Word Final Fhe Group D Report

A REPORT ON
FAMILY HEALTH EXERCISE- 2076
Submitted to
Department of Community Medicine
Gandaki Medical College, Pokhara
Tribhuvan University
Submitted by
MBBS 7th batch, 3rd year
Group D
2076
FAMILY HEALTH EXERCISE, 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 D
Table A: Group members
S.N. Roll no. Name Signature

1 19 Bikrant Khanal
2 20 Binita Basnet (Leader)
3 21 Bom Bahadur Resmi Thapa
4 22 Chiranjibi Sharma (Co-leader)
5 23 Devraj Mahato
6 24 Dewendra Bishwas
7 91 Sadhana Subedi
This report has been accepted and forwarded for final examination.
…………………………
Head of the Community Medicine Department
Gandaki Medical College
Date:
i
GROUP MEMBERS
First row (Left to Right): Sadhana Subedi, Binita Basnet, Chiranjibi Sharma
Second row (Left to Right): Dewendra Bishwas, Devraj Mahato, Bom Bahadur Resmi
Thapa, Bikrant Khanal
ACKNOWLEDGEMENT
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MBBS 7 Batch, Group D
Having successfully completed our family health exercise, we would like to extend
some words of gratitude to all those people without whom it would not have been
possible to accomplish our task.
First and foremost, we would like to extend our honest and heartfelt gratitude to all
the patients and their families for being so kind, helpful and cooperative throughout
the whole exercise, thereby providing us with an overwhelming learning experience.
We particularly feel indebted towards Principal Prof. Dr. Rabeendra Prashad Shrestha
and the Department of Community Medicine, Gandaki Medical College, Pokhara for
guiding us from day one, through orientation, to this day of our completion of task, in
every way. We would like to thank our respected faculties from the department of
community medicine, Head of department Prof. Dr. Ishwari Sharma Poudel, Dr. Hari
Prasad Ghimire, Dr. Bimala Sharma, Dr. Nirmala Shrestha, Dr. Sharad Koirala, Dr.
Saurabh Kishor Sah, Dr. Nisha Gurung, Mr. Ishori Bhandari and Ms. Kiran Adhikari
Subedi for providing us with the essential materials, continual support, guidance and
feedbacks throughout the exercise.
We are thankful to our supervisor Associate Prof. Dr. Bimala Sharma for helping us
throughout the exercise with her proper guidance, support and regular feedbacks.
All the hospital staffs who have helped us find the cases from the hospital records or
in any other way also deserve our sincere thanks. Thanks are also due to Regional
Tuberculosis & DOTS center, Pokhara for helping us to find the cases. We are
grateful to the hospital administration of GMCTH for the benefits provided to our
patients.
Lastly, we express our gratitude to the family members who provided their precious
time during family visit and seniors, friends and every other individual who have
helped us in one way or the other to successfully accomplish the Family Health
Exercise.
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LIST OF ACRONYMS / ABBREVIATIONS
Approx. Approximate
BD Twice daily
Cap Capsule
CNS Central Nervous System
CVS Cardiovascular System
DLC Differential leukocyte count
ESR Erythrocyte Sedimentation Rate
GMCTH Gandaki Medical College Teaching Hospital
DM Diabetes Mellitus
Hb Haemoglobin
HTN Hypertension
HOD Head of Department
Hpf High power field
KAP Knowledge, Attitude and Practice
LPG Liquified petroleum gas
MBBS Bachelor of Medicine and Bachelor of Surgery
mm of Hg Millimetre of mercury
NS Normal Saline
OD Once daily
QID Four times a day

˚F Degree Farenheit
OPD Outpatient Department
RBC Red Blood Cells
Tab. Tablet
TDS Thrice Daily
USG Ultrasonography
WBC White blood cells
CNR Case Notification Rate
FCHV Female Community Health Volunteer
H Isoniazid
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R Rifampin
Z Pyrazinamide
E Ethambutol
S Streptomycin
CRT Cardiac Resynchronization Therapy
DoHS Department of Health Services
NDHS Nepal Demographic and Health Survey
Etc. Et cetera
DOTS Directly Observed Treatment Short Course
UTI Urinary tract infection
LMP Last menstrual period
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EXECUTIVE SUMMARY
Family health is a state of positive dynamic interaction between family members

which enables each and every member of the family to experience optimal physical,
mental, social and spiritual well-being whether disease or infirmity is present or not.
Such healthy interaction between family members gives rise to the health of
individual of the family and to the health of the family as a unit of society thus,
contributing positively to community and national development.
The Family Health Exercise was a great opportunity to learn about the disease process
in the family. With valuable guidance from the Department of Community Medicine
(DCM), we studied five different families with different types of illness. We tried to
learn the various ways in which the illness has affected the family and also in
retrospection, how family values, willingness, health seeking behavior affect the
causation, progression and outcome of the illness.
The family health exercise was conducted with the objective of studying the illness of
a person and analyzing the factors
» lifestyle, education, family environment, socioeconomic condition
» culture, belief, practice, health seeking behaviors, gender status in the family
» Knowledge, Attitude and Practice (KAP) regarding the illness which affect the
course and outcome of the illness and explore the social, psychological, and economic
impact of the illness on the patients and his families.
An orientation session was conducted by DCM, during which fifteen groups were
formed from A-O. We belonged to group D with total seven members. Following the
session, various literatures were reviewed, cases were selected as per the criteria
provided and the hospital records were reviewed.
Observation, interview, review of the records were employed as method to collect

information with the use of observation checklist, interview guidelines, semi-
structured questionnaire and the like.
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We took a case of 33 years male from Amarsingh suffering from pulmonary
tuberculosis. Pulmonary tuberculosis was chosen as per the criteria of infectious
disease. His family was a joint, upper middle-class family who believed in modern
treatment system but not in traditional healing practices. To fulfill the non-infectious
disease criteria, a 49 year old female with Breast carcinoma from Dulegauda was
chosen. There was mainly economical and psychological impact of the disease in this
family. A male of 79 years from Rambazar with the case hemiparesis was sort out
from GMCTH for the criteria of physical disability. His family was economically
stable and believed in modern treatment system of medicine. A case of Alcohol
dependent syndrome was chosen as to meet the guideline of psychosomatic illness.
He was a 26 year male from Kahukhola, his illness had physical, psychological as
well as financial burden on the family. 35 years female from Amarsingh with CKD
was the case of our choice. Patient had to go for dialysis twice a week in GMC. Her
married daughter stay with her and takes care of her. We were able to meet our
objectives of FHE in each of the families that we visited. From how the low socio-
economic status of the family affects the disease and its progression to how even well
off families play a significant role in acquisition of the disease was learnt.
Thus, we concluded that different aspects of the family like socio-economic status,
educational status, knowledge, attitude and practice, customs and traditions have a
great role in the causation, progression and recovery from disease. Once the patients
leave the hospital premises we as a future medical professional are completely
unaware of disease progression, treatment compliance and recovery of patient. During
that period family plays a great role in helping the patient to cope with his disease.
The socioeconomic status has a major role on the reach towards proper treatment and
hence determines the prognosis of any disease. Educated people have good KAP
about the disease which helps them and their family to seek proper treatment, care and
prevention of complication.
Lastly, we would like to thank the Department of Community Medicine for giving us
this opportunity to understand various dynamic aspects of family, thereby helping to
broaden our vision regarding the outlook of disease. By this means we have learnt to
look beyond the level of individual and more towards the impact of disease on the
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family and vice-versa.
TABLE OF CONTENTS
Declaration and approval sheet.......................................................................................i

Group members..............................................................................................................ii
Acknowledgement........................................................................................................iii
List of acronyms / abbreviations...................................................................................iv
Executive summary.......................................................................................................vi
List of tables..................................................................................................................ix
List of figures.................................................................................................................x
Plan of action................................................................................................................xi
Chapter 1........................................................................................................................1
Introduction................................................................................................................1
Background.................................................................................................................3
Objectives...................................................................................................................4
Methodology...............................................................................................................5
Logistic management..................................................................................................7
Chapter 2........................................................................................................................8
Case summary............................................................................................................8
Case I: Pulmonary Tuberculosis.................................................................................9
Case II: Breast Cancer.............................................................................................24
Case III: Alcohol Dependence Syndrome................................................................42
Case IV: Stroke (Hemiparesis).................................................................................57
Case V: Chronic Kidney Disease.............................................................................72
Chapter 3......................................................................................................................92
Conclusion................................................................................................................92
Recommendations....................................................................................................92
Chapter 4......................................................................................................................94
Learning reflections..................................................................................................94
Bibliography.............................................................................................................96
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Annexes....................................................................................................................97
LIST OF TABLES
Table number Title Page number

A Group Members i
1 Plan of action Xi
2 Case details 8
3.1 Family composition and structure 16
3.2 Observation checklist 17
3.3 Activity profile 21
3.4 Access and control profile 22
4.1 Status of breast cancer – 2074/75 26
4.3 Socioeconomic status score table 34
7.1 Stages of chronic kidney disease 71
7.2 Risk factors of CKD 72
7.3 Clinical features 73
7.4 Dietary table 76
7.5 Prescription 77
7.11 Factors affecting disease process 87
8 Kuppuswamy socioeconomic status scale 96
9 Observation checklist 98
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10 Activity profile 98
11 Access and control profile 99
LIST OF FIGURES
Figure Title Page

number number
1 Notified TB cases and Case Notification rate 10
(CNR) by provinces
1.1 Family Genogram 17
2 Triple diagnosis technique of breast cancer 28

2.1 Family Genogram 34
3 Family Genogram 48
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PLAN OF ACTION
Table 1: Plan of action

S. Activities Date
N.
1. Orientation 2076-Poush-8th to 10th
Classes
2. Selection of 2076-Poush-12th to 18th
cases
3. Preparation of 2076-Poush-12th to 18th
techniques and
tools to be used
4. Submission of 2076-Poush-18th
proposal
5. Home visit From 2076-paush-19th to 2076-magh-10th
Cases
I II III IV V
First Visit Poush
Poush 19 Poush 21 20 Poush 19 Poush 20
Second Visit Poush 26 Poush 28 Poush 27 Poush 26 Poush 27
Third Visit
Magh 4 Magh 6 Magh 5 Magh 4 Magh 5
6. Field analysis
and preparation
7. Report
preparation
8. Report
submission
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CHAPTER 1
Introduction
Family
“The family is a group of individuals with a continuing legal, genetic and or
emotional relationship.” -American Association of Family Practitioners.
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.
Health
“Health is a state of complete physical, mental and social well-being but not merely
absence of disease or infirmity.”- WHO (1948).
Family health
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.
Such healthy interaction between family members gives rise to the health of
individual of the family and to the health of the family as a unit of society thus,
contributing positively to community and national development.
Importance of Family Health in Public Health
 Coverage of all aspects of health
 Cost effective
 Comprehensive care
 Integration of health care
 Organized effort
 Research
 Participatory
 Easy to monitor and evaluation
 Accessibility
GMC, 3rd YEAR GROUP D 1 | Page

Family Influences Health
 Genetic factors(Vulnerability, genetic disease or disorder)
 Role on health (determinants)
 Role in recovery during
 Treatment
 Follow-up Service seeking
 Belief attitude and practice (decision making)
 Educational /economic status of the family
 Sick-role (gender + status of the family member)
 Psycho-somatic manifestations of illness
 Family members particularly women (care givers)
 Compliance
 Rehabilitation (Physiotherapy, CBR)
 Impact of Illness on the Family
 Physical
 Psychological (burning out)
 Economic impact
 Social (Pressure/ stress, Social stigma, Alienating, Breakdown of
relationships)
Family Health Exercise

Family health exercise is the field program targeted at enabling students in
understanding the multiple aspects of diseases ranging from socio-economic,
psychological to cultural aspects along with the complex and dynamic interactions of
the diseased persons with the rest of the family and community as a whole.
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 Department of 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 or so called “family physicians”.

BACKGROUND
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, 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 analyzed what role it plays in
the various aspects of disease and health in the family set up.

OBJECTIVES
General objective:
 To understand the socio-economic and psychological aspects of illness and the
roles of gender and asset ownership within the family in causation,
progression and the management of the disease, including follow-up.
Specific objectives:
 To know the detailed history of the disease in the patient
 To learn the status of the factors in the family, those directly or indirectly
affect the health of an individual
 To describe the socio-psychological and economic pressure on the diseased
individual and on the family
 To assess the Knowledge, Attitude and Practice (KAP) of the patient and
his/her family regarding the disease, its prevention and management
 To describe the consequences of the disease on the patient, his/her family and
community
 To assess the gender status in the family and effect of gender status on health
 To advice 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

METHODOLOGY
Methodology is the case study method involving qualitative, quantitative tools and
techniques. It deployed following tools and techniques during our study.
a) Orientation
b) Group division
c) Group discussion
d) Case selection
e) Review of hospital records
f) Literature review
g) Family visits
h) Consultation with supervisor
i) Case analysis
j) Report writing
a) Orientation
The orientation classes (2076-Poush-8th to Poush-10th) regarding the Family Health
Exercise was 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 analysis.
b) Group division
The class was divided into a total of 15 groups. Our group was of 7 members.
c) Group Discussion
We had group discussions for selection of cases, formulation of tools, work
distribution, preparation for family visits, report writing and interpretation of our
findings.
d) Case selection
As per the requisite given to us, five cases were selected from the different wards and
OPD of GMCTH and other health centers in consultation with our faculty members
 Infectious disease: Pulmonary tuberculosis
 Non-infectious disease: Breast Carcinoma
 Physical Disability: Hemiparesis (Stroke)

 Psychosomatic illness: Alcohol dependence syndrome
 Case of choice: Chronic Kidney Disease
e) Review of Hospital records

Knowledge about clinical history, examination, investigation and treatment details
have been obtained from GMCTH & Regional dots center.
f) Literature review
Different text books and lecture notes on community medicine, clinical medicine, and
research methodology and communication skills were reviewed. We also reviewed
reports of our seniors and several web sites relevant to our exercise.
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 and enquired generally about the family. The second visits
were for more detailed discussion on the illness and its impact on the family. We also
used our gender analysis tools in the same visit. The third visits were more or less like
bidding adieus to the family. We asked whatever questions were remaining and
answered their queries. And we were supervised by our group supervisor, Dr. Bimala
Sharma in different visits.
h) Consultation with Group Supervisor

We constantly were in touch with our supervisor and she guided us in each and every
steps of Family health exercise. She was accompanied us in different visits and
without her help it was next to impossible to conduct our family health exercise
smoothly.
i) Case analysis
We all the group members discussed about each and every case and compiled all the
relevant information for our report.
j) Report writing
We tried to write a comprehensive report on our family health exercise encompassing
all the information and analysis we had acquired.

