SECTION-B - Complete Answers

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from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.lib.units import cm
from reportlab.lib import colors
from reportlab.platypus import (
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    HRFlowable, KeepTogether
)
from reportlab.lib.enums import TA_CENTER, TA_LEFT, TA_JUSTIFY
from reportlab.pdfbase import pdfmetrics

OUTPUT = "/tmp/workspace/psm-answers/PSM_Answers_Park_Marrow.pdf"

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    title="PSM Exam Answers – Park & Marrow MBBS",
    author="Orris AI"
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# ── Build story ──────────────────────────────────────────────────────────────
story = []

# Cover
story.append(Paragraph("SECTION-B: Preventive & Social Medicine", title_style))
story.append(Paragraph("Complete Exam Answers – Reference: Park's PSM & Marrow MBBS", subtitle_style))
story.append(hr())
story.append(sp(8))

# ═══════════════════════════════════════════════════════════════════
# Q2
# ═══════════════════════════════════════════════════════════════════
story.append(Paragraph("Q2. Classify Occupational Diseases. Discuss Occupational Lung Diseases with Prevention and Control. (15 Marks)", q_style))
story.append(hr())

story.append(h("CLASSIFICATION OF OCCUPATIONAL DISEASES"))
story.append(p("Occupational diseases are diseases caused by specific hazards arising out of or in connection with work. They are classified based on the causative agent:"))
story.append(sp(4))

occ_table = make_table(
    ["Agent Type", "Disease Examples", "Causative Agent"],
    [
        ["Physical Agents", "Heat stroke, Chilblain, NIHL, Radiation sickness, Caisson disease", "Heat, Cold, Noise, Radiation, Compressed air"],
        ["Chemical Agents", "Plumbism, Minamata disease, CO poisoning, Aplastic anaemia", "Lead, Mercury, Carbon monoxide, Benzene"],
        ["Biological Agents", "Brucellosis, Anthrax, Leptospirosis, Psittacosis", "Farm/wool/sewage/poultry exposure"],
        ["Ergonomic/Mechanical", "Carpal tunnel syndrome, Musculoskeletal disorders", "Repetitive strain, Awkward posture"],
        ["Psychosocial", "Burnout, Occupational stress, Depression", "Work overload, Poor conditions"],
    ],
    col_widths=[3.5*cm, 7*cm, 6.5*cm]
)
story.append(occ_table)
story.append(sp(8))

story.append(h("OCCUPATIONAL LUNG DISEASES"))
story.append(h("1. Pneumoconioses (Dust Diseases)", h3_style))
story.append(p("Caused by inhalation of inorganic dusts:"))

pneu_table = make_table(
    ["Disease", "Causative Dust", "Occupation"],
    [
        ["Silicosis", "Free crystalline silica (SiO2)", "Mining, quarrying, stone cutting"],
        ["Coal Workers' Pneumoconiosis", "Coal dust", "Coal miners"],
        ["Asbestosis", "Asbestos fibres", "Shipbuilding, insulation workers"],
        ["Byssinosis", "Cotton/hemp dust", "Textile mill workers"],
        ["Bagassosis", "Sugarcane bagasse", "Sugar industry"],
        ["Farmers' lung", "Thermophilic actinomycetes", "Farming (mouldy hay)"],
        ["Siderosis", "Iron oxide dust", "Iron foundry workers"],
        ["Berylliosis", "Beryllium dust", "Aerospace, nuclear industry"],
    ],
    col_widths=[4.5*cm, 6*cm, 6.5*cm]
)
story.append(pneu_table)
story.append(sp(6))

story.append(h("Silicosis (Most Important)", h3_style))
for line in [
    "Most common and dangerous pneumoconiosis worldwide.",
    "Mechanism: Silica particles (<5 µm) → phagocytosed by macrophages → macrophage death → cytokine release → progressive pulmonary fibrosis.",
    "Pathology: Dense fibrotic nodules, 'egg-shell calcification' of hilar lymph nodes on CXR.",
    "Predisposes to tuberculosis (silicotuberculosis) – 3× higher risk.",
    "No curative treatment; management is supportive (bronchodilators, treat TB, avoid further exposure).",
]:
    story.append(b(line))

story.append(h("Asbestosis", h3_style))
for line in [
    "Asbestosis (diffuse interstitial pulmonary fibrosis)",
    "Mesothelioma (pleural/peritoneal – pathognomonic of asbestos exposure)",
    "Bronchogenic carcinoma (synergistic with smoking – 50× increased risk)",
    "Pleural plaques and pleural effusion",
    "Asbestos bodies seen in sputum – golden-brown beaded appearance.",
    "Latency period: 15–40 years.",
]:
    story.append(b(line))

