Diagnostic Holistic Of Acute

Diarrhea Without Dehydration

Viewed From Internal Risk Aspects
Through Family Medicine Approach
Created By : Annisa Nur Aini 1102017032
Supervised By : Dr. dr. Erlina Wijayanti, MPH, SpKKLP

Family Medicine
Department Of Public Health
Faculty Of Medicine Yarsi University
Period Of December 5th 2022 – January 7th 2023
Patient Identity
Name : An. R
Age : 3 years old
Gender : Female
Address : Bendungan Hilir, Gang Alfalah 2 RT 09 RW 01
Education : Not yet in school
Religion : Islam
Ethnicity : Sundanese
Occupation : Not working
Date of Examination : Tuesday, 13rd December 2022
Home visit date : Monday, 19th December 2022 and
Wednesday, 21st December 2022
 ● Anamnesis was carried out by alloanamnesis
with the patient's mother at the children's
Medical polyclinic on December 13rd, 2022 at 14.00
WIB.

History ● An. R, 3 years old, came accompanied by his

parent to the Tanah Abang Health Center on
December 13, 2022 with complaints of liquid
bowel movements since 2 days ago.
● Defecate 4 times/day, amount for each
Main Complaint : Watery defecation as much as ¼-½ cup of aqua, liquid
consistency, yellowish, spraying, initially there
bowel since 2 days ago is dregs but over time it is only liquid, not
accompanied by mucus or blood.
● Complaints accompanied by vomiting since 1
day ago. Vomit 2 times as much as ½ glass of
aqua containing leftover food and fluids.
 Medical History
• Her mother also said that her child had a fever since morning, and had a runny
nose since 3 days ago with white mucus
• Patients usually consume 2 small boxes of UHT milk per day. The patient has no
history of changing milk from what she usually drinks.
• There is also a decrease in appetite since diarrhea. According to her mother, it was
difficult for her child to eat, but it was even more difficult since she was sick. His
mother said his daughter did not like random snacks.
• Currently the patient is still actively moving, still wants to drink water, there are
no signs of dehydration.
• The patient was born at term and according to gestational age.
• According to her mother, since birth her child was easily sick, 2 weeks after birth
her child was diagnosed with pneumonia by the pediatrician who handled her, but
the patient had not taken any medication she had taken for 6 months.
 Past Medical Family Medical
History History

● Similar complaint 2 years ago ● Similar Complaint (-)

● Otitis media 1 year ago ● History of Hypertension (+)
● History of allergic rhinitis since in her grandmother
2 years ago
● Diagnosed with pneumonia by a
pediatrician when 2 weeks old
● Denied history of drug allergy.
 Personal Social History
The patient is the 2nd child of 3 siblings. The patient has an older sister (8 years
old) and a younger brother (5 months old). Patients are able to brush their own teeth,
wash their hands themselves, and dress themselves. Patients can also be invited to
play snakes and ladders. The patient can stand on one leg for 2 seconds and jump far,
can name several colors, objects and described their functions.
The patient's daily life is playing. The patient wakes up every morning at 07.00
WIB and on weekends he wakes up at 09.00 WIB, after that the patient takes a
shower and has breakfast, then the patient plays outside the house with his friends
until 12.00 WIB, after that the patient returns home and takes a nap until 17.00 WIB,
after that the patient takes a bath in the afternoon and then has dinner at 18.00 WIB,
after that the patient plays with his family and sleeps at 21.00 WIB. The patient has
an irregular eating pattern of 1-2 times a day with snacks once a day.
 Personal Social History
The patient's mother said her child never washed her hands after
playing outside with her friends or after finishing urinating and
defecating, the patient also rarely washed her hands before eating.
Currently the patient's family income comes from his father who
works as a factory security. The patient's mother said the income
was enough to fulfill the daily life of the patient and his family by
living simply.
 Birth and Growth History
Immunization History
The patient has not been fully
immunized because the patient is
always sick every month, the
patient has only been taken to the
puskesmas for immunization at the
age of 3 months and 7 months but
the patient's mother has forgotten
the type of immunization
Patient was born at RSUD Tarakan
with normal delivery at 9 months
of gestation. Birth weight 3000
grams and body length 51 cm.
During pregnancy there were no
complications, the patient's mother
also did not take drugs and herbs.
Eating History :
● Breastfeeding : 0 - 6 months
● ASI + MPASI : 6 – 24 months
Growth, and
Development History
● Babbling and laughter : 2 months
● Roll over and Prone : 3 months
● Sitting : 6 months
● Crawling : 9 months
● Calling mom and dad : 8 months
● Standing holding on: 10 months
● Walking : 11 months
● First tooth erupts : 9 months
Impression : No delay in growth and development.
Patient Illness Experience
Before the patient went to the puskesmas for control, her mother said that the
liquid bowel movements and vomiting would heal and the complaint would
disappear by itself. Her mother has not given any medicine to her child. Then
finally the patient was taken to the puskesmas because her mother was worried
about her child's complaints, which had not improved for 2 days.

