PSM Exam Answers (5 Marks Each)

Q7. Role of Cultural Factors Prevalent in India in Health and Prevention of Disease

• Supernatural causes - Many rural people believe diseases result from: (a) Wrath of gods/goddesses - e.g., chickenpox is called "Chhoti Mata" and drugs are considered harmful; (b) Breach of taboo - venereal diseases attributed to illicit intercourse; (c) Past sins - leprosy and TB considered punishment; (d) Evil eye - children thought most susceptible, charms and amulets used; (e) Spirit/ghost intrusion - hysteria and epilepsy treated by exorcists.
• Physical causes - Hot/cold theory of disease; blocked body openings; accumulation of body fluids.

• Open defecation in fields is considered normal; latrines seen as "for city dwellers" - promoting faeco-oral diseases.
• Wells are used for bathing, washing clothes and animals, leading to water contamination.
• "Holy rivers" (Ganga) - people drink raw river water, causing cholera/gastroenteritis epidemics.

• Vegetarianism (Hindu religious sanction) can lead to nutritional deficiencies.
• Muslims avoid pork; Hindus avoid beef - religious food restrictions.
• "Hot and cold" concept of food affects nutritional practices.
• Adulteration of milk is common due to economic motives and misbeliefs.
• Religious fasts (Ramzan, Hindu fasts) affect nutrition, especially in vulnerable groups.

• Oral hygiene: use of datun (neem twig) has some antimicrobial benefit; however, infrequent bathing in some communities.
• Tobacco chewing (pan, betel nut) - associated with oral cancer.
• Paan masala, gutkha, bidis widespread in rural and urban populations.

• Delivery by untrained traditional birth attendants (dais) persists in rural areas.
• Colostrum (first milk) discarded as "dirty" - depriving neonates of passive immunity.
• Early weaning and introduction of contaminated supplementary foods promotes malnutrition.
• Male child preference leads to neglect of female children's nutrition.

• Delay in seeking modern medical care; preference for faith healers and quacks.
• Non-compliance with treatment - stopping drugs once symptomatic relief occurs (e.g., TB).

Q8. Difference Between PQLI and HDI

Q9. TB Treatment Regimen for 30-year-old - CBNAAT showing M.TB with Rifampicin Sensitive (NTEP Guidelines)

Regimen: 2HRZE / 4HRE

• Drugs are given as Fixed Dose Combinations (FDC) in weight-band dosages, under direct observation (DOT).
• No extension of IP is required routinely.
• CP can be extended by 12-24 weeks in CNS TB, skeletal TB, or disseminated TB.
• Pyrazinamide is stopped in the continuation phase.
• Pyridoxine (Vitamin B6) 10 mg/day may be added to prevent INH-induced peripheral neuropathy.
• Patient is notified on Nikshay portal and receives Nikshay Poshan Yojana incentive (Rs. 500/month for nutritional support; Rs. 1000 on treatment completion for new case).
• Baseline investigations: LFT, RFT, blood sugar, HIV testing (PITC).
• Follow-up sputum examination at end of IP and end of treatment.

Q10. Management of 2-year-old Child with Severe Dehydration (Vomiting + Loose Stools, Drowsy, Dry Tongue, Skin Pinch Retracts Very Slowly)

PLAN C - Treat Severe Dehydration Urgently

• Give Ringer's Lactate (or Normal Saline) IV: 100 ml/kg total
  • Age <12 months: 30 ml/kg in first 1 hour + 70 ml/kg in next 5 hours
  • Age 1-5 years (this child): 30 ml/kg in first 30 min (fast), then 70 ml/kg in next 2.5 hours
• Reassess every 1-2 hours. If not improving, increase IV drip rate.
• Once hydration improves, shift to Plan B (ORS 75 ml/kg over 4 hours).

• Insert nasogastric (NG) tube and give ORS at 20 ml/kg/hour for 6 hours (120 ml/kg total).
• Refer to higher centre with IV fluids running.

• Give ORS solution during and after IV therapy.
• Continue breastfeeding (if applicable).

• Children <6 months: 10 mg/day for 14 days
• Children >6 months (this child): 20 mg/day for 14 days

• Continue feeding as soon as child can eat (do not withhold food).
• Resume age-appropriate diet.

• Continue monitoring vital signs, urine output, skin turgor.
• Educate mother on signs of dehydration and home ORS preparation (1 litre water + 6 level teaspoons sugar + ½ teaspoon salt).
• Refer immediately from PHC to FRU/district hospital for IV therapy if not available at PHC.

All answers based on Park's Textbook of Preventive and Social Medicine (25th ed.) and current NTEP/IMNCI national guidelines.

