HOLISTIC DIAGNOSIS REPORT ON CONTROLLED
HYPERCOLESTEROL AND HYPERTENSION GRADE I
REVIEWED FROM INTERNAL AND EXTERNAL RISK
ASPECTS THROUGH A FAMILY MEDICINE APPROACH
Arranged by :
Ratu Bionika
4112021075
Supervisor:
Dr. Siti Maulidya
PATIENT IDENTITY
DISEASE ANAMNESIS (DISEASE)
Main Complaint : The back of her neck has felt sore since 1 week
A female patient Mrs. R, 68 years old, came to the Elderly Clinic at the
Menteng District Health Center for routine control of cholesterol and
hypertension which he had been suffering from for one year. Currently the
patient feels sore in the back of the neck area since 1 week of SMRS.
Complaints of soreness appear after the patient consumes fried foods, beef or
seafood such as shrimp and squid. Complaints of intermittent aches usually
appear when the patient wakes up from sleep and after doing activities.
Another complaint that was felt was that the patient often had headaches
like being stabbed and had been coming and going for the past week.
Headache complaints improve when the patient rests lying down. Denied
complaints of dizziness, chest pain, tightness, stomach pain, weakness in
limbs, nausea and vomiting.
DISEASE ANAMNESIS (DISEASE)
At the health center, a laboratory examination was carried out and the
results showed high cholesterol, namely 267 mg/dl. The patient always goes to
the health center regularly for treatment every month and takes simvastatin 20
mg and amlodipine 10 mg every day. The patient admitted that he sometimes
still consumes high cholesterol foods such as fried foods, beef or seafood such
as shrimp and [Link] patient admitted that he was worried if the complaint
he felt did not disappear, thus encouraging the patient to have regular control
and comply with taking medication every day.
The patient believes that the illness he is suffering from is from Allah
SWT and the patient believes that all illnesses can be cured by Allah SWT
through the treatment he gets from the doctor
Past Disease History (and Treatment)
The patient has been suffering from cholesterol and
hypertension since 2022. When the patient is sick, the patient usually
takes medicine at the shop, such as medicine containing paracetamol.
The thing that prompted patients to see a doctor for the first time was
because they often complained of a sore neck and throbbing
headaches that did not subside when given over-the-counter
medicines. Patients admit that they rarely undergo health screening.
History of other diseases in the patient
Family History of Disease
Personal Social History
The patient is the second child of two siblings where the patient has
one older sister. Currently the patient lives with her husband, first child and
third child. The patient's relationship with her husband and children is good.
The patient is a housewife.
The patient admitted that his daily activities were in the morning after
morning prayers, doing light activities such as sweeping the front porch, then
during the day the patient relaxed in the family room, sometimes visiting a
neighbor's house. In the afternoon the patient sometimes does light exercise by
walking around his house. The patient goes to the community health center for
control every 1 month and takes routine medication every day.
Personal Social History
The patient's family has an irregular eating pattern,
namely 2 meals a day. Patients usually eat food they cook
themselves or buy at a food stall near their house. The patient
has a habit of consuming fatty foods such asfried foods, beef
or seafood such as shrimp and squid. The patient admits that
he rarely consumes fruit but likes to eat vegetables. The
patient drinks 2L water a day. The patient often does light
exercise and walks around his home environment.
System Review
ANAMNESIS
OF PAIN
EXPERIENCE
(ILLNES)
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Patient Pain Experience
Mrs. R said that the first time he felt a complaint was in 2022,
the initial complaint was that the patient often felt sore all over the
body, especially in the back of the neck and often had throbbing
headaches. After that, the patient came for treatment to the Menteng
Community Health Center to check his condition and was found to
have high cholesterol and high blood pressure. When he found out
about his condition, the patient felt worried that his complaint could
interfere with his daily activities, so after that the patient committed
to regular check-ups at the health center every month and took
medication every day
Family Assesment
Familly Genogram
J Judging from the genogram above, the
patient is the second child of two siblings where
the patient has one older sister. The patient
currently lives in the same house with her
husband, first child and third child. The
breadwinners in the patient's family are the
patient's first child and the patient's third child.
