Community Medicine - BPT 3rd Year (MGR University)

Important Questions - Syllabus-wise

• 2 x 15-mark essay questions
• 10 x 5-mark short notes
• 10 x 2-mark short answers

UNIT 1: Concepts of Health & Disease

5-Mark Questions (Short Notes)

1. Define health. Explain the determinants of health.
   • WHO definition (1948): "A state of complete physical, mental and social well-being and not merely the absence of disease or infirmity."
   • Determinants: genetic factors, environment (physical, biological, social), lifestyle and behavior, health services access, socioeconomic status (poverty, education, occupation).
2. Natural history of disease - explain with Leavell & Clark's model.
   • Pre-pathogenesis phase: susceptible host + disease agent + environment (ecological triad)
   • Pathogenesis phase: early disease → advanced disease → outcome (recovery, disability, death)
   • Three levels of prevention: primary (health promotion + specific protection), secondary (early diagnosis + prompt treatment), tertiary (disability limitation + rehabilitation)
3. Iceberg phenomenon of disease.
   • Visible tip = diagnosed/known cases
   • Submerged portion = undiagnosed/subclinical/carrier states
   • Importance in community medicine: true disease burden is underestimated; screening programs target the submerged mass
   • Examples: diabetes, hypertension, TB, HIV
4. Primary, secondary, and tertiary prevention - with examples.
   • Primary: before disease onset (vaccination, health education, sanitation)
   • Secondary: early detection and treatment (screening for HTN, cancer, DM)
   • Tertiary: minimize disability and rehabilitate (physiotherapy for stroke, prosthetics for amputees)
5. Role of physiotherapist in preventive medicine.
   • Health promotion in community
   • Ergonomic advice at workplace
   • Postural education in schools
   • Disability prevention and rehabilitation
   • CBR (Community Based Rehabilitation) programs

2-Mark Questions

1. Define disease burden. - Total impact of a health problem measured in terms of morbidity and mortality in a population, often expressed as DALYs (Disability Adjusted Life Years).
2. What is epidemiological triad? - Agent + Host + Environment; the three interacting factors that cause disease.
3. Define morbidity and mortality. - Morbidity = rate of disease in a population; Mortality = death rate in a population.
4. What is subclinical disease? - Disease present in the body but without overt clinical signs/symptoms; detected only by lab tests or screening.
5. What are DALYs? - Disability-Adjusted Life Years; one DALY = one lost year of healthy life.

UNIT 2: Epidemiology

5-Mark Questions

1. Define epidemiology. Explain uses of epidemiology.
   • Definition (John Last): "Study of distribution and determinants of health-related events in specified populations, and the application of this study to control health problems."
   • Uses: describe disease distribution, identify risk factors, evaluate health interventions, plan health services, test hypotheses about disease causation
2. Types of epidemiological studies - observational vs. experimental.
   • Observational: descriptive (case reports, cross-sectional) and analytical (case-control, cohort)
   • Experimental: randomized controlled trials (RCTs), community trials
   • Key difference: in experimental studies, investigator allocates exposure/intervention
3. Case-control and cohort study - differences.

1. Modes of transmission of communicable diseases.
   • Direct: contact (touch, droplet, sexual, vertical/transplacental)
   • Indirect: vehicle-borne (food, water, air), vector-borne (biological, mechanical), fomite-borne
2. Incubation period and its importance.
   • Time between entry of infectious agent and first appearance of symptoms
   • Importance: identifies probable source of infection, determines quarantine/isolation period, helps predict outbreak course
   • Examples: cholera 6h-5 days, typhoid 1-3 weeks, HIV months-years

2-Mark Questions

1. Define incidence and prevalence. - Incidence = new cases per unit population per unit time; Prevalence = all existing cases at a given time.
2. What is herd immunity? - Resistance of a group to attack by a disease because a large proportion of members are immune, protecting the unimmunized minority.
3. Define attack rate. - Number of people exposed who develop disease / Total number exposed x 100; used in outbreak investigation.
4. What is a carrier? - A person who harbors the infectious agent without apparent illness but can transmit it to others (e.g., typhoid Mary).
5. Define epidemic, endemic, pandemic.
   • Epidemic: disease incidence clearly in excess of normal expectancy in a community
   • Endemic: habitual presence of disease in a defined area
   • Pandemic: worldwide epidemic

UNIT 3: Environment and Health

5-Mark Questions

1. Water-borne diseases - causes, prevention.
   • Diseases: cholera, typhoid, hepatitis A, dysentery, giardiasis, fluorosis
   • Causes: fecal contamination of water supply, poor sanitation, open defecation
   • Prevention: water purification (chlorination, boiling), protected wells, safe piped water supply, Swachh Bharat Mission
2. Air pollution - sources, health effects, prevention.
   • Sources: vehicular emissions, industrial effluents, burning of coal/biomass, indoor cooking smoke
   • Health effects: respiratory (COPD, asthma, lung cancer), cardiovascular, ocular irritation, lead poisoning (children)
   • Prevention: smokeless chulhas, air quality monitoring, reducing vehicular pollution (BS-VI norms)
3. Solid waste management.
   • Municipal solid waste: segregation at source (biodegradable vs non-biodegradable vs hazardous)
   • Methods of disposal: sanitary landfill, composting, incineration, biogas generation, recycling
   • Biomedical waste: categorized (sharps, anatomical, chemical); color-coded bags (yellow, red, blue, white)
4. Noise pollution - health effects and control.
   • Sources: traffic, industrial machinery, loudspeakers, construction
   • Health effects: noise-induced hearing loss (>85 dB chronic), hypertension, sleep disturbance, cognitive impairment in children
   • Safe limit: 85 dB for 8 hours/day (occupational); WHO recommends <55 dB daytime outdoor
   • Control: engineering controls (mufflers), administrative controls, PPE (earplugs), zoning laws
5. Safe drinking water standards (BIS/WHO).
   • Physical: colorless, odorless, tasteless, turbidity <1 NTU
   • Chemical: pH 6.5-8.5, TDS <500 mg/L, no heavy metals above permissible limits, fluoride 0.5-1.5 mg/L
   • Biological: zero coliform organisms per 100 mL
   • Disinfection methods: chlorination (residual chlorine 0.5 mg/L), boiling, UV treatment, sand filtration (slow/rapid)

