(a) Discuss in brief the role of ultrasound in the investigation of pain in right hypochondrium. (10 marks)
(b) Outline the pharmacological and non-pharmacological treatment of depressive disorders. (10 marks)
(c) A neonate born at 30 weeks of gestat

Question

(a) Discuss in brief the role of ultrasound in the investigation of pain in right hypochondrium. (10 marks)
(b) Outline the pharmacological and non-pharmacological treatment of depressive disorders. (10 marks)
(c) A neonate born at 30 weeks of gestation is found to have tachypnea, chest retractions and grunt within 30 minutes of birth.
(i) What is the most likely diagnosis? Mention the basis of your diagnosis and state briefly the pathophysiology of the condition.
(ii) Describe the management of this condition. (5+5=10 marks)
(d) A 6-month-old infant attending paediatrics OPD is found to have central cyanosis, clubbing and no hepatomegaly.
(i) What is the most likely cardiovascular condition? State its cardiovascular examination findings and accompanying haemodynamic changes.
(ii) Write about the clinical course and complications related to this condition. (5+5=10 marks)
(e) An adolescent girl fond of wearing artificial jewellery presented with itchy, papulo-vesicular skin lesions on the ears, wrists and neck.
(i) What is the likely diagnosis?
(ii) Name the gold standard test which you would use for the confirmation of diagnosis.
(iii) How would you interpret the test results?
(iv) State the complications of this test. (2+2+3+3=10 marks)

UPSC Answer Check · Accepted Answer

Right hypochondrial pain, depressive illness, neonatal respiratory distress, cyanotic congenital heart disease and allergic contact dermatitis require organ-system and age-specific reasoning, but each can be approached with a focused diagnostic and therapeutic plan.

(a) Ultrasound in right hypochondrial pain. Ultrasound is the first-line investigation because it is non-invasive, inexpensive, repeatable, radiation-free and useful at the bedside. In biliary disease it identifies gallstones, gallbladder wall thickening, pericholecystic fluid, a positive sonographic Murphy sign and common bile duct dilatation; Doppler can assess hepatic and portal vascular flow. In hepatic disease it detects hepatomegaly, focal masses, abscesses, cirrhosis and portal vein thrombosis. It also evaluates the right kidney and ureter for calculi, hydronephrosis or perinephric collections, and can distinguish renal colic from biliary pain. It is especially useful in acute right upper quadrant pain because it can be repeated to monitor gallbladder and hepatic lesions, and in chronic or atypical pain it helps identify fatty liver, hepatic masses, renal pathology and biliary dilatation. Its limitations are operator dependence, reduced views in obesity or bowel gas, and incomplete assessment of distal common bile duct stones; MRCP or ERCP may be needed when ultrasound is equivocal. It can also guide percutaneous drainage of a liver or perinephric collection.

(b) Depressive disorders. Pharmacological treatment is guided by severity, comorbidity, previous response and safety. SSRIs such as fluoxetine, sertraline and escitalopram are usually first-line because of tolerability. SNRIs such as venlafaxine and duloxetine are useful in resistant or painful depression. TCAs such as amitriptyline and nortriptyline are effective but have anticholinergic effects and cardiotoxicity in overdose, so they require caution in the elderly and cardiac patients. MAOIs such as tranylcypromine or moclobemide are reserved for atypical or refractory depression; non-selective MAOIs require a low-tyramine diet, and all MAOIs require avoidance of serotonergic drugs because of hypertensive crisis and serotonin syndrome. ECT is indicated in severe, psychotic, catatonic or suicidal depression, or when rapid response is needed. Treatment should be individualised, with monitoring for side effects, adherence, suicidal ideation and relapse. In mild depression, watchful waiting, psychotherapy and lifestyle measures may be sufficient; in moderate to severe cases, antidepressants are usually started early. Non-pharmacological treatment includes CBT, interpersonal therapy, psychoeducation, problem-solving therapy, regular exercise, sleep hygiene, social support and avoidance of alcohol. Combination of antidepressant and psychotherapy is often more effective than either alone in moderate to severe depression.

