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

(a)(i) Clinical features of dengue fever

After an incubation of 4 to 10 days the illness runs through three phases. Febrile phase (2 to 7 days): sudden high fever, severe headache, retro-orbital pain, myalgia and arthralgia ("break-bone fever"), nausea and vomiting, facial flushing, and a transient maculopapular or erythematous rash; mild bleeding (petechiae, gum bleeding, epistaxis) with a positive tourniquet test; laboratory leucopenia and falling platelets. Critical phase (day 3 to 7, around defervescence): plasma leakage with rising haematocrit, pleural effusion and ascites, and in severe dengue shock, bleeding and organ involvement. Warning signs are severe abdominal pain, persistent vomiting, mucosal bleeding, lethargy or restlessness, liver enlargement and a rising haematocrit with a rapid fall in platelets. Recovery phase: reabsorption of fluid, bradycardia, a convalescent confluent rash with itching, and fatigue.

(a)(ii) Management of dengue haemorrhagic fever (severe dengue)

Management is supportive, because there is no specific antiviral drug, and is guided by close monitoring. Admit the patient and monitor pulse, blood pressure, pulse pressure, urine output (at least 0.5 mL/kg/hour), haematocrit and platelet count every 4 to 6 hours in the critical phase. Fluids: begin with isotonic crystalloid (Ringer lactate or normal saline). For compensated shock give 5 to 10 mL/kg/hour for 1 to 2 hours; for hypotensive shock give 20 mL/kg as a bolus over 15 minutes, then reassess and repeat, and use a colloid if shock persists. Reduce the rate as the haematocrit falls and circulation improves, and stop intravenous fluids by 24 to 48 hours after the critical phase, to avoid fluid overload. Falling haematocrit with persistent shock suggests concealed bleeding: transfuse packed red cells (5 mL/kg) or fresh whole blood (10 mL/kg). Platelet transfusion is given only for significant active bleeding, not to correct the count alone. Use paracetamol for fever and avoid aspirin, NSAIDs, steroids and intramuscular injections. Provide oxygen, correct acidosis, glucose and calcium, and ICU care for complications.

(b) Symptoms of schizophrenia

Positive symptoms: Hallucinations, usually auditory: voices commenting, arguing or repeating thoughts. Delusions: persecutory, referential, grandiose, and delusions of control. First-rank symptoms of Schneider: thought insertion, withdrawal and broadcast, delusional perception, and passivity (made) experiences. Disorganised speech (derailment, loosening of association, word salad) and disorganised or catatonic behaviour.

Negative symptoms: flat or blunted affect, alogia (poverty of speech), avolition, anhedonia and social withdrawal. Cognitive symptoms: impaired attention, memory and executive function. Other features: poor insight, mood and sleep disturbance, and decline in work and self-care. Duration: ICD-10 requires symptoms for at least one month; DSM-5 requires a total of six months with at least one month of active-phase symptoms, other causes (substance, mood disorder) being excluded.

(c)(i) IMNCI: full form and objectives

IMNCI is the Integrated Management of Neonatal and Childhood Illness, India's adaptation (2007) of the WHO and UNICEF strategy for children under five years. Objectives: To reduce death, illness and disability in children under five, and promote healthy growth and development. To improve the case-management skills of health workers through an integrated approach rather than disease-by-disease care. To strengthen the health system, including supplies, supervision and referral. To improve family and community practices on nutrition, immunisation, hygiene and care-seeking.

(c)(ii) Components of integrated care under IMNCI

The strategy has three components: improving the skills of health workers; improving the health system; and improving family and community practices (C-IMNCI, with home visits for newborn care by ASHAs).

Integrated case management follows a sequence. The child is assessed (general danger signs, then cough or difficult breathing, diarrhoea, fever, ear problem, nutritional status and anaemia, and immunisation status) and classified using colour-coded charts: pink (urgent referral), yellow (specific treatment at the facility) and green (home care). Treatment is given according to classification (antibiotic, ORS and zinc, antimalarial, vitamin A, and pre-referral treatment), the caregiver is counselled on feeding, fluids and danger signs, and the child is followed up. For young infants (up to 2 months) the chart covers very severe disease, local bacterial infection, jaundice, feeding problems and low birth weight.

(d) National Immunization Programme (UIP) schedule for infants and children

At birth: BCG, hepatitis B birth dose (within 24 hours) and OPV-0. At 6 weeks, 10 weeks and 14 weeks: pentavalent (DPT, hepatitis B, Hib), OPV and rotavirus vaccine, each at all three visits; fractional IPV and pneumococcal conjugate vaccine at 6 weeks and 14 weeks. At 9 to 12 months: measles-rubella (MR-1), pneumococcal conjugate booster, third fractional IPV, and Japanese encephalitis (JE-1) in endemic districts; vitamin A first dose at 9 months. At 16 to 24 months: MR-2, JE-2, DPT booster 1 and OPV booster; further vitamin A doses every 6 months up to 5 years. At 5 to 6 years: DPT booster 2. At 10 years and 16 years: Td (tetanus and diphtheria).

(e)(i) Diagnosis

Lichen planus: itchy, violaceous, flat-topped papules with oral involvement.

(e)(ii) Oral findings

Oral lichen planus occurs in 30 to 70% of patients with skin disease and may be the only site. Findings: bilateral white reticular lacy lines (Wickham striae) on the buccal mucosa, the commonest; white papules and plaques; atrophic red areas; erosions and ulcers that burn or hurt on eating spicy food; desquamative gingivitis; and lesions of the tongue and lips. Erosive and atrophic forms carry a small (about 1%) risk of malignant change.

(e)(iii) Management

Confirm by biopsy when needed (band-like lymphocytic infiltrate at the dermo-epidermal junction, saw-tooth rete ridges, hypergranulosis and Civatte bodies); look for hepatitis C and drug triggers (ACE inhibitors, beta blockers, thiazides, NSAIDs, antimalarials). Skin: potent topical steroid (clobetasol), antihistamines for itch; for extensive or resistant disease a short course of oral prednisolone, acitretin, methotrexate or narrow-band UVB. Mouth: stop irritants (tobacco, spicy food, sharp teeth or amalgam fillings), maintain oral hygiene, and use topical triamcinolone in orabase, clobetasol gel or mouthwash, or topical tacrolimus; treat candidiasis if present. Follow up the erosive form every 6 to 12 months because of the cancer risk.