Gandaki Medical College & Teaching Hospital

MBBS –Third year

Family health exercise, 2077

CASE I

COMMUNICABLE DISEASE

PULMONARY TUBERCULOSIS

Introduction

Tuberculosis (TB) is globally emerging problem due to its correlation with HIV-AIDS.
Tuberculosis is often caused by Mycobacterium tuberculosis. It commonly affects the lungs
and causes pulmonary tuberculosis. It can also affects the meninges, intestine, lymph-node
and other various tissues of the body. Tuberculosis occurs disproportionately among
disadvantaged population such as those living in overcrowded and substandard housing.
There is an increased occurrence of tuberculosis among HIV-positive individuals.

Clinical Manifestations of Tuberculosis include :

- Chronic cough

- Night sweating

- Weight loss

- Chest pain

- Fatigue

- Loss of appetite - Hemoptysis

- Low grade fever

Problem Statement
A. World
 It is second only to HIV/AIDS as the greatest killer worldwide due to a single
infectious agent.
 Globally, 7.1 million people with TB were reported to have been newly diagnosed
and treated in 2019.
 The biggest contributors to the global increase were India and Indonesia, the two
countries rank first and second worldwide in terms of estimated incident cases per
year.
 In 2019, 10.0 million people fell ill with tuberculosis and 1.2 million died from
the disease.
 In 2019, 57% of pulmonary cases were bacteriologically confirmed.
 Men (aged ≥15 years) accounted for 56% of the people who developed TB in
2019; women accounted for 32% and children (aged<15) accounted for 12%.
 In 2019, an estimated 69% people living with HIV/AIDS became ill with
tuberculosis.
 In 2019, as estimated 390,000 people developed multidrug resistant tuberculosis
among 500,000 people with rifampicin resistant TB.
 The tuberculosis incidence rate dropped by 9% and deaths rate dropped 14%
between 2015 and 2019.
B. Nepal
 Tuberculosis (TB) is still a major public health problem in Nepal. Directly
Observed Treatment Short-course (DOTS) have successfully been implemented
throughout the country since April 2001 and a total of 4382 DOTS treatment
centers are providing TB treatment service throughout the country among which
4204 are government health institutions.
 In Fiscal Year 2075/76, total of 32,043 cases of TB were registered. Among them,
82% were pulmonary bacteriologically confirmed (PBC).
 Most cases were reported among the middle-aged group with the highest among
15-24 year of age (63%). The childhood TB (new and relapse) was 5.5%.
 Male TB cases were reported nearly 1.73 times more than female.
 The Case Notification Rate (CNR) of all forms was 112 per 100,000 population.
 The overall treatment Success rates for new and relapse cases is 91%.
 Treatment failure rate was 1% across all the provinces of Nepal.
Epidemiological Determinants

A. Agent Factors
a) Agent: -
Mycobacterium species specially Mycobacterium tuberculosis, also M. avium, M.
bovis, M. microti and M. africanum. - Slow growing aerobes, non-motile, non-spore
forming and non-capsulated acid fast bacilli, arranged singly or in groups.
b) Source of infection
There are two source of infection-
a) Human source: Sputum positive and cases who haven’t received treatment or not
fully treated.
b) Bovine source: Infection usually from infected milk.

c). Communicability: -

Untreated patient is infective as long as it is not treated. Effective antimicrobial

treatment reduces infectivity by 90% within 48 hours.

c) Mode of Transmission: Droplet infection and droplet nuclei.

d) Incubation Period: May be weeks, months or years. It takes 3-6 weeks for the
development of +ve tuberculin test after infection.
B. Host Factors

a. Age: Affects all ages, developing countries show a sharp rise in infection rates from
infancy to adolescence.

b. Sex: More common in males than in females.

c. Nutrition: Malnutrition one of the major cause.

d. Immunity: No inherited immunity against Tuberculosis infection. Acquired immunity

develops from natural infection or BCG vaccination.

