Disclaimer: This article is primarily intended for my students, and is specific to Kerala University of Health Sciences (KUHS). However, others may find this useful, too.

Background Information:

Both Paper I and Paper II have two ‘Problem Solving’ questions, each worth 5 marks. We will consider the questions of Paper I and Paper II separately.

Key Messages:

Paper II

There are fewer variants of the ‘Problem-solving’ questions in Paper II compared to Paper I. We will consider each of these in turn.

Variant 1: Address/ Manage/Improve a situation/problem

This is the most common variant, and requires candidates to describe how they would resolve a given situation. Identifying such questions is quite straightforward, as they usually contain one of the following terms:

• Strategy/strategies for…
• Project to improve…
• How will you tackle…
• Action plan to address..
• Manage the situation

Often, the question will also state that you are the Medical Officer of a Primary Health Centre (PHC), and include one of the terms listed above. Regardless of whether the question states that you are the MO of a PHC or not, the approach to such questions remains the same. All such questions seek the development of a plan to deal with some problem. Therefore, candidates are expected to apply the planning cycle to the given situation, and incorporate appropriate prevention and control measures within the plan. This may require mention/ better implementation of existing National Programs as well.

Example: The question requires candidates to develop an ‘..action plan to address increasing cardiovascular diseases..’àThe first step is situation analysis/assessment of the problem. One may mention the various risk factors of cardiovascular disease, and how one or other risk factor will be prioritised for control. Next, one must develop objectives based on the results of initial assessment. For the purpose of the answer, one may identify one or more risk factors of cardiovascular disease to illustrate the plan, or simply presume that a particular risk factor is most suitable for intervention. Then, adapt prevention and control measures for the chosen risk factor to your plan, using the steps of the planning cycle to describe the process. Include details of monitoring and evaluation. Since the answer is hypothetical, describing a budget would be inappropriate. However, a gantt chart would be useful to illustrate the plan. If possible, a brief summary of the plan/ project should be provided at the end. Plans should indicate how they will integrate with existing national programs and optimize use of available resources (manpower, equipment/infrastructure, etc.).

Variant 2: Manage case

This is the second most common variant of ‘problem-solving’ questions in Paper II. The question will describe a particular clinical scenario, and candidates are required to describe the clinical management of the same. The question may not indicate the diagnosis, but will provide adequate information to arrive at differential diagnoses. Sometimes the clinical picture described indicates a single condition- pregnancy/ scabies/ gonorrhoea/ PEM/ TB with HIV, etc.; but it may also indicate a broad group of diseases- Acute Respiratory Illness/ Acute Diarrhoeal Disease/ Fever with rash, etc. Where a broad group of diseases is indicated, candidates should try to arrive at a more focused diagnosis based on clues provided in the question. For instance, if the question states that a child has fever, provides respiratory rate, and mentions grunting, students should identify it as very severe disease/ severe disease (ARI)(depending on the age of the child). Candidates should be familiar with the clinical management guidelines of the given condition, and describe the appropriate management pathway. In the illustrative example mentioned previously, management would involve search for other danger signs, and implementation of the treatment protocol for very severe disease. Since management would vary by the facility (PHC/CHC, etc.), one could describe management as if one is in a PHC. If the condition is covered under a National Program, the management described should be aligned with the algorithms recommended in the National Program. For instance, ARI is covered under IMNCI. Therefore, candidates should describe the appropriate colour coding and management according to IMNCI. It is acceptable for students to describe general treatment principles, instead of a customized treatment plan. However, the treatment plan should be appropriate for the condition. One may conclude by adding a note on prevention of the condition.

Essential competences/skills required to answer such questions include:

• Knowledge of, and familiarity with diagnostic criteria for common conditions
• Knowledge of National Programs covering the above conditions
• Knowledge of assessment and treatment guidelines under the relevant National Programs

The broad approach to any such question includes the following steps:

1. Diagnosis/differential diagnosis of condition
2. Assessment of patient (history, examination, laboratory investigations as appropriate)
3. Classification of disease based on assessment
4. Treatment algorithm appropriate for class of disease under related National Program
5. Prevention of condition (in future)

Candidates must strive to use all clinical information provided in the question to arrive at a diagnosis/differential diagnosis. This will yield the most accurate result, and reduce the chance of misdiagnosis.

Variant 3: Investigation of outbreak

Strictly speaking, this should not feature in Paper II, but it has been included in Paper II in the past. The approach to such questions has been described in the previous article.

Useful Link:

Link to article on ‘How to approach problem-solving questions: Paper I’:

https://communitymedicine4asses.com/2018/12/13/how-to-approach-problem-solving-questions-in-the-theory-examination-paper-i/