CMS 2020 Paper I \u2013 Part 2 (Q31\u2013Q60)<\/title>\n<link href=\"https:\/\/fonts.googleapis.com\/css2?family=Playfair+Display:wght@600;700&family=Source+Serif+4:ital,wght@0,300;0,400;0,600;1,400&display=swap\" rel=\"stylesheet\">\n<style>\n\/* \u2500\u2500 Namespace: cms20p1b \u2500\u2500 *\/\n#cms20p1b *,#cms20p1b *::before,#cms20p1b *::after{box-sizing:border-box;margin:0;padding:0}\n\n#cms20p1b{\n --ter:#C0603A;\n --ter-light:#e8825f;\n --ter-pale:#fdf1ec;\n --teal:#2A7A6F;\n --teal-light:#3da394;\n --teal-pale:#eaf4f3;\n --ink:#1a1a1a;\n --ink-mid:#444;\n --ink-soft:#777;\n --line:#e0d8d4;\n --bg:#fdfaf8;\n --white:#ffffff;\n --correct:#1e6f46;\n --correct-bg:#eaf7ef;\n --correct-border:#43a047;\n --wrong:#b83232;\n --wrong-bg:#fdf0f0;\n --wrong-border:#e53935;\n --radius:10px;\n font-family:'Source Serif 4',Georgia,serif;\n font-size:16px;\n color:var(--ink);\n background:var(--bg);\n line-height:1.7;\n padding:0 0 48px;\n}\n\n\/* Sentinel *\/\n#cms20p1b 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border:2px solid var(--teal);\n border-radius:var(--radius);\n margin:28px 0 0;\n padding:28px 24px;\n text-align:center;\n}\n#cms20p1b .cq-score-ring{\n width:110px;height:110px;\n border-radius:50%;\n background:conic-gradient(var(--teal) 0%,var(--line) 0%);\n display:flex;\n align-items:center;\n justify-content:center;\n margin:0 auto 20px;\n position:relative;\n}\n#cms20p1b .cq-score-ring::before{\n content:'';\n position:absolute;\n width:86px;height:86px;\n border-radius:50%;\n background:var(--white);\n}\n#cms20p1b .cq-ring-inner{\n position:relative;\n display:flex;\n flex-direction:column;\n align-items:center;\n line-height:1.2;\n}\n#cms20p1b .cq-ring-pct{\n font-family:'Playfair Display',serif;\n font-size:1.3rem;\n font-weight:700;\n color:var(--teal);\n}\n#cms20p1b .cq-ring-sub{\n font-size:0.6rem;\n color:var(--ink-soft);\n text-transform:uppercase;\n letter-spacing:0.05em;\n}\n#cms20p1b .cq-score h2{\n font-family:'Playfair Display',serif;\n font-size:1.2rem;\n color:var(--ink);\n margin-bottom:8px;\n}\n#cms20p1b .cq-net-line{\n font-size:1rem;\n color:var(--teal);\n font-weight:600;\n margin-bottom:6px;\n}\n#cms20p1b .cq-verdict{\n font-size:0.85rem;\n color:var(--ink-soft);\n margin-bottom:20px;\n}\n#cms20p1b .cq-score-bands{\n display:flex;\n justify-content:center;\n gap:10px;\n flex-wrap:wrap;\n font-size:0.8rem;\n}\n#cms20p1b .cq-band{padding:4px 12px;border-radius:16px;font-weight:600}\n#cms20p1b .cq-band-c{background:var(--correct-bg);color:var(--correct)}\n#cms20p1b .cq-band-w{background:var(--wrong-bg);color:var(--wrong)}\n#cms20p1b .cq-band-s{background:var(--teal-pale);color:var(--teal)}\n\n#cms20p1b .cq-retry-btn{\n margin-top:22px;\n background:transparent;\n border:2px solid var(--teal);\n color:var(--teal);\n border-radius:8px;\n padding:10px 28px;\n font-family:'Playfair Display',serif;\n font-size:0.95rem;\n font-weight:700;\n cursor:pointer;\n transition:background 0.2s,color 0.2s;\n}\n#cms20p1b .cq-retry-btn:hover{background:var(--teal);color:var(--white)}\n\n@media(max-width:480px){\n #cms20p1b .cq-header h1{font-size:1.15rem}\n #cms20p1b .cq-qtext{font-size:0.88rem}\n #cms20p1b .cq-opt-text{font-size:0.84rem}\n}\n<\/style>\n<\/head>\n<body>\n\n<div id=\"cms20p1b\">\n\n \n <div class=\"cq-sentinel\" id=\"cms20p1b-sentinel\"><\/div>\n\n \n <div class=\"cq-statusbar\" id=\"cms20p1b-statusbar\">\n <div class=\"cq-sb-stats\">\n <div class=\"cq-sb-item\"><span class=\"cq-dot cq-dot-c\"><\/span> <strong id=\"cms20p1b-sc\">0<\/strong> Correct<\/div>\n <div class=\"cq-sb-item\"><span class=\"cq-dot cq-dot-w\"><\/span> <strong id=\"cms20p1b-sw\">0<\/strong> Wrong<\/div>\n <div class=\"cq-sb-item\"><span class=\"cq-dot cq-dot-r\"><\/span> <strong id=\"cms20p1b-sr\">30<\/strong> Remaining<\/div>\n <div class=\"cq-sb-sep\"><\/div>\n <div class=\"cq-sb-item\"><span class=\"cq-dot cq-dot-n\"><\/span> Net <strong id=\"cms20p1b-sn\">0<\/strong> \/ <strong id=\"cms20p1b-sm\">120<\/strong><\/div>\n <\/div>\n <div class=\"cq-sb-progress\"><div class=\"cq-sb-fill\" id=\"cms20p1b-fill\"><\/div><\/div>\n <\/div>\n\n \n <div class=\"cq-header\">\n <h1>Combined Medical Services Examination 2020<br>Paper I \u00b7 Part 2<\/h1>\n <p>Nephrology \u00b7 Neurology \u00b7 Haematology \u00b7 Endocrinology<\/p>\n <div class=\"cq-meta\">\n <span class=\"cq-badge\">Questions 31 \u2013 60<\/span>\n <span class=\"cq-badge\">Options reshuffled<\/span>\n <\/div>\n <\/div>\n\n <div class=\"cq-body\">\n <div id=\"cms20p1b-questions\"><\/div>\n <div class=\"cq-submit-wrap\">\n <button class=\"cq-btn\" id=\"cms20p1b-submit\">Submit Answers<\/button>\n <\/div>\n <div class=\"cq-score\" id=\"cms20p1b-score\">\n <div class=\"cq-score-ring\" id=\"cms20p1b-ring\">\n <div class=\"cq-ring-inner\">\n <span class=\"cq-ring-pct\" id=\"cms20p1b-ring-pct\">0%<\/span>\n <span class=\"cq-ring-sub\">score<\/span>\n <\/div>\n <\/div>\n <h2>Your Result<\/h2>\n <div class=\"cq-net-line\" id=\"cms20p1b-net-line\"><\/div>\n <div class=\"cq-verdict\" id=\"cms20p1b-verdict\"><\/div>\n <div class=\"cq-score-bands\">\n <span class=\"cq-band cq-band-c\" id=\"cms20p1b-ct-c\"><\/span>\n <span class=\"cq-band cq-band-w\" id=\"cms20p1b-ct-w\"><\/span>\n <span class=\"cq-band cq-band-s\" id=\"cms20p1b-ct-s\"><\/span>\n <\/div>\n <button class=\"cq-retry-btn\" id=\"cms20p1b-retry\">\u21ba Retry Quiz<\/button>\n <\/div>\n <\/div>\n\n<\/div>\n\n<script>\n(function(){\n 'use strict';\n\n const NS = 'cms20p1b';\n const TOTAL = 30;\n const MAX = TOTAL * 4; \/\/ 120\n\n const QUESTIONS = [\n {\n id:31,\n stem:'What is the target blood haemoglobin level when treating anaemia in Stage-4 chronic kidney disease?',\n correct:'10 to 12 gm\/dL',\n options:['8 to 10 gm\/dL','10 to 12 gm\/dL','12 to 13 gm\/dL','13 to 14 gm\/dL'],\n exp:'Target Hb in CKD anaemia (KDIGO guidelines) is 10\u201312 gm\/dL. Targeting higher levels with ESAs has been shown to increase cardiovascular events without added benefit.'\n },\n {\n id:32,\n stem:'Which one of the following complications of chronic kidney disease is observed in patients with low parathyroid hormone levels?',\n correct:'Adynamic bone disease',\n options:['Adynamic bone disease','Tumoral calcinosis','Osteitis fibrosa cystica','Calciphylaxis'],\n exp:'Adynamic bone disease results from over-suppression of PTH (often iatrogenic with excess calcium\/vitamin D supplementation) leading to low bone turnover. Osteitis fibrosa cystica is the opposite \u2014 seen with HIGH PTH.'\n },\n {\n id:33,\n stem:'All of the following statements about adult polycystic kidney disease are true EXCEPT:',\n correct:'It is usually associated with marked proteinuria',\n options:['It is inherited as autosomal dominant trait','It is usually associated with marked proteinuria','It is usually associated with systemic hypertension from young age','It is associated with Berry aneurysm'],\n exp:'ADPKD causes minimal or absent proteinuria \u2014 heavy proteinuria is NOT a feature. It is autosomal dominant, commonly causes early-onset hypertension, and is associated with intracranial berry aneurysms (~8%).'\n },\n {\n id:34,\n stem:'Consider the following statements in relation to an adult patient:\\n1. Oliguria is defined as passage of urine less than 300 ml per day\\n2. Anuria is said to exist when less than 50 ml urine is passed per day\\n3. Polyuria is defined as urine volume in excess of 3 litre per day\\nWhich of the statements given above are correct?',\n correct:'2 and 3 only',\n options:['1 and 3 only','2 and 3 only','1 and 2 only','1, 2 and 3'],\n exp:'Oliguria is defined as urine output <400 ml\/day (not 300 ml) \u2014 statement 1 is false. Anuria is <50 ml\/day and polyuria is >3 L\/day \u2014 statements 2 and 3 are correct.'