Report On Diabetes Mellitus Type II

Holistic Diagnosis From Internal

Risk Aspects Using A Family
Medicine Approach

Created by
Ayunda Puspita Putri 1102017044

Tutor
dr. Rita Komalasari, MoD, PhD

Family Medicine Clinical Registrar

Section Public Health Sciences
YARSI University Faculty of Medicine
Period 16 May – 23 July 2022
Patient Identity
• Name : Mrs. S • Religion : Islam
• Age : 66 years old • Ethnicity : Sundanese
• Gender : Female • Work : Housewife
• Address : Kebon Kacang II Street • Date of Examination : June 27, 2022
• Education : Primary School • Home Visit date : June 29 and July 1, 2022

Main Complaint
Since 7 days ago, the patient frequently experiences tingling
 Medical History
Mrs. S had been experiencing tingling in the fingertips of both hands for 7 days. The patient also complained of weakness,
blurred eyes, and frequent urination at night with a frequency > 3 times. Chest pain and leg wounds were denied. Regular bowel
movements.
The patient was first diagnosed with type 2 diabetes mellitus about 4 years ago. The patient said that at first, she was always
sleepy after doing activities and often urinated at night with a frequency of > 5 times. Then the patient checked blood sugar at the elderly
posyandu and obtained a Blood Sugar Time of 250 mg/dL. After that, the patient was examined at the Tanah Abang health center and the
results of Fasting Blood Sugar were 152 mg/dL and Post-Prandial Blood Sugar 205 mg/dL. Then the patient routinely takes anti-diabetic
drugs of metformin 2 times a day to lower blood sugar, but during the pandemic the patient stopped taking the drug. The patient admitted
that she did not like to go to the doctor because the distance from her house to the health center was far and there was no one to
accompany her for treatment. Currently, the patient is controlled again and the results of the Timed Blood Sugar examination on June 27,
2022 were 267 mg/dL. Currently, the patient routinely takes metformin 3 times a day. The patient said there were no complaints after
taking medication to lower her blood sugar.
The patient admitted that she often consumes sweets, fried foods, and drinks coffee twice a day. The patient's child actually
always forbids it, but because the patient's child does not live with the patient, the patient's child cannot monitor it every time. The patient
has a history of smoking when she was young, but has stopped since marriage. The patient does not consume alcohol. The patient is the
last child of 10 siblings.

Past Medical History
• History of Hypertension and DM (+)
• Metformin 2 times a day treatment history
• Asthma, heart disease, lung disease, food and drug
allergies, trauma, surgery denied
Family Medical History
• History of Hypertension and DM (+)
• Similar complaints, asthma, heart disease, lung
disease, food and drug allergies were denied.
Personal Social History
•
Mrs. S last education was primary school education. The
last child of 10 siblings. The patient's mother passed away
due to diabetic complications. 
• The patient married at the age of 18 and has five children.
• The patient lives at home alone.
• Every day, the patient wakes up at 4.00 am and goes to bed
at 8 pm. Patient only does activities at home, such as
watching TV and cleaning the house. The patient always
prays the five daily prayers.
• Patients eat two meals a day. The type of food consumed is
not limited. The patient has a habit of drinking coffee two
times a day.
• Patients rarely exercise.
• Patients use elderly funds from the government for daily
needs.
Review System
• Systemic Neurology: Parathesia/tingling
• Endocrinology System: DM Type II
• Genitourinary System: Poliuria
• There are no abnormalities in the respiratory,
cardiovascular, gastrointestinal, reproductive, or
dermatovascular systems.
Experience of Illness
Patient’s Religious Perception
• The patient's religious perception is good, with a total
score of 126.
• The patient believes that his illness is the will of Allah
and that the disease can remove his sins.
• Patients routinely prays, eat and drink halal and thayyib,
and like to help others.

