Community Medicine 3rd Year IOM Report

CHAPTER I
INTRODUCTION
1.1 Background
Family Health Exercise is a clinico-social case study, in which we take diseases as a case to
study the importance of family for the benefit of medicine.
Family health exercise in the TU curriculum of 3rd year MBBS program is so designed that it
enables the students to understand the social, psychological and economical aspects of illness,
the interactions of the ill people with their family members and their community, the role of the
family members in the patients care, the family background and the natural history of the illness
and also the choice of the health care system and the importance of patient follow up.
Family is the basic unit of the society which comprises of a group of individuals related by social
and biological links of marriage and parenthood.
Family health is a situation or a state of positive dynamic interaction between family members
that enables each and every member of the family to experience optimal level of physical,
mental, social and spiritual well being not just absence of disease or infirmity. Such healthy
interaction between family members gives rise to the health of the individual of the family and
the health of the family as a unit of society thus contributing positively to community and the
national development.
Family Health Exercise (FHE) is the practical approach to understand the social, psychological
and economical effect of the illness on the family, thereby affecting the course and outcome of
the disease.
1.2 Objectives
1.2.1 General:
To understand the importance of family in health and its social, psychological and
economical impact on the family.
1.2.2 Specific:
To assess the knowledge, attitude and practice of the patient and family member
regarding the disease and health.
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To understand the role and importance of family in health and disease.
To analyze social, psychological and economic impact of disease and illness on the
family.
To identify various interaction between patient and family members; patient, family
members and healers.
To describe the need to follow up and implement appropriate follow up system.
To refer the patient if necessary.
1.3Methodology
For the accomplishment of the mentioned objectives our family health exercise program was
organized in the following sequence.
Orientation
Classes
Group Division
Case Selection
Literature Review
Hospital Visit
Home Visit
Seminar
Presentation 2
Report Writing
1. Orientation Classes
The principles and the procedures were thoroughly discussed in the orientation classes by
community medicine department which provided us overall idea about the program.
2. Group Division
The whole batch was divided into twelve groups. Our group was H comprising of 12
members. A supervisor was allocated for each group. For the smooth and successful conduction
of the program, assignment was distributed among group members.
3. Case Selection
Based on the criteria and guidelines mentioned in the curriculum and feasibility aspects
we selected the following 5 cases after obtaining approval of the department of community
medicine. All the cases were taken from the National Medical College and Teaching Hospital
(NMCTH), Birgunj.
S.N Type of case Case chosen

1. Communicable disease Pulmonary Tuberculosis(PTB)
2. Non communicable disease Diabetes Mellitus Type II
3. Mental illness Schizophrenia
4. Physical disability Left Femur Fracture(RTA)
5. Case of own choice Chronic Pulmonary Obstructive
Disease
The rationale for selecting the above mentioned cases are:
They are among the most common diseases prevailing in Nepal and are major public
health problems.
These cases provide us an ample scope to understand the importance of various aspect
of family and other health related issues.
They fulfill the curriculum demand made for MBBS courses.
4. Literature Review
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Different books & journals were studied, seniors were consulted, websites were surfed,
and discussions done with the group members and different departments guidance were sought
regarding the matters related to the cases. Literature review played a vital role in enhancing our
understanding of the diseases & planning of the study.
5. Hospital Visit
We interacted with the patients during their hospital stay. We took a detailed history of
patient and clinical assessment & discussion with the concerned physicians were done at the
same time.
Objectives of the Visit were:
a) Rapport building & consent.
b) To obtain history & conduct examination.
c) Exploration of the case sheets.
d) Compliance of the patients and doctors.
e) To judge the background of the patient & ascertain the psychological & economical
setback felt by the family due to the disease.
f) To study the information from the hospital records.
6. Home Visit
First visit of the cases was done as per the decided dates & the subsequent visits at different
intervals. Each case was visited thrice as per the need & on each visit we were accompanied by
the faculty of Community Medicine Department. The aims of the substantial interval between the
consecutive visits were:-
a) To assess the progress of the disease/extent of recovery.
b) To study the impact of economical, familial, psychological & social state on the disease
& vice versa.
c) To assess the knowledge & attitude of the patient & the family members regarding the
disease & health.
d) To give them health education on particular illness.
e) To observe the changes in the family that has brought by our counseling and health
education.
7. Seminar Presentation
Among our five cases, the case of RHD was presented in front of all faculties of
Community Medicine Department, and all our classmates. We received suggestions and
corrections from the teachers which were highly appreciated and taken into account while
making report.
8. Report Writing
All the information collected was put in an organized manner for report writing. The
present report is the scientific documentation of every details of the Family Health Exercise. The
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guidelines that we received during the orientation classes and the remarks and suggestions from
the audience during the seminar presentation very much helped us in drafting the report. Every
aspect of the Protocol of report writing including ethical consideration has been fully taken into
account for drafting this report.
1.4 LOGISTIC MANAGEMENT
1. NMCTH, Birgunj provided us with the funds for transportation.
2. The Community Medicine Department provided us with valuable information in the

form of Orientation classes, supervision during the programme and solutions for every
problems we faced during the Family Health Exercise
3. The DOTs clinic, Psychiatry Department, Medicine Department, Emergency Department

and Record Division of National Medical College provided us with patient information
which was vital for the progress of the Family Health Exercise.
CHAPTER II
Overview of all Cases
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Case I: Tuberculosis
Introduction
Tuberculosis or TB (short for Tubercle bacillus) is a common and often deadly infectious disease
caused by various strains of mycobacteria, usually Mycobacterium tuberculosis in humans.
Tuberculosis is a specific infectious disease caused by Mycobacterium tuberculosis primarily
affecting the lung (pulmonary TB) and can also affect intestine ,brain, bones, joints, meninges,
lymph glands, skin, genito-urinary tract and other tissue of body(extra pulmonary TB).It is
transmitted mainly by inhalation of droplet nuclei or by coming direct contact with an infected
person.
Tuberculosis is a major public health problem all over the globes, especially of developing and
underdeveloped country. Realizing the fact that it is causable type of disease, a lot of effect that
has been put to decrease the morbidity and mortality, has result in decline.
Pulmonary tuberculosis can either be primary or secondary tuberculosis. Primary pulmonary
tuberculosis results from an initial infection with the bacilli and secondary tuberculosis results
from endogenous reactivation of latent infection patients mainly complains of chronic
cough(>2wks)with copious sputum in the morning, may also complain of chest pain loss of
appetite, loss of weight, evening rise of temperature, night sweats and blood in sputum.
A new threat emerging throughout the world is in the form of increasing Multidrug
resistance(MDR)cases, causes of which can be attributed to several factors among which, few to
mention would be waning of compliance of the patient and their family, poor dietary conditions,
faulty medicines, imprudent use of anti-tuberculosis drugs and many more.
Problem Statement
Nepal
TB is a Major public health problem in Nepal.
34121 Reported Cases this year.
15655 new smear positive TB cases.
2202 were smear positive retreatment cases.
6686 were sputum smear negative.
8966 were extra pulmonary TB Cases.
64% male and 36% female.
[Source: Annual Epidemiological Report FY2071/72]
Epidemiological Determinants
A) Agent Factors:
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a) Causative Organisms:
Mycobacterium tuberculosis (most common)
Mycobacterium bovis (Bovine strain)
Mycobacterium avium (HIV/AIDS patient)
b) Source of infection:
1. Human source- Droplet nuclei of sputum from patients who are positive for tubercle
bacilli or who have received no treatment or those who havent completed full treatment.
2. Bovine source-infected milk
c) Communicability: Patients are infective as long as they remain untreated i.e. till the
tubercle bacilli are being discharged (open cases)
B) Host factors:
a) Age: Affects all ages, developing countries show a sharp rise in infection rates from
infancy to adolescence. 75% of mortality and morbidity due to disease occurs in 14-45years
age group.
b) Sex: More common in males than in females due to higher exposure in females.
c) Nutrition: Malnutrition is one of the major predisposing factors.
d) Immunity: No inherited immunity against TB infection has been found.It is acquired as a
result of natural infection or sometimes due to BCG vaccine.
e) Heredity: TB isnt a hereditary disease.
f) Some disease conditions like HIV infection, patients under extensive corticosteroid
therapy have more chance of getting TB infection.
C) Environmental factors:
TB is a social disease with medical aspects. It has been described as barometer of social status.
i. Poor quality of life

ii. Poor housing condition-lack of proper ventilation and overcrowding
iii. Population Explosion
iv. Malnutrition
v. Lack of education
vi. Large family size
TB thrives in the condition of poverty and worsens poverty.
Mode of Transmission
Droplet infection and droplet nuclei.
Incubation Period
May be weeks, months, and years. It takes 3-6 weeks for development of positive TB test after
infection.
Diagnosis
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Sputum smear (detection of Mycobacterium tuberculosis by AFB staining and
microscopy).
Sputum culture
Chest X-ray
CBNAAT
Genexpert
Tuberculin skin test - Mantoux test
Fine Needle Aspiration Cytology (FNAC)
Enzyme linked Immunosorbent Assay (ELISA)
BACTEC
Polymerase Chain Reaction(PCR)
Prevention and Control
1. Health Promotion: Raising the standard of living through socioeconomic development.
Provision of well lighted, well ventilated and open houses.