C. Environmental Factors

a. Poor quality of life, low socio economic status, poor housing, over crowd.

b. Under nutrition

c. Lack of education
 d. Lack of awareness of causes of illness

e. Tuberculosis thrives in condition of poverty and can worsen poverty.

 Case Study

We first met our patient through the DOTS clinic of Manipal College Of Medical
Sciences And Teaching Hospital. We were searching through the files for selecting a
case, when we came across this particular case that could fit into the category of
'infectious disease'. Then we gathered necessary information from duty staff there,
contacted her personally and explained about our family health program and
requested to meet her along with her family and she agreed to help us.

 Rationale

Tuberculosis is often regarded as barometer of social welfare and remains one of

major public health problem in Nepal. It is a chronic disease and requires active and
conscious participation of the patient and family. It reflects the multiple dimensions of
disease, assesses impact on the family and also fulfills of objectives of the Family
Health Exercise. Treatment aspects including compliance and risk of developing
MDR tuberculosis are the important factors to be identified.

First Visit
Particulars of the patient

Name: Mrs. Acharya

Age: 69

Sex: Female

Religion: Hindu

Education status: Illiterate

Occupation: Home maker

Temporary Address: Kaudada , Pokhara

Permanent Address: Kaudada , Pokhara

Date of admission:2077/07/17

Date of discharge: 2077/07/22

Duration of stay: 5 days

Chief Complaints:

 Cough for 2 weeks

History of present illness:

The patient was asymptomatic 2 weeks prior, then she complained of cough which was acute
in onset, continuous and persistant . It was associated with production of yellow colored
sputum which was sometimes stained with blood streaks. Cough was also associated with
fatigue, night sweats, evening raise of temperature and significant loss of weight.

No history of nausea , vomiting , diarrhea , constipation or abdominal pain.

No history of chest pain , breathlessness or palpitation.

No history of syncope , seizure , dizziness.

No history of burning micturition or increase in the urgency or frequency of micturition.

Past medical history:

She had been diagnosed with Hypertension 19 years back and is on oral medication
Telmisartan 20 mg ( SARTEL-20) once a day.

She had also been diagnosed with Type II Diabetes Mellitus 4 years back and is on oral
medication Metformin 500mg 9REFORM-500 SR) and Glimeperide 1mg (ZORYL-1)

No significant past history of seizure attacks or congenital diseases.

Personal history:

She consumes mixed diet (Non Vegetarian)

She has been smoking 5 cigarettes per day for past 20 years.

Pack Year = ( 5 * 20) / 20

= 5 pack year

She does not consume alcohol or any other tobacco products.

Dietary History

Meal Time

Breakfast (Tea and Biscuit ) 7:00 AM

Lunch (rice+ dal+ tarkari ) 12:00 PM

Snack (Boiled egg/fruits) 4:30 PM

Dinner (Roti +Dal+ Tarkari) 8:00 PM

Menstrual history:

Menarche: 16 years

Menopause: 40 years

Family history:

No documented history of allergy to any food or drug.

Socioeconomic history:

She belongs to lower class family.

Treatment history:

No significant history of past surgeries or hospital admission.

Tab. Telmisartan 20 mg ( SARTEL-20) OD

Tab. Metformin 500mg (REFORM-500 SR) OD

Tab. Glimeperide 1mg (ZORYL-1) OD

Physical Examination:

 General Physical Examination:

General Appearance: The patient was comfortable.

General condition: fair

Icterus – absent.

Pallor – absent.

Clubbing – absent.

Cyanosis – absent.

Lymphadenopathy – absent.