Initially, the patient did not realize that she had diabetes. The patient rarely goes to the doctor if she is sick, just enough to
rest and take medicine. The patient first found out about her disease because she often felt sleepy and often urinated at night. The
patient then checked her blood sugar at the elderly posyandu and obtained high blood sugar results. The patient's family has a
similar history. The patient had been suffering from DM for a long time and was getting used to the disease. The patient's children
are supportive and always remind the patient to take medicine regularly and maintain a diet. The patient is often worried if she
forgets to take her medication. The patient hopes that her disease will not cause symptoms that can interfere with daily activities
and wants to achieve blood sugar that is not too high.
 
Home Conditions Work Environment
• Privately owned house. ● The patient does not work
• The resident of the house are only patient.
• The house is not multi-storey with walls made of non-
waterproof boards, a cement floor, and a zinc roof without
a ceiling. The house has 1 front door, 1 living room, 1
bedroom, and 1 kitchen. The house has no windows and no
ventilation.
• Lighting is only from 2 lamps, which are not bright
enough.
• Patient use public restrooms 15 m away from her homes.
The water source comes from PDAM.
• Source of clean water for drinking from refillable gallons.
• The patient's house does not meet the criteria for a healthy
home with a score of 800.
Neighborhood Around The House
• The patient lives in a densely populated area. The
patient's house is adjacent to the neighbor's house.
• Household waste is directly disposed of into a
closed ditch and smells.
• The patient has a garbage bin in the house, which is
then disposed of at a public garbage dump every
day.
 
 
 
PHBS Indicators
• Mrs. S's clean and healthy living behavior is in the good
category.
 
 
 
Family Genogram Family Map

Family Form Stage of Family Cycle

● Single adult living alone ● Stage VIII
 Family APGAR
• The family is highly functional, with a total score of 8.
 
 
Family SCREEM
 

SCREEM Aspects Strength Weakness

Social Patients can socialize and maintain good relationships in the home The patient's children do not live with the
environment.  patient, so they cannot monitor the patient's
diet at all times.
Cultural The patient is of Sundanese ethnicity, and the change does not affect the -
patient's current health status.
Religious The patient's family is Muslim. The total score of the patient's family religion -
perception is 23, which means that the family religion perception is good.
Educational The patient's last education was elementary school. The patient's first, second,
and fourth children graduated from junior high school. The patient's second
child graduated from vocational school, and the patient's fifth child has a - 
bachelor's degree. The family understands her chronic illness.
Economic Patients admit that they only depend on elderly funds from the government. The patient admits that she does not have
enough money to fulfill her daily needs.
Medical The patient has BPJS. The patient relies on cadres in the patient's The patient admitted that access to health
neighborhood to take the patient for treatment. facilities is quite far, about 20 minutes from
home.
Family Life Line
2012 2018

Hypertensi
DM Type II
on

The patient was diagnosed with hypertension The patient felt sleepy and had frequent urination at
when she was pregnant with her fourth child. night. At that time, her blood sugar reached 250 mg/dL.

Family Religion Reception

• The value of family religious perception is 23, which indicates that family religious perception is good.
Vital Sign Anthropometric Measurement
● Blood Pressure : 168/82 mmHg ● Height : 144 cm Geriatric
● ●
Pulse : 97 x/menit Weight : 51 kg
Depression
● Respiration : 20 x/menit ● Waist : 89 cm
Scale
● Temperature : 36,1 oC ● Hip : 84 cm
● SpO2 : 99% ● BMI : 24,6 kg/m2 ● The patient’s
● Waist-Hip-Ratio : 1.05 (high risk factor) total score was
● Status : Overweight with risk 4, indicating no
General Examination depressive
● Awareness : composmentis disorder.
● Examination of the head, neck, heart, Neurological Status
lungs, abdomen, genitals, and • On fine-touch sensory examination, the results are
extremities within normal limits. abnormal on the right and left upper limbs.
   