Congenial working conditions
Good nutrition
Freedom from worry & healthy habits
2. Specific protection:
Case finding: Sputum microscopy for AFB

Sputum culture for AFB
Immunization: BCG vaccination
Isoniazid (INH) prophylaxis for children under 5yrs of age who are in contact with adult
TB patients.
Chemoprophylaxis: INH for 1 yr or INH & Ethanol for 3 months.
Isolation of cases-only for sputum positive cases
Health education
Disinfection: Infected handkerchief, cotton tissues, towels & paper boxes etc. should be
burnt. Proper disposal of sputum by either burning or burying it. Infected cups & utensils
should be disinfected by boiling. Beds & beddings should be exposed to sun.
Multi Drug Resistance TB
According to WHO, MDR TB is defined as the TB that is at least resistant to Isoniazid&

Rifampicin.
Causes of Resistance
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Incorrect Prescription.
Irregular supply of drugs.
Non-compliance of treatment.
Lack of supervision & follow up. It is mainly caused due to inadequate treatment & poor
TB control programme.
Dangers of MDR TB
It is much more difficult to treat as:
Treatment can take at least 2 yrs.& the results are poor.

2nd line drugs cost 30 times as much as drugs used in SCC treatment of nonresistant TB
patient
In order to prevent transmission of primary resistant strains to others, there may be need
for hospitalization & isolation, which adds to the cost of treatment.
Careful precautions are necessary to prevent transmission, especially to health workers
caring for MDR patients.
Thus MDR TB is of serious concern to the developing countries & to the
countries where TB is associated with HIV.
Prevention of Drug Resistance
Treatment with 2 or more drugs in combination.

Using drugs to which the bacteria are sensitive.
Ensuring that the treatment is complete, adequate & regular.
Treatment:
MDR TB cases should be treated with DOTS-Plus
Directly Observed Treatment Short Course (DOTS)
Strategy to ensure cure by providing the most effective medicine & confirming that it is
taken under direct observation of a health care worker.
Relies on the use of a short course chemotherapy(SCC) at home or in health care
facilities
Effective implementation can lead to reduction in relapse & drug resistance
DOTS program in Nepal was commenced from April 1996 with the establishment of
centers at 4 Places: Bhaktapur, Parsa, Nawalparasi, Kailali
DOTS have a nationwide coverage since April 2001 with at least 1 DOTS Centre in each
district.
The coverage reached 100% by July 2003.
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By 16th July 2014,DOTS has been expanded to 1440 treatment centers & 2907 sub-
centers.
The treatment success rate is now approaching 89% & the case finding rate is 70%
(WHO target 70%).
DOTS Components
Political commitment
Detection of cases based on positive case finding.
Direct observation by a healthcare worker or community volunteer
Case detection with the help of microscopy
Establishing of a regular supply of drugs.
DOTS PLUS
Nepal is the first country in SAARC region to introduce DOTS PLUS integrating it with
the NTP since September 2005,there are 5 pilot sectors for DOTS Plus. Each located at
Mahendranagar, Nepalgunj, Kathmandu, and Biratnagar.
WHO green light committee has approved the project & has been supplying 2nd line anti
TB drugs on subsidized rates.
Criteria for operation of DOTS PLUS regimen in Nepal
Any CAT-II failure cases

CAT-I failure with culture &sensitivity test positive for MDR TB
Any history of contact with MDR TB patient along with sputum test & culture positive
for MDR
Any MDR TB with sputum & culture sensitive test positive for MDR.
National TB Programme
Goals
To reduce the mortality, morbidity &transmission of TB until it is no longer a public
health problem.
Objectives
To Dramatically rut the national burden of TB by 2015 in line with MDG and the stop TB
partnership targets.
Achieve universal access to high quality diagnosis and Patient centered treatment.
Reduce the human suffering and socio economic burden associated with TB.
Protect poor and vulnerable population from TB, TB/HIV and multidrug resistant TB.
Strategy
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Expansion of DOTS throughout the country.
Establish a treatment centre and sub-centre in health post & sub health post or in
partnership at a community level.
Establish a diagnostic microscopy center at each constituency level either at PHCC or run
by a private sector.
Pursue quality DOTS expansion.
Address TB with HIV, MDR TB & other challenges.
Contribute to health system strengthening.
Engage people with TB & affected communities.
Reasons for Selecting the Case

TB is one of the most common infectious disease & a major health problem in a
developing country like Nepal
It is a chronic disease & requires active & conscious participation of the patient & family
MDR TB relapse cases are emerging as a leading health problem
Lack of awareness about TB causes delay in seeking treatment & increases the possibility
of transmission of the disease in the family & society
Difficulty & high cost in treating MDR TB have led to heavy economic burden
This is a typical case to understand the specific roles the family in different stages of the
disease process.
Hospital Visit
Patients Profile:
Name- Ramesh (Name Changed)
Age- 18 years
Sex- Male
Religion- Hindu
Marital status- Unmarried
Address- :Parwanipur, Birgunj
Occupation-Student
Weight : 45kg
Chief Complaints:
Fever for 2 week
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Cough for 2 week
Chest pain and breathlessness for 3 days
History of Present Illness:
The patient was apparently well 2 weeks back when he suddenly developed low grade fever of
100F with evening rise of temperature, intermittent in nature, associated with rigor and sweating.
Fever subsided only after taking medicine. Fever was not associated with headache, nausea and
vomiting. Fever was followed by cough.
Cough was productive type, whitish in color initially but later it changed to yellowish without
offensive smell. It was copious in amount (2 cups/day) later he noticed blood in sputum which
was cherry red in color.
Chest pain was gradual in onset, peripheral in site, non-radiating, stabbing in character and
aggravated by coughing and inspiration. Chest pain was also associated with breathlessness.
Breathlessness was gradual in onset and was more during morning and severity increases while
coughing. It persists during rest also. Patient then came to National Medical College and
teaching hospital. Here he was diagnosed as pulmonary tuberculosis patient.
There was no nausea, vomiting, headache, dizziness and drowsiness.
Past History:
No history of, Asthma, Hypertension. No surgical intervention.
Allergic History:
He is not allergic to any substances known to him
Personal History:
Mixed diet and no addiction.
Family History:
There is no history of communicable disease like TB, HIV/AIDS, etc in the family. His father
had the history of Ischaemic Heart Disease and Hypertension. There is no history of genetic
disease in the family.
Examination
General Examination:
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On examination, the patient was ill looking poor built, conscious, co-operative and well oriented
to time, place and person. There was no pallor, icterus, cyanosis, clubbing, koilonychias,
lymphadenopathy, edema and dehydration.
Vitals:
Pulse:-88 beats/min., regular in rhythm, fair in volume ,normal in character, no radio

radial delay, no radio femoral delay, peripheral pulses are palpable.
Blood pressure:-120/70 mm of Hg, in right arm in sitting posture.
Respiratory rate:-28beats/min, normal rhythm, thoraco-abdominal.
Temperature:-980F, taken at the right axilla.
Systemic Examination
Respiratory Examination:
Inspection:
Chest normal in shape bilaterally symmetrical, moving equally with respiration.
No scar, venous engorgement
No swelling and lumps
Trachea central in position
Chest movement normal
Percussion
Normal resonant sound all over the chest
Auscultation
Bilateral vesicular breath sound
Added sounds found.
Cardiovascular System:
Apex beat at the left 5thintercostals space, medial to mid-clavicular line

Normal audible S1&S2
No murmur
Central Nervous System:
Grossly intact
Gastrointestinal System:
Inspection:-normal abdomen
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Palpation:-no any organomegaly
Percussion:-tympanic
Auscultation:-peristaltic sound heard 3-5/min
Investigations
1. Complete blood count
Total leukocyte count: 11,200/cu mm
Differential leukocyte count
Neutrophil - 73%
Leukocyte - 35%
Monocyte - 2%
Basophil - 0%
Eosinophil - 0%
Hemoglobin % - 14.0gm %
Erythrocyte sedimentation rate: - 16mm/hr
2. Sputum examination : Negative
3. Mantoux test:+++
4. Chest x-ray (PA view )
Trachea is centrally placed
Soft tissues are normal
No lesion in the rib cage
No radio-opaque region
Final Diagnosis:
Bacteriologically Confirmed Pulmonary Tuberculosis
Treatment:
The patient is referred to DOTS clinic at NMCTH for anti-tuberculosis treatment under category-
I and is in intensive phase of the therapy which is as follows:-
Tablet Isoniazid - 200mg
Tablet Rifampicin - 400mg
Tablet Pyrazinamide - 1200mg
Tablet Ethambutol - 500mg
The intensive phase is for 2months. Besides, he is given following other medicines
Tablet Pyridoxine - 20mg orally, once daily for 14 days.
Treatment of Tuberculosis As Recommended By Nepal Government
Category of tuberculosis Initial phase* Continuation phase
1 A..New cases (bacteriologically or2 month HRZE 4 month HR

clinically confirmed)of pulmonary TB
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B. New cases of severe form of extra
pulmonary TB
2 New cases of TB relapse, treatment2 month HRZES/ 1 month5 month HRE

failure and return after default. HRZE
. H=Isoniazid, R= Rifampicin. Z=Pyrazinamide, E= Ethambutol, S= Streptomycin.
Advice on Discharge:
To the patient:
Rest
Regular intake of medicine and regular follow up of DOTS clinic.
Usage of mask while going school and playing.
Take protein rich diet.
Visit hospital after 7 days or S.O.S
Cover mouth & nose with handkerchief while coughing and sneezing.
To the Family:
Maintain isolation at home