And well hydrated

 Vitals
 Temperature: 98.2 degree F
 Pulse Rate: 78 beats per minute
 Respiratory Rate: 18 breaths per minute
 Blood Pressure: 150/80 mm of Hg
 Weight: 53 Kg

Systemic Examination

Respiratory System–

Inspection

a) chest is bilaterally symmetrical

b) no bulging, scar marks

c) chest expansion equal on both side

d) intercostal space normal

Palpation:

a) inspection finding are confirmed

b) trachea not shifted

c) increased vocal fremitus

d) no tendeness in the chest region

Percussion:

a) resonate on both side

b) normal liver dullness from 5th intercostals space to lower costal margin

Auscultation:

a) normal vesicular breath sound

b) voice resonance normal

c) crepitation are heard in end inspiratory phase in left infra scapular

Alimentary system:

a) abdomen is soft, non-tender

b) spleen and liver are not palpable

c) normal bowel sound heard

Cardiovascular system:

a) on palpation, apex beat at 5th intercostals space

b) no thrills and additional sound heard

c) on auscultation, normal s1 and s2 heard with no abnormal hear sound

Central nervous system:

a) cranial nerves function intact

b) sensory, motor and autonomic functions normal

c) superficial and deep reflex intact

d) no headache, ocular pain or seizures.

Investigations:

Complete blood count.

Hb: 14gm% Monocytes: 2%

WBC: 11,600/mm3 Eosinophils: 1%

Neutrophils: 56% ESR: 94mm in 1st hour

Lymphocytes: 41% Platelets: 320,000/ mm3

Sugar:

Fasting blood glucose =98mg/dl

Post prandial blood glucose =208 mg/dl

Sputum for AFB: No acid fast bacilli seen

Gram Stain:

Moderate epithelial cells, few pus cells, gram positive cocci in pair and chain and gram
negative cocci seen.

Diagnosis: Pulmonary Tuberculosis

Treatment:
He is being treated according to DOTS category-I regimen as given by the government.
Intensive phase:2 (HRZE) + and continuation phase:4(HR)

Intensive phase: From 2077/07/23 to 2077/09/23 (2 months)

- Tab Rifampicin 600 mg.

- Tab Isoniazide 300 mg.

- Tab Pyrazinamide 1500 mg.

- Tab Ethambutol 1000mg.

Continuation phase: From 2077/09/23 Onwards.

Following drugs were given orally daily for 4 months

- Tab. Isoniazide 300 mg.

- Tab. Rifampicin 600 mg.

- Tab. Ethambutol 100mg.

 Family Health Analysis

Family Visits:

Family Visit Date Time Duration of each visit

First visit 2077/11/10 8:30 45 minutes
Second visit 2077/11/17 9:00 1 hour
Third visit 2077/11/23 9:45 45 minutes

First Visit:

Objective:
 To introduce ourselves to family.
 To explain them about the purpose of our visit
 To gather some basic information regarding family profile, economic, housing and
cultural factors

Activities:
 Rapport building with the patient and family.
 Explained the purpose of our visit to the patient.
 Enquired about the present status of the patient.
 Observation and enquiry about family profile.

Outcomes:

For the Head of the Household:

Family Profile

Type of family: Nuclear

No. of family members: 4

Household head: Ganga Devi Acharya (Self)

Table : Family composition and Structure

S.N. Age Sex Patient Education Occupation Income

Relation

1 69 Femal Self None Home

e maker

2 45 Male Son 12 passed Foreign

employment
 3 40 Femal Daughter 10 passed Foreign
e in law Employment

4 18 Femal Grand 11 class Student

e daughter

Family Tree:

69

45 40 42

18

INDEX

Male-

Female-

Patient-

Dead-
Culture and belief system :

The family follows Hindu religion. Their beliefs, culture, customs are guided by their
religion and caste. All festivals, rites and rituals are followed as per their religion and
caste. However, they don’t believe in traditional healing.