\n },\n {\n id:35,\n stem:'White cell casts in urine examination are strongly suggestive of:',\n correct:'Pyelonephritis',\n options:['Nephritis','Pyelonephritis','Renal stone disease','Papillitis'],\n exp:'WBC casts form when leucocytes aggregate within renal tubules \u2014 pathognomonic of renal parenchymal infection, i.e., pyelonephritis. RBC casts indicate glomerulonephritis; granular casts suggest tubular injury.'\n },\n {\n id:36,\n stem:'A 13-year-old boy presents with haematuria, oliguria, oedema and hypertension two weeks after sore throat. Labs show low C3 and elevated ASO and anti-DNase titres. Which one of the following statements is NOT correct about management?',\n correct:'Immunosuppressants are to be used for crescentic glomerulonephritis',\n options:['Renal biopsy is rarely required for making diagnosis','Antibiotic treatment is given for streptococcal infection','Treatment is largely supportive','Immunosuppressants are to be used for crescentic glomerulonephritis'],\n exp:'Post-streptococcal GN is self-limiting and treatment is supportive. Even in the rare crescentic variant, immunosuppressants are NOT routinely indicated \u2014 evidence for their use is weak and the condition generally resolves. This is in contrast to crescentic GN from ANCA vasculitis or anti-GBM disease.'\n },\n {\n id:37,\n stem:'Which one of the following statements is NOT correct regarding the risk factors for nephrolithiasis?',\n correct:'Higher dietary calcium increases risk',\n options:['Higher dietary calcium increases risk','Higher animal protein intake increases risk','Higher dietary potassium intake lowers risk','Lower urine citrate increases the risk'],\n exp:'Contrary to intuition, higher dietary calcium is actually protective \u2014 it binds oxalate in the gut, reducing oxalate absorption and urinary oxalate excretion. It is supplemental (non-dietary) calcium that may increase risk. Statements about animal protein, potassium, and citrate are all correct.'\n },\n {\n id:38,\n stem:'A 60-year-old patient is admitted with seizure, aphasia and altered sensorium. He has history of fever and headache for the preceding 3 days. The CSF examination is unremarkable. What would be the probable diagnosis?',\n correct:'Viral encephalitis',\n options:['Multiple sclerosis','Tubercular meningitis','Pyogenic (bacterial) meningitis','Viral encephalitis'],\n exp:'Fever + focal neurological signs (aphasia, seizures) + normal CSF = viral encephalitis (typically HSV). TB and bacterial meningitis would show CSF abnormalities. MS does not cause fever or acute encephalitic illness.'\n },\n {\n id:39,\n stem:'Drug of choice for the treatment of Trigeminal Neuralgia is:',\n correct:'Carbamazepine',\n options:['Carbamazepine','Aceclofenac','Thiamine','Prednisolone'],\n exp:'Carbamazepine (a sodium channel blocker) is the first-line drug for trigeminal neuralgia \u2014 effective in ~70% of cases. It suppresses ectopic neuronal firing in the trigeminal pathways. NSAIDs, steroids, and vitamins have no established role.'\n },\n {\n id:40,\n stem:'Constructional skills is a function of which lobe?',\n correct:'Non-dominant parietal lobe',\n options:['Dominant temporal lobe','Non-dominant parietal lobe','Frontal lobe','Non-dominant temporal lobe'],\n exp:'Constructional ability (copying figures, building block designs) is a function of the non-dominant (usually right) parietal lobe. Damage here causes constructional apraxia and visuospatial deficits.'\n },\n {\n id:41,\n stem:'Vertical gaze palsy with convergence retraction nystagmus is seen in:',\n correct:'Parinaud syndrome',\n options:['Weber syndrome','Millard Gubler syndrome','Claude syndrome','Parinaud syndrome'],\n exp:\"Parinaud syndrome (dorsal midbrain syndrome) results from compression of the superior colliculus and pretectal area (e.g., pineal tumour) \u2014 causes upgaze palsy, convergence-retraction nystagmus, and light-near dissociation (Argyll Robertson-like). Known as the 'setting sun sign' in children.\"\n },\n {\n id:42,\n stem:'A patient on looking forward was found to have his right eye deviated downwards and outwards with pupil dilated. He is suffering from:',\n correct:'Right 3rd nerve palsy',\n options:['Left 3rd nerve palsy','Left 6th nerve palsy','Right 4th nerve palsy','Right 3rd nerve palsy'],\n exp:'The oculomotor (3rd) nerve controls all extraocular muscles except SO and LR. Its palsy causes the eye to deviate down and out (unopposed SO and LR) with ptosis and a dilated fixed pupil (loss of parasympathetic fibres that travel on the outer surface of CN III).'\n },\n {\n id:43,\n stem:'All of the following are features of Cauda Equina syndrome EXCEPT:',\n correct:'Extensor plantar response',\n options:['Low back pain','Lower limb areflexia','Loss of bladder function','Extensor plantar response'],\n exp:'Cauda equina syndrome is a lower motor neuron lesion \u2014 plantar responses are absent or flexor, NOT extensor. Extensor plantar (Babinski) response indicates an upper motor neuron lesion (spinal cord or above). Areflexia, bladder dysfunction, and back pain are all LMN features.'\n },\n {\n id:44,\n stem:'A 68-year-old male presents with progressive small handwriting (micrographia). On examination, he had resting tremor, bradykinesia, rigidity and postural instability. This patient is most likely suffering from:',\n correct:\"Parkinson's disease\",\n options:[\"Parkinson's disease\",'Vascular dementia',\"Alzheimer's disease\",'Frontotemporal dementia'],\n exp:\"Parkinson's disease presents with the classic tetrad: resting tremor, bradykinesia, cogwheel rigidity, and postural instability. Micrographia (progressively smaller handwriting) is a hallmark motor sign. Cognitive dementias do not cause this motor syndrome.\"\n },\n {\n id:45,\n stem:'An elderly patient presents with a wide base freezing gait with imbalance, comprising short strides, shuffling along the floor and difficulty with starts and turns. Heel-shin test is normal. Which one of the following is the most likely disorder?',\n correct:'Frontal gait disorder',\n options:['Cerebellar ataxia','Sensory ataxia','Frontal gait disorder',\"Parkinson's disease\"],\n exp:\"Frontal gait disorder (marche \u00e0 petits pas \/ magnetic gait) features short shuffling steps, start and turn difficulty, wide base, and apraxia \u2014 but limb coordination (heel-shin test) is normal. This distinguishes it from cerebellar ataxia. In Parkinson's, the base is typically narrow.\"\n },\n {\n id:46,\n stem:'Cushing reflex, seen in conditions of raised intracranial pressure, includes all of the following EXCEPT:',\n correct:'Hypothermia',\n options:['Bradycardia','Hypertension','Irregular respiration','Hypothermia'],\n exp:\"Cushing's reflex (response to raised ICP) consists of hypertension, bradycardia, and irregular respiration \u2014 forming the Cushing triad. Hypothermia is not part of this reflex. Temperature dysregulation in raised ICP, if present, tends toward hyperthermia.\"\n },\n {\n id:47,\n stem:'A 35-year-old man presents with low grade fever and headache for five weeks with meningismus. After lumbar puncture, he reports worsening headache a day later. Which one of the following features is NOT consistent with \"Post-LP\" headache?',\n correct:'Post-LP headache is most severe upon waking up',\n options:['Post-LP headache usually begins within 48 hours','Post-LP headache worsens in sitting position','Post-LP headache is most severe upon waking up','Post-LP headache may improve with caffeine intake'],\n exp:'Post-LP headache is a postural (orthostatic) headache \u2014 it worsens on sitting or standing and relieves on lying down. It is therefore LEAST severe upon waking (when supine) and worst later in the day. Option (c) is inconsistent with this mechanism.'