FHE Report - Group F

A REPORT ON
FAMILY HEALTH EXERCISE
Submitted to
Department of Community Medicine
Chitwan medical College
(Affiliated to Tribhuvan University)
Bharatpur, Nepal
Submitted by
MBBS 9th Batch, 3rd year
Group F
2078
DECLARATION AND APPROVAL SHEET
We the following students of MBBS 3 rd year/9th batch 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 F
– Roshan Raj Bhattarai (Leader) …………………..

– Serina Adhikari (Vice Leader) …………………..
– Gautam Shah …………………..
– Kishor Mainali …………………..
– Barsha Karn …………………..
– Dipesh Shah …………………..
– Sandeep Shah ………………….
– Suman Shah …………………..
– Ashutosh Jha …………………..
– Shristi Chaudhary …………………..
Date:
This report has been accepted and forwarded for final examination
……………………… …………………………..
Coordinator CBL Unit Head of the Department

Mr. Eak Narayan Poudel Dr.Niki Sherestha
Date Date
Department of Community Medicine and Public Health (Stamp)
Family Heath Exercise, MBBS 9th Batch/ 3rd year, Group F ii

ACKNOWLEDGEMENT
We would like to thank all those people who have helped us by giving their valuable time
and suggestions in exercising Family Health. We are equally thankful to the Department
of Community Medicine and Public Health (DCMPH) for providing the opportunity to
work in groups, to interact and build relationship with families and gain an in-depth view
of factors affecting the human health other than the clinical illness. It has been a great
learning experience for all of us.
We would like to express our appreciation and sincere gratitude to Dr. Niki Shrestha
HOD, School of Public Health, Department of Community Medicine and Public Health),
Mr. Eak Narayan Poudel (CBL coordinator).We would like to express our regards to our
field supervisor Associate Prof. Mr. Harishchandra Ghimire for guiding us during our
exercise through this expertise, valuable suggestions and encouragement. We are
extremely grateful to faculties of Department of Community Medicine, Mr.Subash
koirala, Dr.Mamta Chhetri, Dr, Sarbada Sherestha, Miss Amrita Poudel, and all the
faculties of Department of Community Medicine and Public Health for extending their
continuous support and Guidance during our field work.
We express our heartfelt gratitude to all the patients and their family members who were
kind enough to offer us their time out of their personal lives to make our family visit a
rewarding experience.
Lastly, we would like to thank each and every one who directly or indirectly helped us in
our Family Health Exercise.
Group F
9th Batch MBBS
Chitwan Medical College
Family Heath Exercise, MBBS 9th Batch/ 3rd year, Group F iii
SUMMARY
Health is a dynamic state of complete physical, mental and social well-being and not
merely an absence of disease or infirmity. In recent year, this statement has been revised
to include the ability to lead a “socially and economically productive life”. Family Health
is defined as “a state of positive dynamic interaction between family members which
enables each and every members of the family to experience optimal physical, mental,
social and spiritual well-being and not just merely the absence of disease or infirmity”.
In the present context, the role of the family physician has been emerging greatly to
increase consciousness regarding health related conditions. Family physicians deliver a
range of acute, chronic and preventive medical care services. In addition to diagnosing
and treating illness, they also provide preventive care, including routine checkups, health
risk assessment, immunization and screening test and personalized counseling on
maintaining a healthy lifestyle. Family physician also manages chronic illness, often
coordinating the care provided by other sub specialists.
Family Health Exercise is a follow up study of the illness of a person and analysis of,
how factors like his/her lifestyle, education, family environment, socioeconomic
condition, culture, belief, practice, health seeking behaviors, KAP regarding the illness
and other socio-psychological factors play role in the health of an individual and the
course and outcome of illness.
The objective of the family Health Exercise is to study the effect of family on health and
also the impact of an illness on the family as well as to analyze family health with gender
perspective.
Regarding the methodology for this study, we conducted interviews, reviewed patients
hospital records, took a thorough history and observe patients clinical status as well as the
patient’s surrounding environment.
As per our curriculum we selected five different cases. The cases we choose are as
follows:
Family Heath Exercise, MBBS 9th Batch/ 3rd year, Group F iv

Table No..1 List of case
No. Disease Category Disease
1 Infectious disease Dengue
2 Non-infectious Chronic Kidney disease
3 Differently able Paraperesis Secondary To CNS Vasculitis
4 Mental illness Persistent Depressive Disorder
5 Own choice Autism
Before we conducted any of our case studies, we first took consent from the patient and
their families and noted their contact information so it would be more convenient to get
in touch with them.
1. Dengue: For the case of infectious disease we selected a 50 years old female
from hospital, Dengue. She was diagnosed at Chitwan Medical College, Bharatpur.
Currently, she is on medication and there has been improvement in her health.
We had a wonderful time meeting all the patients and getting to know a little about their
life and their role in society. It was also interesting to see how a single disease has such a
widespread effect on not just the diseased, but also their family and their immediate
surroundings. At the same time, we were able to see different ways in which the family
had an impact on the course of the disease.
We group members presented all our cases in our Family Health Exercise presentation
held on 14th of Bhadra, 2078. It was good to review our information and it further added
to our knowledge about the disease. It also broadened the role of family dynamics and the
role of gender in different aspect of disease. We would like to thank the Department of
Community Medicine and Public Health for encouraging us to conduct this Family
Health Exercise which really helped us in understanding the role of family in the
causation, progression and relief of an illness and how the illness of the individual affects
the entire family.
Family Heath Exercise, MBBS 9th Batch/ 3rd year, Group F v

2. CKD: For non-infectious disease we choose a case of CKD in 33years old female
from hospital. She is now taking dialysis twice a week and assesses her blood creatinine
and urea level at regular intervals. She is well aware and conscious about the possibility
of acute as well as chronic complications of the disease.
3. Paraperesis Secondary to CNS Vasculitis: A 21-year-old male with CNS

Vasculits and paraperesis was taken from the community for the case of differently able.
The disease process started after an incident of Stroke 7 years back. With self-
determination, motivation and physiotherapy he has been coping up with his condition
and does his daily chores by himself.
4. Persistent depressive Disorder: 55 years old female Mrs Bishnu Maya Devkota,
married but separated, hindu by religion, housewife by occupation, presented with chief
complaints of depression with restlessness and loss of sleep for 2 months at Chitwan
Medical Teaching Hospital 2 years ago. She overthought every little situation and even
had suicidal thoughts. She takes medicine regularly and follow ups to CMC every 45
days. She is from lower middle-class family. The family is committed to maintain the
positive environment for her.
5. Autism: For the case of our own choice we selected a 14 year old boy from
community Autism. She was diagnosed at AIMS hospital, New Delhi. Currently, there
has been an evidence of persistent developmental disorder We had a wonderful time
meeting all the patients and getting to know a little about their life and their role in
society. It was also interesting to see how a single disease has such a widespread effect
on not just the diseased, but also their family and their immediate surroundings. At the
same time, we were able to see different ways in which the family had an impact on the
course of the disease.
Family Heath Exercise, MBBS 9th Batch/ 3rd year, Group F vi

We group members presented all our cases in our Family Health Exercise presentation
held on 14th of Bhadra, 2078. It was good to review our information and it further added
to our knowledge about the disease. It also broadened the role of family dynamics and the
role of gender in different aspect of disease. We would like to thank the Department of
Community Medicine and Public Health for encouraging us to conduct this Family
Health Exercise which really helped us in understanding the role of family in the
causation, progression and relief of an illness and how the illness of the individual affects
the entire family.
Family Heath Exercise, MBBS 9th Batch/ 3rd year, Group F vii
Table of Contents
Content Page
No
ACKNOWLEDGEMENT.................................................................................................iii
LIST OF ABBREVIATIONS............................................................................................xi
CHAPTER I..................................................................................................................... 1
1.1 Introduction................................................................................................................ 1
1.2 BACKGROUND.........................................................................................................1
1.3 OBJECTIVES............................................................................................................. 2
1.4 METHODOLOGY......................................................................................................3
1.5 PROCEDURE.............................................................................................................6
1.6 LOGISTIC MANAGEMENT......................................................................................7
CHAPTER II.................................................................................................................... 9
CASE 1:......................................................................................................................... 10
1: INTRODUCTION.......................................................................................................10
Global burden of dengue........................................................................................................11
Problem Statement in Nepal.....................................................................................................12
CASE STUDY:.........................................................................................................................18
History of Present Illness:.........................................................................................................19
General Physical Examination:.................................................................................................20
Systemic examination:..............................................................................................................21
Investigation:............................................................................................................................22
Treatment:.................................................................................................................................23
Family Health Diagnosis:.........................................................................................................23
Table No. 5- Family health diagnosis of Dengue......................................................................23
FAMILY VISITS.....................................................................................................................24
Second visit (2077/04/19).........................................................................................................29
Third visit: (2077/04/26)...........................................................................................................37
CASE 2:......................................................................................................................... 39
Problem statement....................................................................................................................41
Family Heath Exercise, MBBS 9th Batch/ 3rd year, Group F viii
B. JUSTIFICATION FOR SELECTION OF CASE.................................................................41
CASE STUDY.........................................................................................................................42
History of present illness:.........................................................................................................42
Investigations:.....................................................................................................................45
Family Visits.......................................................................................................................46
Family Profile...........................................................................................................................48
House Map:..............................................................................................................................50
Counseling................................................................................................................................59
Third visit(2078/4/27):..............................................................................................................60
CASE 3:....................................................................................................................................61
Persistent Depressive Disorder.................................................................................................61
Introduction..............................................................................................................................61
Epidemiological Factors:..........................................................................................................62
CASE PROFILE:......................................................................................................................65
History of present illness:.........................................................................................................65
Physical and Systemic Examination:........................................................................................68
Investigations:...........................................................................................................................68
FAMILY VISITS.....................................................................................................................69
Counselling...............................................................................................................................82
Third Visit (2072-9-22)............................................................................................................82
CASE 4........................................................................................................................... 84
Introduction..............................................................................................................................84
Causes.......................................................................................................................................85
JUSTIFICATION OF CASE:...................................................................................................88
CASE STUDY:.........................................................................................................................88
History of Present Illness:.........................................................................................................89
General Physical Examination:.................................................................................................90
Systemic examination:..............................................................................................................91
FIRST INTERACTION............................................................................................................93
Family tree................................................................................................................................94
Observation Checklist...............................................................................................................96
Family Heath Exercise, MBBS 9th Batch/ 3rd year, Group F ix

Table No. 27: Observation checklist secondary to CNS vasculitis............................................97
SECOND INTERACTION.......................................................................................................98
Figure no 13: Family health and illness cycle.........................................................................100
THIRD INTERACTION........................................................................................................106
Counselling.............................................................................................................................106
CASE 5...................................................................................................................................107
INTRODUCTION..................................................................................................................107
Etiology..................................................................................................................................108
CASE STUDY........................................................................................................................110
Case Profile............................................................................................................................110
Birth history............................................................................................................................112
Physical examination:.............................................................................................................113
Second Visit............................................................................................................................125
Figure no 16: Family health and illness cycle.........................................................................126
Observation Table...................................................................................................................131
1. Activities and control profile..........................................................................................131
Table No. 34 Activity table.....................................................................................................131
Table No. 35 Access and control profile.................................................................................132
Table No. 36 Factors affecting disease process.......................................................................132
THIRD VISIT.........................................................................................................................133
❏ Activities.........................................................................................................................133
Outcomes :..............................................................................................................................134
❏ Conclusion......................................................................................................................134
CHAPTER III.........................................................................................................................134
CONCLUSION AND RECOMMENDATION......................................................................135
3.1 CONCLUSION.................................................................................................................135
3.3 Learning Reflections.........................................................................................................136
BIBLIOGRAPHY...................................................................................................................138
References..............................................................................................................................138
ANNEXES.............................................................................................................................139
Interview Guidelines and tools...............................................................................................139
Family Heath Exercise, MBBS 9th Batch/ 3rd year, Group F x

List of table
Table No. 1: List of case
Table No. 2: Table of Abbreviations
Table No. 3: Data collection tools and techniques
Table No. 4: Family health diagnosis of Dengue
Table No. 5: Kuppuswamy’s Scale for Dengue patient family
Table No. 6: Observation table
Table No. 7: Impact on family
Table No. 8: Impact on patients for Dengue family
Table No. 9: Activity profile for dengue family
Table No. 10: Access and Control Profile
Table No. 12: Stages of CKD
Table No. 13: Family Visit
Table No. 14: Kuppuswamy’s socioeconomic status scale of CKD patient family
Table No. 15: Observation Checklist for CKD family
Table No. 16: Assessment of disease impact
Table No. 17: Assessment of disease impact on family
Table No. 18: Gender analysis for family
Table No. 19: Access and Control profile for family
Table No. 20: Factor and their impact on family
Table No. 21: Socioeconomic status
Table No. 22: Family visit for persistent depressive disorder
Table No. 23: Kuppuyswamy’s Socioeconomic status scale for depressed patient family
Table No. 24: Observation Checklist for Persistent Depressive disorder
Table No. 25: Gender analysis
Table No. 26: Access and Control
Table No. 27: Factors affecting disease process (health related issues)
Family Heath Exercise, MBBS 9th Batch/ 3rd year, Group F xi

Table No. 28: Family visit for Paraperesis Secondary to CNS Vasculitis
Table No. 29: Kuppuswamy’s status scale of Paraperesis secondary to CNS vasculitis
Table No. 30: Observation checklist secondary to CNS vasculitis
Table No. 31: Gender Analysis
Table No. 32: Control Assess profile
Table No. 33: Control Assess profile
Table No. 34: Family Visit for Autism family
Table No. 35: Kappuswamy socioeconomic scale for autistic patient family
Table No. 36: Observation table for Autism family
Table No. 37: Activity table
Table No. 38: Access and control profile
Table No. 39: Factors affecting disease process
Family Heath Exercise, MBBS 9th Batch/ 3rd year, Group F xii
List of Abbreviations
Table No.. 2 Table of Abbreviations
ANC Antenatal Care
BD Twice daily
CMCTH Chitwan Medical College and Teaching Hospital
CNS Central Nervous System
CVA Cardio Vascular Accidents
CVS Cardio Vascular System
CKD Chronic Kidney disease
DM Diabetes Mellitus
DoHS Department of Health Services
FHE Family Health Exercise
GB Gall Bladder
HTN Hypertension
ICU Intensive Care Unit
IHBD Intra Hepatic Biliary Duct
Family Heath Exercise, MBBS 9th Batch/ 3rd year, Group F xiii
KAP Knowledge Attitude Practice
LPG Liquefied Petroleum Gas
MBBS Bachelors in Medicine and Bachelors in Surgery
PHC Primary Health Care
PKU Phenylketonuria
SPHCM School of Public Health and Community Medicine
TB Tuberculosis
TD Tetanus toxoid
UV Ultra Violet
WHO World Health Organization1
Family Heath Exercise, MBBS 9th Batch/ 3rd year, Group F xiv
CHAPTER I
1.1 Introduction
Family is a group of individuals with a continuing legal genetic and/or emotional relation.
-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, epidemiology unit in
all societies.
-Park textbook of Preventive and Social Medicine
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 just
merely the absence of disease or infirmity.
The family Health Exercise is incorporated into the curriculum of MBBS program in the
second phase, 3rd year of the Tribhuvan University.
The family Health Exercise is designed to enable the students to understand the social,
psychological and economical aspects of illness; the interactions of ill person with the
family members and the community. It helped us in perceiving the role of the family in
the progression and cure of disease and to understand the natural history of disease.
We, the students of MBBS third year are grateful to the Department of Community
Medicine and family Health for providing us with such a self-directed learning exercise
which helped us to look beyond the doors our Hospital based teaching and incorporated
in us the feeling of becoming family doctors for the community.
1.2 BACKGROUND
This report is a result of Family Health Exercise of Group F, MBBS 9th Batch, Chitwan
Medical College, Chitwan in the year 2078 B.S. Family Health Exercise is an integral
part of the curriculum for the MBBS third year students of Tribhuvan University. This
exercise aims to study the determinants of health and disease at the family level.
Family Heath Exercise, MBBS 9th Batch/ 3rd year, Group F 1

This report includes five cases of different diseases: an infectious disease (Dengue), a
non-infectious disease (CKD), a psychosomatic disorder (Persistent chronic depression),
differently able (CNS vasculitis with paraplegia) and a disease of choice (Autism).
The information was mainly collected through family visits and medical records. The
details of the methodology will be described in the respective topics.
Each of the cases will be described under the following sub headings:
 Introduction: This section provides brief introduction to the disease under
consideration, its epidemiology and rationale for selecting the case.
 Case Profile: It includes the characteristics of the patient.
 Overview of the illness: It includes case history, significant findings on physical
examination, significant laboratory findings, treatment history, follow up and
compliance.
 Family profile in connection to the illness: It encompasses the overview of the
various characteristics of the family with the analysis of their role in health, causation,
progression of the disease and recovery. It also includes the effect of the disease on the
various aspects of the family health.
1.3 OBJECTIVES
General objectives
 To study the effects of family on health of an individual and the impact of an
illness on the family.
 To analyze family health with the gender perspective.
Specific objectives
 To know the detailed history of the disease in the patient.
 To ascertain the various factors in the family which directly or indirectly affect
the health of an individual and to determine the association between those factors.