2-Mark Questions

1. What is BOD (Biochemical Oxygen Demand)? - Measure of organic pollution in water; amount of dissolved oxygen needed by organisms to break down organic material at 20°C over 5 days; higher BOD = more polluted.
2. Define threshold limit value (TLV). - Maximum concentration of a chemical substance in workplace air to which workers may be repeatedly exposed without adverse effects.
3. What is hardness of water? - Presence of calcium and magnesium salts; temporary hardness (bicarbonates, removed by boiling), permanent hardness (sulphates/chlorides, removed by chemical treatment or ion exchange).
4. What is fluorosis? - Disease caused by excess fluoride in drinking water (>1.5 mg/L); dental fluorosis (mottled teeth), skeletal fluorosis (joint pain, deformity).
5. Define sanitation. - Control of environmental factors that form links in disease transmission; particularly refers to safe disposal of human excreta, refuse, and wastewater.

UNIT 4: Nutrition and Health

5-Mark Questions

1. Protein Energy Malnutrition (PEM) - types, clinical features, management.
   • Marasmus: severe calorie + protein deficiency; "skin and bones," alert child, no edema, muscle wasting
   • Kwashiorkor: protein deficiency with adequate calories; pitting edema, skin changes (flaky paint), flag sign in hair, apathetic child
   • Management: F-75 then F-100 WHO therapeutic feeds, treat infections, micronutrient supplementation, sensory stimulation
2. Nutritional deficiency diseases - brief overview.
   • Vitamin A deficiency: night blindness, xerophthalmia, Bitot's spots, keratomalacia
   • Iron deficiency anemia: pallor, fatigue, koilonychia; treat with iron + folic acid supplements
   • Iodine deficiency: goiter, cretinism, hypothyroidism; prevention - iodized salt
   • Vitamin D deficiency: rickets (children), osteomalacia (adults); sun exposure + supplements
   • Vitamin C deficiency: scurvy - bleeding gums, perifollicular hemorrhage, delayed wound healing
3. ICMR recommended dietary allowances (RDA) for physiotherapy students.
   • Adult male (sedentary): 2320 kcal/day
   • Adult female (sedentary): 1900 kcal/day
   • Protein: 0.83 g/kg/day
   • Calcium: 600 mg/day
   • Iron: 17 mg/day (male), 21 mg/day (female)
   • Vitamin C: 40 mg/day
4. Mid-Day Meal Scheme and ICDS - role in nutrition.
   • ICDS (Integrated Child Development Services): supplementary nutrition, immunization, health education, referral for beneficiaries <6 years and pregnant/lactating women
   • PM-POSHAN (Mid-Day Meal): cooked meal in schools classes I-VIII; prevents classroom hunger, improves enrollment
   • Both target malnutrition reduction in vulnerable groups

2-Mark Questions

1. What is BMI? Normal range? - Body Mass Index = Weight (kg) / Height² (m²); Normal: 18.5-24.9; Overweight: 25-29.9; Obese: ≥30.
2. Define balanced diet. - Diet containing all nutrients (carbohydrates, proteins, fats, vitamins, minerals, water, fiber) in proportions required for health.
3. What is flag sign in malnutrition? - Alternating bands of normal and depigmented (light-colored) hair in kwashiorkor; reflects periods of adequate vs. inadequate protein intake.
4. What is night blindness? - Inability to see in dim light due to Vitamin A deficiency; earliest sign of xerophthalmia; treated with Vitamin A supplementation.
5. What is goiter? - Enlargement of the thyroid gland, most commonly due to iodine deficiency; endemic in Himalayan belt (India).

UNIT 5: Communicable Diseases

5-Mark Questions

1. Tuberculosis - epidemiology, control measures, role of physiotherapist.
   • Causative agent: Mycobacterium tuberculosis; airborne spread
   • Epidemiology: India has highest TB burden globally; ~2.8 million new cases/year
   • Control: NIKSHAY portal, Revised National TB Control Programme (RNTCP), now National TB Elimination Programme (NTEP)
   • Treatment: DOTS (Directly Observed Treatment Short-course): 2HRZE + 4HR (Category I)
   • Role of physiotherapist: chest physiotherapy, breathing exercises, postural drainage for pulmonary TB; rehabilitation
2. Malaria - life cycle, control.
   • Causative: Plasmodium species (falciparum most dangerous); vector: female Anopheles mosquito
   • Life cycle: mosquito bite → sporozoites → liver (pre-erythrocytic) → RBCs (erythrocytic) → gametocytes → back to mosquito
   • Control: vector control (IRS - indoor residual spraying, ITNs - insecticide-treated nets), larvicides, biological control, personal protection, chemoprophylaxis, treatment (ACT - Artemisinin Combination Therapy)
3. HIV/AIDS - transmission, prevention, PPTCT.
   • Transmission: unprotected sexual contact, blood/blood products, sharing needles, mother-to-child (vertical)
   • NOT transmitted by: casual contact, mosquitoes, shared utensils
   • Prevention: ABC (Abstinence, Be faithful, Condom use), ICTC (Integrated Counselling and Testing Centres), blood screening, needle exchange programs
   • PPTCT (Prevention of Parent to Child Transmission): ART for mother + infant nevirapine; reduces transmission from 45% to <5%
4. Immunization schedule for children (National Immunization Programme).
   • Birth: BCG, OPV-0, Hep-B
   • 6 weeks: OPV-1, DPT-1, Hib-1, Hep-B-2, Rotavirus-1, IPV-1
   • 10 weeks: OPV-2, DPT-2, Hib-2, Rotavirus-2
   • 14 weeks: OPV-3, DPT-3, Hib-3, Hep-B-3, IPV-2, Rotavirus-3
   • 9 months: Measles/MR vaccine, OPV booster
   • 16-24 months: DPT booster, OPV booster, MR-2
   • 5-6 years: DPT booster; 10 years: TT; 16 years: TT
5. Vector-borne diseases - dengue, filariasis.
   • Dengue: vector = Aedes aegypti; urban/peri-urban; classic dengue fever, DHF, DSS; no specific antiviral; supportive treatment; platelet monitoring; prevention = eliminate stagnant water breeding sites
   • Filariasis (lymphatic): Wuchereria bancrofti; vector = Culex mosquito; causes lymphedema (elephantiasis); treat with DEC (diethylcarbamazine); MDA (Mass Drug Administration) under NPELF