\n },\n {\n id:48,\n stem:'Which one of the following investigations is NOT appropriate in a case of recurrent thrombosis?',\n correct:'Bcr-Abl assay',\n options:['Antiphospholipid antibodies','Bcr-Abl assay','Protein C and S assays','Antithrombin level'],\n exp:'Recurrent thrombosis warrants a thrombophilia screen: antiphospholipid antibodies, protein C, protein S, antithrombin, factor V Leiden, prothrombin gene mutation. Bcr-Abl assay diagnoses CML \u2014 it has no role in thrombophilia workup.'\n },\n {\n id:49,\n stem:'All of the following are causes of reactive thrombocytosis EXCEPT:',\n correct:'Megaloblastic anaemia',\n options:['Haemolytic anaemia','Megaloblastic anaemia','Post splenectomy','Chronic inflammatory disorders'],\n exp:'Megaloblastic anaemia causes pancytopenia including thrombocytopenia \u2014 not thrombocytosis. Haemolytic anaemia, post-splenectomy state, and chronic inflammatory disorders are all recognised causes of reactive (secondary) thrombocytosis.'\n },\n {\n id:50,\n stem:'Cryoprecipitate cannot be used for treatment of which one of the following conditions?',\n correct:'Haemophilia B',\n options:['Von Willebrand disease','Hypofibrinogenaemia','Haemophilia B','Haemophilia A'],\n exp:'Cryoprecipitate contains Factor VIII, vWF, fibrinogen, Factor XIII, and fibronectin. It is therefore useful in Haemophilia A (Factor VIII deficiency), vWD, and hypofibrinogenaemia. Haemophilia B is a Factor IX deficiency \u2014 Factor IX is NOT present in cryoprecipitate; it requires Factor IX concentrate or FFP.'\n },\n {\n id:51,\n stem:'Pyruvate kinase deficiency results in deficiency of ATP production and chronic haemolytic anaemia. The disorder is inherited as an:',\n correct:'Autosomal recessive trait',\n options:['Autosomal recessive trait','X-linked recessive trait','Autosomal dominant trait','X-linked dominant trait'],\n exp:'Pyruvate kinase deficiency is inherited as an autosomal recessive condition. It is the most common red cell enzyme defect causing non-spherocytic haemolytic anaemia, affecting both sexes equally.'\n },\n {\n id:52,\n stem:'Sickle cell disease may be associated with any of the following EXCEPT:',\n correct:\"Conn's syndrome\",\n options:['Acute chest syndrome','Aplastic crisis','Splenic sequestration crisis',\"Conn's syndrome\"],\n exp:\"Sickle cell disease is associated with acute chest syndrome (vaso-occlusion in pulmonary vasculature), aplastic crisis (parvovirus B19), and splenic sequestration crisis. Conn's syndrome (primary hyperaldosteronism) is an entirely unrelated adrenal condition.\"\n },\n {\n id:53,\n stem:'Fever with splenomegaly and lymphadenopathy can be seen in:',\n correct:'Both infectious mononucleosis and chronic leukaemia',\n options:['Infectious mononucleosis','Chronic leukaemia','Both infectious mononucleosis and chronic leukaemia','Neither infectious mononucleosis nor chronic leukaemia'],\n exp:'Both conditions present with fever, splenomegaly and lymphadenopathy. EBV-driven infectious mononucleosis causes generalised lymphadenopathy and splenomegaly. CLL and CML both commonly cause massive splenomegaly with lymph node enlargement.'\n },\n {\n id:54,\n stem:'Every individual carries four alpha gene alleles. Deletion of three alleles leads to development of:',\n correct:'Haemoglobin H disease',\n options:['Haemoglobin X disease','Haemoglobin H disease','Haemoglobin F disease','Hydrops fetalis'],\n exp:'Alpha thalassaemia genotype-phenotype: 1 deletion = silent carrier; 2 deletions = alpha thal trait; 3 deletions = HbH disease (\u03b24 tetramers form); 4 deletions = Hydrops fetalis (Hb Bart = \u03b34 tetramers, incompatible with life).'\n },\n {\n id:55,\n stem:'Which one of the following is NOT true regarding Chronic Myeloid Leukaemia (CML)?',\n correct:'Risk of developing CML is increased in monozygotic twins',\n options:['It is a clonal malignancy of haematopoietic stem cells','Risk of developing CML is increased in monozygotic twins','CML is defined by presence of BCR-ABL1 fusion gene','10-year survival with TKI therapy is 85%'],\n exp:'CML is not clearly increased in monozygotic twins \u2014 unlike childhood ALL where concordance in identical twins is established. CML is a sporadic clonal disorder defined by the BCR-ABL1 fusion (Philadelphia chromosome, t(9;22)). TKI therapy has transformed prognosis with ~85% 10-year survival.'\n },\n {\n id:56,\n stem:'Diagnostic criteria of multiple myeloma includes which of the following?\\n1. Increased malignant plasma cells in the bone marrow\\n2. Serum and\/or urinary M protein\\n3. Skeletal lytic lesions\\n4. Skeletal blastic lesions',\n correct:'1, 2 and 3',\n options:['1, 2 and 3','1, 3 and 4','1, 2 and 4','2, 3 and 4'],\n exp:'Multiple myeloma causes osteolytic (not blastic) bone lesions \u2014 statement 4 is incorrect. The diagnostic triad is: malignant plasma cell proliferation in marrow, monoclonal (M) protein in serum\/urine, and end-organ damage (CRAB: hypercalcaemia, Renal failure, Anaemia, Bone lesions).'\n },\n {\n id:57,\n stem:'The most predominant type of serum immunoglobulin involved in patients with plasma cell disorder is:',\n correct:'IgG',\n options:['IgG','IgA','IgD','Light chains only'],\n exp:'IgG myeloma is the most common (~55\u201360% of cases), followed by IgA (~20%). IgD, IgE, and light-chain-only myeloma account for small proportions. IgM excess is characteristic of Waldenstr\u00f6m macroglobulinaemia rather than myeloma.'\n },\n {\n id:58,\n stem:'Which one of the following statements is NOT true regarding thyroid function\/disorder in pregnancy?',\n correct:'Levothyroxine replacement therapy dose should be decreased by 30\u201350% early in pregnancy',\n options:['There is an increase in the metabolism of thyroxine by placenta','Hyperemesis gravidarum may be associated with thyrotoxicosis in pregnancy','Levothyroxine replacement therapy dose should be decreased by 30\u201350% early in pregnancy','Impaired cognitive development may be seen in offspring of mothers with subclinical hypothyroidism'],\n exp:'Levothyroxine dose requirements INCREASE by 30\u201350% in pregnancy (due to increased TBG, placental T4 metabolism, and fetal demands) \u2014 not decrease. The statement saying dose should be decreased is therefore false. The other statements are all correct.'\n },\n {\n id:59,\n stem:'Which one of the following is NOT the criterion for the diagnosis of Diabetes mellitus?',\n correct:'Fasting plasma glucose \u2265 110 mg\/dL',\n options:['Symptoms of diabetes and random plasma glucose \u2265 200 mg\/dL','HbA1c \u2265 6.5%','2-hour plasma glucose \u2265 200 mg\/dL during OGTT','Fasting plasma glucose \u2265 110 mg\/dL'],\n exp:'The ADA criterion for DM diagnosis using fasting plasma glucose is \u2265126 mg\/dL. A fasting glucose of \u2265110 mg\/dL (or 100 mg\/dL by ADA) indicates impaired fasting glucose (pre-diabetes) \u2014 NOT diabetes. The other three are recognised diagnostic criteria.'\n },\n {\n id:60,\n stem:'A young lady presents with complaints of menstrual irregularity, weight gain, hair loss, tiredness and weakness. What will be the investigation of choice?',\n correct:'Free T4 and TSH',\n options:['FSH & LH level','Estrogen level','Free T3 and free T4 level','Free T4 and TSH'],\n exp:'This clinical picture \u2014 menstrual irregularity, weight gain, hair loss, fatigue \u2014 is classic for hypothyroidism. The investigation of choice is serum TSH (most sensitive) combined with free T4. 