Discourage free interaction of patient with siblings.
Screening of all the family members for tuberculosis.
Home Visit
First Home Visit
Objectives
a) To collect data on household demographic.
b) To collect data on socio-economic environment and its facets for recovery and help from
family members.
c) To assess/evaluate the impact of economical, familial, psychological and social state on

the disease and vice versa.
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d) To assess the knowledge, attitude and practice of the patient and the family members
Activities
First home visit was on 2016/09/11 with all the information gathered from the Medicine ward &
DOTS clinic of our college .We went to the patients home, he used to live with his family in his
own house. His house was located at a 5 min. walking distance from the main road. We had
rapport building with the family members and also explained about the purpose of our visit. We
had divided ourselves into subgroups so that some of us could inquire about the clinical course
and treatment while some assessed their economy, hygiene, knowledge, attitude and practice
regarding the disease on the patient and his family members.
Firstly, we made proper visit of house of the patient and have vitals and family profile.
We collected the proper data related to housing, lighting, ventilation, food.
We discussed the case with the family to know the impact of disease on the family and
patient socially, economically and psychologically.
Output
Family composition
INDEX
Patient
53 4 Male
8
Female
22 20 19 17
Dead
Fig: Family composition of the patient
Housing
Patient and his family lives in own pakka house with not adequate set back area. Not well
ventilated, 2 rooms and kitchen which is separate from living rooms, use smoky Chula for
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cooking. We inquired about his health and about his family members. Sanitation around the
house was good with stagnant water near the hand pump. Source of water is hand pump. They do
not use filtered or boil water. Toilet was not present. They used to go to field for defecation. Over
all, we found that the housing & sanitation condition was not good.
Socio-Economic Condition
The patient belongs to lower socio-economic family. 6 members in family with income 14,000
per month. The children are educated up to Class 8 except daughter. Father is educated up to
Class 8.
Knowledge, Attitude and Practice

Patient and his family had some knowledge about TB except his mother but she knows the fact
that TB is cured by regular and complete medication. The family knew that the patient required
the nutritious diet they had made effort to provide nutritious diet to patient. As his family knew
the importance of regular medicine, he was made to visit DOTS clinic at NMCTH as per as
schedule. However, proper isolation of the patient was not done. Although TB is associated with
social stigma, we observed that the neighbors were not known about the patients sickness.
Compliance to Treatment
The patient was taking his medicines regularly. He had not missed a single dose, thus compliance
to treatment was good.
Impact of the Disease

Economic Impact
The cost during hospital stay, for diagnosis and treatment added little burden earlier but now not
due to free medicine from DOTS.
Psychological Impact
On Patient
The continuous cough & fever made the patient feel sad & stressful initially.
Affected schooling.
On Family
They were worried about the patients health.

The patients father sometimes had to miss his work for the checkup of the patient so his
work was being hampered.
Second Visit
Objectives
To collect data on interaction among family members.

To identify coping strategies of family towards the disease.
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To provide health education to family members along with the patient.
To assess the health of the patient and suggest accordingly.
Activities
It was on the 7th day after the first visit that we met the family for the second time. The patient
and his family member were familiar to us and it was easy for us to advise them about the
aspects of the disease unknown to them. We gave them health education regarding the
predisposing factor, causative factor & appropriate measures to prevent the transmission of the
disease and its control. There were very positive towards our instruction & suggestions.
We took a short discussion with the family to know
Their knowledge about the disease.

The attitude towards the disease by family members and the patient.
Output
We imparted health education on:-
Importance of taking regular medicine as per the schedule of DOTS clinic to prevent
resistance and treatment failure.
Affordable source of protein and other nutrients, green leafy vegetables, milk and
soybeans is more quantities.
The transmission & control of the disease.
Importance of isolation and feasible way of isolation other.
Cover his mouth while coughing & sneezing by using a mask.
To wear mask, mainly while going in public places.
BCG vaccination to other young children in the family and neighborhood.
Side effects of the drugs he was taking and asked them to consult the doctor as soon as
she experiences any of them.
Early symptoms of the disease, which if seen in any of the family member should consult
to doctors.
Third Home Visit
Objectives
a) To follow the compliance of treatment procedure and its progress on health.
Activities
After 7 days of our 2nd visit, we again went to their home for our 3rd visit, during which we
assessed the impact to our counseling on the patient and his family.
We asked them how they are now maintaining the health condition of patient.
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A proper discussion was done with the family about what are the changes they have seen
after application of instructions we have given in second visit.
Compliance of the patient was reported.
The family members and the patient have done well cooperation with us.
Output
The condition of the patient was good. He was having soybeans, milk, pulses, egg and occasional
meat in the diet. He also went to DOTS regularly for the medication. The family members had
taken precaution in order to control the transmission. The patient started using handkerchief
while coughing, sneezing, etc. and regular mask most of the time.
Case Summary
From his case, we learnt about the impact of TB on the happiness of whole family, economical
and social aspects and show the role of family and the community in curing the disease. Despite
strong National Programme to control TB, the incidence rate as well as the mortality in Nepal is
still very high. Furthermore, multidrug resistance strains of disease are emerging as a
considerable threat to TB control, especially for developing country.
Case II: DIABETES MELLITUS

Introduction
Diabetes mellitus (DM) comprises a group of common metabolic disorders that share the
phenotype of hyperglycemia. Several distinct types of DM exist and are caused by a complex
interaction of genetics, environmental factors, and life-style choices. Depending on the etiology
of the DM, factors contributing to hyperglycemia may include reduced insulin secretion,
decreased glucose utilization, and increased glucose production. The metabolic dysregulation
associated with DM causes secondary pathophysiologic changes in multiple organ systems that
impose a tremendous burden on the individual with diabetes and on the health care system. In the
United States, DM is the leading cause of end-stage renal disease (ESRD), non-traumatic lower
extremity amputations, and adult blindness. With an increasing incidence worldwide, DM will be
a leading cause of morbidity and mortality for the foreseeable future.
Diabetes can be classified as (WHO classification):
1. Diabetes mellitus:
Insulin dependent DM (IDDM, Type I)
Non-insulin dependent DM (NIDDM, Type II)
Malnutrition related DM (MRDM)
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Other types (secondary to pancreatic, hormonal, drug induced, genetic and other
abnormalities)
2. Impaired glucose tolerance (IGT):
3. Gestational DM:
Type 1 Diabetes was previously termed 'insulin-dependent diabetes mellitus' (IDDM) and is
invariably associated with profound insulin deficiency requiring replacement therapy.
Type 2 Diabetes was previously termed 'non-insulin-dependent diabetes mellitus' (NIDDM)
because patients retain the capacity to secrete some insulin but exhibit impaired sensitivity to
insulin (insulin resistance) and can usually be treated without insulin replacement therapy.
However, up to 20% of patients with type 2 diabetes will ultimately develop profound insulin
deficiency requiring replacement therapy so that IDDM and NIDDM were misnomers. It affects
more than 120 million people world-wide, and it is estimated that it will affect 220million by the
year 2020. Diabetes is usually irreversible and, although patients can have a reasonably normal
lifestyle, its late complications result in reduced life expectancy and major health costs. These
include macro vascular disease, leading to an increased prevalence of coronary artery disease,
peripheral vascular disease and stroke, and micro vascular damage causing diabetic retinopathy
and nephropathy, and contributing to diabetic neuropathy.
Type 1 diabetes is a disease resulting in insulin deficiency. In Western countries almost all
patients have the immune-mediated form of the disease (type 1A). Type 1 diabetes is prominent
as a disease of childhood, reaching a peak incidence around the time of puberty, but can present
at any age. A 'slow-burning' variant with slower progression to insulin deficiency occurs in later
life and is sometimes called latent autoimmune diabetes of adults (LADA). This may be difficult
to distinguish from type 2 diabetes. Clinical clues are considerable weight loss; hyperglycemia
which fails to correct with diet and tablet treatment.
Problem Statement
Nepal
According to stepwise non communicable diseases risk factors survey, 2007/08.
Little more than one in ten Nepalese people were found to have diabetes where
women were relatively more than man. Almost equal proportion of man (59.1%)
and women (56.8%) used oral hypoglycemic drugs.
Similarly 14.1% of the patients were taking insulin.
Nine out of ten diabetic patients appear to have received life style related advices
such as losing weight, exercise etc.
According to 2015 survey of Internation Diabetes Federation about 526000 cases
of cases are present in Nepal.
Clinical Features
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Acute presentation
Polyuria - due to the osmotic diuresis that results when blood glucose levels exceed the
renal threshold.
Thirst - due to the resulting loss of fluid and electrolytes.
Weight loss - due to fluid depletion and the accelerated breakdownFat and muscle.
Polyphagia
Ketoacidosis may be the presenting feature if these early symptoms are not recognized
and treated in type 1 diabetes.
Sub-Acute presentation
Staphylococcal skin infections