2-Mark Questions

1. What is DOTS? - Directly Observed Treatment Short-course for TB; health worker watches patient swallow anti-TB drugs; key strategy to prevent drug resistance.
2. Define zoonosis. - Infectious diseases transmissible between animals and humans (e.g., rabies, brucellosis, anthrax, leptospirosis, plague).
3. What is herd immunity threshold? - Minimum proportion of immune individuals in a population needed to prevent disease spread; for measles it is ~95%, for polio ~80-85%.
4. What is seroprevalence? - Proportion of persons in a population who test seropositive (have antibodies) for a specific disease; indicates past infection or vaccination coverage.
5. Define quarantine and isolation. - Quarantine: restriction of movement of exposed but not yet ill persons; Isolation: separation of ill (infectious) persons from healthy ones to prevent spread.

UNIT 6: Non-Communicable Diseases (NCDs) & Lifestyle Diseases

5-Mark Questions

1. Risk factors for cardiovascular diseases - prevention and control.
   • Modifiable: hypertension, hyperlipidemia, diabetes, smoking, physical inactivity, obesity, stress
   • Non-modifiable: age, sex (male > female before menopause), family history
   • Prevention: NPCDCS (National Programme for Prevention and Control of Cancer, Diabetes, CVD and Stroke)
   • Role of physiotherapy: cardiac rehabilitation, exercise prescription, weight management
2. Obesity - public health significance, classification, management.
   • BMI ≥30 = obese; Asian cut-off BMI ≥25 = obese
   • Health risks: Type 2 DM, HTN, CVD, OSA, joint problems (osteoarthritis), fatty liver, certain cancers
   • Management: dietary modification, physical activity (150 min/week moderate intensity), behavioral therapy, pharmacotherapy (orlistat), bariatric surgery for morbid obesity
3. Diabetes mellitus - epidemiology, prevention in community.
   • India is "diabetes capital" - 77 million cases (2nd globally after China)
   • Type 2 DM: insulin resistance + relative insulin deficiency; linked to obesity, sedentary lifestyle
   • Community prevention: reduce sugar/processed food intake, increase physical activity, weight reduction, screening programs (FPG, HbA1c)
   • National Diabetes Control Programme is part of NPCDCS
4. Role of physiotherapy in prevention of occupational diseases.
   • Ergonomic assessment and workplace modification
   • Back care programs for sedentary workers
   • Prevention of repetitive strain injuries (RSI)
   • Education on proper posture and lifting techniques
   • Pre-placement and periodical medical examination

2-Mark Questions

1. What are NCDs? - Non-communicable diseases (also called chronic diseases); not passed from person to person; e.g., CVD, cancer, diabetes, chronic respiratory diseases.
2. What is metabolic syndrome? - Cluster of conditions: central obesity + hypertension + high blood sugar + high triglycerides + low HDL; increases risk of heart disease and diabetes.
3. What is primary hypertension? - High blood pressure with no identifiable secondary cause; also called essential hypertension; BP ≥140/90 mmHg; most common type (90-95% of cases).
4. Define sedentary lifestyle. - Insufficient physical activity (less than 150 min moderate-intensity activity/week); major modifiable risk factor for most NCDs.
5. What is cancer screening? - Tests to detect cancer before symptoms appear (e.g., Pap smear for cervical cancer, mammography for breast cancer, colonoscopy for colorectal cancer).

UNIT 7: Health System, National Health Programs & Community Based Rehabilitation

5-Mark Questions (Essay-level)

1. Primary Health Care (PHC) - Alma Ata Declaration 1978.
   • Essential health care based on practical, scientifically sound methods accessible to all people
   • Components (8 pillars): education on health problems, food supply/nutrition, safe water/sanitation, maternal and child health (MCH), immunization, prevention of endemic diseases, treatment of common diseases and injuries, provision of essential drugs
   • PHC in India: Sub-centre, PHC, Community Health Centre (CHC), District Hospital (4-tier system)
2. Explain the health care delivery system in India.
   • Sub-centre: 1 per 5000 rural / 3000 tribal population; ANM + MPW
   • PHC (Primary Health Centre): 1 per 30,000 rural / 20,000 tribal; 1 medical officer + 14 staff
   • CHC (Community Health Centre): 1 per 1,20,000; 30-bed hospital, 4 specialists (surgeon, physician, OBG, pediatrician)
   • District Hospital: apex referral for district
   • Urban: ESI hospitals, municipal hospitals, teaching hospitals
3. Community Based Rehabilitation (CBR) - principles, role of physiotherapist.
   • CBR: strategy to enhance quality of life of persons with disabilities within their own community
   • WHO CBR matrix: 5 components - Health, Education, Livelihood, Social, Empowerment
   • Role of physiotherapist: assessment of disability, training family members, home program design, assistive device prescription, advocacy, school/workplace re-integration
4. National Health Mission (NHM) - components and objectives.
   • NHM = NRHM (National Rural Health Mission, 2005) + NUHM (National Urban Health Mission, 2013)
   • Key strategies: ASHA (Accredited Social Health Activist), strengthening sub-centres/PHCs, RKS (Rogi Kalyan Samiti), JSSK (Janani Shishu Suraksha Karyakram), VHSNC (Village Health Sanitation and Nutrition Committee)
   • Objectives: reduce IMR, MMR, TFR; universal health coverage; address social determinants
5. Maternal and Child Health (MCH) programs in India.
   • Janani Suraksha Yojana (JSY): cash incentive for institutional delivery
   • Pradhan Mantri Matru Vandana Yojana (PMMVY): maternity benefit
   • Reproductive and Child Health (RCH) Programme
   • Immunization: Universal Immunisation Programme (UIP) - targets 90% coverage
   • Integrated Management of Neonatal and Childhood Illness (IMNCI)
   • Key indicators: MMR (97/100,000 live births, India 2018-20), IMR (28/1000 live births, 2020)