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class=\"cq-qhead\">'+\n '<div class=\"cq-qnum\" id=\"'+NS+'-n'+q.id+'\">'+q.id+'<\/div>'+\n '<div class=\"cq-qtext\">'+q.stem.replace(\/\\n\/g,'<br>')+'<\/div>'+\n '<\/div>'+\n '<div class=\"cq-options\" id=\"'+NS+'-opts'+q.id+'\">'+\n opts.map(function(o,i){\n return '<div class=\"cq-opt\" id=\"'+NS+'-o'+q.id+'-'+i+'\" data-qid=\"'+q.id+'\" data-val=\"'+esc(o)+'\" role=\"button\" tabindex=\"0\">'+\n '<span class=\"cq-opt-letter\">'+LETTERS[i]+'<\/span>'+\n '<span class=\"cq-opt-text\">'+o+'<\/span>'+\n '<\/div>';\n }).join('')+\n '<\/div>'+\n '<div class=\"cq-explanation\" id=\"'+NS+'-exp'+q.id+'\">'+\n '<div class=\"cq-exp-label\">Explanation<\/div>'+\n q.exp+\n '<\/div>';\n\n container.appendChild(card);\n\n opts.forEach(function(_,i){\n document.getElementById(NS+'-o'+q.id+'-'+i)\n .addEventListener('click',function(){ pick(q.id,i); });\n });\n });\n }\n\n function pick(qid,oi){\n if(userAnswers[qid]!==undefined)return;\n const q=QUESTIONS.find(function(x){return x.id===qid;});\n const opts=shuffledOpts[qid];\n const chosen=opts[oi];\n const correct=chosen===q.correct;\n userAnswers[qid]=correct?'correct':'wrong';\n answered++;\n\n opts.forEach(function(o,i){\n const el=document.getElementById(NS+'-o'+qid+'-'+i);\n if(o===q.correct) { el.classList.add('cq-correct','cq-locked'); }\n else if(i===oi) { el.classList.add('cq-wrong','cq-locked'); }\n else { el.classList.add('cq-dimmed','cq-locked'); }\n });\n\n const num=document.getElementById(NS+'-n'+qid);\n num.classList.add(correct?'ans-c':'ans-w');\n\n document.getElementById(NS+'-exp'+qid).style.display='block';\n updateStats();\n }\n\n function updateStats(){\n const c=Object.values(userAnswers).filter(function(v){return v==='correct';}).length;\n const w=Object.values(userAnswers).filter(function(v){return v==='wrong';}).length;\n const r=TOTAL-answered;\n const net=(c*4)-w;\n\n document.getElementById(NS+'-sc').textContent=c;\n document.getElementById(NS+'-sw').textContent=w;\n 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the weaker areas.';\n else if(pct>=40) v='Fair \u2014 systematic revision of these topics is recommended.';\n else v='Needs significant revision across these topics.';\n document.getElementById(NS+'-verdict').textContent=v;\n\n document.getElementById(NS+'-ct-c').textContent='\u2713 '+c+' Correct';\n document.getElementById(NS+'-ct-w').textContent='\u2717 '+w+' Wrong';\n document.getElementById(NS+'-ct-s').textContent='\u2014 '+s+' Skipped';\n\n const sc=document.getElementById(NS+'-score');\n sc.style.display='block';\n sc.scrollIntoView({behavior:'smooth',block:'center'});\n }\n\n document.getElementById(NS+'-submit').addEventListener('click',showScore);\n document.getElementById(NS+'-retry').addEventListener('click',function(){\n build();\n window.scrollTo({top:0,behavior:'smooth'});\n });\n\n \/* IntersectionObserver \u2014 status bar slides in when sentinel leaves viewport *\/\n new IntersectionObserver(\n function(entries){\n document.getElementById(NS+'-statusbar')\n 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Quiz<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"neve_meta_sidebar":"","neve_meta_container":"","neve_meta_enable_content_width":"","neve_meta_content_width":0,"neve_meta_title_alignment":"","neve_meta_author_avatar":"","neve_post_elements_order":"","neve_meta_disable_header":"","neve_meta_disable_footer":"","neve_meta_disable_title":"","footnotes":""},"categories":[18],"tags":[],"class_list":["post-36513","post","type-post","status-publish","format-standard","hentry","category-cms"],"yoast_head":"\n<title>CMS 2020 P1 Part-2 - atsixty<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/atsixty.com\/index.php\/2026\/04\/07\/cms-2020-p1-part-2\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta 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{"id":36513,"date":"2026-04-07T14:36:36","date_gmt":"2026-04-07T09:06:36","guid":{"rendered":"https:\/\/atsixty.com\/?p=36513"},"modified":"2026-04-08T08:34:41","modified_gmt":"2026-04-08T03:04:41","slug":"cms-2020-p1-part-2","status":"publish","type":"post","link":"https:\/\/atsixty.com\/index.php\/2026\/04\/07\/cms-2020-p1-part-2\/","title":{"rendered":"CMS 2020 P1 Part-2"},"content":{"rendered":"\n\n\n\n\n\nCMS 2020 Paper I \u2013 Part 2 (Q31\u2013Q60)<\/title>\n<link href=\"https:\/\/fonts.googleapis.com\/css2?family=Playfair+Display:wght@600;700&family=Source+Serif+4:ital,wght@0,300;0,400;0,600;1,400&display=swap\" rel=\"stylesheet\">\n<style>\n\/* \u2500\u2500 Namespace: cms20p1b \u2500\u2500 *\/\n#cms20p1b *,#cms20p1b *::before,#cms20p1b *::after{box-sizing:border-box;margin:0;padding:0}\n\n#cms20p1b{\n --ter:#C0603A;\n --ter-light:#e8825f;\n --ter-pale:#fdf1ec;\n --teal:#2A7A6F;\n --teal-light:#3da394;\n --teal-pale:#eaf4f3;\n --ink:#1a1a1a;\n --ink-mid:#444;\n --ink-soft:#777;\n --line:#e0d8d4;\n --bg:#fdfaf8;\n --white:#ffffff;\n --correct:#1e6f46;\n --correct-bg:#eaf7ef;\n --correct-border:#43a047;\n --wrong:#b83232;\n --wrong-bg:#fdf0f0;\n --wrong-border:#e53935;\n --radius:10px;\n font-family:'Source Serif 4',Georgia,serif;\n font-size:16px;\n color:var(--ink);\n background:var(--bg);\n line-height:1.7;\n padding:0 0 48px;\n}\n\n\/* Sentinel *\/\n#cms20p1b .cq-sentinel{height:1px}\n\n\/* Fixed status bar \u2014 slides in via IntersectionObserver *\/\n#cms20p1b .cq-statusbar{\n position:fixed;\n top:0;left:0;right:0;\n z-index:99999;\n background:var(--white);\n border-bottom:2px solid var(--line);\n border-left:4px solid var(--ter);\n box-shadow:0 2px 12px rgba(0,0,0,0.11);\n opacity:0;\n pointer-events:none;\n transform:translateY(-110%);\n transition:opacity 0.22s ease,transform 0.22s ease;\n}\n#cms20p1b .cq-statusbar.visible{\n opacity:1;\n pointer-events:auto;\n transform:translateY(0);\n}\n#cms20p1b .cq-sb-stats{\n display:flex;\n align-items:center;\n padding:0.4rem 0.85rem;\n font-size:0.72rem;\n color:var(--ink-soft);\n flex-wrap:nowrap;\n overflow-x:auto;\n}\n#cms20p1b .cq-sb-item{\n display:flex;\n align-items:center;\n gap:0.22rem;\n padding:0.1rem 0.55rem;\n border-right:1px solid var(--line);\n white-space:nowrap;\n line-height:1;\n}\n#cms20p1b .cq-sb-item:last-child{border-right:none}\n#cms20p1b .cq-sb-item strong{color:var(--ink);font-size:0.82rem;font-weight:700}\n#cms20p1b .cq-dot{\n width:7px;height:7px;\n border-radius:50%;\n display:inline-block;\n flex-shrink:0;\n}\n#cms20p1b .cq-dot-c{background:var(--correct-border)}\n#cms20p1b .cq-dot-w{background:var(--wrong-border)}\n#cms20p1b .cq-dot-r{background:#aaa}\n#cms20p1b .cq-dot-n{background:var(--ter)}\n#cms20p1b .cq-sb-sep{flex:1;min-width:0.3rem}\n#cms20p1b .cq-sb-progress{\n height:4px;\n background:var(--line);\n overflow:hidden;\n}\n#cms20p1b .cq-sb-fill{\n height:100%;\n background:linear-gradient(90deg,var(--ter),var(--teal));\n width:0%;\n transition:width 0.4s ease;\n}\n\n\/* Header *\/\n#cms20p1b .cq-header{\n background:var(--teal);\n color:var(--white);\n padding:28px 24px 22px;\n text-align:center;\n}\n#cms20p1b .cq-header h1{\n font-family:'Playfair Display',serif;\n font-size:1.45rem;\n font-weight:700;\n letter-spacing:0.01em;\n line-height:1.3;\n}\n#cms20p1b .cq-header p{\n font-size:0.85rem;\n opacity:0.85;\n margin-top:6px;\n font-style:italic;\n}\n#cms20p1b .cq-meta{\n display:flex;\n justify-content:center;\n gap:20px;\n margin-top:14px;\n flex-wrap:wrap;\n}\n#cms20p1b .cq-badge{\n background:rgba(255,255,255,0.15);\n border:1px solid rgba(255,255,255,0.3);\n