(c) Neonatal respiratory distress. (i) The most likely diagnosis is respiratory distress syndrome, also called hyaline membrane disease. The basis is a 30-week preterm infant developing tachypnea, chest retractions and grunting within 30 minutes of birth, a classic presentation of surfactant deficiency. Pathophysiology is immaturity of type II pneumocytes, reduced surfactant, increased alveolar surface tension, progressive alveolar collapse, decreased lung compliance, ventilation-perfusion mismatch, hypoxaemia and pulmonary hypertension. (ii) Management is in a NICU with thermoregulation, correction of hypoglycaemia, fluid and electrolyte balance, and antibiotics if sepsis is suspected. If preterm birth was anticipated, antenatal corticosteroids reduce the severity of RDS. After birth, maintaining normal body temperature is critical because hypothermia worsens acidosis and oxygen demand. Respiratory support starts with CPAP; if the infant deteriorates, intubation and mechanical ventilation with lung-protective settings are used. Surfactant replacement therapy is given through the endotracheal tube; minimally invasive surfactant therapy (MIST) or less invasive surfactant administration (LISA) may be used where available. Surfactant is usually repeated if oxygen requirements remain high, and the infant is weaned as lung maturity improves. Follow-up includes oxygen titration, monitoring for apnoea, bronchopulmonary dysplasia and retinopathy of prematurity. Caffeine may be used for apnoea of prematurity.

(d) Cyanotic infant. (i) The most likely condition is tetralogy of Fallot, a cyanotic congenital heart defect with pulmonary stenosis, ventricular septal defect, overriding aorta and right ventricular hypertrophy. Examination shows central cyanosis, clubbing, a loud ejection systolic murmur at the left upper sternal border due to right ventricular outflow obstruction, and a single or soft second heart sound because pulmonary flow is reduced. The absence of hepatomegaly argues against congestive heart failure from a large left-to-right shunt. Pulses are usually normal unless there is associated aortic coarctation. Haemodynamically, right ventricular pressure approaches systemic pressure, and deoxygenated blood crosses the VSD into the aorta, causing right-to-left shunting, reduced pulmonary blood flow and cyanosis. Cyanosis is often more evident during crying or feeding, when right-to-left shunting increases. (ii) The clinical course may be stable in mild pulmonary stenosis but severe disease causes hypercyanotic “tet” spells, often relieved by squatting. Squatting increases systemic vascular resistance and reduces the shunt, thereby improving oxygenation. Complications include polycythaemia, brain abscess from septic emboli or bacteraemia shunted right-to-left, infective endocarditis, paradoxical embolic stroke, and iron deficiency that can worsen hypoxaemia. Corrective surgery is usually planned in infancy; a palliative systemic-to-pulmonary shunt may be needed in very young or low-weight infants. Long-term follow-up after repair includes arrhythmias, residual pulmonary regurgitation and exercise limitation.

(e) Allergic contact dermatitis. (i) The likely diagnosis is allergic contact dermatitis to nickel, suggested by artificial jewellery and itchy papulo-vesicular lesions on ears, wrists and neck. Avoidance of nickel-containing items is the main preventive measure. (ii) The gold standard confirmatory test is patch testing with a standardised nickel allergen applied to intact skin, usually on the back. Patch testing should be performed when the acute dermatitis has settled, to avoid false-negative or irritant confounding. (iii) Results are read at 48 and 96 hours. A positive reaction shows erythema, papules, vesicles, induration or crusting at the application site, graded from doubtful to strongly positive; a negative result shows no reaction, while an irritant reaction is non-specific and may occur in sensitive skin. (iv) Complications of patch testing include active sensitisation to new allergens, irritant reactions, persistent hyperpigmentation or hypopigmentation, and rare anaphylactoid reactions.

Thus, the way forward in each case is a structured, evidence-based response: targeted imaging for right hypochondrial pain, combined biological and psychological treatment for depression, surfactant and respiratory support for preterm RDS, early cardiac correction for tetralogy of Fallot, and allergen avoidance with patch-test confirmation for nickel dermatitis.

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