story.append(h("2. Occupational Asthma", h3_style))
for line in [
    "Caused by workplace allergens: flour dust (bakers' asthma), isocyanates (spray painters), latex.",
    "Reversible airflow obstruction – may become permanent with prolonged exposure.",
    "Monday morning peak not seen (unlike byssinosis).",
]:
    story.append(b(line))

story.append(h("3. Byssinosis", h3_style))
for line in [
    "Cotton, flax, hemp dust → airway inflammation and bronchoconstriction.",
    "'Monday morning asthma' – symptoms worst on first day of work after weekend.",
    "Graded 0, ½, 1, 2, 3 (grade 3 = permanent disability).",
]:
    story.append(b(line))

story.append(h("4. Hypersensitivity Pneumonitis (Extrinsic Allergic Alveolitis)", h3_style))
story.append(p("Immune-mediated (Type III + IV) reaction to organic dust antigens:"))
for line in [
    "Bagassosis – sugarcane bagasse", "Farmers' lung – mouldy hay",
    "Bird fanciers' lung – bird proteins", "Mushroom workers' lung",
]:
    story.append(b(line))

story.append(h("5. Occupational Lung Cancers", h3_style))
for line in [
    "Mesothelioma: asbestos", "Lung cancer: asbestos, chromium, nickel, arsenic, radon",
    "Nasal cancer: nickel, hardwood dust",
]:
    story.append(b(line))

story.append(sp(6))
story.append(h("PREVENTION AND CONTROL"))
story.append(h("Primary Prevention", h3_style))
for line in [
    "Engineering controls: substitution of hazardous material, enclosure of process, local exhaust ventilation, wet drilling (suppresses silica dust).",
    "Personal Protective Equipment (PPE): respirators, dust masks, protective clothing.",
    "Pre-employment medical examination to exclude susceptible individuals.",
    "Environmental monitoring: regular dust sampling (threshold limit values – TLVs).",
    "Worker education and training.",
]:
    story.append(b(line))
story.append(h("Secondary Prevention", h3_style))
for line in [
    "Periodic medical examinations and chest X-rays at regular intervals.",
    "Lung function tests (spirometry) – annually.",
    "Early detection and removal from further exposure.",
]:
    story.append(b(line))
story.append(h("Tertiary Prevention", h3_style))
for line in [
    "Treatment of complications (TB, cor pulmonale, respiratory failure).",
    "Rehabilitation and vocational retraining.",
    "Compensation under Employees' Compensation Act, 1923.",
]:
    story.append(b(line))
story.append(h("Legislative Measures", h3_style))
for line in [
    "Factories Act, 1948",
    "Mines Act, 1952",
    "Workmen's Compensation Act / Employees' Compensation Act",
    "Occupational Safety, Health and Working Conditions Code, 2020",
]:
    story.append(b(line))

story.append(Paragraph("<i>Reference: Park's Textbook of PSM, Ch. Occupational Health</i>", note_style))
story.append(sp(10))

# ═══════════════════════════════════════════════════════════════════
# Q3
# ═══════════════════════════════════════════════════════════════════
story.append(Paragraph("Q3. Define 'Low Birth Weight'. Prevention, Control and Community Management. (10 Marks)", q_style))
story.append(hr())

story.append(h("DEFINITION"))
story.append(p("<b>Low Birth Weight (LBW):</b> Birth weight of less than 2,500 g (up to and including 2,499 g), measured preferably within the first hour of life, before significant postnatal weight loss has occurred. (WHO, 1948; Park's PSM, p. 625)"))
story.append(sp(4))
story.append(p("<b>Epidemiology:</b> LBW is the single most important determinant of an infant's chances of survival. India: ~18.6% babies are LBW (Rapid Survey on Children, 2014) vs. 4% in developed countries."))

story.append(h("Classification of LBW", h3_style))
lbw_table = make_table(
    ["Category", "Birth Weight", "Gestational Age"],
    [
        ["LBW", "<2,500 g", "Any"],
        ["Very LBW (VLBW)", "<1,500 g", "Usually preterm"],
        ["Extremely LBW (ELBW)", "<1,000 g", "Extremely preterm"],
        ["Preterm", "<2,500 g", "<37 completed weeks"],
        ["SGA/IUGR (term LBW)", "<10th percentile", "37+ weeks"],
    ],
    col_widths=[4.5*cm, 4*cm, 8.5*cm]
)
story.append(lbw_table)
story.append(sp(6))