Family Map
APGAR SCORE
Score:
8 – 10 = Very functional
4 – 7 = Moderate dysfunctional
0 – 3 = Severely dysfunctional
Conclusion :
In table 2 it can be concluded that the
patient's family's APGAR score is
8 so it can be said that the
patient's family is in a very
functional condition
Family SCREEM
Score:
8 – 10 = Very functional
4 – 7 = Moderate dysfunctional
0 – 3 = Severely dysfunctional
Conclusion :
In table 2 it can be concluded that the
patient's family's APGAR score is
8 so it can be said that the
patient's family is in a very
functional condition
‘
HOLISTIC DIAGNOSIS OF PERSONAL
ASPECTS OF THE PATIENT'S
RELIGIOUS PERCEPTION
Score:
8 – 10 = Very functional
4 – 7 = Moderate dysfunctional
0 – 3 = Severely dysfunctional
Conclusion :
In table 2 it can be concluded that the
patient's family's APGAR score is
8 so it can be said that the
patient's family is in a very
functional condition
‘
HOLISTIC DIAGNOSIS
OF PERSONAL
ASPECTS OF THE
PATIENT'S RELIGIOUS
PERCEPTION
‘
HOLISTIC DIAGNOSIS
OF PERSONAL
ASPECTS OF THE
PATIENT'S RELIGIOUS
PERCEPTION
The patient's religious perception
is good, but the patient admits
that he rarely performs Sunnah
Dhuha prayers, rarely reads the
Qur’an and rarely makes dhikr of
Allah SWT, especially when he is
sick
FAMILY LIFE LINE
Perception of Family Religion
PHYSICAL
EXAMINATIO
N
1. General Condition =Good
2. Awareness =Composmentist
3. Vital Signs
Blood Pressure: 130/70 mmHg
Pulse : 90x/minute
Respiration : 20x/minute
Temperature : 36.6oC
SpO2 : 99% in room air
4. Anthropometrics
Height : 145 cm
Weight :51 kg
Mass Index Body (BMI) : 24 kg/m2 [TB
(meters)/ BW (kg)2]
Hip Circumference :84 cm
Upper Arm Circumference : 23 cm
Nutritional status : Excess weight
5. General Inspection
Head:
Shape: oval, symmetrical
Hair: grows thick, black, not easy to pull out.
Eyes: anemic conjunctiva (-/-), icteric sclera
(-/-), round pupils, isochor, RCL (+/+). RCTL
(+/+).
Ears: normotia, symmetrical, discharge (-), not
using hearing aids.
Nose: deviated septum (-), discharge (-).
Mouth: lips moist, cyanosis (-), tongue clean,
pharynx not hyperemic, tonsils T1-T1
Neck:
There was no visible enlargement of the thyroid gland
and no palpable enlargement of the lymph nodes.
Thoracic
Lungs
Inspection: normochest, symmetrical movement of
the chest wall right and left, scars (-), scars (-).
Palpation: right and left symmetrical tactile and
vocal fremitus, crepitus (-), mass (-), tenderness
(-).
Percussion: sound throughout the lung fields.
Auscultation: vesicular breath sounds throughout
the lung fields, crackles (-), wheezing (-).
Heart
Inspection: ictus cordis is not visible.
Palpation: ictus cordis is palpable at the ICS IV left
midclavicular line.
Percussion: heart boundaries within normal limits.
Auscultation: pure regular first and second heart
sounds, murmur (-), gallop (-).
Abdomen
Inspection : flat abdomen, dilated veins (-),
ascites (-)
Auscultation: normoperistaltic bowel sounds.
Palpation : supple, mass (-), tenderness (-).
Percussion : tympanic throughout the abdominal
area
Anogenital
No inspection carried out.
Extremities
Superior: warm acral (+/+), edema (-/-),
deformity (-/-), crepitation (-/-), CRT < 2
seconds, no ROM limitations.
Inferior: warm acral (+/+), edema (-/-),
deformity (-/-), crepitation (-/-), CRT < 2
seconds, no ROM limitation.
SPECIAL
EXAMINATIO
N
Activity of Daily Living (ADL) assessment with instruments
Activity of Daily Living (ADL) assessment with instruments
Geriatric Depression Scale Instrument Geriatric
Depression Scale (GDS)
Conclusion
Total score on Mrs. R is 2
which means the
absence of depressive
disorders.
Nutritional
Status
Weight :51 kg
Height : 145 cm
Nutritional status : Excessive
Weight
Body Mass Index : 24 kg/m2
Ideal BB : BBI = (TB – 100) – (10%
(TB – 100)) (Ministry of Health, 2017).
BBI = 45 – 4.5 = 41.5Kg
CALORIE
CALCULATION
• Basal Calories: BMR (Women) = 25 Kcal x
BBI (Ministry of Health, 2017).= 25 Kcal x
41.5 = 1,037.5 Kcal
Correct :
• Light physical activity = + 10-20% basal
calories= 10 % x 1,037.5 = (+103.75)
• Overweight = - 10% x 1,037.5 = (- 103.75)
• Mild Metabolic Stress = + 10 % x 1037.5 =
(+103.75)
• Total calorie requirements = 1,037.5 + 103.75
= 1141 Calories
Food records Mrs. R
Average calories
1 40%
1.578 Kcal
Average carbohydrates
2 30%
189.5 gr
3 20%
Average protein 92.1
gr
4
Average fat
10%
48.4 gr
After calculating and evaluating Mrs. R for 3 days, it can be concluded that the
patient's food menu is sufficient for daily calorie needs (1,141 Kcal).