When the patient was diagnosed with acute diarrhea without dehydration, the
patient's mother did not deny that her child was sick. The patient continues to
carry out daily activities well. Her mother always helps the patient to take
medicine regularly. Her mother is worried that her child will be limp and unable
to carry out her usual activities because of this illness.
PATIENT
RELIGIOUS
PERCEPTIO
NS
The patient's mother's
religious perception value
= 98 (Enough)
 Assesment of
Home Home
Healthy Home
Conditions Environment
Criteria
The patient lives in his The patient lives in a
own house with a densely populated, the The house that the
building area of about 3 x environment is next to a An family lives in. R
6 m. The residential river. The water source at (total score = 643) is
buildings have tiled the patient's house comes included in the
floors, permanent walls from the PAM jet, the criteria for an
made of white bricks, and quality of the water is unhealthy house
the roofs of the houses are clean, odorless, colorless based on the
dirty and leaky because and tasteless. Guidelines for the
they are difficult to clean. Assessment of
Healthy Homes.
 Clean and Healthy Lifestyle Indicator
No. PHBS Indicator Answer
Yes No
1. Delivery assisted by health personnel ✓  
2. Exclusive breastfeeding in infants aged 0-6 months ✓  
3. Weigh the weight of the toddler every month ✓  
4. Using clean water that meets health requirements ✓  
5. Washing hands with clean water and soap ✓  
6. Use healthy latrines ✓  
7. Eradicate mosquito nests at home and the environment once a week ✓  
8. Consume vegetables and or fruit every day ✓  
9. Doing physical activity or sports   ✓
10. No smoking inside the house ✓  
Conclusion: Patients apply Clean and Healthy Behavior (PHBS)
Family Genogram Family Map

Family Life Cycle

Family Stage III
Nuclear
Structure
 Family APGAR
Family APGAR Almost Sometime Almost
always (2) s (1) never (0)
I feel satisfied because I can ask my family for ✓    
help when I face problems
I am satisfied with the way my family discusses ✓    
things with me and shares problems with me.
I feel satisfied because my family accepts and ✓    
supports my wishes to start new activities or
goals in my life.
I am satisfied with the way my family expresses ✓    
affection and responds to my feelings, such as
anger, sadness and love.

I feel satisfied with the way my family and I ✓    

share time together.
Total score: 10 (Very functional family)
 Family SCREEM
Aspek Strength Weakness (pathology)
SCREEM
Social Patients are able to brush their own teeth, -
wash their hands themselves, and dress
themselves. Patients can also be invited to
play snakes and ladders.
Cultural Sundanese family, does not affect the -
patient's current health status.

Religious Patients and families are Muslim, carry out Patients and families are
worship and carry out provisions according sometimes negligent in praying
to Islamic rules. 5 times a day, praying, and
dhikr.
Educational The patient has not attended school. -
Economic The patient's family can meet their daily -
needs by living simply through their work.