   
   
Activity of Daily Living Assessment Fall Risk Assessment
• Independent with a total score of 20. • Mrs. S has a high risk of falling with a total score of 6.
Nutritional Status Physical Activity
The patient’s total calorie requirement for a day is 1.100 calories. From the
results of the patient’s food record for 3 days, it was obtained The average total energy expenditure of
• The average calorie intake of the patient is 1.411,3 calories Mrs. S over three days (representing one
• The average carbohydrate intake is 196.34 g week) of filling in the activity diary is
• The average protein intake is 69.95 g
• the average fat intake is 37.72 g (39,7 + 38,44 + 40,46) / 3 = 39,53 kcal /
The patient’s calorie intake is more than the patient’s total calorie needs
kgBB / 15 minutes

Based on the physical activity performed

Supporting Examination by the patient for three days, it is known
Laboratory (March 8, 2018) Advice: that Mrs. S’s daily activities are only light
• GDP : 152 mg/dL • Recheck GDP, G2PP, and physical activities
• G2PP : 205 mg/dL HbA1c
• Ophthalmologic
examination
 HOLISTIC DIAGNOSIS
Personal Aspect
• Reason: The patient often feels tingling.
• Expectations: The patient hopes that her disease will not cause symptoms that interfere with daily
activities and can reduce her blood sugar levels.
• Concerns: The patient is worried if she forgets to take her medication.
• Medical perception: Patients believe that if they take their medicine regularly, their disease will not
recur frequently.
• Religious perception: The patient's religious perception is good, with a total score of 126. Patients
believe that the disease that God has given is the will of God and that the disease can removel their
sins.

Clinical Aspect

Neuropati Diabetikum with Diabetes Melitus Type 2 + Hypertension

Internal Aspect
• The patient's family has a history of diabetes mellitus, namely the patient's mother.
• The patient rarely exercises.
• The patient has difficulty maintaining a diet.
• The patient likes to drink coffee.
 Eksternal Aspect
• She does not routinely go to the doctor because the distance from home to the health center is far
and there is no one to accompany her.
• Nutritional status of overweight with risk
• The family cannot monitor the patient's diet at all times.
• The patient only relies on monthly elderly funds from the government, so it is not enough to fulfill
daily needs.
• The patient’s house is categorized as an unhealthy house.

Functional Degree Aspect

Based on the ICPC criteria, it can be concluded that the patient's current functional status is degree 1.  

Description of Holistic Diagnosis

Mrs. S, 66 years old, with a diagnosis of diabetic neuropathy with type II DM accompanied by
hypertension. Influencing factors from the internal risk aspect are that the patient's mother has the same history,
the patient is overweight, rarely exercises, has difficulty maintaining a diet, and likes to drink coffee. The
distance to the health center is far, no one accompanies the treatment, the family can not monitor the patient's
diet at all times, the monthly elderly fund from the government is not enough, and unhealthy house to be an
influencing factor from the external risk aspect.
 PATIENT CENTERED

Educational Related to Disease

• Immediately consult if there are symptoms that interfere with daily activities
• Educate patients to start routine treatment again and check blood sugar levels with the doctor
so that blood sugar levels are always monitored.
• Educate patients to take DM medications safely and regularly.
• Educate patients to do screening for DM complications.
• Perform regular foot care.
• Patients are encouraged to continue doing daily activities.
• Motivate patients to stop consuming sugary drinks
• Maintain a healthy lifestyle and do moderate exercise to prevent complications.
• Educate patients to eat in sufficient quantities, not too much or too little.
Education on Diet and Physical Activity
Dietary Advice
• Maintain a diet that meets your calorie needs per day. Calories required per day 1.100
calories
• Consume calorie-containing foods such as carbohydrates (45-65% of total energy intake), fat
(20-25% of total energy intake), and protein (10% of total energy intake).
Dietary Educations
• Education for consumption of foods with balanced nutrition, low glucose index, low protein,
low fat, high fiber, and fruit.
• Patients are encouraged to eat fewer salty foods.
• Education to reduce consumption of sugary drinks, such as coffee.
• Patients are encouraged to organize a regular diet.
 
