Group J 8thbatch

A REPORT ON
FAMILY HEALTH EXERCISE
Submitted to:
Department of Community Medicine
Chitwan Medical College
(Affiliated to Tribhuvan University)
Bharatpur-5, Nepal
Submitted by:
MBBS 8th Batch, 3rd year
Group J
2076
DECLARATION AND APPROVAL SHEET
We, the following students of MBBS third year have produced this report as an outcome
of Family Health Exercise Field. We have invested our sincere efforts and consider this
work to be original.
Group J
1. Bhupneshwar Shah Teli

2. Durgesh Yadav
3. Gaurav Upreti (Leader)
4. Hari Shrestha
5. Prasanna Rana
6. Pukar Neupane
7. Robin Prasad Sah
8. Senjisa Lama Gole (Vice-Leader)
9. Srijana Acharya
Date:
This report has been accepted and forwarded for final examination.
-------------------------------- -----------------------------------
Asst. Prof. Eak Narayan Poudel Asso. Prof. Dr. Nikki Shrestha
Co-ordinator, CBL Unit Head of the Department

Date: Date:
(stamp)
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GROUP MEMBERS
From right to left: (Front Row) - Prasanna Rana, Srijana Acharya, Gaurav Upreti, Asst.
Prof. Eak Narayan Poudel (Supervisor), Hari Shrestha, Bhupneshwar Shah Teli
(Back Row) - Senjisa Lama Gole, Durgesh Yadav, Robin Prasad Sah, Pukar Neupane
Supervisor- Asst. Prof. Eak Narayan Poudel
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ACKNOWLEDGEMENTS
Our sincere thanks go to the Department of Community Medicine and public Health,
Chitwan Medical College, for providing us with this wonderful opportunity to go beyond
the patient and learn about the different aspects of family and its co-relation with disease
process and its relief. It not only helped us to socially interact with families but also to
explore minute details that serve as bridge between a family and its health.
We are very grateful to all the faculty members and facilitators who guided and supported
us throughout our entire field exercise. We would like to express our gratitude to
associate Asso. Prof. Dr. Nikki Shrestha (HOD, community medicine, CMC). We would
like to express our regards to our field supervisor Ass. Prof. Ek Narayan Poudel for
guiding us during our family visits via her valuable suggestions and encouragement. We
are extremely grateful to all the faculty members (Mrs.Amrita Poudel, Mr. Harish
Chandra Ghimire, Dr. Kishor Adhikari, Dr. Mamta Chhetri, Mr.Subash Koirala).
We would also like to thank all the clinical departments of Chitwan Medical College
Teaching Hospital (CMCTH), Bharatpur Hospital for providing in-depth clinical
knowledge about the cases. Also, a special mention to the in-charges and ward staffs of
different hospitals of Chitwan for their help and cooperation in our case selection.
We would like to thank all the families without whom this family health exercise would
have been impossible. Despite of the illnesses and hardships they helped us and
welcomed us into their homes with warm hospitality and immensely contributed to our
learning exercises.
Lastly, we would like to thank all who directly or indirectly helped us in family health
exercise.
Group members
Family health exercise
MBBS, 8th batch CMC
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SUMMARY
The family is a primary unit of all societies. American association of family practitioners
defines family as “a group of individuals with a continuing legal, genetic and/or
emotional relationship.” Family is a biologically related individuals living together and
eating from a common kitchen. As a biological unit, the family members share a pool of
genes, as a social unit, they share a common physical and social environment. As a
cultural unit, the family reflects the culture of wider society of which it forms a part and
determines the behavior and attitude of its members.
Family health can be defined as a state of positive dynamic interaction between family
members which enables each and every members of the family to experience optimal
physical, mental, social and spiritual well being whether disease or infirmity is present or
not.
Family health exercise is a follow up study of the illness of a person and analysis of how
factors like lifestyles, education, family environment, socioeconomic condition, culture,
belief, practice, health seeking behaviors, knowledge, attitude, practice regarding the
illness and other socio psychological factors playing role in the health of an individual
affect the course and outcome of the illness.
In the present context, the role of the family physician has been emerging greatly
increased consciousness regarding health related conditions. Family physicians deliver a
range of acute, chronic and preventive medical care services. In addition to diagnosing
and treating illness, they also provide preventive care, including routine checkup, health
risk assessments, immunization and screening test, and personalized counseling on
maintaining healthy lifestyles. Family physician also manages chronic illness, often
coordinating care provided by other subspecialists.
Tribhuban university(TU) has always remained special among the medical universities in
south Asia due to its community oriented MBBS curriculum, family health exercise done
during the 3rd year is an integral part of this curriculum. In family health exercise, five
families having five different types of illnesses are chosen and those illnesses are studied
depth exploring there social, psychological and economic impact on the patients and their
families.
Gender status analysis in the patient’s families is included in our family health exercises.
“Gender” is an important determinant of health in a family. The role, played by this
factor in the families, is a reflection of the gender status in our country.
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This report will present five cases of different diseases and disabilities as guided by the
curriculum. Following the regular classes on community medicine and orientation session
about the family health exercise, we developed our own action plan to execute the
exercise, so as to make at least 3 family visits for each case over three months periods.
Regular supervisions and guidance by the faculty members proved to be an immense
help.
Here is the summary of the cases:
Infectious Disease (Tuberculosis)
20 years old Mr. Shahi permanent resident of Bharatpur Metropolitan City-12, Chitwan,
and Hindu by religion was diagnosed with Pulmonary Tuberculosis at Narayani
Samudayik hospital on Shrawan of 2076. The case was taken from NATA Center,
Chitwan. He is under DOTS treatment since Mangsir. Not significant past history in the
family. He lives in a nuclear family of upper middle class. There was no economic
burden to the family during his treatment. His family is supportive.
Non-Infectious Disease (Chronic Obstructive Plumonary Disease)
69 years old female, Mrs. Poudel , resident of Bharatpur Metropolitan City-10, Chitwan
was admitted to the hospital due to acute exacerbation of COPD leading to shortness of
breath, chest pain, cough. She is a known case of hypertension, COPD, gastritis, heart
disease. She lives in a nuclear family with her husband and daughter-in-law. The family
is very supportive and does not have a high burden for medicines and other health
facilities as the income is fairly strong however the expense is huge due to many
medicines prescribed for different diseases.
Psychosomatic Disorder (Anxiety Disorder)
39 year old male, Mr. Rana resident of Kalika Nagarpalika-10,Chitwan, Hindu by

religion came to OPD of CMCTH with complaints of palpitation, fear, dizziness.He was
diagnosed with anxiety and was treated .The main income source of the family is
agriculture .They are a nuclear family. The condition caused physiological and
economical burden to family.
Physical disability (Amputation Seconadary To Road Traffic Accident)
46 years old male, Mr. Subedi, permanent resident of Madi Nagarpalika-3,Chitwan,

Hindu by religion had an accident while travelling in bus. He was diagnosed with crush
injuries and lacerations on both legs. He has to undergo surgical amputation due to road
traffic accident. He lives in house with his wife and daughter while his son is a foreign
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employee. He is under physiotherapy treatment. The condition has had heavy impact on
his day to day life. He can do his daily chores by himself and needs help in heavy work.
Case of our choice (Stomach Cancer)
26 years old female, Mrs. Mahato, resident of Kalika Nagarpalika-6,Chitwan was

diagnosed with Stomach Cancer 2 months back and is on chemotherapy since then .The
case was taken from Cancer Hospital. She has history of Gastritis before. She lives in a
joint family of upper lower class. There was economic burden to the family during her
treatment. Her family is supportive and is under regular medications.
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TABLE OF CONTENTS
Declaration and Approval Sheet …………………………………….…ii
Acknowledgement…………………………………………………….…iv
Summary………………………………………………………………....v
Table of Contents………………………………………………………..vi
List of tables…………………………………………………………..….x
List of figures……………………………………………………………xi
Abbreviations …………………………………………………………...xii
CHAPTER I: Introduction……………………………………………..1
Background……………………………………………………………… 1
Objectives…………………………………………………………………2
Methodology……………………………………………………………....3
Activities and approaches…………………………………………………5
Study Tools and Techniques…………………………………………...….6
Logistic Management…………………………………………………….11
CHAPTER II: Case Study……………………………………………..11

Introduction………………………………………………………………11
Case 1: Tuberculosis……………………………………………………...13
Case 2: COPD……………………………………………….....................30
Case3: Anxiety Disorder………………………………………………….50
Case4: Amputation………………………………………………………..66
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Case5: Stomach Cancer…………………………………………………...72
CHAPTER III: Conclusion and Recommendations…………….98
Conclusion…………………………………………………………....98
Recommendation to Department of community medicine ………..…98
CHAPTER IV: Learning Reflections...............................................99

Bibliography…………………………………………………………………...100
Annexes...............................................................................................................100
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LIST OF TABLES
Table No. Description of tables Page No.
Data Collection Tools and Techniques
1 7
Kuppuswamy's socio-economic status scale
2 10
Overview of cases
3 12
Family visits of TB patient
4 19
Kuppuswamy score of TB patient's family
5 21
Observation checklist of TB patient's house
6 23
Activity profile of TB patient's family
7 26
Access and control profile of TB patient's family
8 27
Family visits of COPD patient
9 36
Kuppuswamy score of COPD patient's family
10 40
Observation checklist of COPD patient's house
11 42
Activity profile of COPD patient's family
12 46
Access and control profile of COPD patient's family
13 47
Family visits of Anxiety disorder patient
14 55
Kuppuswamy score of Anxiety disorder patient's family
15 57
Observation checklist of Anxiety disorder patient's house
16 58
Activity profile of Anxiety disorder patient's family
17 62
Access and control profile of Anxiety disorder patient's family
18 63
Family visits of Amputation patient
19 71
Kuppuswamy score of Amputation patient's family
20 73
Observation checklist of psychotic Amputation house
21 75
Activity profile of Amputation patient's family
22 78
Access and control profile of Amputation patient's family
23 79
Family visits of Stomach Cancer patient
24 87
Kuppuswamy score of Stomach Cancer patient's family
25 90
Observation checklist of Stomach Cancer patient's house
26 92
Activity profile of Gastric Stomach Cancer family
27 95
Access and control profile of Stomach Cancer patient's family
28 96
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LIST OF FIGURES
Figure No. Description of figures Page No.
Family tree of TB patient
1 20
House map of TB patient
2 21
Family tree of COPD patient
3 38
House map of COPD patient
4 39
Family tree of Anxiety disorder patient
5 56
House map of Anxiety disorder patient
6 57
Family tree of Amputation patient
7 72
House map of Amputation patient
8 73
Family tree of Stomach Cancer patient
9 88
House map of Stomach Cancer patient
10 90
ABBREVIATIONS
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BP Blood pressure
BD Twice daily
CAT Category
CMCTH Chitwan Medical College
Teaching Hospital
CNS Central Nervous System
COPD Cronic Obstructive Pulmonary
Disease
CVS Cardiovascular system
CXR Chest X-ray
CVA Cardiovascular Accident
DLC Differential Leukocyte Count
SPHCM School of Public Health and
Community Medicine
ECG Electro-cardiography
ESR Erythrocyte Sedimentation Rate
GI Gastro-intestinal
HIV Human Immune deficiency Virus
Hb Hemoglobin
HTN Hypertension
KAP Knowledge, Attitude and
Practice
MBBS Bachelor of Medicine and
Bachelor of Surgery
MRI Magnetic Resonance Imaging
NAD No Abnormality Detected
OD Once daily
OPD Outpatient Department
RBC Red Blood Cell
R/E Routine examination
RR Respiratory Rate
S1 1st heart sound
S2 2nd heart sound
SGOT Serum Glutamate Oxaloacetate
Transaminase
SGPT Serum Glutamate Pyruvate
Transaminase
TC Total Cells
TLC Total Leukocyte Count
TU Tribhuwan University
USG Ultrasonography
WBC White Blood Cells
WHO World Health Organization
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CHAPTER- I
INTRODUCTION
1.1 BACKGROUND
The family is a group of individual with a continuing legal, genetic and or emotional
relationship.
-American Association of Family Practitioner
Family is a group of biologically related individuals living together and eating from a common
kitchen. Family is the primary biological, social, cultural, epidemiological unit in all societies.
-Park’s textbook of Preventive and Social Medicine
A family is a building block of all societies and comprises a group of blood-related people living
together and having food from a common kitchen.
As a social unit, they share a common physical and social environment. As a cultural unit, the
family reflects the culture of the wide society of which it forms a part and determines the
behavior and attitude of its members. The family is also an epidemiological unit and a unit for
providing social services as well as comprehensive medical care.
Family physicians are helping to transform an uncooperative health care system into a patient-
centered care delivery model. Family physicians being guided by ethical norms and obligations
to patient surely deliver a range of acute, chronic and preventive medical care services and
besides diagnosing and treating illness, they also provide preventive care, including routine
checkups, health-risk assessments, immunization and screening tests, and personalized
counseling on maintaining a healthy lifestyle. Family physicians are changing role of the patients
from passive dependent state to active and autonomous participant in his/her health behavior and
problems.
Family health is the situation in which each and every member of a family is able to experience
optimal level of physical, mental, social and spiritual well-being and not just merely the absence
of disease or infirmity.
The family health exercise is incorporated into the curriculum of the MBBS program in the
second phase, the third year, of the Tribhuvan University. The family health exercise is designed
to enable the students to understand the social, psychological and economical aspects of illness;
the interactions of ill persons with family members and the community. It helps us in perceiving
the role of the family in the progression and cure of the disease; and to understand the natural
history of disease.
We, the students of MBBS third year are grateful to the School of Public Health and Community
Medicine for providing us with such a self-directed learning exercise which helped us to look
beyond the doors of our hospital based teaching and incorporated into us the feeling of becoming
family doctors, doctors for the community.
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As per curriculum, the Family Health Exercise enables its students to look at the complete
picture and have a holistic approach of health and disease. The community diagnosis program
during the first year and family health exercise during third year are integral parts of the
community oriented MBBS curriculum. While the first-year community diagnosis program
enabled us to look at the community as a whole and understand the various aspects of its
relationship to health, the third-year family health exercise was a more in-depth study about the
dynamics of family and its relationship to the various aspects of disease.
In family health exercise, we studied individuals living in families having five different types of
illnesses, exploring the various ways in which the illness has affected the family and also in
retrospection try to find out how factors like the family values and culture, environment,
lifestyle, economic status, beliefs, health seeking behavior had any role in the causation,
progression, prevention, control and treatment and rehabilitation of illness. We took up the
family unit and explored each and every facet of its interrelationship with health.
We also looked at the gender status in the family and analyze what role it plays in the various
aspects of disease and health in the family set up.
OBJECTIVES OF FHE
General objectives
• To study the effects of family on health and the impact of an illness on the family.
• To analyze family health with gender perspective.
Specific objectives
• To know about natural history of disease and its prognosis.