LOGISTIC MANAGEMENT
During the entire course of our family visits, it was really challenging for us to
manage time for our autopsy postings and allocate time for family visits in different
families parallely. We, all the group members, collected fund and used it for all the
resources to conduct our field report. Our group arranged the transportation fare
needed during our visits to the families. We also managed cost for the tools (like
questionnaire, observation checklist, gender analysis tool) and the printing of report.

CHAPTER 2
Case summary
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.
Table 2: Case details
S. Category Name of patient Age/ Diagnosis Case Address
N. Sex identified
from
1. Infectious Bal Jung Gurung 33/M Pulmonary Regional Amarsingh,
disease Tuberculosis Dots Pokhara
Center
2. Non- Maya Devi 49/F Breast and GMC Dulegauda,
infectious Sigdel Ovarian Tanahun
disease Carcinoma
3. Physical Chandra 78/M Hemiparesis GMC Rambazar,

disability Bahadur Chhetri (CVA) Pokhara
4. Psychoso Raj Gurung 26/M Alcohol GMC Kahunkhola

matic Dependence , Pokhara
illness Syndrome
5. Case of Min Kumari 35/F Chronic GMC Amarsingh,

choice Gurung Kidney Pokhara
Disease

CASE I: PULMONARY TUBERCULOSIS
Introduction
Tuberculosis (TB) is globally emerging problem due to its correlation with HIV-
AIDS. Tuberculosis is often caused by Mycobacterium tuberculosis. It commonly
affects the lungs and causes pulmonary tuberculosis. It can also affects the meninges,
intestine, lymph-node and other various parts of the body. Tuberculosis occurs
disproportionately among disadvantaged population such as those living in
overcrowded and substandard housing. There is an increased occurrence of
tuberculosis among HIV-positive individuals.
Clinical Manifestations
 Chronic cough
 Night sweating
 Weight loss
 Chest pain
 Fatigue
 Loss of appetite
 Hemoptysis
 Low grade fever
Problem Statement
Global scenario: According to the latest WHO Global TB Report 2018, Tuberculosis
Mortality rate was 23 per 100,000 populations, which exclude HIV+TB. As per the
Global TB report, 6000 to 7000 people are dying per year from TB disease, However,
TB death among registered TB patients was 3% (1,023 deaths) among 31,644
registered TB cases in FY 2073/74.
Nepal: During this reporting year, National Tuberculosis Program (NTP) registered
32,474 all forms of TB cases, which includes 31,723 incident TB cases (new and
relapse). Among all forms of incident TB cases (new and relapse) 18,000 (57%) were
bacteriologically confirmed (PBC) incident TB cases, 4,411 (14%) were pulmonary
clinically diagnosed (PCD) incident TB cases and 9,312 (29%) were extra pulmonary
incident TB cases reported during the reporting year. Out of total registered cases in
NTP, there were 11,889 (37%) female and 20,585 (63%) male.

Fig. 1: Notified TB cases and Case Notification Rate (CNR) by provinces FY
2074/75
Epidemiological Determinants
A. Agent Factors
1. Agent
Mycobacterium species especially Mycobacterium tuberculosis, also M.
avium, M. bovis, M. microti and M. africanum. They are slow growing
aerobes, non-motile, non-spore forming and non-capsulated acid fast bacilli,
arranged singly or in groups.
2. Source of infection
There are two source of infection:
 Human source: Sputum positive and cases who haven’t received
treatment.
 Bovine source: Infection usually from infected milk.
3. Communicability
Untreated patient is infective. Effective antimicrobial treatment reduces
infectivity by 90 % within 48 hours.
4. Mode of Transmission
Droplet infection and droplet nuclei.
5. Incubation Period
It may be weeks, months or years. It takes 3-6 weeks for the development of
positive tuberculin test after infection.

B. Host Factors
1. Age
It affects all ages. The developing countries show a sharp rise in infection rates
from infancy to adolescence.
2. Sex
More common in males than in females due to higher exposure.
3. Nutrition
Malnutrition is one of the major cause for increasing the progression and
severity of disease.
4. Immunity
No inherited immunity against Tuberculosis infection. Acquired immunity
develops from natural infection or BCG vaccination.
C. Environmental Factors
1. Poor quality of life and low socio economic status
2. Poor housing and overcrowding
3. Under nutrition
4. Lack of awareness of causes of illness.
5. Tuberculosis thrives in condition of poverty and can worsen poverty.
Case Study
We first met our patient in the Regional Tuberculosis & DOTS center. We were
searching through the files for selecting a case, when we came across this particular
case that could fit into the category of 'infectious disease'. Then we gathered
necessary information from duty staff there, contacted his family, and explained to
them about our family health program and requested for their support. They agreed to
help us.
Rationale
Tuberculosis is often regarded as barometer of social welfare and remains one of
major public health problem in Nepal. It is a chronic disease and requires active and
conscious participation of the patient and family. WHO estimates that around 45,000
people develop active TB every year in Nepal, Nearly fifty percentage of them are
estimated to have infectious pulmonary disease and can spread the disease to others.

Case History
Patient’s Profile
Name: Mr. Bal Jung Gurung
Age: 33 years
Sex: Male
Marital Status: Married
Religion: Buddhist
Occupation: Fiber Technician
Address: Amarsingh, Pokhara
Education: Class 12
Chief Complaints
 Cough for one week
 Difficulty in breathing for one week
 Weakness
 Weight loss by 5 kg
History of Present Illness

The patient was apparently well one & half months back, when he developed Cough,
which was productive, sudden onset, and occasional in nature with no aggravating and
relieving factors.
Sputum was yellowish in color, small in amount without blood stained. He also
complained of difficulty in breathing, weakness and weight loss of around 5 kg.
The bladder habit was normal as per the patient. There was no history of seizures or
any other relevant symptoms.
Past history
There was no any history of DM, HTN, asthma and any surgical interventions.
Personal history
He was an occasional drinker, smoker and prefers non vegetarian diet.
Drug history: There was no any history of taking any drugs for longer period of time
for any chronic illness.

Family history:
There is no history of tuberculosis, diabetes, hypertension, asthma and epilepsy in the
family.
Socio-economic history:
According to kuppuswamy scale he belongs to upper middle class family with score
of 18. The main source of income is from his job as fiber technician and other source
is from his wife job in laundry.
Dietary history:
He starts his day by having a breakfast. He usually takes tea, braed or biscuits and egg
for his breakfast. He takes rice, daal and tarkari in his lunch. Nearly in the midday he
takes noodles or bread and eggs as nasta and in the evening as a dinner he usually take
rice, daal and tarkari.
Physical examination:
The patient was comfortable, conscious, cooperative and well oriented to time place
and person. He was lying comfortably on the bed.
General condition:
Fair
Weight: 56 kg
Height: 5’5”
Vitals:
 B.P.: 110/80 mmHg
 Pulse: 80/min.
 Temperature: 98.4 °F
 Respiratory rate: 16/min
Cardinal signs:
Icterus – absent, Pallor – absent, Clubbing – absent, Cyanosis – absent,
Lymphadenopathy – absent and well hydrated.
Systemic Examination
Respiratory System

Inspection
During inspection it was found that the chest was bilaterally symmetrical, no bulging
and no any scars marks were present. Chest expansion was equal on both side and
intercostal space was normal in appearance.
Palpation
Through palpation the findings of inspection was confirmed. There was no tracheal
shift or increased vocal fremitus and no any tenderness was present over chest region.
Percussion
On percussion there was resonant note on both side of chest and normal liver dullness
was heard from 5th intercostal space to lower costal margin.
Auscultation
On auscultation normal vesicular breath sound was heard along with normal voice
resonance.
Gastrointestinal system
On GI examination the abdomen was found to be soft and non tender. Spleen and
liver were not palpable. Normal bowel sound was heard on particular interval of time.
Cardiovascular system
On palpation apex beat was felt at 5 th intercostal space. No any thrills and additional
sounds were heard. On auscultation normal heart sounds (S1 and S2) were heard.
Central nervous system
All cranial nerves functions were intact. Sensory, motor and autonomic functions
were normal and superficial and deep reflex were intact.
Investigations
Sputum sample was given for AFB and found to be positive.
Diagnosis
Pulmonary Tuberculosis
Treatment
He is being treated according to DOTS category-I regimen as given by the
government. Intensive phase: 2(HRZE) and continuation phase: 4(HR)
Intensive phase: From 2076/07/022 to 2076/09/21 (2 months)
 Tab. Rifampicin 600 mg.

 Tab. Isoniazide 300 mg.
 Tab. Pyrazinamide 1500 mg.
 Tab. Ethambutol 1000mg.
Continuation phase: From 2076/09/22 onwards for 4 months:
 Tab. Isoniazide 300 mg.
 Tab. Rifampicin 600 mg.

Family Visit
First Visit (2076/09/19)

Objectives
 To locate the house of the patient.
 To explain them about the purpose of our visit.
 Introduction and rapport building with the family members, key informant
interview and interview with the head of the house.
 To observe the physical facilities and evaluate socio-economic status.
Activities
After all necessary arrangement, we were prepared for the first visit. The meeting was
arranged through telephone contact. It wasn’t difficult to locate the house, we called
the patient and he came to pick us from a nearby intersection. We observed the house,
its built and its surrounding environment. The objective of rapport building was
achieved. After that, we left reminding the patient to take his medicine regularly.
Outcomes
Mr. Gurung is living in rented house. He had taken two rooms on rent, of which one
room is pakka and other one is sheeted. The rooms were not well ventilated with
inadequate light entering rooms. They used LP-Gas for cooking. The house is located
on roadside and the area is densely populated with poor sanitation in the surrounding.
They had piped water supply. The toilet is not properly maintained. Disposable waste
was disposed in a pits and non-disposable waste are taken by sub-metropolitan truck.
Family profile
There are 5 members in the family.
Family type: Joint family
Table 3.1: Family composition and structure
S.N. Name Age Patient’s Education occupation Income
relation
1 Khim 64 Father Literate(informal) Retired -
Badadur Army
Gurung
2 Chin Maya 55 Mother Illiterate Housewife -
Gurung

3 Bal Jung 33 (Self) Class12 Fiber Rs.20,000
Gurung technician
4 Tik Maya 31 Wife Class 8 Laundary Rs.15,000
Gurung
5 Sikmit 12 Daughter Class 7 Student -
Gurung
Family genogram
64 55
33 31
12
Fig 1.1: Family genogram

Index
Female:
Male :
Patient:
Married:

Observational Checklist
Table 3.2: Observational checklist
Housing Assets Sanitation
 Type of house: Pakka  Television: 1  Toilet: water

 Tenure : Rented  Mobile: 2 sealed and
 Number of rooms: 2  Cooking appliances: poorly
 Lighting : Insufficient present maintained
 Ventilation: Poor  Furniture: 3 beds, 1  Odour: absent
 No of windows per wardrobe, 1 table  Flies: absent
room: 1  Garbage waste
disposal site:
municipality
vehicle
 Source of water:
public
 Kitchen
exhaust: no
 Source of fuel:
LPG

Second visit (2076/09/26)
Objectives
 To know about the disease progression
 To access the knowledge attitude and practice of the family.
 To know about the effect of disease on the family and the consequent change
in their KAP regarding this.
 To evaluate their housing and environmental condition.
 To evaluate the gender role through the gender analysis tool.
Activities
We utilized the second visit for gathering information. We talked to the patient and
asked about the health condition, enquired upon the compliance to the advices and
follow up. We obtained information of the patient and family about the knowledge,
attitude and practice about the disease, its causation, effects on the family and any
predisposing factors based on the semi-structured questionnaire we had prepared.
Outcomes
KAP on illness and health seeking behaviour
The family members seem to have a good KAP on common illness. They visit TB
center for regular sputum checkup since having positive TB patient in family.
Beliefs, Culture, Customs and Religion
The family follows Buddhism. Their beliefs, culture and customs are guided by
their religion and caste. All festivals, rites and rituals are followed as per their
religion and caste. Belief in lama is quite not present but they value traditional
healing.
Care and Support System by the Family Members
The family provides good care & support to the patient as is indicated by the
cleanliness of his room. He is alerted every day for regular medicine intake and for
regular health checkup by his family members.