Retinopathy noted during a visit to the optician
Polyneuropathy causing tingling and numbness in the feet
Diabetic retinopathy
Arterial disease, resulting in myocardial infarction or peripheral gangrene.
Diagnosis
The diagnosis of DM can be established using any of the following criteria:
1) Plasma glucose 126 mg/dL(7.0 mmol/L) after an overnight fast. A positive value should
be confirmed with a repeat test.
2) Symptoms of diabetes (polyuria, polydipsia fatigue, weight loss) and a random plasma
glucose level of 200 mg/dL(11.1 mmol/L).
3) Oral glucose tolerance test (OGTT) that shows a plasma glucose level of 200 mg/dL (11.1
mmol/L) at 2 hours after ingestion of 75 g of glucose.
Hospital Visit
Patients Profile:
Name : Harihar Shah (Name changed)
Age : 42 yrs
Sex : Male
Marital status: Married
Religion :Hindu
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Address :Vishuwa , Birgunj
Occupation: Shopkeeper
Chief Complaints:
Difficulty in Vision since 1 year.
Weakness since 2-3 day
Mr. Harihar Shah, a known case of type-2 Diabetes Mellitus since last 18 years and under
medication presented with difficulty in Vision since 1 year. There is also the decreased sensation
of pain & temperature over the limbs and weakness of entire body.
Patient is known case of DM-2 since 18 years. He is on IV medication since last 4 years .
No H/O fever, vomiting, abdominal pain, diarrhea, constipation, bleeding from any site, chest
pain, shortness of breath, fainting, seizures & loss of consciousness.H/O increased frequency of
urine with incomplete voiding & passing urine 6 times during night.
Past History
There was no past history of infectious diseases like tuberculosis, typhoid, malaria, kala-azar
jaundice.
Personal History
He is 42 year married with 2 daughters and a son. He is educated. He has mixed diet. He doesnt
chew tobacco or smoke and has no bad habit. His bowl and bladder habit was normal. Sleep and
appetite was decreased.
Family History
There is no family history of DM . There was no family history of any infectious disease like TB,
malaria, kala-azar etc.
Drug History
There was no any allergy history of drug.
22
Examination
General Examination
The patient is moderately built, well oriented to time, place and person. The general condition of
the patient is fair. There was no icterus, no lymphadenopathy, no clubbing, no cyanosis and no
sign of dehydration. Edema was present in the left foot and mild pallor.
Vitals:
Pulse :84 beats per minute, regular, fair in volume,

arterial wall-elastic and collapsible, no radio- radial &
no radio- femoral delay & all peripheral pulses are palpable.
Blood pressure: 150/90 mm of Hg, right arm in sitting position.

Temperature: 98oF taken under right axilla.
Respiration: 20 times per minute, regular, abdominothoracic type.
Respiratory System:
Chest bilaterally symmetrical, normal vesicular breath sound, no added sound heard.
S1, S2 heard. No murmur
A. On Inspection - Normal fullness.
B. On Palpation - There is no tenderness in the epigastric region.
C. On percussion Normal.
D. On Auscultation - Bowel sound present.
Central Nervous System
23
a) Higher mental function- intact.
b) Sensory function- intact.
c) Motor function - intact.
Investigations
1. Routine blood examination.
TLC - 13000 / Cu mm.
DLC - N-68% L-28% E-0%, B-00%, M-1%
2. Blood Sugar:
Fasting-230mg/dl
PP-380mg/dl
3. Serum electrolytes.
Na+-125mEq/L;
K+- 6mEq/L ;
HCO3 - 15mmol/dL .
4. Urinary
Glucose: +++
Ketone body:++
5. Chest X-ray PA view Normal.
Final Diagnosis: Diabetes mellitus
Home Visit
First Home Visit
Objectives
24
family members.

Activities
The patient's house is at a convenient distance from our hospital. As we had already traced his
house, we had no problems to reach there. We began by introducing ourselves and then talked to
him about his problems. He was co-operative and willingly gave us all the information and
explained us all about his disease from the very beginning. We came to know that even though
the patient seemed perfectly all right, at present, there has been regular fluctuation of blood sugar
level to very high and low We then took vitals of the patient; we also talked of his daily activities
and diet. After sometimes, we left promising to visit again after few days.
We discussed the case with the family to know the impact of disease on the family and
patient socially, economically and psychologically.
Output
Housing Condition
The patient lives in his own Pakka house located in Vishuwa, Birgunj. The house consists of 3
bed rooms, a kitchen and a bath room with attached toilet. There was no physical crowding, the
kitchen hygiene was satisfactory and they used LPG and some time in burning wood for cooking.
Hand pump water supply is the main source of water, which serves for their drinking and other
household purposes. The house was well lighted and well ventilated.
Socio-Economic Status:
His Family income is NRs.20000/- which is adequate to meet their basic requirements. His son
has been engaged in work and he supports his father financially for treatment.
Socio-Cultural Practice
25
The family is Hindu by religion and celebrates every festival celebrated by Hindu. The males are
educatedup to school level and females are illiterate, they know about the common diseases. In
his family, there are no misperceptions regarding the etiology of diabetes, such as supernatural
cause. There are no social stigmas or taboos attached to it and his relatives and family dont
believe that diabetes is a communicable disease.
Family profile
The family consists of 5 members including the patient, his wife, his 2 daughters and son.
INDEX
Female
Male
Dead
Patient
Fig: Family composition of the patient
Health seeking behavior
If there is any kind of disease in the family, they first visit the local medical shop and inquire
about the disease and get the drug without prescription instead of going to traditional healers. If
its not cured or the symptoms still persist they go to the hospital.
Knowledge, Attitude, and Practice
The patient is health conscious and he knows about his disease very well. He is having regular
consultations with Physician and is aware about the side effects and the various complications
that he might face in the future. He knows that the disease is non-communicable. According to
26
him, the disease is incurable and the best he can do is keep proper control on his blood sugar
level in order to prevent and delay complications. He manages himself accordingly by making
proper adjustment in his dietary habits. The family on the whole are very much health conscious
and visits to their doctor in Birgunj for their health related problems.
Impact of Disease
On Patient:
The patient has come a long way fighting 18 long years with the disease affecting him in various
ways. After he was diagnosed as the case of diabetes mellitus, a large portion of income was
spent on his medication. he has spent most of his life visiting doctors, hospitals and going for the
long list of never ending routine checkups and tests.
On the family:
The family has been very much supportive towards him. They have always encouraged him. His
family, especially his wife has to spend extra time to look after him and work extra hour for
earnings. They have always been very strong in front of him always encouraging him but they
are always worried about him, his health and his future. The family has visited various
physicians despite the high expenses for his checkups, tests, visit etc.
Second Visit
Objectives

Activities
We made our second visit after a gap of 7 days.We take a short discussion with the family to
know

Output
Advice Given:
27
1. We advised him for regular physical exercise like morning walk.
2. We explained him about the proper dietary habits, how to take proper food(low
carbohydrate &fat diet, and take diet with high fiber) in proper time(as sudden
hypoglycemic coma is more chance to develop on prolong fasting).
3. We told him the importance of proper hygiene, as diabetic individuals are more
susceptible to infections.
4. We also asked him to avoid stress.
The patient and his family members were familiar to us and it was easy for us to assess the
compliance of the patient and gave him certain advices.
Compliance with treatment:
There is a good adherence to the treatment and the advice given by the physician. He is
managing his diabetic diet strictly. He keeps on visiting doctor regularly including eye checkups,
takes his medicine regularly.
Third Visit
Objectives
Activities
We made our 3rd home visit after 7 days.
Output
We then talked to them and assessed the changes in the patients day-to-day life as per the health
education imparted in our previous visit. We found that the patient had made an appointment
with a doctor for a thorough check up and to read just his medication. He said us that he did
exercises and is strictly controlling his diet. He also said that he goes for morning walk every
day.
28
Case Summary
Diabetes is a multifaceted disease, which has a chronic course and affects many vital systems of
the body. If the disease is not detected and treated, it leads to various complications like diabetic
foot, renal failure, cataract eye, CVA. This is the condition which taxes the patient to a maximum
in terms of emotions and economy. Whole family is also affected by the disease as it proves to be
a heavy economic burden.
This is a disease which needs to be managed medically as well as with social support. The old
age itself is a difficult time and when diabetes intervenes, this period could become plagued with
frustrations and disabilities. The patient should be advised on proper care and maintenance of
blood glucose level as well as the weight. The health policy makers should emphasize on health
education regarding diabetes as it is on the rise in Nepal as well. Once more as we come across
another disease, we realize how important it is for us to not just look at the blood sugar level but
at the patient who is a part of a family.
Case 3: SCHIZOPHRENIA
Schizophrenia, severe mental illness characterized by a variety of symptoms, including loss of

