(a) A 40-year-old male who was bedridden for the last two months following a fracture in the lower limb developed sudden breathlessness.
(i) What is the most probable diagnosis ?
(ii) How will you investigate the case ?
(iii) How will you manage the

Question

(a) A 40-year-old male who was bedridden for the last two months following a fracture in the lower limb developed sudden breathlessness.
(i) What is the most probable diagnosis ?
(ii) How will you investigate the case ?
(iii) How will you manage the case ? (2+8+10=20 marks)

(b) A term neonate born to 'O' negative blood group mother was found to have deep jaundice involving palms and soles, excessive crying and convulsions at 20 hours of life.
(i) How would you assess the clinical severity of jaundice in this neonate ?
(ii) List the key investigations to arrive at the diagnosis.
(iii) Describe the management of this neonate. (3+4+8=15 marks)

(c) (i) Give the clinical findings of lichen planus at the following sites :
- Nails
- Scalp
- Mucosa
- Palms and Soles

(ii) State the histopathological findings of oral lichen planus.

(iii) Discuss the management of oral lichen planus. (5+5+5=15 marks)

UPSC Answer Check · Accepted Answer

The directive 'describe' demands systematic, detailed exposition of clinical features, investigations, and management across all three scenarios. Allocate approximately 40% of time/words to part (a) pulmonary embolism (20 marks), 30% to part (b) neonatal jaundice (15 marks), and 30% to part (c) lichen planus (15 marks). Structure each part as: brief clinical interpretation → diagnostic workup → stepwise management, with part (c) additionally requiring site-specific clinical descriptions and histopathology.
- Part (a): Identify pulmonary embolism (PE) as the diagnosis; explain Virchow's triad relevance in post-immobilization state; outline D-dimer, CTPA/Wells score, and ECG findings (S1Q3T3); detail anticoagulation (LMWH→warfarin/DOACs), thrombolysis criteria, and IVC filter indications
- Part (b): Recognize ABO/Rh hemolytic disease with early-onset severe hyperbilirubinemia; describe Kramer's rule for jaundice staging and clinical signs of kernicterus; list direct Coombs test, peripheral smear, reticulocyte count, serum bilirubin (direct/indirect), and maternal antibody titres; explain intensive phototherapy, IVIG, exchange transfusion criteria, and neurological monitoring
- Part (c)(i): Site-specific findings—nails (pterygium, thinning, ridging), scalp (cicatricial alopecia, follicular lichen planus), mucosa (Wickham's striae, erosive/reticular/bullous types), palms/soles (palmoplantar lichen planus, hypertrophic variant)
- Part (c)(ii): Histopathology showing saw-tooth rete ridges, band-like lymphocytic infiltrate, Max-Joseph spaces, civatte bodies (colloid bodies), and basement membrane degeneration
- Part (c)(iii): Management hierarchy—topical corticosteroids (high potency), calcineurin inhibitors, systemic agents (corticosteroids, retinoids, immunomodulators), and surveillance for malignant transformation

Dimension	Weight	Max marks	Excellent	Average	Poor
Concept correctness	20%	10	Demonstrates precise pathophysiology: for (a) explains thrombus propagation from deep veins and hemodynamic consequences of massive/submassive PE; for (b) correctly distinguishes physiological vs pathological jaundice timing and bilirubin metabolism; for (c) accurately describes cell-mediated autoimmune mechanism and lichenoid tissue reaction pattern	States correct diagnoses and basic mechanisms but with gaps—e.g., mentions PE without Virchow's triad, describes jaundice without conjugated/unconjugated distinction, or lists lichen planus features without autoimmune basis	Fundamental errors: confuses PE with MI, attributes neonatal jaundice to sepsis without hemolysis workup, or describes psoriasis features instead of lichen planus
Clinical correlation	20%	10	For (a): correlates sudden dyspnea with pre-test probability (Wells score) and clinical signs of right heart strain; for (b): integrates early presentation (<24 hours), maternal Rh status, and neurological signs to predict kernicterus risk; for (c): distinguishes between erosive vs non-erosive oral LP and prognostic implications for squamous cell carcinoma surveillance	Provides clinical context but superficially—mentions risk factors without scoring systems, notes jaundice severity without bilirubin thresholds, or describes oral lesions without malignant potential warning	Misses critical clinical connections—ignores temporal relation in PE diagnosis, fails to recognize emergency nature of neonatal presentation, or omits symptomatology entirely for lichen planus
Diagram / pathway	20%	10	Includes: for (a) diagnostic algorithm flowchart (Wells score → D-dimer → CTPA) and/or pathophysiology diagram of thromboembolism; for (b) bilirubin metabolism pathway with enzyme defects and phototherapy mechanism; for (c) labeled histopathology diagram showing rete ridge pattern and inflammatory infiltrate zone	Mentions investigations or pathways in text without visual representation, or provides incomplete diagrams lacking key labels (e.g., CTPA without radiation dose consideration, phototherapy without wavelength specification)	No diagrams or flowcharts; purely textual description without structured algorithmic approach to diagnosis or management in any part
Differential / staging	20%	10	For (a): differentiates massive vs submassive vs low-risk PE using hemodynamic criteria and RV dysfunction markers; for (b): stages jaundice by Kramer's zones and bilirubin levels, distinguishes Rh vs ABO incompatibility severity; for (c): classifies oral LP into reticular, erosive, atrophic, bullous subtypes with malignant transformation risk stratification	Lists differentials without systematic classification—mentions MI, pneumonia, aortic dissection for (a) without prioritization; notes sepsis, G6PD deficiency for (b) without comparative timing; describes LP variants without malignant potential grading	No differential diagnosis offered, or seriously incorrect differentials (e.g., COPD for PE, hypothyroidism for neonatal jaundice); confuses lichen planus with lichen sclerosus or psoriasis
Management / public-health angle	20%	10	For (a): stepwise protocol—LMWH bridging, DOAC selection (rivaroxaban/apixaban), thrombolysis (alteplase) criteria, and IVC filter placement; for (b): evidence-based phototherapy thresholds per AAP guidelines, exchange transfusion indications, and long-term neurodevelopmental follow-up; for (c): WHO/Indian guidelines for erosive LP, topical tacrolimus vs clobetasol, and 6-monthly malignancy surveillance with biopsy indications	Describes standard treatments without protocol precision—mentions 'blood thinners' without specific agents, 'light therapy' without irradiance specifications, or 'steroids' without potency grading; omits follow-up protocols	Dangerous or outdated management—recommends streptokinase as first-line for PE, suggests sunlight exposure for neonatal jaundice without phototherapy, or prescribes systemic steroids as first-line for oral LP without topical trial

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