border-radius:20px;\n padding:4px 14px;\n font-size:0.78rem;\n letter-spacing:0.03em;\n}\n\n\/* Body *\/\n#cms20p1b .cq-body{\n max-width:760px;\n margin:0 auto;\n padding:0 16px;\n}\n\n\/* Cards *\/\n#cms20p1b .cq-card{\n background:var(--white);\n border:1px solid var(--line);\n border-radius:var(--radius);\n margin:24px 0;\n overflow:hidden;\n transition:box-shadow 0.2s;\n}\n#cms20p1b .cq-card:hover{box-shadow:0 2px 12px rgba(192,96,58,0.1)}\n\n#cms20p1b .cq-qhead{\n background:var(--ter-pale);\n border-bottom:1px solid var(--line);\n padding:14px 18px;\n display:flex;\n gap:12px;\n align-items:flex-start;\n}\n#cms20p1b .cq-qnum{\n flex-shrink:0;\n width:26px;height:26px;\n border-radius:50%;\n background:var(--ter);\n color:#fff;\n font-size:0.72rem;\n font-weight:700;\n display:flex;\n align-items:center;\n justify-content:center;\n margin-top:2px;\n transition:background 0.2s;\n}\n#cms20p1b .cq-qnum.ans-c{background:var(--correct-border)}\n#cms20p1b .cq-qnum.ans-w{background:var(--wrong-border)}\n#cms20p1b .cq-qtext{\n font-size:0.93rem;\n color:var(--ink);\n line-height:1.65;\n}\n\n\/* Options *\/\n#cms20p1b .cq-options{\n padding:14px 18px;\n display:flex;\n flex-direction:column;\n gap:8px;\n}\n#cms20p1b .cq-opt{\n display:flex;\n align-items:flex-start;\n gap:10px;\n padding:10px 14px;\n border:1.5px solid var(--line);\n border-radius:8px;\n cursor:pointer;\n transition:border-color 0.15s,background 0.15s;\n background:var(--white);\n -webkit-tap-highlight-color:transparent;\n}\n#cms20p1b .cq-opt:hover:not(.cq-locked){\n border-color:var(--teal);\n background:var(--teal-pale);\n}\n#cms20p1b .cq-opt-letter{\n flex-shrink:0;\n width:20px;height:20px;\n border-radius:50%;\n border:1.5px solid var(--line);\n display:flex;\n align-items:center;\n justify-content:center;\n font-size:0.65rem;\n font-weight:700;\n color:var(--ink-soft);\n transition:all 0.15s;\n margin-top:1px;\n}\n#cms20p1b .cq-opt-text{\n font-size:0.89rem;\n color:var(--ink-mid);\n line-height:1.55;\n}\n#cms20p1b .cq-opt.cq-correct{\n border-color:var(--correct-border);\n background:var(--correct-bg);\n cursor:default;\n}\n#cms20p1b .cq-opt.cq-correct .cq-opt-letter{\n background:var(--correct-border);\n border-color:var(--correct-border);\n color:#fff;\n}\n#cms20p1b .cq-opt.cq-correct .cq-opt-text{color:var(--correct);font-weight:600}\n#cms20p1b .cq-opt.cq-wrong{\n border-color:var(--wrong-border);\n background:var(--wrong-bg);\n cursor:default;\n}\n#cms20p1b .cq-opt.cq-wrong .cq-opt-letter{\n background:var(--wrong-border);\n border-color:var(--wrong-border);\n color:#fff;\n}\n#cms20p1b .cq-opt.cq-wrong .cq-opt-text{color:var(--wrong)}\n#cms20p1b .cq-opt.cq-dimmed{opacity:0.42;cursor:default}\n#cms20p1b .cq-opt.cq-locked{cursor:default}\n\n\/* Explanation *\/\n#cms20p1b .cq-explanation{\n display:none;\n background:var(--teal-pale);\n border-top:1px solid #b2d8d3;\n padding:10px 18px 12px;\n font-size:0.82rem;\n color:#1a4f49;\n line-height:1.62;\n}\n#cms20p1b .cq-exp-label{\n font-size:0.7rem;\n font-weight:700;\n letter-spacing:0.08em;\n text-transform:uppercase;\n color:var(--teal);\n margin-bottom:4px;\n}\n\n\/* Submit *\/\n#cms20p1b .cq-submit-wrap{\n text-align:center;\n padding:28px 16px 8px;\n}\n#cms20p1b .cq-btn{\n background:var(--ter);\n color:var(--white);\n border:none;\n border-radius:8px;\n padding:13px 36px;\n font-family:'Playfair Display',serif;\n font-size:1rem;\n font-weight:700;\n cursor:pointer;\n letter-spacing:0.02em;\n transition:background 0.2s,transform 0.1s;\n}\n#cms20p1b .cq-btn:hover{background:var(--ter-light)}\n#cms20p1b .cq-btn:active{transform:scale(0.98)}\n\n\/* Score panel *\/\n#cms20p1b .cq-score{\n display:none;\n background:var(--white);\n border:2px solid var(--teal);\n border-radius:var(--radius);\n margin:28px 0 0;\n padding:28px 24px;\n text-align:center;\n}\n#cms20p1b .cq-score-ring{\n width:110px;height:110px;\n border-radius:50%;\n background:conic-gradient(var(--teal) 0%,var(--line) 0%);\n display:flex;\n align-items:center;\n justify-content:center;\n margin:0 auto 20px;\n position:relative;\n}\n#cms20p1b .cq-score-ring::before{\n content:'';\n position:absolute;\n width:86px;height:86px;\n border-radius:50%;\n background:var(--white);\n}\n#cms20p1b .cq-ring-inner{\n position:relative;\n display:flex;\n flex-direction:column;\n align-items:center;\n line-height:1.2;\n}\n#cms20p1b .cq-ring-pct{\n font-family:'Playfair Display',serif;\n font-size:1.3rem;\n font-weight:700;\n color:var(--teal);\n}\n#cms20p1b .cq-ring-sub{\n font-size:0.6rem;\n color:var(--ink-soft);\n text-transform:uppercase;\n letter-spacing:0.05em;\n}\n#cms20p1b .cq-score h2{\n font-family:'Playfair Display',serif;\n font-size:1.2rem;\n color:var(--ink);\n margin-bottom:8px;\n}\n#cms20p1b .cq-net-line{\n font-size:1rem;\n color:var(--teal);\n font-weight:600;\n margin-bottom:6px;\n}\n#cms20p1b .cq-verdict{\n font-size:0.85rem;\n color:var(--ink-soft);\n margin-bottom:20px;\n}\n#cms20p1b .cq-score-bands{\n display:flex;\n justify-content:center;\n gap:10px;\n flex-wrap:wrap;\n font-size:0.8rem;\n}\n#cms20p1b .cq-band{padding:4px 12px;border-radius:16px;font-weight:600}\n#cms20p1b .cq-band-c{background:var(--correct-bg);color:var(--correct)}\n#cms20p1b .cq-band-w{background:var(--wrong-bg);color:var(--wrong)}\n#cms20p1b .cq-band-s{background:var(--teal-pale);color:var(--teal)}\n\n#cms20p1b .cq-retry-btn{\n margin-top:22px;\n background:transparent;\n border:2px solid var(--teal);\n color:var(--teal);\n border-radius:8px;\n padding:10px 28px;\n font-family:'Playfair Display',serif;\n font-size:0.95rem;\n font-weight:700;\n cursor:pointer;\n transition:background 0.2s,color 0.2s;\n}\n#cms20p1b .cq-retry-btn:hover{background:var(--teal);color:var(--white)}\n\n@media(max-width:480px){\n #cms20p1b .cq-header h1{font-size:1.15rem}\n #cms20p1b .cq-qtext{font-size:0.88rem}\n #cms20p1b .cq-opt-text{font-size:0.84rem}\n}\n<\/style>\n<\/head>\n<body>\n\n<div id=\"cms20p1b\">\n\n \n <div class=\"cq-sentinel\" id=\"cms20p1b-sentinel\"><\/div>\n\n \n <div class=\"cq-statusbar\" id=\"cms20p1b-statusbar\">\n <div class=\"cq-sb-stats\">\n <div class=\"cq-sb-item\"><span class=\"cq-dot cq-dot-c\"><\/span> <strong id=\"cms20p1b-sc\">0<\/strong> Correct<\/div>\n <div class=\"cq-sb-item\"><span class=\"cq-dot cq-dot-w\"><\/span> <strong id=\"cms20p1b-sw\">0<\/strong> Wrong<\/div>\n <div class=\"cq-sb-item\"><span class=\"cq-dot cq-dot-r\"><\/span> <strong id=\"cms20p1b-sr\">30<\/strong> Remaining<\/div>\n <div class=\"cq-sb-sep\"><\/div>\n <div class=\"cq-sb-item\"><span class=\"cq-dot cq-dot-n\"><\/span> Net <strong id=\"cms20p1b-sn\">0<\/strong> \/ <strong id=\"cms20p1b-sm\">120<\/strong><\/div>\n <\/div>\n <div class=\"cq-sb-progress\"><div class=\"cq-sb-fill\" id=\"cms20p1b-fill\"><\/div><\/div>\n <\/div>\n\n \n <div class=\"cq-header\">\n <h1>Combined Medical Services Examination 2020<br>Paper I \u00b7 Part 2<\/h1>\n <p>Nephrology \u00b7 Neurology \u00b7 Haematology \u00b7 Endocrinology<\/p>\n <div class=\"cq-meta\">\n <span class=\"cq-badge\">Questions 31 \u2013 60<\/span>\n <span class=\"cq-badge\">Options reshuffled<\/span>\n <\/div>\n <\/div>\n\n <div class=\"cq-body\">\n <div id=\"cms20p1b-questions\"><\/div>\n <div class=\"cq-submit-wrap\">\n <button class=\"cq-btn\" id=\"cms20p1b-submit\">Submit Answers<\/button>\n <\/div>\n <div class=\"cq-score\" id=\"cms20p1b-score\">\n <div class=\"cq-score-ring\" id=\"cms20p1b-ring\">\n <div class=\"cq-ring-inner\">\n <span class=\"cq-ring-pct\" id=\"cms20p1b-ring-pct\">0%<\/span>\n <span class=\"cq-ring-sub\">score<\/span>\n <\/div>\n <\/div>\n <h2>Your Result<\/h2>\n <div class=\"cq-net-line\" id=\"cms20p1b-net-line\"><\/div>\n <div class=\"cq-verdict\" id=\"cms20p1b-verdict\"><\/div>\n <div class=\"cq-score-bands\">\n <span class=\"cq-band cq-band-c\" id=\"cms20p1b-ct-c\"><\/span>\n <span class=\"cq-band cq-band-w\" id=\"cms20p1b-ct-w\"><\/span>\n <span class=\"cq-band cq-band-s\" id=\"cms20p1b-ct-s\"><\/span>\n <\/div>\n <button class=\"cq-retry-btn\" id=\"cms20p1b-retry\">\u21ba Retry Quiz<\/button>\n <\/div>\n <\/div>\n\n<\/div>\n\n<script>\n(function(){\n 'use strict';\n\n const NS = 'cms20p1b';\n const TOTAL = 30;\n const MAX = TOTAL * 4; \/\/ 120\n\n const QUESTIONS = [\n {\n id:31,\n stem:'What is the target blood haemoglobin level when treating anaemia in Stage-4 chronic kidney disease?',\n correct:'10 to 12 gm\/dL',\n options:['8 to 10 gm\/dL','10 to 12 gm\/dL','12 to 13 gm\/dL','13 to 14 gm\/dL'],\n exp:'Target Hb in CKD anaemia (KDIGO guidelines) is 10\u201312 gm\/dL. Targeting higher levels with ESAs has been shown to increase cardiovascular events without added benefit.'