(a) A 60-year-old male presents with progressively increasing jaundice for 2 months. He is having clay coloured stools and…

(a)(i) Investigations

Progressive jaundice with clay-coloured stools, pruritus and a palpable gallbladder indicates obstruction below the cystic duct, most likely carcinoma of the head of pancreas or the periampullary region.

• Liver function tests: conjugated hyperbilirubinaemia with markedly raised alkaline phosphatase and GGT; PT/INR, complete blood count, renal function and albumin.
• Ultrasound: dilated intra- and extrahepatic ducts, distended gallbladder, mass or lymph nodes.
• Triple-phase pancreatic-protocol CT for tumour, vascular involvement and metastases; MRCP for ductal anatomy.
• Endoscopic ultrasound with fine-needle aspiration for tissue; ERCP with brush cytology if drainage is also required.
• CA 19-9 (baseline; may be falsely high with jaundice) and chest imaging for staging.

(a)(ii) Courvoisier's law and exceptions

Courvoisier's law: in a patient with jaundice, a palpable, non-tender, distended gallbladder is unlikely to be due to gallstones, because a stone-bearing gallbladder is usually fibrosed and contracted and cannot distend. The obstruction is therefore usually malignant (pancreatic head, ampulla, lower bile duct).

Exceptions, where gallbladder is distended despite stones:

• Double impaction: stones in both cystic duct and common bile duct.
• Stone obstruction of the common bile duct in a gallbladder that was never fibrosed.
• Chronic pancreatitis or pancreatic head inflammatory mass (with a normal gallbladder).
• Mirizzi syndrome and cystic duct mucocele or hydrops in some cases.

Exceptions in the other direction, where the gallbladder is not palpable in malignancy: pre-existing cholecystitis with fibrosis, intrahepatic or hilar tumours above the cystic duct, and a tumour that obstructs the duct above the cystic duct junction.

(a)(iii) Treatment options

• Preoperative drainage only for cholangitis, severe jaundice or delayed surgery (stent by ERCP, or percutaneous drainage).
• Resectable disease: pancreaticoduodenectomy (Whipple's), classic or pylorus-preserving, with lymphadenectomy, followed by adjuvant chemotherapy (modified FOLFIRINOX or gemcitabine-based).
• Borderline resectable disease: neoadjuvant chemotherapy (FOLFIRINOX or gemcitabine with nab-paclitaxel) with or without radiotherapy, then reassessment for surgery.
• Unresectable or metastatic: endoscopic self-expanding metal stent (preferred) or percutaneous transhepatic drainage; surgical bypass (hepaticojejunostomy with gastrojejunostomy) in selected patients; palliative chemotherapy.
• Supportive care: coeliac plexus neurolysis for pain, pancreatic enzyme replacement, nutrition and vitamin K.

(b)(i) What is MCTS

The Mother and Child Tracking System, launched in December 2009 under the National Rural Health Mission, is a web-based, name-based tracking system for every pregnant woman and child up to 5 years (later integrated with the RCH portal). Each beneficiary is registered with a unique ID and followed up for due services.

(b)(ii) Objectives

• To ensure timely delivery of the full range of services to pregnant women and children: early ANC registration, ANC checks, institutional delivery, postnatal care and immunisation.
• To cut down missed and dropout cases and reduce maternal and infant mortality.
• To give managers reliable data for planning and monitoring, and to link payments such as Janani Suraksha Yojana incentives to verified service delivery.

(b)(iii) Operation

ANMs and ASHAs identify beneficiaries and report details; data operators at primary health centres or blocks enter name, address, phone and service details on the portal. The system generates work-plans for ANMs and ASHAs listing due services, and sends SMS reminders to beneficiaries and health workers. State and district officers use dashboards and reports to monitor registration, coverage and dropouts, and to take action.

(c)(i) Investigating the couple

Because the wife is 35, evaluation can begin after 6 months of trying.

• History and examination of both partners: cycle pattern, coital frequency, previous pregnancies, pelvic infection or tuberculosis, surgeries, drugs, smoking, alcohol and BMI.
• Husband: semen analysis (WHO criteria), repeated if abnormal; hormones and scrotal ultrasound if indicated.
• Wife: ovulation (mid-luteal progesterone), ovarian reserve (AMH, antral follicle count, day-3 FSH and oestradiol), TSH and prolactin; transvaginal ultrasound; tubal patency (hysterosalpingography or HyCoSy); uterine cavity (saline sonography or hysteroscopy); laparoscopy and chromopertubation when indicated.

(c)(ii) Major factors affecting fertility

Female age (decline in oocyte quantity and quality), male age and semen quality, ovulatory disorders (PCOS, hyperprolactinaemia, thyroid disease), tubal and pelvic disease (pelvic infection, genital tuberculosis, endometriosis), uterine factors (fibroids, polyps, adhesions), timing and frequency of intercourse, BMI, smoking, alcohol, stress, drugs and environmental toxins.

(c)(iii) Treatment of unexplained infertility

• Counselling, lifestyle correction, folic acid and timed intercourse.
• Mild ovarian stimulation (letrozole or clomiphene) with intrauterine insemination for 3–4 cycles; gonadotropins with IUI can follow.
• If this fails, or sooner at this age, in vitro fertilisation (with ICSI as needed); donor gametes or adoption counselling when ovarian reserve is poor.