Economic status:

Source of income: Foreign Employment

Expenditure:

Observation Checklist:

1. Housing
 Type of house – Semi-pakka
 Status of house - Own house
 No. of rooms: 2
 No. of windows per room: 2
 Lighting – not adequate
 Cross Ventilation – no
 No. of people living in a same room: 1

2. Sanitation
 Kitchen – Separate
 Toilet – Water seal
 Distance to toilet:
 Dust on smooth surfaces – no
 Odor – unremarkable
 Flies – no
 Garbage/Waste Disposal site – collected by Municipality
 Source of water – tap
 If tap- everyday
 Sufficiency of water - sufficient
 Access/ Time taken to obtain water: none
 Use of water purification techniques – boiling and filter
 Source of fuel – LPG / electricity
 Pets – none

3. Environment
 Nearby forests/Trees/Greenery? - yes
 Nearby factories – no
  Noise – none
 Nearby open spaces – yes
 Nearby open sewage/polluted rivers – no
 Road access –Smaller
 Nearest hospital - 30 min–1hour

4. Assets
 Information system
• Television
 Furniture – well-furnished
 Kitchen appliances
• Cooking appliances
 Vehicle
• No
 Health related instruments
• None

Second visit (2077/11/17)

Objectives:

a) To know about the disease progression

b) To access the knowledge attitude and practice of the family.

c) To know about the effect of disease on the family and the consequent change in their
KAP regarding this.

d) To evaluate their housing and environmental condition.

e) To evaluate the gender role through the gender analysis tool.

ACTIVITIES:

We went for second visit a week later. In this visit, we were focused in asking the questions
about disease progression as well as improvement of the patient and the effects of disease on
the patient, family and society. We also evaluated the role of the family in the causation,
progression and recovery of the disease. We also asked about the health seeking behavior,
knowledge, attitude and practice and belief system and coping strategies of the family
members. We also assessed the gender status in the family.

OUTCOMES:

KAP ON ILLNESS AND HEALTH SEEKING BEHAVIOUR

 The patient herself was uneducated so she was not fully aware about the causation,
mode of transmission and prevention of the disease she was suffering but was aware
that it was curable from news from radio. She did not believe in the orthodox practices
like consulting “ Dhami and Jhakri”. Before visiting the hospital she tried some home
remedies like gargling with salt water at home. She also took medication for productive
cough from local medical store. She visited Manipal Hospital as there was no signs of
improvement from initial local remedies.

COMPLIANCE OF PATIENT WITH DISEASE

The patient was compliant in taking her daily medications in a timely manner. She
takes her drugs as prescribed by the doctor. She is not bed ridden and visits hospital for
follow ups as per doctor’s suggestion. She believes that the medications and treatment
has relieved most of her symptoms and improved her condition.

BELIEFS, CULTURE, CUSTOMS AND RELIGION

The family follows Hindu religion. Their beliefs, culture, customs are guided by their
religion and caste. All festivals, rites and rituals are followed as per their religion and
caste. However, they don’t believe in traditional healing.

CARE AND SUPPORT SYSTEM BY THE FAMILY MEMBERS

The family provides good care & support to the patient as is indicated by the
cleanliness of her room. She is herself alert every day for regular medicine intake and
for regular health checkup and her granddaughter reminds her sometimes.

ROLE OF FAMILY IN DISEASE:

Role in causation:

In this case, there seems to be no role of family in causation of disease as proper

sanitation and healthy food habits are maintained. There is no record of affected TB
patient in the society. The patient has not visited any overcrowded area in the recent
past and there is no record of affected family members or visitors

Role in progression:
In this case, the disease has chance of progression as she seeked for medical assistance only
after 2 weeks of onset of illness after trying out home remedies and local medicines. She was
then diagnosed 1 week after visiting the hospital which also led to progression.

Role in recovery:

The family has been playing crucial role in disease recovery. They are supporting the patient
emotionally and physically. They aware the patient for daily and timely intake of the drugs
and also visit the DOTS center every week on her behalf to get the medication. They aslo
provide her adequate rest by minimizing her chores and maintain proper nutrition, sanitation
and cleanliness for her fast recovery.