PSM Short Answers

11. Klinefelter's Syndrome

• Definition: A chromosomal disorder where a male has an extra X chromosome - karyotype 47, XXY (instead of normal 46, XY).
• Incidence: ~1-3 per 1000 male births; most common cause of primary hypogonadism in males.
• Features:
  • Tall stature with long legs
  • Small, firm testes (hypogonadism) - testicular atrophy
  • Infertility (azoospermia)
  • Gynecomastia (enlarged breast tissue)
  • Sparse body and facial hair
  • Female hair distribution pattern
  • Low testosterone, elevated FSH and LH
  • Mild intellectual disability possible
• Associated risks: Increased risk of SLE (~14x), breast cancer, osteoporosis
• Treatment: Testosterone replacement therapy; assisted reproduction (micro-TESE for sperm retrieval)

12. Triage

• Definition: The process of sorting and prioritizing patients based on the severity of their condition and urgency of treatment, especially when resources are limited (mass casualties, disasters, emergencies).
• Origin: From French word "trier" meaning "to sort."
• Purpose: To do the greatest good for the greatest number with available resources.
• Standard Triage Categories (START system):

• Uses: Mass casualty incidents, emergency departments, battlefield medicine.

13. Eligible Couple and Target Couple

• A currently married couple wherein the wife is in the reproductive age group (15-45 years).
• Approximately 150-180 eligible couples per 1000 population in India.
• About 20% are in the 15-24 year age group.
• All are in need of family planning services.
• Recorded in the Eligible Couple Register - a basic document for organising family planning work.

• A subset of eligible couples who are a priority group for family planning services.
• Originally defined as couples with 2-3 living children (most in need of contraception).
• Definition later enlarged to include couples with 1 child or even newly married couples - to inculcate family planning from the earliest stage.
• In effect, the term "target couple" has now largely merged with the concept of "eligible couple" and the latter term is more widely used today.

14. Hind Kusht Nivaran Sangh

• Founded: 1950, headquartered in New Delhi.
• Precursor: Indian Council of the British Empire Leprosy Relief Association (B.E.L.R.A.), renamed as LEPROA in 1950.
• A voluntary health agency dedicated to leprosy control in India.
• Activities include:
  1. Rendering financial assistance to leprosy homes and clinics
  2. Health education through publications and posters
  3. Training of medical workers and physiotherapists in leprosy care
  4. Conducting research and field investigations on leprosy
  5. Organising All-India Leprosy Workers' Conferences
  6. Publishing "Leprosy in India" - a quarterly journal
• Has branches all over India and works in close cooperation with the Government and other voluntary agencies.

15. PERT (Programme Evaluation and Review Technique)

• Definition: A management tool/technique used for planning, scheduling, and controlling complex projects - especially useful in health programme management.
• Developed by the US Navy in 1958 for the Polaris missile programme.
• Key features:
  • Activities are mapped as a network diagram (nodes and arrows).
  • Three time estimates used for each activity: Optimistic (to), Most likely (tm), Pessimistic (tp).
  • Expected time = (to + 4tm + tp) / 6
  • Identifies the Critical Path - the longest sequence of activities that determines minimum project duration.
• Uses in PSM/Public Health:
  • Planning immunisation campaigns
  • Hospital construction projects
  • National health programme implementation
  • Monitoring and evaluation of health schemes
• Helps identify bottlenecks and ensures timely completion of health projects.

16. Enumerate 'At Risk' Infants

1. Low birth weight (LBW) - birth weight < 2.5 kg
2. Very low birth weight (VLBW) - < 1.5 kg / Extremely low birth weight < 1 kg
3. Preterm infants - born before 37 weeks of gestation
4. Post-term infants - born after 42 weeks
5. Small for gestational age (SGA) / IUGR infants
6. Large for gestational age (LGA) - birth weight > 4 kg (of diabetic mothers)
7. Infants of diabetic mothers
8. Infants born to mothers with PIH (pre-eclampsia/eclampsia)
9. Birth asphyxia / low APGAR score (< 6 at 5 min)
10. Multiple births (twins, triplets)
11. Congenital malformations
12. Infants born to mothers with infections (TORCH - Toxoplasma, Rubella, CMV, Herpes)
13. Infants of teenage mothers or mothers > 35 years
14. Infants with neonatal jaundice (hyperbilirubinemia)

17. Self Care in Diabetes Mellitus (DM)

1. Diet control:
   • Balanced low glycaemic diet; restrict refined carbohydrates, saturated fats, salt
   • Regular meal timings; avoid skipping meals
   • Increase dietary fibre intake
2. Physical activity:
   • Minimum 30 minutes of moderate exercise (walking) 5 days/week
   • Helps improve insulin sensitivity
3. Medication adherence:
   • Take oral hypoglycaemics or insulin as prescribed; do not miss doses
   • Know how to self-administer insulin (if applicable)
4. Blood glucose monitoring:
   • Self-monitoring of blood glucose (SMBG) using glucometer
   • Know targets: Fasting < 130 mg/dL; Post-prandial < 180 mg/dL; HbA1c < 7%
5. Foot care:
   • Daily inspection of feet; keep feet clean and dry
   • Avoid walking barefoot; wear proper footwear
   • Seek prompt care for any wound or ulcer
6. Recognition of hypoglycaemia:
   • Know symptoms (sweating, trembling, confusion)
   • Carry sugar/glucose tablets; apply Rule of 15
7. Regular follow-up and eye/renal check-ups
8. Quit smoking and alcohol