2-Mark Questions

1. What is ASHA? - Accredited Social Health Activist; village-level link worker between community and public health system; trained female community health worker (1 per 1000 population) under NHM.
2. What is Swachh Bharat Mission? - National sanitation campaign launched 2014; aims for open defecation free India through construction of household/community toilets; renamed PM SVANidhi for urban areas.
3. Define disability as per WHO. - Any restriction or lack of ability to perform an activity in the manner considered normal for a human being; arises from impairment.
4. What is universal health coverage (UHC)? - All individuals receive needed health services (promotive, preventive, curative, rehabilitative, palliative) without suffering financial hardship.
5. What is PHC? - Primary Health Centre; first contact point between individual/community and health system; provides basic curative and preventive care; serves 30,000 rural population; staffed by one medical officer.

UNIT 8: Social Sciences and Health

5-Mark Questions

1. Social factors affecting health - discuss.
   • Education: higher literacy = better health awareness, hygiene, utilization of services
   • Poverty: poor nutrition, overcrowding, inadequate sanitation, delayed medical care
   • Gender: women often have less access to health care and decision-making
   • Occupation: occupational hazards (silicosis, asbestosis, back pain)
   • Social support networks: social isolation linked to mental health disorders
2. Role of family in health and disease.
   • Health promotion: healthy diet, physical activity, vaccination compliance
   • Transmission of disease: within household (TB, skin infections, COVID-19)
   • Caregiver role: chronic illness, rehabilitation
   • Family types (nuclear, joint) - affect access to healthcare
   • Family life cycle and health: maternal health, child health, geriatric care

2-Mark Questions

1. What is social determinants of health? - Conditions in which people are born, grow, live, work, and age; include economic stability, education access, neighborhood environment, social and community context.
2. Define health literacy. - Degree to which individuals can obtain, process, and understand basic health information to make appropriate health decisions.
3. What is Panchayati Raj Institution's role in health? - Local self-governance bodies; involved in oversight of Village Health Sanitation and Nutrition Committees (VHSNCs), water supply, sanitation, and implementation of health schemes at grassroots level.

Quick Revision: Most Repeated Questions in Previous MGR University Papers

5-Marker Most Asked

• Natural history of disease with Leavell & Clark model
• Epidemiological triad
• DOTS and TB control
• PHC and its components (Alma Ata)
• Role of physiotherapy in CBR
• Water-borne diseases and prevention
• Immunization schedule
• PEM - Marasmus vs Kwashiorkor

2-Marker Most Asked

• Define health (WHO)
• Define epidemic, endemic, pandemic
• ASHA worker
• Herd immunity
• BMI classification
• Define quarantine/isolation
• What is DOTS?
• Levels of prevention (1°, 2°, 3°)
• Define incidence vs prevalence
• Night blindness

Exam tip: MGR University Community Medicine paper has 100 marks total - 2 essays (15 marks each), 10 short notes (5 marks each), and 10 short answers (2 marks each). Focus your preparation on bold terms - learn definitions precisely for 2-mark answers, and for 5-mark answers structure your response as: definition + classification/types + clinical features/mechanism + prevention/management.

Lathyrism

Definition

The Pulse (Causative Agent)

• Scientific name: Lathyrus sativus
• Common name: Khesari dhal (also Teora dhal, Lak dhal, Batra, Gharas, Matra)
• Characteristic triangular shape, grey colour; resembles red gram or bengal gram when dehusked
• A good source of protein, but dangerous due to its neurotoxin
• Eaten mostly by the poor because it is cheap, drought-resistant, and high-yield
• Risk threshold: >30% of diet consumed over 2-6 months leads to neurolathyrism

The Toxin

• Beta-oxalyl amino alanine (BOAA) - also called beta-ODAP (beta-N-oxalyl-L-alpha,beta-diaminopropionic acid)
• Water-soluble - this property is exploited for detoxification
• Acts as a structural analogue of glutamate - an excitatory amino acid
• Causes excitotoxic damage to upper motor neurons in the lateral corticospinal tracts
• A blood-brain barrier exists; therefore large amounts must be eaten over months to overcome it

Epidemiology

• Endemic in: Madhya Pradesh, Uttar Pradesh, Bihar, Odisha, also Maharashtra, West Bengal, Rajasthan, Assam, Gujarat
• Historically massive: Rewa district (MP) alone had 25,000 cases; Satna district had 32,000 cases
• Global burden: Ethiopia (~6 per 1000), India (~5.3 per 1000), Bangladesh (~1.4 per 1000)
• Recent outbreaks: Ethiopia (1997-99), China (1973), Bangladesh (1976), Nepal and Afghanistan (1998)
• Predominantly affects: young men aged 15-45 years

Risk Factors

• Heavy physical activity (increases toxin uptake)
• Male gender
• Young age (15-25 years most vulnerable)
• Micronutrient deficiency (Zinc, Copper, Vitamin C, Vitamin A)
• Poverty and food insecurity (especially during famines/droughts)