Effect of Disease
On the patient
Physical and psychological: Initially patient felt fatigue and weight loss by 5kg.
Due to prolonged fatigue he was not able to perform his daily tasks. Because of
impairment in the daily performance he has got psychological disturbance and he
was tensed.
On social relationship
He was unable to attend social gatherings and functions due to hesitation. He was
quite conscious and worried about his medical condition.
On the family
Physical and psychological: Since patient was able to manage his finance and
livelihood properly and was able to take nutritive diets there was no such
psychological pressure regarding his illness in the family. He was able to continue
his job. Though he was slightly weak due to illness but it didn’t created much
difference.
On daily activities
Daily activities of the family members were not hampered by the disease because
he can visit hospital alone for medication and can perform his daily routine wroks
by himself.
On the community
As it is an infectious disease there is a chance of transmission to other people in the
community. He is in contact with many people due to his job and the risk of
transmission is increased as he doesn’t use mask or cover mouth with tissue paper
while sneezing and coughing. He even don’t wash his hand or use sanitizer after
coughing or sneezing. People except his family members doesn’t know about his
disease. Even the people in the office doesn’t know about his disease due to which
they don’t use any precaution and are at high risk to get infected.
Role of family in disease

Role in causation
In this case the family has great role in the causation of the disease. As he was in
close contact with his brother in law who was diagnosed with pulmonary

tuberculosis. Despite of being known case they didn’t take appropriate precautions
and neglected the seriousness of the disease. Also the living condition of the
patient was inappropriate. There was overcrowding, no cross ventilation and
dampness in the room which ultimately created a favourable condition for the
causation of the disease.
Role in progression
In this case, the chance of developing of the disease to other members was high
due to overcrowding. Since the mode of transmission is via droplet nuclei, there is
high chance of inhalation of contaminated droplets due to overcrowding. But the
progression of disease to advanced stage was checked by the family members,
since they are having proper nutritive diet, they aware the patient for daily and
timely intake of drugs.
Role in relief
The family has crucial role in disease recovery. They are supporting the patient in
every aspect possible aspect. They aware the patient for daily and timely intake of
the drugs and helps him with nutritive diets.
Gender Analysis
Tool I: Activity profile
Table 3.3: Activity profile
Activities Women/Girls Men / Boys
Source of income
Agriculture
Business 
Employment  
Domestic routine works 
Water related
Collection 
Washing clothes 
Cleaning dishes 
Fuel related
Obtaining gas or kerosene  
Cooking 
Health related chores
Child immunization 
Care during ill health 

Taking sick to hospital  
Buying medicines  
Child care 
Cleaning and  
maintenance task
Budget allocation and 
marketing
Activity profile helps to understand the trend of involvement of male and female in
several works in their household. It gives the pattern of work distribution in the
family. Here in this family the more daily routine household works are done by
female while outdoor works are mainly carried out by men.
Tool II: Access and control profile

Table 3.4: Access and control profile
Particulars Access Control
Girls Boys Girls Boys
Land/housing ++ ++ ++
Equipment ++ ++ + ++
Labor and division of labor ++ ++ ++ ++
Cash/economic resources ++ ++ + ++
Education/ training + ++ ++
Ownership ++ + ++
Assets ++ ++ + ++
Basic needs
Food/clothing/shelter ++ ++ ++ ++
(Difference in number of + sign of less than 5 signifies good gender situation.)

(Difference in number of + sign of 5 to 9 signifies satisfactory gender situation.)
(Difference in number of + sign of 10 and more signifies poor gender situation.)
Since the difference in number of + sign is less than 5 we can see that there is gender
equality in the family.

Third visit (2076/10/04)
Objectives
 To know about the disease progression
 To explore about the progression of the disease over the period of time
 To counsel the patient and family members and encourage them for change if
necessary.
Activities
We called our patient and fixed the time of visit. We asked him about the change in
attitude toward the disease regarding its prevention and transmission. We
conducted a counseling regarding the importance of covering face while sneezing
and coughing, importance of mask and washing hands. We advice him to stop
drinking and smoking habit. Lastly we thanked the family for their cooperation and
support.
Outcomes
We convinced the patient to go for a follow up which they agreed. We made him
aware about the mode of transmission of disease and he agreed to use mask while
working outside. We also told that family members should also visit for sputum
examination. We taught them how the disease can be prevented by maintaining
personal hygiene and environmental sanitation.
Counseling
We counsel the patient that not to be more anxious about the disease. We also
assure him that disease will be cured after completion of DOTS and disease has
very less infectivity after initiating the Anti-tubercular treatment. We told the
patient not to smoke and drink alcohol.

CASE II - BREAST CANCER
Introduction
Cancer: “An abnormal mass of tissue, the growth of which exceeds and is
uncoordinated with that of normal tissue and persists in the same excessive manner
after the cessation of stimuli which evoked the change”.
Breast cancer: Breast cancer is a malignant proliferation of epithelial cells lining the
ducts of lobules of the breast.
Types of Breast cancer:
a) Ductal carcinoma in situ
b) Invasive ductal carcinoma
Ovarian cancer: Cancer that forms in the tissues of the ovary
Types of Ovarian cancer:
a) Epithelial ovarian cancer
b) Germ cell ovarian cancer
c) Stromal cell ovarian cancer
Risk factors and etiology

Breast cancer:
Exact cause of Breast cancer remains unclear.
a) Age: The risk of breast cancer increases with age.
b) Genetics: Women who carry certain mutation in BRCA1 & BRCA2 genes have a
higher chance of developing breast cancer, ovarian cancer or both, people inherit
these genes from their parents. Mutation in the TP53 gene also increases the risk of
breast cancer.
c) A history of breast cancer or breast lump.
d) Estrogen exposure
e) Alcohol consumption
f) Radiation exposure
g) Nulliparity
Ovarian cancer:

a) Age: Most common in older age women of 55 years or older.
b) Genetics: Women with a mother, sister, grandmother who has had ovarian cancer
have a higher risk of developing the diseases.
Genetic mutation: BRCA1 gene mutation have 35-70% higher risk of ovarian cancer
& BRCA2 mutation have 10-30% higher risk.
However vast majority of ovarian cancer in women don’t have either mutation. Lynch
syndrome and Peutz-Jeghers syndrome have higher risks of developing ovarian
cancer.
c) Previous history of breast, colorectal & endometrial carcinoma.
Clinical manifestations
Breast cancer
a) A lump or mass in the breast is present
b) Swelling of all or some part of breast
c) Pain in breast and nipple
d) Nipple retraction, nipple discharge present
e) Redness, scaly or thickened nipple or breast skin
f) Change in breast color, increasing in breast size and shape
Long term effect of Breast cancer: Fatigue, pain & numbness, headache,
lymphedema, menopausal symptoms, infertility etc.
Ovarian cancer
a) Abdominal bloating or swelling
b) Quickly feeling full when eating
c) Weight loss
d) Discomfort in the pelvic area
e) Changes in bowel habits (constipation)
f) A frequent need to urination
Complication of ovarian cancer: Ascites, extreme pain, bowel obstruction, edema of
extremities, pleural effusion, bladder obstruction.

Problem statement
Breast cancer
Global: Breast cancer is the most common leading cause of death in women, rarely in
men. According to WHO in 2018, it is estimated that 627,000 women died from
breast cancer, while breast cancer rates are higher among women in more developed
region and rates are increasing in nearly every region globally.
Nepal: Breast cancer is the 2nd most common malignant disorder among Nepalese
women.
According to the Annual report of DOHS 2074/075, 1808 new cases of breast cancer
were diagnosed in Nepal.
Table 4.1: Status of breast cancer – 2074/75
Province Province Bagmati Gandaki Province Karnali Sudur
1 2 Province province 5 province paschim
province
11 cases 29 cases 1435 278 cases 47 cases 2 cases 6 cases
cases
Ovarian cancer
Global: According to the world cancer fund and American institute for cancer
research, ovarian cancer is the 8th most common occurring cancer in women. Nearly
300,000 new cases of ovarian cancer were detected in 2018.
Nepal: According to WHO, In 2017 Ovarian cancer deaths in Nepal reached 649.
A. Agent factors: *Human Cytomegalovirus (HCMV) and Epstein-Barr virus
(EBV) of the family Herpesviridae family have been implicated as a cause of
breast cancer.
B. Host factors:
 Breast cancer
 Age: Age group more than 50 years are at high risk
however breast cancer can strike below 50 years of age
also.
 Sex: Most common in female

 Ovarian cancer
 Age: Most common 50-60 years usually after menopause
but some cases are diagnosed at the age 40s & 50s also.
 Sex: Female
C. Environmental factors:
 Breast cancer
 Tobacco smoke (both active & passive exposure)
 Dietary (charred and processed meats)
 Alcohol consumption
 Environment carcinogens (Ex-exposures to pesticides,
radiation, environmental & dietary estrogens)
 Obesity
 Menopause
 Ovarian cancer
 Older age
 Family history of ovarian cancer
 Reproductive history and infertility
• Early menstruation
• Not giving birth to any child
• No exposure to any oral contraceptive pills
• Infertility
• Menopause
Method of diagnosis
A. Clinical examination of breast: Involves a thorough physical examination of
whole breast area including both breast, nipple, armpits and collar bone.
B. Mammography:

 Screening mammography: Done after palpable mass has been detected
in breast tissue.
 Diagnostic mammography: Evaluating the rest of breast before biopsy
is performed to exclude immediate biopsy.
Dominant mass
Suspicious Not suspicious
Mammography Mammograp
yyyy yy hy
suspicious
Biopsy Not
suspicious
Suspicious
Fine needle
aspiration
N
ot
suspicious
Consider
observation
Fig 2: ‘Triple Diagnosis’ Technique

Justification for case selection
Breast cancer is the second most common and deadliest non-communicable diseases
in Nepalese women; which being a leading cause of death in women, it has physical,
psychological, social, and economical burden to the individual and the family. Thus
giving us the best opportunity to fulfill our objective. In context of Nepal, most of the
women are unaware about the cancer, their risk factors, its occurrence and its
management. So, we felt it was necessary to choose this as our case and to know its
impact in depth in family & community basis.
Case History
Patient profile
Name: Maya Devi Sigdel
Age: 49 years
Sex: Female
Address: Dulegauda, Tanahun
Marital status: Married
Educational status: Up to 7 class
Occupation: Housewife
Religion: Hindu
Informant: Self
Chief complaints
1. Left lower abdominal pain for 1 week
2. Fullness of abdomen for 1 week
3. Vomiting for 1 week
History of present illness
Patient was apparently well a week before then she developed acute, spasmodic, non-
migrating pain in lower left flank with episodes of vomiting associated with mild
fever, headache, weakness and loss of appetite. Pain is not associated with burning
micturition, constipation and shortness of breath.
Past medical history

History of ovarian cancer and has done hysterectomy with bilateral salpingo-
oophorectomy on 2070-mangsir-24 and also a history of partial mastectomy of left
breast due to breast carcinoma on 2072-baisakh-21. No history of COPD,
Tuberculosis, DM, HTN.
Personal history
Mrs. Sigdel don’t smoke and consume alcohol. She consumes mixed diet and her
bowel, bladder and sleep pattern were normal.
Family history
Mrs. Sigdel mentioned that her father had hypertension, her mother had diabetes
mellitus along with hypertension. Her elder sister passed away due to uterine
carcinoma and there was no history of COPD, tuberculosis and other chronic illness in
the family.
Menstrual history
She had her 1st periods at the age of 15. Menstrual cycle was of 3-5 days with no
blood clots and without dysmenorrhea. She used to use 1-2 pads per day. Since she
went through bilateral salpingo-oophorectomy the menstrual cycle is stopped.
Obstetric history
She married at the age of 19 years.
Gravida: 0, Para: 3, Abortion: 0, Living child: 3
Drug history
Lactulose 10ml OD
Sodium Picosulfate 10mg OD
Prednisolone 40mg OD
Morphine 10mg BD
Paracetamol 500mg QID
Pregablin 75mg OD
Domiperidone 10 mg TDS
Rabeprazole 20mg BD
Drug and allergy history
No any drug and allergic history

Clinical examination
Clinical examination was performed with patient’s consent.
General examination
The patient was conscious, cooperative, and well oriented to time place and person.
She was lying comfortably on supine position on her bed.
Cardinals sign:
Pallor - absent, Icterus - absent, cyanosis - absent, clubbing - absent,
lymphadenopathy - absent, edema - absent and dehydration – mild dehydration seen.
Vitals:
 Temperature: 99.2 degree Fahrenheit taken on right axilla.
 Pulse: 78 beats per minute, regular in rhythm, normal in volume, no radio-
radial delay
 Respiratory rate: 18 breathes per minute
 Blood pressure: 120/80 mm of Hg measured over right brachial artery on lying
position.
Systemic examination
Respiratory system
On auscultation normal vesicular breathes sounds heard over bilateral lung fields. Due
to some personal problem she didn’t allowed us for inspection, palpation and
percussion of thorax region.
On auscultation normal first and second heart sounds were heard and no murmurs
were present.
Gastro-intestinal system
On GI examination abdomen was found to be scaphoid in shape, there was no any
venous prominence, no any sings of enlargement of nearby organs. Mild tenderness
was present on the lower abdomen. Tympanic sound was heard during percussion.

Investigations
 BP: 120/80 mm of Hg
 Hb: 12.1 gm/dl
 RBS: 100 mg/dl
 WBC: 5.86*10^9/L
 Neutrophils: 3.71*10^9/L
 RBC: 4.65 million/mm3
 Serum urea: 18 mg/dl
 Serum creatinine: 0.7 mg/dl
 A:G ratio: 1.3 mg/dl
Current diagnosis
Breast carcinoma of left breast with the history of left sided partial mastectomy and
hysterectomy with bilateral salpingo-oophorectomy.
Nutritional assessment
She takes a cup of black tea with few biscuits, fresh seasonal fruits and few bowls of
jaaulow in a day.
Treatment Seeking Priority
Patient and her family had a good treatment seeking behavior. They prefer visiting
private clinics and hospitals as soon as possible for any illness. Being an earlier
FCHV she had a good knowledge and she knows the importance of early visiting of
hospitals and health settings.