Physical Activity Advice
• Patients are recommended to do regular physical exercise 3-5 days a week for 30-45
minutes, such as leisurely walking.
• Avoid strenuous activity.
• Educate patients to do diabetic foot exercises and keep the feet from getting injured.
Curative
• Metformin 3 x 500 mg PO • Vitamin B12 1 x 10 mg PO
• Amlodipin 1 x 10 mg PO • Sivit-Zink 1 x 10 mg PO
• Vitamin B6 1 x 10 mg PO
Rehabilitative
Resistance exercise
 FAMILY FOCUSED
No. Name Medical Screening Counselling Imunizatio Chemoproph
Status n ylaxis

1. Mrs. S Sick Screening Diabetes - -

COMMUNITY ORIENTED
DM education, a
healthy diet, • Provide counseling to families and residents
and regular
physical around the patient's environment about Type
activity for
30-45 2 Diabetes Mellitus and its complications.
minutes three
times a week
• What to do if diagnosed with Type 2 Diabetes
Mellitus
2. Mr. I Healthy BMI Diabetes - -
(Overweigh education, a • About the meaning and necessity of DM
t) healthy diet,
control and monitoring on an ongoing basis.
and regular
physical • Maintaining a healthy diet, activity, and
activity for
30-45 adequate rest for Type 2 Diabetes Mellitus
minutes three  
times a week
3. Mrs. S Healthy - - - -
4. Mrs. B Healthy - - - -
 FAMILY PROFILE

No Name Gender Date of Work Number Medical Status Family

Birth Status

1. Mr. M L 53 years old - - Passed Away Husband

2. Mrs. S P 66 years old Housewife 085719395264 Sick Wife

3. Mr. A L 29 years old - - Passed Away Child

4. Mr. D L 26 years old - - Passed Away Child
5. Mr. I L 45 years old Courier 081310395439 Healthy Child
6. Mrs. S P 32 years old Housewife 085320366484 Healthy Child
7. Mrs. B P 26 years old Employee - Healthy Child
Visit Date Note, Conclusion, and Follow Up Plan

1.   Wednesday First time patient interview and examination

June 29, 2022 - The patient felt symptoms of tingling, frequent weakness, blurred eyes, and frequent
nighttime urination
- The patien has an irregular diet
- The patient rarely exercise

Conclusion
- The patient understand and accepts her illness
- The patient accepts education well

Follow-up Plan
- Educate patients to take DM medication, hypertension medication, and vitamins
regularly.
- Encourage patients to avoid drinking coffee and to follow a healthy diet.
- Intervene and remind patients to do physical exercise
- Education to prevent foot wounds
- Educations about healthy homes
- Follow up again on Friday
2.  Friday Follow Up:
July 1, 2022 - Record the patient’s physical activity and food records
- The patient has done physical exercise, namely walking in the morning on
Thursday, June 30, 2022 for 15 minutes
- The patient takes DM medication, hypertension medication, and vitamins
regularly
- The patient has stopped drinking coffee and started eating vegetables and fruits.
- The patient said she no longer felt weak
- Provide education to control the doctor again and check blood sugar levels

Conclusion
The patient accepted and began to apply the education that had been given by taking
medication on time, a good diet, and regular physical exercise
 
Follow-up Plan
Re-intervene and remind patient that it is important to maintain a healthy lifestyle and
do physical exercise
 Documentation
Prognosis
• Ad Vitam: Ad Bonam
• Ad Functionam: Ad Bonam
• Ad Sanationam: Dubia Ad Bonam

Coping Score
The result of coping score 3 is that the family
cares for the patient but still relies on other
people as reminders, such as doctors. 
THANK YOU