• To evaluate family factors relation in causation and progression of disease.
• To define consequences of disease on family, social factors and economic status.
• To assess the KAP of the patient and his /her family regarding the disease, its prevention
and management.
• To advise the patient and the family members to change the KAP regarding the illness if
necessary.
• To motivate the patient for regular follow up as necessary.
1.2 METHODOLOGY
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A. Study Design:
This is a case-study based on retrospective patient record examination, concurrent history taking
and examination and follow up in their respective family. Number of qualitative and quantitative
techniques and tools were used for the case study, they are as follows:
Objective Field site Respondent/ Data Tools for

Source of data Collection Data
Technique Collection
Hospital
To collect clinical Hospital Patient record file Record review records
And
treatment history
Of
the patient
To collect patient Hospital Patient/ Family

History House Member
To collect patient Hospital Clinician/nurse Key informant

treatment plan House Patient Interview
And Respondent
other details on
follow-up and
Prognosis
To collect data on House Household head, Observation Checklist

Household Household And
demographic, environment interview in
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Socio households,
and
facilities, neighbours and
Gender neighbourhoods
and its facets for
recovery and help
from family
members.
To collect the House Family In-depth

data on members/patient Interview
interaction among
family members
And
coping strategies
Of
the family
Towards
Disease
To collect data on House Patient/care taker Interview and Format

belief system and Prescription
compliance of review and
treatment and observation of
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Progress medicine taken
Health By
Patient
To collect House Family members Group discussion

activities,
process,
resources,
care seeking
Practices
and perception of
health services,
cultural,
Behavioural
and cost of
treatment,
etc.
1.3 ACTIVITIES AND APPROACHES
To conduct the family health exercise successfully, following activities and approaches were
adopted:
A. Orientation
The orientation classes (Shrawan 9, 10, 12, 13, 14) regarding the family health exercise were
organized for us. We were empowered with the knowledge and the experiences shared by all the
teachers. We were told what we were expected to do and given the guidelines so as to carry out the
exercise. We were also enlightened with classes on gender, nature of communities and system of
approach.
B. Group division
The class was divided into a total of 1 groups and each member was allocated randomly. Our group
consists of 9 members.
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C. Group Discussion
We had group discussions for selection of cases, work division, preparation for family visits, report
writing, presentation and interpretation of our findings.
D. Literature review
Different text books and lecture notes on community medicine, clinical medicine, research
methodology, and communication skills were reviewed. We also reviewed reports of our seniors,
Annual reports and several web sites relevant to our exercise.
E. Case selection
As per the requisite given to us, five cases were selected from Chitwan Medical College (Anxiety
Disorder), College Of Medical Science (COPD), NATA Center (TB), Bharatpur Hospital
(Amputation Secondary to road traffic accident), BP Koirala Memoriyal Cancer Hospital(Stomach
Cancer).
1. Case of infectious disease (TB)

2. Case of non-infectious disease (COPD)
3. Case of psychiatric disorder (Anxiety Disorder)
4. Case of physical disability (Amputation)
5. Case of our choice (Gastric Carcinoma).
F. Review of Hospital records
Knowledge about clinical history, examinations, investigations and treatment details have been
obtained from their hospital records.
G. Family visits
Following the addresses and instruction given by the families, we made three visits per family. The
first visit was more or less introductory and we strengthened our rapport with the family, took
thorough History, examined and enquired generally about the family. The second visits were for
more detailed discussion on the illness, its impact on the family and counseling regarding disease and
patient conditions. We also used our gender tools in the same visit. We enquired and observed
whether the recommendations and counseling were followed and accepted. We asked whatever
questions were remaining and answered their inquiries.
H. Consultation with Group Supervisor
We constantly were in touch with our supervisor and she guided us in each and every step of Family
health exercise. She was also with us in one visit of each case and without her help it was next to
impossible to conduct our family health exercise smoothly.
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I. Case Analysis
We all the group members discussed about each and every case and compiled all the relevant
information for our report.
K. Class presentation
We presented all the cases in the class in front of faculty members of Department of community
medicine and our classmates on 2076-11-07. The presentation contained the findings, the counseling
we did and the outcomes/ positive changes in the family members due to our visits.
J. Report writing
We tried to write a comprehensive report on our family health exercise encompassing all the
information and analysis we had acquired.
1.4 STUDY TOOLS AND TECHNIQUES
Tool 1: Physical examination (Hospital records and anthropometric measures)

Tool 2: Gender Analysis
A.Activity profile
Activities Women Girls Men Boys
Production activities
Agricultural work
Income generation activities
Employment
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Others
Reproductive activities
Water related
Fuel related
Health related activities
Child immunization
Care provider during illness
Taking the sick to the hospital
Buying medicine
Cleaning
Repair
Market related and others
Table No.:1
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B. Access and control profile
Access Control
Particulars
men/boys women/girls men/boys women/girls
Land
Equipment
Labor
Cash
Education/training
Benefits
Outside Income
Assets Income
Basic needs
Food/clothing/shelter
Education
Political
power/prestige
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Tool 4: Assessment of Disease Impact
1. On the Patient:
Inability to perform normal daily activities

Employment and status
Family relation
Social relation
Self-esteem and confidence
2. On the Family:
 Effects on the routine of the family members
 Economic burden
 Social effects
 Care of the diseased
3. On the Society:
 About social stigma
Tool 5: Observation Checklist:
Observation Yes No
Own house
Rented house
House type
Rooms
Number
Ventilation
Sunlight
Kitchen
Ventilation/ Exhaust
Energy source of cooking
Toilet
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Cleanliness
Around the house
Of the diseased person
Water
Source
Sufficiency
Treatment of drinking water
Waste disposal
Vehicles
Electronic appliance
Pets
Yard/Lawn
Helpers/Servants
Domestic Animals
Tool 6: Kuppuswamy’s socio-economic status scale (Modified for 2019):
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Table No.:2
1.5 LOGISTIC MANAGEMENT
During the entire course of our family visits, it was really challenging for us to manage time for
our clinical postings, theory classes and allocate time for family visits in different families. Our
group arranged the transportation fare needed during our visits to the families. We also managed
cost for the tools (like observation checklist) and the report for printing.
CHAPTER II
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OVERVIEW OF CASES
INTRODUCTION
In this chapter, we have discussed about the five different cases focusing on the case
selection, detailed case history, impact of family on disease and impact of disease on
family.
As per the guidelines, the cases were selected based on the hospital record of CMCTH,
College of Medical Science and BP Koirala Cancer Hospital, Bharatpur. Criteria are:
1. Case of infectious disease
2. Case of non-infectious chronic disease
3. Case of psychosomatic disorder
4. Case of physical disability
5. Case of our choice
Based on the criteria, details of the case were done. Some in depth interview with history
taking was done. Specifics of the respective cases were collected on each family visits, the
cases were actually specifically assigned to respective group members. Detailed
characteristics social economic and other family related information were obtained and data
were thoroughly recorded by using the tools and techniques mentioned above.
Overview of Cases
S.N Cases Age Sex Case Address

. Identified
From
1 Pulmonary 20 M NATA Center Bharatpur
Metropolitan City-11,
Tuberculosis Chitwan
2 COPD 69 F College Of Bharatpur Metroplitan

Medical City-10, Chitwan
Science
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3 Anxiety Disorder 39 M Chitwan Kalika Nagarpalika-
Medical 10, Chitwan
College
4 Amputation 46 M Bharatpur Bharatpur
Hospital Metropolitan City-
7,Chitwan
5 Gastric Carcinoma 26 F BP Koirala Kalika Nagarpalika-6,

Cancer Hospital Chitwan
Table No.:3
CASE 1: PULMONARY TUBERCULOSIS
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A. INTRODUCTION
Tuberculosis (TB) is a communicable disease usually caused by Mycobacterium tuberculosis
bacteria. Tuberculosis generally affects the lung, but can also affect other parts of the body
except hair and nail. Tuberculosis may infect any part of the body, but most commonly occurs in
the lungs (known as pulmonary tuberculosis). Extrapulmonary TB occurs when tuberculosis
develops outside of the lungs, although extrapulmonary TB may coexist with pulmonary TB.
Most infections do not have symptoms, in which case it is known as latent tuberculosis. About
10% of latent infections progress to active disease which, if left untreated, kills about half of
those infected. The common symptoms of active TB are Cough that lasts 3 weeks or longer,
Coughing of sputum or blood, Chest pain, Fever, Chills, Weight loss, Anorexia, Night sweat. It
was historically called "consumption" due to the weight loss. Infection of other organs can cause
a wide range of symptom.
Epidemiology:
AGENT
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The main causative agent is Mycobacterium tuberculosis (MTB), a small, aerobic, non
motile bacillus. The high lipid content of this pathogen accounts for many of its unique clinical
characteristics. Mycobacterium has an outer membrane lipid bi-layer. If a Gram stain is
performed, MTB either stains very weakly "Gram-positive" or does not retain dye as a result of
the high lipid and mycolic acid content of its cell wall. Since MTB retains certain stains even
after being treated with acidic solution, it is classified as an acid-fast bacillus.
HOST
• Age – In the developing world, TB rates are highest among young adults, reflecting
primary transmission in this age group. In developed countries, the rate of TB among
older adults is higher than among younger adults and children, reflecting reactivation
disease, possibly attributable to impaired immunity with aging .
• Gender – Among HIV-uninfected individuals, the rate of TB is higher among men than
women, beginning in the young adult years and persisting throughout life.
• Immuno-suppression
HIV infection — Among HIV-infected individuals, the risk of acquiring TB is 9 to 16

times that of HIV-uninfected individuals. Diabetes mellitus, cancer, corticosteroid
therapy also increase risk for TB.
• Substance abuse-drug use, tobacco, alcohol
• Nutritional status — Malnutrition is generally understood to be an important risk factor

for TB, although the relation between impaired immunity due to malnutrition and risk of
acquiring TB has not been well characterized. People who are underweight and have
decreased serum Vitamin D level are at increase risk for TB.
ENVIRONMENT
• Socioeconomic status — TB has traditionally been associated with low socioeconomic

status, which also may be associated with crowding, poor nutrition, poor access to
medical care, public assistance, unemployment, and low education.
• Household contacts — Close household contact with an individual with smear-positive

pulmonary TB is the most important risk factor for TB
Problem statement:
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• Globally, an estimated 1.7 billion people are infected with M. tuberculosis and are thus at
risk of developing the disease. Tuberculosis (TB) is one of the top 10 causes of death
worldwide.
• Globally, an estimated 10.0 million (range, 9.0–11.1 million) people fell ill with TB in
2018, a number that has been relatively stable in recent years. The burden of disease
varies enormously among countries, from fewer than five to more than 500 new cases per
100 000 population per year, with the global average being around 130. Geographically,
most TB cases in 2018 were in the WHO regions of South-East Asia (44%), Africa (24%)
and the Western Pacific (18%), with smaller percentages in the Eastern Mediterranean
(8%), the Americas (3%) and Europe (3%).
• Globally, the average rate of decline in the TB incidence rate was 1.6% per year in the
period 2000−2018, and 2.0% between 2017 and 2018. The global reduction in the total
number of TB deaths between 2015 and 2018 was 11%.
-WHO
B. JUSTIFICATION FOR SELECTION OF CASE

• Tuberculosis (TB) is a public health problem in Nepal that affects thousands of people
each year and is one of the leading causes of death in the country. WHO estimates that
around 45,000 people develop active TB every year in Nepal.
• During 2074/75 reporting year, National Tuberculosis Programme (NTP) registered

32,474 all forms of TB cases, which includes 31,723 incident TB cases (new and
relapse).
• TB cases notification from 2070/71 to 2074/75, it has decreased gradually from 136 per
100,000 populations in 2070/71 to 111 per 100,000 populations in 2073/74 but has
slightly increased in 2074/75 to 112 per 100,000 populations.
• It not only affects the health of the person but it’s surrounding contacts and also affects in
economy and social aspects of people. So, for selection of case, TB could fit in the
category of Infectious disease.
it not only affects

the health of the person but its
surrounding contacts and
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also affects in economy and social
aspects of pe
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A Report On Family Health Excercise-2076
C. CASE STUDY
PATIENT PARTICULARS
Name: Mr. Shahi
Age/Sex: 20 years/ Male
Address: Bharatpur Metropolitan City-12, Chitwan
Religion: Hindu
Occupation: Student
Source of information: Patient and His Mother
CHIEF COMPLAINTS
Cough for 10 days
Fever for 7 days
HISTORY OF PRESENT ILLNESS
The patient was apparently well 10 days back when he had cough which was gradual on onset, 8-
10 episodes per day. The cough was intermittent, productive contained blood, non-foul smelling
and mostly during daytime. The sputum was mucoid with fresh bright red colored blood. He also
complained of fever for 8 days which was intermittent (quotidian), maximum temperature
recorded was 102 F mostly at evening with no chills and rigor. He also has history of anorexia
and weight loss. No history of chest pain, shortness of breath, noisy and labored breathing.
COURSE OF TREATMENT
He went to Narayani Samudayik Hospital where relevant investigations were done and He was
diagnosed with Pulmonary Tuberculosis Category-1. He was referred in DOTS. He started
DOTS on Mangsir 2.
HISTORY OF PAST ILLNESS
He has no significant past history. There is no history of Hypertension, Diabetes Mellitus and
COPD. No significant surgical history.
FAMILY HISTORY
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Group J
No history of TB in family except him. No hereditary and genetic disease in family.
PERSONAL HISTORY
He is non-vegetarian, doesn’t consume alcohol, smoke and chew tobacco. His bowel habit and
bladder function are normal.
SOCIO ECONOMIC HISTORY
He lives in cemented house which is proper lighted and well ventilated. There are 2 bedrooms,
kitchen and toilet. The source of water is Tap and water is not filtered before drinking. The
source of fuel is LP Gas.
DRUG HISTORY
He is currently on medication for Pulmonary Tuberculosis. He is in intensive phase of TB

treatment.
ALLERGIC HISTORY
There is no known allergy history to any drug and food until now.
GENERAL PHYSICAL EXAMINATION
The patient is ill looking, conscious and oriented to time, place and person, at the time of visit.
He is calm and cooperative. He is wearing mask and is thin built in appearance.
Pallor, Icterus, Cyanosis, Clubbing, Lymphadenopathy, Edema and Signs of Dehydration were
absent.
VITALS
Temperature: 98 F and is afebrile.
Pulse: 82 beats per minute which is regular in rhythm, normal in volume with no radio-raidal
delay and all peripheral pulse are palpable.
BP : 120/80 mm of Hg taken on right hand in sitting position.
RR: 16/min which is of regular rhythm and thoraco-abdominal.
SYSTEMIC EXAMINATION:
Respiratory system
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Group J
On examination of upper airway, bilateral patency present with no nasal septal deviation and the
nasal mucosa was pink with no secretions. Oral cavity is clean and the tonsils are of normal size.
No any visible neck swelling.
Respiratory system
• Inspection- Chest was dome-shaped and bilaterally symmetrical. Both sides moving
equally with respiration. No venous prominence, No chest retraction, No use of accessory
muscles during respiration.
• Palpation- The chest expansion was symmetrical, trachea is at center. No localized rise
in temperature and tenderness. Symmetrical movement of chest. Tactile fremitus was
equal on all lung fields. Trachea was not shifted.
• Percussion- Lung fields were resonant. Liver dullness started in the 6th intercostals space.
Tactile vocal fremitus equal on both side of chest. Resonant sound was heard in all areas.
• Auscultation- normal vesicular bronchial sound was heard. Wheeze was heard over the
apex area of right lung.
Cardiovascular System
First and second heart sound are heard with no murmur.
Gastrointestinal System
No abdominal tenderness, swelling, scar and organomegaly.
Central Nervous System
Higher mental function is intact.
INVESTIGATIONS
1) Sputum AFB 1-2 bacilli/field

