CMS 2021 Paper I \u2013 Part 1 (Q1\u2013Q30)<\/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: cms21p1a \u2500\u2500 *\/\n#cms21p1a *,#cms21p1a *::before,#cms21p1a *::after{box-sizing:border-box;margin:0;padding:0}\n#cms21p1a{\n --ter:#C0603A;--ter-light:#e8825f;--ter-pale:#fdf1ec;\n --teal:#2A7A6F;--teal-light:#3da394;--teal-pale:#eaf4f3;\n --ink:#1a1a1a;--ink-mid:#444;--ink-soft:#777;\n --line:#e0d8d4;--bg:#fdfaf8;--white:#ffffff;\n --correct:#1e6f46;--correct-bg:#eaf7ef;--correct-border:#43a047;\n --wrong:#b83232;--wrong-bg:#fdf0f0;--wrong-border:#e53935;\n --radius:10px;\n font-family:'Source Serif 4',Georgia,serif;\n font-size:16px;color:var(--ink);background:var(--bg);\n line-height:1.7;padding:0 0 48px;\n}\n#cms21p1a .cq-sentinel{height:1px}\n#cms21p1a .cq-statusbar{\n 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id=\"cms21p1a\">\n\n <div class=\"cq-sentinel\" id=\"cms21p1a-sentinel\"><\/div>\n\n <div class=\"cq-statusbar\" id=\"cms21p1a-statusbar\">\n <div class=\"cq-sb-stats\">\n <div class=\"cq-timer-item\" id=\"cms21p1a-timer-item\">\u23f1 <strong id=\"cms21p1a-timer-display\">30:00<\/strong><\/div>\n <div class=\"cq-sb-item\">\u2705 <strong id=\"cms21p1a-sc\">0<\/strong><\/div>\n <div class=\"cq-sb-item\">\u274c <strong id=\"cms21p1a-sw\">0<\/strong><\/div>\n <div class=\"cq-sb-item\">\u23f3 <strong id=\"cms21p1a-sr\">30<\/strong> left<\/div>\n <div class=\"cq-sb-sep\"><\/div>\n <div class=\"cq-sb-item\">Net <strong id=\"cms21p1a-sn\">0<\/strong> \/ <strong id=\"cms21p1a-sm\">120<\/strong><\/div>\n <\/div>\n <div class=\"cq-sb-progress\"><div class=\"cq-sb-fill\" id=\"cms21p1a-fill\"><\/div><\/div>\n <\/div>\n\n <div class=\"cq-grace\" id=\"cms21p1a-grace\">\n <div class=\"cq-grace-box\">\n <h3>Time's Up!<\/h3>\n <p>Submitting in<\/p>\n <div class=\"cq-grace-count\" id=\"cms21p1a-grace-count\">10<\/div>\n <button class=\"cq-grace-btn\" id=\"cms21p1a-grace-now\">Submit Now<\/button>\n <\/div>\n <\/div>\n\n <div class=\"cq-header\">\n <h1>Combined Medical Services Examination 2021<br>Paper I \u00b7 Part 1<\/h1>\n <p>Cardiology \u00b7 Respiratory \u00b7 Gastroenterology<\/p>\n <div class=\"cq-meta\">\n <span class=\"cq-badge\">Questions 1 \u2013 30<\/span>\n <span class=\"cq-badge\">Options reshuffled<\/span>\n <button class=\"cq-timer-btn\" id=\"cms21p1a-timer-btn\">\u23f1 Start Timed Mode<\/button>\n <\/div>\n <\/div>\n\n <div class=\"cq-body\">\n <div id=\"cms21p1a-questions\"><\/div>\n <div class=\"cq-submit-wrap\">\n <button class=\"cq-btn\" id=\"cms21p1a-submit\">Submit Answers<\/button>\n <\/div>\n <div class=\"cq-score\" id=\"cms21p1a-score\">\n <div class=\"cq-score-ring\" id=\"cms21p1a-ring\">\n <div class=\"cq-ring-inner\">\n <span class=\"cq-ring-pct\" id=\"cms21p1a-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=\"cms21p1a-net-line\"><\/div>\n <div class=\"cq-verdict\" id=\"cms21p1a-verdict\"><\/div>\n <div class=\"cq-score-bands\">\n <span class=\"cq-band cq-band-c\" id=\"cms21p1a-ct-c\"><\/span>\n <span class=\"cq-band cq-band-w\" id=\"cms21p1a-ct-w\"><\/span>\n <span class=\"cq-band cq-band-s\" id=\"cms21p1a-ct-s\"><\/span>\n <\/div>\n <button class=\"cq-retry-btn\" id=\"cms21p1a-retry\">\u21ba Retry Quiz<\/button>\n <\/div>\n <\/div>\n\n<\/div>\n<script>\n(function(){\n 'use strict';\n const NS='cms21p1a', TOTAL=30, MAX=TOTAL*4;\n const TIMER_SECS=30*60;\n const GRACE_SECS=10;\n\n const QUESTIONS=[\n {\n id:1,\n stem:'A 60-year-old man comes to emergency with acute