(a) A 23-year-old woman with type I diabetes mellitus presents with nausea, vomiting and altered sensorium. On examination, she…

(a)

The presentation is diabetic ketoacidosis (DKA). The 2024 international consensus (ADA/EASD/JBDS) criteria are: D – glucose ≥200 mg/dL or known diabetes; K – blood β-hydroxybutyrate ≥3.0 mmol/L or urine ketones ≥2+; A – pH <7.3 and/or bicarbonate <18 mEq/L, with a raised anion gap. Severity is graded by pH (mild 7.25–7.30, moderate 7.00–7.24, severe <7.00) and mental status; this patient, with altered sensorium and hypotension, is severe. Kussmaul breathing and a fruity (acetone) odour are typical. The history should elicit insulin omission, infection, myocardial infarction, pancreatitis or drugs. Examination shows tachypnoea, altered sensorium and hypotension from volume depletion due to osmotic diuresis and vomiting. Initial assessment includes temperature, heart rate, blood pressure, respiratory rate, level of consciousness and urine output. Diagnosis is confirmed by random blood sugar, urine ketones, serum ketones, venous blood gas, serum electrolytes, renal function, complete blood count, ECG, blood and urine cultures, and chest X-ray if infection is suspected. Management is stepwise. First, ABC stabilisation: airway, oxygen if hypoxic, two large-bore IV lines, cardiac monitoring, urinary catheter, and correction of hypotension with isotonic saline. Give 0.9% saline 15–20 mL/kg in the first hour; thereafter replace deficits at 250–500 mL/hr (about 4–8 mL/kg/hr in a 60–70 kg adult), switching to 0.45% saline with dextrose when glucose falls to ~250 mg/dL. Start fixed-rate IV insulin 0.1 U/kg/hr (no bolus needed) after confirming potassium is at least 3.5 mEq/L (2024 consensus; older ADA guidance used 3.3); if K+ is 3.5–5.0, add 20–40 mEq potassium to each litre of fluid, if <3.5 hold insulin and replace potassium first, and if >5.0 give no potassium but recheck every 2 hours, aiming for serum potassium 4–5 mEq/L. Insulin is reduced to 0.05 U/kg/hr once glucose is below 250 mg/dL, with dextrose added to keep glucose around 150–200 mg/dL until ketosis clears. Bicarbonate is given only if pH <7.0 (older guidance <6.9); phosphate is replaced only if <1 mg/dL or with cardiac or respiratory compromise. Monitor glucose hourly, electrolytes, ketones, fluid balance and mental status, watching for cerebral oedema. DKA is resolved when pH ≥7.3 (or bicarbonate ≥18 mEq/L) and β-hydroxybutyrate <0.6 mmol/L; IV insulin is then stopped 1–2 hours after the first subcutaneous basal insulin dose to prevent rebound ketosis, and the patient starts a basal-bolus regimen once eating. Before discharge she needs education on sick-day rules, ketone testing and insulin adherence. Simultaneously identify and treat precipitating factors: infection, insulin omission, myocardial infarction, pancreatitis and drugs.

(b)(i)

Acute diarrhoea in children is passage of three or more loose stools in 24 hours for less than 14 days. Causes are viral (rotavirus, norovirus), bacterial (ETEC, Shigella, Salmonella, Vibrio cholerae), protozoal (Giardia, Entamoeba) and non-infectious (antibiotic-associated, lactose intolerance); in India, rotavirus is a leading cause of severe acute diarrhoea in under-fives. Dehydration is assessed using IAP/IMNCI: no dehydration, some dehydration, severe dehydration and shock. Examine general condition (alert, restless/irritable, lethargic/unconscious), eyes (normal or sunken), tears (present or absent), skin pinch (normal, slow, very slow), thirst (drinks normally, drinks eagerly, drinks poorly or unable) and radial pulse (present, weak, not palpable); two or more signs in the middle column (restless, sunken eyes, drinks eagerly, skin pinch goes back slowly) indicate some dehydration (deficit 5–10%), treated under Plan B with ORS 75 mL/kg over 4 hours; two or more severe signs (lethargic, sunken eyes, drinks poorly, skin pinch very slow ≥2 s) indicate severe dehydration (deficit >10%), treated under Plan C with IV Ringer's lactate 100 mL/kg (infants: 30 mL/kg in 1 hour then 70 mL/kg in 5 hours; older children: 30 mL/kg in 30 minutes then 70 mL/kg in 2½ hours). Children with no dehydration receive Plan A: ORS after each loose stool at home. Weighing, if available, helps estimate deficit, but clinical assessment guides immediate action. In severe dehydration, the child may be lethargic or unresponsive, with absent tears, very slow skin pinch, inability to drink and weak or absent radial pulse.

(b)(ii)

Nutritional management is continued feeding without fasting: breast milk or formula, age-appropriate energy-dense foods, small frequent meals, low-osmolarity ORS for dehydration, and zinc 10 mg/day for children under six months or 20 mg/day for older children for 10–14 days; avoid sugary drinks. ORS should be given according to age/weight, and feeding should resume as soon as the child can drink. Prevention includes exclusive breastfeeding for six months, continued breastfeeding with safe complementary feeding, safe drinking water, sanitation, handwashing, ORS corner promotion and rotavirus vaccine under India’s UIP.

(c)(i)

Eczema is a non-specific term for an inflammatory dermatosis with pruritus, erythema and epidermal changes such as scaling, vesiculation, crusting or lichenification.

(c)(ii)

Eczema is classified clinically as acute (erythema, oedema, vesicles, oozing), subacute (scaling, crusting) or chronic (lichenification, fissuring), and aetiologically as endogenous—atopic, seborrhoeic, nummular, dyshidrotic, lichen simplex chronicus—and exogenous—contact, photodermatitis, stasis.

(c)(iii)

Allergic contact dermatitis is type IV delayed hypersensitivity, requires prior sensitisation, has no dose threshold, is well-demarcated to the contact site though it may spread, and is caused by nickel, chromate (cement), fragrances, hair dye (paraphenylenediamine) or plant allergens such as Parthenium in India. Irritant contact dermatitis is direct cytotoxicity, is threshold-dependent, occurs immediately or after repeated exposure, is confined to the contact site, and is caused by detergents or acids. ACD often recurs on re-exposure and may show vesicles; ICD recurs with continued irritant and shows burning, fissures or erosion. Patch testing is positive in ACD and negative in ICD. ICD is commoner (about 80% of occupational contact dermatitis), typically on the hands of housewives, health workers and wet workers.