contact with reality, bizarre behavior, disorganized thinking and speech, decreased emotional
expressiveness, and social withdrawal. Usually only some of these symptoms occur in any one
person. The term schizophrenia comes from Greek words meaning split mind. However,
contrary to common belief, schizophrenia does not refer to a person with a split personality or
multiple personality. To observers, schizophrenia may seem like madness or insanity.
Perhaps more than any other mental illness, schizophrenia has a debilitating effect on the
lives of the people who suffer from it. A person with schizophrenia may have difficulty telling
the difference between real and unreal experiences, logical and illogical thoughts, or appropriate
and inappropriate behavior. Schizophrenia seriously impairs a persons ability to work, go to
school, enjoy relationships with others, or take care of oneself. In addition, people with
schizophrenia frequently require hospitalization because they pose a danger to themselves. About
10 percent of people with schizophrenia commit suicide, and many others attempt suicide. Once
people develop schizophrenia, they usually suffer from the illness for the rest of their lives.
Although there is no cure, treatment can help many people with schizophrenia lead productive
lives.
Symptoms:
a) Delusion
b) Hallucinations
c) Bizarre Behaviour
29
Diagnosis
Schizophrenia is diagnosed clinically. The DSM-IV-TR diagnostic criteria include

specifiers (prognosis) that offer clinicians several options and describe actual clinical situation.
Characteristic symptoms: Two (or more) of the following, each present for a significant portion
of time during a one-month period(or less if successfully treated):
Delusion*
Hallucination**
Disorganised speech
Catatonic behaviour
Negative symptoms (affective flattening, avolition, alogsia)
Social/occupational dysfunction
Duration
Exclusion of other conditions:
Schizoaffective disorder
Mood disorder
Substance abuse
General medical condition
*only one criterion if delusion are bizarre
**only one criterion required if a voice keeping up running commentary on persons behaviour
or thoughts, or two or more voices conversing with each other
Epidemiology
Nepal:
Though there is no specific data of the cases of schizophrenia in Nepal, as evidenced by the
records of our college and world, the trend can be presumed to be increasing. With a total of
about 20,000 cases registered to National Medical College Psychiatry ward (indoor as well as
outdoor), almost 800 were diagnosed as Schizophrenia, which is as a matter of fact, alarming.
30
Moreover, it was found that the number of cases reported per year has been increasing, which
makes the condition a concern for the public health.
Predisposing Factors:
a) Host factors:
Age: peaking in between 15-25 years for males, 25-35 years in females
Sex: equally prevalent in both male and female. Earlier onset is seen in men, and better outcome
is seen in women.
Genetic factors: children born to a parent with schizophrenia has ten fold increase risk of
Schizophrenia, and ones born to parents with both having history of schizophrenia, has fifty fold
increase risk of schizophrenia.
b) Environmental Factors
Seasonal Variation: Person born in winter and early spring are more prone to develop the disease.
Population density: Schizophrenia is more common in cities that are densely populated and
apparently absent in cities with low population density.
Reasons for selecting the case:
Schizophrenia is the worst disease affecting mankind.
It is one of the leading causes of disability worldwide leading to huge number of suicides every
year.
To impart knowledge about schizophrenia to the society and make them know that it can be
effectively treated with medications and psychotherapies.
Increasing emotional disturbances, stress, frustration, etc. in schizophrenia.
Social stigma and discrimination regarding psychiatric disorders even neurotic disorders.
Hospital visit:
31
We first met our patient at National Medical College Teaching Hospital, Psychiatry ward where
we interacted with him and his uncle and took a detailed history and examined him under the
supervision of doctor.
Particulars of the patient:
Name: Shyam Kumar Mahato
Age: 18 years
Sex: Male
Occupation: Mason
Marital status: Unmarried
Religion: Hindu
Address: Lalparsa, Bara
Chief Complaints:
Persecutory Delusion since 1 week
Disorganized Speech since 1 week
Mood Changes since 1 week
History of Present Illness
According to the patient, he was apparently well 1 week back. Then she developed fear of his
relatives that they are trying to harm him.
According to his uncle, he was apparently well 1 week back. Then he noticed his fast speaking
pattern and sudden mood changes.
Past History:
The patient has no past history of any acute or chronic diseases.
Personal History:
32
Marriage: He is unmarried.
Diet: mixed diet
Non-smoker
Non-alcoholic
No history of other drug abuse
Allergic History:
Not known
Family History:
No similar illness in family.
Examination
o Patient was conscious, irritable and alert, oriented with time, place and person.
o Decubitus- Sitting position.
o Average built, well nourished.
o Mental state-confused and frightened.
o Involuntary Movements - Absent.
Vitals:
Pulse 82beats per minute, regular, fair in volume, arterial wall-elastic and collapsible no
radio- radial or radio- femoral delay.
Blood pressure 126/70 mm of Hg, right arm in sitting position.
Temperature 98 0 F taken under axilla.
Respiration 16 per minute, regular, thoraco-abdominal type.
There is no pallor, icterus, lymphadenopathy, clubbing, cyanosis, oedema and dehydration.
33
Systemic Examination:
Nervous System:
Higher Mental FunctionFindings:
Appearance: Clothes thrown away, slightly frightened with no facial expression.
Behaviour: Reserved.
Speech: Fast Speaking
Mood: Changing Constantly
Cranial Nerves Examination: Grossly intact.
Sensory Examination: Grossly intact.
Motor Examination: Grossly intact.
Special Test: Grossly intact.
Abdominal and GI Examination:
Inspection
Abdomen: Normal, umbilicus centrally placed and inverted. No visible peristalsis,
pulsation and lump. All the regions of the abdomen move symmetrically with Respiration.
Palpation
Superficial Palpation Normal Temperature. No tenderness. No palpable Mass.
Deep palpation Normal.
Percussion
Normal.
Auscultation
Normal bowel sound present.
Respiratory system Examination:
Chest bilaterally symmetrical.
Vesicular breathe sound present.
34
No added sounds were heard as such.
Cardiovascular system examination:
S1 S2 normal with no added sounds.
Investigations:
1. Complete Blood Count
Total Leukocyte Count: 9,000/cu mm

Differential Leukocyte Count:
i. Neutrophils: 63%
ii. Lymphocytes: 35%
iii. Monocytes: 2%
iv. Basophils: 0%
v. Eosinophils: 0%
Haemoglobin % : 12.30 gm%
Erythrocyte Sedimentation Rate : 14mm/hr
Blood grouping : O+ve
Bleeding Time : 3 minutes
Clotting Time : 4 minutes
2. Routine Examination
a) Blood sugar random 125mg/dl
b) HIV negative
c) HbsAg Negative
3. Urine Examination
a) Colour Straw colour
b) Albumin Nil
c) pH 6.5
d) Epithelial Cells 1-2/HPF
e) Red Blood Cell Nil
f) White Blood Cell 1-2/HPF
g) Glucose absent
35
Treatment History:
Medical treatment:
Megazine 50mg BD
Tilaz 5mg BD
Klozep 0.5mg TDS
Diagnosis
Schizophrenia
Advice at the time of discharge
To the family:
To provide friendly environment to the patient.

Monitor regular drug therapy in the patient.
To be aware of any abnormalities in the behaviour of the patient.
To visit the hospital after 12 days.
To the patient:
Take the drugs regularly.

Attend psychotherapy or behavioural modification therapy.
Home Visit
First Home Visit
Objectives
family members.
36
Activities
We reached Lalparsa after contacting with his uncle. When we reached there, we were easily able
to locate the house of the patient by a call made to the patients uncle. When we reached the
house, the patient was feeling frightened and was anxious finding us around. We did a quick
interaction and then, a general survey of his house, environment and living conditions.
Activities
We discussed the case with the family to know the impact of disease on the family and patient
socially, economically and psychologically.
The interaction with his uncle provided with lot of helpful information about the patients
behaviour at home.
We attempted a conversation with the patient about his interests, his society and his family. He
was not interested in discussing about them. On being inquired about the cause of this condition;
he told about the persecutory delusions of him.
Output
Family Tree
Dead
Patient
Female
Male
37
Socio-economic Condition
He and his father earned for the family. His father earned 15000 per month and he earned 10000
per month.
Per Capita Income = Total Income/Total members in family
= 25000*12/8
= Rs. 37500
= $375
They are above poverty line.
Socio-cultural Practices
The family is a religious Hindu family. They follow all their rituals as a respect to god
and the community they live in.
Housing condition
The patient lives with his grandfather, father, mother, two sisters and two brothers in the
kachha house with a sound setback area. His house was small with no sufficient ventilation and
lightning. There were three rooms, with attached kitchen. The kitchen was clean with smoky
chula and with improper drainage. The source of water was hand pump. There was a public toilet
and it was water sealed type.
Food and Hygiene
The patients family had a sound knowledge about the food hygiene. They drink filtered
water and eat well cooked food. The family had enough income to sustain their family expenses
and provide well balanced diet to the family members.
They firmly believe in God. However, they dont have any misconceptions about the health
related problems and always consult health personnel in case of any kind of illness. They had
38
sound knowledge about the communicable and non communicable diseases. Their health seeking
behaviour was satisfactory.
They are hopeful for the complete cure of the patient. They gave every dose of medication to the
patient without missing one dose.
Impact
On the Patient
The patient bears maximum impact of the condition. Due to this problem he had to get isolated
from the society. He cant go to the factory for working which has negative economic impact on
the family.
On the Family Members
Mr. Ram Gyan Mahato, doesnt consider the patient as a problem. It came as a shock when he
had found that his nephew is suffering from the mental disorder. Now, he is in constant fear
about his nephew. These days, he never let him alone or go to places without any company.
Second Home Visit
Objectives