Clinical Features

Key Features

• Symmetrical spastic paraplegia (upper motor neuron lesion)
• Sensation is spared (only motor involvement)
• Sphincters are spared
• Irreversible after latent stage (permanent disability)

Pathology

• Degeneration of the lateral corticospinal tracts (pyramidal tracts)
• Upper motor neuron destruction in the spinal cord
• The cortical neurons are relatively preserved (peripheral axons affected more)

Prevention and Control

(a) Vitamin C Prophylaxis

• 500-1000 mg of ascorbic acid daily for a week can help repair damage in early stages
• Generous Vitamin C in the diet can prevent toxin damage (demonstrated in animal models)

(b) Banning the Crop

• The Prevention of Food Adulteration Act in India has banned lathyrus in all forms (whole, split, or flour)
• However, the ban is not effectively enforced in endemic states (MP, Bihar, Odisha, Gujarat)
• Practical advice: if khesari dhal must be eaten, it should not exceed 25% of total daily cereal + pulse intake

(c) Removal of Toxin (Detoxification Methods)

1. Steeping method (home method): Soak pulse in hot water for 2 hours → drain soak water → wash with clean water → dry in sun → then use. Drawback: loss of vitamins and minerals.
2. Parboiling: Similar to parboiling of rice; soaking in lime water overnight then boiling destroys the toxin and also destroys trypsin inhibitors. Lime is easily available.

(d) Health Education

• Public education on the dangers of consuming this pulse
• Teaching detoxification methods to households in endemic areas

(e) Genetic Approach

• Certain strains of lathyrus contain very low toxin levels (~0.1%)
• Selective propagation of low-toxin varieties by the Indian Agricultural Research Institute (IARI)
• Most effective long-term strategy without requiring change in food habits

Treatment

• No definitive treatment - the paralysis is irreversible beyond the latent stage
• Supportive care: physiotherapy, walking aids, crutches
• Physiotherapy role: muscle strengthening, gait training, preventing contractures, providing assistive devices, community-based rehabilitation
• Early withdrawal of the pulse in the latent stage leads to complete remission

Types of Lathyrism (Summary)

Exam Quick Points

• Causative pulse: Lathyrus sativus = Khesari dhal
• Toxin: BOAA (Beta-oxalyl amino alanine)
• Mechanism: Excitotoxic UMN damage (glutamate agonist)
• Clinical: Spastic paraplegia, sensation and sphincters spared
• Irreversible except in latent stage
• Prevention: Vitamin C, banning crop, detoxification (steeping/parboiling), low-toxin varieties
• Endemic in: MP, UP, Bihar, Odisha (India)
• Mostly affects: Young males 15-45 years

MTP Act - Medical Termination of Pregnancy Act 1971

Background

• Before 1971, abortion in India was governed by the Indian Penal Code 1860 and Code of Criminal Procedure 1898 - abortion was a criminal offence except to save the mother's life
• The Shantilal Shah Committee (1964) recommended legalization of abortion
• The MTP Act was passed in 1971 and came into force on April 1, 1972 (extended to J&K from November 1, 1976)
• Rules revised in 1975 and 1992
• Amended in 2021 - upper gestational limit extended to 24 weeks

Purpose of the Act

1. Reduce maternal morbidity and mortality from unsafe illegal abortions
2. Provide an opportunity to motivate women to adopt contraception

Three Key Provisions of the MTP Act

1. Conditions under which a pregnancy can be terminated
2. Persons who can perform such terminations
3. Place where terminations can be performed

1. Conditions for MTP (5 Grounds)

Consent Rules

• Women under 18 years of age: written consent of guardian is necessary
• Lunatics (of any age): written consent of guardian is necessary

2. Who Can Perform MTP

Qualifications of RMP to Perform MTP (MTP Rules 1975)

• (a) 6 months housemanship in Obstetrics and Gynaecology (OBG)
• (b) Postgraduate qualification in OBG
• (c) 3 years of practice in OBG (for those registered before the 1971 Act)
• (d) 1 year of practice in OBG (for those registered after the Act)
• (e) Assisted a RMP in 25 cases of MTP in an approved institution (on-the-spot training - added in 1975 rules)

Certification

3. Where MTP Can Be Done

• Only at:
  • A government hospital, OR
  • A place approved by the government for MTP purposes
• Under 1975 rules: private/non-governmental institutions can also perform MTP if they obtain a licence from the CMO of the district
• Services provided in strict confidence - the woman's name is kept confidential (abortion treated as a personal matter)

MTP Amendment Act 2021 - Key Changes

State Medical Board Composition (2021 Amendment)

• Gynaecologist
• Paediatrician
• Radiologist/Sonologist
• Other members appointed by State Government

Impact of the MTP Act

• Legal abortions: ~6.1 per 1000 pregnancies
• Illegal abortions in India still estimated at ~13.5 per 1000 pregnancies
• Gap reflects: lack of awareness, poor access to MTP services in rural areas, social stigma

Exam Quick Points

Jones Criteria - Acute Rheumatic Fever (ARF)

What is ARF?

• Follows throat infection only - NOT skin infections (important exam point)
• Interval between streptococcal infection and ARF: 1-5 weeks
• Common in: children aged 5-15 years, overcrowded/poor socioeconomic conditions

The Jones Criteria (Revised 2015 - AHA)

Prerequisite: Evidence of Preceding GAS Infection

• Positive throat culture for Group A Streptococcus
• Positive rapid streptococcal antigen test
• Elevated or rising streptococcal antibody titre (ASO titre / anti-DNase B)
• Recent documented streptococcal infection

MAJOR Criteria - Mnemonic: "JONES"

India (moderate-high risk population): Monoarthritis also counts as a major criterion (2015 revision)

MINOR Criteria

Note: Arthralgia cannot be used as a minor criterion if arthritis is already counted as a major criterion. Similarly, prolonged PR interval cannot be a minor criterion if carditis is the major criterion.