Family Visit
First visit (2076/09/21)

Objectives
 To locate the house of the patient.
 Introduction and rapport building with the family members, key informant
interview and interview with the head of the house.
 To observe the physical facilities and evaluate socio-economic status.
 To explain them about the purpose of our visit.
Activities
We had prior contact with the patient party fixing our date of first visit. We gathered
in Prithivi Chowk and went to Dulegauda by bus on our day of visit and after phone
call we got directions of patients address. It was very difficult to locate the house
because of being out of Pokhara. Rapport building was done with the patient and rest
of members, detailed history and examination was done after taking consent. We also
observed house and environment. Then we left after deciding date and time of our
second visit.
Family profile
Type of family: Nuclear family
Family size: 4 members
Household head: Muktinath sigdel
Source of income: Government school Teacher
S.n. Name Age / Relation with Education Occupation
Sex patient
1. Radhika Sigdel 82 / F Mother in law Illiterate Housemaker
2. Muktinath Sigdel 50 / M Husband Masters Teacher
3. Maya Devi Sigdel 49 / F (Self) Class 7 Housemaker
4. Madan Sigdel 29 / M Son MBS Student
Family Genogram

(Pt’s Father) (Pt’s Mother)
49 50
(Pt’s brother) (Pt’s brother) (Pt’s Sister) (Pt’s Sister) (Pt’s Sister)
29 24 22
Fig 2.1: Family genogram
Index
Female:
Male :
Patient:
Dead male:
Dead female:
Affected female:
Married:
Socio-economic status
According to the Kuppuswamy socioeconomic status scale, the score is 22 and the
family belongs to upper middle class family. The main source of income is from job
of the head of the family as a teacher in government school.
Table 4.3: Socioeconomic status score table

S.no. Criteria Score
1. Occupation of the head of the 10

family
2. Education of the head of the 6
family
3. Total Monthly income of the 6
family (around 20,000)
Total score 22
Observation checklist
Housing condition: The house was cemented, made up of concrete, there were 2
rooms for 4 members. According to person per room criteria and sex separation
criteria, there was overcrowding. Lighting was satisfactory. Cross ventilation was
present. There was provision of separate kitchen with chimni system and they utilize
LPG gas to cook food.
Environmental sanitation: Tap water was the source of drinking water. Usually they
use it without processing but occasionally they use to boil it before drinking. The
latrine was water seal type with septic tank method of excreta diposal and they use
soap for hand washing after using it. Solid waste was collected by the municipality.
There were no pets in the house.
Table 4.4: Observation check list
 Type of house: pakka,  Television/computer/  Toilet: present

rented house. laptop: television is  Toilet type: water
 No. of rooms: 4 present seal
 Lighting is not  Telephone/mobile:  Septic tank:
satisfactory. 4 mobiles present
 Cross ventilation:  Vehicles: none  Flies: absent
present  Cooking appliances:  Mode of disposal
 Smoke outlet in kitchen- present of household
present.  Refrigerator: present wastes:
 Source of fuel: LPG gas  Washing machine: none municipality
container
 Source of water:

tap water
 Ditches around
houses: absent.

Second Visit (2076/09/28)
Objectives
 To understand the impact of disease in the family.
 To know the role of family in the disease process.
 To assess the gender status in the family and its role in illness.
 To check for compliance.
 To collect information on the progression of the disease.
 To know the KAP about the disease.
Activities
We had our second visit arranged after a week and had consulted about it with our
supervisor Dr. Bimala Sharma. In this visit after reaching the home of the patient we
received the warm welcome. We inquired the patient about the knowledge, attitude,
and practice towards the disease. Their health seeking behavior and compliance
towards the treatment were asked in detailed. History was taken on two way
association of family and disease. We inquired about the role of family members on
the causation, progression and recovery of the diseases. We also asked about the
impact of the disease on the individual and family.
Outcome
KAP on illness and health seeking behaviour
My patient was aware about the disease she was suffering from. She thinks that it is
non-communicable and she was aware about the disease, its sign and symptoms. But
she was unaware of the complication and the ways of preventing it. Her family
members were supportive, with positive attitude and good practice about the disease.
She had fear of consequences of the disease. She has been taking regular medicine for
last 4 years and time to time she goes for follow up in Gandaki Medical College and
teaching hospital.
Health seeking behavior
When she first felt small palpable mass on her left breast, she immediately went to the
hospital care and get prompt treatment with the diagnosis of breast cancer. The patient
and her family members does not believe in traditional healers, witch doctors or

homeopathy and prefers allopathic doctors and hospitals. For minor illness, the
medical stores in their locality is favoured and for major illness, hospitals are
favoured. Decisions regarding health seeking behavior is made collectively by family.
The compliance of family to medication and follow up at health instiution is good.
Role of family in disease

Role in causation and progression
The family members were not aware about the preventing measures of disease. As she
was suffering from cancer, where she had already known about her elder sister who
died by the uterine cancer 2 years before she developed the cancer and therefore, due
to the delay by unaware about the disease preventing measures she got delay for the
treatment and the cancer cells were progressively increasing in number over the breast
tissues.
Role in recovery
After consulting with the doctor disease was diagnosed as breast cancer then she went
under treatment with long term medication. The family members provided full
support to the patient for rapid recovery. They helped her to attend the visits of doctor
and also helped in taking the medicine.
Effect of disease
On the patient
Physical and Psychological impact: 2 years before she went through partial
mastectomy she had gone through hysterectomy with bilateral salpingo-oophorectomy
after that she started feeling weak and lethargic. After her operation she mentally get
stressed thinking about the consequences of the disease. She had a huge drop in body
weight since illness. The patient did not felt any type of restriction in the social
activities because of her condition but because of her weakness she did not actively
participate in social gatherings. According to her family the society and neighborhood
didn’t show any negative attitude towards her and her illness.
On the family
Since the diagnosis and till the treatment date her family had to bear a huge sum of
loan. Her husband had to manage official leaves from his work to take care of her.
She used to be a FCHV before she had developed the illness but now she had to leave

the post. Her son was out of country for further studies and he used to be tensed about
her condition and used to manage to send some sum of money for her treatment. Her
family had to leave her village and had to settle in town for her proper treatment. Her
two married daughters had to manage time and take care of her. They used to take her
to hospital for visits and stay with her during her hospital stay. So there was some
economical and psychological problem with in the family.
On the social relationship
The family members have no problem in disclosing her condition from the society.
The social relationship has not affected due to the disease. She was invited in many
social gatherings and functions. Society and her neighborhood got knowledge and
information about the seriousness of the disease and changed their perspective
towards the health seeking attitude.
Economical impact
Due to her illness her family member had to take a large sum of loan. They had to sell
their cattle for collecting the money. They left their farm barren because every family
members were busy in taking care of her, thus directly and indirectly there was a huge
economical impact on her family due to her illness.
Gender analysis
Activities Women/girl Men/boys Both
s
Breadwinner 
Sources of income 
Agriculture
Business
Jobs 
Household chores 
Washing clothes 
Cleaning dishes 
Cooking 
Health related activities
Decision of health care 
Care during illness 

Taking sick to health care center 
Buying medicine 
Immunization of child 
Child care 
Cleaning and maintenance tasks 
Activity profile helps to understand the trend of involvement of male and female in
several works in their household. It gives the pattern of work distribution in the
family. Here in this family the more daily routine household works are done by
females while outdoor works are mainly carried out by men. Some of the important
tasks are done on common understanding by both.

Access Control
Land/housing ++ ++ ++
Labor and division of labor ++ ++ + ++
Cash/economic resources + ++ + ++
Education/ training ++ ++ + ++
Ownership + ++ + ++
Assets ++ ++ + ++
Basic needs ++ ++ ++ ++
(Difference in number of + sign of less than 5 signifies good gender situation.)

(Difference in number of + sign of 5 to 9 signifies satisfactory gender situation.)
(Difference in number of + sign of 10 and more signifies poor gender situation.)
Since the difference in number of + sign is 10, it indicates that there is poor gender
situation in the family.

Third visit (207610/6)
Objectives
 To counsel the patient and family members and encourage them for change, if
necessary.
 To know about the progress of the visit over the period of time.
Activities
Prior notice was given to patient about our visit. We conducted counseling and health
education considering their KAP regarding the disease. Necessary and remaining
questions were inquired as well. Several suggestions were given to them, based on our
observation and feedback was taken from them. We concluded our visit with words of
gratitude for cooperation.
Compliance
The patient was under routinely medication since last 4 years but she refused to go
under further chemotherapy for her breast cancer because it was costly and she
couldn’t bear the side effects of the treatment. Hence the compliance was not good in
this case.
Counseling
The patient was counseled to take her medicine timely and properly. Also, she was
counseled to follow up timely and regularly according to the schedule given by the
doctor. Rest of family members specially her daughters were counseled about the
preventive measures and techniques for timely diagnosis of such illness.

CASE III: ALCOHOL DEPENDENCE SYNDROME
Introduction
Alcohol dependence is a chronic form of disease where a pattern of self-
administration of alcohol or the drinks containing alcohol that usually results in
tolerance, withdrawal and compulsive alcohol taking behaviour is seen. A person with
this disease continues the use of alcohol despite of significant alcohol related
problems.
Symptoms
 Unable to keep a drink limit
 Restless without drink
 Difficulty rejecting drinking
 Missing meals
 Memory lapses, blackouts
 Morning retching and vomiting
 Sweating excessively at night
 Withdrawal fits (motor seizures)
 Hallucinations, frank delirium tremens
 Anxiety, psychomotor agitation
 Convulsions
Problem Statement
Global scenario
According to the Global Status Report on Alcohol and Health (WHO) worldwide per
capita consumption of alcoholic beverages in 2005 equaled 6.13 liters of pure alcohol
consumed by every person aged 15 years or older. A large portion of this
consumption i.e 28.6% was homemade and illegally produced alcohol. A large
variation exists in adults per capita consumption. The highest consumption levels can
be found in developed world, mostly the Northern Hemisphere. Low consumption
levels can be found in populations of Islamic faith which have very high rates of
abstention.

Scenario in Nepal
According to Non Communicable Disease Risk Factor Survey, 2007/08, 28.5% of the
total respondents were found to consume alcohol (31.3% of men and 13.3% of
women).
By religion, Kirant has the highest prevalence of alcohol, followed by Buddhist. They
are mostly clustered in mountains and hills. In most parts of the country , liquor is
freely available and unlicensed home-brewing accounts for the major production of
alcohol. In fact, the Liquor Control Act of Nepal allows the production of homemade
forms of alcohol for domestic use, although much homemade alcohol is diverted to
the market.
Diagnostic criteria of Alcohol dependence
According to the International Classification of Diseases (ICD-10) following criteria
should be fulfilled:
1. A feeling of compulsion to use of the alcohol
2. Difficulties in controlling the level of use
3. Withdrawal state or use of substance to avoid withdrawal symptoms
4. Presence of tolerance to the alcohol’s effects
5. Persistent use of alcohol despite evident presence of harmful consequences
The CAGE questionnaire is still held by many as a screening test:
 Have you ever felt you should CUT down on your drinking?
 Have people ANNOYED you by criticizing your drinking?
 Have you ever felt GUILTY about your drinking?
 Do you ever have a drink first thing in the morning (as an EYE opener)?
Positive answers to two or more questions suggest problem drinking.
Justification for the choice of case
Since this case is due to alcohol which is very much abundant in our society, it’s vital
for us to acquaint about the harmful effects of the substance so that we can educate
others about the seriousness of these issues. Alcohol being locally produced in our
society, being cheap, easily available and acceptable by some of our traditions and
customs, it is continually posing its risk in our health.
Patient profile

Name of Patient: Raj Gurung
Age/Sex: 26 years / Male
Address: Kahun khola-Naya jeep station, Pokhara
Marital status: Unmarried
Occupation: Shopkeeper
Religion: Hindu
Education: up to 11 class
Date of Hospital visit: 2076/09/07
Chief Complaints
 Epigastric pain since yesterday
 Vomiting multiple times
 Chest pain since yesterday
According to the patient he has a habit of taking alcohol for 1.5 years. He used to
drink 1 to 2 bottles of beer on average per day few years back but started taking beer
along with homemade alcohol on regular basis for last 1.5 years. Patient mentioned
that he could not control on the amount of litres of alcohol while drinking. Vomit was
projectile in nature, non billous and consist of ingested food particles. The bowel and
bladder habit is abnormal with disturbed sleep pattern. No history of fever and loss of
consciousness.
Past history
Patient had a history of hypertension for past 2 years.
No history of diabetes, tuberculosis and epilepsy.
No history of any surgical intervention.
Personal history
Our patient is chronic alcoholic, occasional smoker and non-vegetarian by diet.
Alcohol history
 Type of drink: local alcohol and beer
 Quantity: around 3 to 4 liters
 Daily/weekly pattern: daily for 5-6 days
 Morning drinking: not on regular basis

 Usual place of drinking: nearby hotels
 Alone or accompanied: accompanied with friends
 Purpose: without any reason since he is a habitual drinker
 Amount of money spent on alcohol: on average Rs.5000-6000 per month
 Attitudes to alcohol: Guilty now
Family history
No history of diabetes mellitus, tuberculosis, hypertension and epilepsy in the family.
No known history of any drug and allergic reactions till date.
Clinical Examination
General physical examination
Our patient was alert, well oriented to the time, place and person and cooperative.
Vitals
 Pulse: 74beats/min
 Respiratory rate: 15breaths/min,
 Blood pressure: 126/92 mm of Hg,
 Temperature: 98◦F
Cardinals
No pallor, icterus, lymphadenopathy, cyanosis, clubbing, edema and dehydration.
Respiratory System
Inspection
During inspection it was found that the chest was bilaterally symmetrical, no bulging
and no any scars marks were present. Chest expansion was equal on both side and
intercostal space was normal in appearance.
Palpation
There was no tracheal shift or increased vocal fremitus and no any tenderness was
present over chest region.
Percussion
On percussion there was resonant note on both side of chest and normal liver dullness
was heard from 5th intercostal space to lower costal margin.