 To assess the psychological and economic burden of the disease on the patient
and his/her family members.
 To differentiate the nature of the problem while seeing the patient in the family
from the nature of same problem when the patient is seen in clinic or hospital.
 To assess the KAP of the patient and his/her family members regarding the
disease, its prevention and management.
 To assess the gender status in the family and effect of gender status in decision
making on health related issues.
 To counsel and motivate the patient for bring change in Knowledge, Attitude and
Practice if necessary and to regular follow up as necessary.
1.4 METHODOLOGY
Study Design
This is a Case-study based on retrospective patient record examination, concurrent
history taking and examination and follow up in their respective family. Number of
qualitative and quantitative techniques and tools were used for case study, they are as
follows:

Table No.. 3 Data collection tools and techniques
Objective Field Respondent/ Data collection Tools for
site Source of data Technique Data
Collection
To collect clinical House Patient record Record review Record
and treatment file Guideline
history of the
patient
To collect patient Patient/ Family In-depth Interview
history House Member Interview Guideline
To collect patient Clinician/nurse Key informant Interview
treatment plan and House Patient interview Guideline
other details on Respondent
follow-up and
prognosis
Objective Field Respondent/ Data Collection Tools for Data
Site Source of data Technique Collection
To collect data on House Household head, Observation and Checklist
household household interview in
demographic, environment households,
socio economic neighbours and
environment and neighbourhoods
facilities, gender
and its facets for
recovery and help
from family
members
To collect the data House Family In-depth In-depth

on interaction members/patient Interview Interview
among family Guideline
members and
coping strategies
of the family
towards disease
To collect data on House Patient/care Interview and Format
belief system and taker prescription
compliance of review and
treatment and observation of
progress health medicine taken by
patient
To collect House Family members Group discussion Guideline
activities, process,
resources, care
seeking practices
and perception of
health services,
cultural,
behavioural and
cost of treatment
etc.
Examination the House Patient Physical Sphygmomano-
patient Examination meter
And Stethoscope
Anthropometry Measuring Tape
Jerk Hammer

1.5 PROCEDURE
FHE was conducted using the case study design according to the curriculum.
 ORIENTATION: (2078/04/03 - 2078/04/08)

During the orientation classes we were informed about the purpose of family health
exercise and given the guidelines to carry out the exercise. There were some special
classes regarding the gender analysis.
 LITERATURE REVIEW:
During the orientation classes we were provided different materials helpful for the family
health exercise, preparation for presentations and report writing. We studied different
books on clinical medicine and public health and consulted senior’s reports as well.
 GROUP DIVISION:
Altogether 10 groups were formed as per the direction of Faculty member. Our group
consisted of 10 members.
 CASE SELECTION:
Five cases having five different types of illness were selected:
1. Case of infectious disease (Dengue)
2. Case of non-infectious chronic disease (CKD)
3. Case of Mental illness (Chronic Persistent Depression)
4. Case of physical disability (CNS Vasculitis And Paraperesis)
5. Case of our choice (Austism)
 REVIEW OF HOSPITAL RECORDS:

Knowledge about clinical history, examination, investigation and treatment details have
been obtained from the patient.

 FAMILY VISITS
Following the address and the 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, its impact on the family and information regarding
gender perspective in family. The third visit included counseling, answering any queries
put forward by family and thanking the family for giving their time.
 CONSULTATION WITH GROUP SUPERVISOR

We constantly were in touch with our supervisor and he guided us in each and every step
of Family Health Exercise. He was with us in our second and third visit, interacting and
even counseling our patient.
 CASE ANALYSIS
All our group members discussed each and every case and compiled all the relevant
information for our report.
 REPORT WRITING
We tried to make a comprehensive report on our Family Health Exercise encompassing
all the information and analysis we acquired.
 CLASS PRESENTATION
We presented all the cases in the class in front of faculty members of DCMPH and our
class mates on 2078/08/18
1.6 LOGISTIC MANAGEMENT
During the entire course of our family visits, it was really challenging for us to manage
time for our clinical postings, theory classes and allocate time for family visit in different

families. We, all the group members, collected fund and used it while preparing the
report. Our group arranged the transportation fare needed during our visit to the families.
We also managed cost for tools (like questionnaire, observation checklist, gender analysis
tool) and the report for printing.

CHAPTER II
In this chapter, we have discussed about our five different cases focusing on case
selection, detailed case history, impact of family on disease, impact of disease on family.
Table No.-4: Different cases focusing on case selection
Name of Age Sex Diagnosis Case Address Mobile No

Patient identified
From
Kamala 35 Fem CKD Hospital Bharatpur 17 9806879972
Devkota ale
Fulmaya 50 Fem Dengue Hospital Bharatpur 10, 9809239459
Rai ale Hakim
Chowk
Amrit 14 Male Autism Community Bharatpur 9845365770
Khanal 11,Aroma
School
Chowk
Kausal 23 Male CNS Community Bharatpur 10, 9862546536
Kafle Vasculitis with Dhungana
Paraplegia Chowk,
Bishnu 58 Fem Persistent Community Gaidakot 6, 9845368448
Maya ale Depressive Bharatpur
Devkota disorder
The name of the patient is changed.
CASE 1:

Dengue
Source Wikipedia
Figure no 1: Aedes aegypti spreading Dengue
1: INTRODUCTION
Dengue is a mosquito-borne viral disease that has rapidly spread in all regions of WHO
in recent years. Dengue virus is transmitted by female mosquitoes mainly of the
species Aedes aegypti and, to a lesser extent, Ae. albopictus. These mosquitoes are also
vectors of chikungunya, yellow fever and Zika viruses. Dengue is widespread throughout
the tropics, with local variations in risk influenced by rainfall, temperature, relative
humidity and unplanned rapid urbanization.
Dengue causes a wide spectrum of disease. This can range from subclinical disease
(people may not know they are even infected) to severe flu-like symptoms in those
infected. Although less common, some people develop severe dengue, which can be any
number of complications associated with severe bleeding, organ impairment and/or
plasma leakage. Severe dengue has a higher risk of death when not managed
appropriately. Severe dengue was first recognized in the 1950s during dengue epidemics
in the Philippines and Thailand. Today, severe dengue affects most Asian and Latin

American countries and has become a leading cause of hospitalization and death among
children and adults in these regions.
Dengue is caused by a virus of the Flaviviridae family and there are four distinct, but
closely related, serotypes of the virus that cause dengue (DENV-1, DENV-2, DENV-3
and DENV-4). Recovery from infection is believed to provide lifelong immunity against
that serotype. However, cross-immunity to the other serotypes after recovery is only
partial, and temporary. Subsequent infections (secondary infection) by other serotypes
increase the risk of developing severe dengue.
Dengue has distinct epidemiological patterns, associated with the four serotypes of the
virus. These can co-circulate within a region, and indeed many countries are hyper-
endemic for all four serotypes. Dengue has an alarming impact on both human health and
the global and national economies. DENV is frequently transported from one place to
another by infected travellers; when susceptible vectors are present in these new areas,
there is the potential for local transmission to be established.
Global burden of dengue
The incidence of dengue has grown dramatically around the world in recent decades. A
vast majority of cases are asymptomatic or mild and self-managed, and hence the actual
numbers of dengue cases are under-reported. Many cases are also misdiagnosed as other
febrile illnesses.
One modelling estimate indicates 390 million dengue virus infections per year (95%
credible interval 284–528 million), of which 96 million (67–136 million) manifest
clinically (with any severity of disease) [2]. Another study on the prevalence of dengue
estimates that 3.9 billion people are at risk of infection with dengue viruses. Despite a
risk of infection existing in 129 countries [3], 70% of the actual burden is in Asia.

The number of dengue cases reported to WHO increased over 8 fold over the last two
decades, from 505,430 cases in 2000, to over 2.4 million in 2010, and 5.2 million in
2019. Reported deaths between the year 2000 and 2015 increased from 960 to 4032.
This alarming increase in case numbers is partly explained by a change in national

practices to record and report dengue to the Ministries of Health, and to the WHO. But it
also represents government recognition of the burden, and therefore the pertinence to
report dengue disease burden. Therefore, although the full global burden of the disease is
uncertain, this observed growth only brings us closer to a more accurate estimate of the
full extent of the burden.
Problem Statement in Nepal

The first dengue case was reported from Chitwan district in a foreigner. The earliest cases
were detected in 2005.Since 2010, dengue epidemics have continued to affect lowland
districts as well as mid-hill areas. This trend of increased magnitude has since continued
with number of outbreaks reported each year in many districts- Chitwan, Jhapa, Parsa
(2012-2013), Jhapa, Chitwan (2016-2016), Rupandehi, Jhapa, Mahottari(2017), Kaski
(2018) and Sunsari, Kaski, Chitwan (2019). The mostly affected districts are Chitwan,
Kanchanpur, Kailali, Banke, Bardiya, Dang, Kapilbastu, Parsa, Rupandehi, Rautahat,
Sarlahi, Saptari and Jhapa, reflecting the spread of the disease throughout the Teraiplains
from west to east. In 2011, 79 confirmed cases were reported from 15 districts with the
highest number in Chitwan (55). During 2012 -15, the dengue cases still continued to be
reported from several districts but the number fluctuated between the years. In 2019, we
experienced the outbreak at Sunsari (Dharan), Chitwan(Bharatpur) and Kaski (Pokhara)
and since then the number of cases are increasing till 2020. The number of reported
dengue cases has significantly increased from 3424 in FY 2075/76 to 10808 in F/Y
2076/77. The major cause of increasing the reported case is the impact of dengue
outbreak in Nepal. The majority of cases have been reported from Chitwan, Kathmandu,
Rupandehi and Kaski.

Epidemiology
1) Agent :
 Dengue virus , an arbovirus (flavivirus)
 4 serotypes are present i.e. DEN-1, DEN-2, DEN-3 and DEN-4
 All serotype produces same illness.
 Multiple infections with different serotypes lead to severe form of dengue : DHF/DSS
2) Host factor
a) Age : affects all age but children are more affected but children usually have milder
disease than adult
b) Sex : Female are more prone
In contrast to other infections it is more common in well-nourished children
3) Environmental Factors
a) Climate: hot climate of tropics region (terai region of Nepal )
b) Vector : two vectors known :
i) Aedes aegypti : principal vector , breeds in standing water .
ii) Aedes albopictus: Some Southeast Asian countries
c) More clustering in urban and semiurban areas
Mode of transmission
 Vector transmission through the bite of infected Aedes mosquitoes.
 The aedes mosquito becomes infective by feeding on a patient from the day before onset
to 5th day of illness .
 An extrinsic incubation period in mosquito = 8 to 10 days
 Once a mosquito becomes infective , it remains so far life.
 Transovarian transmission


Cycle of transmission
Virus transmitted to human in mosquito saliva after mosquito bite
Virus enters the WBCs and lymphatic tissues and reproduce inside the cells while they
move throughout the body
Virus released and circulation in blood and release chemical / biological mediators
causing plasma leakage and bleeding manifestation
Second mosquito ingests virus with blood
Virus replicates in mosquito mid gut and other organs, infects salivary glands
Virus replicates in mosquito salivary gland

Incubation period: 2 – 7 days
Clinical Features:

Source
Wikipedia
Figure No. 2- Clinical Manifestation of Dengue
1. Undifferentiated fever
-simple fever undifferentiated from other viral infections.
2. Classical dengue fever
-sudden onset of high grade fever with chills and rigor
-intense headache, muscle and joint pain
-retro orbital pain, photophobia, extreme weakness, anorexia, constipation, colicky
abdominal pain, rashes (may be maculopapular or scaralatiniform)
3. Dengue hemorrhagic fever
-infection with more than one dengue virus

-double infection with dengue virus – 1st infection sensitize the patient while the second
appear to produce immunological catastrophe.
-abrupt onset of high grade fever, facial flushing, headache
-Hemorrhagic manifestation – any of following may be present:
 petechiae, purpura, ecchymosis
 epitaxis, gum bleeding
 Haematemesis/melena
 -positive tourniquet test is the most common haemorrhagic manifestation.
 -hepatomegaly
 -feature of shock absent.
4. Dengue shock syndrome

 feature of shock present (i.e. rapid and weak pulse, dangerously low blood pressure, cold
and clammy skin and restlessness)
 resulting in bleeding, low levels of blood platelets and blood plasma leakage
Treatment
There is no specific treatment for dengue fever. Fever reducers and pain killers can be
taken to control the symptoms of muscle aches and pains, and fever.
 The best options to treat these symptoms are acetaminophen or paracetamol.

 NSAIDs (non-steroidal anti-inflammatory drugs), such as ibuprofen and aspirin
should be avoided. These anti-inflammatory drugs act by thinning the blood, and in a
disease with risk of hemorrhage, blood thinners may exacerbate the prognosis.
For severe dengue, medical care by physicians and nurses experienced with the effects
and progression of the disease can save lives – decreasing mortality rates from more than
20% to less than 1%. Maintenance of the patient's body fluid volume is critical to severe

dengue care. Patients with dengue should seek medical advice upon the appearance of
warning signs. These are:
 severe abdominal pain

 persistent vomiting
 rapid breathing
 bleeding gums
 fatigue
 restlessness
 Blood in vomit.
Justification for case selection:

a. Satisfies the criteria for “communicable disease”
b. Case was easily available from the hospital and we had keen interest to learn the case.
c. Dengue has high prevalence in Chitwan district
CASE STUDY:
Case Profile:
A. Patient Profile
 Name: Ful maya Rai (Name of patient is changed)

 Age: 50 yrs
 Sex: Female
 Marital Status: Divorced
 Address: Bharatpur 10
 Occupation: Housewife

 Education: upto 3 class
 Religion: Christian
B. Family Profile
 Type of Family: Nuclear

 No. of Family Members: 7
 Head of the Family: Elder son
 Source of Income: Elder son’s job
C. Case History
Chief Complaint:
 Fever for 2 months
 Headache for 10 days
 Vomiting for 5 days

History of Present Illness:

According to patient she was apparently asymptomatic 2 months back when she develop
fever on/off for 2 months and continuous for last 5 days, acute in onset , high grade ,
documented maximum up to 102 F , continuous in character , diurnal variation with
maximum in evening , associated with chills and rigor and body pain that last until
medication was taken.
She also complained of headache 15 days back which was severe throbbing, frontal and
retro-orbital in location, last until medication was taken, no any aggravating and relieving
factor, not associated with photophobia, nuchal rigidity
She also complained of vomiting 5 days back, 10-15 episodes, non-projectile, containing
food particles, non-bile stained and non-blood stained.

No history of abnormal body movement, altered sensorium, cough, shortness of breath,
chest pain, abdominal pain, altered bowel movement, urgency, frequency, burning
micturition and rashes.
Past Medical History:

She is a diagnosed case of diabetes mellitus for which she is taking medication and is
well controlled.
History of COVID positive on 2078/01/31 moderate in severity.
No history of Hypertension, Thyroid disorder, Tuberculosis and Malignancy.
Personal History:
She does not smoke nor drink any form of alcohol. She doesnot take betel nut and had no
history of substance abuse. She had normal bowel and bladder habit. Her appetite was
normal.
Family History:
No history of Hypertension, Thyroid disorder, Diabetes mellitus and Malignancy in her
family
Drug history
She has been taking antidiabetic drugs for 1 year.
Allergy history
There was no significant drug allergic history till date.
Socioeconomic history:
She lives in rented pakka house of rooms with separate toilet and kitchen. House is
adequately lighted and ventilated. Source of drinking water is government water supply
and good sanitation is maintained around home.

General Physical Examination:
She looks alert, well oriented to time, place and person. She is medium-built in
appearance. Pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema and signs of
dehydration were absent.
Vitals:
 Temperature: 98.8 F, recorded from right axilla.