IMPACT ASSESSESMENT:

 PHYSICAL IMPACT

Initially the patient felt difficulty in doing her daily household chores. However she
could eat, go to toilet, change her clothes and walk on her own. She still feels
lethargic and can’t do her daily chores in the same pace as in the past.

 SOCIAL IMPACT

In her locality, her neighbours and relatives are aware about her illness. She hasn’t
become victim of any social taboos or social pressure. In fact her neighbours even
help her my managing transportation for her hospital visits. She and her family have
not been boycott from any social gatherings or programmes but she herself avoides
them to prevent transmission and lead to fast recovery.

 PSYCHOLOGICAL IMPACT

Patient

She constantly worries whether this disease will get her bed-ridden and become
burden to her family. It also concerns her that if she can put up with the investigation
and treatment cost in long run. She also fears hospital visits and medical procedures.

Family

Her family members are concerned about her health but they believe that the
disease won’t do much damage and she will be fit and fine soon after the
completion of the treatment.
  ECONOMICAL IMPACT

Direct:

Hospital Follow Ups and investigation of blood glucose – Rs 2000 twice a

month

DM and HTN medicine cost – Rs 1000 per month

Indirect :

Transportation cost – Rs 400 per hospital visit in taxi

Opportunistic :

Sometimes her granddaughter has to skip college classes to take patient

to the hostital.

TOOLS FOR GENDER ANALYSIS

TOOLS FOR ACTIVITY PROFILE

Table no. 2.1.4: Tools for activity profile

Activities Girls /Women Boys/Men Both

Agriculture

Breadwinner +

Budget allocation and +

marketing

Business

Buying medicine + ++ +

Care during ill health + + +

Child care

Child immunization +

Cleaning and maintenance +

tasks
 Cleaning dishes ++

Cooking ++

Employment ++

Fuel(obtain gas/kerosene) +

Health related chores +

Taking sick to medical institute + ++

Washing clothes ++

Source of income ++

(Activity profile shows equal division of work in both sexes.)

TOOLS FOR ACCESS AND CONTROL

Table: 2.1.5 Tools for access and control

Access Control

Girls Boys Girls Boys

Land/housing ++ ++ ++

Equipment ++ ++ + ++

Labor and division of labor ++ ++ ++ ++

Cash/economic resources ++ ++ + ++

Education/ training + ++ + ++

Ownership ++ ++

Assets ++ ++ ++

Basic needs

Food/clothing/shelter ++ ++ ++ ++

All the resources were accessed by both male and female in the family but was
controlled mainly by male. Hence, they had satisfactory gender situation.
 THIRD VISIT(2077/11/23)

Objective

- To know about the disease progression

- To explore about the progression of the disease over the period of time

- To facilitate the recovery process.

- To counsel the patient and family members and encourage to change if

necessary.

Activities:

a) Meeting with the family.

b) Explain that transmission of TB is reduced by 50% in 1 st week of intake of

anti TB drugs at DOTS and followed by no transmission at all at 2 nd week of
treatment.

c) Thanked the family for their cooperation and support.

Outcome:

We convinced the patient to go for a follow up which was agreed. Taught how the
disease can be prevented by maintaining personal hygiene and environmental
sanitation.

COUNSELING:

We counsel the patient that not to be more anxious about the disease. We also assure her that
disease will be cured after completion of DOTS and disease has very less infectivity after
initiating the Anti-tubercular treatment.

Conclusion:

TB is a communicable disease which is more common in developing countries. The main

risk factors for having TB are weakened immune system due to diseases like HIV, Diabetes,
Elder age, malnutrition, etc., poverty and substance abuse. As our patient was of elder age
group and she was malnourished so she developed TB. During our visits, we counseled her
and her family to improve diet and sanitation. Knowledge of family regarding the disease
was good and drug compliance was excellent.