Medical The patient has a BPJS that is used for -

treatment. The distance between the
patient's house and the health center is
quite close.
The Patient’s Family Religius Perception Family Life Line
Year Age Life Events/ Severity of
Crisis : Illness :
2019 0 years patient was birth -
old
2020 2 weeks Suffering from Outpatient and
old bronchyectasis routine control
with a
pediatrician
and taking
medication

2022 3 years Suffering from Outpatient and

old acute diarrhea taking
without medication
dehydration

The value of family religious

perceptions = 19 (Enough)
 Physical Examination
Consciousness : Composmentis
Blood Pressure : 110/60 mmHg Head to Toe Examination
Heart Rate : 93 x/m
Respiratory Rate : 20 x/m • Head, hair, eyes, nose, ears, mouth,
Temperature : 36,8OC neck are within normal limits
• The lungs, heart, and abdomen are
Anthropometry within normal limits
• Genitalia is nor examinated
Weight : 95 cm • Extremities warm acral, skin turgor
Height : 12 kg returns quickly, cyanosis (-/-), edema
BMI :13,3 kg/m2 (-/-)
Nutritional Status :
H/A : 0 SD (normal)
W/A : 0 SD < x > -2 SD (normal)
W/H : -1 SD < x > -2 SD (good nutrition/normal)
BMI/A : -2 SD (good nutrition/normal)
 Physical Examination
DATE TOTAL CARBOHYDRATE PROTEIN FAT
CALORIES
Dec 14th , 2022 749,4 kcal 130,3 g 21,8 g 14,4 g

Dec 16th, 2022 1094,6 kcal 165 g 35,3 g 32,5 g

Dec 18th , 2022 682,6 kcal 103,8 g 24,5 g 18,2 g

Girls' basal calories :

(16,969 x BB) + (1,618 x TB) + 371,2
= (16,969 x 12) + (1,618 x 95) + 371,2 = 728,538 kcal From the results of the 3-day food
Correction : Light Physical Activity record, the patient's average calorie
intake is 842.2 kcal, which is less
= 20% x 728,538 kcal = 145,7 kkal
than the patient's daily caloric needs.
Total needs = 728,538 kcal + 145,7 kcal = 874,25 kcal
 Daily Activity

Day 1 : 34,64
Day 2 : 34,64
Day 3 : 29,84

the average amount of energy expenditure of physical

activity An. R for 3 days was 33.04 kcal/kg/15 minutes with
light moderate activity.
Diagnostic
Holistic and
Treatment
Planning
 Personal Aspect
1. Reason for arrival : liquid bowel movements (BAB) since 2 days ago
2. Hope : The patient's mother hopes that this disease will not recur so
that it does not interfere with her child's activities.
3. Concern : The patient's mother is very worried about her child's
complaints that are not getting better
4. Medical Perception : The patient's mother admits that she does not
know the medical language of her child's illness, so she does not know the
causes and complications of her child's disease.
5. Religious Perception : From the aspect of faith, the patient's parents'
religious perception is sufficient. The patient's family is sometimes still
negligent in worshiping the 5 daily prayers, The patient's mother believes
that her illness is a test and a reminder to get closer to Allah SWT.
 Clinical Internal Risk Factor
•The
Aspect
Acute diarrhea
patient's immunization
history is incomplete
without dehydration •Poor patient personal hygiene
•The patient's eating pattern is
irregular, it is difficult for the
External Risk Factor patient to eat
● The patient's house is included in the
unhealthy house category and is in a
densely populated environment
Functional Degree
● The patient's mother does not provide Grade 1 (Patient can still carry out
balanced nutritious food daily activities without depending
on others)
Holistic Diagnosis Description
• An.R, 3 years old, came with complaints of liquid bowel
movements (BAB) since 2 days ago
• Factors that influence from the internal aspect are a 3-year-old
patient with an incomplete patient history of immunization,
poor patient personal hygiene, and an irregular eating pattern
and not eating a balanced nutritious diet.
• Another factor that plays a role from the external factors are
that the patient's house is in the category of an unhealthy house
and is in a densely populated environment, and the patient's
mother does not provide balanced nutritious food
Comprehensive
Management
Patient Centered
Disease-Related Education
• Education to mothers about diarrhea, the dangers of diarrhea, emergency signs
of diarrhea, and signs of dehydration in children when diarrhea.
• Educating the patient's mother to complete immunization for her child in order
to increase the patient's immunity.
• Adopting a healthy lifestyle and not snacking carelessly and always washing
hands with running water when leaving the house, cooking, eating, and after
going to the bathroom
• Motivating patients to always be patient and put their trust in facing tests from
Allah SWT
 Patient Centered
Disease-Related Education
• Educating patients to maintain a diet to meet daily caloric needs.
• Patients are advised to pay attention to food hygiene from the outside
• Educating patients to meet nutritional needs such as carbohydrates,
protein, vitamins, fiber, etc. in a balanced manner
 Curative Rehabilitative
Acute diarrhea without dehydration : • Diet control
• Non Medikamentosa: Healthy lifestyle, • Balance eating
improve personal hygiene and regular vegetables and fruit
physical activity • Regular exercise
• Medicamentosa : • Improve personal
 Zinc 20 mg tablet 1x1 for 10 days hygiene
 ORS after every bowel movement
 Pulveres a mixture of domperidone 10
mg and vitamin B6 10 mg 2x1 is made 10
pulveres (to be taken if vomiting)
Family-Focused (Family Wellness Plan)
1. Family education about the importance of choosing clean and
healthy food for family members.
2. Family education on healthy lifestyles and the importance of
physical activity.
3. Family education about the importance of personal hygiene.
4. Family education about diarrhea prevention, first aid for diarrhea in
children, complications of diarrhea, and knowledge of signs of
dehydration in children.
5. Education regarding family support in the treatment of patients
No. Name Health Screening Counseling Immunization chemoprophyla
Status xis