story.append(h("CAUSES / RISK FACTORS"))
story.append(h("Maternal factors:", h3_style))
for line in [
    "Malnutrition and anaemia (most significant in India – foetal growth retardation)",
    "Infections during pregnancy (malaria, UTI, syphilis)",
    "Short maternal stature, very young maternal age (<18 years)",
    "High parity, short inter-birth intervals (<2 years)",
    "Hard physical labour during pregnancy",
    "Smoking, alcohol, substance abuse",
    "Hypertension, gestational diabetes, pre-eclampsia",
]:
    story.append(b(line))
story.append(h("Fetal/Placental factors:", h3_style))
for line in [
    "Multiple gestation (twins, triplets)",
    "Congenital anomalies, chromosomal abnormalities",
    "Placenta praevia, abruptio placentae",
]:
    story.append(b(line))

story.append(h("COMPLICATIONS OF LBW"))
for line in [
    "Hypothermia, hypoglycaemia, hyperbilirubinemia",
    "Respiratory Distress Syndrome (RDS), apnoea",
    "Necrotizing Enterocolitis (NEC)",
    "Intraventricular haemorrhage",
    "Retinopathy of prematurity (if excess oxygen given)",
    "Long-term: cerebral palsy, delayed development, stunting",
]:
    story.append(b(line))

story.append(h("PREVENTION AND CONTROL AT COMMUNITY LEVEL"))
story.append(h("A. Antenatal Care (ANC):", h3_style))
for line in [
    "Minimum 4 ANC visits (WHO now recommends 8)",
    "Early registration of pregnancy",
    "Iron-Folic Acid supplementation (100 mg iron + 0.5 mg folic acid daily)",
    "Tetanus Toxoid (TT) immunization",
    "Balanced energy-protein supplementation for undernourished mothers",
    "Screening and treatment of infections (malaria, syphilis, UTI)",
    "Calcium supplementation to prevent pre-eclampsia",
    "Management of hypertensive disorders",
]:
    story.append(b(line))
story.append(h("B. Nutritional Interventions:", h3_style))
for line in [
    "Food supplementation through ICDS (Integrated Child Development Services)",
    "Promotion of diverse diet and micronutrient supplementation",
    "Management and treatment of maternal anaemia",
]:
    story.append(b(line))
story.append(h("C. Other Preventive Measures:", h3_style))
for line in [
    "Family planning – optimal inter-birth spacing of ≥2–3 years",
    "Reducing teenage pregnancies through education",
    "Promotion of institutional deliveries (Janani Suraksha Yojana – JSY)",
    "Skilled birth attendants for all deliveries",
]:
    story.append(b(line))

story.append(h("MANAGEMENT AT COMMUNITY LEVEL"))
story.append(h("1. Kangaroo Mother Care (KMC) – Park's PSM, p. 626", h3_style))
story.append(p("Introduced in Colombia (1979) by Drs. Hector Martinez and Edzar Rey. Four essential components:"))
for line in [
    "Skin-to-skin positioning: baby placed upright between mother's breasts, head turned to one side",
    "Kangaroo nutrition: exclusive breastfeeding / expressed breast milk on demand",
    "Ambulatory care: early discharge from hospital, KMC continued at home",
    "Support for mother and family: regular follow-up, psychosocial support",
]:
    story.append(b(line))
story.append(p("<b>Benefits:</b> Maintains normothermia, reduces infection/NEC, promotes breastfeeding, reduces hospital costs, reduces mortality by ~40%."))

story.append(h("2. Facility-Based Newborn Care:", h3_style))
for line in [
    "Newborn Care Corner (NBCC) – at delivery points: resuscitation, warmth",
    "Newborn Stabilization Unit (NBSU) – at PHC/FRU level",
    "Special Newborn Care Unit (SNCU) – at district hospital level",
]:
    story.append(b(line))
story.append(h("3. Thermal Care – Warm Chain:", h3_style))
for line in [
    "Warm delivery room, immediate drying, skin-to-skin contact",
    "Warm wrapping, delayed bathing, warm transport",
    "Incubator care for VLBW/ELBW in SNCU",
]:
    story.append(b(line))
story.append(h("4. Feeding:", h3_style))
for line in [
    "Breastfeeding preferred (Indian mothers secrete 450–600 mL/day, 70 kcal/100 mL)",
    "Nasogastric tube feeding if baby cannot suck",
    "WHO F-75 and F-100 protocols for nutritional rehabilitation",
]:
    story.append(b(line))

story.append(Paragraph("<i>Reference: Park's Textbook of PSM, pp. 625–629</i>", note_style))
story.append(sp(10))

# ═══════════════════════════════════════════════════════════════════
# Q4
# ═══════════════════════════════════════════════════════════════════
story.append(Paragraph("Q4. Short Notes (5 × 4 = 20 Marks)", q_style))
story.append(hr())

# 4a
story.append(h("(a) Sample Registration System (SRS)"))
for line in [
    "<b>Introduced:</b> 1964–65 (pilot); 1969–70 (full scale) by Registrar General of India (RGI).",
    "<b>Objective:</b> To provide reliable annual estimates of fertility and mortality at national and state levels.",
    "<b>Design:</b> Dual Record System (DRS) – combines (1) Continuous enumeration by part-time resident enumerator + (2) Independent retrospective survey by supervisor every 6 months.",
    "<b>Sample:</b> ~7,597 sampling units (4,436 rural + 3,161 urban) covering ~8.1 million population.",
]:
    story.append(b(line))
story.append(h("Indicators Provided:", h3_style))
for line in [
    "Crude Birth Rate (CBR)", "Crude Death Rate (CDR)",
    "Infant Mortality Rate (IMR)", "Total Fertility Rate (TFR)",
    "Neonatal Mortality Rate", "Maternal Mortality Ratio (MMR)",
    "Life expectancy at birth",
]:
    story.append(b(line))
story.append(p("<b>Recent SRS Data (2020):</b> CBR = 19.5/1000; CDR = 6.0/1000; IMR = 28/1000 live births"))
story.append(p("<b>Significance:</b> Only system providing annual vital statistics at state level in India."))
story.append(sp(6))

# 4b
story.append(h("(b) Newer Contraceptives"))
story.append(h("Oral Contraceptives:", h3_style))
for line in [
    "<b>Centchroman (Saheli/Chhaya):</b> Non-steroidal weekly pill; 30 mg weekly for 3 months, then fortnightly; failure rate ~1–2/100 WY; minimal hormonal side effects.",
    "<b>DMPA (Depo Provera/Antara):</b> Injectable progestogen; 150 mg IM every 3 months; efficacy >99%; part of National Family Planning programme.",
    "<b>Noristerat:</b> NET-EN 200 mg IM every 2 months.",
]:
    story.append(b(line))
story.append(h("Intrauterine Devices:", h3_style))
for line in [
    "<b>CuT-380A:</b> Copper T, lasts 10 years; failure rate <1%.",
    "<b>LNG-IUS (Mirena):</b> Levonorgestrel IUD; effective 5 years; reduces menorrhagia.",
]:
    story.append(b(line))
story.append(h("Emergency Contraception:", h3_style))
for line in [
    "<b>Levonorgestrel (I-pill):</b> 1.5 mg single dose within 72 hours.",
    "<b>Ulipristal acetate:</b> Effective up to 120 hours.",
]:
    story.append(b(line))
story.append(h("Implants & Other:", h3_style))
for line in [
    "<b>Etonogestrel implant (Implanon):</b> Subdermal; effective 3 years.",
    "<b>RISUG:</b> Reversible Inhibition of Sperm Under Guidance – intravasal injection; Indian innovation; reversible; Phase III trials completed.",
    "<b>Female condom (Femidom):</b> Barrier method; also protects against STIs.",
    "<b>Contraceptive vaginal ring (NuvaRing):</b> Monthly etonogestrel + EE ring.",
]:
    story.append(b(line))
story.append(sp(6))

# 4c
story.append(h("(c) ASHA (Accredited Social Health Activist)"))
for line in [
    "<b>Launched:</b> Under National Rural Health Mission (NRHM), 2005.",
    "<b>Coverage:</b> One ASHA per 1,000 population (one per habitation in hilly/tribal areas).",
    "<b>Selection:</b> Female, married/widow/divorced preferred, resident of village, 18–45 years, minimum 8th class educated; selected by Gram Sabha/Village Health & Sanitation Committee.",
    "<b>Training:</b> 23 days residential training + 6 days refresher; Modules 1–7.",
]:
    story.append(b(line))
story.append(h("Key Responsibilities:", h3_style))
for line in [
    "Creating awareness on nutrition, sanitation, hygiene and healthy living",
    "Mobilizing community for health and nutrition services",
    "Escorting pregnant women to health facility for ANC and institutional delivery",
    "Home visits for newborn care and postnatal care",
    "Distributing medicines: ORS, chloroquine, IFA, condoms, OCP",
    "Reporting births, deaths, disease outbreaks to health system",
    "Promoting Janani Suraksha Yojana (JSY) and other government schemes",
]:
    story.append(b(line))
story.append(p("<b>Incentives:</b> Performance-based (not salary) – Rs. 600 for institutional delivery escort + various RMNCH+A incentives."))
story.append(p("<b>Drug Kit:</b> ASHA carries kit with ORS, IFA, chloroquine, condoms, OCP, DDT."))
story.append(sp(6))

# 4d
story.append(h("(d) MMR (Maternal Mortality Ratio/Rate)"))
story.append(p("<b>Definition (WHO):</b> Death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of duration and site of pregnancy, from any cause related to or aggravated by the pregnancy or its management, but NOT from accidental or incidental causes."))
story.append(p("<b>Maternal Mortality Ratio (MMRatio):</b> = (Maternal deaths / Live births) × 100,000"))
story.append(p("<b>Maternal Mortality Rate (MMRate):</b> = (Maternal deaths / Total women aged 15–44) × 1,000"))
story.append(h("Types:", h3_style))
for line in [
    "<b>Direct obstetric deaths:</b> Haemorrhage (most common worldwide), Sepsis, Eclampsia/pre-eclampsia, Obstructed labour, Unsafe abortion",
    "<b>Indirect obstetric deaths:</b> Pre-existing disease aggravated by pregnancy – Anaemia (most common indirect cause in India), Heart disease, Malaria",
    "<b>Late maternal death:</b> Death from obstetric cause 42 days to 1 year after delivery",
]:
    story.append(b(line))
story.append(h("MMR in India (SRS):", h3_style))
for line in [
    "MMR 2018–20: 97 per 100,000 live births",
    "SDG Target: <70 per 100,000 live births by 2030",
    "Highest MMR: Assam (~195) | Lowest: Kerala (~19)",
]:
    story.append(b(line))
story.append(h("Three Delays Model (for intervention):", h3_style))
for line in [
    "Delay 1: Deciding to seek care (community/individual level)",
    "Delay 2: Reaching care facility (transport/infrastructure)",
    "Delay 3: Receiving adequate care (health system level)",
]:
    story.append(b(line))
story.append(p("<b>Key schemes:</b> JSY (Janani Suraksha Yojana), LaQshya, PMSMA (Pradhan Mantri Surakshit Matritva Abhiyan), JSSK (Janani Shishu Suraksha Karyakram)"))
story.append(sp(10))

# ═══════════════════════════════════════════════════════════════════
# Q5
# ═══════════════════════════════════════════════════════════════════
story.append(Paragraph("Q5. Justify & Comment (5 × 4 = 20 Marks)", q_style))
story.append(hr())

story.append(h("(a) Chlorination of Water"))
story.append(p("<b>Justification:</b> Chlorination is the most widely used method of water disinfection because it is effective, cheap, feasible for large-scale use, and provides residual protection against recontamination in distribution pipes."))
story.append(h("Methods:", h3_style))
for line in [
    "Continuous chlorination: municipal water supply (0.5 mg/L after 30 min contact time)",
    "Double pot method: bleaching powder in earthen pots for individual well",
    "Tablet form: Halazone (4 mg/L), Aquatabs – for emergency/individual use",
]:
    story.append(b(line))
story.append(h("Mechanism:", h3_style))
story.append(p("Chlorine + Water → HOCl (hypochlorous acid) + HCl. HOCl is the active germicidal agent – destroys bacterial cell membrane enzymes. More effective at lower pH (acidic conditions)."))
story.append(h("Break-Point Chlorination:", h3_style))
story.append(p("The dose needed to: oxidize all organic matter + ammonia + achieve residual of 0.2 mg/L at consumer tap. Required: 0.5 mg/L residual after 30 min at application point."))
story.append(h("Comment/Limitations:", h3_style))
for line in [
    "Does NOT kill Cryptosporidium or Giardia cysts (requires UV/ozone)",
    "Produces Trihalomethanes (THMs) – carcinogenic byproducts when chlorine reacts with organic matter",
    "Taste and odour problems at high doses",
    "Does not remove turbidity, heavy metals, or chemical contaminants",
    "Overall: Best available method for community water treatment despite limitations",
]:
    story.append(b(line))
story.append(sp(6))

story.append(h("(b) Integrated Vector Management (IVM)"))
story.append(p("<b>Definition (WHO):</b> A rational decision-making process for optimal use of resources for vector control."))
story.append(p("<b>Justification:</b> Single-method vector control (e.g., only DDT spraying) leads to insecticide resistance, environmental pollution, non-target organism toxicity, and is unsustainable."))
story.append(h("WHO Principles of IVM:", h3_style))
for line in [
    "Advocacy, social mobilization and legislation",
    "Collaboration within health sector and with other sectors (agriculture, environment, urban planning)",
    "Integrated approach – combining biological, chemical, and environmental methods",
    "Evidence-based decision making with local data",
    "Capacity building of healthcare workforce",
]:
    story.append(b(line))
story.append(h("Components:", h3_style))
for line in [
    "<b>Environmental management:</b> Source reduction – eliminating breeding sites, draining stagnant water, filling pools, water management",
    "<b>Biological control:</b> Larvivorous fish (Gambusia, Guppy), Bacillus thuringiensis israelensis (Bti), copepods",
    "<b>Chemical control (judicious):</b> LLINs (Long-Lasting Insecticidal Nets), IRS (Indoor Residual Spraying), larvicides (temephos, Bti)",
    "<b>Personal protection:</b> Insecticide-treated bed nets, repellents (DEET), protective clothing",
    "<b>Community participation:</b> Education, awareness, clean-up drives",
]:
    story.append(b(line))
story.append(p("<b>Programme:</b> NVBDCP (National Vector-Borne Disease Control Programme) – covers malaria, dengue, filaria, kala-azar, JE, chikungunya using IVM principles."))
story.append(sp(6))

story.append(h("(c) Kangaroo Mother Care (KMC)"))
story.append(p("<b>Justification:</b> LBW babies are at high risk of hypothermia, infection, and death. Incubators are expensive and require electricity. KMC offers a simple, low-cost, highly effective alternative that can be implemented in resource-poor settings."))
story.append(h("4 Essential Components:", h3_style))
for line in [
    "<b>Kangaroo position:</b> Upright skin-to-skin contact on mother's chest, head turned to one side (airway patent), frog position",
    "<b>Kangaroo nutrition:</b> Exclusive breastfeeding or expressed breast milk on demand",
    "<b>Ambulatory care:</b> Early discharge from hospital; KMC continued at home",
    "<b>Support:</b> Regular follow-up; emotional and psychosocial support for mother and family",
]:
    story.append(b(line))
story.append(h("Benefits (Comment):", h3_style))
for line in [
    "Maintains body temperature (mother's chest = natural incubator)",
    "Reduces risk of infection and sepsis (by 58%)",
    "Reduces hypothermia (by 72%)",
    "Promotes breastfeeding and weight gain",
    "Reduces apnoea episodes",
    "Reduces hospital stay and costs",
    "Improves maternal-infant bonding",
    "WHO recommends KMC for all LBW babies <2,000 g when clinically stable",
    "Cochrane review: reduces mortality in LBW babies by ~40%",
]:
    story.append(b(line))
story.append(sp(6))

story.append(h("(d) Post-Exposure Prophylaxis (PEP) of Rabies"))
story.append(p("<b>Justification:</b> Rabies is 100% fatal once clinical symptoms appear, but 100% preventable if PEP is given correctly and promptly after exposure. PEP is the cornerstone of rabies prevention globally."))

story.append(h("WHO Category of Exposure:", h3_style))
cat_table = make_table(
    ["Category", "Type of Contact", "Management"],
    [
        ["Category I", "Touching, feeding animal; licks on intact skin", "Wash only. No vaccine needed"],
        ["Category II", "Nibbling of uncovered skin; minor scratches/abrasions without bleeding", "Wound toilet + Vaccine"],
        ["Category III", "Single/multiple transdermal bites; scratches with bleeding; licks on broken skin; mucous membrane contamination; bat contact", "Wound toilet + Vaccine + RIG"],
    ],
    col_widths=[2.5*cm, 7*cm, 7.5*cm]
)
story.append(cat_table)
story.append(sp(6))

story.append(h("PEP Steps:", h3_style))
story.append(p("<b>Step 1 – Wound Care (IMMEDIATE):</b> Wash wound with soap and water for minimum 15 minutes. Apply povidone-iodine or 70% alcohol. Do NOT suture immediately. Do NOT apply turmeric, chilli, oil."))
story.append(p("<b>Step 2 – Rabies Immunoglobulin (RIG) – Category III only:</b>"))
for line in [
    "Human RIG (HRIG): 20 IU/kg body weight",
    "Equine RIG (ERIG): 40 IU/kg body weight (do skin test first)",
    "Infiltrate maximum possible RIG into and around wound; give remainder IM at site distant from vaccine",
    "Give on Day 0 ONLY",
]:
    story.append(b(line))
story.append(p("<b>Step 3 – Anti-Rabies Vaccine:</b>"))
for line in [
    "Essen regimen (IM): 5 doses – Days 0, 3, 7, 14, 28 (deltoid / anterolateral thigh)",
    "Updated Thai Red Cross regimen (ID): 2-2-2-0-2 or 2-0-2-0-1-1",
    "Zagreb regimen: 2-1-1 (2 doses Day 0; 1 each Days 7 and 21)",
    "Vaccines: PCECV (Purified Chick Embryo Cell Vaccine), PVRV (Purified Vero cell Rabies Vaccine)",
]:
    story.append(b(line))
story.append(p("<b>Pre-Exposure Prophylaxis (PrEP):</b> For high-risk groups (veterinarians, lab workers) – 3 doses on Days 0, 7, 21/28."))
story.append(sp(10))

# ═══════════════════════════════════════════════════════════════════
# Q6
# ═══════════════════════════════════════════════════════════════════
story.append(Paragraph("Q6. Differences Between (3 × 3 = 9 Marks)", q_style))
story.append(hr())

story.append(h("(a) Type I vs Type II Lepra Reaction"))
lepra_table = make_table(
    ["Feature", "Type I (Reversal Reaction)", "Type II (ENL – Erythema Nodosum Leprosum)"],
    [
        ["Hypersensitivity", "Type IV (Cell-mediated, delayed)", "Type III (Immune complex / Arthus)"],
        ["Leprosy Type", "Borderline (BT, BB, BL)", "Lepromatous (LL, BL)"],
        ["Mechanism", "Shift toward CMI (Th1) – upgrading reaction", "Complement activation + immune complex deposition"],
        ["Skin Lesions", "Existing lesions become erythematous, raised, oedematous", "NEW tender erythematous nodules (ENL nodules)"],
        ["Nerve Involvement", "Common – acute painful neuritis", "Less common; less severe nerve damage"],
        ["Systemic Features", "Usually absent", "Fever, malaise, lymphadenopathy, iritis, orchitis, arthritis"],
        ["Treatment", "Prednisolone 40–60 mg/day, taper over 3–6 months", "Thalidomide (drug of choice*), Prednisolone, Clofazimine"],
        ["Prognosis", "Good if treated early; may reverse nerve damage", "Recurrent episodes; chronic management needed"],
    ],
    col_widths=[3.5*cm, 6*cm, 7.5*cm]
)
story.append(lepra_table)
story.append(Paragraph("<i>*Thalidomide: contraindicated in females of childbearing age (teratogenic)</i>", note_style))
story.append(sp(8))

story.append(h("(b) Health Education vs Health Propaganda"))
he_table = make_table(
    ["Feature", "Health Education", "Health Propaganda"],
    [
        ["Definition", "Process of helping people change behaviour through knowledge, attitudes & skills using scientific methods", "One-sided persuasion to promote a health message/policy, may lack full scientific basis"],
        ["Communication", "Two-way, interactive, participatory", "One-way, top-down mass communication"],
        ["Goal", "Long-term behaviour change through understanding and empowerment", "Short-term change in opinion/behaviour through persuasion"],
        ["Methods", "Group discussions, demonstrations, counselling, role plays, audio-visuals", "Mass media (radio, TV, posters), slogans, billboards"],
        ["Target", "Individual or small group", "Mass population"],
        ["Autonomy", "Respects individual's right to make informed decisions", "May manipulate or coerce"],
        ["Sustainability", "Long-lasting; creates genuine health literacy", "Short-term; needs constant reinforcement"],
        ["Example", "Teaching ORS preparation; family planning counselling", "Anti-tobacco billboards; 'Boil water' slogans"],
    ],
    col_widths=[3*cm, 6.5*cm, 7.5*cm]
)
story.append(he_table)
story.append(sp(8))

story.append(h("(c) Marasmus vs Kwashiorkor"))
mk_table = make_table(
    ["Feature", "Marasmus", "Kwashiorkor"],
    [
        ["Cause", "Deficiency of BOTH protein AND calories (total starvation)", "Predominantly PROTEIN deficiency with adequate calories (carbohydrates)"],
        ["Age", "Infants <1 year (during/after weaning)", "Children 1–3 years (post-weaning)"],
        ["Onset", "Gradual", "Relatively rapid"],
        ["Weight", "Severely reduced (<60% of expected)", "May appear normal or near-normal due to oedema"],
        ["Oedema", "ABSENT", "PRESENT (hallmark) – pitting; starts at feet, extends upward"],
        ["Appearance", "'Old man / Monkey face'; loose wrinkled skin; 'skin and bones'", "'Moon face' (oedematous); miserable 'flag' expression"],
        ["Skin", "Loose, wrinkled, dry", "Flaky paint dermatosis; depigmentation; erosions"],
        ["Hair", "Thin, sparse", "Flag sign (alternating depigmented/pigmented bands); easily pluckable; silky texture"],
        ["Liver", "Normal or mildly enlarged", "Hepatomegaly (fatty liver – reduced apolipoprotein synthesis)"],
        ["Appetite", "Good (hungry)", "Anorexia"],
        ["Serum Albumin", "Normal or mildly reduced", "Markedly reduced (<2.5 g/dL)"],
        ["Behaviour", "Active, alert (though irritable)", "Apathetic, miserable, withdrawn"],
        ["Prognosis", "Better prognosis", "Worse prognosis; higher mortality"],
        ["Treatment", "Nutritional rehabilitation (WHO F-75, then F-100 protocol)", "Same + potassium supplementation; treat infections; gradual refeeding"],
    ],
    col_widths=[3.5*cm, 6*cm, 7.5*cm]
)
story.append(mk_table)
story.append(sp(10))

# ═══════════════════════════════════════════════════════════════════
# Q7
# ═══════════════════════════════════════════════════════════════════
story.append(Paragraph("Q7. Enumerate (2 × 3 = 6 Marks)", q_style))
story.append(hr())

story.append(h("(a) Stages of a Disaster Cycle"))
story.append(p("The disaster management cycle consists of the following phases (continuous cycle):"))
disaster_table = make_table(
    ["Stage", "Key Activities"],
    [
        ["1. Prevention / Mitigation", "Prevent hazards from becoming disasters; reduce impact – building codes, flood barriers, vaccination, deforestation control, risk mapping"],
        ["2. Preparedness", "Planning, training, stockpiling supplies, establishing early warning systems, mock drills, community education"],
        ["3. Response / Relief", "Immediate post-disaster actions – search and rescue, emergency medical care, food, water, shelter, evacuation"],
        ["4. Recovery / Rehabilitation", "Restore community to pre-disaster level – rebuilding infrastructure, psychological support, livelihood restoration, disease surveillance"],
        ["5. Development / Reconstruction", "Long-term measures to build back better and reduce future vulnerability (DRR – Disaster Risk Reduction)"],
    ],
    col_widths=[4.5*cm, 12.5*cm]
)
story.append(disaster_table)
story.append(sp(6))

story.append(h("(b) Vaccines at 6 Weeks as per National Immunization Schedule (NIS)"))
nis_table = make_table(
    ["Vaccine", "Dose", "Route", "Site"],
    [
        ["Pentavalent-1 (DPT + Hib + Hep B)", "0.5 mL", "IM", "Anterolateral thigh (left)"],
        ["OPV-1 (Oral Polio Vaccine)", "2 drops", "Oral", "—"],
        ["IPV-1 (Inactivated Polio Vaccine)", "0.1 mL", "ID", "Deltoid (right)"],
        ["Rotavirus Vaccine-1 (RVV)", "5 drops", "Oral", "—"],
        ["PCV-1 (Pneumococcal Conjugate Vaccine)", "0.5 mL", "IM", "Anterolateral thigh (right)"],
    ],
    col_widths=[7*cm, 2*cm, 2*cm, 6*cm]
)
story.append(nis_table)
story.append(p("<b>Note:</b> Pentavalent vaccine combines DPT + Hib + Hepatitis B in one injection. IPV was added to NIS in 2015. PCV and RVV are included in Universal Immunization Programme."))
story.append(sp(6))

story.append(h("(c) Any 4 Pneumoconioses"))
pneumo_table = make_table(
    ["Pneumoconiosis", "Causative Dust", "Occupation", "Key Feature"],
    [
        ["1. Silicosis", "Free crystalline silica (SiO2)", "Mining, quarrying, stone cutting, sandblasting", "Most common; 'eggshell calcification'; predisposes to TB"],
        ["2. Coal Workers' Pneumoconiosis (CWP)", "Coal dust", "Coal miners", "Simple CWP → Progressive Massive Fibrosis (PMF); Caplan syndrome"],
        ["3. Asbestosis", "Asbestos fibres", "Shipbuilding, insulation, roofing", "Mesothelioma, lung CA; 'asbestos bodies'; latency 15–40 yr"],
        ["4. Byssinosis", "Cotton, hemp, flax dust", "Textile/cotton mill workers", "'Monday morning asthma'; Grade 0–3"],
        ["5. Berylliosis", "Beryllium dust", "Aerospace, nuclear, electronics", "Granulomatous disease (sarcoid-like); systemic involvement"],
        ["6. Siderosis", "Iron oxide dust", "Iron foundry, welders", "Relatively benign; 'red lung'; no significant fibrosis"],
    ],
    col_widths=[3.5*cm, 4*cm, 4*cm, 5.5*cm]
)
story.append(pneumo_table)
story.append(sp(10))

# Footer note
story.append(hr())
story.append(Paragraph(
    "<b>References:</b> Park's Textbook of Preventive and Social Medicine, 26th Edition (Park PSM) | Marrow MBBS Community Medicine Notes | WHO Guidelines",
    note_style
))

# Build
doc.build(story)
print("PDF generated:", OUTPUT)