PHYSICAL ACTIVITY
ASSESMENT
Total Estimated Amount of Energi Expenditure ( / 15 mins )
Day 1 = 42.24
Day 2 = 42,14
Day 3 = 42,46
Based on the assessment tablephysical activity above, the average amount of
physical activity energy expenditure of patients for 3 days was 42.28
kCal/KgBB/15 minutes.
From the physical activity table above for 3 days, it can be seen that the physical
activity most frequently carried out by patients falls into the light - moderate
physical activity category.
HOME CONDITION
• The area of the patient's house is 3 x 4 m2.
• The house consists of 1 bedroom located on
the top floor and 2 family rooms which are
made into rooms.
• There are two windows, one on the ground
floor and one on the top floor but they are
rarely opened.
• Have dusty ventilation above each window
with an area of > 10% of the floor area.
• Lighting is only obtained from lamps in
each room and light that comes from
windows and doors when opened.
Indicator PHBS
HOLISTIC DIAGNOSIS
Clinical Aspects:
Hypercholesterolemia and Hypertension
Personal Aspect:
- Main complaint : The patient came to the Menteng District Health
Center with complaints of soreness in the back of his neck for 1 week
- Hope :The patient hopes that the disease he is suffering from is not
something serious and can recover quickly without recurrence so that it does
not interfere with his activities.
- Concern :The patient is worried because his complaint of
soreness does not go away and interferes with his activities
- Medical Perception :The patient believes that the illness he is suffering
from can be cured if the patient undergoes treatment.
HOLISTIC DIAGNOSIS
Internal Risk Aspects:
- Patient is female
- The patient admits that he still has
difficulty controlling the food he eats and Functional Degree Aspects:
often eats fatty foods such as fried foods,
beef and seafood such as shrimp and squid. Based on the International Classification
Primary Care (ICPC) criteria, it can be
External Risk Aspects: concluded that the patient's current
functional level is level 1 where the
patient has no difficulty in carrying out
- Child patients sometimes often forget to daily activities. Patients currently have
remind them of medication and control on no limitations in carrying out activities
time due to busy work. they usually do.
- The patient's house is included in the
unhealthy house category.
HOLISTIC DIAGNOSIS
Mrs. R, 68 years old, came to the Gambir District Health Center
with complaints of sore back of the neck for 1 week SMRS. Factors that
influence patient complaints from the internal aspect include female
patients. Patients admit that they still have difficulty controlling the food
they eat and often consume fatty foods such as fried foods, shrimp and
squid. External factors that influence patient complaints are the patient's
environment which does not remind them of medication and timely
control. The patient's house is included in the unhealthy house category.
The patient's functional level is included in level 1 because the patient is
still able to carry out daily activities independently.
COMPREHENSIVE MANAGEMENT
Patien centered
a. Disease-related education
Patient education regarding risk factors for the disease they suffer from, such as consuming
foods high in fat (fried food, red meat, offal, processed seafood), high salt (salted fish, salted
eggs)excess body weight (obesity), lack of physical activity, hereditary factors, smoking
habits, lack of sleep and stress management. bad.
b. Education on diet and physical activity
Educate patients to consume foods with balanced nutrition, meeting daily calorie needs with
sufficient amounts of carbohydrates, protein and fat at each meal.
Educate on the importance of physical activity and encourage patients to do light physical
activity
c. Curative
Simvastatin 20 mg 1 x 1 tablet after meals
Amlodipine 10 mg 1 x 1 tablet after meals
COMPREHENSIVE MANAGEMENT
Family-Focused (Family Wellness Plan)
Education regarding the importance of having a healthy home.
Education regarding the importance of family support in the patient
treatment process.
Family education regarding the importance of psychosocial support
such as providing attention and reminding patients about rest,
managing stress or maintaining a healthy lifestyle so that patients
feel more comfortable in a family environment.
COMPREHENSIVE MANAGEMENT
Family Data of core family
Focused Mrs.
R
COMPREHENSIVE MANAGEMENT
Community-oriented Education to the community
- Provide counseling to residents around the patient's environment
about what to do if diagnosed with hypercholesterolemia and
hypertension.
- Provide counseling to residents around and cadres of the patient's
environment about the importance of maintaining a healthy diet and
the importance of exercise for people with hypercholesterolemia and
hypertension.
-Provide education to residents affected by hypercholesterolemia
and hypertension for routine control at the health facility every
month
HOME VISIT
PROGNOSIS COPING SCORE
Ad Vitamin:Ad Bonam
Ad function:Ad Bonam
Ad sanitation:Dubia
Ad Bonam
THANKS