Diagnostic Rule

2015 AHA Revision - Key Changes

India is a moderate-to-high-risk population for ARF.

Clinical Features in Detail

1. Carditis (~50-70% of cases)

• Most important manifestation - leads to Rheumatic Heart Disease (RHD)
• Affects all layers: pancarditis
• Most common valve lesion: Mitral regurgitation (acute); Mitral stenosis (chronic - years later)
• Subclinical carditis detected by Doppler echocardiography even without murmur
• 35-70% progress to chronic RHD

2. Polyarthritis (~75% - most common manifestation)

• Migratory - moves from joint to joint
• Large joints predominantly - knees, ankles, elbows, wrists
• Extremely painful but no permanent joint damage
• Dramatically responds to aspirin (so dramatic that failure to respond = question the diagnosis)

3. Sydenham's Chorea (~10-15%)

• Appears weeks to months after the streptococcal infection (late manifestation)
• Involuntary, purposeless, rapid movements of limbs and face
• "Milk-maid grip" - inability to maintain sustained grip
• Emotional lability, grimacing, slurred speech
• Resolves spontaneously in weeks to months
• Can occur without other criteria - still diagnostic of ARF

4. Erythema Marginatum (~5-10%)

• Pink rings / serpiginous margins with central clearing
• On trunk and proximal limbs - never on face
• Transient and evanescent (comes and goes)

5. Subcutaneous Nodules (<5%)

• Firm, painless, small (0.5-2 cm)
• Over bony prominences (elbows, wrists, knees, scalp, spine)
• Always associated with severe carditis
• Resolve within weeks

Treatment of ARF

Secondary Prophylaxis Duration

Exam Quick Points

DOTS - Directly Observed Treatment Short-course

Definition

RNTCP was later renamed NTEP - National Tuberculosis Elimination Programme (in line with the "End TB Strategy" of WHO 2014).

Why DOTS Was Introduced

• National Tuberculosis Programme (NTP) had been running since 1962 but treatment success rates were unacceptably low
• Death and default rates remained high
• Multi-drug resistant TB (MDR-TB) was spreading due to incomplete treatment
• In 1993, Government of India revitalized the programme with international assistance → RNTCP formed → adopted DOTS strategy
• RNTCP expanded to cover the whole country by March 2006

5 Components of DOTS Strategy (RNTCP)

How DOTS Works in Practice

DOT Agent

• Peripheral health staff (MPW - Multipurpose Worker)
• Anganwadi workers
• Teachers
• ASHA workers
• Dais (traditional birth attendants)
• Ex-TB patients
• Social workers / NGO volunteers
• Any community volunteer acceptable to the patient

DOT agents are paid an incentive/honorarium of Rs. 150 per patient completing treatment

Drug Supply System

• Drugs supplied in patient-wise boxes (PWBs) containing the full course of treatment in blister packs
• Intensive phase: each blister pack = 1 day's medication
• Continuation phase: each blister pack = 1 week's supply
• Box colour coded:
  • Red box = Category I patients
  • Blue box = Category II patients

TB Treatment Regimens under NTEP

Category I (New Cases)

Category II (Previously Treated)

• 2HRZES / 1HRZE / 5HRE (includes Streptomycin in initial IP)

India has transitioned to a daily regimen for all forms of TB (including paediatric) using Fixed Dose Combinations (FDCs)

DOTS Objectives (RNTCP)

1. Achieve at least 85% cure rate of infectious (sputum smear positive) cases through DOTS
2. Detect at least 70% of estimated cases through quality sputum microscopy

STOP TB Strategy (WHO 2006) - Built on DOTS

1. Pursuing quality DOTS - expansion and enhancement
2. Addressing TB/HIV and MDR-TB
3. Contributing to health system strengthening
4. Engaging all care providers (public + private)
5. Empowering patients and communities
6. Enabling and promoting research (diagnostics, treatment, vaccine)

End TB Strategy (WHO 2014) → NTEP

• Approved by World Health Assembly 2014
• Vision: Zero death, disease, and suffering due to TB
• 20-year programme
• India renamed RNTCP to NTEP (National TB Elimination Programme)
• Target: Eliminate TB by 2025 (5 years ahead of global target of 2030)

New Initiatives under NTEP

DOTS - Three Core Components (Simple Definition)

1. Appropriate medical treatment (correct drugs, correct dose, correct duration)
2. Supervision and motivation by health/community worker (watching patient swallow drugs)
3. Monitoring of disease status by health services (sputum conversion, weight gain, side effects)

Exam Quick Points

Dengue Fever

Definition

Causative Agent

• Dengue virus - belongs to genus Flavivirus, family Flaviviridae
• 4 serotypes: DENV-1, DENV-2, DENV-3, DENV-4
• Infection with one serotype gives lifelong immunity to that serotype only - short-term cross-immunity to others
• Secondary infection with a different serotype → more severe disease (DHF/DSS) due to antibody-dependent enhancement (ADE)

Vector

• Primary vector: Female Aedes aegypti mosquito
• Secondary vector: Aedes albopictus
• Bites during daytime (unlike Anopheles which bites at night)
• Urban mosquito - breeds in clean, stagnant water in containers (flower pots, tyres, coolers, tanks, discarded items)
• Does NOT breed in dirty water / drains

Epidemiology

• Distribution: Tropical and subtropical regions; India, Southeast Asia, Latin America, Africa
• India: Major outbreak in Delhi in 1996; now reported pan-India
• Predominantly urban and peri-urban disease
• All ages and both sexes susceptible
• Children usually have milder disease than adults

Incubation Period

• 3 to 10 days (commonly 5-6 days)

Clinical Manifestations

Spectrum of Dengue Infection

Dengue Virus Infection
├── Asymptomatic
└── Symptomatic
    ├── Undifferentiated Fever
    ├── Classical Dengue Fever (DF)
    └── Dengue Haemorrhagic Fever (DHF)
        └── Dengue Shock Syndrome (DSS)