2) NS1 antigen Negative
3) SGOT (AST) 380 U/L
4) SGPT(ALT) 280 U/L
5) ALP 320 IU/L
6) Bilirubin(total) 3.1 mg/dl
7) Random Glucose 90 mg/dl
8) Hemoglobin 12 g/dl
TREATMENT
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Group J
He is now under his intensive phase of Anti Tubercular Therapy Regimen, which consists of
(HRZE) in combination.
Rifampicin 150mg OD
Isoniazid 75mg OD
Pyrazinamide 400mg OD
Ethambutol 275mg OD
D. FAMILY VISITS
Family Visit Date

First Visit 2076-9-10
Second Visit 2076-9-28
Third Visit (Supervision) 2076-10-8
Table No. : 4
First Visit (2076/09/10)
Objective:
 To introduce ourselves to family

 To explain them about the purpose of our visit
 To gather some basic information regarding family profile 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
We got the information of the patient from NATA, Narayangarh. We got his contact number
from there which made us easy to manage our meeting. We did our first visit in her home. When
we reached his home, the patient and his mother welcomed us. After introduction, we talked in
detail regarding his experiences during the course of illness and other health related behavior.
We discussed about the diagnosis, transmission, the impact of disease in patient’s life and family
life, his approach for treatment and new challenges in his life.
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Group J
1. Family Profile:
 No. of family members:4

 Type of family: Nuclear
 Religion: Hindu
 Dietary Habit: Regular Nepali Diet
 Head of family: Patient’s Father
 Occupation of family head: Indian Army
 Economic Status: Medium
 Chronic Illness in family: No
Family tree:
Fig 1: Family tree
2. Family members and relations
The family is socially respectable in the community .They have good understanding and mutual
cooperation between family members and between them and community too.
3. Housing and Environment
The house is cemented with properly lighted and well ventilated. The house is two storied with
one kitchen and two bedrooms. There are 1 window in each room . In kitchen, LPG gas and
sometimes firewood is used for cooking. They use government tap as the source of drinking
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Group J
water and water is drunk directly without filtration or boiling. They have water-sealed latrine
attached to the house.
House map:
Fig 2:House map
3. Economic status (According to Kuppuswamy’s socioeconomic status scale)
S. NO PARAMETERS SCORE
1 Education 4
2 Employment 6
3 Income 6
TOTAL 16
Table No.: 5
- Belongs to Upper middle class Family
Source of income
His father is the main source of income for the family. His mother is housemaker. His brother is
unemployed.
Expenditure
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Group J
In addition to daily household expenses, they need to pay for the education fee of the patient.
They also spend money on patient treatment, fooding, housing materials, clothes and so on
making a total of RS 25,000- 30,000.
4. Educational Status
Patient is studying bachelor. His father and his brother have passed from high school. His mother
have passed SLC.
5. Lifestyle and Food Habits
They buy some items of food from market while some items are grown in their own field. They
eat general Nepalese food and sometimes meat. Special food is consumed in special occasions
and festivals. They wear good clothes. Overall they have a satisfactory hygiene regarding their
work.
6.Cultural and belief systems
They are Hindu by religion and celebrate all major festivals.
Observation Checklist
Observations Yes No
Own house √
Rented house √
House type Cemented(pakka) type with wooden

door and windows
Rooms
Observations Yes No
 Number 2
 Ventilation √
 Sunlight √
Kitchen
 Ventilation/Exhaust √
 Energy Source for cooking LPG
Toilet 1, modern, clean
Cleanliness
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Group J
 Around the house √
 Of the diseased person √
Water
 Source Tap water
 Sufficiency √
 Treatment of drinking water Directly without filtration or boiling
Waste disposal Proper method of waste management,

Governmental waste management
Vehicles √
Electronic Appliances T.V., Radio, 1 mobile phone each
Pets √
Yard/Lawn √
Helpers/Servants √
Table No.: 6
Second Visit (2076-09-28)
Objectives:
 To observe and enquire about gender status in the family.

 To enquire and observe about the health of family and personal habits, KAP and disease
impact on family and patient.
 To have general examination of patient, simultaneously with other enquiry, if she have
complaints of any illness.
Activities:
 Enquiry about improvement of the patient.

 Observation and enquiry about gender status in the family.
 Enquiry and observation of health of family and personal habits, health seeking
behavior, KAP and disease impact on family and patient.
 Counseling
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Group J
1. Heath seeking and behavior and KAP
He was well aware about TB and its symptoms. He visited the hospital after getting sick as the
symptoms appeared which did not significantly affect his daily activity. His overall health
seeking behavior was satisfactory.
Knowledge: He have in depth knowledge about TB. He knew that TB is an infectious

communicable disease.
Attitude: He knows that one should visit the hospital or any health institution when he/she feels
sick. He does not have beliefs in Dhami and Jhakris.
Practice: He visits hospital when needed.
2. Effects of family in the disease
Role in causation
There is exposure history of patient by his friend who was TB infected. His nutritional
status is not satisfactory that might have lowered her immunity, which lead to infection.
Role in progression
The family played important role in halting the progression of disease by taking him to
hospital after development of symptoms. The family members take good care of him,
they were concerned about follow up, regular medication, diet.
Role in recovery
Family played an important role in curing the disease. They took good care regarding
food, rest and medical care during her illness. They encourage him to follow all medical
care and eat healthy foods. They support him psychologically to get rid of the disease.
Family role in health promotion and risk reduction:

Family is supportive and encourage patient to take regular medication and follow ups. Family provides
basic resources to the patient. The family was providing nutritious foods. They had also played important
role to minimize exposures like dust, smokes, cold.
Family role in disease onset and relapse:

There is no role of family in disease onset and relapse.
Family’s beliefs about illness appraisal

They believe allopathic medicines and don’t believe in ayurvedic medicine. They do visit
dhami and jhakris but don’t fully depend on them. The decision about health care is taken
by his father and mother.
Family’s role in acute response:

During acute episode of any disease, they take the patient to the hospital immediately.
Family’s role in adaptation in illness and recovery:

The family is supporting and encouraging her physically, mentally and emotionally to get
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Group J
rid of the disease. The family has taken preventive measures in order to prevent
transmission.
3. Impact of disease in family, patient and society
Impact on family
Effects on the routine of family members The family members have to leave their
home and their work so that they could bring
patient to hospital for treatment
Economic burden Medicine was supplied from NATA
so there was no direct economic
burden but they have economic
burden of indirect cost which include
food, transportation.
Social effect The society has positive and helpful attitude
towards the diseased and the family. They
offer to provide help and support when
needed.
Care of the diseased The family is well known about the disease
condition of the patient so they provide
proper care and emotional support. They took
good care regarding food habits, personal
hygiene and regular check up at the hospital.
Impact on patient
Inability to perform normal daily activities He is able to perform normal activities and
study.
Employment and status He can study well and go to college as usual.
Family relation Not affected. His family members support
him and provide enough care and affection.
Social relation There is good relation of his and his family
with their neighbors.
Self esteem and confidence There was strong self confidence.
Impact on society
The society is well aware about the disease and the fatal consequences of ignoring
disease condition. They have developed helpful attitude towards the patient and family.
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Group J
GENDER ANALYSIS
There is no gender discrimination in the family. His family are provided with quality
education. His mother is well respected in the family. The household works are
performed by both male and female. Though the control of the family matters is more by
the male member but female also share major portion of all the controls and all the assets.
 ACTIVITY PROFILE
Agricultural work √ √
Income generating activities √ √
Employment √
Others
Reproductive activities √ √
Water related √ √
Fuel related √ √
Heath care related activities
Child Immunization √ √
Care provider during illness √ √
Taking the sick to the hospital √ √
Buying medicine √ √ √
Cleaning √ √
Repair √ √
Market related and others √ √
Table No.: 7
 ACCESS AND CONTROL PROFILE

Access Control
Particulars
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Group J
Land √ √ √ √
Equipment √ √ √ √
Labor √ √ √ √
Cash √ √ √
Education/training √ √ √
Benefits
Outside Income √ √
Assets Income √ √
Basic needs
Food/clothing/shelter √ √ √ √
Education √ √ √
Political power/prestige √ √ √
Table No.: 8
4. FACTORS AFFECTING DISEASE PROCESS (Health related issues)
Factors How does it affect?
As he was socially active and exposure from TB infected

Exposure to household/ friend
occupational hazard
Age related No any significant impact.
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Group J
Day to day activities No any significant impact.

and responsibilities of
men and women.
Educational status and After the development of disease, proper health seeking
health seeking behavior behavior and KAP about the disease has halt the
progression of disease.
Economic status and its They belong to upper middle class family. There is no
impact on health burden of direct cost since medicine from NATA are free
but they have burden of indirect cost.
Gender norms and There is no gender discrimination and all the family
values in health. members are taken to hospital when they are sick.
Access to and control No any significant impact.

over resources and the
impact.
Perception of disease in People from community are well aware about TB.There is
the society and other no stigma regarding his condition in society.
social norms and values
that affect disease
process.
Access to information His family members have information about the disease
and its impact. and they are making every effort for improvement of
patient condition.
Counseling
During counseling we focused on issues such as healthcare, physical, financial, psycho-

social and nutritional needs. We informed about TB, consequences of not following
treatment guidelines, multi drug resistance TB, likely adverse events during therapy. We
counseled him to follow hygienic practices, properly dispose sputum and use surgical
mask. We advised him to visit DOTS center daily on time. We also counsel his mother to
take him to hospital for regular follow ups. We advised him to maintain balanced diet
and eat more green vegetables and fruits. We counseled the family regarding importance
of regular medication, types of food which he should take and motivated him. We
encouraged his family member to be supportive.
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Group J
Third visit (2076/10/08)
Objectives:
 To counsel the family members regarding the illness and importance of compliance.
 To enquire about important factors to be noted and if had been omitted in previous visits.
 To see the progression of disease and patients recovery.
Activities:
 We principally reviewed the information missed during the first two visits.
 Enquiry about the improvement of the patient.
 Counsel about the patient’s compliance and follow ups.

Outcomes:
There was improvement in health status and dietary habits. He was wearing surgical mask and
following hygienic practices. The family members were aware as well as concerned about the
patient and his illness and were willing to improve the health condition of the patient by adopting
proper dietary habits.
Conclusion:
Tuberculosis is a chronic disease that is affecting most of the individuals all over the world. It is
caused by the Mycobacterium tuberculosis in any organ of the body but involvement in the extra
pulmonary sites like breast, spleen, skeletal muscles is very rare. When people with Tuberculosis
in the lung cough, sneeze, sing, spit, speak, they expel the infectious droplets and transmit to
other people. TB is almost always curable if the patient adheres to the treatment regimen of
taking several special medications for six to nine months. As long time and multiple therapy
medication are taken, adverse reactions are most common. A discontinuous medication either
temporarily or permanently show risks to the individuals and TB resistance become complex or
has serious adverse effects. TB resistance is increasing day by day. Proper DOTS treatment and
complete treatment is necessary in order to reduce the complications, resistance and relapse cases
in future.
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Group J
In this case, Mr. Shahi is under medication of Category-1 Anti-Tubercular drug therapy. His
health seeking behavior and KAP are satisfactory. During our visit during Family Health
Exercise we counseled him and his family about his disease, its prognosis and preventive and
treatment measures. Thus, our counseling has made positive impact on him and his family.
Case 2: Chronic Obstructive Pulmonary Disease
Introduction
Chronic Obstructive Pulmonary Disease (COPD) is defined as a disease characterized by
persistent airflow limitation that is usually progressive and associated with an enhanced chronic
inflammatory response in the airways and the lungs to noxious particles or gases. COPD has both
pulmonary and systemic components, the presence of airflow limitation combined with
premature airway closure leads to gas trapping and hyperinflation, adversely affecting pulmonary
and chest work compliance. It is characterized by chronic obstruction of lung airflow that
interferes with normal breathing and is not fully reversible. It is a progressive life-threatening
lung disease that causes breathlessness(initially with exertion) and predisposes to exacerbations
and serious illness.
Acute exacerbation of COPD: it is characterized by an increase in symptoms and deterioration of
lung function and health status. They become more frequent as the disease progresses and are
usually triggered by bacteria, viruses, or a change in air quality.
Problem Statement
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Group J
 The Global Burden of Disease Study reports a prevalence of 251 million cases of COPD
globally in 2016.
 Globally, it is estimated that 3.17 million deaths were caused by the disease in 2015 (that
is, 5% of all deaths globally in that year).
 More than 90% of COPD deaths occur in low and middle-income countries.
 COPD are likely to increase in coming years due to higher smoking prevalence and aging
populations in many countries.
 In 2002 COPD was the fifth leading cause of death. Estimates show that COPD will
fourth leading cause of death by 2030.
-WHO
Nepal:
 According to annual report FY 2074/75, COPD is the number one cause of inpatient
morbidity.
 COPD was the 1st leading cause of mortality and 2nd leading cause of morbidity among
in-patients in Bir hospital (NAMS).
 Maximum number of cases are from province 3.
 Some sub-nationals studies conducted in Nepal have reported the prevalence of COPD
ranging from 23%-43%.
 The government of Nepal, in alignment with the global commitment for 25% relative
reduction in premature mortality from NCDs by 2025.
Epidemiological determinants
Risk Factors:
 Exposure to tobacco smoke: The most significant risk factor for COPD is long-term
cigarette smoking. The more years you smoke and the more packs you smoke, the greater
your risk. Pipe smokers, cigar smokers and marijuana smokers also may be at a risk, as
well as people exposed to large amount of second-hand smoke.20-30% of smokers
develop COPD.
 People with Asthma who smoke: The combination of asthma, a chronic inflammatory
airway disease, and smoking increases the risk of COPD even more
 Occupational exposure to dust and chemicals: Long term exposure to chemical fumes,
vapours and dusts in the work place can irritate and inflame the lungs.
 Exposure to fumes and burning fuel: In the developing world, people exposed to fumes
from burning fuels for cooking and heating in poorly ventilated homes are at higher risk
of developing COPD. In these regions, women are more susceptible than men.
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Group J
 Age: COPD develops slowly over years so most people are at least 40 years old when
symptoms begin.
 Genetics: The uncommon genetic disorder alpha-1 antitrypsin deficiency is the cause of
some cases of COPD. Also, the incidences of increase in frequency of allergies and
increase in airway hyper-responsiveness. Other genetic factors likely make certain
smokers more susceptible to the disease.
Host Factors:
 Age: Middle and old age
 Gender: Similar susceptibility
 Alpha1 anti-trypsin deficiency: It’s deficiency increases susceptibility
 Race: Asians less susceptible
 Occupation: Occupation related to dust and smoke at higher risk
 Childhood respiratory infection increases risk
 Malnutrition
Socio-Economic Factors:
 General exposure to dust at work: eg:Coal mining, gold mining
 Air pollution: indoor air pollution high rates in non-smoking women in many developing
countries. Also, related to outdoor air pollution
 Passive smoking: seen among family members of smokers
 Respiratory infections: overcrowding, overpopulation, lack of proper sanitation
 Lack of access to health care services and facilities
Clinical features:
 Shortness of breath, especially during physical activities
 Wheezing
 Chest tightness
 Having to clear your throat first thing in the morning, due to excess mucus in your lungs
 A chronic cough that may produce mucus (sputum) that may be clear, white, yellow or
greenish
 Blueness of the lips or fingernail beds (cyanosis)
 Frequent respiratory infections
 Lack of energy
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Group J
 Unintended weight loss (in later stages)
 Swelling in ankles, feet or legs
Preventive measures:
1) Primary Prevention-:
o Air pollution control measures:

Containment,Replacement,Dilution,Legislation,International action
o Quite tobacco smoking
o Change the source of cooking fuel
2) Secondary Prevention-:
A) Early diagnosis
B) Proper Management of cases
3) Tertiary Prevention-:
A) Disability limitation
B) Rehabilitation measures by physiotherapy , O2 therapy, lung transplantation,
occupation and residence change.
Complications:
COPD can cause many complications, including:
 Respiratory infections. People with COPD are more likely to catch colds, flu and

pneumonia. Any respiratory infection can make it much more difficult to breathe and could
cause further damage to lung tissue. An annual flu vaccination and regular vaccination
against pneumococcal pneumonia can prevent some infections.
 Heart problems. For reasons that aren't fully understood, COPD can increase your risk
of heart disease, including heart attack. Quitting smoking may reduce this risk.
 Lung cancer. People with COPD have a higher risk of developing lung cancer. Quitting

smoking may reduce this risk.
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Group J
 High blood pressure in lung arteries. COPD may cause pulmonary hypertension.
 Depression. Difficulty breathing can keep you from doing activities that you enjoy. And
dealing with serious illness can contribute to development of depression.
Justification for selection of case:

A systematic analysis of global burden of disease 2015 has ranked Nepal as one of the top four
countries with highest age/ standardized Disability Adjusted Life Years (DALY) rates, this is
quite a concern for the high mortality and morbidity. This is a serious issue and has become a
growing concern. This disease is highly prevalent and study of particularly high burden diseases
would help us know the real scenario and problems faced by the patients in the entire course of
their illness including causation, progression, medication, cost burden, family impacts and the
impact of the disease in their everyday life. Since the disease is common, every other house
could be represented by this case therefore it was definitely a case that was in the preference of
our list.
CASE STUDY
Patient Particulars:
Name- Mrs. Saraswati Devi Poudel
Age- 69 years/Female
Address- Bharatpur Metropolitan City-10,Chitwan
Religion- Hindu
Occupation- Housewife
Chief Complaints:
- Chest pain for 5 days
Cough for 5 days

Shortness of breath for 3 days
History of Present Illness:
The case is a known case of COPD, Hypertension, Gastritis, acute kidney injury and paroxysml
ventricular fibrillation. She had been diagnosed with HTN almost 25 years back for which she
started medication. She has been taking less amount of salt and is also controlling her diet. The
course of disease lasted long therefore the hospital stay was an extended 9 days admission for
which she was prescribed nasal spray which has to be used regularly. From then she is quite
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Group J
allergic to cold with the presentation of the respiratory system like rhinorrhea, sneezing, SOB.
She is allergic to pollen and mustard seeds. 3 months ago she was again admitted to CMCTH due
to exacerbation of COPD due to inhalation of mustard seed dust during some agricultural work.
The medication is continued but is not very compliant as she takes his medication only once a
day which has been prescribed twice a day.
4 year ago she was diagnosed with gastritis and is currently under medication and
also she was diagnosed with acute kidney injury 2years back which she is under medication. and
also ventricular fibrillation which was diagnosed when admitted in CMCTH. Currently she
complained of chest pain,shortness of breath and cough.
Past History:
History of gastritis for 4years
Family History:
There is no significant family history of COPD, asthma, epilepsy, HTN,cancer.
Physical Examination
During the visit of home, the patient was fair-looking, oriented to time place and person.
No pallor, icterus, lymphadenopathy, cyanosis, clubbing, edema and the patient was well
hydrated.
Vitals
Pulse: 72 beats/min
Blood Pressure: 130/90 mm Hg
Respiratory Rate: 20 breaths/min
Temperature: 97 F
General and Systemic Examination

Respiratory:
 On inspection: symmetrical movement of chest on respiration, no scars, no venous

prominence, no visible lumps, pulsations, intercostal recession and retraction.
 On palpation: trachea was central in position and tactile vocal fremitus was intact
 On percussion: normal resonant sound,
 On Auscultation: wheezing was heard during expiration and at the end of inspiration
Abdominal Examination:
 On inspection: rounded abdomen, abdomino-thoracic movement of abdomen,central and
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Group J
inverted umbilicus, no visible veins, no visible scars, no visible pulsations and hernia
orifices were intact.
 On palpation: temperature is normal in all quadrants, no superficial tenderness, no
rigidity, no guarding, no palpable mass found and no organomegaly.
 On percussion: tympanic sound was noted, shifting dullness and fluid thrill were absent.
 On auscultation: normal bowel sound heard.
CVS Examination:
 On inspection: no abnormal pulsations and prominent veins were seen.

 On palpation: apex beat was on the 5th intercostal space in midclavicular line, no heave
and thrusts present.
 On palpation:No thrills and additional sound
 On auscultation: S1 and S2 heard over all 4 auscultatory area with no additional heart
sounds.
CNS Examination:
 All cranial nerves are intact.

 Meningeal signs negative.
 Motor system: intact
 Sensory system: intact
Drugs History:
Salmeterol 50mcg BD
Amlodipine 5mg OD
Sucrafil 10ml (500mg) QDS
Family visit of Patient
Family Visit Date Time Duration
First Visit 2076/8/17 2.30-4.30 2 hours
Second Visit 2076/8/21 11-12.30 1 and half hour
Third Visit 2076/08/28 2.30-4.00 1 and half hour

Table No.:9
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Group J
FAMILY VISITS
First Visit
Objectives:
 General introduction between us and the family.
 To gather some basic information regarding family profile, economic, housing and
cultural factors
Activities:
Outcomes:
As this case was chosen from known person we called her then we explained the process and
objectives of our family health exercise. The patient was very keen to know about our exercises
and after the briefing granted us the permission to visit her. After fixing the date and time for the
visit on phone, we reached there for our first visit. The house was located in the residential area
inside the city. As we reached we were warmly welcomed with bright smile and friendly
namaste. After a general introduction of ours as well as of the family members we once again
described the purpose of our visit. Finally after two long hours of conversation with the family
members, we were quiet satisfied with the fulfillment of our visit. We talked in detail regarding
her experiences during the course of illness and other health related behavior. We discussed
about the diagnosis, transmission, the impact of disease in patient’s life and family life, her
approach for treatment and new challenges in her life based on the semi-structured questionnaire
we had prepared.
They were very cooperative.
1. Family Profile:
She lives in a joint family, she along with her husband and her daughther in law and grandson.
Her elder son lives separately from them with his family. Younger son works in abroad.
 No. of family members: 11

 Type of family: Joint
 Religion: Hindu
 Head of family: Her Husband
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Group J
 Occupation of family head: Ex Army

Figure no.: 3
2. Housing and Environment:

They live in a concrete house. The house had 4 rooms altogether excluding the kitchen. . Each
room had 4 windows and 1 door. All the rooms were well-ventilated. They drink water from the
government water supply directly with purification by filtering. They had access to easy, proper
and clean toilet. They used LPG-gas for main source of fuel . There was no fence around the
house. They had a small kitchen garden beside their house to grow sufficient amount of
vegetables. As a whole, the house looks clean.
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Group J
Figure No.: 4
3. Economic Status
She belongs to an upper middle class family. She is a housewife by occupation. Her younger son
is working in abroad and elder son working in Nepal but live separately with his family. They do
support the family by sending money at intervals to support the family.
Source of income:
Her sons are the main source of income for the family . Her son working abroad (Dubai) have
provided the funding that helps support the family. Remittance has thus become the major source
of income in the family which has helped the members of the family to fulfill the needs and
wants. Pansion is her secondary source of income.
Expenditure:
In addition to daily household expenses, they spend money on fooding, housing materials,
clothes,medicine and so on and also pay for grandson and granddaughther education. Totaly
expenditure 25000-3000 monthly.
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Group J
Our patient is Illiterate .Her husband and all her sons other daughter in laws and grandchildren
are educated. All her sons have completed their undergraduate level. One of his grandchild is
doing BBA and one studies in grade 10 and another studies in grade 8.
 Patient- ILLiterate
 Husband-Literate
 Daughter-Literate
 Son-Literate
 Son-Literate
 Daughter-in-law-Literate
 Daughter-in-law-Literate
 Grandson- Literate
 Granddaughter-Literate
 Grandson-Literate
Kupuuswamy score of COPD patient’s family
S.No. Parameter Score

1. Education 4
2. Occupation 6
3. Monthly Family Income 10
Total 20
Table No.:10
Interpretation- From above table, it is concluded that it is upper middle class family.
5. Lifestyle and Food Habit:

Our patient is an old women of 69 years of age. She spends her time with her daughter-in-
law,grandson and grandson at home and occasionally goes out. Since, she has COPD she is not
much involved in the household and agricultural work. She visits hospital regularly for follow-
up.
They grow their vegetables in their own farm land and sometimes they buy from the local
market. They eat general Nepalese food. Special foods are consumed in special occasions and
festivals. They wear good clothes. Furniture of house is sufficient to accommodate their family
and one or two visitors. Overall they have a satisfactory hygiene regarding their work.
Observation checklist:
Observations Yes No
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Group J
Own house √
Rented house √
House type Concrete, two storey house with doors

and windows made up of cement
Rooms
Observations Yes No
 Number 4
 Ventilation √
 Sunlight √
Kitchen
 Ventilation/Exhaust √
 Energy Source for cooking LPG
Toilet 1, clean, inside the house
Cleanliness
 Around the house √
 Of the diseased person √
Water
 Source Tap water
 Sufficiency √
 Treatment of drinking water Directly with filtration or boiling
Waste disposal Municipality van
Vehicles √
Electronic Appliances T.V., 1 mobile phone each
Pets √
Yard/Lawn √
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Helpers/Servants √
Table No.:11
Second Visit
Objectives:
Activities:
behaviour, KAP and disease impact on family and patient.
utcome:
The second visit was scheduled and we were once again welcomed by the family in the
same manner as before. The family members were very responsive and the assessment of
KAP was not a very difficult task as it seemed. We asked the members about the disease
and their attitude towards it. The patient being very enthusiastic was a very fun person to
assess and was emotional. She shared quiet a lot about her past and present practices as
well as the difference of the attitudes then and now.
Knowledge:
They had a fairly good knowledge and used layman terms and their attitude towards it
reflected the life in the city outskirts which really fascinated us. The patient was aware
about the causation and progression of the disease.
Attitude:
The attitude towards the disease was fair. They were quiet optimistic about the health of
the patient and other members as well. They very well understood the importance of diet,
exercise and health foe which mostly home remedy is focused along with other
medications.The family doesnot believes strongly in dhamis, jhakris and other witch
doctors.
Practice:
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Group J
The practice however was very strict as she do take the prescribed dose of medicines and
do listen to the family members when she is asked to take her medications as indicated.
She however stays away from the cold and other allergens.
Effects of family on disease:

 Role in causation:
The role of family in the causation of disease is quiet important. The main factor
affecting the disease lies within the family. Proper care of health is the initial
responsibility of the family, where each member is entitled fully to use the
freedom to exercise health and obtain optimum health. Healthy behaviour and
health seeking habit in the individuals are inculcated in by the family from the
early years of life. In the case of our patient the causation of disease seems to
point towards her habit of smoking in her early life. Also the use of firewood as
the main source of fuel for cooking adds to the cause. Also she being allergic to
pollen dust and mustard seeds have role as she belongs to a family related to
agricultural background.
 Role in Progression:
There seems to be no significant role of family in the progression of disease but
as it seems that without the proper care of the patient the disease might rapidly
progress in no time. So here too when we look through the state we can see that
the progression has been taken into consideration by the family and so she is
given proper amount of rest, food , and the environment to share her emotions.
Dietary changes have been significantly made, for example the quitting of
smoking, drinking of lukewarm water at regular intervals during the day,having
food with less amount of salt etc.
 Role in relief:
The change in behaviour by the family with respect to the disease shows the
efforts made in the relief of the patient. Family takes marked steps like change in
the daily routine, alterations in the diet, proper sanitation, and frequent health
check-up which will definitely benefit the patient. In this case too patient is
barred from doing agricultural works and household work as her symptoms get
aggravated by agricultural works. Her diet is altered significantly with less
carbohydrate, less salt and high protein diet. The compliance to medication
however is high and family member has been able to convince her to take her
medicines as prescribed by the doctor.
Family’s role in different aspects

 In health promotion and risk reduction
The support of family is well known aspect in pages of diseases. The health promoting
behaviour of the family decides whether the disease progression heads forward or
backward. In our patient the family encourages the health promoting activities by
providing the patient with timely health checkups and medicine and also made available
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Group J
timely proper nutritious and balanced diet. She is protected from cold by providing hot
water and nutritious food along with adequate rest. Also the risk reduction is taken into
account by not allowing our patient to work in the agriculatural and household work and
keeping patient warm.
 In disease onset and relapse
The role of family in this case for onset of disease seems negligible as there are lesser
known genetic factors that might have caused this disease. Reason behind the onset of
the disease is mainly related to smoking habit of the patient in the past. However there
seems to be role in the relapse of the disease i.e. acute exacerbation of the COPD, which
might be due to negligence of the family towards the patient. As in the previous episode
of exacerbation the family didn’t take into consideration his allergy to cold which
resulted into shortness of breath.
 Family’s belief about illness
Family decides the visit of patient to the hospital viewing the state of illness. In the
Nepalese society, there is still belief in the dhami and jhakris more than the allopathic
medical system. If the family beliefs that the illness to be treated by dhami and jhakris
instead of treatment by the doctor then the risk of worsening of the patient condition is
high. Here though the family believes in both the health systems, COPD was treated in
medical institution.
 Family’s decision about healthcare
The decision regarding health care was taken by the patient's husband and daughter-in-
law . There is prompt access to health care and all the family members have proper
access to health service. Frequent visits are made to the hospital for checkups when
necessary.
 Role in acute response
She was having symptom of shortness of breath which make her difficult in
breathing and became severe to hamper her daily activities. She took her to the
neary by hospital COMS. She was provided with appropriate medication.
 Family’s role to adaptation and recovery
Family played important role in her recovery. Taking good care regarding food,
rest and medicines during her illness had great impact in her recovery.
Health seeking behaviour:

Our patient visits hospital regulary for followup. She knows what is good and bad during
her illness. She knows well about the food and rest that are to be adopted during the
course of illness.
Her family is also well informed about the disease and they responded well. They took
good care of patient and managed to take to hospital. The family’s KAP regarding this
disease is considerably good.
Impacts of disease on family, patient and society
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Group J
On family
COPD was not a very big burden in the family as they were taking good care of the
patient as well as the patient was complying to all the methods. The cost of medicines
however worried her because there were range of medicine she needed to take and she
also complained that the medicine are brought from kathmandu which showed economic
burden. Also our patient is also a known case of Acute kidney injury and ventricular
fibrillation which even make them in economic burden for buying medicine of those
disease and follow check up. Her family however was conscious regarding her health and
sensitive towards the need of the patient. They took good care of her food, hygiene,
exposure to dust and regular checkup at the hospital.
On patient
 Psychological Effect
COPD has barred her to do her daily agricultural and household works and also
going out for different occasion which make her to stay at home.
 Physical Effects
She is not able to perform household works and works of field which she used to
perform because it triggers her asthmatic attack. Any exposure to cold or allergen
gives her a difficult time, severe symptoms including breathing difficulty barring
her from performing physical activity.
 Social Effects
There is good relation of her family with their neighbours. According to the
patient, the neighbours are well co-operative and render their help in needs. The
locality people seemed friendly and helped each other during the time of need.
Effect on economy:
The family is upper middle class family so does not have a high burden for medicines
and other health facilities however the expense is huge due to many medicines prescribed
for different diseases.
Gender Analysis
The gender status of the family is good. The household works are performed by both
male and female. Though the control of the family matters is more by the male member
but female also share major portion of all the controls and all the assets.
Activity Profile
Production activities √ √
Agricultural work √
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Group J
Income generating activities √
Employment √
Others √ √
water related √ √ √ √
Fuel related √
Heath care related activities √
Child Immunization √ √ √
Care provider during illness √ √
Taking the sick to the hospital √ √
Buying medicine √ √
Cleaning √ √
Repair √
Market related and others √ √
Table No.:12
Table no.8
B. Control Assess Profile
Access Control
Particulars
Land √ √
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Group J
Equipment √ √ √
Labor √ √
Cash √ √ √
Education/training √ √
Benefits
Outside Income √ √
Basic needs
Education √ √ √ √
Political
power/prestige √ √
Table No.:13
C. Factors affecting disease process (health related issues)
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Exposure to household/occupational Exposure dust and cold may trigger the asthmatic
hazards attack
Age related Significant in elderly patient
Day to day activities and

During day to day household works, the exposure to
responsibilities of men and dust and cold may trigger the attack.
women.
Educational status and health The delay in health seeking behavior may cause
seeking behaviour progression of disease.
They are upper middle class family. So, the sanitation

and occupation may contribute towards communicable
Economic status and its impact diseases.
on health
Women usually involved in household works may

Gender norms and values in increase exposure.
health.
Access to and control over No significant impact.

resources and the impact.
Perception of the disease in

society and other social norms no any effective support, counseling and care which
and values that affect disease have made irresponsible as in a member of the society.
process.
Family members have good knowledge about disease

Access to information and its which make them take good care of patient during
impact illness.
.
In second visit, we also counselled the patient by providing information about the causation,
treatment, complication of disease and the role of family member to treat the disease and about
the personal behaviour to prevent the disease. We counselled them about the acute attacks and
informed them to be ready for seeking health care when similar symptoms appear. We also
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Group J
informed the patient about the importance of taking proper dose of medicines as prescribed by
the doctor.
Third Visit
Objectives:
 To enquire about anything important to be noted and if had been omitted in previous visit
 Reviewed information about progress of patient.
Outcome:
She started using while going out of the house and wearing warm cloth in winter. As she was
patient of acute kidney injury,gastritis and ventricular fibrillation, we counselled her mainly to
focus on her diet and take medicine in time as prescribed by doctor and focus on sanitation. She
stopped involving herself in agricultural and household work. She was more focused on selecting
her diet according to her health.
In third visit, we observed the progression of patient’s condition. We tried to provide information
about the causation, treatment, complication of disease and the role of family member to treat the
disease and about the personal behaviour to prevent the disease. We counselled them about the
acute attacks and informed them to be ready for seeking health care when similar symptoms
appear. We also informed the patient about the importance of taking proper dose of medicines as
prescribed by the doctor.
Conclusion:
Chronic Obstructive Pulmonary Disease (COPD) is defined as a preventable and treatable
disease characterized by persistent airflow limitation that is usually progressive and associated
with an enhanced chronic inflammatory response in the airways and the lungs to noxious
particles or gases. It can be prevented by cessation of smoking, less exposure to noxious
chemicals, staying away from allergic chemicals and dusts. Proper care of the medication, food,
warmth and proper rest is a must.
CASE 3: ANXIETY DISORDER
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A. INTRODUCTION
Anxiety is an emotion characterized by an unpleasant state of inner turmoil, often accompanied

by nervous behavior such as pacing back and forth, somatic complaints, and rumination. It is the
subjectively unpleasant feelings of dread over anticipated events. Anxiety is a feeling of
uneasiness and worry, usually generalized and unfocused as an overreaction to a situation that is
only subjectively seen as menacing. Normally considered to be appropriate, when anxiety is
experienced regularly the individual may suffer from an anxiety disorder. Anxiety is closely
related to fear, which is a response to a real or perceived immediate threat; anxiety involves the
expectation of future threat. People facing anxiety may withdraw from situations which have
provoked anxiety in the past. There are several anxiety disorders, including
 generalized anxiety disorder

 specific phobia,
 social anxiety disorder
 agoraphobia,
 panic disorder, and
 selective mutism
Common symptoms for patients who have anxiety disorder:
 Panic, fear, and uneasiness.

 Sleep problems.
 Not being able to stay calm and still.
 Cold, sweaty, numb or tingling hands or feet.
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 Shortness of breath.
 Heart palpitations.
 Dry mouth.
 Nausea.
PROBLEM STATEMENT
The proportion of the global population with anxiety disorders in 2015 is estimated to be 3.6%.
As with depression, anxiety disorders are more common among females than males (4.6%
compared to 2.6% at the global level). The total estimated number of people living with anxiety
disorders in the world is 264 million. This total for 2015 reflects a 14.9% increase since 2005, as
a result of population growth and ageing.
-WHO
EPIDEMIOLOGY
Risk factors:
 Trauma. ...
 Stress due to an illness. ...
 Stress buildup. ...
 Personality. ...
 Other mental health disorders. ...
 Having blood relatives with an anxiety disorder. ...
 Drugs or alcohol.
Remitting factors:
 Family care and support.

 Psychiatric consultation.
 Drug therapy.
Complications:
 Depression (which often occurs with an anxiety disorder) or other mental

health disorders.
 Substance misuse.
 Trouble sleeping (insomnia)
 Digestive or bowel problems.
 Headaches and chronic pain.
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Group J
 Social isolation.
 Problems functioning at school or work.
 Poor quality of life.
.
B. JUSTIFICATION FOR SELECTION OF CASE
Mental illness affects the functioning and thinking process of the individual, greatly diminishing
his/her social role and productivity in the community. In addition, because mental illnesses are
disabling and lasts for many years, they are associated with a significant burden of morbidity and
disability. They take a tremendous toll on the emotional and socioeconomic capabilities of
relatives who care for the patient despite being common, mental illness is under diagnosed by
doctors. Less than half of those who meet diagnostic criteria for psychological disorders are
identified by doctors.
C. CASE STUDY
PATIENT PARTICULARS
Name: Basanta Rana
Age/Sex: 39years/ male
Address: Kalika Nagarpalika-10 , Chitwan
Religion: Hindu
Occupation: Farmer
Source of information: Patient
CHIEF COMPLAINTS
 Palpitation
 Fear
 Dizziness
HISTORY OF PRESENT ILLNESS
The patient was apparently well 10 months back before he developed anxiety disorder. The
symptoms were gradual in onset. He first developed sleep disturbance and had anxiety,fear
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thought,palpitation for 10 days,which was of gradual onset ,not associated with chest pain or any
radiation.
There was no history of head trauma and hallucinations.
He also complains of dizziness
Hospital Course:
He had OPD visit 10 months back ,prescribed with antidepressant medications, ask to followup,
during this period,he had 5 OPD visit, at 5th OPD visit ,we got this case
HISTORY OF PAST ILLNESS
No history of such complaints ,no history of DM ,TB,hospital admit, no surgical history
FAMILY HISTORY
There is no significant history of mental illness in any of the family members.
PERSONAL HISTORY
He is non-vegetarian, doesn’t consume alcohol neither smoke nor take tobacco. His bowel habit
and bladder function are normal.
He lives in combined kacha and cemented house which is adequately lighted and ventilated.
There are 2 bedrooms, a kitchen and a toilet which is separated outside. The source of water is
Tube well and water is not filtered before drinking. The source of fuel is LP Gas and firewoods.
DRUG HISTORY
No significant past drug history ,ongoing antidepressants drugs
ALLERGIC HISTORY
There is no allergy history to any drug and food until now.
The patient looks well, conscious and oriented to time, place and person. He is calm and
cooperative. He is of moderate built.
Pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema and signs of dehydration were
absent.
Vital examination
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Group J
Temperature: 98 F
Pulse: 87 beats per minute which is regular in rhythm, normal in volume with no radio-raidal
delay and all peripheral pulse are palpable.
BP : 120/80 mm of Hg taken on right hand in sitting position.
RR: 16/min which is of regular rhythm and thoraco-abdominal.
Systemic examination
Respiratory system
Normal vesicular breath sounds in the lung fields with no added sounds.
Cardiovascular System
First and second heart sound are heard with no murmur.
Gastrointestinal System
Normal shape and symmetry of abdomen.
No abdominal tenderness, swelling, scar and organomegaly.
Central Nervous System
 Higher mental function is normal.

 Cranial nerve examination is normal.
 Motor system normal.
 Sensory system normal.
Mental state examination ( at home after treatment)
 Moderate built, conscious, maintained hygiene, wearing clothes, appropriate to
age, sex and climate.
 No catatonic
 Talk and speech: normal
 Mood: anxiety
 Thought perception: normal
 Attention: attentive
 Grade of knowledge: educated
INVESTIGATIONS
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9) WBC- 7000/cumm
10) Platelets- 172000/cumm
11) Hb%- 14.4gm/dl
12) RBC- 4.96/cumm
13) Urea- 17mg/dl
14) Creatinine- 0.72mg/dl
15) Sodium(Na+)- 139.1mmol/L
16) Potassium(K+)- 4.2mmol/L
17) Blood sugar(R)- 85mg/dl
TREATMENT
TAB Escitalopram 20mg OD
D. FAMILY VISITS
Family Date
Visit
Table No.:14
First Visit (2076/08/18)
Objective:

Activities:

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Outcomes
We got the information of the patient in from psychiatric ward of CMCTH. We got his contact
number from there which made us easy to manage our meeting. We did our first visit in his
home. When we reached his home, the patient and his wife warmly welcomed us. After brief
introduction, we talked in detail regarding his experiences during the course of illness and other
health related behavior. We discussed about the diagnosis, the impact of disease in patient’s life
and family life, his approach for treatment and new challenges in his life .
1. Family Profile:

 Religion: Hindu
 Head of family: Patient
 Occupation of family head: Farmer
Family tree:
Fig No.: 5
2. Housing and Environment
He has a kacha and cemented type of house which is adequately ventilated and properly lighted.
The house is one storeyed with common kitchen and two bedrooms. There are 2 windows in
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each room except patient’s room has only 1 window. In kitchen, LPG gas and sometimes
firewood is used for cooking. They use tube well as the source of drinking water and water is
drunk directly without filtration or boiling. They have water-sealed latrine outside to the house.
They have a small kitchen garden just sufficient to grow few leafy vegetables and also had a
small farm where hens were kept.
House map: First floor Ground floor
Fig 6: House Map
3. Economic status (According to kuppuswamy’s socioeconomic status scale)
1 Education 4
2 Employment 5
3 Income 3
TOTAL 12
Table No.:15
- Belongs to Middle/Lower middle class Family
Source of income
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The main source of income is from the shop he owns and agricultural product . other source of
income is milk production .
Expenditure
In addition to daily household expenses, they need to pay for the education fee of her sons and a
daughter. They also spend money on patient treatment, fooding, housing materials, clothes and
so on making a total of RS 10,000- 15,000 per month.
Patient has primary level of education and his wife has primary level of education.His son is
studying in primary level, daughter in primary level.
5. Lifestyle and Food Habits
Our patient is socially active and attends social gatherings and functions in the society. They buy
some items of food from market while some items are grown in their own field. They eat general
Nepalese food and sometimes meat. Special food is consumed in special occasions and festivals.
They wear good clothes. Furniture of house is sufficient to accommodate their family and one or
two visitors. Overall they have a satisfactory hygiene regarding their work.
Observations Yes No
Own house √
Rented house √
House type Cemented(pakka) and kaccha type

with wooden door and windows
Rooms
Observations Yes No
 Number 3
 Ventilation 
 Sunlight 
Kitchen
 Ventilation/Exhaust 
 Energy Source for cooking LPG; firewoods.
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Toilet 1, modern, clean
Cleanliness
 Around the house 
 Of the diseased person 
Water
 Source Tube well
 Sufficiency 
 Treatment of drinking water Directly without filtration or boiling
Waste disposal Proper method of waste management,

however some are burned in nearby
land
Vehicles 
Electronic Appliances T.V., Radio, 1 mobile phone each
Pets 
Yard/Lawn 
Helpers/Servants 
Table No.:16
Second Visit (2076-10-05)
Objectives:

 To have general examination of patient, simultaneously with other enquiry, if she have
Activities:

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 Counseling
Our patient visits hospital when needed. They have no belief on dhami and jhakri. He
knows what is good and bad during her illness. He had little knowledge about mental
illnesses but had no information about anxiety disorder. He is quite compliant and go for
regular follow ups in CMCTH.
His family is not very well informed about the disease and about the real cause of
disease. They took good care of patient and managed to take to hospital.
Role in causation
No family role is seen in causation of diseases.
Role in progression
He is emotionally supported by his family members and never left alone. They take
proper care of his medication and regular follow-up.
Role in recovery
Family played an important role in curing the disease. They took good care regarding
food, rest and medical care during his illness. They supported him emotionally.
Family role in health promotion and risk reduction:

His family is fully supportive, emotionally and mentally and took care of his follow ups
and medications. He isn’t left alone in her home.
Family role in disease onset and relapse:

All the family members live together,there is no role of family in diseases onset and
relapse
Family’s beliefs about illness

They only believe on allopathic medicines.
Family decision about health care:

The decision about health care is taken by himself.
Family’s role in acute response:

Whenever he feels discomfort or any health related acute problem, they immediately took
him to nearby health centers.
Family’s role in adaptation in illness and recovery:

The family is supporting and encouraging his physically, mentally and emotionally to get
rid of the disease. All family members behave very well with his. And every weekend his
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son managed to visit his.