Auscultation
On auscultation normal vesicular breath sound was heard along with normal voice
resonance.
Abdomen was found to be soft and non tender. Spleen and liver were not palpable.
Normal bowel sound was heard on particular interval of time.
On palpation apex beat was felt at 5 th intercostal space. No any thrills and additional
sounds were heard. On auscultation normal heart sounds (S1 and S2) were heard.
Investigations
CBC: Hb: 17.4g/dl (H), WBC: 12.12*10^9/L (H), DLC: Neutrophils: 9.11*10^9/L
(H) and all other remaining parameters are in normal range.
Liver function test: Aspartate aminotransferase (AST): 52 U/L (H), Alanine
transaminase (ALT): 80 U/L(H), Serum Amylase: 484 U/L (H) and all other
remaining parameters are in normal range
Renal function test: Sodium: 132 mMol/L (L), Potassium: 6.5 mMol/L (H) and all
other remaining parameters are in normal range.
Diagnosis
Alcohol dependence syndrome
Treatment history
Tab. Naltrexone 50mg
Tab. Amlodipine 5mg
Tab. Fluoxetine 20mg
Tab. Thiamine (B-one) 100mg

Family Visit
First Visit (2076/09/20)
Location- Kahukhola
Objectives
 To mutually introduce the group members with the family members.
 To build a positive rapport with all the family members.
 To understand the social and cultural beliefs of the family and analyse how it
affects the health of family.
 To observe the housing, assets and environmental sanitation using the
observation checklist
 To estimate the economic status of the family and relate it to the status of
health in the family.
Activities
The family members were informed about the visit the previous day through
telephone contact. Family provided us with a warm welcome. The patient’s family
members were quite cheerful and cooperative. We clarified them about the purpose of
our visit. We asked the patient about his illness. According to the Family, patient was
improving over last month. The focus of the visit on rapport building, collecting data
on health seeking behaviour, and various aspects regarding disease was achieved. We
also filled the observation checklist regarding housing and environment. After a long
and good communication of about two hours, we returned to our home after obtaining
permission for our second visit.
Outcome
Family Profile
The family is leading a life of upper middle socio-economic class. The patient is 26
years old male from kahunkhola diagnosed to have Alcohol dependence syndrome.
After being treated for few days, he is improving. He is unmarried and lives with his
family. The family has done every effort for the treatment and is hopeful for the
improvement.

S. Family Relation Age/ Marital Education Occupation
No. member with patient Sex Status
1. Kul Bdr. Father 60/ Married Up to class Shopkeeper
Gurung M 7
2. Dhan kumari Mother 59/F Married Proad House
Gurung sikshya maker
3. Binod Gurung Elder brother 32/ Married Up to 12 Taxi driver
M class
4. Uma Gurung Sister in law 30/F Married Bachelor House
maker
5. Anil Gurung Brother 24/ Unmarried Bachelor Jeep driver
M
Family Genogram
60 59
32 30 26 24
Fig 3: Family genogram
Index
Male:
Female:
Patient:
Married:
Socioeconomic status
According to Kuppuswamy’s scale, they fall under upper middle class family
(Kuppuswamy’s scale 16-25). Their main source of income is from driving vehicles.
Their family income is around Rs. 40,000 to 60,000 per month. As he became ill, he
has to frequently visit clinics and hospitals, so the expenditure has risen up.

Table 5.2: Socioeconomic status table
S. Criteria Score
no.
1. Occupation of the head of the family (shop 5
owner)
2. Education of the head of the family (up to class 3
7)
3. Total monthly income of the family (40,000 to 12
60,000)
Total score 20
Housing and environment

The family lives in their own house. The rooms are well ventilated and well lit. They
use LPG gas for cooking. They are well supplied with public water supply. Bathroom
is tiled and latrine is of water-seal type. The house and surrounding is clean and
hygienic. They have backyard land in which they grow vegetables.
Table 5.3: Observation checklist
 Type of house:  Television  Toilet: water sealed

Pakka  Refrigerator and well
 Tenure : Own  Mobile maintained
 Number of rooms: 5  Vehicle: 2 wheeler  Odor: absent
 Number of windows  Cooking appliances:  Flies: absent
per room: 1 rice cooker  Garbage waste
 Lighting:  Furniture : poorly disposal site:
satisfactory furnished proper
 Cross ventilation:  Source of water:
not present water supply and
plenty
 Kitchen exhaust:
yes
 Source of fuel:
LPG

Objectives
 To understand the impact of the disease on the family.
 To understand the role of the family in the disease process.
 To understand the Knowledge, Attitude and Practice of the patient and the
care provider and regarding the disease.
 To check for compliance.
 To assess the gender status of the family using specific gender tools.
 To counsel the family if required.
Activities
When we reached the house for second visit, the patient’s condition was good enough.
This time we held conversations about the disease, its impact on the patient and his
family. Various open and closed questions were asked to the patient and the family
members to know their KAP regarding illness and health seeking behaviour of the
family. We also discussed with them about the compliance with the treatment and
follow ups to the hospital. Gender analysis was done using the specific tools. We also
asked different questions to know about the impact of disease in the family and role of
family in causation, progression and relief of the disease. After two hours of long
chat, we gathered necessary information required and concluded our visit by thanking
them. We also informed them about our final visit and arrange the time for the same.
Outcome
KAP regarding illness and Health seeking behaviour
Though the patient and his parents hadn’t achieved higher formal education but they
are aware about the impact of the disease upon their children and on society. Specially
his parents used to advice him to stop the drinking habit. Patient was found
determined to stop drinking and according to his parents he hasn’t been drunk since
the last hospital visit. They understood the importance of the compliance in treatment
and followed all the instructions given to them regarding treatment precisely.

Care and support system by family members and community
The patient is getting adequate support from the family members. They convinced
him to have a positive behaviour towards the disease and that this is not a big
problem. This gave him ample amount of confidence to overcome the disease and
return back to his normal life as soon as possible.
Compliance of patient with treatment
Patient is trying his best. He has been taking medicine as scheduled. He thinks the
medicine has helped him enough to relieve his symptoms related to anxiety, insomnia,
anorexia and depression but he has not given up his drinking habits completely.
Impact of disease
On patient
Physical and psychological: According to patient he was weak and lethargic and unable to
perform regular work after the disease. He feels guilty about himself for what he has done.
The disease took a massive effect on him physically as well as psychologically. The patient
has realized that alcohol consumption is the main precipitating factors and it is the illness
that can be controlled only by medications, family support and alcohol abstinence.
On Social relationship: Despite of this kind of problem his neighbours didn’t

criticised him. According to his parents he is also equally invited to any social
gatherings and function by their neighbours.
Financial Impact: Economic impact was seen in his family as his parents has to give
more time to him and also do the household works and business. He is also not
completely able to handle his shop. A lot of money has been spent as a treatment
expenses. About Rs.8 lakhs to 9 lakhs has been spent on his treatment.
On the family
Physical and Psychological: The patient family members were worried about the
behaviour and future of the patient due to his behaviour. They had the additional
burden of taking care of him and taking him to hospital. The disease has put both
physical and psychological burden on family members.
Economic impact: There was economic burden on family members during the
hospital visit of patient in GMC teaching hospital. The Treatment expenditure was
about Rs.8 lakhs to 9 lakhs including investigation, medicine and transportation fares.

On daily activities
His parents had to do all the household activities as well as to take care of him and do
his works also. Thus the daily activities were hampered a little.
On the community
Occasionally his friends persuade him to come and drink with them, but the frequency
is decreased as his health is deteriorating and his parents convinced them to not
encourage him to drink anymore.
Gender Analysis
The patient has access to assets and other needs. The monetary management is carried
out by the patient’s parents mainly. Important decisions were made on a common
consensual between them.
Table 5.4: Activity Profile
Activities Women / girls Men / boys
Source of income
Agriculture
Business 
Employment 
Domestic chores
Water related
Collection  
Washing clothes 
Cleaning dishes  
Fuel related
Obtaining gas/ kerosene  
Cooking 
Taking sick to medical  
institute
Buying medicine  
Child care 
Cleaning and maintenance 
task
Budget allocation and  
marketing

(Activity profile shows the pattern of distribution of labor, and the burden of work
each sex has to bear. The values are either positive or negative, and the skewing of
positive values towards a particular sex shall imply that the respective gender bears a
greater burden of work than the other.)
Women/ Men/ boys Women/girls Men/ boys

girls
Land / housing ++ ++ ++ +
Equipment ++ ++ ++ +
Labour and division ++ ++ ++
of labour
Cash/economic ++ ++ ++ +
resources
Education/training + + + +
Ownership of assets ++ ++ ++
Basic needs
Food /clothing/ shelter ++ ++ ++ ++
(Difference in number of + sign of less than 5 signifies good gender situation.

Difference in number of + sign of 5 to 9 signifies satisfactory gender situation.
Difference in number of + sign of 10 and more signifies poor gender situation.)
Since the difference is 7; it signifies satisfactory gender situation.
Role of family on disease
Role in causation
Earlier by profession he used to work as a jeep driver. After the work he and his
friends used to gather and take alcohol to relieve the stress. This process continued for
long duration and he eventually became chronic alcoholic. He became habitual
drinker and started to drink without any reason or occasion. He takes some pegs of
alcohol whenever he is free from his work though his family members scold him a lot.

Role in progression
Though he tried to quit the drinking habit a couple of times but he could not do so due
to his addiction towards alcohol. So, his continuous drinking habit along with addition
of other abuse substances and hence increased the progression of the disease.
Role in relief
The love and concern of his family members resulted in his speedy recovery. He has
promised to give up drinking for the sake of his health, future and his family
members.

Objectives
 To counsel the patient and family members regarding the illness and personal
hygiene and environmental condition as well as the importance of compliance.
 To know about the disease progression.
Activities
After confirming about the date and time of our visit through telephone, we visited the
patient’s house. Prior to this visit we had made a list of things we had forgotten to ask.
So we inquired about them. The family was very happy that we visited them and then
treated us with great hospitality. They were enthusiastic to know more about the
disease and asked us queries regarding its progression and treatment. We fulfilled
their queries to our full capabilities.
We counsel about illness and explained the importance of regular drug intake and
follow up. We departed after thanking for their courtesy and cooperation. They
blessed us to be good doctors. We were happy to know that patient was co-operating
with the family members to get rid of this disorder and doing his utmost to make
change in his behaviour by self-commitment. Finally, we expressed our sincere thanks
to the patient and his family for availing us their valuable time and cooperation.
Outcome
We evaluated the changes that had been brought to the family with our counseling,
suggestions and knowledge provided to them. We saw the behavioural and cognitive
changes in the family members regarding the disease. They were feeling determined
and more concerned that he would quit his drinking habits.
Counseling
During counseling we made the patient more aware about the hazards of drinking
alcohol and its impact in family member and his future. We also counseled his family
members to have patience and to behave with him properly until his bad habits are
gone. Counseling was also done on the part of maintaining peace and harmony in the
family by understanding each other problems and trying to solve them collectively
and also to understand the state of mind of his son and act accordingly.

Conclusion
Alcohol dependence is a public health problem. It is also a social and economic
problem. It causes significant morbidity along with loss of prestige, finance, career.
Its incidence is increasing nowadays in our society and the early age group people are
being addicted to alcohol as seen in our case. Since this is a social and public health
problem, there is significant impact of the disease on the individual, family as well as
society and significant role of family and society in the causation, progression and
management of the disease.

CASE IV: STROKE (HEMIPARESIS)
Introduction
Cerebrovascular disease is the third most common cause of death in high income
countries after cancer and ischemic heart disease and the most common cause of
physical disability. It includes range of disorder of central nervous system. Stroke is
the most common clinical manifestation of cerebrovascular disease and result in
episode of brain dysfunction due to focal ischemia or hemorrhage.
Risk factors
A. Unavoidable risk factors
 Age
 Gender (male > female except at extreme of age)
 Race ( Afro-Caribbean> Asian > European
 Previous vascular event
• Myocardial infarction
• Stroke
• Periphery vascular disease
 Heredity
 High fibrinogen
B. Modifiable risk factors
 Blood pressure
 Cigarette smoking
 Hyperlipidemia
 Excessive alcohol intake
 Diabetes mellitus
Symptoms
 Dizziness, Difficulty in swallowing
 Black out, numbness and weakness that can cause complete paralysis
 Sudden and several headache
 Sudden loss of vision, Problem in balancing and coordination
 Difficulties in speaking understanding
Complications

The most common complication of stroke are:
 Brain edema: swelling of brain after stroke
 Pneumonia: cause breathing problem
This is very common after stroke or may be worsen in someone who had depression
before stroke.
Justification for the selection of case
Stroke is the third common cause of death in high income countries and Nepal is also
among the high risk country to develop the non-communicable disease like stroke in
future. The rate of stroke is in increasing order. It occurs due to poor physical
exercise, sedentary and consumption of high source of lipid and this problem is seen
in Nepal day by day. This may be future burden for our country. It causes both
physical and mental infirmity in the patient and his family. So we thought the case of
stroke would be relevant for our family health exercise, as a case of physical
disability.
Case History
Patient Profile
Name: Chandra Bahadur Chhetri
Age: 79 years of age
Sex: Male
Marital status: Married
Religion: Hindu
Address: Rambazar ,Pokhara
Education: N/A
Occupation: Retired Indian Army
Source: Khadka Kumari chhetri (Wife of the patient)
Reliability: Good
Chief Complaint
Unable to move right part of body.
According to the informant, the patient has been unable to function properly with
right parts of his body. Along with that, he has been suffering with episodic seizures.