Activities
We planned the second home visit after 7 days.
We take a short discussion with the family to know
a) Their knowledge about the disease.
b) The attitude towards the disease by family members and the patient.
39
We started talking to the patient. We found him to be more open to us this time. We concentrated
out conversation in the state of the patients mind after the incident. He told us that his family
members were more receptive to her these days and was happy about it. We talked to the family
regarding the advices given at the hospital and reminded them of the importance of those
advices. We told the family and the patient not to hesitate in taking psychotherapies adding its
importance in their case. They were very positive about them and were sincerely trying to give
the best to him.
Output
a) Health education given to the patient and his family
b) Explanation on psychiatric disorders like Schizophrenia and its social impact.
c) Patient should undergo psychotherapy or behaviour modification therapy.
d) Improve bonding with the patient through positive interactions and improve family
problem solving and conflict resolution.
e) Patient should feel free to present his feelings to the family. He should share his
experiences, sweet as well as bitter to his family members.
f) Control of psychosocial stress on the patient.
g) They should maintain a positive attitude about psychotherapies rather than being
ashamed of attending them.
Third Home Visit
Objectives
Activities
We went for our final visit 7 days after our 2nd visit.
A proper discussion was done with the family about what are the changes they have seen after
application of instructions we have given in second visit.
40
Compliance of the patient was reported. Compliance was good because father was also the
mental disease patient since 10 years and was taking medicines regularly without missing doses.
Output:
We were actually happy to find that he was progressing from his family members. He told us
about the improvement in Patients health and his state of mind. He had started taking interest in
his surroundings. We inquired about how he is feeling and how is it been going with him. After
talking for a while and being satisfied with his positive attitude, we bade goodbye.
41
Case IV: Left Femur Fracture (Road Traffic Accidents)
Road Traffic Accidents is defined as unexpected, unplanned accident taking place on road
between a moving vehicle and an object (moving or stationary). WHO advisory group in 1956
defined accident as unpremeditated event resulting in recognizable damage.
Accidents have their own natural history and follow the same epidemiological pattern as any
other disease- that is agent ,host and environment interacting together to produce injury or
damage. Majority of the accidents are preventable.
Epidemiology
Global Situation
According to W.H.O, RTA is currently ranked 4th leading cause of death and it is expected that in
2020, RTA will be 3rd leading cause of disability in the world. 8% of the total deaths take place in
world due to RTA. More than 50% of deaths and injuries occur in 15-44yrs age group with peak
mortality and morbidity in 15-24yrs age group. Statistical studies have shown that developing
countries have more number of accidents than developed countries.
Problem In Nepal
With the major epidemiological transition, socio-demographic changes and technology
revolution, among the member countries of the South-East Asia Region, RTA is given the first
priority in Nepal among the injuries.
Every year well over 800 people die in road traffic accidents across Nepal. In 2007 alone, there
were 962 reported road traffic fatalities and 2653 non-fatal road traffic injuries.
Road Traffic Accidents are increasing more in todays scenario.
Reasons for selecting the case:
With RTA emerging as major problem in world it encourage us for selecting the case. It is the 3 rd
leading cause of death in our country & securing 8th position in the world. More than 50% of the
population affected is of 15-44yrs age group. Weather conditions of Nepal and condition of roads
favors RTA. Low levels of awareness among the people regarding the traffic rules also
encouraged us to select this case. Alcohol consumption by the drivers and pedestrians is a major
42
problem which is in maximum cases associated with accidents. There is increment of 54.81%
new vehicle registrations in our country in last 5 years (as per DoTs,Nepal).
Hospital Visit
Patient profile
Name: Mumtaz Khatun(Name Changed)
Age: 40 years
Sex: Female
Occupation: Housewife
Marital status: Married
Religion: Muslim
Address: Bhediyahi, Parsa
Mode of Admission: Emergency
Date of Admission: 2016-9-3
Date of Discharge: 2016-9-8
Chief Complaints:
Bike accident and injury on the left femur 2 days back.
Two days back when she was on her way to home from buying vegetables she suddenly collided
with a bike which was coming from the opposite direction.
Within few minutes the people of the locality gathered and took her to National Medical College
and Teaching Hospital, Emergency Department. She was treated symptomatically there and
admitted for three days in orthopedic ward.
The patient gave the history of bleeding from right forearm and right leg, abrasion of right
shoulder, and pain in left leg.
There is no history of vomiting. He was unconscious for about three hours when taken to
Emergency Department where after symptomatic treatment he gained his consciousness.
Past History:
43
There is no history of head injury, or any systemic illness. There history of unconsciousness just
after accident which was for about three hours.
There is no history of hypertension, T.B., diabetes or any other chronic disease.
Personal History:
She is non-vegetarian, non-alcoholic, has no any other addiction like smoking, tobacco chewing,
etc.
Allergic History:
There is no any known allergic history.
Family History:
No any diseases in the family.
Examination
General Examination
Patient was conscious, cooperative and alert, well oriented with time, place and person.
Decubitus - Supine position, extended lower limbs without any movement.
Gait - Cant walk without support.
Speech - Normal.
Mental state - Depressed.
Arms and legs drift - upper limbs; absent and lower limbs; positive
Movements of neck and cervical spine-normal.
Pallor- present
Edema, cyanosis, clubbing , dehydration, Icterus- absent
Vitals:
Pulse: 80/min regular, fair in volume, no radio-radial or radio-femoral delay.

Blood Pressure: 130/85 mm Hg, Rt. brachial artery, supine position
Oral temperature: 98.6 F
Respiratory rate: 18/min
44
Central Nervous System Examination
All the cranial nerves were intact.
Locomotory Function
Lumbar spine:
Pain exacerbated in the lumbar region by the movement of spine by Straight leg raising test-
restricted in both lower limbs.
Motor Function (Both Lower Limbs):
1) Inspection and palpation:
Muscle bulk-lower limbs: normal

Lower limbs: muscle wasting
No fasciculation or abnormal movements found.
Tone-Absent
Power-Grade 0 in Right lower limb and Grade1 in left lower limb.
Coordination-absent
2) Deep tendon and planter reflexes-absent
Sensory Function (Both Lower Limbs)
Superficial(pain, touch, temperature) Absent

Deep(joint sensation, position sensation, pressure sensation, vibration sensation)-
Absent
Reflexes
Both superficial and deep reflexes are absent in lower limbs.
Visceral Function
Bladder- catheterization is present

Bowel-incontinence is present
Swallowing-normal
Respiratory System:
Chest elliptical, bilaterally symmetrical, vesicular breath sound, no any added sound.
45
Cardiovascular System
S1, S2 heard no murmur.
Investigations
1. ROUTINE BLOOD EXAMINATION

TLC-11300/cu mm
DLC-within normal range
Hb%-7.9%
E.S.R-60
Blood grouping- O+ve
BT & CT- within normal range
Blood glucose random-125mg/dl
2. X-Ray Abdomen: unstable L5 posterior fracture

3. CT scan of dorsal spine: D7-D11 with 3D reconstruction-showing type 3, chance fracture
causing anterior displacement of proximal segment causing canal compression.
Treatment History
Trauma management at NMCTH

Tab MEGAPEN
Cap BECASOL
Tab LIMCEE
Tab PHENYTOIN
Diagnosis:
Left Femur Fracture
Advice on Discharge
Daily and proper dressing of the bed sores.

Regular massage of the lower limbs.
Consult with physiotherapist once a week.
Regular medication and follow up.
46
Home Visit
First Home Visit

Objectives
family members.

Activities
We reached the patients house after 15 minutes from NMCTH. We were warmly welcomed by
the family. They seem pretty depressed about her condition but were pretty much relieved by
seeing a group of people in Medical attire. She was sitting on one side of the bed. Her mother in
law and husband were standing by her side and soon herd of people staying nearby gathered out
of curiosity. We grabbed the details of housing and socio-economic conditions, nutritional and
food habits.
Output
Housing Condition:
The patient & her family members live in a pukka house with 4 rooms including kitchen. The
rooms had inadequate ventilation. There was no set back area. Natural lighting was improper.
They use tube well as a source for drinking water and toilet was within the house maintained in
good condition. Drainage system was proper.
Socio economic status:

The patient and his husband who is a farmer are economically active members in the family.
Monthly income is approx. Rs 20,000
Family tree
47
Male
Female
Patient

The family does not believe on traditional healers. For any sort of treatment they go to the nearby
medicine shop and then to the hospital. They get some health information from TV, radio etc.
Regarding this accident she believes that it was her bad luck & destiny.
When we enquired them about the road traffic signals and the rules, zebra crossings, they had
idea about it. We advised them to walk in the footpath and cross roads in zebra crossing and
during crossing roads they should look for vehicles.
Impact Of The Disease