Impact on family
Effects on the routine of family members All the family members stays together
Economic burden There was no obvious economic
burden to the family.
Social effect The society has positive and helpful attitude

towards the diseased and the family. They
offer to provide help and support when
needed.
Care of the diseased The family is well known about the disease
condition of the patient so they provide
proper care and emotional support. They took
good care of her regarding her food habits,
personal hygiene, mental wellbeing and
regular check up at the hospital.
Impact on patient
normal daily activities he is able to perform agricultural works and
works of field which he used to perform
when she wasn’t ill.
Employment and status he stays in shop, rear chicken and can do it
even now.
Family relation Not affected. His family members support
him and provide enough care and affection.
Social relation Mental illness in our society is not perceived
well as other disease, so he had to hide the
real reason of her illness and this leads to
considerable reduction in his social
relationships but nowadays the problem
regarding his health is obvious to the society.
However he is not still able to return back to
his original stage of social and productive
life.
Self esteem and confidence Previously he had fear of doing any work and
was mentally week but recently hisr mental
problems are improved and self esteem is
considerably increased.
Impact on society
Because of the family’s request, we didn’t inquire other people in the community.
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GENDER ANALYSIS
There is no gender discrimination in the family. All of her children are provided with
quality education. The female members are well respected in the family. The household
works are performed by both male and female. The earning members of the family are
both male and female.
 ACTIVITY PROFILE
Agricultural work 
Income generating activities  
Employment  
Others  
Reproductive activities  
Water related 
Fuel related 
Heath care related activities  
Child Immunization  
Care provider during illness  
Taking the sick to the hospital 
Buying medicine  
Cleaning  
Repair 
Market related and others  
Table No.:17
 ACCESS AND CONTROL PROFILE

Access Control
Particulars
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Land   
Equipment    
Labor  
Cash    
Education/training    
Benefits
Outside Income  
Assets Income
Basic needs
Food/clothing/shelter    
Education    
Political
power/prestige   
Table No.:18
3. FACTORS AFFECTING DISEASE PROCESS (Health related issues)

No any significant impact.
Exposure to household/
occupational hazards
Age related No any significant impact.
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Day to day activities and No any significant impact.

responsibilities of men
and women.
Educational status and After the development of disease, proper health seeking
health seeking behavior behavior and KAP about the disease has halt the
progression of disease.
Economic status and its They are middle class family. So, no any economic barrier
impact on health for seeking health care.
Gender norms and There is no gender discrimination and all the family
values in health. members are taken to hospital when they are sick.
Access to and control No significant impact because there is proper access to

over resources and the resource.
impact.
Perception of disease in Because of the family’s request, we didn’t inquire other
the society and other people in the community.
social norms and values
that affect disease
process.
Access to information His son and family members have information about the
and its impact. disease and they are making every effort for improvement
of patient condition.
Counseling
There is a huge role of the family in exacerbation or remmision in such cases of psychiatric
disorders. So, we stressed the fact that love and care can provide far better relief to the patient
and also said that frequent visit of her children if possible would be a good for the patient’s
improvement. Compliance to drug therapy is equally important and so we asked her son to
strictly maintain the drug schedule.
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Third visit( 2076/10/11)
Objectives:
 To enquire about anything important to be noted and if had been omitted in previous
visits.
 To see the progression of disease and patients recovery.
Activities:
 We principally reviewed the information missed during the first two visits.
Outcomes:
Previously, He had fear of doing anywork and depressed mood. But after our counseling of prior
visits, he is motivated and encouraged to live his life. We made his realize that he is not only
important for himself, but also to his family. It was seen that he got involved in various social
activities at the time of third visit. he seems happy and cheerful during third visit.
Summary:
 Psychiatric disorder has a complex interplay of genetic, socioeconomic, and familial

factors in causation, progression and relief. Proper care and love from family members
can drastically improve the patient condition. Awareness of disease, development of
positive attitude from family members and society, changes in health promoting behavior
and proper compliance to therapy play a prudent role in the disease recovery.
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CASE 4: Amputation Secondary To Road Traffic Accident
Introduction
Amputation is the removal of a limb by trauma, medical illness, or surgery. As a surgical

measure, it is used to control pain or a disease process in the affected limb, such
as malignancy or gangrene. An amputation secondary to RTA is when a part of the body,
usually a limb, is removed from the body due to trauma after an accident. Traumatic
amputations are widely seen in car accidents every year where a limb is pulled from the body
or crushed so badly that it cannot be saved. These are one of the most serious and debilitating
injuries that occur after a car accident.
Every year, thousands of victims will lose a limb during what is known as ‘traumatic
amputation,’ which is when a limb is fully or partially severed from the body. Amputations
can either be referred to as ‘incomplete’ or ‘complete’ amputations. If you have suffered a
complete injury, this means that there are no tissues, ligaments, or any other types of
structures connecting the limb to your body. In a situation involving an incomplete
amputation, some of the soft tissues will remain intact. There are many serious injuries and
symptoms that can take place when a body part is amputated including bleeding, shock, and
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infection. This is why those who have had a limb amputated suddenly in an accident should
receive emergency care.
Problem statement
Approximately 1.35 million people die each year as a result of road traffic crashes.The2030
Agenda for Sustainable Development has set an ambitious target of halving the global
number of deaths and injuries from road traffic crashes by 2020.Road traffic crashes cost
most countries 3% of their gross domestic product. More than half of all road traffic deaths
are among vulnerable road users: pedestrians, cyclists, and motorcyclists.93% of the world's
fatalities on the roads occur in low- and middle-income countries, even though these
countries have approximately 60% of the world's vehicles. Road traffic injuries are the
leading cause of death for children and young adults aged 5-29 years.
-WHO
Nepal's scenario: According to the latest WHO data published in 2017 Road Traffic Accidents
Deaths in Nepal reached 4,921 or 3.01% of total deaths. The age adjusted Death Rate is 20.13
per 100,000 of population ranks Nepal 79 in the world.
Deaths % Rate World rank

4,921 3.01 20.13 71
JUSTIFICATION FOR SELECTION OF CASE
An amputation of lower extremity is a permanent incompetence which limits activities and

participation and causes a decrease in quality of life about health. Amputations are still
performed in orthopedic surgery frequently. The purpose of amputation is to remove
infected,injured or non-functional extremity.Rehabilitation and prosthetic services in Nepal need
to increase proportionally as they contribute to enabling those people to a better daily life.
Access to education vocational training has the potential to improve the socioeconomic status of
those with lower limb amputation due to lack of employment not requiring physical effort.
CASE STUDY
Patient particulars:
Name of the patient: Ram Prasad Subedi
Age: 46 years
Sex: Male
Temporary Address: Bharatpur Metropolitan City-11, Chitwan
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Permanent Address: Madi Nagarpalika-3, Chitwan
Religion: Hindu
Occupation: Unemployed
Marital status: Married
Source of information: Patient
Chief complaints:
 Crush injury on left leg
History of present illness:
He was apparently well 12 years back when he had bus accident in Amleshganj, Bara. The
incident took place on 2064-2-22. He was among one of the passengers of the bus and victim of
road traffic accident. The bus overturned at the corner of the road due to excessive speed and
overloaded passengers. Both of his legs were trapped in the bars of the bus with minor injuries
above the leg. There was loss of consciousness following the accident. There was no history of
vomiting, seizure, difficulty in breathing.
Course of treatment:
Immediately following the bus accident, he was taken to College of Medical Sciences,
Bharatpur. After 3 days of investigation and treatment, his left femur was found to be broken and
gangrene formation on whole of the left leg. For further assurance the patient was taken to B&B
hospital, lalitpur and after 15 days he had to undergo surgical leg amputation in order to prevent
from septic shock. After surgery he went under physiotherapy and is currently prosthetic leg in
his left leg.
PAST MEDICAL AND SURGICAL HISTORY:
History of DM, history of laparoscopic kidney stones,history of prostatitis. No history of TB,

thyroid disorder.
FAMILY HISTORY
There is no significant history in any of the family members.
PERSONAL HISTORY
Our patient is non-vegetarian. He is non-alcoholic and non-smoker.
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He lives in cemented house provided as quarter by Cancer Hospital from his wife occupation,
which is adequately lighted and ventilated. There are 2 bedroom, common kitchen, attached
toilet. The source of water is government tap water and water is not filtered before drinking. The
source of fuel is LP Gas. They use to burn the non-degradable wastes and use degradable wastes
as compost.
DRUG HISTORY
He has been taking drugs for diabetes since past 6 years.
ALLERGIC HISTORY
There is no known allergy history to any drug and food till date.
Patient looks well and was average built, sitting on wheelchair and was oriented to time, place
and person. Pallor was present, icterus, clubbing and cyanosis were absent. There were no signs
of dehydration. There is tenderness over right knee, mild swelling but no raise in local
temperature
VITAL EXAMINATION
Pulse: 76 beat per minute regular in rhythm normal volume and character.
Blood pressure: 130/80 mm Hg on right arm in supine position.
Respiratory rate: 18 breaths per minute, abdominal-thoracic in pattern.
Temperature: 98.7 degree F and is afebrile.
SYSTEMIC EXAMINATION
Respirartory examination:
 On inspection- symmetrical movement of chest on respiration, no scars, no venous

prominence, no visible lumps, pulsations, intercostals recession
 On palpation- chest moves equally on respiration
 On percussion- normal resonant sound,
 On auscultation- normal vesicular breath sound was heard.
CVS examination:
 On palpation apex beat was on the 5thintercostals space,

 No thrills and additional sound palpated,
 On auscultation, feeble S1 and S2 heard with no abnormal heard sounds.
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Abdominal examination:
 On inspection- flat abdomen with midline, descended downwards and inverted

umbilicus, Surgical scars of laparoscopic renal stone present on the abdomen,
 On palpation- no fluid trill, no organomegaly
 On percussion- dull note was noted over epigastrium, normal tympanic sound ,no shifting
dullness
 On auscultation - normal bowel sound heard.
Central nervous system:
Higher mental function:
 Concentration, memory, speech and language were normal.
Motor examination:
 Muscle size was equal on both side.

 Muscle tone was flaccid.
Sensory examination:
 Sensation of fine touch, crude touch, pain and temperature were comparatively more
perceived on the right side.
Cranial nerve examination:
 Pupillary light reflex was present on both the eyes. All the facial movements were
possible.
INVESTIGATIONS
1. Hematology:
Hb : 10.1 gm/dl, WBC : 7200/cumm, Neutrophils : 85 % , Lymphocytes : 12 % , Monocytes : 2

% , Eosinophils : 1 % , Basophils : 00 , RBC : 5.68/ cumm , PCV : 43.9 % , MCHC : 32.6 % ,
MCV : 77.3 fi , MCH : 25.2 pg , blood group : A +ve
2. Biochemistry:
Sodium : 134 mEq/l , potassium : 3.8 mEq/l , Random glucose : 90 mg/dl , urea : 22 mg% ,
creatinine : 1 mg/dl
3. Urine analysis:
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Appearance : slightly turbid , Color : light yellow , pH : acidic , Albumin : nil , Sugar : nil ,
RBC : 0-1/ HPF , pus cells : 1-2 / HPF , Epithelial cells: 3-5 /HPF , Crystals : nil , Casts : nil
4. Serological tests:
HIV I , HIV II , HBsAg , HCV : Negative
5. Liver function test:
Total bilirubin : 0.3 % , Conjugated bilirubin : 0.15 %
SGPT : 30 IU/l , SGOT : 24 IU/l , Alkaline phosphatase : 76 IU/l
Treatment:
Metformin 500mg OD
FAMILY VISITS
Family Date
Visit
Table No.:19
First visit (2075/07/13)
Objective:

Activities:

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Outcomes
We got the information of the patient in from COMS. We did our first visit in his home. When
we reached his home, the patient and his wife warmly welcomed us. After brief introduction, we
talked in detail regarding his experiences during the course of illness and other health related
behavior. We discussed about the diagnosis, the impact of disease in patient’s life and family
life, his approach for treatment and new challenges in his life.