He is under Foley’s catheterization and has been suffering from recurrent UTI. He is
also suffering from constipation for longer duration of time.
History of Past illness
He had a history of HTN about 15 years ago (not under medication right now). He
also had a history of fall injury 40 years back. He went through amputation of right
leg 40 years back due to frost bite. He mentioned that he had gone through a total of
11 surgeries till date but he couldn’t mention the specific name of the surgeries.
Personal History
He used to drink alcohol and smoke cigarettes 15 years ago and now he had stopped
taking since.
Family History
There is no history of tuberculosis, diabetes mellitus, hypertension and epilepsy in the
family.
Socio-economic status
According to the Kuppuswamy’s scale (1976), this family falls under middle lower
middle socio-economis class.
No any allergy history. He has been taking lactulose 20ml every 5 days for past few
years.
Nutritional status
Meal content: Oats, milk, potato and vegetables occasionally
Meat: Once or twice a month
Green vegetable/fruits: According to season
Drink cow milk daily
Drink about 1.5 liters of water daily
General condition
Vitals
 Pulse: 73/ min in left radial artery
 Respiratory rate: 18/ min in sitting position
 Blood pressure: 120/80 mm of Hg Temperature: 98.6^0 F
Cardinals

Pallor, Icterus, Lymphadenopathy, Cyanosis, Clubbing, Edema are absent and no
signs of dehydration were seen.
Respiratory system
Bilateral breath sound heard
Cardio-vascular system
1st (S1) and 2nd (S2) heart sounds were heard and no murmurs were present.
Neurological examination
Higher mental function was intact. Power at right shoulder, elbow, knee were
decreased in right upper and lower limbs, tone was normal.
Muscle strength grading: left hand: 4 and right hand: 2
Investigations
ECG and MRI was done and other investigations couldn’t be reported.
Diagnosis
Right sided hemiparesis secondary to left ischemic CVA with bowel and bladder
involvement with UTI.
TREATMENT
During hospitalization
 Inj. Pantop 40 mg iv BD
 Inj. Zydotum 1.5gm iv TDS
 Syp. Lactulose 20ml PO HS
 Syp. Osrovit 500mg 2.5ml PO OD HS
 Cap. Vit-d 1000d 1cap daily sublingual
 Whey-o-life 2 tsf PO TDS with 1 cup of milk
 Syp. Dj Citral 10ml in 1 glass of water PO TDS
 Tab. Clopid 75mg PO OD//S
 Tab. Rovastin 20mg PO OD
 Nebulisation with a:i:ns(1:1:2) 8 hourly
 Tab. Sonate 300mg PO OD
Advice at the time of discharge
 Physiotherapy for three month
 Maintain personal hygiene

 Watch Foley’s catheter and change the catheter timely
 Avoid spicy and fried foods

FAMILY VISIT

Location: Rambazar
Objectives
 To locate the house of the patient
 To build a positive rapport with the patient and his family members.
 To explain the family members about the purpose of our visit.
 To get to know the patient, family members, socio-economic status of
the family, social and cultural beliefs of the family and analyze how it
affects the health of the family.
 To observe the condition of housing, assets and sanitation using
observation checklist.
Activities
We got the contact number of the patient from OPD of Gandaki Medical College,
Pokhara.We arranged a meeting with his family via telephone contact. After reaching
the patient’s residence, we greeted and introduced ourselves to the family members.
The family provided us with a warm welcome. The patient and his wife were quite
cheerful and cooperative. We clarified them about the purpose of our visit and
discussed with them about their family, surroundings and analyzed about any possible
risk factors if any in relation to the disease. Our patient couldn’t talk properly so, we
mostly interacted with his wife. We interacted with her and asked as many questions
to meet the objectives of our visit. The observation checklist tool was used to evaluate
the housing condition, assets and sanitation. The discussion continued for about an
hour and then we informed them about our second visit. We thus met the objectives of
our first visit.
Outcome
Mr. Chandra Bahadur Chhetri is living in his own house, which is pakka type, having
five rooms. The house is attached side to side and has adequate setback. The rooms
are well ventilated, with cross ventilation & well lighted. They have a separate
kitchen and use LPG for cooking. They drink water from jar water. They own assets
like television, refrigerator, heater,mobiles and rice cooker. The rooms were well

furnished. The toilet was water shield type with pleasant odor. No cattle shed is
present around house. The sanitation of the house is satisfactory.
Family profile
The family is a nuclear family type with 11 members in total. He has two wife living
separately .He live with his second wife. Family composition and structure:
S.N Name/Relation with Age Education Occupation

patient
1. Chandra Bdr Chhetri 79 N/A Ex-army
2. Khadka kumari Chhetri / 69 N/A Housewife
wife
3. Chok Bdr Chhetri / son 38 SLC Business
4. Kalpana Chhetri / 36 SLC Business
daughter in law
5. Balaram chhetri / grand 15 Class 9 -
son
6. Khhusi chhetri / grand 17 class 12 -
daughter

Family genogram
79 69
(Pt’s Brother) (Pt’s Brother) (Pt’s Sister) (Pt’s Sister)
36 38
(Pt’s Daughter) (Pt’s Daughter) (Pt’s Daughter)
17 15

Index
Female:
Male :
Patient:
Dead male:
Dead female:
Married:

Observation Checklist
 Type of house: Pakka  Television  Toilet: Water

 Tenure : Owned  Refrigerator sealed and well
 Number of  Mobile maintained
rooms:5  Cooking  Odor: Absent
 Lighting :  appliances:  Flies: Absent
 Sufficient Present  Garbage waste
 Ventilation:  Furniture : well disposal site:
 Satisfactory furnished  Municipality

vehicle
 No. of windows per
room: 1  Source of water:
Tap water
 Kitchen exhaust:
Present
 Source of fuel:
LPG
The family belongs to upper middle socio-economic class according to Kuppuswamy
socioeconomic scale with a score of 23. At present there are 2 members (patient and
his wife) in the family living at their home. The main source of income is from
pension of the patient. They have a family house in Rambazar, Pokhara. The family
was well equipped with all the technological and entertainment facilities in the house.
All the family needs, requirements and demands were met without any kind of
difficulty. They have average income of 75,000 from patient’s pension. The family is
socially well respected and loved in the community. They do not have disputes with
the neighbors or their kinds.

Objectives
 To understand the role of the family in the causation of
disease.
 To understand the impact of the disease on the family.
 To understand the KAP of the patient and the care provider
regarding the disease.
 To assess the gender status of the family using specific
gender tools.
Activities
After a week of our first visit, we made a second visit in the family. This time we
were focused on the detailed discussion of the patient’s condition. We conversed
about the disease, the kind of impact it has caused on the patient and his family for
about an hour. We asked some closed questions to the patient’s wife to know the KAP
of the family regarding that particular disease and health seeking behavior of the
family. We asked her if he was dependent on anyone for his daily activities and got to
know that he was totally dependent upon his wife. Since he is a member of
independent living society he is well aware about all the limitations and complications
of his condition.
Outcome
Health seeking behavior and KAP about disease: The patient and the family members
are aware about his disease. The family do not believe in the traditional healers. They
seek help of medical professional in case of any illness. Compliance of the family to
medications and follow-up in health institution is satisfactory. They are satisfied with
the health facilities they have received.
Compliance
Patient is trying his best. He is being taken cared of very well by his wife. He is
compliant to the medications and intsructions which is given to him.

Impact of disease
On patient
Physical and psychological: Based upon our observation, it was found that the patient
was quiet affected by his disease. His inability to perform his daily activities might
have had an effect upon him. He seemed very happy when shown upon affection.
Lack of affection from his family member other than his wife has made an impact
upon him. The patient used to cry when shown upon affection by anyone.
On social relationship
His social relation seems to be alright. He is a well known person in his community.
His neighbors help him several times when needed. People came to visit him with
fruits and vegetables. On the other side he was unable to attend the social gatherings
and functions due to his illness.
On financial aspect
Economic burden doesn’t seem to be a problem for the family. Since the family
belongs to the upper middle class and the size of family being small there is no any
problems in the regard of money. He is not an outgoing person and doesn’t have any
extravagant expenses. Also he earns from his pension being sufficient for him and his
wife.
On the family
Physical and psychological: The patient family members were worried about the
condition of the patient. Patient’s family were aware about patient’s disease and the
situation. His wife has taken care of him and he is completely dependent upon her for
his daily activities. Psychologically, family seems to have coped well. His wife is the
one working hard to make the situation better. There is no significant economic
burden to the family. But due to hospitalization of patient, there is slight loss in
bothson’s business.
On The Community
The people living close to his house have nothing but sympathy and love towards
him. They often visit him, talk with him and make him feel that they are with him and
he is not alone. There is no any other significant effect on community.
Role of family on disease
Role in causation

Family and its eating habits have a huge role in causation of the disease. . At the time,
he was suffering from HTN and wasn’t focused on his diet. Family couldn’t
effectively take the measures to provide him with good and healthy diet suitable for
his condition. Excessive consumption of fatty food,red meat and high serum
chloesterol seem to be the precipitating causes.
Role in progression
The disease hasn’t progressed since discharge from hospital. But,patient has been
suffering from UTI now and then due to long term Foley’s Catherisation. Family’s
inablitiy to timely change the foleys catheterization seem to be the cause.
Role in relief
The patient’s wife has played an immense role in the relief process. Thus patient stay
in hospital for few days but his family provided him with physical, emotional and
psychological support all throughout this long run of life. His wife is the one to take
care of him at home, take him to the hospital and assist him in daily activities.
Encouragement, emotional support and a family environment filled up with love
helped the patient nurture her self-esteem, confidence and forget all the worries,
anxieties and stress.
Gender Analysis
Unlike a stereotypical Nepali family, the females in the family exercise a decisive role
in household undertakings. Our patient isn’t upon any family activities.

Table 6.3: Activity Profile
Activities Women / Girls Men / Boys
Source of income
Agriculture
Business
Employment 
Domestic chores
Water related
Collection 
Washing clothes 
Cleaning dishes 

Fuel related
Obtaining gas/ kerosene 
Cooking 
Taking sick to medical institute 

Buying medicine

Child care
Cleaning and maintenance task 
Budget allocation and 
marketing
(Activity profile shows the pattern of distribution of labor, and the burden of work each
sex has to bear. The values are either positive or negative, and the skewing of positive
values towards a particular sex shall imply that the respective gender bears a greater
burden of work than the other.) Here in this family the major work load is covered by
female.

Land/housing ++ ++ ++ +
Equipment ++ + ++ +
Labor and division of labor ++ + ++ +
Cash/economic resources ++ + ++ +
Education/ training ++ ++ + ++
Ownership + ++ + ++
Assets + ++ ++ +


Difference in number of + sign of 10 and more signifies poor gender situation. ) Since
the difference is less than 5; it signifies good gender situation.

Objectives
 To enquire about the improvement of the patient.
 To counsel the family members regarding the illness and importance of
compliance.
 To counsel the patient regarding the disease.
Activities
This was the last visit to the family. We greeted the family. They were still helpful
and cooperative. Prior to the visit we had reviewed our previous interview notes and
made a list of things remaining to be asked. We couldn’t be happier that our
counseling has had some positive effect on him. He was emotionally stronger.
Appropriate counseling was provided to the patient and family members. We also
encouraged the family members to not lose hope, and be supportive to him. We
expressed our sincere appreciation to the patient and his family for the hospitality they
showered upon us in these three visits. Finally, we bid farewell to the family and
departed wishing him good health and good luck for him future endeavors.
Conclusion
Disability cases are increasing day by day, mainly due to traumatic events, genetic
causes and infections during pregnancy and mal nutrition. As it is a disabling disease,
it needs the support of family and society along with the therapeutic interventions.
Emotional and psychological supports are the medicines of disability. A study based
on US has generated the fact that this cases is present about 2.3-3.6 per 1000 live
births. There is no forbidding of the fact that there is no cure for cerebrovascular
accidents but this condition can be assisted. The people can really be benefitted and
these individuals can live a long, healthy and quality life. Not only in Nepal but in a
global scenario disability has a huge impact upon the working hands of the nation.
They directly affect the economy of the country. Here in this case, lack of compliance
is also contributory to the causation of disease. Had the patient been on a healthy diet
and been taking his medication for hypertension regularly and doing proper checkup

and follow ups, this situation wouldn’t have come. So, compliance from the side of
the patient is really necessary in such kinds of diseases. So it is a disease of concern.

CASE V: CHRONIC KIDNEY DISEASE
Introduction
The term chronic renal failure applies to the process of continuing significant
irreversible reduction in number of nephrons, deterioration in renal function and
usually develops over a period of years. Initially, it manifests as a biochemical
abnormality leading to eventual loss of excretory, metabolic and endocrine functions
of kidney. This causes clinical symptoms and signs of renal failure, which is referred
to as uremia. When death is likely without Renal Replacement Therapy, it is known as
End Stage Renal Disease.
Stages of chronic kidney disease
Table 7.1: Stages of chronic kidney disease
CKD stage eGFR (ml/min/1.73m2) Discription
1 ≥90 Kidney damage with

normal or increased GFR
2 60-89 Kidney damage with mild

decrease GFR
3a 45-59 Moderate decrease in GFR
3b 30-44
4 15-29 Severe decrease in GFR
5 <15 End stage kidney disease
Risk factors and etiology
Risk factors that increase the risk of CKD even in individuals with normal Glomerular
Filtration Rate are as follows:
Table 7.2: Risk factors of CKD
Disease Proportion Comments

1. Congenital and inherited 5% e.g. polycystic kidney disease,
Alport’s Syndrome
2. Renal artery stenosis 5%
3. Hypertension 5-20%
4. Glomerular disease 10-20% IgA nephropathy (most
common)
5. Interstitial disease 20-30%
6. Systemic inflammatory 5-10% e.g. vasculitis, SLE
disease
7. Diabetes Mellitus 20-40%
8. Unknown 5-20%
Criteria for referral of CKD disease patient to a nephrologist

 eGFR <30ml/min/1.73m2
 Rapid detoriation in renal function (>25% from previous or

>15ml/min/1.73m2/year)
 Significant protein urea (PCR >100mg/mmol or ACR>70mg/mmol) , unless

know to be due to diabeties and patient is already on appropriate medication
 ACR >30mg/mmol with non visible hematuria
 Hypertension that remains poorly controlled despite atleast 4 antihypertensive

medications
 Suspicion of renal involvement in multisystem disease
• (PCR= Protein : Creatinine Ratio )
• (ACR= Urine albumin : Creatinine Ratio)

Clinical features
Table 7.3: Clinical features
Organ system Symptoms Signs

General Fatigue, weakness Sallow-appearing,
chronically ill
Skin Pruritus, easy bruisability Pallor, ecchymoses,
excoriations, edema,
xerosis
ENT Metallic taste, epistaxis Urinous breath
Eye Pale conjunctiva
Pulmonary Shortness of breath Rales, pleural effusion
Cardiovascular Dyspnea on exertion, retrosternal Hypertension,
pain on inspiration(pericarditis) cardiomegaly,
frictional rub
Gastrointestinal Anorexia, nausea, vomiting, hiccups
Genitourinary Nocturia, erectile dysfunction Isosthenuria
Neuromuscular Restless legs, numbness and cramps
in legs
Complication
 Anaemia
 Gout
 Bone disease and high phosphorous
 Heart disease
 High potassium fluid build up
Global Burden
Chronic kidney disease affected 753 million people globally in 2016: 417 million
females and 336 million males. The global burden disease 2015 study estimated that
1.2 million deaths(an increase of 32% since 2005) , 19 million disability adjusted life
years. The causes that contribute to the greatest number of deaths are high blood
pressure at 550,000, followed by diabetes at 418,000, and glomerulonephritis at
238,000. In 2010 an estimated 2.3-7.1 million people with end stage kidney diseas

die without access to chronic dialysis . In general, females have a higher prevalence
than males, especially in the middle-aged groups.
Status of Nepal
According to annual report 2074/75, Nepal conducted two kidney transplantations
from a brain dead donor for the second time in its history, and a total of 153 kidney
transplant were conducted in the FY 2074/75. According to research performed by
National kidney research center, Banasthali, Kathmandu 96 samples were collected
between 15- 31 October, 2012. The mean age of the patients was 47 years, with
almost half of the patients (46%) from 41-60 years age group. Among the patients, 65
% were male, 85% were married, 80% were literate, 57% were past smoker and 75%
were drinker and 59% were from Kathmandu valley. Likewise, most of them were
Newar, work as housewife as the main occupation. One third (37%) had to sell their
property for the treatment. On an average patient spent Rs.240000 per year in dialysis.
Similarly, medication cost was Rs.180000 and transplantation cost was Rs.500000 to
1000000.
A. Agent factor
Infections like leptospirosis, hanta virus, leprosy and malaria have been known to lead
to chronic kidney disease.
B. Host factor
• Sex: More prevalent in females.
• Age: May affect any age group, commonly seen in above 40 years of age.
• Familial risk: Greater risk in 1st and 2nd degree relatives.
• Race: African Americans and Asians have been found to have higher risk of
developing CKD.
• Pre-existing conditions: Diabetes mellitus, Hypertension, Glomerular diseases
C. Environmental factors

• Occupational exposure: Lead, cadmium, arsenic, mercury
• Drug induced: NSAIDs
Rationale for case selection
CKD is a global epidemic which is associated with high cost and financial burden to
patients, families and health system of any country. At the same time, CKD is also
associated with increased risks of cardiovascular diseases, premature deaths and
decreased quality of life. It has been found that identifying CKD in its earliest stage
could prevent disease progression and can lessen high medical costs.. As we know,
HTN and diabetes are two of the most prevalent non-communicable diseases in our
country and they have been pushing a greater population at risk for developing CKD.
We wanted to assess the role of the family in such condition and its impact on the
family. Therefore, we believed this case would provide knowledge on all the aspects
of FHE, as it is an emerging burden on public health.
Case details
Patient’s profile:
Name: Min Kumari Gurung
Age: 35 years
Sex: Female
Address: Amarshingh, Pokhara
Occupation: Housewife
Religion: Buddhist
Marital Status: Married
Education: 5 class
Reliability: Excellent
Chief complaints

Loss of consciousness for about 30 minutes.
According to the patient, she was asymptomatic 5 years back then suddenly one day
she lost her consciousness and fell down. She was then taken to Lamjung, Besisahar
hospital after symptomatic treatment she was referred to higher center where she was
diagnosed with CKD stage 5. Since then she is on dialysis twice a week. She also
complained of edema around leg and abdomen after hospital admission. The edema
had subsided 4 years back. Patient had no history of headache, vomiting, chest pain.
Past History
No significant past history. No surgical history or any accidents.
Family history
Her small brother is suffering from diabetes mellitus since 10 years and her mother
died due to sudden cardiac arrest.
Personal History
She consumes alcohol occasionally. She does not smoke or chew tobacco. She is a
non-vegetarian.
Allergic history
No known food or drug allergy till date.
Dietary history
Table 7.4 :Dietary table
Braekfast (1 or 2 boiled eggs and a cup 7:00 AM

of black tea)
Lunch (rice, daal, Vegetables) 10:00 AM
Tiffin (usually fried rice ) 3:00 PM
Dinner (rice, daal, vegetables and nonce 7:00 PM

a month boiled meat)

Menstrual history
Menarche at the age of 13.She has regular cycle and experiences dysmenorrhea.
LMP: 2076/08/29
Obstetric History
Age at marriage: 16 years
She has 3 child two living and had second child aborted at 8 month.
Gravida:0, Para:3, Living:2
Drug History
Table 7.5: Prescription
Tab. Prazosine hydrochloride 5 mg OD after food at morning
Tab. Amlodipine 5mg BD after food
Tab. Clonidine hydrochloride 100mcg BD after food
Tab. Alfacalcidole capsule 0.25mcg OD after food at evening
Tab. Pantoprazole 40mg OD before food
Tab. Calcium and Vitamin D3 500mg BD after food
General Condition
Patient is co-operative and well oriented to time, place and person. She is sitting up
with a fistula on her left hand.
General examination
Icterus: absent
Pallor: absent
Lymphadenopathy: absent
Cyanosis: absent

Clubbing: absent
Edema: no edema
Dehydration: absent
Vitals
Temperature: 96.3 °F
Pulse: 81 beats per min on right radial artery
Respiratory rate: 16/minute
Blood pressure: 214/117 mmHg on right arm (taken 1 day before dialysis)
CRT: 2 sec
Respiratory system
Bilateral equal expansion of chest
Mark of opening of vein on the neck for dialysis
Central placement of trachea
Normal vesicular breath sound heard without any added sounds
1st and 2nd heart sounds heard. No added sounds.
No tenderness and no local rise of temperature on superficial palpation. No

organomegaly.
Central Nervous system
CNS was grossly intact, no motor or sensory deficit in any part of the body.
Investigations: Could not be documented

Diagnosis
Chronic Kidney Disease Stage 5
Treatment
Dialysis twice a week (on tuesday and friday)

FAMILY VISITS
Objectives
 To locate the house, introduce ourselves and build rapport

 To explain the purpose of our visit and aims to the family
 To interview the head of the household in order to explore family background
 To collect data on physical facilities and socioeconomic conditions through
observation checklist
 To check the patient’s compliancy towards treatment and progress in health
status.
Activities
We met the patient during her dialysis at the hospital and took her daughter’s contact
number. So it was not difficult to find the location of the house as it was in
Amarshingh (on way to miapatan). The family members warmly welcomed us all. We
enquired about the wellbeing of the patient and if she was feeling well or not. Then
we explained the purpose of our visit. We asked about the family members, their
education and occupation. We assessed their housing and sanitation through our
observation checklist. After our objectives were fulfilled we returned describing them
about the second visit simultaneously.
Outcomes
Family profile
The family is a nuclear family with 3 members
S Name or relation with Age/ Marital Education Occupation

N patient sex status
1 Patient 40/F Married 5 class Home maker
2 Krishna Bdr Gurung / 41/ Married N/A Foreign

Husband M employment

3 Sunil Gurung/Son 8/M Single 2 class Student with
high ambition
Family genogram
40 41
(Pt’s Sister) (Pt’s Brother) (Pt’s Brother) (Pt’s Brother) (Pt’s Sister)
(Pt’s Son in law) (Pt’s Daughter)
Index
Male:
Female:
Patient:
Married:
Affected male:
Affected Female:
Table 7.7: Socioeconomic status score table
SN Component Score

1 Education of head of family 1
2 Occupation of head of family 2
3 Total monthly income of family 10
Total score- 10+2+1= 13
Socio economic class= Middle Lower Middle class (III)
 Type of house: pakka,  Mobiles phone: 1  Toilet: present

rented house.  Vehicles- none  Toilet type: water
 No. of rooms: 2  Cooking appliances: seal
 Lighting is not present  Septic tank: present
satisfactory.  Bed 1  Flies: absent
 Cross ventilation:  Mode of disposal of
absent household wastes:
 Smoke outlet in municipality
kitchen: absent. container
 Source of fuel: LPG  Source of water: tap
gas water
 Ditches around
houses: absent.

Objectives
 To know about the disease progression and compliance of patient towards

disease
 To evaluate the role of family on disease and impact of disease on family
 To know about health seeking behavior and Knowledge, Attitude and
Practices (KAP) regarding the disease
 To assess the gender status of family using gender analysis tools
 To learn about the patient's compliance and counsel them about the
importance of compliance in case of non-compliance (if applicable)
Activities
We went for the 2nd visit a week later. We explained the purpose of our second visit to
the patient and her family. This time we were focused on disease progression,
compliance, and role of the family in disease and effect of the disease on the patient
as well as the family. We also assessed gender status through access and control
profile, KAP of the patient towards the disease and explored the coping strategies of
patient and family members towards the disease. We found that the patient was
worried about her lifelong dialysis needed and its huge impact on their family and
daily lifestyle.
Outcomes
Compliance of patient with treatment
The patient follows the instructions and advice given by the doctor properly regarding
daily activities and lifestyle modification. She is taking her medications on time and
goes on dialysis twice a week at GMCTH.
Effects of family on the disease
Role in causation
The patient had pregnancy induced hypertension during her antenatal checkup of third
child. But after the delivery she didn’t went for a regular checkup and later on after 2
years she landed having CKD.

Role in progression
The family has played a vital role in progression of the disease. She was taken to
various hospitals for initial diagnosis. Her daughter had left her study to take care of
her mother. She stays on her mother house just to take care of her mother. She takes
her mother to the hospital for dialysis two times a week and Physiotherapy centre
every day. Her condition has improved since the dialysis, as she was unable to move
about in the past.
Role in relief
The patient was taken to many hospitals for diagnosis and treatment of her disease.
According to the patient, due to the caring nature, emotional support and
understanding of her family, she was being able to deal with her disease. Her daughter
takes her for regular follow-ups on time as well as for dialysis regularly.
Belief, customs, culture and religion
The family follows Buddhist religion. They visit private clinic or hospitals for every
disease.
Effect of the disease
On the patient
Physical: The patient was weak, fatigued and ill looking. She has a fistula on her left
hand. She is not very strong and is unable to walk for long time. As she has to go for
dialysis two times a week, it is really affecting her daily routine. Even to bath she is
dependent on her daughter. Due to these reasons, she is not able to work properly.
Psychological: The patient suffers from a chronic, irreversible disease. As a result, she
was very worried about both herself and for her husband and son and daughter also.
Due to her inability to work, she is frustrated and stressed out.
Economical: She didn’t contribute to the family before the disease but used to do
farming which provided basic food. But now they have to buy everything. She had
left her village Lumjung since 1 year for her dialysis. Her husband is also working in
foreign country just to manage expenses.

Social impact: Due to the necessity of regular dialysis twice a week, the patient had
left her village Lumjung since 1 year.
On the family
Her disease has caused a huge economic burden on the family. Although, she has
been receiving dialysis free of cost under the recommendation of Nepal Government,
she also requires other medication, blood transfusion and laboratory investigations
which amount up to 20,000 NRs per month. As she has to go to hospital twice a week
for dialysis, her daughter’s daily routine has also been affected, as he has to be there
for her most of the time. They are also very worried about the patient and are under
enormous stress.
Knowledge, attitude and practice and health seeking behavior
The knowledge, attitude and practices of the family are not satisfactory. They did not
know about the causation of her disease. But now as per doctor’s advice she follows
the medication and has brought changes to her dietary habits.
Gender Analysis
Activities Women/Girls Men/Boys Both

Breadwinner 
Sources of income 
Business 
Jobs 
Budget allocation 
Household chores 
Cooking 
Water related 
Water collection 
Washing clothes 
Cleaning dishes 
Marketing 
Health related activities 

Decision of health care 
Care during illness 
Taking sick to health care center 
Purchasing medicines 
Immunization of child 
Family planning 
Child care 
Maintenance tasks 
All the family members have adapted and are used to with their work. Her daughter
seems to do the household chores of cooking, cleaning and maintaining the house .As
her husband is in abroad, most of the works are done by her daughter like purchasing
medicine, taking her to hospital and caring her. So, the gender status in this family
seems unsatisfactory. The female member had to do everything on their own.
Access and control profile
Access Control
Particulars Women/girl Men/boys Women/girl Men/boys
s s
Land/Housing + ++ + ++
Labor and decision of ++ ++ ++ ++
labor
Cash/Economic resource ++ ++ + ++
Education/Training ++ ++ ++ ++
Ownership of assets + ++ + ++
Food/Shelter/Clothing
Access and control profile shows a difference of less than 5 (that is 2). So the gender
situation is good.
Note:
• Difference in number of + sign of less than 5 signifies good gender situation.

• Difference in number of + sign of 5 to 9 signifies satisfactory gender situation.
• Difference in number of + sign of 10 and more signifies poor gender situation.
Factors affecting disease process
Table 7.11: Factors affecting disease process
Particulars How does it affect the patient and the family

members?
ENVIRONMENT: Exposure The surroundings of the house has poor sanitation

to household/ occupational and unhygienic. The environmental impact is little
hazards significant in this case.
Age related As the age progresses, there is the high chance that
one can land to the renal diseases. Though the
patient is not such in extremes of age, other
various factors has predisposed her to the CKD.
Day to day activities and The patient is housewife and performs daily
responsibilities of men and household activities. Her day-to-day activities are
women significant for the causation of this disease.
Educational status and health Although the patient and her husband were
seeking behavior uneducated , they were not much aware of the
various risk factors and don’t have knowledge on
disease till she was diagnosed of CKD.
Economic status and its impact CKD is the disease requiring long-term dialysis.
on health Though at present she is doing dialysis under the
aid of Nepal Government, crisis situation may
appear in near future, as the cost of investigation
and medications has to be born by the patient’s
family themselves.
Gender norms and values in There is gender inequality in the family daughter
health and wife had to mange everything on their own
husband had only finanacial support. all the family
member are worried equally about the disease and

its consequences.
Access to and control over The control and access has no such significant
resources and the impact impact on disease process.
Perception of disease in the CKD is the disease requiring the lifelong dialysis
society and other social norms and renal transplantation is only the permanent
and values that affect disease solution for it. So people and other member of the
process society takes it as a devastating disease. But all
relatives and community people had the love and
affection towards the patient.
Access to information and its They are uneducated and had no access to the
impact modern equipment but after the diagnosis of
disease they have gained adequate knowledge on
the disease process.

Objectives
 To know about the progress of the disease over the period of time.
 To counsel the patient and family members and encourage them for
change, if necessary.
 To measure the effects of the second visit.
 To facilitate the recovery of illness if possible.
Activities
On our third visit we discussed about the further prognosis of the disease. We advised
the patient to consider kidney transplantation as she has her whole life ahead of her
and a transplant would increase her quality of life by a significant amount. We
thanked the family for their cooperation and wished them all the best for their future.
Outcomes
Counseling to the patient
The patient was not aware about the complications of CKD and its proper
management. We counseled her as well as her family about the dietary changes and
the importance of compliance of drug with at least 30mins exercise daily, regular
health checkup required for proper management of the disease. We also advised her to
stay emotionally and mentally strong, as the disease would require further effort and
management in future also. We also advised her to consider kidney transplantation, as
it would improve her quality of life. We also encouraged her family to steer the
patient towards a kidney transplant.
Conclusion
Chronic kidney disease is emerging as a major public health problem. With high
prevalence of DM and HTN, the two most important causes of CKD, the disease has
been on an increasing trend. However, preventing the emergence of risk factors such
as smoking, dietary habits, sedentary lifestyle and alcohol consumption can prevent
the disease.

CKD is a chronic condition, which requires lifelong medication and dialysis.
Although kidney transplant is an option, circumstances may not always allow it. Also
donor criteria are not easy to fulfill. Even if the patient goes for renal transplant, she
needs to be under prolonged immunosuppressive therapy. Hence this disease has
significant economic burden on the family. So the progression of disease and the
recovery, to a great extent, depends upon the health seeking behavior and the
economic condition and the support given by the family.

CHAPTER 3
Conclusion
The family health exercise is a descriptive and qualitative study. It was solely based
on in-depth interview and observation of patients and their families in their homes.
Tools such as interview guidelines, observation checklist and tools for gender analysis
were developed for this purpose.
After completion of the visits, we came to the conclusion that different aspects of the
family like socio-economic status, educational status, knowledge, attitude and
practice, customs and traditions have a great role in the causation, progression and
recovery from disease. Similarly, we also found out that disease can result various
impacts on the patient and his/her family. Family plays a great role in helping a
patient cope with his disease but a disturbed family may also play role in causation of
stress and certain psychiatric disease. The socioeconomic status has a major effect
regarding towards the proper treatment and thus plays a great role in determining
prognosis of any disease. Educated people have a pretty good knowledge of the
disease through which they or their family members are suffering and know about the
control and prevention majors as well.
To sum it all up we feel proud to have been a part of this exercise which helped us to
see beyond the individual, into to the family and its overall impact which remained in
dark side, unexplored and most often hidden behind the curtains. Any disease
however minor has a huge impact on the family of the diseased person.
And now here we all are, with our outlooks into disease having changed and ready to
take giant leaps towards being a better human being. We will always cherish the
golden moments and great experiences spent with the family which will always
inspire and motivate us to move ahead for the whole of our future. And all the credit
goes to the Department of Community Medicine as per to the curriculum for
organizing this exercise.
Recommendations
To the hospital
The hospital should provide some sort of identity like cards or tokens to avoid
inconveniences by patients to seek services made free for them in health care settings.

The free services allocated for the patient should be uniform in future years to come.
To the department of community medicine
The supervision and guidance was appropriately done by the department. If the
session of orientation would be more than we students would have clear vision about
our project work. The necessary tools like measuring tape, weighing machine etc.
should have been given to students for field works.

CHAPTER 4
Learning Reflections
1. Group dynamics
During our FHE, we learned how to work effectively in groups. We discussed
each and every case after field visits. Throughout this process, we got the chance
to develop our interpersonal as well as communication skills. Finally it was our
combined effort that made us capable to complete FHE effectively and
successfully.
2. An insight into social approach and patient counseling
It was our second time of community visit, the first one was done in the first year.
We got the chance to see the patient in their own habitat which is completely
different from the hospital scenario. We moved beyond the walls of hospital
(disease based approach) to community and learned to deal with each patient in a
social approach (person- person relationship). We learned how to counsel patient
to some extent and our supervisor Dr. Bimala sharma helped a lot, particularly
regarding this matter.
3. The picture of the burden
The illness presented to the hospital is completely different from that one in the
family or home itself. FHE had helped us know the real burden of illness related
to the patient, family and community as a whole which we couldn’t have learned
by studying text books.
4. To deal with the family which is in a state of psychological, physical and
economic stress
This exercise helped us realize that disease affects not only an individual but the
family as a whole. Along with the patient, the family as well suffers
psychologically, physically and economically. We counseled not only the patient
but also the family during our FHE.
5. A social stigma and the KAP that overrules it
Apart from the above mentioned points, the field let us know about the social
stigma of the disease and how the patient cope with the disease with respect to the
community and also about the behaviors of the neighbors and every other people
concerned regarding the disease. Self-medications and prevailing of faith healers

still now are worth mentioning.
6. The role of family in disease process and treatment including compliances
Family has an immense role in the recovery and relief process. With the proper
care and support from the family, healing process is accelerated while in absence
of it, the disease worsens.
7. Gender bias and its role in accentuation
Gender biasness is responsible for progression of particular disease like in mental
disease, where increased workload and stress in the family are the main factors.

BIBLIOGRAPHY
1. K. Park, Park’s Textbook of PREVENTIVE AND SOCIAL MEDICINE. 23rd

edition, 2015
2. Sir Stanley Davidson, Stuart H. Ralston, Ian D. Penman, Mark W. J. Strachan,
Richard P. Hobson, Davidson’s principles and practice of Medicine. 23rd edition,
2018
3. Kasper, Fauci, Hauser, Longo, Jameson, Loscalzo, HARRISON’S PRINCIPLES
OF INTERNAL MEDICINE. 19th edition
4. Government of Nepal, Ministry of Health and Population, Department of Health
Services, Annual Report 2074/75 (2017/18)

ANNEXES
Annex 1: Kuppuswamy Socioeconomic Status Scale
Table 8: Kuppuswamy socioeconomic status scale

A. Education of family head Score
Professional or honors degree 7
Graduate or postgraduate 6
Intermediate or diploma after high 5
school
High school certificate 4
Middle school certificate 3
Primary school or literate 2
Illiterate 1
B. Occupation Score
Professional 10
Semiprofessional 6
Clerical, shop owner, farmer 5
Skilled worker 4
Semi-skilled worker 3
Unskilled worker 2
Unemployed 1
C. Monthly income of family (in Score
Rs) 2017
41430 12
20715-41429 10
15536-20714 6
10357-15535 4
6214-10356 3
2092-6213 2
≤ 2091 1
Total score Socioeconomic class
26-29 Upper class
16-25 Upper middle class
11-15 Middle lower middle class
5-10 Lower upper lower class
<5 Lower class

Annex 2: Interview Guidelines
Family Profile
 Type of Family
 Number of Family Members
 Family and Relationship
Scio-economic Status
 Number of economically active people
 Sources of Income
 Loan/Mortgaging during economic need
Educational status of family members
 Formal or informal education
 Level of education
Health seeking behavior and KAP
 Care pattern of healer
 Belief in causation and treatment, Compliance
 High Risk Behavior
 Changes in belief pattern and cultural practices brought by disease awareness
 Life Style modification after awareness
Role of family and community on disease
 Role in disease causation and progression
 Role in relief, rehabilitation, cure and disease prevention
 The sick roles involved
Effect of disease on the patient
 Employment, Source of Income
 Disability/Handicap/Disfigurement
 Inter-personal and family relationships, social relations and community
behavior.
 Psychological and emotional, including self-esteem and confidence
 Changes in Health related KAP

Annex 3: Observation Checklist
Table 9: Observation checklist
 Type of house  Television  Toilet and its type
 Tenure  Refrigerator  Odor
 Number of rooms  Cooking  Flies

appliances
 Number of  Source of water
windows per room  Vehicle
 Waste
 Cross ventilation  Furniture management
 Lighting  Source of fuel
Annex 4: Gender Analysis tools

Table 10: Activity Profile
Activities Women/Girls Men / Boys
Source of income
Agriculture
Business
Employment
Domestic chores
Water related
Collection
Washing clothes
Cleaning dishes
Fuel related
Obtaining gas or kerosene
Cooking
Child immunization
Care during ill health
Taking sick to hospital

Buying medicines
Child care
Cleaning and
maintenance task
Budget allocation and
marketing
(Activity profile shows the pattern of distribution of labor and the burden of work
each sex has to bear. The values are either positive or negative and the skewing of
positive values towards a particular sex shall imply that the respective gender bears a
greater burden of work than the other.)

Table 11: Access and control profile
Access Control
Land/housing
Equipment
Labor and division of
labor
Cash/economic resources
Education/ training
Ownership
Assets
Basic needs
Food/clothing/shelter

Difference in number of + sign of 10 and more signifies poor gender situation.)

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A REPORT ON

FAMILY HEALTH EXERCISE- 2076

Department of Community Medicine

Gandaki Medical College, Pokhara

MBBS 7th batch, 3rd year

DECLARATION AND APPROVAL SHEET

S.N. Roll no. Name Signature

2 20 Binita Basnet (Leader)

3 21 Bom Bahadur Resmi Thapa

4 22 Chiranjibi Sharma (Co-leader)

QID Four times a day

CNR Case Notification Rate

FCHV Female Community Health Volunteer

Family health is a state of positive dynamic interaction between family members

Observation, interview, review of the records were employed as method to collect

Declaration and approval sheet.......................................................................................i

Table number Title Page number

Figure Title Page

2 Triple diagnosis technique of breast cancer 28

Table 1: Plan of action

GMC, 3rd YEAR GROUP D 1 | Page

Family Health Exercise

GMC, 3rd YEAR GROUP D 2 | Page

GMC, 3rd YEAR GROUP D 3 | Page

GMC, 3rd YEAR GROUP D 4 | Page

GMC, 3rd YEAR GROUP D 5 | Page

e) Review of Hospital records

h) Consultation with Group Supervisor

GMC, 3rd YEAR GROUP D 6 | Page

GMC, 3rd YEAR GROUP D 7 | Page

3. Physical Chandra 78/M Hemiparesis GMC Rambazar,

4. Psychoso Raj Gurung 26/M Alcohol GMC Kahunkhola

5. Case of Min Kumari 35/F Chronic GMC Amarsingh,

GMC, 3rd YEAR GROUP D 8 | Page

GMC, 3rd YEAR GROUP D 9 | Page

GMC, 3rd YEAR GROUP D 10 | Page

GMC, 3rd YEAR GROUP D 11 | Page

History of Present Illness

GMC, 3rd YEAR GROUP D 12 | Page

GMC, 3rd YEAR GROUP D 13 | Page

GMC, 3rd YEAR GROUP D 14 | Page

GMC, 3rd YEAR GROUP D 15 | Page

First Visit (2076/09/19)

GMC, 3rd YEAR GROUP D 16 | Page

Fig 1.1: Family genogram

GMC, 3rd YEAR GROUP D 17 | Page

 Type of house: Pakka  Television: 1  Toilet: water

GMC, 3rd YEAR GROUP D 18 | Page

GMC, 3rd YEAR GROUP D 19 | Page

Role of family in disease

GMC, 3rd YEAR GROUP D 20 | Page

GMC, 3rd YEAR GROUP D 21 | Page

Tool II: Access and control profile

(Difference in number of + sign of less than 5 signifies good gender situation.)

GMC, 3rd YEAR GROUP D 22 | Page

GMC, 3rd YEAR GROUP D 23 | Page

Risk factors and etiology

GMC, 3rd YEAR GROUP D 24 | Page

GMC, 3rd YEAR GROUP D 25 | Page

GMC, 3rd YEAR GROUP D 26 | Page

GMC, 3rd YEAR GROUP D 27 | Page

Suspicious Not suspicious

Fig 2: ‘Triple Diagnosis’ Technique