18. Job Responsibilities of a Female Health Worker (ANM - Auxiliary Nurse Midwife)

1. Antenatal care - registration, ANC check-ups, TT immunisation, IFA supplementation
2. Conduct normal deliveries (if trained); refer high-risk cases
3. Postnatal care - check mother and newborn
4. Immunisation of infants and children (Universal Immunisation Programme)
5. Oral Rehydration Therapy (ORT) for diarrhoea management

19. Bubonic Plague

• Causative agent: Yersinia pestis - a gram-negative coccobacillus
• Reservoir: Wild rodents (rats, squirrels)
• Vector: Infected rat flea (Xenopsylla cheopis)
• Transmission: Bite of infected flea; rarely by direct contact with infected material
• Incubation period: 2-6 days
• Clinical features:
  • Sudden onset of high fever, chills, headache, malaise
  • Bubo - painful, swollen lymph node (usually inguinal > axillary > cervical) - the hallmark sign
  • Bubo may suppurate and drain
  • Septicaemia may develop (septicaemic plague)
  • Can spread to lungs - pneumonic plague (most dangerous, person-to-person spread)
• Diagnosis: Gram stain/culture of bubo aspirate, blood culture; showing bipolar "safety pin" staining
• Treatment: Streptomycin (drug of choice), Doxycycline, Ciprofloxacin; Chloramphenicol for plague meningitis
• Prophylaxis: Rat control, flea control, plague vaccine (killed); chemoprophylaxis (Doxycycline) for contacts

20. Six Opportunistic Infections in AIDS

All answers based primarily on Park's Textbook of Preventive and Social Medicine (25th ed.) and standard PSM references. Short answers are written at the 2-3 mark level of detail appropriate for exam purposes.

Treatment of Rifampicin-Resistant Tuberculosis (RR-TB) - NTEP Guidelines

Definition

• India accounts for ~27% of the global MDR/RR-TB burden.
• Diagnosed via CBNAAT (GeneXpert MTB/RIF) showing "Rifampicin Resistance Detected."

Pre-Treatment Evaluation

1. Drug Susceptibility Testing (DST) - Line Probe Assay (LPA) for fluoroquinolone (FQ) resistance
2. Baseline investigations: LFT, RFT, blood sugar, haemogram, ECG (QTc interval), thyroid function
3. HIV testing (PITC), visual acuity testing, audiometry
4. Notify on Nikshay portal; refer to Nodal/District DR-TB Centre (NDR-TBC/DDR-TBC)

Three Treatment Options Under NTEP (2024 Guidelines)

Option 1 - BPaLM Regimen (Preferred, Newest - 6 months)

• Total duration: 6 months (all oral, injection-free)
• If FQ-resistant: Moxifloxacin is dropped → becomes BPaL regimen
• Can be extended if extensive bilateral cavitary disease or slow response
• Adopted by NTEP in September 2024 based on WHO 2022 recommendations
• Treatment success >90% shown in clinical trials (Nix-TB, TB-PRACTECAL trials)

Option 2 - 9-11 Month Shorter Oral MDR/RR-TB Regimen

• Key change (2024): Linezolid (Lzd) for 2 months replaces Ethionamide (Eto) in IP
• Total duration: 9-11 months (all oral)
• FQ resistance must be ruled out before starting

• Bdq = Bedaquiline, Lzd = Linezolid, Lfx = Levofloxacin, Mfx = Moxifloxacin
• Cfz = Clofazimine, Z = Pyrazinamide, H(hd) = High-dose Isoniazid, E = Ethambutol

Option 3 - 18-20 Month Longer Oral M/XDR-TB Regimen

• Pre-XDR TB (RR + FQ resistance)
• XDR TB (RR + FQ resistance + Bdq or Lzd resistance)
• Patients ineligible for shorter regimens

• Use at least 4-5 effective drugs in the regimen
• All oral, injection-free regimen preferred
• Duration: 18-20 months

Monitoring During Treatment

Key Points for Exam

1. CBNAAT showing "Rif Resistance" → start RR-TB workup → refer to DDR-TBC
2. BPaLM is the newest preferred regimen (6 months) - adopted by NTEP in 2024
3. Injections (Kanamycin, Amikacin) are NO longer routinely used - all regimens are now oral
4. Treatment given under direct observation (DOT) throughout
5. Patient-wise drug boxes remain under custody of treatment supporter
6. Nikshay Poshan Yojana: Rs. 2000 at end of IP + Rs. 3000 at end of treatment
7. Outcome definition at 24 months for longer regimens; at 12 months for BPaLM