 Religion: Hindu
 Head of family: Patient himself.
 Occupation of family head: Unemployed
 Economic Status: Upper Lower class
 Chronic Illness in family: None
1. Family profile:
Our patient lives in nuclearfamily with his wife only. He has 1 son and a daughter.Since his
children are out-of-city in order to acquire higher education, he gets all the help needed for his
daily chores from his wife.
Family Tree
Fig No.: 7
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Family members and relations
The family is socially respectable in the community. They have good understanding and mutual
cooperation between the family members. Although the family members are apart for the sake of
their studies, they always have their presence when any member is in need of care. The family
members are well aware of the patients health condition and have mutual care and
understanding.
2. Housing and environment:

He lives in cemented house and 2 storeyed, which is inadequately lighted and not well-
ventilated. There is 1 bedroom,1 living room and akitchen that is attached to the
bedroom.There is only 1 windowin each room.The source of water is government tap
water and water is not filtered before drinking. The source of fuel is LP Gas and
firewood. They use to burn the non-degradable wastes and use degradable wastes as
compost.
Fig No.:8
3. According to kuppuswamy socioeconomic status scale(Economic status)
1 Education 5
2 Employment 1
3 Income 3
TOTAL 9
Table No.:20
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- Belongs to Upper Lower class
Source of income:
His Wifeis the main the main source of income for the family. She is working as a desk attendant
in the B.P koirala Memorial cancer Hospital.Our patient also has the provision of pension of Nrs.
1600 monthly from the Government of Nepal. Income is tightly sufficient for their daily
household works and treatments.
Expenditure:
Daily household activities and his treatments are the main expenditures, making a total of
10,000-15,000 per month. Since his children are also currently studying and don’t have earning
of their own, he has to send them monthly expenses.
Educational status:
Our patient and his wife are both high school graduated. His daughter is studying nursing
currently in Birgunj.His sonis studying high school in kathmandu.
Lifestyle and Food Habits:
Our patient is quite socially active and is also a member of the Apanga samaj, Chitwan.He can
attend social gatherings and functions in the society overcoming his disability. They buy most of
the items of food from market while some items are grown in their own field. They eat general
Nepalese food. Special food is consumed in special occasions and festivals. They wear good
clothes. Furniture of house is sufficient to accommodate their family. But the environment
around was not kept clean and personal hygiene was also not maintained satisfactorily.
Cultural and belief system:
They are Hindu by religion and celebrate major festivals. They don’t believe in traditional
healing.
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Observation checklist:
Observations Yes No
Own house '√
Rented house √
House type Made up of bricks and cement with wooden doors
and windows.
Rooms
 Numbers 2
 Ventilation √
 Sunlight √
Kitchen
 Ventilation/exhaust √
 Source of cooking LPG
Toilet Attached to the house watersealed
Cleanliness
 Around house √
 Of the patient √
Water
 Source Government tap water
 Sufficiency √
 Treatment of drinking water Directly without boiling/filtration
Waste disposal Municipality van
Vehicles √(onefour-wheeled
scooter)
Electronic appliances T.V. Radio, 1 each and 2 mobile phones

Pets √
Yard/lawn √
Helpers/servants √
Table No.:21
Second Visit: (2075/08 /06)

::
Objectives:
 To enquire and observe about the health of family and personal habits, health seeking

 To have general examination of patient, simultaneously with other enquiry, if he have
 Counseling.
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Activities:
In this visit, we asked about his knowledge, attitude and practice regarding his disease and
prognosis. We asked about the impact of his disability in his life and also in his family, economic
burden due to treatment and her family support. We took detailed history on follow ups, number
of hospital visits. We took indepth interview on effect of disease on his daily activities,
psychosocial behavior and economy of family. We asked about his personal habits, diet and
other protective measures to control the disease. We also asked questions reflecting the gender
equality in the family.
1. Health seeking behavior and KAP:

The family doesn’t believe on traditional healers. Although, the physiotherapy was effective, our
patient refused to take physiotherapy due to non-compliance of treatment. Whenever he or
anyone of the family members feels discomfort or health related problems, they take immediate
response and take that particular member to thehospital.
He is aware about his condition and takes medication on time. His wife regularly takes him to
hospital for follow ups and takes care of him. Patient is able to handle small household work on
his own because his wife is working and cannot be with him at all times.He is able to get up by
himself and walks with the support of crutches. There is dietary restriction in salt and
carbohydratesas the patient also suffers from diabetes.
2. Effects of family in the disease:
 Role in causation:
Not paying enough attention while walking in the road, reckless driving, drunk-driving or
speeding could be some of the major causes.
 Role in progression:
Family has vital role in the progression or betterment in the health of the injured individual. He
was immediately taken to the hospital following accident and after surgery patient is regularly
taken for physiotherapy. His family is concerned about his health status and took good care
regarding food, rest, and medical care during the illness. Dietary restriction of salt and
carbohydrates is adopted by the family. Family is supportive and disease is well controlled.
c. Role in recovery:
When he had this pain in right knee, he was taken to by his wife. Early detection, effective
treatment and family support helped to relieve pain. They take him to nearby cancer hospital,
take care of his medication and other needs. Expenses of his medication is taken care by his wife.
d. Role in health promotion and risk reduction:

His family is fully supportive, emotionally and physically and to meet his basic needs
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which has created disability friendly environment.
e. Family’s beliefs about illness:

They only believe on allopathic medicines.
f. Family decision about health care:

The decision about health care is taken by his wife that in case of any illness the family
will seek for professional medical support.
g. Family’s role in acute response:

Whenever he feels discomfort or any health related acute problem, they immediately visit
cancer hospital.
h. Family’s role in adaptation in illness and recovery:

The patient is provided with wheel chair by which he can move around the house and he
also has four-wheeled scooter from which he manages to visit places on his own. The
family is supporting and encouraging him physically, mentally and emotionally.
Effects of disease on family, patient and society:
On patient:
Since the date of accident the patient experiences frequent bouts of fatigue and weakness but has
well-adjusted to the situation by the passing time. He can walk on his own and can also attend
meetings, social gatherings and occasionally visit market on his four-wheeled scooter. He can
move around the house with the help of crutches without any support. He is not anxious or
depressed due to his condition.
On the family:
His wife has to take care of him but can’t give much time because of her job. Since most of the
family members are out-of-city, there is no direct burden but indirectly cost in the family due to
his illness is quite heavy as the only breadwinner in the family seems to be the patient’s wife.
The economic burden is increased as he has to replace his prosthetic leg every 2-3 years. His
condition hasn’t created psychological effects on his family.
On the society:
There is no stigma regarding his condition in society, instead his neighbors support him. His
neighbors are always ready to provide help if needed.
4. Gender Analysis
We assessed the gender equality on the basis of involvement of male and female members in
different activities required to run a family and access and control of family resources, income,
basic needs etc.
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We found that both members participate in all activities except only female look after kitchen
and cleaning of house and also generate income for the family as our patient is unable to do so
because of his disability. Both members had access over every particulars like resources, benefits
and other but the control of resources benefit and decision making is vested in hand of male
members as tabulated below:
A. Activity profile

Production activities √
Agricultural works √
Income generation activities:
Employment √
Others √
Reproductive activities √
Water related √
Fuel related √
Health related activities
Child immunization √
Care provider during illness √
Taking sick to hospital √
Buying medicine √ √
Cleaning √
Repair √
Market related activities √ √
Table No.:22
B. Access control profile:
Particulars Access Control

Women/girls Men/boys Women/girls Men/boys
Resources:
Land √ √
Equipment √ √
Labour √ √
Cash √ √
Training √
Benefits √ √
Outside income √ √
Asset income √ √
Basic needs:
Food √ √
Shelter √ √
Clothing √ √
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Education √ √ √ √
Political √ √
power/decision
Table No.:23
C. Factors affecting disease process (health related issues)
Exposure to household/
occupational hazards No significant effect.
Age related No relation
Day to day activities and No significant effect.

responsibilities of men and
women.
Educational status and He has been properly counselled on RTA and its effects.
health seeking behaviour As an active member of Apangasamaj ,Chitwan he was
very keen to know about his health status.
Economic status and its He is self employed and economic status has no impact on
impact on health his health.
Gender norms and values in There is no gender discrimination in the family.

health.
Access to and control over No significant impact.

Perception of disease in the People from community are well aware about his
society and other social disability and its complications. His neighbours are
norms and values that affect supportiveand help him when his wife is not in home.
disease process. There is no stigma regarding his condition in society.
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Access to information and His family hasall informationabout disability and they are
its impact. putting tremendous efforts for the improvement of the
patient condition.There is no change in perception.
Counseling
We advised him to take medicine regularly on time. We told him to check blood pressure for at
least once a week in a local clinic. We also counselled his wife to take him to hospital for regular
follow ups. Since the patient also suffers from prostatitis we advised him to limit carbohydrates,
caffeine, spicy and acidic foods that can irritate the bladder and eat more green vegetables and
fruits. We also requested him to do physiotherapy if possible.
Third visit (2075/08 /27)
 To enquire about anything important to be noted and if had been omitted in previous
visits.
Activities:
We principally reviewed the information missed during the first two visits. Furthermore we
talked about avoidance of aggravating factors, dietary habit modification and other preventive
measures.
Outcomes:
Third visit was to review our information and to add any if missing from the previous two visits.
We also conducted counseling and answered any of the family’s pressing questions.After
counseling, he started to do simple physical exercises daily. He started to checkup his blood
pressure at least once a week. Dietary restriction of carbohydrates, spicy and acidic foods is
maintained as usual. The patient and his wife knew more about the health condition, it’s
preventive measures. Even after counseling, he refused to take physiotherapy, so, we focused on
these topics and again counseled him and his wife. Finally, we thanked the family for their
courtesy and for their help and cooperation for making our visits successful. They also requested
for more visits and we promised that we would come whenever we get time. We also assured
him to help whenever he visits our hospital.
Conclusion:
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Globally, Road Traffic Injury (RTI) is the eighth leading cause of death and is projected to rise to
the top five by 2030.There are multiple causes of Road traffic accidents, mainly related driving
and driver’s behavior, mechanical condition of the vehicles involved and the road condition.
Before developing policy and appropriate interventions to curtail and prevent RTI, it is important
to understand its epidemiology. It can lead to permanent disability which has tremendous impact
on the family in emotional, financial, psychological as well as social aspects. The management
and rehabilitation of differently abled largely depends on the family and social support. In the
lack of appropriate intervention strategies and lifestyle modification, this can lead to various
complications, morbidity and mortality.
Summary:
Mr. subedi, 46 yrs old male, resident of Bharatpur-7, met with an accident in Amleshganj, Bara
nearly 12 years back. He was diagnosed with broken left femur as well as infection due to
gangrene on the whole of the left leg leading to surgical leg amputation. He currently lives with
his wife while his son and daughter are out-of-city for their studies. He is under physiotherapy
and uses prosthetic leg in his left leg.
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CASE 5: Stomach Cancer
Introduction
Stomach cancer, also known as gastric cancer, is a cancer that develops from the lining of
the stomach. Most cases of stomach cancers are gastric carcinomas, which can be divided into a
number of subtypes including gastric adenocarcinomas.Lymphomas and mesenchymal
tumors may also develop in the stomach. The cancer may spread from the stomach to other parts
of the body, particularly the liver, lungs, bones, lining of the abdomen and lymph nodes.
The stomach is a muscular organ located on the left side of the upper abdomen. The stomach
receives food from the esophagus. As food reaches the end of the esophagus, it enters the stomach
through a muscular valve called the lower esophageal sphincter.
In general, cancer begins when an error (mutation) occurs in a cell's DNA. The mutation causes
the cell to grow and divide at a rapid rate and to continue living when a normal cell would die.
The accumulating cancerous cells form a tumor that can invade nearby structures. And cancer
cells can break off from the tumor to spread throughout the body.
Sign and Symptoms
Early symptoms may include heartburn, upper abdominal pain, nausea and loss of appetite.
Later signs and symptoms may include weight loss, yellowing of the skin and whites of the
eyes, vomiting, difficulty swallowing and blood in the stool among others.
Risk factors
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The most common cause is infection by the bacterium Helicobacter pylori, which accounts for
more than 60% of cases. Certain types of H. pylori have greater risks than others. Smoking,
dietary factors such as pickled vegetables and obesity are other risk factors. About 10% of cases
run in families, and between 1% and 3% of cases are due to genetic syndromes inherited from a
person's parents such as hereditary diffuse gastric cancer.
Magnitude of the disease
Cancer is the second leading cause of death globally, and is responsible for an estimated 9.6
million deaths in 2018. Globally, about 1 in 6 deaths is due to cancer. Approximately 70% of
deaths from cancer occur in low- and middle-income countries. Gastric cancer remains one of
the most common and deadly cancers worldwide, causing 1.03 million cases and 783 000 deaths
in 2018.Gastric cancer is among the most common malignancies in Asia, comprising 74% of all
global cases.
-WHO
Justification of case
Cancer accounts for 9.5% of all deaths in developing countries. Lung cancer being common
cancer in the world. In developing countries it is followed by stomach cancer, liver cancer
whereas in female -breast, cervical cancer are common. Tobacco, smoking, alcohol, dietary
factors, genetic factors being the major risk factors for stomach cancer. Thus it provides an
opportunity to study the complications of the illness as well as the impact of the illness on the
family and society. Further, we found our patient co-operative. Hence we felt justified in
studying this case as it fits into the required parameters of a case of non-infectious disease.
CASE PROFILE
Patient Particulars
Name: Hira Mahato
Age: 26 years
Sex: Female
Address: Padampur, Kalika Nagarpalika-6 , Chitwan
Occupation: Farmer
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Education: Illiterate
Religion: Hindu
Marital status: Married
Identified from:
Date of diagnosis:
Beginning of treatment:
Chief complaints
1) Abdominal pain for 2 and half month
History of presenting illness
The patient was apparently well 2 months back before she had visited Narayani Samudahik
Hospital. She had pain in right hypochondrium and epigastric region which was insidious in
onset, gradually progressive, on and off type, colicky type, non-radiating, non-shifting and was
not relieved by medication (i.e pantoprazole). The abdominal pain was aggravated on taking
fatty food and severe enough to restrict her daily activities. It was associated with water brash,
loss of appetite, loss of appetite, nausea and weight loss.
Treatment History
With all these complains she visited Narayani Samudahik Hospital .Hospital reffered to Cancer
hospital. She was then scheduled for 1 session of chemotherapy on 2076/08/05.
Past History
There is history of gastritis. There is no history of hypertension, diabetes mellitus, Tuberculosis.
Menstrual History
She attained her menarche at 15 years of age .
Family History
No history of similar illness in family.
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No history of DM, HTN, TB in her family.
Nutritional History
She consumes the staple foods of the Nepali diet (dal, bhaat, tarkari) and fruits.
Personal History
She is non-vegetarian by diet. She was nonsmoker and nonalcoholic. Bowel habit and bladder
function normal. Sleep normal.
No known Drug allergy.
General Physical Examination
She was ill looking, average built, calm ,cooperative and well oriented to time, place and person.
Vitals
 Temperature: 100°F, recorded from the right axilla

 Pulse: 74 beats per minute at right radial artery. It is regular, has normal volume and character.
There is no radio-radial and radio-femoral delay. All the peripheral pulses are palpable.
 Respiratory Rate: 16 per minute, which is mainly thoraco-abdominal.
 Blood Pressure: 120/70mm of Hg on the right brachial artery measured on supine position.
On General Examination
Icterus was evident in the bulbar conjunctiva. The patient was not pale, had no clubbing,
cyanosis, lymphadenopathy and edema and had no signs of dehydration.
Systemic Examination
Gastrointestinal system
Inspection
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- Abdomen is scaphoid and skiny

- Skin over abdomen is smooth and shiny.
- Umbilicus is central, everted with transverse slit.
- All quadrants move equally with respiration.
- There is no other pigmentation or dilated veins.
Palpation
- Tenderness in epigastrium
Percussion
- Tympanic note all over the abdomen.