 Pulse: 72 beat per minute at right radial artery. It is regular of normal volume and
character. There is no radio-radial delay or radio-femoral delay. All her peripheral pulses
are palpable.
 Respiratory Rate: 15 breaths per minute, which is abdomino-thoracic. There is normal
periodic breathing. There is no use of accessory muscles.
 Blood Pressure: 130/90 mm of Hg on right brachial artery, measured in sitting position.
Systemic examination:
1. Respiratory:
a) On Inspection:
• Chest was elliptical shaped and bilaterally symmetrical.
• Both sides moving equally with respiration.
• There are no scars marks present.
b) On Palpation:
• Symmetrical movement of chest
• Tactile fremitus was equal on all lung fields
• Trachea was centrally placed

c) On Percussion:
• Lung fields were resonant.
d) On Auscultation:
• Normal breath sounds.
2. Cardio-Vascular System:
• First and second heart sounds heard with no murmurs.
3. Abdomen:
a) On Inspection:
• Umbilicus was central in position
• All quadrants moving equally during respiration
• No surgical scar
• All hernial sites intact.
b) On Palpation:
• Superficial palpation: No tenderness in any quadrant
• Deep palpation: No organomegaly.
c) On Percussion:
• No fluid thrill present
• No shifting dullness is present
d) On Auscultation:
• Three to four bowel sounds heard per minute

Investigation:
She was gone through
1. Complete blood count : Hb = 10.4 gm/dl
Neutrophils = 80%
Platelet = 132000/cumm
2. Liver function test : Gamma GT : 137.36 IU/L
Total protein: 4.7 gm/dl
Albumin: 2.55 gm/dl
AST: 172 U/L
3. Malaria parasite serology : negative
4. Thyroid function test : normal
5. CRP : 70.74
6. Serum Pro calcitonin : 4.05 ng/ml
7. Anti-Dengue virus , IgM : 1.1 sample index
8. SAR-CoV-2 : negative
9. Ultrasonography : normal scale
Treatment:
Currently, she is under the following medications:

1. Tablet Acyclovir 800mg per oral 5 times a day for 7days
2. Pregabalin capsule 75mg per oral 2 times a day for 7 days
3. Ointment mupirocin locally applied 2 times a day for 7 days
4. Syrup Lactulose 30ml per oral at bed time for 7 days
5. Tablet calcium carbonate with vitamin D3 500mg per oral once a day for 30 days
6. Capsule multivitamin 1 capsule per oral once a day for 1 month
7. Tablet Tranexamic 500 mg per oral three times a day for 5 days

Family Health Diagnosis:
Table No. 5- Family health diagnosis of Dengue

Family Visit Date
First visit 2078/04/12
Second visit 2078/04/19
Third visit 2078/04/26
FAMILY VISITS
First Interaction (2075/06/11)

Objective:
 To introduce ourselves to family.

 To explain them about the purpose of our visit.
 To gather some basic information regarding family profile, housing, environmental,
economic and cultural factors.
Activities:
 Rapport building with the patient and family

 Explained the purpose of our visit to the patient
 Enquired about the present status of the patient
 Observation and enquiry about family profile
 Observation for housing and environmental factor for causation and progression of
disease.

Outcomes
We got the information of the patient from hospital. We did our first visit in her home..
After brief introduction, we talked in detail regarding her experiences during the course
of illness and other health related behavior. We discussed about the diagnosis,
transmission, the impact of disease in patient’s life and family life, her approach for
treatment and new challenges in her life. We came to know about their family and role
for causation of disease which are explained below in brief
Family Profile

 Head of the Family: Her elder son
 Source of Income: Her elder son’s income
Family Tree
Figure no 3: Family Tree of this family

Family members and relations
The family is socially respectable in the community .They have good understanding and
mutual cooperation between family members and between them and community too.
Housing and environment.

She has a cemented type of house which is well ventilated and lighted. The house is 1
storied with common kitchen and 3 bedrooms. There are 2 windows in each room. In
kitchen, LPG gas is used for cooking. They use government tap as the source of drinking
water and water is drunk directly without filtration or boiling. They have water-sealed
latrine attached to the house. They have a small kitchen garden just sufficient to grow few
leafy vegetables.

4. Economic status (According to kuppuswamy’s socioeconomic status scale)
Table No. 6: Kuppuswamy’s Scale for Dengue family
S. NO PARAMETERS SCORE
1 Education of head of the family 5
2 Occupation of head of the family 5
3 Income income of head of family 10
TOTAL 20
- Belongs to upper middle class Family
Source of income
Her elder son’s job and other son’s job are the main source of income for the family. Her
elder son works abroad, one of the son is a driver and one work as a mechanic.
Expenditure
In addition to daily household expenses, they need to pay for rent of house and education
of her younger daughter. They also spend money on patient treatment, fooding, housing
materials, clothes and so on making a total of RS 25,000- 30,000.
4. Educational Status
She is uneducated. Her elder and other two sons studied up to class 12. Her younger
daughter is studding in class 11.
5. Lifestyle and Food Habits

They buy some items of food from market while some items are grown in their own field.
They eat general Nepalese food and sometimes meat. Special food is consumed in special
occasions and festivals. They wear good clothes. Furniture of house is sufficient to
accommodate their family and one or two visitors. Overall they have a satisfactory
hygiene regarding their work.
6. Cultural and belief systems
They are Christian by religion and celebrate all major festivals.

Observation Checklist
Table No. 6: Observation table
Observations Yes No
Own house √
Rented house √
House type Cemented(pakka) type with wooden door and windows
Rooms
Observations Yes No
Number 4
Ventilation √
Sunlight √
Kitchen
Ventilation/Exhaust √
Energy Source for cooking LPG
Toilet 1, modern, clean
Cleanliness
Around the house √
Of the diseased person √
Water
Source Tap water
Sufficiency √
Treatment of drinking water Directly without filtration or boiling
Waste disposal Proper method of waste management
Vehicles √
Electronic Appliances T.V., Radio, 1 mobile phone each

Pets √
Yard/Lawn √
Helpers/Servants √
Second visit (2077/04/19)
Objectives:
• To observe and enquire about gender status in the family.
• To enquire and observe about the health of family and personal habits, health seeking
behavior, KAP and disease impact on family and patient.
• To counsel the patient and her family members about life style modification

Activities:
• Enquiry about improvement of the patient.
• Observation and enquiry about gender status in the family.
• Enquiry and observation of health of family and personal habits, health seeking
Health Seeking Behavior and KAP:

Whenever someone get sick in the family their acute response is to take that family
member to nearby hospital. They do not believe in traditional healers. Though she is
uneducated , she regularly visits hospital for any illness. She has good knowledge about
her illness and has maintained the lifestyles and dietary habits accordingly. Her family is
quite aware of dangers of her disease. They are quite compliant and do regular follow ups
in CMC. She is aware about course and complication of her disease.
EFFECT OF FAMILY ON DISEASE:

Role in causation:
No significant role of the family was found in the causation of the disease. However, the
poor nutritional status, poor sanitation and sleeping without bed net might have played a
role in the disease causation.
Role in progression:
Patient did not seek medical advice immediately after the appearance of the symptoms
like fever headache, vomiting for about a week and this played a considerable role in
progression of dengue in the patient.
Role in recovery:

Family played an important role in recovery of the patient. They took good care
regarding food, rest and medical care during her illness.
Family role in health promotion and risk reduction:

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

There are no adverse factor that would aid in disease onset and relapse.
Family’s beliefs about illness

They believe on allopathic as well as Ayurveda medicines.
Family decision about health care:

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

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

After diagnosis of her disease, her family started to take precautions like using bed nets,
mosquito repellant, wearing full sleeve clothes and increased regular hospital visits. Her
diet is also well modified and adjusted.
Impact of disease in family, patient and society

Table No. 7: Impact on family
Effects on the routine of family It has not hampered any of other family
members Members physically and
psychologically.
Economic burden There was economic burden due to
Direct as well as indirect cost as she had to
stay in intensive care unit for a week and
one earning member had to stay with her.
The drugs were expensive too.
Social effect The society have positive and helpful
attitude towards the diseased and the
family. They offer to provide help and
support when needed.
Care of the diseased The family is concerned about her diet,
medications and follow ups.
Impact on patient:
Table No. 8: Impact on patients for Dengue family
Inability to perform normal daily She can walk and perform normal daily
activities Activities without support.
Employment and status No effect on employment status.

Family relation Not affected. Her family members
support her and provide enough care and
affection.
Social relation She has been isolated until she become
perfectly well.
Self-esteem and confidence She seems emotionally strong.
On the society:
They have developed helpful attitude towards the patient and family.
GENDER ANALYSIS:
The patient son has access over the property. All the household works are performed by
her daughter. The female members are respected in the family. There is no gender
discrimination in the family. Both men and women have equal access to resources
1. Activity profile
Activity profile for dengue family

Table No. 9: Activity profile for dengue family
Activities Women Girls Men boys
Production activities  
Agricultural works 
Income generation 

activities
Employment 
Others   
Reproductive activities   
Water related  
Fuel related  
Health related activities 
Child immunization   
Care provider during   
illness
Taking the sick to the  
hospital
Buying medicine   
Cleaning  
Repair  
Access and Control Profile

Particulars Access Control

Boys/ women/ Men/boys Women
men girls /
girls

Land    
Equipment    
Labour    
Cash    
Education/training   
Outside income    
Assets income    
Basic needs    
Foods/clothing/    
Shelter
Education    
Political power/   
Prestige

Factors How does it affect?
Exposure to household/ occupational No any significant impact.

hazards
Age related As the patient is getting older and older

day by day her immune system is
getting weaker too.
Day to day activities and No any significant impact.

responsibilities of men and women.
Educational status and health seeking After the development of disease, proper
behavior health seeking behavior and KAP about
the disease has halt the progression of
disease.
Economic status and its impact on They are middle class family. So, no any
health economic barrier for seeking healthcare.
Gender norms and values in health There is no gender discrimination and

all the family members are taken to
hospital when they are sick
Access to and control over resources No significant impact because there is
and the impact. proper access to resource.
Perception of disease in the society and Because of the family’s request, we

other social norms and values that didn’t inquire other people in the
affect disease process. community.
Counseling
We advised them to sleep under net, take medicines as per prescribed and adopt a habit of
exercising regularly. We counseled them about the consequences of not following
prescription properly and counseled them for timely intake of drugs and regular
assessment of the disease condition. We asked the patient to avoid stress.
As a whole, we counseled them in following aspects:-
1. Prevention of vector borne disease
 Sleeping under nets.

 Wear full sleeve clothes.
 Spraying of insect repellant in and around house.
 Prevent collection of water in ditches, unused tires, flower vase etc.
 Keep environment clean.
2. Exercise
 perform daily activities as usual

 morning exercise or walk for 30 min 5 days a week
 participation in daily household and social activities
3. Stress
 Meditation
Third visit: (2077/04/26)
Objective:
 Reviewing any missed information in prior visits.

 Enquiry about improvement on patient.
 Counselling and recommendations.
Activities:

 We enquired about the improvement of the patient.
 We encouraged the patient to go for regular checkups.
 We informed the patient regarding the importance of taking the medications regularly.
We advised her to take mixed diet , fruits, whole grain, lean protein and healthy fat and
also do regular exercise, as it can boost energy, decrease stress and strengthen her
immunity.
 We finally thanked our patient and her family members for providing us a wonderful and
warm learning experience.
Outcomes
Third visit was to review our information and to add any if missing from the previous two
visits. We conducted counseling and answered few of the queries put forward by the
other members of the family related to the disease. The patient is found to be concerned
about taking medicine regularly. Although they knew few thing about the transmission
and preventive measures of dengue, we educated them about the rest of the factors, which
encourages disease progression (for example, proper nutrition). We counseled them to
maintain proper sanitation, housing environment and adopt other preventive measures.
There was improvement in her health status and dietary habits. Her confidence level and
self-esteem was increased at the time of third visit. The family members were aware as
well as concerned about the patient and her illness and were willing to improve the health
condition of the patient by regular intake of medications and adopting proper preventive
measures.
Conclusion:
Dengue is a tropical disease and currently a problematic global infection. All the agent,
host and environmental factors that we observed played a significant role in development,

progression and impact of disease on the patient as well as the family. This case provide
us with first-hand knowledge about how this disease is not merely a result of an infection,
but is the result of culmination of environmental and social factors as well.
CASE 2:
CHRONIC KIDNEY DISEASE

Source Wikipedia
Figure No.5 Kidney with Chronic Kidney Disease
A.INTRODUCTION
Chronic kidney disease refers to an irreversible deterioration in renal function which

classically develops over a period of years. It is defined as the kidney damage lasting for
at least three months as characterized by structural and functional abnormalities of the
kidney with or without decreased GFR. The disease is more common among old aged
people. CKD is divided into five stages based on the level of GFR estimated from level
of serum creatinine and height using the modified Schwartz formula:
Table 12: Stages of CKD

Stage GFR (ml/min/1.73 Description
s m2)
1 >90 Kidney damage with normal or increased
GFR
2 60-89 Kidney damage with mild reduction of GFR
3 30-59 Moderate reduction of GFR

4 15-29 Severe reduction of GFR
5 <15 or dialysis Kidney failure
Common causes of CKD:

 Diabetes Mellitus: Large racial and geographical differences.
 Hypertension
 Renal artery stenosis
 Glomerular disease: IgA nephropathy is most common
 Interstitial diseases
 Systemic inflammatory disease: e.g. SLE, vasculitis
 Renal hydro nephrosis
Clinical features
 General Symptoms : Malaise, weakness, fatigue

 GI disturbances: Anorexia, nausea, vomiting hiccups.
 Neurologic complications
 Peripheral neuropathy and
 Hyperkalemia
 Metabolic Acidosis
Problem statement
Chronic kidney disease (CKD) has been recognized as a leading public health problem
worldwide. The global estimated prevalence of CKD is 13.4% (11.7-15.1%), and patients
with end-stage kidney disease (ESKD) needing renal replacement therapy is estimated

between 4.902 and 7.083 million. Through its effect on cardiovascular risk and ESKD,
CKD directly affects the global burden of morbidity and mortality worldwide. The global
increase in this disease is mainly driven by the increase in the prevalence of diabetes
mellitus, hypertension, obesity, and aging. But in some regions, other causes such as
infection, herbal and environmental toxins are still common.
Chronic kidney disease (CKD) is a global health problem with estimate that it affects 8–
16% of the world’s population [1, 2]. It is a major public health problem in Nepal. It is
estimated that the prevalence of CKD is around 10.6% in urban areas of Nepal
B. JUSTIFICATION FOR SELECTION OF CASE

Hypertension and Diabetes mellitus are the common causes of CKD. As many families
are suffering from these two disease in our community, they may have the problem of
CKD. In Nepal, estimate showed that NCDs like CKD accounted for 39% of the total
countries disease burden and nearly half of all death is due to NCDs. Chronic kidney
disease is one of the most common cause of renal failure. Renal transplantation is not
affordable for the developing country like Nepal. There High economic burden to the
family due to the need of regular dialysis also. It is also a case of surgical emergency
(renal transplantation) and we wanted to assess the role of family in such emergency
condition and its impact on the family health that is why we chose this case as the case of
non-infectious disease.
CASE STUDY
Interview Guidelines and tools

1. Case Profile
1. Personal Identification:
a. Name of the patient: Kamala Devkota (Name of patient is changed)
b. Age: 33 years
c. Sex: Female
d. Address: Kesarbaag,Chitwan
e. Religion: Hindu
f. Occupation: Housewife
g. Date of admission to the hospital: 15th Bhadra,2073
h. Date of diagnosis
Chief complaints: Headache on and off for 1months

Edema of leg and face for 1week
Blurring of vision for 2 days
Vomiting for 1 day
History of present illness:

The patient was apparently well five years back when she started having intermittent
episodes of headache for one month. Headache was mild in severity intermittent in
character. There was no history of trauma. There were no exacerbating factors but was
relieved on rest. There were no associated factors as well.
Swelling of face and legs was observed for 1 week 5 yrs back which started from eyes
gradually developed in whole face then was observed in legs and abdomen.it was
associated with increased frequency of urination, urgency, increased volume of urination.