\n },\n {\n id:32,\n stem:'Which one of the following complications of chronic kidney disease is observed in patients with low parathyroid hormone levels?',\n correct:'Adynamic bone disease',\n options:['Adynamic bone disease','Tumoral calcinosis','Osteitis fibrosa cystica','Calciphylaxis'],\n exp:'Adynamic bone disease results from over-suppression of PTH (often iatrogenic with excess calcium\/vitamin D supplementation) leading to low bone turnover. Osteitis fibrosa cystica is the opposite \u2014 seen with HIGH PTH.'\n },\n {\n id:33,\n stem:'All of the following statements about adult polycystic kidney disease are true EXCEPT:',\n correct:'It is usually associated with marked proteinuria',\n options:['It is inherited as autosomal dominant trait','It is usually associated with marked proteinuria','It is usually associated with systemic hypertension from young age','It is associated with Berry aneurysm'],\n exp:'ADPKD causes minimal or absent proteinuria \u2014 heavy proteinuria is NOT a feature. It is autosomal dominant, commonly causes early-onset hypertension, and is associated with intracranial berry aneurysms (~8%).'\n },\n {\n id:34,\n stem:'Consider the following statements in relation to an adult patient:\\n1. Oliguria is defined as passage of urine less than 300 ml per day\\n2. Anuria is said to exist when less than 50 ml urine is passed per day\\n3. Polyuria is defined as urine volume in excess of 3 litre per day\\nWhich of the statements given above are correct?',\n correct:'2 and 3 only',\n options:['1 and 3 only','2 and 3 only','1 and 2 only','1, 2 and 3'],\n exp:'Oliguria is defined as urine output <400 ml\/day (not 300 ml) \u2014 statement 1 is false. Anuria is <50 ml\/day and polyuria is >3 L\/day \u2014 statements 2 and 3 are correct.'\n },\n {\n id:35,\n stem:'White cell casts in urine examination are strongly suggestive of:',\n correct:'Pyelonephritis',\n options:['Nephritis','Pyelonephritis','Renal stone disease','Papillitis'],\n exp:'WBC casts form when leucocytes aggregate within renal tubules \u2014 pathognomonic of renal parenchymal infection, i.e., pyelonephritis. RBC casts indicate glomerulonephritis; granular casts suggest tubular injury.'\n },\n {\n id:36,\n stem:'A 13-year-old boy presents with haematuria, oliguria, oedema and hypertension two weeks after sore throat. Labs show low C3 and elevated ASO and anti-DNase titres. Which one of the following statements is NOT correct about management?',\n correct:'Immunosuppressants are to be used for crescentic glomerulonephritis',\n options:['Renal biopsy is rarely required for making diagnosis','Antibiotic treatment is given for streptococcal infection','Treatment is largely supportive','Immunosuppressants are to be used for crescentic glomerulonephritis'],\n exp:'Post-streptococcal GN is self-limiting and treatment is supportive. Even in the rare crescentic variant, immunosuppressants are NOT routinely indicated \u2014 evidence for their use is weak and the condition generally resolves. This is in contrast to crescentic GN from ANCA vasculitis or anti-GBM disease.'\n },\n {\n id:37,\n stem:'Which one of the following statements is NOT correct regarding the risk factors for nephrolithiasis?',\n correct:'Higher dietary calcium increases risk',\n options:['Higher dietary calcium increases risk','Higher animal protein intake increases risk','Higher dietary potassium intake lowers risk','Lower urine citrate increases the risk'],\n exp:'Contrary to intuition, higher dietary calcium is actually protective \u2014 it binds oxalate in the gut, reducing oxalate absorption and urinary oxalate excretion. It is supplemental (non-dietary) calcium that may increase risk. Statements about animal protein, potassium, and citrate are all correct.'\n },\n {\n id:38,\n stem:'A 60-year-old patient is admitted with seizure, aphasia and altered sensorium. He has history of fever and headache for the preceding 3 days. The CSF examination is unremarkable. What would be the probable diagnosis?',\n correct:'Viral encephalitis',\n options:['Multiple sclerosis','Tubercular meningitis','Pyogenic (bacterial) meningitis','Viral encephalitis'],\n exp:'Fever + focal neurological signs (aphasia, seizures) + normal CSF = viral encephalitis (typically HSV). TB and bacterial meningitis would show CSF abnormalities. MS does not cause fever or acute encephalitic illness.'\n },\n {\n id:39,\n stem:'Drug of choice for the treatment of Trigeminal Neuralgia is:',\n correct:'Carbamazepine',\n options:['Carbamazepine','Aceclofenac','Thiamine','Prednisolone'],\n exp:'Carbamazepine (a sodium channel blocker) is the first-line drug for trigeminal neuralgia \u2014 effective in ~70% of cases. It suppresses ectopic neuronal firing in the trigeminal pathways. NSAIDs, steroids, and vitamins have no established role.'\n },\n {\n id:40,\n stem:'Constructional skills is a function of which lobe?',\n correct:'Non-dominant parietal lobe',\n options:['Dominant temporal lobe','Non-dominant parietal lobe','Frontal lobe','Non-dominant temporal lobe'],\n exp:'Constructional ability (copying figures, building block designs) is a function of the non-dominant (usually right) parietal lobe. Damage here causes constructional apraxia and visuospatial deficits.'\n },\n {\n id:41,\n stem:'Vertical gaze palsy with convergence retraction nystagmus is seen in:',\n correct:'Parinaud syndrome',\n options:['Weber syndrome','Millard Gubler syndrome','Claude syndrome','Parinaud syndrome'],\n exp:\"Parinaud syndrome (dorsal midbrain syndrome) results from compression of the superior colliculus and pretectal area (e.g., pineal tumour) \u2014 causes upgaze palsy, convergence-retraction nystagmus, and light-near dissociation (Argyll Robertson-like). Known as the 'setting sun sign' in children.\"\n },\n {\n id:42,\n stem:'A patient on looking forward was found to have his right eye deviated downwards and outwards with pupil dilated. He is suffering from:',\n correct:'Right 3rd nerve palsy',\n options:['Left 3rd nerve palsy','Left 6th nerve palsy','Right 4th nerve palsy','Right 3rd nerve palsy'],\n exp:'The oculomotor (3rd) nerve controls all extraocular muscles except SO and LR. Its palsy causes the eye to deviate down and out (unopposed SO and LR) with ptosis and a dilated fixed pupil (loss of parasympathetic fibres that travel on the outer surface of CN III).'