1. Tn. I Healthy Measurement of blood - - -

pressure and risk factors for
hypertension, assessment of
work stress
2. Ny. R Healthy - Prevention and first aid in Educating the patient's -
children with diarrhea, parents to complete the
changes in diet, personal patient's immunization
hygiene, sanitation, and
routine physical exercise

3. An. S Healthy W : 27 kg, H : 125 cm, BMI - - -

17,3 (thin)
4. An. R Sick Anamnesis, physical - - -
examination, signs of
dehydration
5. An. A Healthy ASI, W : 7,2 kg, H : 62 cm, - - -
Good nutrition, good stature
 Community-Oriented
● Provide counseling to families and the community
regarding acute diarrheal disease, causes, prevention,
complications, first aid for children when diarrhea, and
recognize the signs of dehydration in children when they
have diarrhea.
● Provide counseling to families and communities to
maintain cleanliness and personal hygiene
● Provide counseling to families and the community
regarding healthy eating patterns and fulfillment of
adequate nutrition for the body
 Core Family Member Data
No. Name Gender Birth date/Age Profession Phone Health Status
Number

1. Tn. I L 32 Th Security - Healthy

2. Ny. R P 25 Th Housewive 08821451 Healthy

2989
3. An. S P 8 Th Student - Healthy
4 An. R P December 9th 2019 / 3 - - Sick
year 0 month 9 days
5 An. A L 5 bulan - - Healthy
 Prognosis
Coping
Score
Before examined and receiving
Ad vitam : ad bonam education is 4 (the family pays full
attention to the patient, sometimes they
Ad functionam : ad bonam need other people as a reminder),
Ad sanationam : ad bonam After the second examination and
education the patient's coping score is
given to 5 (the family can pay full
attention to the patient).
 Additional Notes On Home Visit
No. Results
Date Notes, Conclusions and Follow-Up Plans

1 Friday, Dec • Anamnesis :

16th 2022  The patient's complaints began to decrease, the patient was able to carry out activities as usual
 Drug consumption by patients
 The patient's daily activities, diet and lifestyle of the patient
• Assessing the condition of the house, environment and behavior, and religious perceptions of the family
• Educating to recognize and avoid trigger factors for diarrhea, first aid for children with diarrhea, signs of dehydration
when children have diarrhea, and when to take them to the emergency room

- Follow up the patient's physical activity and food record

2 Monday, Dec
19th 2022 - Educate the patient's family to manage their diet and encourage them to cook for themselves

- Tell about the lack of An. R food intake and educate the patient's mother about An. R caloric needs and nutritional
needs and how to suffice it

- Education about personal hygiene and environmental hygiene and sanitation

Documentation
Thank
You