- Fluid thrill and shifting dullness absent.
- No organomegaly
Auscultation
- Bowel sound: 3-4 per minute
Other Systems
- Respiratory system: Normal

- Cardiovascular system: Normal
Recent Investigations
1) Haematology
a. WBC: 8700/ cu.mm
b. Hemoglobin: 10.3 gm/dl
c. Platelets count: 2,45,000/mm3
d. Neutrophil: 68 %
e. Lymphocytes: 30 %
f. Eosinophil: 2%
g. Monocyte: 0%
h. Basophil: 0%
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2) Biochemistry:
a. Sugar random: 136 mg/dl
b. Creatinine: 0.8 mg/dl
c. Bilirubin total: 0.8 mg/dl
d. Bilirubin direct: 0.2 mg/dl
e. SGOT: 128 U/L
f. SGPT: 193 U/L
g. ALP: 753 IU/L
 ENDOSCOPY : ULCEROPROLIFERATIVE MASS OVER THE ANTRUM
EXTENDING TO PYLOROUS
TREATMENT : Ranitidine 30
Family Health Diagnosis
Family Date
Visit
Table No.: 24
First Visit (2076 – 08 - 21)
Objectives
• To introduce ourselves
• 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 the family profile
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• Construction of family tree

• Mapping of the house
Outcomes
We found this case in BPMCH during the search for cases. We asked for her consent explaining
about our family health exercise and she agreed. We visited her at her home after making an
appointment. After brief introduction, we talked in detail about the course of illness, her
experiences and other health related problems. We also talked to her family about the perception
and effects on the illness. Meanwhile, we noted various details on environmental aspects like
conditions of home, latrine, sanitation and waste disposal system. Keeping the agent-host-
environment triad in mind, we observed different aspects of the case. The patient was on
chemotherapy which would be followed by surgery.She wasnt able to perform all her daily
chores and household work.
Family status
She lives in Joint family with 6 members.All hindu by religion .patient husband was head in the
family .
Family Tree
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Fig No.: 7
Housing and environment
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Her family lives in their own house. It is a pakka house with four rooms and a separate kitchen
and toilet. The kitchen and the rooms were well-lit and well ventilated. The family uses LPG gas
as a fuel for cooking. They use water supplied by government for drinking without any
treatment. The toilet is water-sealed. The family rear cattle. They have good drainage system.
Fig No.: 8
Economic status ( Kuppuswamy’s Socio-economic Scaling)
Parameters Score
Education 3
Occupation 5
Family income per month 2
Total = 10
Table No.: 25
She belongs to Lower upper lower class family according to Kuppuswamy’s socio-economic
status scale with the total score of 10. Her husband ,brother in law and sister in law are the
earning members in the family and family income is not sufficient for the expenditure .They took
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loan from village money lenders for her treatment of gastric cancer.their monthly expense is
about Rs.10000-15000.
Source of Income: Her husband, brother in law,sister in law works in agriculture especially
banana farming. Mother in law and she herself is house maker.
Observation Yes No
Own House √
Rented House √
House Type Pakka type
Rooms
Observation Yes No
Number 6
Ventilation √
Sunlight √
Kitchen
Ventilation √
Energy source for cooking LPG
Toilet Outside the house

Cleanliness
Around the house √
Of the diseased person √
Water
Source Government tap water
Sufficiency √
Treatment of drinking water √
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Waste Disposal Burning

Vehicle √
Electronic Appliances TV, Fan, Mobile
Pets √
Yard/Lawn √
Helpers/servants √
Table No.: 26
Second Visit: (2076-10-05)
Objective:
 To enquire and observe about the health of family and personal habits, health seeking
Activities:
 In depth interview was made.
 Discussed about the disease, its causation and risk factors.
 Talked about the impact of disease in patient’s life and also in the family, economic
burden due to treatment and KAP regarding the disease.
 Dietary chart was provided for changing the food habit.
OUTCOMES
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She was taken to the hospital by her husband. She didn’t know about the importance of early
visit to hospitals in curing the diseases. She visited hospital when the severity of the disease was
high and was advised by the neighbours. Their knowledge, attitude and practice regarding
diseases is not satisfactory.
 Role in Causation :
The patient ate a lot of spicy and oily foods also she had no proper eating time.
That led to gastritis and eventually followed by gastric carcinoma.
 Role in Progression:
The family was enthusiastic to know the illness after she had significant weight
loss and lump felt in upper abdomen. She was taken to the hospital by her
husband. They are taking good care of him. This has led to improvement of his
health.
 Role in Relief :
The family in our case is very much supportive and caring. Her family is taking
care of her during her illness.
5. Role of gender and specific norms, values, roles and activities :
Our society demands females to perform all the household chores and caring for the children.
Here the case is similar.
 Family role in health promotion and risk reduction:

His family is fully supportive, emotionally and physically and took care of his follow ups
and medications. He isn’t left alone in his home.
 Family role in disease onset and relapse:

There is no role of family in disease onset and relapse.
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 Family decision about illness appraisal:

The decision about health care is taken by her husband.
 Family’s role in acute response:

Whenever she feels discomfort or any health related Acute problem, they
immediately took her to nearby health centers.
 Family’s role in adaptation in illness and recovery:

The family is supporting and encouraging her physically, mentally and
emotionally to get rid of the disease.
4. Analysis of gender and illness:
 Gender status :
There is no discrimination against women in the family. However financial,
household and day to day activities have to be done by her making her delay in
health seeking behavior.
 On the family:
The family had difficult in the cost of treatment and admission. Her husband,
brother and sister helped her financially.
Socially the family members refrained from work and were more concerned
towards providing ample care to her. We can assume a negative effect in the
family’s social health.
 On the patient:
Physically, the patient looks lethargic and grossly concerned about the
abdominal lump.She used to work a lot previously but now seems a difficult to
work for her due to weakness from chemotherapy.
 On the community:
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Due to her illness, she is inactive in social interactions. The people in the
community are curious and worried about her health.
Gender Analysis Tools
A Activity profile
Table 24: Activity Profile

Income generating activities:
Business
Employment √ √
Agriculture √ √
Other
Water related
Collection √
washing clothes √
Doing utensils √
Fuel related
Cooking √
obtaining gas/kerosene √
Health related √ √
child immunization √
care provision during ill health √ √
taking the sick to medical √ √
institutions
buying medicine √ √
cleaning activities √
Repairing √
Market related √ √
Child care √
taking care of the children √
Table No.: 26
A. Access and Control profile
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Table 25: Access and control profile
Access Control
Particulars
Land √ √ √
Equipment √ √ √ √
Labor √ √ √ √
Cash √ √
Education/training √ √ √
Benefits
Outside Income √ √ √
Basic needs
Education √ √ √
Political
power/prestige √ √
Table No.: 27
Both men and female have equal access to resources. The decisions are made mutually.
Third Visit: (2076 -10-10)
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Objective:
Activities:
Outcomes:
Counseling and recommendations to the family:
We counseled the patient and her family on the need to complete the chemotherapy and surgery
as advised by the doctors, so that the gastric carcinoma gets cured completely. We counsel her to
take rest and take adequate nutrition and have positive attitude towards the disease. For queries
about the disease and treatment methodology we convince her to get information from the
authentic health personal and not to be manipulated from others unconcerned people.
We recommended the family to a more positive attitude towards modern medicine. And we
highlighted the importance of family as support for relief and rehabilitation of the patient to her
studies and normal day to day activities.
Conclusion:
Gastric carcinoma is a chronic non communicable disease which may be due to Gastritis caused
by H. pylori, smoking ,food habit ,hereditary. No treatment at proper time might have led to
metastasis to other organs. The patient was worried about her health. Due to the expenses having
burden upon the family in terms of finance and treatment process being long and difficult, the
family members were anxious regarding the patients' health. They are compliant towards the
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doctor's advice and take medicines on time.Gastric cancer in Nepal is usually diagnosed at an
advanced stage and has a poor prognosis. Thus, early detection is the key to improve the survival
of gastric cancer patients.
CHAPTER III
Conclusion
Finally, we have come to the end of our family health exercise. Looking back, we are able
to see the difference of knowledge we had before this exercise and the knowledge
we gained after it. It helped us to understand the disease in a real family setting and its
effects on the patient and the whole family and community. We studied about five
different cases and we were able to trace out that a disease whether acute or chronic,
disabling or non-disabling, physical or mental, when is present in an individual not only
affects the diseased person but also has a debilitating effect on his family and society.
It was understood that family members had a vital role in every aspect of disease starting
from its causation, transmission, progression and the recovery. In fact, in the course of
natural history of any disease, family and community has an undeniable role to play. By
realizing different aspects of the disease, we could provide proper communication and
counseling to the patients and their family.
For every case, we viewed from different perspectives like environment, culture, custom,
habits, gender and their role in the natural course of disease. Being in the patient’s house
itself and interacting with the family members, we were able to go through all the above
factors and analyze their role in the disease pattern which is totally different from the
hospital set-up.
We also came to know that there is an increasing communication gap between the doctor
and patient and to understand the disease process, knowledge and skills alone does not
count to treat any disease but doctor-patient relationship plays vital role in understanding
the patient’s emotions and helping to reach the correct diagnosis.
FHE was always a group work. So we learnt to work in a group, approach the patient
along with his family and to provide appropriate guidance regarding the modifications they
could undertake for better quality of life both for the family and the patient
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Concluding, FHE was an immemorial voyage which helped us to broaden our

knowledge and definitely play a vital role in making us a better doctor as we were able
to learn to approach a patient in a more holistic way.
Recommendation to the Department of community medicine
We appreciate the effort put in by the teachers in the orientation classes as well as during
the family health exercise.
However we need further guidance from the faculty in some areas like:
 Transportation facility should be managed well for both supervisors and student.
 Some level of financial assistance would further make the family visits easier to conduct
 Early commencement of orientation, so that report can be finished earlier to exam.
 he provided logistic materials weren’t well enough.
CHAPTER IV
LEARNING REFLECTIONS
Family health exercise has seeded in us a practical application of what we read in our
books. It has enabled in us the skill to look at a disease, not just as an entity of patient but
of his family and community. We have learned so much from this experience, we are sure
our learning will be reflected in our future practice.
• We were able to acknowledge various aspects of an individual’s life and

family that affects the causation, progression and recovery of an illness. We were
able to know about the natural history of diseases. .
• Family health exercise was a great opportunity for students to enable and rate
their individual leadership quality, team work and group co-ordination.
• Broaden our views regarding the factors that directly or indirectly have a role in
the causation of any disease.
• We understood the effectiveness of group work, importance of

communication and health education.
• We acquired new perspective on the suffering of the patient which is beyond their
clinical condition, which includes economical, psychological and behavioral
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Group J
impacts on patient and family.
• Family health exercise was an opportunity for us to mould our knowledge into
practical settings.
BIBLIOGRAPHY
1. K Park,(2009),Park’s Textbook of Preventive and social medicine.20 thed.India:Bhanot
2. N.R.Colledge,B.R.Walker,(2011), Davidson’s Principles and Practice of
Medicine.21sted.London:Elsevier
3. L.longo,S.Fauci et al,(2012), Harrison’s Principles of Internal Medicine.18 th ed.USA:McGrawHill
4. Annual health report 2074/75, DOHS
6. Records of different hospitals
7. Report of WHO
8. Lecture notes
Annexes
Kuppuswamy’s socio-economic status scale (Modified for 2019):
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Observations Yes No
Own house
Rented house
House type
Rooms
Observations Yes No
 Number
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 Ventilation
 Sunlight
Kitchen
 Ventilation/Exhaust
 Energy Source for cooking
Toilet
Cleanliness
 Around the house
 Of the diseased person
Water
 Source
 Sufficiency
 Treatment of drinking water
Gender Analysis
A. Activity profile
Agricultural work
Income generating activities
Employment
Others
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water related
Fuel related
Heath care related activities
Child Immunization
Care provider during illness
Taking the sick to the hospital
Buying medicine
Cleaning
Repair
Market related and others
B. Access Control Profile

Access Control
Particulars
Land
Equipment
Labor
Cash
Education/training
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Benefits
Outside Income
Assets Income
Basic needs
Food/clothing/shelter
Education
Political
power/prestige
Factors affecting disease process (health related issues)

Exposure to
household/occupational
hazards
Age related
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Day to day activities and

responsibilities of men and
women.
Educational status and health

seeking behaviour
Economic status and its impact

on health
Gender norms and values in

health.
Access to and control over

Perception of the disease in

society and other social norms
and values that affect disease
process.
Access to information and its

impact
.
PHOTO GALLERY
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Group J

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A REPORT ON

FAMILY HEALTH EXERCISE

1. Bhupneshwar Shah Teli

Co-ordinator, CBL Unit Head of the Department

Supervisor- Asst. Prof. Eak Narayan Poudel

Here is the summary of the cases:

Infectious Disease (Tuberculosis)

Non-Infectious Disease (Chronic Obstructive Plumonary Disease)

Psychosomatic Disorder (Anxiety Disorder)

39 year old male, Mr. Rana resident of Kalika Nagarpalika-10,Chitwan, Hindu by

Physical disability (Amputation Seconadary To Road Traffic Accident)

46 years old male, Mr. Subedi, permanent resident of Madi Nagarpalika-3,Chitwan,

Case of our choice (Stomach Cancer)

26 years old female, Mrs. Mahato, resident of Kalika Nagarpalika-6,Chitwan was

Declaration and Approval Sheet …………………………………….…ii

Activities and approaches…………………………………………………5

Study Tools and Techniques…………………………………………...….6

CHAPTER II: Case Study……………………………………………..11

Case3: Anxiety Disorder………………………………………………….50

CHAPTER III: Conclusion and Recommendations…………….98

Recommendation to Department of community medicine ………..…98

CHAPTER IV: Learning Reflections...............................................99

• To know about natural history of disease and its prognosis.

Objective Field site Respondent/ Data Tools for

To collect patient Hospital Patient/ Family

To collect patient Hospital Clinician/nurse Key informant

To collect data on House Household head, Observation Checklist

To collect the House Family In-depth

To collect data on House Patient/care taker Interview and Format

To collect House Family members Group discussion

1. Case of infectious disease (TB)

F. Review of Hospital records

H. Consultation with Group Supervisor

1.4 STUDY TOOLS AND TECHNIQUES

Tool 1: Physical examination (Hospital records and anthropometric measures)

Activities Women Girls Men Boys

Income generation activities

Health related activities

Care provider during illness

Taking the sick to the hospital

Market related and others

Inability to perform normal daily activities

Tool 5: Observation Checklist:

Tool 6: Kuppuswamy’s socio-economic status scale (Modified for 2019):

1.5 LOGISTIC MANAGEMENT

S.N Cases Age Sex Case Address

2 COPD 69 F College Of Bharatpur Metroplitan

5 Gastric Carcinoma 26 F BP Koirala Kalika Nagarpalika-6,

CASE 1: PULMONARY TUBERCULOSIS

HIV infection — Among HIV-infected individuals, the risk of acquiring TB is 9 to 16

• Substance abuse-drug use, tobacco, alcohol

• Nutritional status — Malnutrition is generally understood to be an important risk factor

• Socioeconomic status — TB has traditionally been associated with low socioeconomic

• Household contacts — Close household contact with an individual with smear-positive

B. JUSTIFICATION FOR SELECTION OF CASE

• During 2074/75 reporting year, National Tuberculosis Programme (NTP) registered

it not only affects

Name: Mr. Shahi

Age/Sex: 20 years/ Male

Address: Bharatpur Metropolitan City-12, Chitwan

Source of information: Patient and His Mother

Cough for 10 days

Fever for 7 days