\n },\n {\n id:43,\n stem:'All of the following are features of Cauda Equina syndrome EXCEPT:',\n correct:'Extensor plantar response',\n options:['Low back pain','Lower limb areflexia','Loss of bladder function','Extensor plantar response'],\n exp:'Cauda equina syndrome is a lower motor neuron lesion \u2014 plantar responses are absent or flexor, NOT extensor. Extensor plantar (Babinski) response indicates an upper motor neuron lesion (spinal cord or above). Areflexia, bladder dysfunction, and back pain are all LMN features.'\n },\n {\n id:44,\n stem:'A 68-year-old male presents with progressive small handwriting (micrographia). On examination, he had resting tremor, bradykinesia, rigidity and postural instability. This patient is most likely suffering from:',\n correct:\"Parkinson's disease\",\n options:[\"Parkinson's disease\",'Vascular dementia',\"Alzheimer's disease\",'Frontotemporal dementia'],\n exp:\"Parkinson's disease presents with the classic tetrad: resting tremor, bradykinesia, cogwheel rigidity, and postural instability. Micrographia (progressively smaller handwriting) is a hallmark motor sign. Cognitive dementias do not cause this motor syndrome.\"\n },\n {\n id:45,\n stem:'An elderly patient presents with a wide base freezing gait with imbalance, comprising short strides, shuffling along the floor and difficulty with starts and turns. Heel-shin test is normal. Which one of the following is the most likely disorder?',\n correct:'Frontal gait disorder',\n options:['Cerebellar ataxia','Sensory ataxia','Frontal gait disorder',\"Parkinson's disease\"],\n exp:\"Frontal gait disorder (marche \u00e0 petits pas \/ magnetic gait) features short shuffling steps, start and turn difficulty, wide base, and apraxia \u2014 but limb coordination (heel-shin test) is normal. This distinguishes it from cerebellar ataxia. In Parkinson's, the base is typically narrow.\"\n },\n {\n id:46,\n stem:'Cushing reflex, seen in conditions of raised intracranial pressure, includes all of the following EXCEPT:',\n correct:'Hypothermia',\n options:['Bradycardia','Hypertension','Irregular respiration','Hypothermia'],\n exp:\"Cushing's reflex (response to raised ICP) consists of hypertension, bradycardia, and irregular respiration \u2014 forming the Cushing triad. Hypothermia is not part of this reflex. Temperature dysregulation in raised ICP, if present, tends toward hyperthermia.\"\n },\n {\n id:47,\n stem:'A 35-year-old man presents with low grade fever and headache for five weeks with meningismus. After lumbar puncture, he reports worsening headache a day later. Which one of the following features is NOT consistent with \"Post-LP\" headache?',\n correct:'Post-LP headache is most severe upon waking up',\n options:['Post-LP headache usually begins within 48 hours','Post-LP headache worsens in sitting position','Post-LP headache is most severe upon waking up','Post-LP headache may improve with caffeine intake'],\n exp:'Post-LP headache is a postural (orthostatic) headache \u2014 it worsens on sitting or standing and relieves on lying down. It is therefore LEAST severe upon waking (when supine) and worst later in the day. Option (c) is inconsistent with this mechanism.'\n },\n {\n id:48,\n stem:'Which one of the following investigations is NOT appropriate in a case of recurrent thrombosis?',\n correct:'Bcr-Abl assay',\n options:['Antiphospholipid antibodies','Bcr-Abl assay','Protein C and S assays','Antithrombin level'],\n exp:'Recurrent thrombosis warrants a thrombophilia screen: antiphospholipid antibodies, protein C, protein S, antithrombin, factor V Leiden, prothrombin gene mutation. Bcr-Abl assay diagnoses CML \u2014 it has no role in thrombophilia workup.'\n },\n {\n id:49,\n stem:'All of the following are causes of reactive thrombocytosis EXCEPT:',\n correct:'Megaloblastic anaemia',\n options:['Haemolytic anaemia','Megaloblastic anaemia','Post splenectomy','Chronic inflammatory disorders'],\n exp:'Megaloblastic anaemia causes pancytopenia including thrombocytopenia \u2014 not thrombocytosis. Haemolytic anaemia, post-splenectomy state, and chronic inflammatory disorders are all recognised causes of reactive (secondary) thrombocytosis.'\n },\n {\n id:50,\n stem:'Cryoprecipitate cannot be used for treatment of which one of the following conditions?',\n correct:'Haemophilia B',\n options:['Von Willebrand disease','Hypofibrinogenaemia','Haemophilia B','Haemophilia A'],\n exp:'Cryoprecipitate contains Factor VIII, vWF, fibrinogen, Factor XIII, and fibronectin. It is therefore useful in Haemophilia A (Factor VIII deficiency), vWD, and hypofibrinogenaemia. Haemophilia B is a Factor IX deficiency \u2014 Factor IX is NOT present in cryoprecipitate; it requires Factor IX concentrate or FFP.'\n },\n {\n id:51,\n stem:'Pyruvate kinase deficiency results in deficiency of ATP production and chronic haemolytic anaemia. The disorder is inherited as an:',\n correct:'Autosomal recessive trait',\n options:['Autosomal recessive trait','X-linked recessive trait','Autosomal dominant trait','X-linked dominant trait'],\n exp:'Pyruvate kinase deficiency is inherited as an autosomal recessive condition. It is the most common red cell enzyme defect causing non-spherocytic haemolytic anaemia, affecting both sexes equally.'\n },\n {\n id:52,\n stem:'Sickle cell disease may be associated with any of the following EXCEPT:',\n correct:\"Conn's syndrome\",\n options:['Acute chest syndrome','Aplastic crisis','Splenic sequestration crisis',\"Conn's syndrome\"],\n exp:\"Sickle cell disease is associated with acute chest syndrome (vaso-occlusion in pulmonary vasculature), aplastic crisis (parvovirus B19), and splenic sequestration crisis. Conn's syndrome (primary hyperaldosteronism) is an entirely unrelated adrenal condition.\"\n },\n {\n id:53,\n stem:'Fever with splenomegaly and lymphadenopathy can be seen in:',\n correct:'Both infectious mononucleosis and chronic leukaemia',\n options:['Infectious mononucleosis','Chronic leukaemia','Both infectious mononucleosis and chronic leukaemia','Neither infectious mononucleosis nor chronic leukaemia'],\n exp:'Both conditions present with fever, splenomegaly and lymphadenopathy. EBV-driven infectious mononucleosis causes generalised lymphadenopathy and splenomegaly. CLL and CML both commonly cause massive splenomegaly with lymph node enlargement.'\n },\n {\n id:54,\n stem:'Every individual carries four alpha gene alleles. Deletion of three alleles leads to development of:',\n correct:'Haemoglobin H disease',\n options:['Haemoglobin X disease','Haemoglobin H disease','Haemoglobin F disease','Hydrops fetalis'],\n exp:'Alpha thalassaemia genotype-phenotype: 1 deletion = silent carrier; 2 deletions = alpha thal trait; 3 deletions = HbH disease (\u03b24 tetramers form); 4 deletions = Hydrops fetalis (Hb Bart = \u03b34 tetramers, incompatible with life).'\n },\n {\n id:55,\n stem:'Which one of the following is NOT true regarding Chronic Myeloid Leukaemia (CML)?',\n correct:'Risk of developing CML is increased in monozygotic twins',\n options:['It is a clonal malignancy of haematopoietic stem cells','Risk of developing CML is increased in monozygotic twins','CML is defined by presence of BCR-ABL1 fusion gene','10-year survival with TKI therapy is 85%'],\n exp:'CML is not clearly increased in monozygotic twins \u2014 unlike childhood ALL where concordance in identical twins is established. CML is a sporadic clonal disorder defined by the BCR-ABL1 fusion (Philadelphia chromosome, t(9;22)). TKI therapy has transformed prognosis with ~85% 10-year survival.'\n },\n {\n id:56,\n stem:'Diagnostic criteria of multiple myeloma includes which of the following?\\n1. Increased malignant plasma cells in the bone marrow\\n2. Serum and\/or urinary M protein\\n3. Skeletal lytic lesions\\n4. Skeletal blastic lesions',\n correct:'1, 2 and 3',\n options:['1, 2 and 3','1, 3 and 4','1, 2 and 4','2, 3 and 4'],\n exp:'Multiple myeloma causes osteolytic (not blastic) bone lesions \u2014 statement 4 is incorrect. The diagnostic triad is: malignant plasma cell proliferation in marrow, monoclonal (M) protein in serum\/urine, and end-organ damage (CRAB: hypercalcaemia, Renal failure, Anaemia, Bone lesions).'\n },\n {\n id:57,\n stem:'The most predominant type of serum immunoglobulin involved in patients with plasma cell disorder is:',\n correct:'IgG',\n options:['IgG','IgA','IgD','Light chains only'],\n exp:'IgG myeloma is the most common (~55\u201360% of cases), followed by IgA (~20%). IgD, IgE, and light-chain-only myeloma account for small proportions. IgM excess is characteristic of Waldenstr\u00f6m macroglobulinaemia rather than myeloma.'\n },\n {\n id:58,\n stem:'Which one of the following statements is NOT true regarding thyroid function\/disorder in pregnancy?',\n correct:'Levothyroxine replacement therapy dose should be decreased by 30\u201350% early in pregnancy',\n options:['There is an increase in the metabolism of thyroxine by placenta','Hyperemesis gravidarum may be associated with thyrotoxicosis in pregnancy','Levothyroxine replacement therapy dose should be decreased by 30\u201350% early in pregnancy','Impaired cognitive development may be seen in offspring of mothers with subclinical hypothyroidism'],\n exp:'Levothyroxine dose requirements INCREASE by 30\u201350% in pregnancy (due to increased TBG, placental T4 metabolism, and fetal demands) \u2014 not decrease. The statement saying dose should be decreased is therefore false. The other statements are all correct.'\n },\n {\n id:59,\n stem:'Which one of the following is NOT the criterion for the diagnosis of Diabetes mellitus?',\n correct:'Fasting plasma glucose \u2265 110 mg\/dL',\n options:['Symptoms of diabetes and random plasma glucose \u2265 200 mg\/dL','HbA1c \u2265 6.5%','2-hour plasma glucose \u2265 200 mg\/dL during OGTT','Fasting plasma glucose \u2265 110 mg\/dL'],\n exp:'The ADA criterion for DM diagnosis using fasting plasma glucose is \u2265126 mg\/dL. A fasting glucose of \u2265110 mg\/dL (or 100 mg\/dL by ADA) indicates impaired fasting glucose (pre-diabetes) \u2014 NOT diabetes. The other three are recognised diagnostic criteria.'\n },\n {\n id:60,\n stem:'A young lady presents with complaints of menstrual irregularity, weight gain, hair loss, tiredness and weakness. What will be the investigation of choice?',\n correct:'Free T4 and TSH',\n options:['FSH & LH level','Estrogen level','Free T3 and free T4 level','Free T4 and TSH'],\n exp:'This clinical picture \u2014 menstrual irregularity, weight gain, hair loss, fatigue \u2014 is classic for hypothyroidism. The investigation of choice is serum TSH (most sensitive) combined with free T4. TSH alone is adequate for screening but TSH + fT4 gives both diagnosis and severity assessment.'\n }\n ];\n\n \/* \u2500\u2500 Fisher-Yates shuffle \u2500\u2500 *\/\n function shuffle(arr){\n const a=[...arr];\n for(let i=a.length-1;i>0;i--){\n const j=Math.floor(Math.random()*(i+1));\n [a[i],a[j]]=[a[j],a[i]];\n }\n return a;\n }\n\n function esc(s){\n return s.replace(\/&\/g,'&').replace(\/<\/g,'<').replace(\/>\/g,'>').replace(\/\"\/g,'"');\n }\n\n const LETTERS=['A','B','C','D'];\n let userAnswers={};\n let answered=0;\n let shuffledOpts={};\n\n function build(){\n const container=document.getElementById(NS+'-questions');\n container.innerHTML='';\n userAnswers={};\n answered=0;\n shuffledOpts={};\n document.getElementById(NS+'-score').style.display='none';\n updateStats();\n\n QUESTIONS.forEach(function(q){\n const opts=shuffle(q.options);\n shuffledOpts[q.id]=opts;\n\n const card=document.createElement('div');\n card.className='cq-card';\n\n card.innerHTML=\n '<div class=\"cq-qhead\">'+\n '<div class=\"cq-qnum\" id=\"'+NS+'-n'+q.id+'\">'+q.id+'<\/div>'+\n '<div class=\"cq-qtext\">'+q.stem.replace(\/\\n\/g,'<br>')+'<\/div>'+\n '<\/div>'+\n '<div class=\"cq-options\" id=\"'+NS+'-opts'+q.id+'\">'+\n opts.map(function(o,i){\n return '<div class=\"cq-opt\" id=\"'+NS+'-o'+q.id+'-'+i+'\" data-qid=\"'+q.id+'\" data-val=\"'+esc(o)+'\" role=\"button\" tabindex=\"0\">'+\n '<span class=\"cq-opt-letter\">'+LETTERS[i]+'<\/span>'+\n '<span class=\"cq-opt-text\">'+o+'<\/span>'+\n '<\/div>';\n }).join('')+\n '<\/div>'+\n '<div class=\"cq-explanation\" id=\"'+NS+'-exp'+q.id+'\">'+\n '<div class=\"cq-exp-label\">Explanation<\/div>'+\n q.exp+\n '<\/div>';\n\n container.appendChild(card);\n\n opts.forEach(function(_,i){\n document.getElementById(NS+'-o'+q.id+'-'+i)\n .addEventListener('click',function(){ pick(q.id,i); });\n });\n });\n }\n\n function pick(qid,oi){\n if(userAnswers[qid]!==undefined)return;\n const q=QUESTIONS.find(function(x){return x.id===qid;});\n const opts=shuffledOpts[qid];\n const chosen=opts[oi];\n const correct=chosen===q.correct;\n userAnswers[qid]=correct?'correct':'wrong';\n answered++;\n\n opts.forEach(function(o,i){\n const el=document.getElementById(NS+'-o'+qid+'-'+i);\n if(o===q.correct) { el.classList.add('cq-correct','cq-locked'); }\n else if(i===oi) { el.classList.add('cq-wrong','cq-locked'); }\n else { el.classList.add('cq-dimmed','cq-locked'); }\n });\n\n const num=document.getElementById(NS+'-n'+qid);\n num.classList.add(correct?'ans-c':'ans-w');\n\n document.getElementById(NS+'-exp'+qid).style.display='block';\n updateStats();\n }\n\n function updateStats(){\n const c=Object.values(userAnswers).filter(function(v){return v==='correct';}).length;\n const w=Object.values(userAnswers).filter(function(v){return v==='wrong';}).length;\n const r=TOTAL-answered;\n const net=(c*4)-w;\n\n document.getElementById(NS+'-sc').textContent=c;\n document.getElementById(NS+'-sw').textContent=w;\n 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the weaker areas.';\n else if(pct>=40) v='Fair \u2014 systematic revision of these topics is recommended.';\n else v='Needs significant revision across these topics.';\n document.getElementById(NS+'-verdict').textContent=v;\n\n document.getElementById(NS+'-ct-c').textContent='\u2713 '+c+' Correct';\n document.getElementById(NS+'-ct-w').textContent='\u2717 '+w+' Wrong';\n document.getElementById(NS+'-ct-s').textContent='\u2014 '+s+' Skipped';\n\n const sc=document.getElementById(NS+'-score');\n sc.style.display='block';\n sc.scrollIntoView({behavior:'smooth',block:'center'});\n }\n\n document.getElementById(NS+'-submit').addEventListener('click',showScore);\n document.getElementById(NS+'-retry').addEventListener('click',function(){\n build();\n window.scrollTo({top:0,behavior:'smooth'});\n });\n\n \/* IntersectionObserver \u2014 status bar slides in when sentinel leaves viewport *\/\n new IntersectionObserver(\n function(entries){\n document.getElementById(NS+'-statusbar')\n 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Quiz<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"neve_meta_sidebar":"","neve_meta_container":"","neve_meta_enable_content_width":"","neve_meta_content_width":0,"neve_meta_title_alignment":"","neve_meta_author_avatar":"","neve_post_elements_order":"","neve_meta_disable_header":"","neve_meta_disable_footer":"","neve_meta_disable_title":"","footnotes":""},"categories":[18],"tags":[],"class_list":["post-36513","post","type-post","status-publish","format-standard","hentry","category-cms"],"yoast_head":"\n<title>CMS 2020 P1 Part-2 - atsixty<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/atsixty.com\/index.php\/2026\/04\/07\/cms-2020-p1-part-2\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta 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