(a) Briefly describe the clinical features, diagnostic workup and management of a patient of choledochal cyst. (3+4+3=10…

(a) Choledochal cyst. Choledochal cyst is a congenital dilatation of the biliary tree, classically classified by Todani into type I (saccular or fusiform common bile duct dilatation), type II (diverticulum), type III (choledochocele), type IV (multiple intrahepatic and extrahepatic dilatations), and type V (Caroli disease). It presents in children or adults with the classic triad of abdominal pain, jaundice and a palpable mass, though many patients have recurrent cholangitis, pancreatitis, biliary colic, or are asymptomatic. The pain is often colicky, jaundice may be intermittent, and the mass is usually in the right hypochondrium; recurrent cholangitis may produce fever, rigors and sepsis. Diagnostic workup begins with ultrasound showing cystic biliary dilatation, liver function tests showing an obstructive pattern, amylase/lipase if pancreatitis is suspected, and complete blood count if cholangitis is present. MRCP is the preferred non-invasive test to define anatomy and Todani type; ERCP is reserved for therapeutic drainage, stone removal, or when MRCP is equivocal, and cholangiography may be used intraoperatively. Management is surgical excision of the cyst with cholecystectomy and Roux-en-Y hepaticojejunostomy, because retained cyst wall carries a risk of cholangiocarcinoma; in unfit or septic patients, temporary biliary drainage by ERCP or percutaneous transhepatic cholangiography may precede definitive repair, and long-term surveillance for biliary malignancy is advised.

(b) Colles’ fracture. Colles’ fracture is a distal radius fracture with posterior (dorsal) displacement and dorsal angulation, usually after a fall on an outstretched hand. Clinically the wrist is painful, swollen and tender over the distal radius, with limited active and passive motion. The distal fragment is displaced dorsally and may be angulated, producing a step deformity at the wrist. The characteristic ‘dinner fork’ deformity is seen in lateral view due to dorsal displacement, and the hand may appear bayonet-shaped in anteroposterior view because of radial shortening and ulnar styloid prominence. There may be crepitus, local tenderness, and neurovascular assessment is essential to exclude median nerve compression. Five important complications are malunion with persistent dorsal angulation and loss of grip, carpal tunnel syndrome from median nerve compression, Sudeck’s atrophy or complex regional pain syndrome, post-traumatic wrist arthritis, and extensor tendon rupture, especially extensor pollicis longus; stiffness and avascular necrosis of the scaphoid may also occur.

(c) FGR. Foetal growth restriction is defined as estimated foetal weight below the 10th percentile for gestational age, or serial abdominal circumference lagging behind the expected centile, after excluding multiple pregnancy, wrong dates and congenital anomalies. Common causes include placental insufficiency, maternal malnutrition or anaemia, TORCH infections, chromosomal anomalies, maternal hypertension or pre-eclampsia, diabetes with vascular disease, smoking, and chronic maternal illness. In a severely growth-restricted pregnancy diagnosed at 26 weeks with a previous caesarean section at 32 weeks and no living children, management must balance the risks of prematurity against intrauterine death. Severe FGR is often associated with oligohydramnios, reduced biophysical profile score, and abnormal umbilical artery Doppler; serial non-stress tests or biophysical profiles may be used. The patient should be admitted for serial growth ultrasound and Doppler surveillance of the umbilical artery, middle cerebral artery and ductus venosus. Antenatal corticosteroids are given for fetal lung maturity, and magnesium sulphate for neuroprotection if delivery is anticipated before 32 weeks. If the umbilical artery shows absent or reversed end-diastolic flow, or if the ductus venosus shows absent or reversed a-wave, delivery should be planned after steroids and neuroprotection where feasible. If Dopplers remain reassuring, expectant management with close surveillance, fetal testing, and treatment of any maternal cause is continued. Timed delivery is planned at the point where the risk of intrauterine death outweighs the risks of prematurity. Because of the previous lower-segment caesarean section and prior preterm birth, the uterus is scarred and the risk of uterine rupture during labour is higher; if delivery becomes necessary for fetal compromise, a planned caesarean section is reasonable, while vaginal delivery may be considered only if the fetus is stable, labour is controlled, and there is no fetal distress. The aim is to prolong pregnancy safely until fetal maturity improves, but not to delay delivery when Doppler deterioration indicates imminent fetal risk.

(d) Menopause and HRT. Menopause is the permanent cessation of menstruation due to loss of ovarian follicular activity, diagnosed retrospectively after 12 months of amenorrhoea in a woman of appropriate age without other cause. Medical indications for HRT include moderate to severe vasomotor symptoms such as hot flushes and night sweats, genitourinary syndrome of menopause when local oestrogen is insufficient or systemic therapy is needed, prevention or treatment of osteoporosis in early menopause or oestrogen-deficient women, and selected cases of early ovarian failure where bone protection and symptom control are required. HRT is not recommended for routine primary prevention of cardiovascular disease in older women, and systemic therapy is avoided in unexplained vaginal bleeding, active thromboembolism, liver disease, or known breast cancer. The concept of universal HRT has been demerited by controversies arising mainly from the Women’s Health Initiative, which reported increased risks of breast cancer, venous thromboembolism, stroke and cardiovascular events in some age and timing groups. These findings, together with concerns about dose, duration, route and individual risk factors, led to the current view that HRT should not be prescribed universally but should be individualised, using the lowest effective dose for the shortest necessary period, with informed consent and regular review.

(e) Dengue in India. The geographic expansion of dengue in India is linked to rapid unplanned urbanisation, peri-urban expansion, water storage practices, poor drainage, and the domestic adaptation of Aedes aegypti, which thrives in artificial containers. Serotype shifts, with DEN-2 historically dominant in many Indian outbreaks and later circulation of DEN-1, DEN-3 and DEN-4, have altered severity and secondary infection risk. Delayed reporting, inadequate larval source reduction, and movement of people and goods have also facilitated spread from endemic urban cores to suburban and rural belts. Climate change is impacting the disease by widening the temperature range suitable for vector breeding and viral replication, shortening the extrinsic incubation period, increasing vector survival and biting frequency, and extending the transmission season. Altered rainfall patterns, flooding and drought create more breeding sites, while warming allows Aedes to expand into higher altitudes and new districts. In India, this has been reflected in repeated outbreaks in cities such as Delhi, Mumbai, Chennai, Bengaluru and parts of Karnataka, Kerala and the Northeast, prompting ICMR surveillance, National Vector Borne Disease Control Programme interventions, and the National Dengue Guidelines for case management, vector control and reporting.