(a) (i) Enlist the clinical features of dengue fever. (ii) Outline the management of a patient with dengue haemorrhagic…

A structured clinical outline is as follows.

Dengue fever. Dengue fever usually presents with abrupt high fever lasting two to seven days, severe headache, retro-orbital pain, marked myalgia and arthralgia, nausea, vomiting, anorexia, maculopapular rash, and sometimes mild bleeding such as petechiae, epistaxis or gum bleeding. Laboratory clues include thrombocytopenia, leucopenia, rising haematocrit and positive NS1 antigen or IgM/IgG serology. In the WHO 2009 framework, dengue is classified into dengue, dengue with warning signs, and severe dengue; dengue haemorrhagic fever corresponds to the severe end with haemorrhagic manifestations, plasma leakage, haemoconcentration, pleural effusion or ascites, hypotension, and shock if decompensated. Warning signs such as abdominal pain, persistent vomiting, mucosal bleeding, liver enlargement, increasing haematocrit with falling platelets, or fluid accumulation require close observation. The critical phase usually begins with defervescence, when capillary leakage is maximal and shock is most likely.

Management of dengue haemorrhagic fever is supportive and monitoring-driven. The patient should be hospitalised, kept at rest, given oral fluids if stable, and monitored for pulse, blood pressure, urine output, haematocrit, platelet count and signs of fluid overload. Paracetamol is used for fever; aspirin, NSAIDs and intramuscular injections are avoided. In shock, rapid isotonic crystalloid boluses of 20 ml/kg of Ringer lactate or normal saline are given over 15–30 minutes and repeated until stable, followed by 10–30 ml/kg/hour, then tapered as haematocrit and circulation improve. Dextrose-containing fluids are added once shock resolves. Platelet transfusion is reserved for significant bleeding or very low platelets with bleeding, and packed red cells are given for symptomatic anaemia or low haemoglobin. Haematocrit should be checked every 6–8 hours in the critical phase, and fluid rate adjusted according to haematocrit, urine output and clinical response. If shock persists despite adequate crystalloids, colloid or blood products may be considered under specialist supervision, and severe cases require ICU care. Close observation during the critical defervescence phase, with careful fluid titration, is essential to prevent both shock and fluid overload.

Schizophrenia. Symptoms are grouped into positive, negative and cognitive domains. Positive symptoms reflect excess or distortion of normal mental functions and include auditory hallucinations, persecutory, referential or grandiose delusions, disorganized speech, and grossly disorganized or catatonic behaviour. Negative symptoms reflect loss of function and include alogia, avolition, affective flattening, anhedonia and asociality. Cognitive symptoms involve impaired attention, memory and executive function, which often affect work, study and self-care. For diagnosis, DSM-5 requires at least six months of disturbance, with at least one month of active-phase symptoms, while ICD-10 requires characteristic symptoms to be present for at least one month; functional impairment and exclusion of other causes are also considered. The illness is usually chronic and requires long-term psychiatric care, psychosocial rehabilitation and family support.

IMNCI. IMNCI stands for Integrated Management of Neonatal and Childhood Illness. Its objectives are to reduce under-five mortality and morbidity, improve the quality of care for sick children, integrate treatment of common childhood illnesses with nutrition, immunization and growth monitoring, and strengthen community and facility-based care. It aims to reduce deaths from pneumonia, diarrhoea, measles, malaria and neonatal conditions, and to reduce malnutrition-related illness. The strategy targets children from birth to five years and is delivered through ANMs, ASHAs, sub-centres, primary health centres and referral facilities. The clinical algorithm is built around four steps: assess the child, classify the illness, treat according to the classification, and counsel the caregiver. Integrated care under IMNCI also includes management of fever, cough and cold, diarrhoea, pneumonia, measles, malaria, anaemia, malnutrition, immunization, growth monitoring, oral rehydration, zinc, vitamin A, hygiene and referral. Counseling includes feeding, immunization, hygiene, danger signs and follow-up.

Immunization schedule. Under the National Immunization Programme, the UIP schedule for infants and children includes BCG, Hepatitis B birth dose and OPV-0 at birth, with the Hepatitis B birth dose ideally given within 24 hours. At 6, 10 and 14 weeks, children receive Pentavalent, OPV, IPV and PCV; Rotavirus is given at 6 and 10 weeks. In Japanese encephalitis endemic districts, JE vaccine is given at 16 and 20 weeks. MR-1 is given at 9 months. At 16–24 months, children receive Pentavalent booster, OPV-4 and MR-2. OPV-5 is given at 4–6 years, and DPT booster is given at 10–12 years, with TT/TT boosters as per the school-age schedule. The schedule is designed to prevent vaccine-preventable diseases such as tuberculosis, polio, hepatitis B, diphtheria, tetanus, pertussis, measles, rubella, rotavirus diarrhoea, pneumococcal disease and Japanese encephalitis. Mission Indradhanush strengthens this schedule by targeting zero-dose and partially immunized children through door-to-door visits, sub-centre days, camps and catch-up immunization drives, supported by cold-chain maintenance and AEFI surveillance. Full immunization means completion of all scheduled doses, including catch-up for missed doses.

Lichen planus. The described itchy, violaceous, flat-topped papules with oral burning are diagnostic of lichen planus. The classic skin features are pruritic, purple, polygonal, planar papules, often on wrists, ankles and mucous membranes, and may show Koebner phenomenon after trauma. Diagnosis is usually clinical, but biopsy may be done when the presentation is atypical. Oral findings include white reticular Wickham striae, most commonly on buccal mucosa, as well as erosive, atrophic, plaque-like or bullous lesions on the tongue, gingiva, lips or palate; erosive forms may cause burning, pain and secondary infection.

Management is stepwise. The first step is to identify and remove triggers, provide dental care, avoid irritants, smoking and alcohol, and treat secondary infection. Topical corticosteroids such as clobetasol, betamethasone or fluocinonide are first-line for skin and oral lesions; topical calcineurin inhibitors may be used for oral disease. For severe, widespread or refractory disease, systemic corticosteroids, antimalarials such as hydroxychloroquine, retinoids, or immunosuppressants such as azathioprine, methotrexate or cyclosporine may be used. Antihistamines relieve itching, and analgesics help oral pain. Management of oral disease also includes soft diet, topical anaesthetics, and treatment of candidal superinfection if present. Long-term follow-up is important, especially for erosive oral lichen planus, because of the small risk of malignant transformation.

Thus, the outline moves from acute febrile and psychiatric care to child-health systems and dermatology, reflecting India’s integrated primary-care and immunization architecture.