1. Classical Dengue Fever (DF)

• Onset: Sudden, with chills and high fever (39-40°C)
• Headache: Intense
• "Break-bone fever": Severe muscle pain, joint pain (myalgia + arthralgia) - prevents all movement
• Retro-orbital pain: Pain behind eyes, especially on eye movement or pressure - within 24 hours
• Photophobia
• Other symptoms: Extreme weakness, anorexia, constipation, altered taste, sore throat
• Biphasic fever curve - fever → remission of few hours to 2 days → second febrile phase
• Rash: Appears in 80% of cases during remission or second febrile phase
  • Early: diffuse flushing, mottling, fleeting pin-point eruptions on face/neck/chest
  • Late (3rd-4th day): maculopapular or scarlatiniform rash; starts on chest/trunk → spreads to extremities; accompanied by itching; lasts 2 hours to several days; followed by desquamation
• Fever lasts ~5 days (rarely >7 days); recovery usually complete
• Case fatality: Exceedingly low

2. Dengue Haemorrhagic Fever (DHF) - 3 Phases

• Abrupt onset of high fever (40-41°C) with facial flushing, headache
• Anorexia, vomiting, abdominal pain (right costal margin tenderness)
• Resembles classical DF initially
• Positive tourniquet test - most common haemorrhagic finding
  • BP cuff inflated to midpoint between systolic and diastolic for 5 min
  • Positive: ≥10 petechiae per 2.5×2.5 cm (1 sq inch)
  • DHF: usually ≥20 petechiae
• Rising haematocrit + thrombocytopenia = key distinguishing features

• Occurs around defervescence (temperature drops to <37.5-38°C)
• Increased capillary permeability → plasma leakage (lasts 24-48 hours)
• Rapid decrease in platelet count + progressive leukopenia precede plasma leakage
• Manifestations of plasma leakage:
  • Pleural effusion (mostly right-sided)
  • Ascites
  • Haemoconcentration (Hct rise ≥20%)
  • Hypoproteinaemia/albuminaemia
  • Gall bladder oedema
• Patients without increased capillary permeability improve; those with it may deteriorate → shock

• Reabsorption of plasma; improvement of symptoms
• Bradycardia common
• Wide pulse pressure (due to fluid shift)
• Risk of fluid overload if excessive IV fluids given
• Most deaths from profound shock, complicated by fluid overload

3. Dengue Shock Syndrome (DSS)

• Tachycardia, cool extremities, delayed capillary refill, weak pulse
• Lethargy or restlessness
• Pulse pressure ≤20 mmHg (e.g., BP = 100/80 mmHg)
• Hypotension: systolic <80 mmHg (<5 years); 80-90 mmHg (older children and adults)

WHO Grading of Dengue Severity

Grades I & II = Dengue Fever; Grades III & IV = Dengue Shock Syndrome

Criteria for Diagnosis

Dengue Fever (Probable)

• Headache, retro-orbital pain, myalgia, arthralgia/bone pain, rash
• Haemorrhagic manifestations
• Leucopenia (WBC ≤5000/mm³)
• Thrombocytopenia (platelets <150,000/mm³)
• Rising haematocrit (5-10%)
• Plus supportive serology or occurrence at same location/time as confirmed case

DHF - All 4 Required:

1. Acute fever lasting 2-7 days
2. Haemorrhagic manifestations (positive tourniquet test / petechiae / ecchymoses / mucosal bleeding)
3. Platelet count ≤100,000/mm³
4. Plasma leakage evidence: Haematocrit rise ≥20% OR pleural effusion/ascites/hypoproteinaemia

Laboratory Diagnosis

Sentinel Surveillance: 521 sentinel hospitals + 14 Apex Referral Laboratories identified across India. Ban on serological tests: Unlike TB serology, dengue serology (IgM/IgG rapid tests) are still used but WHO-validated kits required.

Treatment

Dengue Fever (Outpatient)

• Oral rehydration: ORS, fruit juices, coconut water, electrolyte-rich fluids
• Paracetamol for fever (interval ≥6 hours); tepid sponging
• AVOID: Aspirin, ibuprofen, other NSAIDs (aggravate gastritis and bleeding; aspirin → Reye's syndrome)
• Warning signs to return to hospital immediately:
  • No improvement, severe abdominal pain, persistent vomiting
  • Cold/clammy extremities, lethargy/restlessness
  • Bleeding (black stools, coffee-ground vomiting)
  • No urine for >4-6 hours

DHF - Febrile Phase

• Same as DF management
• Paracetamol to keep temp <39°C
• Copious oral fluids; IV fluids if persistent vomiting

DHF - Critical Phase

• IV fluid therapy - guided by haematocrit (monitor daily from Day 3)
• Isotonic crystalloids (normal saline / Ringer's lactate) as first-line
• Colloids (dextran, gelatin) if no improvement with crystalloids
• Monitor: Hct, platelet count, pulse, BP every 1-4 hours
• No aspirin, no steroids, no antibiotics (unless secondary infection)
• Platelet transfusion only if very low or active bleeding

DSS

• Rapid IV fluid resuscitation
• Oxygen therapy
• Monitor closely for fluid overload in recovery phase

Prevention and Control

Vector Control (Most Important)

• Source reduction: Remove breeding sites (empty/clean water containers weekly, cover water tanks, drain stagnant water)
• Larviciding: Temephos (abate) in water containers; BTi (Bacillus thuringiensis israelensis)
• Fogging/indoor residual spraying: Pyrethroid-based insecticides during outbreaks
• Biological control: Gambusia fish (larvae eaters) in ponds

Personal Protection

• Wear full-sleeved clothing (day protection - Aedes bites in daytime)
• Mosquito repellents (DEET-based)
• Window/door screens; mosquito nets (not as effective as for malaria since Aedes bites in day)

Government Measures (India - Mid-Term Plan 2011)

1. Surveillance - disease and entomological
2. Case management - lab diagnosis + clinical management
3. Vector management - source reduction + chemical control + personal protection
4. Outbreak response - epidemic preparedness + media management
5. Capacity building - training and research
6. BCC (Behaviour Change Communication) - IEC/social mobilization
7. Inter-sectoral coordination - urban development, panchayati raj, education, transport
8. Monitoring and supervision

Vaccine

• Dengvaxia (CYD-TDV): Tetravalent live attenuated vaccine; available in some countries; recommended only for seropositive individuals (prior dengue infection confirmed) due to risk of severe disease in seronegative recipients

Exam Quick Points

Scar Tissue - Physiotherapy Perspective

Definition

The tensile strength of scar tissue never fully reaches that of unwounded skin - maximum ~80% of original tissue strength.

