)
decrease decrease
Temperature Are not done Are not Are not done Are not
done done

Vibrate Are not done Are not Are not done Are not
done done
Activity of Daily Living Assessment

Mild dependence with a total score of 19

Fall Risk Assessment

The patient has a low risk of falling with a total score of 2

Geriatric Depression Scale

The patient’s total score was 3, no indicating depressive disorder.

 Nutritional Status Physical Activity

The patient's total calorie needs in a day are 1863 – Based on the physical activity assessment table, the

2049 Calories. From the results of the patient's average amount of physical activity energy

food record for 3 days, the patient's average calorie expenditure for 3 days of the patient is 41,93

count is 1597.9 calories, which is calorie input kcal/kgBB/15 minutes with light-moderate

less than the patient's calorie needs in a day of activity.

265.1-451.1 calories that is, the equivalent of 1 to 2

medium bowls of vegetable soup. In addition, the
patient's average intake of carbohydrates was 201.5
g, protein 54.73 g, and fat 53.3 g.
HOLISTIC
DIAGNOSIS
 Personal Aspect
Main complaint : Religious perception:
Pain in the back of the left leg The patient's religious perception is good, with
a total score 116, Patients believe that the
Hope :
disease that Allah has given is the will of
The patient hopes that the disease will
Allah and that the disease can removel their
improve soon, no more complaints will arise,
sins.
and the next control of the patient's blood
glucose will be within normal limits.
Clinical Aspect
Worries:
The patient is worried if the symptoms he is § Diabetic ulcus + Diabetic Neuropathy
experiencing are a serious illness.
ec Diabetes Mellitus type II
Medical perception:
The patient believes that if the patient takes
treatment, the complaints will decrease and
heal.
 Internal Risk Aspect
§ Age 65 years (elderly)
§ The patient's eating pattern is irregular and not
in accordance with balanced nutrition, the habit
of consuming sweet foods and drinks
§ Patients often forget and feel bored to take
their medicine and rarely go to the puskesmas
for control.
§ The patient never exercised.
§ The hereditary factor of diabetes mellitus in the
family is the patient's father and older sister.
External Risk Aspect
§ The patient's house is included in the unhealthy
house category.
§ The patient's family often forgets to remind the
patient to take the medicine.
§ The patient's family is less assertive in
managing the patient's diet.
Aspect of Functional Degree
According to the ICPC, the patient's
functional degree is grade 1
 Holistic Diagnostic Description
Mr. M, 65 years old, came to the health center accompanied by his wife with complaints of pain in
the left instep since 6 months ago, as well as decreased sensation of touch on the instep of his left leg, the
tips of the patient's toes tingled, felt weak, and got tired quickly. The patient has been diagnosed with Type 2
Diabetes Mellitus since 2005. History of treatment with Metformin 3x500 mg. Factors that influence from the
internal aspect are patients aged 65 years (elderly), eating patterns that are irregular and not in accordance with
balanced nutrition, often forget and feel bored to take medication and rarely control to go to the health center,
never exercise, and there is a DM heredity factor in the family . External factors that affect the patient's condition
are the patient's house in the unhealthy home category, the family often forgets to remind them to take medicine,
and the family is not strict in managing eating patterns. The patient's functional aspects are included in degree 1.
COMPREHENSIVE
MANAGEMENT
 PATIENT-CENTERED
Education Related To The Disease
§ Provide an understanding that DM type 2
cannot be cured but can be controlled and
complications due to DM can be prevented
so it does not get worse.
§ Advise patients for a healthy lifestyle such
as exercising, and maintaining a healthy
diet.
§ Patients are encouraged to take medication
regularly and routine control every month.
§ Advise patients to immediately come to the
nearest health service (hospital, health
center, or clinic) when they have symptoms.
§ Provide education on how to take care of
diabetic feet.
§ Motivating patients to always be patient and
put their trust in facing tests from Allah
SWT
 PATIENT-CENTERED
Education Related To The Diet and Physical Activity

§ Advise patients to maintain and manage their
diet by consuming food three times a day
with 2 distractions, with reduced portions.
Good sources of protein such as fish, shrimp,
squid. Lean meat, skinless chicken, low-fat
dairy products and nuts.
§ Patients are advised to increase eating high-
fiber foods, such as vegetables and
consuming fruits so that balanced nutritional
needs are met.
§ Advise patients to reduce consumption of
carbohydrates, sweet foods and drinks such
as rice, pastries, chocolate, packaged tea and
coffee.
§ Advise patients to do sports, which at least
are healthy walks or diabetes gymnastics to
be done 3x/week for 30 minutes.
 PATIENT-CENTERED
Curatif Rehabilitative

§ Metformin 3x500mg § Controlling blood sugar levels regularly with

§ Glibenclamide 1x 5mg routine control
§ Paracetamol 3x500 mg § Take medicine regularly
§ Vitamin B12 1x1 tab § Perform diabetic foot care
§ Consultation to Sp. GK and went to Sp. PD
§ Exercise regularly
 FAMILY-FOCUSED
Educating family members about their risk factors and the importance of early detection, including
checking blood sugar. Ask family members to provide support for the patient's diet, and the rules for taking the
patient's medication. Remind patients and families to always worship and pray to Allah SWT.

No. Name Health Status Screening Counseling Immunization Chemoprophylaxis

1. Mr. M sick DM screening Suggest to take medication - -

and control regularly.
Education on healthy
lifestyles from diet and
exercise
2. Mrs. J Healthy - - - -

3. Mr. A Healthy - - - -

4. Mrs. S Healthy - - - -

5. An. K Healthy - - - -
 COMMUNITY-ORIENTED
§ Provide education to the public to carry out physical sports activities in the patient's
home environment to prevent non-communicable diseases while still prioritizing
social distancing.

§ Provide education not to forget to carry out health screening, especially if you are
over 40 years old.
 FAMILY PROFILE
No Name Gender Age Work No. Mobile Health Family Status
phone Status
1. Mr. M M 65 y.o Retired 081287592404 Sick Patient
2. Mrs. J F 63 y.o Housewife - Healthy Wife
3. Mr. A M 30 y.o Employee - Healthy Child
4. Mrs. S F 28 y.o Housewife - Healthy Daughter-in-law

5. An. K M 2 y.o - - Healthy Grandchild

 Prognosis Coping Score

Ad vitam : Ad bonam The patient's coping score is 3,

families pay attention to patients and
Ad functionam : Dubia ad bonam
are still dependent, need other people
Ad sanationam : Dubia ad bonam as reminders (doctors).
Additional Notes Home Visit
Attachment
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