Economical Impact:
Family had a moderate socio-economic status. Conditions became worse when Mrs. Mumtaz met
the accident and was bedridden. And a lot of money had been spent for her treatment.
She is not able to perform her daily activity due to disability.
Psychological Impact:
On The Patient:
She is totally shattered after the dreadful incidence happened to her. According to her husband
his wife now talks very less with the neighbors, doesnt go to the village gatherings. She really
feels sorry for her family for no assistance from her side. She finds herself good for nothing and
feels that she has done nothing but added a big burden to her family.
On The Family Members:

Her husband tries to help her out mentally and physically. Intimacy with his wife is vanishing
and their sexual life has been adversely affected which is acting as a hindrance in their relation.
48
Her mother-in-law encourages her to keep her busy with the things she can perform. As her
children are too small, they do not even know what happened to their mother.
Second Visit
Objectives

Activities
We made our 2nd home visit after 7 days of first home visit which mainly focused on monitoring
the progression of health condition of the patient & health counseling to the patient & other
family members.
Advices given to them are:

a) Not to sit idle lonely in home but to take part actively in any social programmes.
b) We told the family not to take her as burden and support her.
c) Maintenance of hygiene of wound.
d) Consultation of physiotherapist once a week.
e) To take nutritious diet.
f) Proper bandaging of wound.
Health education given to the family:-

a) We taught them about the traffic signals, rules and regulations, sign boards, importance of
traffic lights.
b) Importance of zebra crossings, pedestrian lanes and footpaths was explained.
c) We told them that while walking the roads, always the lane of left side is to be
maintained, if a big vehicle was heading then a pass should be given to it.
d) Mental alertness was very much required while on the road.
e) Use of torch lights while doing a night journey.
f) We encouraged her husband to keep patience and to strengthen the bonds with his wife as
he was the one who can bring her back to her normal mental status though itll take time.
g) Other family members were encouraged to keep her busy and she should not be left
alone.
Third Visit
Objectives
Activities
Third visit was made after 14 days. We saw whether she was following the advice given by the
doctors or not and what positive changes she had developed and how far she had achieved her
49
confidence in herself. A smile on her face which was missing in the previous meetings assured
that patient was on her way towards improvement. We also saw her that she was doing
physiotherapy exercise taught by the doctors.
Case Summary
She has undergone a severe mental trauma from where its really difficult to come out. First a
dreadful accident and then a permanent disability looming on his future. Still continuous efforts
from her and her family side can bring her out of the major turmoil. We referred them to the
NGOs working for physically disabled. After imbibing lots and lots of motivation from our
escorting teacher and members, seeing the spark in her eyes to live a new life ahead, we came
back wishing her luck.
Case V : Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease is not a single disease, but a branching term used to
describe chronic lung disease that causes limitations in lung airflow. The more familiar terms
chronic bronchitis and emphysema are no longer used, but are now included within COPD
diagnosis.
The most common symptoms of COPD are shortness of breath, excessive sputum production,
and chronic cough. However, COPD is not just a smokers cough but an under-diagnosed, life
threatening airway disease that may progressively lead to death
Diagnosis of COPD
Spirometry is a simple and painless test which measures the capacity of the lungs.
Spirometry: A COPD diagnosis is confirmed by a simple test called spirometry, which measures
how deeply a person can breathe and how fast air can move into and out of the lungs.
Clinical Symptoms
Diagnosis of COPD should be considered in any patient who has symptoms of chronic cough,
sputum production, dyspnoea and a history of exposure to risk factors for the disease.
Where spirometry is unavailable, clinical symptoms and signs, such as abnormal shortness of
breath and increases forced expiratory time, can be used to help with the diagnosis. A low peak
flow is consistent with COPD, but may not be specific to it, because it can be caused by other
lung disease and by poor performance during testing.
50
Chronic cough and sputum production often precede the development of airflow limitation by
many years. Although, not all individuals with cough and sputum production go on to develop
COPD, because COPD develops slowly, it is most frequently diagnosed in people aged 40 years
or above.
Management of COPD
An effective COPD management plan includes four components:-
1. Assess and monitor disease

2. Reduce risk factors
3. Manage stable COPD
4. Manage exacerbations
The goal of effective COPD management is to:
Prevent disease progression

Relieve symptoms
Improve exercise tolerance
Improve health status
Prevent and treat complications
Prevent and treat exacerbations
Reduce mortality
These goals should be reached with minimum side effects from treatment, a particular challenge
in patients with COPD where co-morbidities are common. The extent to which these goals can
be reached varies with each individual, and some treatments will produce benefits in more than
one area.
Problem Statement in Nepal
COPD is an emerging public health problem in Nepal. In the fiscal year2061/2062, COPD was
the 8th common cause for OPD visits, 7th common cause for hospitalization. The highest
mortality and morbidity among the hospitalized patients in Bir Hospital was from COPD. A cross
sectional study of 2826 adults in rural hilly region of Nepal was done and was found that the
prevalence of COPD was 18.3%, similar in man and woman. According to hospital data of
TUTH, Bir Hospital, Patna hospital, and the increasing trend showed that during the last ten
years time COPD in Kathmandu valley has increased by more than 70%. COPD has become a
major health problem in Nepal with the increase in air pollution, smoking habit and other risk
factors. Irreversible nature of disease, multi factorial causation and costly treatment are the
challenges against the war with COPD in Nepal.
51
Epidemiological Determinants
Host Factors
Demographic Factors
- Age Above 40 yrs
- Sex male more commonly
Familial Risk: Familial factors likely deficiency of -1 antitrypsin, a recessive genetic
trait; increased frequency of allergies and increased airway responsiveness pose greater
risk of COPD.
Immune hyperactivity (IgE)
Childhood respiratory infections
Socio-economic status: Prevalent in low socio-economic status because of:
- High rate of cigarette smoking
- Poor nutrition
- High levels of indoor smoke exposure
- Poor housing conditions
- High frequency of other respiratory illness
- Occupational exposure
- Lack of access to health care services and health education
Environmental Factors
Cigarette Smoking
- Single most important cause of COPD
- Higher COPD mortality in smokers and non smokers
Air Pollution
- Indoor air pollution
- Use of smoking chulha in absence of proper ventilations
- Use of woods, soft coal, and animal dung as fuel
- Outdoor air pollution
- Vehicles, industries, constructions sites
- People inhale many hazardous gases like oxides of nitrogen and sulfur, and smoke in
polluted air which increases risk of COPD
Occupational Exposure: Due to dusts and chemicals of different working conditions exacerbate
COPD.
52
Hospital Visit
Patients Profile
Name : Dev Mati
Age : 65 yrs.
Gender : Female
Religion : Hindu
Marital Status : Married
Occupation : Housewife
Address : Parwanipur, Ward No-2, Parsa, Narayani
Date of Admission : 05/09/2016
Date of Discharge : 09/09/2016
Chief Complaints
Breathlessness 20 days
Chest pain 8 days
History of Present Illness
Patient was apparently well when she developed difficulty in breathing 20 days back. It was
started while she was sleeping at night. Breathlessness was relieved on sitting and aggravated on
lying down and changing posture. There is also history of pain in chest 8 days back. Pain was
gradual in onset, continuous in nature, non radiating and non referred to any other sites. It was
aggravated on sleeping and relieved on medications. It was associated with cough which was dry
in nature.
53
Past History
There was history of similar events in the past which was relieved on medications.
Personal History
She was a smoker but non alcoholic. She had been having sleep disturbances. She had normal
bowel and bladder habits.
The patient was sitting on her bed, was ill looking, moderate in built, conscious, co-operative and
well oriented to time, place and person. There was mild pallor and edema. There was no icterus,
cyanosis, clubbing, koilonychias, lymphadenopathy and dehydration.
Vitals
Pulse: 88/minute; in normal rhythm, volume and character. No radio radial delay and all
peripheral pulses were palpable and symmetrical.
Blood Pressure: 116/80 mm of Hg, in supine position on right arm taken in brachial artery.
Respiratory Rate: 18 per minute, abdomino-thoracic
Temperature: 98oF, in right axilla.
Respiratory Examination:
Inspection
Chest was normal in shape, bilaterally asymmetrical, moving unequally with respiration.
No scar marks and venous prominence
No swelling and lump
Palpation
Trachea slightly deviated to right due to slight consolidation of trachea.
Percussion
54
Decreased resonant sounds heard all over the chest.
Auscultation
Bilateral vesicular breath sound

Wheeze heard on the right side.
Apex beat at the left 5th inter-costal space, medial to mid clavicular line.
Normal audible S1 and S2 and no murmur present.
Central Nervous System:
Grossly intact
Inspection : Normal abdomen
Palpation : No any organomegaly
Percussion : Tympanic
Auscultation : Peristaltic sound heard 3-5 / min
Investigations:
Routine Blood Examination

- Total Leukocyte Count: 13,100/cu mm
- Differential Leukocyte Count:
Neutrophils : 78%
Lymphocytes : 21%
Monocytes: 0%
Basophils : 0%
Eosinophils : 0%
- Haemoglobin %: 12.70 gm%
Blood Chemistry
- Urea : 25mm/l
- Sugar : 142mm/l
- Creatinine : 1.07umol/l
X-ray Chest:
- Hyper dense lung field
- Tubular heart shadow
- Spacing of the ribs
55
Diagnosis
Chronic obstructive pulmonary disease
Treatment History
Injection Enhancin
Tab Panzol
Aerocort Rotacap
Syrup Rappitus
Nebulization with asthalin
Home Visit
First Visit
Objectives
family members.