Phases of Wound Healing and Scar Formation

Key Timeline Facts

• Collagen synthesis begins: Day 4-5
• Rapid tensile strength gain: Day 5-17
• Collagen formation essentially complete: 21-28 days
• Scar continues to widen: for another month after that
• Collagen remodelling continues: up to 1 year (some say 2 years)
• Scar appears red and raised: 3-8 weeks
• Scar revision timing: should not be done before 6-12 months after injury

Types of Wounds / Healing

Types of Scars

1. Normal (Mature) Scar

• Flat, pale, soft
• Stays within wound boundaries
• Collagen arranged in parallel bundles
• No symptoms (or mild itching)

2. Hypertrophic Scar

• Raised, red, firm, itchy
• Stays within the wound boundary (does not invade surrounding skin)
• Common after: deep dermal burns, wounds crossing tension lines, wounds healing by secondary intention (>3 weeks)
• May regress spontaneously over months to years
• Collagen in parallel pattern (more organized than keloid)
• Higher percentage of myofibroblasts (apoptosis delayed to 19-30 months instead of normal time)

3. Keloid Scar

• Grows beyond the original wound boundary - invades surrounding healthy skin
• Does NOT regress spontaneously
• Difficult to treat; high recurrence rate
• Genetic predisposition; more common in darker skin pigmentation
• Often follows minor trauma (ear piercing, vaccination)
• Collagen arranged in disorganized, whorled bundles - thick hyalinized collagen bundles
• Common sites: ear lobes, chest, shoulders, upper back

4. Atrophic Scar

• Depressed below skin level
• Thin, weak scar
• Example: acne scars, stretch marks, scars after chickenpox

5. Contracture Scar

• Scar that shortens/tightens during healing → restricts movement
• Common after burns over joints
• Can limit ROM (range of motion) significantly
• Requires physiotherapy intervention early

Differences: Hypertrophic vs Keloid

Factors Affecting Scar Formation

Local Factors

• Poor blood supply / ischaemia
• Infection / contamination
• Foreign bodies
• Wound tension
• Radiation

Systemic Factors

• Advanced age
• Obesity
• Malnutrition (esp. Vitamin C, Zinc, protein deficiency)
• Smoking
• Diabetes mellitus
• Connective tissue diseases
• Medications: steroids, immunosuppressants, chemotherapy
• AIDS / Immunocompromised state

Physiotherapy Role in Scar Management

1. Early Phase (Day 1 onwards - especially burns)

• Elevation - reduces oedema/swelling
• Splintage - maintains position, prevents contracture
• Active and passive exercises - prevent stiffness, maintain ROM, reduce swelling
• Patient education - reinforce daily on scar care

2. Scar Massage (Cross-friction / Circular massage)

• Applied once wound is fully healed (epithelialised, no open areas)
• Technique: firm circular/cross-friction movements over scar with lubrication (Vitamin E oil, coconut oil, silicone gel)
• Benefits:
  • Softens and flattens scar
  • Breaks down adhesions between scar and underlying tissue
  • Improves scar mobility and skin extensibility
  • Reduces itching and hypersensitivity
  • Improves cosmetic appearance
• Duration: 5-10 minutes per session, 2-3 times/day

3. Stretching and Mobilisation

• Scar mobilisation - direct manual mobilisation of scar over underlying tissue in all directions
• Stretching exercises - to prevent/treat contractures
• Important over joints: neck, axilla, elbow, hand, knee, ankle

4. Pressure Therapy

• Pressure garments - custom-made compression garments
• Mechanism: reduces blood flow to scar → less collagen production → flatter, softer scar
• Worn for 6-18 months, 23 hours/day
• Used for: hypertrophic scars, burn scars
• Silicone gel sheets/patches - used where pressure garments difficult to apply (face, small areas)
  • Worn 12-24 hours/day for 3-6 months
  • Reduces transepidermal water loss; hydrates stratum corneum

5. Ultrasound Therapy

• Thermal and non-thermal effects on collagen
• Softens mature/fibrotic scar tissue
• Increases extensibility of collagen
• Frequency: 1 MHz for deep scars; 3 MHz for superficial
• Technique: continuous mode for thermal; pulsed for non-thermal effects

6. Laser Therapy

• Pulsed dye laser, fractional CO2 laser
• Reduces redness, flattens hypertrophic scars
• Low-level laser therapy (LLLT) suppresses collagen synthesis

7. TENS and Electrotherapy

• Reduces scar-related pain and hypersensitivity
• Iontophoresis with corticosteroids into hypertrophic scars

Medical / Surgical Management of Scars

Vitamin C and Zinc in Wound Healing (Important for BPT)

• Vitamin C (Ascorbic acid): Required for hydroxylation of proline and lysine → collagen cross-linking → scar strength. Deficiency causes scurvy (wounds reopen).
• Zinc: Cofactor for metalloproteinases; essential for collagen synthesis and immune function; deficiency delays healing.
• Protein: Provides amino acids (especially glycine, proline) for collagen synthesis.

Exam Quick Points