onset chest pain. The ECG shows ST depression and T wave inversion. Cardiac biomarkers in blood are not elevated. What will be the appropriate management?',\n correct:'Antiplatelets + LMW Heparin subcutaneous',\n options:['Oxygen + Aspirin + Ticagrelor + Metoprolol','Oxygen + Sublingual nitroglycerin + Antiplatelets + Streptokinase','Antiplatelets + LMW Heparin subcutaneous','Oxygen + Sublingual nitroglycerin + Digoxin'],\n exp:'ST depression + T wave inversion + negative biomarkers = NSTE-ACS (NSTEMI or unstable angina). Management is antiplatelet therapy + anticoagulation (LMWH). Thrombolysis (streptokinase) is contraindicated in NSTEMI. Digoxin has no role in ACS management.'\n },\n {\n id:2,\n stem:'A victim is found unconscious at the roadside. As a trained rescuer, after checking response and pulse, you decide on resuscitation. What is the recommended ratio of chest compression to ventilation during CPR?',\n correct:'30 : 2',\n options:['90 : 4','60 : 2','30 : 2','60 : 1'],\n exp:'Current AHA\/ERC guideline ratio for adult CPR (single or two rescuers) is 30 compressions to 2 rescue breaths. Compressions are delivered at 100\u2013120\/min to a depth of 5\u20136 cm. Minimising interruptions is the key principle.'\n },\n {\n id:3,\n stem:'Which one of the following is NOT a differential diagnosis of ST segment elevation in ECG?',\n correct:'Hypocalcaemia',\n options:['Acute pericarditis','Trauma to ventricles','Hypothermia','Hypocalcaemia'],\n exp:'ST elevation causes include: STEMI, acute pericarditis (saddle-shaped), hypothermia (Osborn\/J waves), ventricular trauma, Brugada syndrome, LV aneurysm, and early repolarisation. Hypocalcaemia causes QT prolongation, not ST elevation. Hypocalcaemia is therefore the EXCEPT answer.'\n },\n {\n id:4,\n stem:'Which one of the following is a non-shockable rhythm in respect to use of AED (Automatic External Defibrillator)?',\n correct:'Pulseless electrical activity',\n options:['Monomorphic ventricular tachycardia','Polymorphic ventricular tachycardia','Ventricular fibrillation','Pulseless electrical activity'],\n exp:'AED\/defibrillation is indicated for shockable rhythms: VF and pulseless VT (both mono and polymorphic). Pulseless Electrical Activity (PEA) shows organised electrical activity without a perfusing pulse and is non-shockable. Treatment is CPR plus reversing the 4Hs and 4Ts. Asystole is also non-shockable.'\n },\n {\n id:5,\n stem:'A 50-year-old man reports to Emergency with breathlessness, palpitations and acute chest pain. On auscultation there is a systolic murmur at apex and ECG shows ST elevations in anterior chest leads. Which one of the following would be the next choice of investigation?',\n correct:'Cardiac marker troponin T\/I',\n options:['Cardiac marker troponin T\/I','Echocardiography','TMT','24-hour Holter monitoring'],\n exp:'ST elevation in anterior leads (V1\u2013V4) indicates likely anterior STEMI. The immediate next investigation is cardiac biomarkers (troponin T\/I) to confirm myocardial necrosis. TMT is contraindicated in acute MI. Biomarkers are the critical confirmatory step before initiating reperfusion therapy.'\n },\n {\n id:6,\n stem:'Which of the following electro-cardiographic findings are manifestations of digitalis intoxication?