Activities
We found patients house from the address that we took from hospital. It was situated at a
distance of 50minutes from our hospital. We made the visit on 07/15/2016. On reaching her
house, we were welcomed by her family. After introducing ourselves, we met the patient and her
family.
They were cooperative and explained us about her disease and accordingly what they did. We
explained them about the purpose of our visit. We assessed the housing, environment and socio-
economic condition, psychological and economic impact of the disease on the patients family as
a whole.
Output
56
Housing
They had a pucca house. There were 3 rooms with moderate ventilation and a separate kitchen.
They used hand-pumps as a source of drinking water. They had a proper drainage system. The
set back area was poorly equipped. They used gas stoves and chulha.
Family Composition
INDEX
MALE FEMALE PATIENT DEAD
57
Socio-Economic Condition
There were 10 members in the family and two of them were earning. So great deal of
dependence was present and the family was of low socio economic group.
Knowledge Attitude and Practice
The family was well aware of the situation. They are aware that the disease can be severe if good
care was no taken. They did not know how the disease was caused though they were providing
the medicines prescribed by the doctors.
Impact of the Disease
On the Patient
a) She was feeling restless and complained of difficulty in mild work.
b) Normal day to day activities were hampered.
On the Family
a) They were worried because she had been having difficulty in breathing.
b) They have had some financial difficulties due to medical costs and loss of time.
c) The patient had two daughter-in-laws, one of which died, the pressure of care taking of
the children and patient befalls on one daughter in law.
Second Visit
Objectives

Activities
We again visited them 7 days after our first visit to them. They were very welcoming as they had
already known us.We take a short discussion with the family to know
58
Output
We tried to assess the progress. We talked to the family members and gave them some
suggestions. We tried to convince her sons who were the earning members in the family that
she had to be kept in a proper ventilated room with someone to take care of her always
available at home.
Health Education Given To Them Were:
a) Avoiding dust and smoke

b) Staying away from indoor pollution
c) Proper ventilation in kitchen
d) Avoiding cold environment
e) Hazards of passive smoking
f) Precautions while going out of the house
g) Importance of regular medication
h) Arrangement of nebulisation and domiciliary oxygen therapy
Third Visit
Objectives
Activities
We made our third home visit 7 days after our second home visit. We were welcomed by the
family.
Output
She was looking much better. There were positive changes seen in the health of the patient and a
better attitude towards her illness.
Case Summary
59
COPD is a growing problem in todays rapidly developing world. Both developed and
developing countries are affected. It can be prevented and controlled if there is joint effort of the
family members because if a member of the family is affected then whole family has to suffer
directly.
CHAPTER III
Conclusion
Disease, health or ill health cannot be looked at as a separate entity without social contacts and
consequences. The brief period of time where the patient is treated at the hospital is just a very
small step of progress on the road towards recovery.
Each and every disease whether it is communicable like tuberculosis or a chronic and debilitating
disease like diabetes and hypertension or an accident affects not only the patient but his family as
well. The family bears not just the financial aspects of the treatment and the loss of working days
and a decline in income, but there is whole different kind of impact which is psychological and
emotional.
The community where the patient lives is of great importance, as the knowledge, attitude and
practice of the community towards the disease considerably affects the social aspects of the
patients life. There is a great need of acceptance of the patient by those around him or her rather
that treating the patient as a social outcast.
As future doctors, we need to break away from the perception and the practice of looking at the
patient as just someone with a disease or disability. We have to consider the psychosocial aspects
of the disease while treating the patient and know that the family plays and are affected just as
much or even more than the patient. The health care system should try to be more considerate of
the impacts of the disease on the patient and his or her surroundings while approaching towards
treatment.
The family health exercise focuses on the importance of following up a patient after the brief
interaction at the hospital and in making sure that the doctors advice is properly followed and to
ensure that the treatment is effective. If not, also on guidance of patient to obtain appropriate
measures and bring about changes both by the patient and the family if necessary.
60
Recommendations
1. Orientation classes should be conducted a little earlier so that we have a variety of cases
to choose.
2. Provision of better transportation facilities for the students during home visits.
3. Provision of financial help or free distribution of medicines for those who are unable to
afford.
CHAPTER IV
Learning Reflections
We were able to know about the socio-economic, psychological, cultural and

environmental factors affecting health of the diseased people.
61
We were able to understand the importance of team work.
We could see the great diversity of knowledge, attitude and practice towards health
seeking behavior of the patient and family.
We developed the skills and perfected the art and technique of counseling.
We learnt many reasons behind lack of follow up and compliance.
We were able to recapitulate theoretical knowledge into practice.
We were able to appreciate just how big a role the family plays in the recovery of the
patient; it was from taking medicine on time and encouragement.
During our visit, we were able to get a firsthand experience in regards to the impact of
the family on the outcome of the disease.
Inspired to be doctor with better professional skills as well as humanitarian ethics

which is most essential for control of any kind of disease.
BIBLIOGRAPHY
Park, K. (2013). Parks Textbook of Preventive and Social Medicine. Jabalpur: M/s
Banarsidas Bhanot Publishers.

Fauci, A.S., Kasper D.L., Longo, D.L., et al. (2008). Harrisons Principle of Internal
Medicine. USA: The McGraw-Hill Companies, Inc.
62
Walker, B.R., Colledge, N.R., Ralston, S.H., et al. (2014). Davidsons Principle and
Practice of Medicine. New Delhi: Reed Elsevier India Private Limited.

Douglas, G., Nicol, F., & Robertson, C. (2013). Macleods Clinical Examination. China:
Churchil Livingstone Elsevier.

Apley, A.G., & Solomon, L. (2001). Apleys System of Orthopaedics and fractures.
London:Arnold.
Field Report of Senior Batches
Group H FHE
From Left to Right:
First Row: Saroj Kumar Yadav, Saurav Kumar Shrestha, Satyabrata Mohanty
63
Second Row: Sanjay Paudel, Shahrukh KC, Saroj Sah, Santosh Kumar Sah, Shafiullah
Siddique
Third Row: Shishir Saurabh, Shankar Shrestha, Santosh Kumar Yadav, Shahrukh Hawari
64

Community Medicine 3rd Year IOM Report

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CHAPTER I

To describe the need to follow up and implement appropriate follow up system.

To refer the patient if necessary.

S.N Type of case Case chosen

The rationale for selecting the above mentioned cases are:

1.4 LOGISTIC MANAGEMENT

1. NMCTH, Birgunj provided us with the funds for transportation.

2. The Community Medicine Department provided us with valuable information in the

3. The DOTs clinic, Psychiatry Department, Medicine Department, Emergency Department

i. Poor quality of life

TB thrives in the condition of poverty and worsens poverty.

Prevention and Control

1. Health Promotion: Raising the standard of living through socioeconomic development.

Provision of well lighted, well ventilated and open houses.

Case finding: Sputum microscopy for AFB

Multi Drug Resistance TB

According to WHO, MDR TB is defined as the TB that is at least resistant to Isoniazid&

It is much more difficult to treat as:

Treatment can take at least 2 yrs.& the results are poor.

Prevention of Drug Resistance

Treatment with 2 or more drugs in combination.

Directly Observed Treatment Short Course (DOTS)

Criteria for operation of DOTS PLUS regimen in Nepal

Any CAT-II failure cases

Reasons for Selecting the Case

Name- Ramesh (Name Changed)

Marital status- Unmarried

Address- :Parwanipur, Birgunj

Fever for 2 week

Chest pain and breathlessness for 3 days

History of Present Illness:

There was no nausea, vomiting, headache, dizziness and drowsiness.

Pulse:-88 beats/min., regular in rhythm, fair in volume ,normal in character, no radio

Apex beat at the left 5thintercostals space, medial to mid-clavicular line

Central Nervous System:

Treatment of Tuberculosis As Recommended By Nepal Government

Category of tuberculosis Initial phase* Continuation phase

1 A..New cases (bacteriologically or2 month HRZE 4 month HR

2 New cases of TB relapse, treatment2 month HRZES/ 1 month5 month HRE

. H=Isoniazid, R= Rifampicin. Z=Pyrazinamide, E= Ethambutol, S= Streptomycin.

Maintain isolation at home

First Home Visit

a) To collect data on household demographic.

c) To assess/evaluate the impact of economical, familial, psychological and social state on

Fig: Family composition of the patient

Knowledge, Attitude and Practice

Impact of the Disease

They were worried about the patients health.

To collect data on interaction among family members.

We took a short discussion with the family to know

Their knowledge about the disease.

We imparted health education on:-

Third Home Visit

a) To follow the compliance of treatment procedure and its progress on health.

Case II: DIABETES MELLITUS

Diabetes can be classified as (WHO classification):

According to stepwise non communicable diseases risk factors survey, 2007/08.

Staphylococcal skin infections

The diagnosis of DM can be established using any of the following criteria:

Name : Harihar Shah (Name changed)

Marital status: Married

Difficulty in Vision since 1 year.

Weakness since 2-3 day

History of Present Illness: