(a) A 65-year-old lady has progressively increasing dysphagia for last 6 months. She also has significant weight loss. How will…

(a) Investigation of progressive dysphagia In a 65-year-old woman with six months of progressive dysphagia and significant weight loss, the investigation is directed first toward excluding oesophageal carcinoma. The history should clarify solid versus liquid dysphagia, regurgitation, pain, reflux, smoking, alcohol, and nutritional status; examination should look for anaemia, cachexia, cervical or supraclavicular lymph nodes, and abdominal masses. The first radiological test is a barium swallow, which may show an irregular apple-core or shouldering lesion in carcinoma, while a smooth rat-tail tapering suggests achalasia. Upper gastrointestinal endoscopy is the central investigation; it localises the lesion, assesses length and mucosal pattern, and allows biopsy for histopathology. Staging is done with contrast-enhanced CT of chest and abdomen to detect local invasion, lymphadenopathy and distant metastasis; PET-CT is added when available to clarify equivocal nodes or distant disease. Additional tests include complete blood count, liver and renal function, coagulation profile, and nutritional assessment. Differential diagnoses to exclude are achalasia, peptic stricture, external compression, and benign inflammatory stricture. Before invasive tests, the patient is assessed for dehydration, anaemia and malnutrition, and consent is taken for biopsy and staging. The aim is to confirm malignancy, stage it accurately, and identify benign mimics. The sequence is therefore barium swallow, endoscopy with biopsy, cross-sectional staging, and PET-CT where indicated, with early multidisciplinary planning to enable timely diagnosis, accurate staging, and treatment that preserves nutrition and quality of life.

(b) Management of severe haematemesis in portal hypertension The management is emergency, simultaneous resuscitation, haemostasis and prevention of rebleeding. The patient is kept nil by mouth, monitored, and two large-bore IV lines are started. The patient is placed in a monitored bed or ICU if unstable, with oxygen, pulse oximetry, and frequent vital signs. Blood samples are sent for cross-match, liver function, coagulation, and lactate. Fluids are given cautiously, with packed red cells to maintain haemoglobin around 7–8 g/dL, fresh frozen plasma or platelets if coagulopathic, and correction of electrolytes. Overtransfusion is avoided because it may raise portal pressure. Child-Pugh and MELD scoring are done early to grade liver reserve and guide prognosis. Vasoactive drugs are started immediately: terlipressin or octreotide/somatostatin to reduce portal pressure. Prophylactic antibiotics, commonly IV ceftriaxone, are given because infection worsens rebleeding and mortality. Urgent upper GI endoscopy is performed within 12 hours after initial stabilisation; if oesophageal varices are bleeding, endoscopic variceal ligation is preferred, while sclerotherapy is used when ligation is not feasible. If bleeding continues, balloon tamponade with a Sengstaken-Blakemore tube is a short bridge, not definitive therapy. Rebleeding is watched for by repeated haemoglobin, melaena, and haemodynamic instability. Refractory or recurrent bleeding is managed by TIPS, and selected patients are referred for liver transplantation. The ordered steps are resuscitation, vasoactive drugs, antibiotics, endoscopic haemostasis, rescue tamponade, and TIPS/transplant when needed, aiming to stop bleeding, prevent rebleeding, reduce infection, and preserve liver function.

(c) Pelvic organ prolapse (i) Five risk factors are parity with vaginal delivery, advancing age, menopause with estrogen deficiency, chronic raised intra-abdominal pressure from chronic cough, constipation or heavy lifting, and connective tissue disorders. These factors weaken the pelvic support or increase the load on it. (ii) For a 60-year-old postmenopausal woman with procidentia, cystocoele, enterocoele and rectocoele, management is individualised. Conservative options include pelvic floor muscle training, weight reduction if overweight, treatment of constipation, and a vaginal pessary for symptom relief or as a bridge when surgery is unsuitable. A pessary may be used long-term if surgery is declined. Surgical correction is the main option for symptomatic advanced prolapse. Preoperative assessment includes anaesthetic fitness, bladder and bowel function, and discussion of recurrence. A vaginal approach may include vaginal hysterectomy with anterior colporrhaphy for cystocoele, posterior colporrhaphy for rectocoele, McCall culdoplasty for enterocoele, and sacrospinous fixation for apical support. An abdominal or laparoscopic sacrocolpopexy is considered when the patient is fit, has good tissue quality, and needs durable apical suspension, especially with significant enterocoele. The combined repair must address the apical, anterior, posterior and vault compartments. The choice depends on fitness, comorbidities, patient preference, sexual function, and surgeon expertise. Postoperative care includes pelvic rest, stool softeners, and follow-up for recurrence, with the goal of durable symptom relief, continence, and restoration of pelvic organ function.

(d) Chronic pelvic pain Chronic pelvic pain in women is defined as non-cyclic pelvic pain lasting six months or more, with or without functional limitation, and not limited to menstruation. Chronic pelvic pain may be primary, without identifiable pathology, or secondary to an organic cause. It can affect quality of life, sexual function, and work. The history should distinguish cyclic from non-cyclic pain, radiation, urinary or bowel symptoms, and psychological stress. Causes are best organised anatomically. Gynaecological causes include endometriosis, adenomyosis, chronic pelvic inflammatory disease, ovarian remnant syndrome, pelvic congestion, and fibroids. Urological causes include interstitial cystitis, recurrent urinary tract infection, and urethral syndrome. Gastrointestinal causes include irritable bowel syndrome, inflammatory bowel disease, constipation, and adhesions. Musculoskeletal causes include pelvic floor tension myalgia, myofascial pain, and postural or spinal disorders. Psychological and neurogenic factors, such as anxiety, depression, central sensitisation, and neuropathic pain, may coexist and amplify pain. Examination includes abdominal, pelvic, and rectal assessment, and targeted tests are chosen only when clinically indicated. The description is therefore a systematic review of gynaecological, urological, gastrointestinal, musculoskeletal and psychological contributors, with investigation guided by history, examination and targeted tests, aiming to identify reversible causes, reduce pain, and restore function.

(e) Janani-Shishu Suraksha Karyakram The Janani-Shishu Suraksha Karyakram, under the Ministry of Health and Family Welfare, provides free and quality institutional care to pregnant women and neonates. Entitlements to pregnant women include free antenatal care, free delivery including normal delivery and caesarean section when medically indicated, free postnatal care, and free diagnostics, drugs, consumables and skilled attendance. Free transport from home to the facility and back is provided, including ambulance or other arranged transport where needed. For neonates, the scheme provides free treatment of sick neonates up to 30 days, including neonatal intensive care where available, and free transport between facilities for referral and return. The entitlements are intended to make institutional delivery financially safe, with no out-of-pocket charges for the listed services. The scheme is linked with Janani Suraksha Yojana and ASHA incentives to encourage institutional delivery. In effect, JSSK removes cost and transport barriers so that every pregnant woman and neonate can access safe institutional care.