It exacerbated when exposed to cold temperature and increased consumption of water and
relieved by warmth.
Blurring of vision was observed for 2 days five years back which was bilateral and
associated with dizziness, fatigue and weakness. There was no history of any trauma.
One episode of Vomiting for 1 day five years back which was projectile in nature and
contained food particle and non-bullous.
Then she was admitted to emergency department of CMCTH on 15th of Bhadra, 2073
.She was kept in ICU for one and half months and was then shifted to ward for twenty
days. She was prescribed anti-hypertensive medication which she took for 1 year. After
one year of taking medications, she did not get any better and her dialysis was started.
Systemic Examination:
Respiratory System: no history of cough, shortness in breath, chest pain, change in voice
Cardiovascular System: no history of chest pain, epigastric pain, breathlessness,
palpitation,
GI system: no history of epigastric pain, vomiting, diarrhea, constipation, melena, ascites
Renal system: no history of fever, burning micturition
Central nervous system: no history of loss of consciousness, vertigo,
Menstrual history:

She had her menarche at 14 years. Her cycles are irregular. The duration of cycle is 2 to 3
days. She uses 2 pads per day. There was history of clots. There was no history of
dysmenorrhea.
Obstetric history:
She is married for eleven years. Her obstetric score is P3L3A1
Contraceptive History:
No method of contraception used till date.
Past medical and surgical history:

She is a known case of chronic kidney disease since last five years and is under
medication. Blood transfusion is done every 15 days and dialysis is done every 2 weeks.
She had history of tuberculosis and was under medication for 6 months .There is no
significant history of surgical intervention in the past.
Personal history:
She is non vegetarian by diet and drinks direct tap water without filtering it .Her sleep
and bowel habits are normal .She neither drinks alcohol nor smokes cigarettes.
Family history:
Her father has history of hypertension and asthma .There is no history of consanguineous
marriage.
Drug and allergy history:

She took anti-hypertensive medications for 1 year. There is no known allergy history
till date.

Physical examination:
Due to verbal communication through online platform physical examination was not
performed.
2) Family profile:
i. Family type: Nuclear

ii. Family size: 5
iii. Head of family: Father
iv. Total earning members: 1
v. Education status of each family members
vi. Application of family tree to demonstrate the family members:
Investigations:
Hematology
WBC: 9470/ cu.mm
Hb: 9.5gm/dl
Differential count:
Neutrophil: 74.6 %
Lymphocytes: 31 %
Eosinophil: 6.5%

Monocyte: 6.8%
Basophil: 0%
Diagnosis: CKD V with HTN
Treatment:
 Iron Polymaltose Complex & Folic Acid,1 tab per oral BD

 Amlodipine 5mg PO OD
 Prazosin hydrochloride 5 mg PO OD
 Clonidine 100mcg PO TDS
 Calcium supplement 500mg PO TDS
 Citicoline sodium 1500mcg PO OD
 Sodium bicarbonate 500mg PO BD
 Torsemide 20mg PO BD
 Vitamin B complex 1 capsule PO BD
 Pantoprazole 40mg PO OD
 Paracetamole 500mg PO as per needed

Family Visits
Table No. 13: Family Visit
No Visit Date
1 First visit 2078/04/12
2 Second visit 2078/04/19
3 Third visit 2078/04/27
First Visit(2078/04/12):
Objective:

 To explain them about the purpose of our visit
 To gather some basic information regarding family profile, economic, housing
and cultural factors
Activities:
 Rapport building with the patient and family.

 Explained the purpose of our visit to the patient.
 Enquired about the present status of the patient.
 Observation and enquiry about family profile.
Outcomes:

We met the patient in CMC hospital, Bharatpur, Chitwan. We had his father’s contact
number which made us easy to manage our meeting. We did our first visit in his home at
Gitanagar, Bharatpur.Chitwan. When we reached there all the members of the family
were happy to see us and they warmly welcomed us. After brief introduction we talked in
detail about his experiences regarding the illness and other health related behavior. We
discussed about diagnosis, the impact of disease in patient’s life and also in the family,
his approach for the treatment and new challenges in his life.
Family details:
a. No. of family members: 5

b. Type of family- Nuclear
c. Religion: Hindu
d. Dietary habits: Regular Nepali diet
e. Head of family: Patient’s husband
f. Occupation of family head: foreign employment
g. Economic status: Lower middle class
h. Chronic illness in family: Hypertension and Asthma in patient’s father.

Family Profile
Type of family: Nuclear
No. of economically active members: 1
Family Tree:
vii. Application of family tree to demonstrate the family members:

viii. Family Tree

Figure no 6: Family tree of chronic kidney disease patients
Family members and relations
The family is socially respectable in the community .they have good understanding and
mutual cooperation between family members and between them and community too.
Housing and environment:
They live in their own house, just beside the road. He lives in a single kachha type of
house, which is poorly ventilated and lighted. The sanitation is poor. They have a
common kitchen, 2 bed rooms. They use LPG as a source of fuel and tube well water
without purification as a source of water. They have a sanitary latrine far from the source
of water, almost 10 meters distance.

House Map:
Fig 7: House map
Economic status (According to kuppuswamy’s socioeconomic status scale)

Table No. 14: Kuppuswamy’s socioeconomic status scale of CKD family
1 Education 3
2 Employment 3
3 Income 4
TOTAL 10
- Belongs to upper lower class according to Kuppuswamy’s Scale
Source of income:
There is one active working member in the family who is in abroad for foreign
employment.
Expenditure:
In addition to daily household expenses, they need to pay for medicines, and

transportation cost. Income is insufficient for them.
Education status:
Our patient is illiterate, she had formal education but could not continue it. Her husband
is also illiterate. But her daughters are studying currently in class 7 and class 9.
Observation Checklist:
Table No. 15: Observation Checklist for CKD family
Observations Yes No

Own house √
House type Kachha house

Observations Yes No
Number 2
Ventilation/ Sunlight √
Kitchen
Ventilation/Exhaust √
Energy Source for cooking LPG
Toilet Separate 1 toilet
Cleanliness
Around the house √
Of the diseased person √
Water
Source Hand pump
Treatment of drinking No purification

water
Vehicles √
Electronic Appliances T.V, Radio, 1

mobile phones
Yard/Lawn √
Second Visit (2078/4/19)

Objective:
 To observe and enquire about gender status in the family.

 To enquire and observe about the health of family and personal habits, health
seeking behavior, KAP and disease impact on family and patient.
Activities:
 Enquiry about improvement of the patient.

 Observation and enquiry about gender status in the family.
 Enquiry and observation of health of family and personal habits, health seeking
Counseling
Outcomes:
Health Seeking Behavior and KAP
Whenever someone get sick in the family their acute response is to take that family
member to nearby clinic. They do not believe in traditional healers. she has regularly
visits hospital for any illness. She has good knowledge about her illness and has
maintained the lifestyles and dietary habits accordingly .Her family is quite aware of
dangers of his disease. They are quite compliant and do regular follow ups in Chitwan
Medical College and teaching hospital and dialysis twice a week.. He is aware about
course and complication of his disease.
EFFECT OF FAMILY ON DISEASE

Role in causation:
No significant role of the family was found in the causation of the disease.

The family members of the patient were found to be accompanying his most of the times
and providing supportive care. They are concerned about his dialysis schedule and
regular follow ups. They have reduced salt intake and are following proper diet.
Role in recovery:
Family played an important role in recovery of the patient. They took good care regarding
food, rest and medical care during his illness.
The family made medicines available at home and took him for dialysis twice a week.
And there was at least one member every time taking care of him. They were following
the strict dietary guidelines and the amount of water he should drink.
There is no role of family in disease onset and relapse.
Family’s beliefs about illness
They only believe on allopathic medicines.
The decision about health care is taken by his father and grandfather.
Whenever he feels discomfort or any health related acute problem, they immediately

took him to nearby health centers.

Family’s role in adaptation in illness and recovery:
The family is supporting and encouraging him physically, mentally and emotionally to
get rid of the disease. The family didn’t let him to work in fields
Assessment of disease impact
1. On the patient:
Table No. 16: Assessment of disease impact
Inability to perform normal She can walk and perform normal daily activities
daily activities without support.
Employment and status She is unemployed and do small household works.
Family relation Not affected. Her family members support her and
provide enough care and affection.
Social relation She is able to socialize and visit her friends,
acquaintances and engage in social activities.
Self-esteem and confidence She seems emotionally strong and confident.
2. On the family:
Table No. 17: Assessment of disease impact on family
Effects on the The family members have to reschedule their daily works to
routine of family provide extra care and to take him for regular checkups.

members
Economic burden There is economic burden because the family cannot afford the
treatment although dialysis is free of cost. They have to pay for
the medications and transportation.
Social effect The society has positive and helpful attitude towards the
diseased and the family. They offer to provide help and support
when needed.
Care of the diseased The family is well known about the disease condition of the
patient so they provide proper care and emotional support.
3. On the society:
The society is well aware about the disease and the fatal consequences of ignoring disease
condition. They have developed helpful attitude towards the patient and family. Because
of his illness, he is not being able to participate in the productive activities in the
community. Peoples of her community have collected fund and donated it to her family
to relieve their some economic burden.
GENDER ANALYSIS:
Table No. 18: Gender analysis for family
Activities Women Girl Men Boys
s
Income generating activities:
Employment √

Production activities
Reproductive activities √ √
Water related √ √ √ √
Fuel related √ √
Health related activities
Child immunization √
Care provider during illness √ √ √ √
Taking the sick to the √ √

hospital
Buying medicine √
Cleaning √
Repair √ √
Market related and others √
Access and Control profile for family

Table No. 19: Access and Control profile for family
Access Control
Men Wome Men Women

n
Resources

Land √ √ √ √
Equipment √ √ √ √
Labor √ √
Cash √ √ √ √
Training √ √
Benefits √ √
Outside income √ √
Asset ownership √ √
Basic needs
Food √ √
Shelter √ √
Clothing √ √
Education √ √ √ √
Political √ √
power/Decision
Table No. 20: Factor and their impact on family

Exposure to There is no any impact.

household/occupational
hazards

Age related Elder age group are more prone to diabetes and
hypertension
Day to day activities and No significant impact has been noted. She has been
responsibilities of taking rest from his daily activities and the family
men and women members have a sense of responsibility towards his
care.
Educational status and health It is satisfactory since she used to measure her blood
seeking behavior pressure and sugar levels once in two to three
months.
Economic status and its impact There is significant impact as the family is not able to
on health afford for the treatment till date
Gender norms and values in There is no significant impact as there is proper
health access for medical care for both genders.
Access to and control over No significant impact because there is proper access
resourses and the impact to the resources.
Perception of disease The patient and the family were aware enough about
the disease and its severe consequences if neglected,
which might have played a role in progression of the
disease.
Counseling
We counseled them about the consequences of not maintaining proper diet restrictions
and healthy recommended diet and counseled them for timely intake of drugs and regular
assessment of the disease condition. We counseled him to restrict the potassium rich diets
like banana, tomato, coffee etc and appropriate carbohydrate diet. Also counseled to get
plenty of rest and get more sleep at night and move around and bend your legs to avoid
getting blood clots when you rest for a long period of time.

Third visit(2078/4/27):
Objectives:
 To counsel the family members regarding the illness
Activities:
 Enquiry about the improvement of the patient.
 Counsel about the patient’s health and follow ups. We gave muffler to the
patient.
Outcomes:
When we reached her through video calls she was co-operative and was frank about her
illness. We counseled here to maintain his emotional strength strong enough like now.
We also asked whether our family health exercise visit and work was useful or not and
asked for the feedback of the family.
Conclusion
CKD is chronic noninfectious disease which has no permanent cure. Though the kidney
transplantation is considered as surgical treatment but it is not accessible to everybody.
Dialysis is only the way for the survival for CKD patient besides renal transplantation.
This disease has much economic burden in family. So the progression of disease and the
recovery, to a great extent depends upon the health seeking behavior, the economic
condition and the support given by the family.

CASE 3:
Persistent Depressive Disorder
Introduction
According to World Health Organization, worldwide it is estimated the prevalence of
Depression (including persistent depressive disorder/dysthymia) is approximately 12%.
The American Psychiatric Association defines Persistent Depressive Disorder as
 depressed mood most of the time for at least two years, along with
 at least two of the following symptoms: poor appetite or overeating; insomnia or
excessive sleep; low energy or fatigue; low self-esteem; poor concentration or
indecisiveness; and hopelessness.
In the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), Persistent

Depressive Disorder is defined as a serious state of depression, which persists for at least
two years (one year for children and adolescents). About 20–30% of depressive disorders
have a chronic course, and are associated with more severe health consequences and
poorer outcomes than non-chronic depression
Persistent Depressive Disorder symptoms usually come and go over a period of years,
and their intensity can change over time. But typically, symptoms don't disappear for
more than two months at a time. Symptoms of persistent depressive disorder can cause
significant impairment and may include:
 Loss of interest in daily activities
 Sadness, emptiness or feeling down
 Hopelessness
 Tiredness and lack of energy

 Low self-esteem, self-criticism or feeling incapable
 Trouble concentrating and trouble making decisions
 Irritability or excessive anger
 Decreased activity, effectiveness and productivity
 Avoidance of social activities
 Feelings of guilt and worries over the past
 Poor appetite or overeating
 Sleep problems
In children, symptoms of persistent depressive disorder may include depressed mood and
irritability. These signs may vary with individual; maybe hard to establish when the
complication develops in the individual.
In Nepal, a study conducted in three districts, Dhanusha, Dolakha and Bhaktapur shows
prevalence of 2% in children and 46% in adults. A significant percentage of this
population is unaware of the condition; thus, has never sought medical and psychological
attention.
Epidemiological Factors:
Predisposing factors:
1. Biological Factors:
a. Alteration in neurotransmitters:

-Serotonin, Epinephrine, Dopamine, Histamine, Acetylcholine
b. Neuroendocrine Dysregulation:
-Adrenal Axis, Thyroid Axis, Growth Hormone.
c. Genetics: Family History
d. Sex: Females> Males
2. Psychosocial Factors:
-Life events
-Dysfunctional Family Dynamics
-Learned Helplessness
-Limited Coping Mechanism
3. Remitting factors:
-Family care and support
-Psychiatric consultation
-Drug therapy
Problem Statement:
Global Burden:
In a study conducted globally on major depressive disorders, it has been found that the
number of incident cases of depression worldwide increased by 49.86% from 1990 to
2017. Only 6.3% of the patients with depression in 2017 had persistent depressive
disorder in 2017. The age-standardized incidence rate of persistent depressive disorder
varied widely among the 195 countries and regions in 2017, being highest in the United
States (0.26 per 1000), followed by Canada (0.25 per 1000) and Greenland (0.25 per
1000), and lowest in Colombia (0.13 per 1000), followed by Romania (0.15 per 1000)

and Panama (0.15 per 1000). The number of incident cases of persistent depressive
disorder worldwide increased from 10 million in 1990 to 16 million in 2017, representing
an increase of 58.98%. A WHO report predicted that major depressive disorder will
become the leading cause of disability in the world by 2030 (Yang et al., 2015), and
stated that controlling major depressive disorder is the best way to address depression.
National Burden:
In a study conducted on depressive and anxiety disorders in Nepal (1990-2017), it has
been found that Depressive and anxiety disorders were the predominant mental health
problems with higher occurrence among adults of 40-49 years. Inadequate education, low
income, personality traits, reduced social functioning, unhealthy lifestyle, and poor health
are some reasons for mental health issues. In contrast, high income countries have not
followed the pattern of our findings of depressive disorder burden increasing with age. In
young and adolescents, anxiety disorder has been increasing in Nepal and India. The risk
factors are low household income, gender discrimination, bullying, social media, family
history, temperament, and personality.
The persistent burden of depressive and anxiety disorders from 1990 to 2017 remains one
of the topmost causes of disabilities in the Nepalese population predominantly among
females. The burden varies by age, peaking in older adults for depressive disorders and
middle-aged for anxiety disorders. A comprehensive integrated social, environmental and
behavioral approach along with investment in mental health services to provide
affordable treatment, care, and rehabilitation is urgent and essential to address the
escalating problem of depressive and anxiety disorders in context of Nepal.
Justification for case selection:
a. Mental health issue is one of the most neglected and stigmatized cases in our society and
it is mostly affected by the family environment.
b. There are not enough studies conducted regarding persistent depressive disorder in Nepal.

c. A large percentage of a mental health issues is subclinical, unreported, or otherwise
hidden from view.
d. Satisfies the criteria for “psychiatric illness”
e. Plays a role in a substantial number of family conflicts, relationship difficulties and
domestic violence incidents.
f. Case was easily available from the community and we were interested to learn the case.
CASE PROFILE:
Name: Bishnu Maya Devkota (Name of patient is changed)
Age: 55 years
Sex: female
Religion: Hindu
Address: Gaindakot, Chitwan
Marital status: Married but Separated
Education: Uneducated
Clinical history:
At the time of visiting Chitwan Medical College Teaching Hospital 2 years back on
2076/02/11, the chief complaints were:
-Restlessness for 2 months
-Loss of sleep for 2 months
History of present illness:

The patient was in her usual state of health 2 months back before she visited Chitwan
Medical College Teaching Hospital when she started having restlessness and loss of sleep
that was insidious in onset and gradually worsening. The patient stated that she had
difficulty in initiating sleep and the length of sleep time was 3 hours per day usually in

the morning. The loss of sleep was associated with anxiety, palpitations, sweating and she
was suspicious that people are not faithful. For a few times she used to get out of the
house by herself and kept wandering aimlessly all day long and returned back during
evening.
The patient also developed suspicions about family members that they poisoned her food.
She also complained of something stuck in her throat. Gradually she also developed
suicidal tendencies.
No history of seizures, fluctuating consciousness or hallucinations.
Treatment history:
Her family visited Chitwan Medical Teaching Hospital when she began to develop
suicidal thoughts where she was diagnosed with Persistent Depressive Disorder and was
given oral medication:
Clonazepam p.o. 1 time in evening
Paroxetine HCL p.o. 1 time in morning
The condition of patient is stable at the present. She is feeling better still she says she is
dependent on medicine to fall asleep. She tries to keep herself away from unfavorable
situations. She has negative thoughts but can control them.
Past history:
The patient had no history of Thyroid disease, Diabetes Mellitus or hypertension.
She had an accident one year in which she suffered some injuries. Her 6 left ribs were
fractured which gave rise to difficulty in breathing. Her left hand was fractured for which
she had undergone surgery and intramedullary rod was placed in her fractured arm during
surgery. She also had some minor head injuries. Her breathing problem was subsided
upon recovery.
She had no previous history of psychiatric illness.

Personal History
She consumes mixed diet. She does not consume alcohol and tobacco. She is a past
smoker. She used to smoke 2-3 sticks per day.
Socioeconomic History
According to kuppuswamy scoring, she belongs to lower middle class family.She lives in
cemented house which is abundantly lighted and well ventilated. There are 2 bedrooms,
kitchen and separate toilet. The source of water is Tap and water is filtered before
drinking. The source of fuel is LP Gas.
Socioeconomic Status
No Parameters Score
1 Education 4
2 Occupation 3
3 Income 4
Total 11
Kuppuswamy’s Socio-economic Scaling of MR patient’s family is middle class
Menstrual History
She attained her menarche at the age of 12. She had regular menstrual cycle with a cycle
length of 28 days. She had her menopause at the age of 50 i.e. 5 years back.
Obstetric History:
She has 4 sons. She had no complications during pregnancies and her all sdelivery were
normal.

Family History
Her mother had similar problem of restlessness and loss of sleep 3 years back for which
she had taken medications for 1 year.
Physical and Systemic Examination:

Due to covid crisis, we were instructed to communicate with the patient through phone
calls and video calls only. As physical visits could not be conducted during this
pandemic, physical and systemic examination were not done and is excluded in this case
with the permission of Community Medicine Department of CMCTH.
Investigations:
 Hematology
o Hemoglobin: 11.6 gm/dl
o Platelet’s count: 2,30,000/mm3
o Neutrophil: 60 %
o Lymphocytes: 35 %
o Eosinophil: 03%
o Monocyte: 02%
o Basophil: 00%
 Biochemistry:
o Sugar random: 92.1 mg/dl
4) Thyroid Levels:
a. Free T3: 2.42 Pg/ml
b. Free T4: 12.49/Pg/ml
c. TSH: 1.29 mcIU/ml
Diagnosis: Persistent Depressive Disorder

FAMILY VISITS
Table No. 22: Family visit for persistent depressive disorder

Family visit Date Time Duration of each visit
First Visit 2078-04-13 3:30pm 2 hours
Second 2078-04-20 2 pm 1hour and 30minutes
Visit
Third Visit 2078-04-28 4 pm 1 hour
Dates of Family visit on Patient with MR
FIRST VISIT
Objectives
 To establish rapport with family members.
 To explain them about the purpose of our visit.
 To gather some basic information regarding family profile, family tree, economic,
housing and cultural factors.
Activities
 Rapport building with the patient and family.
 Explained the purpose of our visit to the patient.

 Enquired about the present status of the patient.
 Observation and enquiry about family profile.
 Construction of the family tree.
Outcomes
Family Profile
No of family members: 6
Type of family: Joint
Religion: Hindu
Dietary Habit: Regular Nepali Diet
Head of the family: Son
Occupation of the family head: Employee in Polymer Company
Economic Status: Lower Middle class family (According to Kuppuswamy scoring)
Family Tree
Figure no 8. Family tree of Persistent Depressive Disorder

The patient has been married but separated. She has 4 sons. Three of them are married
while one is unmarried. The patient lives with two sons; one of them is married and has a
son and daughter while another son is unmarried. Her sons are of 35 years and 30 years
while daughter in law is 24 years old. Her grandson is 5 years old and granddaughter is 3
years old. Her other two sons are also married and lives with her husband.
Socioeconomic Status
No Parameters Score
1 Education 4
2 Occupation 3
3 Income 4
Total 11
Kuppuswamy’s Socio-economic Scaling of MR patient’s family
She belongs to a lower middle-class family according to Kuppuswamy’s socio-economic
status scale. Her both son work in the water company as laborer and family income is
about Rs 20,000. They do not have any agricultural land and other income sources. The
patient herself does not contribute in income of the family. She is not educated. Her sons
have studied up to high school.
Housing and Environment

She lives in a rented house which is concrete, one storey houses. Doors and windows are
made up of wood with three rooms (2 bed room and a kitchen). Whole area is clean and
well maintained. Kitchen is separate. They use LPG gas as a source of fuel. All the rooms

are well ventilated with 1 ventilator in each room. There is 1 bathroom outside the house
(10 meters away), water sealed and clean. They use tap water for drinking with treatment
of drinking water. Waste materials are collected by government solid waste disposal
servicers. They possess a scooter, T.V. and each member of the family has their own
mobile. They do not have pets, yard and helpers/servants.
Figure no 9: House map for Persistent depressive disorder

Table No. 24: Observation Checklist for Persistent Depressive disorder
Observation Yes No
Own house √
Rented house √
House type Concrete House
Rooms
Number 3
Ventilation √
Sunlight √
Kitchen
Ventilation/Exhaust √
Energy Source for cooking LP Gas, fire woods
Toilet 1 toilet at a distance of 10 meters from house
Cleanliness
Around the house √
Of the diseased √
Water
Source Governmental tap water
Treatment of drinking √
water
Waste disposal √
Vehicles √
Electronic Appliances Television, mobile
Pets √
Yard/Lawn √
Helpers/Servants √
Expenditure

They spend money on patient treatment, fooding, housing materials, clothes and so on
making a total of RS 15000-18000 per month.
Educational Status
Patient is not educated. Her sons and daughter in law has studied up to high school. Her
grandson studies in school.
Lifestyle and Food Habits

They buy food item from market as they do not have agricultural land and are not
involved in agriculture. They eat general Nepalese food and sometimes meat. They wear
normal clothes. Furniture of house is sufficient to accommodate their family but not for
one or two visitors. Overall, they have a satisfactory hygiene regarding their work.
Cultural and belief systems

They are Hindu by religion and celebrate all major festivals.
SECOND VISIT (2074-06-25)

Objectives
To observe and enquire about the gender status in the family.
To enquire and observe about the health of family and personal habit, health seeking
behavior, KAP and disease impact on family and patient .
To have general examination of patient, simultaneously with other enquiry, if he/she
complaints of any illness.
Activities
 Enquiry about improvement of the patient.
 Observation and enquiry about gender status in the family.
 Enquiry and observation of the health of family and personal habit, health seeking
behavior, KAP and disease impact on patient and family.

Outcomes:
Religion and Belief:
She is Hindu by religion and celebrates all festivals. Her mother believes in faith healers
like Dhami/Jhakris. The family also believes in Homeopathic and modern Allopathic
medicine. Family prefers hospitals and the health institutions when anyone is sick.
Health Seeking Behavior and KAP:
Her son and brother are well aware about the patient’s health condition; they have no
hesitation in seeking best health care available. They visit Chitwan Medical Teaching
Hospital and other private hospitals for any illness. She is looked after by her son, brother
and other relatives.
Patient’s compliance towards medication/treatment:

Her son and brother give her the medicine routinely as prescribed by the doctor. Her
medication routine is known to both her son and brother. She is mostly being cared by
her son. She has good support from family.
Role of family on Disease:

I. Role in causation:
Her husband got married to other woman which has played crucial role in her illness. Her
condition worsened when she got separated with her husband. After splitting of family,
she began to develop trust issues and now her condition worsened along with
development of suicidal thoughts.

II. Role in progression:
After her husband’s second marriage, there has been a lot of disputes in the family. She
often had to deal with family disputes and being introvert in nature, she could not share
her feelings with anyone which ultimately led to the progression of disease.
III. Role in relief:

The brother of the patient was found to be accompanying her most of the times and
providing supportive care, so he played the major role in improvement of her health
condition, at the same time her son has also played a significant role. Tender love and
care by the family is a lot better than just pills for relief of a patient, especially in
psychiatric case. The family in her case is very supportive and caring.
IV. In vulnerability and disease onset:
The patient’s mother suffers from similar illness so there might be the genetic
predisposition of the illness.
V. In illness appraisal:
Her family understands her illness and is very supportive to her illness.
VI. In acute response:
She was brought to the hospital after appearance of suicidal tendencies.
VII. In adaptation to illness and recovery:

She is helped to adapt to her illness by constantly observing her activities and taking care
of her.
VIII. In health promotion and risk reduction:
Her brother and son bring her to the hospital for monthly follow ups and keeps track of
her medication regularly.

Source Google
Figure 10: Family health and illness cycle
Effect of the disease

I. On individual
Physical:
No physical harm was seen. However, the patient would not eat food and wander all day
long which would make her family stressed.
Psychological:
Because of her deteriorating health condition, she tends to develop suicidal tendencies
and trust issues.
Social:
She does not like attending gatherings and social meetings. She often feels stigmatized by
the society regarding her health condition.
II. On family
1. Economy: There is financial burden due to the disease condition. They often have to
arrange money from others for patient’s checkup.
2. Family relations: They have adapted to live with her mental status and hence try to
provide positive environment for her and also encourage to get herself engaged. One of
the family member’s times is invested in taking care of her.
Gender Analysis:
The gender status in the family is satisfactory. Males have control over property and cash
but females also have equal access on property and cash. All the members of family have

equal access and control over basic needs like food, clothing and shelter. Females are
always involved in decision making. Though the control of family matters is greater with
the male gender but she also shares a major portion of the controls.
Gender Perspectives
Gender analysis
Table No. 25: Gender analysis
Activities Women Girls Men Boys

Income generating activities √
Agricultural work
Water related √ √
Fuel related √
Health related activities
Child immunization √ √
Care provider during illness √ √
Taking sick to hospital √ √
Buying medicine √
Cleaning √
Washing clothes √
Cooking √
Repair √
Market related and others √

Access and Control
Table No. 26: Access and Control
Particulars Access Control
Women/Girl Men/Boys Women/Girl Men/Boys

s s
Land √ √ √
Equipment √ √ √ √
Income √ √ √
Labor √ √
Cash √ √ √ √
Asset ownership √ √ √
Food/clothing/shelter √ √ √ √
s
Education √ √ √ √
Basic needs √ √ √ √
Access and Control Profile of MR patient’s family

Factors affecting disease process
Table No. 27: Factors affecting disease process (health related issues)
Exposure to household/ occupational No such affect is seen. Sometimes her son

hazards gets angry on people coming to factory.
Age related No such age-related progression is seen.
Day to day activities and responsibilities She does all her daily activities by herself.
of men and women
Educational status and health seeking Family visits hospital in case of any
behavior health problems.
Economic status and its impact on health Family has to arrange money before
taking her to the hospital.
Gender norms and values in health No such differences are seen in family
regarding health problems.
Access to and control over resources and Slight delay was seen in arranging money
the impact during emergency.
Perception of the disease in society and Disease is often stigmatized by the
other social norms and values that affect society. However, family is supportive in
disease process. her treatment.
Access to information and its impact. Each member of the family are aware of
the disease and provides abundant care
towards her.

Counselling:
During counseling we addressed issues such as healthcare, physical, financial, psycho-
social and nutritional needs. Also informed about persistent depressive disorders, how the
disease occurs, signs and symptoms, consequences of not following treatment guidelines,
why treatment is long and why completion of treatment is critical, likely adverse events
during therapy, and cost involved in treatment and the role of family in mental health of
patients. We encouraged her family member to be supportive. We counseled the family
regarding importance of regular medication, types of food which she should take and
motivated her. We also advised them to visit CMC for regular follow ups.
Third Visit (2072-9-22)
Objectives
 To counsel the patient as well as the family members regarding the illness and
importance of compliance and follow up.
 To enquire about anything important to be noted and if had been omitted in
previous visits.
 To see the progression of disease and patients’ recovery.
Activities
 We principally reviewed the information missed during the first two visits.
 Enquiry about the improvement of the patient.
 Counsel about the patient’s compliance and follow ups.
Outcomes

Third visit was to review our information and to add any if missing from the previous two
visits. We conducted counseling and answered few of the queries put forward by the
other members of the family related to the disease. The patient who was anxious around
strangers became comfortable with the group members and communicated through phone
calls and video calls, which made her family extremely happy and added the hope of
improvement in patient. Normalizing her health condition, awareness regarding her
disease and increase in support from her family are the positive changes which we
believed to have occurred in our patient from our visits.
Conclusion:
Persistent depressive disorder (PDD) is a mild to moderate chronic depression. It
involves a sad or dark mood most of the day, on most days, for two years or more. PDD
is common and can happen to anyone at any age. The most effective treatment combines
medication, counseling and healthy lifestyle choices. Families, as primary caregivers for
persons with psychiatric disability, are increasingly recognized for their potential role in
fostering mental health and well-being (Mental Health Commission of Canada, 2009).
The recovery paradigm in mental health acknowledges families as important players in
the recovery process. Families are often at the center of people’s social worlds, providing
them with primary support networks. Families are invested in, and highly influential, in
the recovery process of persons with serious mental illness. Along with support of family,
timely hospital visits, proper counselling and intake of prescribed medications and
regular follow ups is proven beneficial for the patients to cope up with their mental health
issue

CASE 4
PARAPARESIS SECONDARY TO CNS VASCULITIS
Introduction
Central nervous system (CNS) vasculitis means that blood vessel walls in the brain and
spine are inflamed (swollen). This inflammation can be caused by a variety of conditions
and illnesses.
Vasculitis
Vasculitis is the inflammation (swelling) of the blood vessels, the network of hollow
tubes that carry blood throughout the body. Vasculitis can affect very small blood vessels
(capillaries), medium-size blood vessels (arterioles and venules) or large blood vessels
(arteries and veins). If blood flow in a vessel with vasculitis is reduced or stopped, the
parts of the body that receive blood from that vessel begin to die.
Central nervous system (CNS) vasculitis
Central nervous system (CNS) vasculitis is inflammation of blood vessel walls in the
brain or spine. (The brain and the spine make up the central nervous system.) CNS
vasculitis often occurs in the following situations:
 Accompanied by other autoimmune diseases such as systemic lupus

erythematosus, dermatomyositis and rarely, sarcoidosis and rheumatoid arthritis.
 Infection, such as viral or bacterial.
 Systemic (affecting the whole body) vasculitic disorders, which
include granulomatosis with polyangiitis GPA), eosinophilic granulomatosis with
polyangiitis (EGPA), microscopic polyangiitis, cryoglobulinemic vasculitis and Behçet's
syndrome).

It can also occur without any associated systemic disorder. In this case, the vasculitis is
only confined to the brain or the spinal cord and it’s referred to as primary angiitis of the
CNS (PACNS).
CNS vasculitis is a serious condition. The inflamed vessel wall can block the flow of
oxygen to the brain, causing a loss of brain function and ultimately strokes. In some
cases, CNS vasculitis is life-threatening. It’s important to get treatment for this condition
Causes
In most cases, the exact cause is unknown, but the immune system (which helps keep the
body healthy) plays a role. While the immune system usually works to protect the body,
it can sometimes become "overactive" and attack the body. In most cases of vasculitis,
something causes an immune or "allergic" reaction in the blood vessel walls.
Substances that cause allergic reactions are called antigens. Sometimes certain medicines
or illnesses can act as antigens and start this process.
Symptoms
Symptoms of CNS vasculitis can include the following:
 Severe headaches that last a long time.

 Strokes or transient ischemic attacks ("mini-strokes").
 Forgetfulness or confusion.
 Weakness.
 Problems with eyesight.
 Seizures.
 Encephalopathy (swelling of the brain), that can manifest as change is mood or
personality and decrease level of consciousness.
 Sensation abnormalities.

Diagnosis
The diagnosis of vasculitis, including CNS vasculitis, is based on a person's medical

history, symptoms, a complete physical examination and the results of special laboratory
tests. Blood abnormalities that are found in vasculitis include:
 Anemia (a shortage of red blood cells).

 A high white blood cell count.
 A high platelet (which allows blood to clot) count.
 Kidney or liver problems.
 Elevation of inflammatory markers.
 Special markers in the blood that can be present in certain types of vasculitis.
(In PACNS, when the vasculitis is only confined to the brain or spinal cord, the above
symptoms and signs are often lacking and people see the symptoms of CNS vasculitis
only.)
Other tests may include X-rays, tissue biopsies (taking a sample of tissue to study under a
microscope) and blood vessel scans. A provider might also want to examine the spinal
fluid to see what is causing the inflammation, through a procedure called lumbar puncture
or spinal tap. This test is often performed in CNS vasculitis.
Other essential test include magnetic resonance imaging (MRI), computer tomography

(CT) or angiogram of the brain. An angiogram can show which blood vessels are
narrowed.
Because other conditions can cause some of the same brain vessel abnormalities as CNS
vasculitis, a brain biopsy is the only way to make certain of a diagnosis. A brain biopsy
can distinguish between CNS vasculitis and other diseases that may have similar features.

MANAGEMENT AND TREATMENT
CNS vasculitis is usually treated in stages.
The initial stage is known as induction therapy. Here high-dose steroids are usually

administrated, often intravenously, with or without other immunosuppressive medications
such as cyclophosphamide or mycophenolate mofetil medication that decreases the
immune system's response to autoimmune diseases. Then steroids are tapered off over six
months.
When a person is in remission they enter in a maintenance phase where

cyclophosphamide (if used in the induction phase) is switched to other
immunosuppressive medication such as mycophenelate mofetil. Low dose steroid may be
used in the maintenance phase. Treatment must be continued for a prolonged period,
sometimes for life.
If the patient has another illness (such as lupus) or systemic vasculitis, then treatment
should also include guidelines for the specific condition.
Global Status
Because of the rarity of CNS vasculitis and the absence of definitive diagnostic tests,
epidemiologic studies are virtually inexistent. An annual incidence of 2.4 per million
people has been recently estimated in North America. It has been reported in children and
in the elderly. However, it appears to be more frequent in males in their fourth and fifth
decades of life. PACNS may represent 1.2% of vasculitis involving the CNS.

Problem Statement in Nepal
Cross sectional study between January 2011 and December 2015 at Patan Hospital, Patan
Academy of Health Sciences, Lalitpur, Nepal. The medical records of patients diagnosed
with vasculitides in adults rheumatology service of the hospital were reviewed.
Results: Ninety six patients were diagnosed with vasculitides during the study period.
The mean age was 42.2 years. Sixty nine (71.8%) patient had small vessel, 20 (20.8%)
large vessel and five (5.2%) had variable vessel vasculitides. Seventy five patients
(78.1%) had primary and 21 (21.8%) secondary vasculitides. Cutaneous
leucocytoclasticangitis was seen in 27 (28.1%), Takayasu arteritis in 17 (17.7), Henoch-
Schonlein purpura in 11 (11.4%) and Rheumatoid arthritis associated vasculitis in nine
patients. Purpura was present in all 96 (100%). The overall mortality was 9 (9.3%).
JUSTIFICATION OF CASE:
a. Satisfies the criteria for “psychiatric illness”
b. Plays a role in a substantial number of child abuse and domestic violence incidents.
c. Case was easily available from the community and we had keen interest to learn the
cas
CASE STUDY:
A. Patient Profile
 Name: Kushal Kafle
 Age: 21 yrs
 Sex: Male
 Marital Status: Unmarried
 Address: Bharatpur-10, Dhungana chowk
 Occupation: Student

 Education: Bachleor
 Religion: Hindu
B. Family Profile

 Head of the Family: Father
 Source of Income: His father
C. Case History
Chief Complaint:
 Backache for 1 month 7 years back
 Difficulty walking for 20 days 7 years back
 Headache for 10 days 7 years back
History of Present Illness:

According to patient he was apparently asymptomatic 7 years back when he develop
lower back pain for 1 months, gradual in onset , moderate in severity , continuous in
character ,non radiating , associated with numbness of leg and exacerbated on prolonged
standing and relieved on rest and medication .
He also complained of difficulty walking 20 days later after first symptom in the form of
limping of left leg associated with slipping of slippers with knowledge but no history of
associated difficulty in getting up from sitting posture and patient was even able to play
football.
He developed headache 10 days later, unilateral, stabbing type, intermittent relieved on
taking medication but reoccur again, associated with double vision on looking leftward,
not associated with nausea, vomiting, neck rigidity, altered sensorium and fever.

No history of loss of consciousness, abnormal body movement, trauma, yellowish
discoloration of eyes, bowel disturbance, rashes.
Past Medical History:

No history of asthma, epilepsy, measles,Hypertension, Thyroid disorder , Tuberculosis
and Malignancy.
Personal History
He had good appetite and was non vegetarian. He was a occasional smoker and drink
alcohol. There was no history of bowel disturbance or sleeping difficulties .
Family History:
No history of Hypertension ,Thyroid disorder , Diabetes mellitus and Malignancy in her
family.
Drug history: No history of drug intake.

Allergy history: There was no significant drug allergic history till date.
Socioeconomic history:
He lives in pakka house of rooms with separate toilet and kitchen. House is adequately
lighted and ventilated. Source of drinking water is government water supply and good
sanitation is maintained around home.
General Physical Examination:

He looks alert, well oriented to time, place and person. She is medium-built in
appearance. Pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema and signs of
dehydration were absent.

Vitals:
 Temperature: 98.8 F, recorded from right axilla.

 Pulse: 72 beat per minute at right radial artery. It is regular of normal volume and
character. There is no radio-radial delay or radio-femoral delay. All her peripheral pulses
are palpable.
 Respiratory Rate: 15 breaths per minute, which is abdomino-thoracic. There is normal
periodic breathing. There is no use of accessory muscles.
 Blood Pressure: 130/90 mm of Hg on right brachial artery, measured in sitting position.
Systemic examination:
1. Respiratory:
a) On Inspection:
• Chest was elliptical shaped and bilaterally symmetrical.
• Both sides moving equally with respiration.
• There are no scars marks present.
b) On Palpation:
• Symmetrical movement of chest
• Tactile fremitus was equal on all lung fields
• Trachea was centrally placed
c) On Percussion:
• Lung fields were resonant.
d) On Auscultation:
• Normal breath sounds.
2. Cardio-Vascular System:
• First and second heart sounds heard with no murmurs.
3. Abdomen:

a) On Inspection:
• Umbilicus was central in position
• All quadrants moving equally during respiration
• No surgical scar
•b) On Palpation:
• Superficial palpation: No tenderness in any quadrant
• Deep palpation: No organomegaly.
c) On Percussion:
• No fluid thrill present
• No shifting dullness is present
d) On Auscultation:
• Three to four bowel sounds heard per minute
Family visit
Table No. 28: family visit for Paraperesis Secondary to CNS Vasculitis
Family Visit Date Time Duration
2078/04/1
First Visit 3.30-4.15 2 hours
5
2078/04/2
Second Visit 10-10.35 45minutes
6
2078/04/3
Third Visit 1.10-1.40 40 minutes
2

FIRST INTERACTION
Objectives:
· General introduction between us and the family.
· To explain them about the purpose of our visit
· To gather some basic information regarding family profile, economic, housing and
cultural factors
Activities:
· Rapport building with the patient and family
· Explained the purpose of our visit to the patient
· Enquired about the present status of the patient
Observation and enquiry about family profile
Outcomes:
1. Family Profile:
He lives in a nuclear family with is father mother and sister.

· No. of family members: 4
· Type of family: nuclear
· Religion: Hindu
· Dietary Habit: Regular Nepali Diet
· Head of family: Patient
· Occupation of family head: engineer
· Economic Status: Upper middle
Family tree
Fig
ure no 11: Family tree of Paraperesis secondary to CNS vasculitis
2. Family Members and Relations
There are four members in the family. They have a nuclear family which includes patient
his father mother and sister

3. Housing and environment.
storied with common kitchen and 3 bedrooms. There are 2 windows in each room . In
leafy vegetables.
Figure no 12: House map of Paraperesis secondary to CNS vasculitis
4. Economic status (According to kuppuswamy’s socioeconomic status scale)

Table No. 29: Kuppuswamy’s Socioeconomic status scale of Paraperesis secondary
to CNS vasculitis

TOTAL 20
Source of income
His father and he are the main source of income for the family.
Expenditure
In addition to daily household expenses, they need to pay for education of her younger
daughter. They also spend money on patient treatment, fooding, housing materials,
clothes and so on making a total of RS 25,000- 30,000.
4. Educational Status
Our patient is literate and has studies up to bachelor. His father is an engineer. His mother
is a house wife
5. Lifestyle and Food Habits

They buy some items of food from market while some items are grown in their own field.
They eat general Nepalese food and sometimes meat. Special food is consumed in special
occasions and festivals. They wear good clothes. Furniture of house is sufficient to
accommodate their family and one or two visitors. Overall they have a satisfactory
hygiene regarding their work.
6. Cultural and belief systems

They are hindu by religion and celebrate all major festivals.
Direct costs
● Approximately 20 lakhs was spent for the treatment during hospital course and
medications.
Indirect costs

● Also, approximately 100 thousand rupees was spent for accommodation and
transportation
Table No. 30: Observation checklist secondary to CNS vasculitis
Observations Yes No
Own house 
Rented house 
House type Pakka
● Number 2rooms 1 kitchen 1
● Ventilation 
● Sunlight 
Kitchen

● Ventilation/Exhaust 
● Energy Source for cooking LPG
Toilet 
Cleanliness
● Around the house 

● Of the diseased person 
Water
● Source Tap water
● Sufficiency 

● Treatment of drinking water 
Waste disposal o Municipality

Vehicle
Vehicles  One bike
Helpers/Servants 
SECOND INTERACTION
Objectives:
To enquire and observe about the health of family and personal habits, health seeking
behaviour, KAP and disease impact on family and patient and gender status in family.
Activities:
In second interaction, we took detail data about his family and we had assessed
knowledge, attitude and behavior on disease causation. Besides this, we assessed the
progression of disease, impact of drugs, side effects and his compliance to treatment. We
took detail history on follow up and number of hospital visits. We took depth interview
on effect of disease on his daily activities, psychosocial behavior and economy of family.
We asked about his personal habits, diet, sanitation and hygiene. We communicated with
his family members on his disease, its progression and about social, economic and moral
support to her by the family.
Outcomes:
Health seeking behavior and KAP
He was unaware about the CNS Vasculitis and its symptoms before he was diagnosed
with the disease. He visited the hospital as soon as the symptoms appeared which
affected his daily activities. His overall health seeking behavior was unsatisfactory.

Knowledge
After being diagnosed with the CNS Vasculitis he hasn’t adequate knowledge about the
disease.
Attitude
● He knows that one should visit the hospital or any health institution when he/she feels
sick. He doesn’t have beliefs in witchcraft, dhami and jhakris.
● They understood importance of healthy diet.
Practice
● Patient takes his medications as per indication.

● He avoids harmful use of alcohol and unhealthy diet.
● He goes to hospital for health check-ups regularly.
Role of the family and society in the causation, progression and relief
Role in disease causation

● Patient’s family was following healthy food.
Role in disease progression

● Family is supportive and does not indulge in smoking and other harmful practices.
●
Role in disease recovery
● His family is very supportive emotionally and psychologically and takes care of his
medication, diet and helps him with physical fitness.

● His parents are also very concerned about his health.
FAMILY HEALTH AND ILLNESS CYCLE
Source Google
Figure no 13: Family health and illness cycle
Family’s role in vulnerability and disease onset/relapse
Family’s role in illness appraisal
● The patient visits the hospital for regular follow up and his family members as well. His
family is very understanding.
Family’s role in acute response

● Family has adequate knowledge on the disease to know about warning signs and when to
take the patient to the hospital.
Family’s role in health promotion and risk reduction.
His family is extremely cautious about the patient’s diet and medication helps to stick to
strict regimen
Family’s role in adaptation to illness and recovery

● The patient father accompanies to all doctor’s visits and help with medical compliance
regularly.
IMPACT OF DISEASE ON FAMILY, PATIENT AND SOCIETY
Psychological impact on patient

The patient was unaware of the disease only after being diagnosed, he learned about the
disease. Now the patient has adequate knowledge about the disease, treatment, and
precautions. He has a fear of what will happen if medications stop working. The patient
complains about the medication regimen as well. Patient actively searched for treatment
in various hospitals.
Economic Impact on patient
Study had become difficult due to symptoms of the disease. Although there are no
economic problems in the family at present, all his savings around 20 lakhs were spent
due to illness.
Physical Impact on Patient

The patient was unable to perform normal daily activities and was unable to go to his
college.
Social impact on patient
He goes outside the house for exercise and attends social functions too.
There is good relation of him and his family members with his neighbors and other
members of society.
Impact on society
● The society is well aware about the disease and the fatal consequences of ignoring
disease condition. They have developed helpful attitude towards the patient and family.
● There is no stigma regarding his condition in society, instead his neighbors support him.
Impact on family
● The family knows well about the disease condition of the patient so they provide proper
care and emotional support. His family takes good care of him regarding his food habits,
personal hygiene and regular check-ups at the
Gender analysis
● There is no gender discrimination in the family.
● The female members are well respected in the family.
● The important decision of the family are made by his parents.
● The household works are performed by female. Though the control of the family matters
is more by the male member but female also share major portion of all the controls and
all the assets.
GENDER ANALYSIS
Table No. 31 FOR GENDER ANALYSIS

Income generating activities: o o  
Production activities  o  
Agriculture o o o 
Washing clothes    
Fuel related  o  o
Cooking    o
Obtaining gas/kerosene  o  o
Health related  o  o
Child immunization    
Care provision during ill health    
Taking the sick to medical institutions  o  o
Buying medicine    
Cleaning activities  o  
Repairing o o  
Market related    
B. Control Assess Profile
Table No. 32 FOR Control Assess profile
Access Control
men/boys women/gir men/boys women/

ls girls
Land     
Equipment     
Labor     
Cash     
Asset ownership    
Basic needs     
Food/clothing/shelter     
Education     
    
Control Assess profile
Table No. 33 For Control Assess profile

hazards
hypertension
Day to day activities and No significant impact has been noted. He has been
responsibilities of taking rest from his daily activities and the family
men and women members have a sense of responsibility towards his
care.
Educational status and health It is satisfactory since he used to measure her blood
seeking behavior pressure and had regular checkup once in two to three
months.
Economic status and its impact There is no significant impact as the family is able to
on health afford for the treatment till date
Gender norms and values in There is no significant impact as there is proper
health access for medical care for both genders.
Access to and control over No significant impact because there is proper access
resourses and the impact to the resources.
Perception of disease The patient and the family were aware enough about
the disease and its severe consequences if neglected,
which might have played a role in progression of the
disease.
THIRD INTERACTION
Counselling
1. During counselling we addressed issues such as healthcare, physical, financial, psycho-

social and nutritional needs and gave special emphasis on importance of healthy lifestyle.
2. Also informed about :
● CNS Vasculitis ,
● possible risk factors and mechanism of disease onset and progression,

● signs and symptoms,
● consequences of not having healthy lifestyle
● Why treatment is critical,
● Likely adverse events during therapy.
3. We encouraged his family members to be supportive.

4. The family members were aware as well as concerned about the patient and his illness
and were willing to improve the health condition of the patient by adopting proper dietary
habits, compliance to drug and regular physical activities.
CASE 5
AUTISM
INTRODUCTION
Autism is a spectrum and everybody with autism is different .It's not a disease but a
complex developmental condition that involves persistent challenges in social interaction,
speech , nonverbal communication and restricted or repetitive behaviors .Autism
spectrum disorder is a broad range of condition which is complex, lifelong and different
developmental ability that typically appears during early childhood and can impact a
person’s social skills , communication, relationships and self-regulations. It causes
children to experience the world differently from the way most other children do.
Autism Spectrum Disorder has problems on two major aspects
1) Social communication and interaction
2) Restricted or Repetitive behaviour
1) Social communication and interaction problems include
i) Social reciprocity - How child responds & reciprocated
They normally try to be alone
ii) Joint attention- wanting to share interest
They don’t want to share interest with parents
iii) Nonverbal communication-- using or interpreting
They don’t express they want to be picked up by parents neither understand parent’s
anger
iv) Social relationship- developing or maintaining
2) restricted or repetitive behavior

- Lining of toys, flapping hands, imitating
- Fixed on certain routine
- Restrictive thinking; Specific knowledge
Etiology
i) Genetics- Affects brain development
Gene unknown
ii) Environmental Triggers?
No clear risk factors
Treatment
Tailored to each child
Educational program and behavior therapy
Three Functional Levels of Autism
Source Google Pictures
Figure no 14 Functional spectrum of Autism
Problem statement
The prevalence of Autism Spectrum Disorder has increased dramatically in recent
decades, supporting claims of an autism epidemic. It has become a global phenomenon.
An estimated 1-2%of children worldwide lie on the autism spectrum, with approximately
52 million autistic individuals around the globe.
Systematic monitoring of ASD allows estimating prevalence and identifying potential
sources of variation over time and geographical areas.
Scenario in Nepal
The Autism Care Nepal Society website states that there is no reliable estimate for
prevalence of autism in Nepal as autism is not known to many people.
The estimated prevalence of autism in Nepal is 3.2/1000.
Justification for selection of case:
a. Satisfies the criteria for “psychiatric illness”
b. Plays a role in a substantial number of child abuse and domestic violence incidents.
c. Case was easily available from the community and we had keen interest to learn the
case
CASE STUDY
Case Profile
a) Name of the patient : Amrit Khanal (Name of patient is changed)
b) Age : 14
c) Sex : male
d) Address : Bharatpur 10
e) Religion : Hindu
f) Occupation Student but left since 2 years
g) Date of admission to the hospital : 13th october,2017
h) Date of diagnosis : 13th September ,2017
2. Chief complaints
Delayed development since birth
3. History of present illness

My patient was presented to AIIMS hospital on 13th october,2017 with developmental
delay which was present since birth. He was not able to reciprocate normal
developmental stages as shown by his correspondence. He was not able to communicate
and be socially involved with anyone. He had difficulty in climbing bed and and perform
other activitie
Developmental History
 Gross motor Development
He was not able to roll on his back until 3 years of age, while he started to walk with
support only at 4 years and walk without support after he was more than 5 year old. He
climbed stairs only after 7years of age.
 Fine motor Development

Grasping
He showed bidextrous grasps in the 4th year of his life while the start of undexterous
grasp and transfer of objects between hands could not be recalled by his mother, but now
he is perfectly able to grasp and transfer objects between his hands. Pincer grasp is also
achieved by 7 years.
Drawing
He cannot draw a perfect circle till this age of life.
Arrangement of cubes
He still cannot still arrange cubes of 2 blocks.
Dressing and undressing
He is able to dress and undress only under supervision at 14 year of life.
 Language development
At 7 year old he was able to produce monosyllabic words, and after 10 years he was able
to produce disyllabic words. And now at 14 year old he is able to produce 2 words with
meaning at at a time, while he is still not able to interact with a complete meaningful
sentence
 Social Development
He was able to recognize his mother only at 5 year, play in the mirror at 7 years and was
able to say no and wave his head only at the 10th year of his life. He used a diaper until
the age of 6 years, then slowly he was trained to use the toilet and now he is able to go to
the toilet alone but requires assistance while cleaning his private areas.
Further analysis on development
He was admitted to normal school at 11 years, but due to his uncooperative behavior and
risk to harm to other children (as pushing) was dropped out from the school and was
admitted to special school. But now at 14th year he is able to hug and kiss his family and
friends and enjoys company and is hyper excited by the presence of strangers also.
 Noci and Thermo reception

He was indifferent to pain or temperature and had an elevated perceptual threshold for
thermal and pain stimuli. And additionally he had an increased level of sweating.
Birth history
He was born before 13 days of expected delivery date, by normal vaginal delivery at
Bharatpur hospital on a general bed at Ashar 2nd, 2064 (not in a labor room) after 4 hrs
of labor. He was 2.5 kg at birth, cried immediately and had a normal Apgar score at 1st
and 5th minute according to the nurse. But after a few hours the baby was reported to
have increased breathing, and decreased oxygen saturation, which was difficult to
manage at Bharatpur hospital and was referred to Kanti hospital, Kathmandu. He was
admitted to the hospital for 46 days and was diagnosed with pneumonia which was
suspected due to aseptic delivery. He was formula fed until his hospital stay, after which
his weight was reduced to 1.3 kg.
Past medical and surgical history

He had multiple hospital stays up to 5 years of age due to recurrent pneumonia.
Pneumonia resolved completely after 8 years by adequate medication and preventions.
He had frequent diarrhea (3 times a week) up to 5 years, which was due to heavy
consumption of milk (up to 4 liters/day). And diarrhea was resolved after limiting the
amount of milk.
Personal history:
He is non vegetarian, with a proper bowel and bladder habit. He was admitted to special
school, but is on hold due to COVID-19 situation. He is not able to concentrate on
reading and writing, but is able to use a smartphone and recognize family members by
pictures. He scribbles and sometimes even tears pages and throws it under tables and
beds so as to hide it from his parents.
He has no significant passive smoking and alcohol history.
Drug and Allergy history
On age of 5 he was misdiagnosed and used differents CNS medication (suspectedly anti
epilectlic medications) which showed different side effect as bed wetting, constant
drooling, splinting of eyes, excessive sleeping, etc. Medication were discontinued after a
month after which all side effects were subsided
Physical examination:
 General condition: My patient was well looking, uncooperative, moderate to heavy
built, oriented to time, place and person. He was 52kg by weight and height, and BMI
was
 Vitals
 BP: The blood pressure after measuring on the right arm was noted to be 110/82 mmHg.
 Pulse rate: After examining the right radial artery with three finger method, his pulse was
found 96 beats/min, regular in rhythm. Pulse was normovolemic and normal character on
the carotid artery. There was neither radio radial nor radio femoral delay. Peripheral
pulses were palpable.
 Respiratory rate: Respiration was abdominothoracic and rate was 14 breath/min
 Temperature : The patient was afebrile
 General examination: On general examination
 Pallor absent
 Icterus absent
 Clubbing absent
 Cyanosis absent
 Lymphadenopathy absent
 Edema absent
✔ Systemic examination
Respiratory Examination
On inspection: Chest was elliptical shaped, bilaterally symmetrical, no venous

prominence, no scar marks, no skin discolouration,no skin lesions and nodules, no use of
accessory respiratory muscles. The respiration was thoracoabdominal, and both sides
moved equally with respiration
On palpation: There was no local rise of temperature and tenderness on the chest.
Trachea was central and slightly deviated to right. There was no nodules on thyroid
gland. Vocal fremitus was equal on all lung fields
On percussion: There was resonant note on all lung field
On auscultation: There was normal vesicular sound on all lung field, no added sounds
were presents
CVS examination
On Inspection: Chest was elliptical shaped, bilaterally symmetrical, no venous

prominence, no scar marks, no skin discoloration, no skin lesions and nodules. Apical
impulse was not visible.
On palpation: Apex beat was felt on mid clavicular line 9cm from midline at 5th
intercostal space.
On auscultation; both first and second heart sound were audible on all four areas, without
any added sounds
Abdominal examination
On Inspection: Abdomen was fatty, centrally placed inverted umbilicus. There were no
scar marks, venous prominence, no scar marks, no skin discoloration, no skin lesions and
nodules, no flank fullness, no supraclavicular fullness. All quadrant moves equally with
respiration
On palpation
Superficial palpation: No tenderness in any quadrant
Deep palpation: Liver is of normal span.
On percussion
No fluid thrill present, No shifting dullness present
On auscultation
3-4 bowel movements were heard per minute. No exacerbated sound were heard.
Diagnosis
Diagnostic Criteria of Autism
1. Persistent deficits in social communication and social interaction across multiple

contexts, as manifested by the following, currently or by history
i) Social reciprocity- pre

ii) Joint attention
iii) Nonverbal communication
iv) Social relationship
Severity is based on social communication impairments and restricted, repetitive patterns

of behavior
Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least

two of the following
Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor
stereotypes, lining up toys or flipping objects, echolalia, idiosyncratic phrases).
2 Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal
or nonverbal behavior (e.g., extreme distress at small changes, difficulties with
transitions, rigid thinking patterns, greeting rituals, need to take the same route or eat the
same food every day).
3 Highly restricted, fixated interests that are abnormal in intensity or focus (e.g., strong
attachment to or preoccupation with unusual objects, excessively circumscribed or
perseverative interests).
4 Hyper- or hypo reactivity to sensory input or unusual interest in sensory aspects of the
environment (e.g. apparent indifference to pain/temperature, adverse response to specific
sounds or textures, excessive smelling or touching of objects, visual fascination with
lights or movement).
Symptoms must be present in the early developmental period (but may not become fully
manifest until social demands exceed limited capacities, or may be masked by learned
strategies in later life).
D. Symptoms cause clinically significant impairment in social, occupational, or other

important areas of current functioning.
E. These disturbances are not better explained by intellectual disability (intellectual

developmental disorder) or global developmental delay. Intellectual disability and autism
spectrum disorder frequently co-occur; to make comorbid diagnoses of autism spectrum
disorder and intellectual disability, social communication should be below that expected
for general developmental level
Our finding
1) Social communication and interaction
Our patient lacked joint attention as he was not able to share his interest with his parents
or other family members. He also lacked proper social and communication skills as he
was dropped out of school after not being able to cope with normal children’s. And he
also lacked eye to eye contact with others during conversation. But his social reciprocity
was observed and development on nonverbal communication was significant.
Furthermore he has started to show joint attention by pointing to objects, suggesting his
interest and giving a positive response to social initiation made by others.
2) Restricted or repetitive behavior
Stereotyped behavior of imitating others (even strangers) was observed however

repetitive movements were not present. He was fixated on the arrangement of his
belongings and showed affection to dolls. He is also fixated to light colored clothes and
avoid dark colored ones. He was indifferent to pain or temperature and had an elevated
perceptual threshold for thermal and pain stimuli. And additionally he had an increased
level of sweating. This show hypo response to thermal and pain stimuli
The autism symptoms were significantly present during early development.

He is not able to understand or learn words and is perfectly able to recognize normal pets
and birds by pictures which show decreased intellectual development or global
developmental delay.
Thus patient showed character of ASD level 3 requiring very substantial support
Treatment: His caretaker is his mother who is knowledgeable and gives him special care
and invest all her time in feeding him, assisting him for dressings and using toilets. She
also tries to teach him appropriate behavior and help him discontinue undesirable
behavior, for instance commanding him not to touch fire, not to sit on railings of terrace,
making him wear his slippers and washing hands. His mother also left her career and job
to give full attention to him, support him with his daily activity and hasn’t left him alone
for a complete night till the date. His father and sisters were also highly supportive and
enthusiastic for his treatment and ready to give their time and support for his better life.
The family is also very welcoming for newer strategies and intervention for his treatment.
In this educated and supportive family our patient is obtaining very substantial support as
required and is progressive toward better quality of life. Which is evident by his
improving status on Functional level of autism.
FIRST INTERACTION
Objectives:
· General introduction between us and the family.
· To explain them about the purpose of our visit
· To gather some basic information regarding family profile, economic, housing and
cultural factors
Activities:
· Rapport building with the patient and family
· Explained the purpose of our visit to the patient
· Enquired about the present status of the patient
Observation and enquiry about family profile Family Visit

Table No. 34 Family Visit for Autism family
no Family Visit Date
1 First visit 2078/04/12
2 Second visit 2078/04/19
3 Third visit 2078/04/26
❏ 2) Family Outcomes :
● No. of family members: 4
● Type of family: Nuclear
● Religion: Hindu
● Dietary Habit: Regular Nepali Diet
● Head of family: Patient’s Father
● Occupation of family head: Teacher
● Economic Status: Upper class
Family tree
Figure no 14: Family tree of Autism family
Housing and Environment
Figure no 15: Housemap of autism family
2. Family Members and Relations
There are four members in the family. They have a nuclear family which includes patient
his father mother and sister
3. Housing and environment.

storied with common kitchen and 3 bedrooms. There are 2 windows in each room . In
leafy vegetables.
4. Educational Status:
•Our patient is studying at special school, his father is graduate and mother had studied
up to +2 and his sister is studying at grade 8
Socioeconomic status
Table No. 35 Kappuswamy socioeconomic scale
TOTAL 27
According to Kappuswamy socioeconomic scale, the family lies in upper class.
➢ Our patient is a young boy of 14 years age.
➢ He spends his day in his home and his mother helps him at daily activities.
➢ He takes meal 6 time a day, assisted by his mother, starting with light breakfast of biscuit
and milk, then lunch of traditional Nepali meal, followed two times of light afternoon
meal of fruits and snacks, after which he takes traditional Nepali dinner and then a cup of
milk before going to bed
➢ They buy vegetables and food items from the local market.
➢ They eat general Nepalese food. Special foods are consumed in special occasions and
festivals.
5. Lifestyle and Food Habit

➢ Our patient is a young boy of 14 years age.
➢ He spends his day in his home and his mother helps him at daily activities.
➢ He takes meal 6 time a day, assisted by his mother, starting with light breakfast of
biscuit and milk, then lunch of traditional Nepali meal, followed two times of light
afternoon meal of fruits and snacks, after which he takes traditional Nepali dinner and
then a cup of milk before going to bed
➢ They buy vegetables and food items from the local market.
➢ They eat general Nepalese food. Special foods are consumed in special occasions
and festivals.
Table No. 36 Observation table for Autism family

Observations Yes No
Own house  
House type Pakka
Rooms
● Ventilation 
● Sunlight 
Kitchen
● Energy Source for cooking LPG
Toilet 
Cleanliness
● Around the house 
● Of the diseased person 
Water
● Source Municipality
● Sufficiency 
● Treatment of drinking water 
Waste disposal o Municipality
Vehicles  Vehicle
Electronic Appliances o Radio TV
Pets  Refrigerator
Helpers/Servants  
Second Visit
Knowledge:
 has sound knowledge of disease.
 was aware about the causation,progression and recovery status of the disease.
Attitude:
 Fair and optimistic
 They very well understood the importance of diet, exercise.
 The family doesn’t believe in dhami, jhakri and other witch doctors.
Practice:
 Takes his medications as indicated.
 Stays away from the cold and other allergens.
 Supportive and caring family environment
❏ Outcomes :
❏ He is cognitively incapable to know about his illness, but is showing progress by

handling much of his daily activities such as using toilets, self-cleanliness and is
comparatively much more easy to take care as compared to past
❏ They don't believe in both traditional method of healing and ayurvedic medicine.
They only believe in allopathic medication.
❏ The important decision of the family are made by head of the family who is his
father.
❏ There is no gender discrimination in the family.
❏ The female members are well respected in the family.
❏ The household works are performed by both male and female. Though the control
of the family matters is more by the male member but female also share major
portion of all the controls and all the assets.
Figure no 16: Family health and illness cycle
Role in causation:
No significant role of family in causation
No significant role of family in progression
Adaptation to illness and recovery:
Family played an important role in curing the disease. They took good care regarding
food, rest, Physiotherapy and medical care during his illness. His mother left her job to
take care of his son, and till this age is taking care of his every needs and devoting all her
time on him. They have also visited AIMS hospital of India multiple times to inquiry
about his illness and recovery process
Illness Appraisal
● There is good health seeking behavior in his family. His family is very positive
and careful toward his illness. They do not believe in dhami jhakri and traditional healer.
● There no role of family in disease onset and relapse.
Family’s beliefs about illness:
● They only believe on allopathic medicines.
The decision about health care is taken jointly by his father and mother.
Whenever he feels discomfort or any health related acute problem, they immediately
took him to nearby Narayani Samudaik hospital and to COMS as much permitted by
time.
His family is fully supportive, emotionally and physically and took care of his follow
ups and helped him through his daily activities. He isn’t left alone in his home. And
his mother hasn’t left him alone for a single night
Impact of Illness on Family
His mother take care of him and has left her job to take care on his personal
shortcomings. She feeds him 6 times daily, baths him, help him in toilets and
bathroom and help him to get to his bed. She take care of him like a 3 year old child
and isn’t even slightly bothered by him instead enjoys to help him on daily basis.
His father works regularly to support his family leaving behind his son under care of
his wife. But he take leave from his work to visit different national and foreign
hospital and participate actively in treatment and care of his son.
His father being a teacher, has good earning and easily bear expenses for Amrit’s
treatment and his conditions hasn’t created economic burden on his family .
Care of the diseased
The family is well known about the disease condition of the patients so they provide
care and emotional support.
They took good care of him regarding his personal hygiene, daily activities like
taking food, using bathroom playing around etc.
They take him to hospital regularly
His mother is personal care taker for him
Impact on patients
Psychological effects :
 Education and status :
● He was admitted to normal school but due to lack of cooperative behavior was
withdrawn and then placed to special school, which is also closed since 2 year due to
lockdown.
 Self-esteem and confidence :
● His self-esteem and confidence are progressive as compared to past, he uses

mobile, he is friendly with family members.
Physical effects:
 Inability to perform normal daily activities :
● He is not able to perform normal daily activities and take care of his own, so he is
assisted by his mother for every simple works since childhood.
❏ Effect on Economy:
The family belong to upper class according to kuppuswamy scale
There is not much economy burden to take care of the diseased.
The family can take care of all the expenses during his treatment and care.
❏ Social relation :
● He is unable to communicate, but his neighborhood are supportive and respond

each time he call them.
● He do not go outside house much and donot attain social functions at all.
● There is good relation of his and his family members with his neighbors and other
members of society
Impact on society:
● The society is well aware about the disease. They have developed helpful attitude
towards the patient and family.
There is no stigma regarding his condition in society, instead his neighbor support him
Gender Analysis:
• There are no gender issues in family.
• Male members of the family are involved mainly in income generating activities.
• The household works like cooking are performed by female while cleaning
houses and washing clothes are performed by both male and female.
• Activities like child immunization, care provision during ill health, buying
medicine are done by both male and female.
• Though the control of the family matters is more by the male member but female
also share major portion of all the controls and all the assets.
• Though female member have exposed to activities both outside and inside the
house still more concentrated inside.
Observation Table
1. Activities and control profile

Table No. 37 Activity table
Income generating activities: o o  
Production activities  o  
Agriculture o o o 
Washing clothes    
Fuel related  o  o
Cooking    o
Obtaining gas/kerosene  o  o
Health related  o  o
Child immunization    
Care provision during ill health    
Taking the sick to medical  o  o
institutions
Buying medicine    
Cleaning activities  o  
Repairing o o  
Market related    
2. Access and Control profile
Table No. 38 Access and control profile

Access Control
men/boys women/girls men/boys women/girls

Land    
Equipment  o  
Labor    
Cash    
Asset ownership  o  
Basic needs    
Food/clothing/shelt    
er
Education    
Factors affecting disease process (health related issues)
Table No. 39 Factors affecting disease process

hazards
hypertension
Day to day activities and No significant impact has been noted. He has been taking
responsibilities of rest from his daily activities and the family members
men and women have a sense of responsibility towards his care.
Educational status and It is satisfactory since he had regular checkup once in
health seeking behavior two to three months.
Economic status and its There is no significant impact as the family is able to
impact on health afford for the treatment till date
Gender norms and values There is no significant impact as there is proper access
in health for medical care for both genders.
Access to and control over No significant impact because there is proper access to
resources and the impact the resources.
Perception of disease The patient and the family were aware enough about the
disease and its severe consequences if neglected, which
might have played a role in progression of the disease.
THIRD VISIT
❏ Activities :
● Missing data were collected and family was counselled regarding the various
aspects of disease.
● During counseling we addressed issues such as healthcare, physical, financial,

psycho-social and nutritional needs and gave special emphasis on importance of healthy
lifestyle .
● Also informed about Autism Spectrum disorder, Possible risk factor and
mechanism of disease onset and progression, signs and symptoms, consequences of not
having healthy lifestyle in heart disease patients, why family care and support is critical
to prevent further worsening, and cost involved in treatment and what free/public services
are available to patients
Outcomes :
● The family members became more aware as well as concerned about the patient
and his illness and ensured to improve the health condition of the patient by proper care
and support.
● They committed for the regular health checkup and follow up.
❏ Conclusion :
● Autism spectrum disorder (ASD) is a complex developmental condition that

involves persistent challenges in social interaction, speech and nonverbal
communication, and restricted/repetitive behaviors which can be managed by behavioral
management therapy, cognitive behavior therapy, early intervention, educational and
school-based therapies, joint attention therapy, medication treatment, nutritional and
occupational therapy.
● Autism is a spectrum and everybody with autism is different .It's not a disease but
a complex developmental condition that involves persistent challenges in social
interaction, speech, nonverbal communication and restricted or repetitive behaviors.
● The prevalence of Autism Spectrum Disorder has increased dramatically in recent

decades, supporting claims of an autism epidemic.
● A proper family care and support is necessary to stop progression of disease.
● Every person with autism should be treated not only with equality but by equity.
And more research must be done to manage their disease
Chapter III
Conclusion and Recommendation
3.1 Conclusion
In retrospect, the Family Health Exercise was a valuable study for us students and it was
rightfully part of our curriculum to help us understand the complex interconnections
between family and their impact on health. It did a great deal to teach us that health was
not merely an absence of disease but a combination of physical, mental and social well-
being.
We conducted five studies overall, and each gave us a unique outlook into different
aspects of family health. Throughout our visits and thorough interview with each of these
patients, we saw how family could have both a positive and negative impact on the
causation, progression and relief of disease. Although we could read about this from our
textbooks, visiting these patients at their homes and standing where they stood, we were
able to look at life from their angle and see how all the different environmental and health
related factors might have played a role in the disease process.
Our family health exercise is a part of our curriculum; nevertheless, it’s been an integral
part of our lives during the entire FHE period. Reaching out to the families and getting a
deeper understanding of their sorrows let us understand what disease as a short term or
long term complication could hamper the quality of life. This had been an immense
overwhelming experience.
3.2 Recommendations to the School of Public Health and Community Medicine
We sincerely appreciate all the efforts the department has made for proper conduction of
this family health exercise. But as we know, there’s always a room for getting things
better, we’d like to recommend some of the ideas to our department for conduction of
Family Health Exercise in more efficient ways in further batches.
We felt we need further guidance from the faculty in some areas like:
 Dealing with patient’s emotions in better ways so as to make them feel easier to
open up.
 Some level of financial assistance would further make the family visits easier to
conduct
 Early commencement of orientation program could help a lot enough time for
report writing and submission before exams.
 Providing some guidelines about “do”s and “don’t”s of conduct would be of much
value.
3.3 Learning Reflections

Any experience is learning per se. Family health exercise has also been a great
experience for all of us. We got to deal with people from different walks of life, interact
with them, and know in detail about their disease and their routines, their perception
about health related and non-related subjects. We have widened the ways in which we
saw things in general.
The learning reflections for our group are enlisted as follows.
1. Group dynamics: We worked together as a group and we learnt to deal with problems
in a group approach, we learnt to be there for one another.
2. Patient counseling: Patient counseling had been a theoretical subject matter to us.
When we went to families and discussed about their disease, we learnt to help them
modify their ill-perceptions like belief in faith healers. We also learned that counseling
the family members is as important as counseling the patient as the disease of the
individual has impact on the entire family.
3. Impact of socioeconomic condition: For us, health has been a matter of negligence
and economy an extravagance but with families we learnt what degraded health could do
to people and how lack of economy could cripple them of health.
4. Disease as social stigma: In the society, psychiatric cases are mostly taken as disease
of social stigma; a psychiatric patient is always taken as one to be aware of. There in the
families when we dealt them on our own, we learnt that was a misconception.
5. KAP and the difference: We have always known that disease is an arduous thing to
deal. But we saw how proper knowledge about the disease, attitude towards the outcomes
and practice as per the knowledge could bring about difference in prognosis.
6. Viewing disease as a multiple aspects: We learnt how disease was not just a clinical
manifestation and how things like environment, gene, culture, occupation, crowding, and
belief played roles in the occurrence of the disease.
7. Family as a boon: George Bernard Shaw rightly said, “A happy family is nothing but
an earlier heaven.” We learnt how togetherness in a family could prove to be a boon in
times of trial.
We are hopeful that all that we’ve learnt is going to come into implementation in our
academic and professional careers as well as in the personal development.
BIBLIOGRAPHY
• Park K. 2011, Park’s Textbook of Preventive and Social Medicine, 21th edition,
India:Bhanot
• Fausi AS, Kasper DL, Longo DL, et al. 2009. Harrison’s Principles of Internal
Medicine, 18th edition
• Colledge Nr, Walker Br, Ralston Sh. 2010. Davidson’s Principles and Practice of
Medicine, 21st edition
• Department of health Services Annual report 2070/2071. Ministry of Health and
Population, Government of Nepal
References:
1. Kessler RC, Ormel J, Petukhova M, McLaughlin KA et. al, Development of lifetime

comorbidity in the World Health Organization world mental health surveys. Arch Gen
Psychiatry. 2011 Jan;68(1):90-100.
2. Anjani Kumar Jha, Saroj Prasad Ojha et al (2019), Prevalence of mental disorders in
Nepal: Findings from the pilot study
3. QingqingLiu, HairongHe, JinYang, Xiaojie et al, Changes in the global burden of

Depression from 1990 to 2017: Findings from Global Burden of Disease
4. Deepa Kumari Bhatta, Kreeti budhathoki et al, Burden of Anxiety and Depressive
disorders in Nepal, 1990-2017: An analysis of Global Disease Burden of Disease Data.
ANNEXES
Interview Guidelines and tools

1. Case Profile
a. Name of the patient
b. Age
c. Sex
d. Address
e. Religion
f. Occupation
g. Date of admission to the hospital
h. Date of diagnosis
2. Chief complaints
2. History of present illness
2. Past medical and surgical history
2. Personal history:
a. Smoking history:
i. Do you smoke? (yes/no)
ii. Does any other family member smoke?
ii. If yes, then at average how many sticks per day do you smoke?
ii. Which type of smoking (cigarette/cigars/pipe)?
ii. At what age did you start smoking/ how long has it been?
ii. No. of pack year = (no. of cigarette per day/20) × (No. of smoking years)
b. Alcohol history:
i. Do you drink alcohol? (yes/no) If yes:
ii. What type of drink? (Locally made/beer/whisky/wine etc.)
iii. When did you start drinking?
iv. How often? (daily/weekly/occasionally)
v. How much? (quantity in units) (1 unit=25 ml of 40% alcohol=10ml ethanol)
vi. Usual place of drinking? ( home/ shop etc.)
vii. Alone or accompanied
viii. Amount of money spent in alcohol?
ix. CAGE criteria:
 Have you ever felt need to Cut down on your drinking?
 Have people Annoyed you by criticizing your drinking?
 Have you ever felt bad or Guilty about your drinking?
 Are you an Eye opener?
c. Exercise
c. Diet
6. Physical examination:
 General condition
 Vitals
 BP
 Pulse rate
 Respiratory rate
 Temperature
7. General examination:
 Pallor
 Icterus
 Clubbing
 Cyanosis
 Lymphadenopathy
 Edema
 Signs of dehydration
 Systemic examination
8. Anthropometric examination
8. Investigation
8. Diagnosis
8. Treatment
2) Family profile:
i. Family type
ii. Family size
iii. Head of family
iv. Total earning members
v. Education status of each family members
vi. Application of family tree to demonstrate the family members
TOOLS:
Observation Checklist:
Observations Yes No
Own house
Rented house
House type
Rooms
Observations Yes No
Number
Ventilation
Sunlight
Kitchen
Ventilation/Exhaust
Energy Source for
cooking
Toilet
Cleanliness
Around the house
Of the diseased
person
Water
Source
Sufficiency
Treatment of
drinking water
Waste disposal
Vehicles
Electronic Appliances
Pets
Yard/Lawn
Helpers/Servants
Gender Analysis:
Tool 1: Activity profile
Activities Women Girls Me Boys

n
Income generating activities:
Agriculture
Washing clothes
Fuel related
Cooking
Obtaining gas/kerosene
Health related
Child immunization
Care provision during ill health
Taking the sick to medical
institutions
Buying medicine
Cleaning activities
Repairing
Market related
Tool 2: Access and Control profile
Access Control
men/boy women/girls men/boys women/girls

s
Land
Equipment
Labor
Cash
Asset ownership
Basic needs
Food/clothing/shelter
Education
KUPPUSWAMY’S SOCIO-ECONOMIC SCALING
Heading Score
Education
Profession of Honor 7
Graduate or Post Graduate 6
Intermediate or post high school diploma 5
High school Certificate 4
Middle School Certificate 3
Primary School Certificate 2
Illiterate 1
Occupation
Profession 10
Semi-profession 6
Clerical, shop-owner, farmer 5
Skilled worker 4
Semi-skilled worker 3
Unskilled 2
Unemployed 1
Family Income per month
>/= 45751 12
22851-45750 10
17151-22850 6
11451-17150 4
6851-11450 3
2301-6850 2
</= 2300 1
Total Socio-economic Class

Score
26-29 Upper(I)
16-25 Upper Middle(II)
11-15 Lower Middle(III)
5-10 Upper Lower(IV)
<5 Lower(V)
Photo Gallery
Examination the patient with Autism
Examination of Patient with Dengue
Group Photo of Group Members

FHE Report - Group F

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

FHE Report - Group F

Uploaded by

Copyright:

Available Formats

A REPORT ON

FAMILY HEALTH EXERCISE

– Roshan Raj Bhattarai (Leader) …………………..

Coordinator CBL Unit Head of the Department

Department of Community Medicine and Public Health (Stamp)

Family Heath Exercise, MBBS 9th Batch/ 3rd year, Group F ii

9th Batch MBBS

Chitwan Medical College

Family Heath Exercise, MBBS 9th Batch/ 3rd year, Group F iv

Family Heath Exercise, MBBS 9th Batch/ 3rd year, Group F v

3. Paraperesis Secondary to CNS Vasculitis: A 21-year-old male with CNS

Family Heath Exercise, MBBS 9th Batch/ 3rd year, Group F vi

Family Heath Exercise, MBBS 9th Batch/ 3rd year, Group F ix

Family Heath Exercise, MBBS 9th Batch/ 3rd year, Group F x

Family Heath Exercise, MBBS 9th Batch/ 3rd year, Group F xi

Family Heath Exercise, MBBS 9th Batch/ 3rd year, Group F 1

Family Heath Exercise, MBBS 9th Batch/ 3rd year, Group F 2

Family Heath Exercise, MBBS 9th Batch/ 3rd year, Group F 3

Family Heath Exercise, MBBS 9th Batch/ 3rd year, Group F 4

Family Heath Exercise, MBBS 9th Batch/ 3rd year, Group F 5

 ORIENTATION: (2078/04/03 - 2078/04/08)

 REVIEW OF HOSPITAL RECORDS:

Family Heath Exercise, MBBS 9th Batch/ 3rd year, Group F 6

 CONSULTATION WITH GROUP SUPERVISOR

1.6 LOGISTIC MANAGEMENT

Family Heath Exercise, MBBS 9th Batch/ 3rd year, Group F 7

Family Heath Exercise, MBBS 9th Batch/ 3rd year, Group F 8

Table No.-4: Different cases focusing on case selection

Name of Age Sex Diagnosis Case Address Mobile No

The name of the patient is changed.

Family Heath Exercise, MBBS 9th Batch/ 3rd year, Group F 9

Family Heath Exercise, MBBS 9th Batch/ 3rd year, Group F 10

Global burden of dengue

Family Heath Exercise, MBBS 9th Batch/ 3rd year, Group F 11

This alarming increase in case numbers is partly explained by a change in national

Problem Statement in Nepal

Family Heath Exercise, MBBS 9th Batch/ 3rd year, Group F 12

Family Heath Exercise, MBBS 9th Batch/ 3rd year, Group F 13

Second mosquito ingests virus with blood

Virus replicates in mosquito salivary gland

Family Heath Exercise, MBBS 9th Batch/ 3rd year, Group F 14

Family Heath Exercise, MBBS 9th Batch/ 3rd year, Group F 15

4. Dengue shock syndrome

 The best options to treat these symptoms are acetaminophen or paracetamol.

Family Heath Exercise, MBBS 9th Batch/ 3rd year, Group F 16

 severe abdominal pain

Justification for case selection:

 Name: Ful maya Rai (Name of patient is changed)

Family Heath Exercise, MBBS 9th Batch/ 3rd year, Group F 17

 Type of Family: Nuclear

History of Present Illness:

Family Heath Exercise, MBBS 9th Batch/ 3rd year, Group F 18

Past Medical History:

Family Heath Exercise, MBBS 9th Batch/ 3rd year, Group F 19

 Temperature: 98.8 F, recorded from right axilla.

Family Heath Exercise, MBBS 9th Batch/ 3rd year, Group F 20

• First and second heart sounds heard with no murmurs.

Family Heath Exercise, MBBS 9th Batch/ 3rd year, Group F 21

Currently, she is under the following medications:

Family Heath Exercise, MBBS 9th Batch/ 3rd year, Group F 22

Table No. 5- Family health diagnosis of Dengue

First visit 2078/04/12