\\n1. Ventricular bigeminy\\n2. Ventricular tachycardia\\n3. Atrial flutter\\n4. Atrial tachycardia with variable block',\n correct:'1, 2 and 4',\n options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],\n exp:'Digitalis toxicity causes: ventricular bigeminy (very characteristic), ventricular tachycardia, atrial tachycardia with AV block (pathognomonic), and junctional tachycardia. Atrial flutter is NOT a recognised feature of digoxin toxicity. Statements 1, 2, and 4 are correct.'\n },\n {\n id:7,\n stem:'According to modified WHO classification of Heart Disease in Pregnancy, which cardiac lesion is a contraindication for pregnancy?',\n correct:'Pulmonary arterial hypertension',\n options:['Hypertrophic cardiomyopathy','Uncomplicated, small or mild pulmonary stenosis','Successfully repaired Tetralogy of Fallot','Pulmonary arterial hypertension'],\n exp:'WHO Class IV cardiac lesions are absolute contraindications to pregnancy (mortality risk above 25%). These include pulmonary arterial hypertension, severe systemic ventricular dysfunction (EF below 30%), and severe mitral stenosis. PAH carries the highest maternal mortality in pregnancy, approaching 30\u201350%.'\n },\n {\n id:8,\n stem:'A 35-year-old patient presents in Emergency with sudden onset palpitations. His heart rate is 150\/minute and reverts after carotid massage. The most probable diagnosis is:',\n correct:'Paroxysmal supraventricular tachycardia',\n options:['Paroxysmal supraventricular tachycardia','Ventricular tachycardia','Ventricular fibrillation','Atrial flutter with block'],\n exp:'Reversion to sinus rhythm with carotid sinus massage (vagal manoeuvre) is diagnostic of PSVT (AV nodal re-entrant tachycardia or AVRT). VT and VF do not respond to vagal manoeuvres. Atrial flutter may slow with increased AV block but does not typically terminate with carotid massage.'\n },\n {\n id:9,\n stem:'Which one of the following statements is correct regarding Opening Snap in cardiac auscultation?',\n correct:'It is a high-pitched diastolic sound.',\n options:['It is a high-pitched diastolic sound.','It is due to opening of stenosed aortic valve.','It indicates pulmonary arterial hypertension.','It precedes the aortic component of second heart sound.'],\n exp:'Opening Snap (OS) is a high-pitched, snapping diastolic sound caused by sudden tensing of the stiffened mitral valve leaflets at maximum excursion in mitral stenosis. It follows S2 (does not precede it). A shorter S2\u2013OS interval indicates more severe stenosis. It is NOT due to the aortic valve.'\n },\n {\n id:10,\n stem:'A 35-year-old labourer with recurrent chest pain (family history of similar complaint, brother died at 40) was prescribed sublingual nitroglycerin. After taking it, the chest pain INCREASED in intensity. Which one of the following is most likely?',\n correct:'Hypertrophic obstructive cardiomyopathy',\n options:['Hypertrophic obstructive cardiomyopathy','Chronic type A dissection of aorta','Degenerative mitral regurgitation','Sub-acute bacterial endocarditis involving aortic valve'],\n exp:'Nitroglycerin reduces preload (venous pooling) which reduces LV filling. In HOCM, reduced filling worsens dynamic outflow obstruction, increasing chest pain. This paradoxical worsening with nitrates combined with positive family history of sudden cardiac death in young age is classic for HOCM. Confirmed by echo showing asymmetric septal hypertrophy and systolic anterior motion of mitral valve.'\n },\n {\n id:11,\n stem:'A patient with atrial fibrillation on regular treatment presents with photosensitivity, skin discoloration and peripheral neuropathy. Which drug may be implicated?',\n correct:'Amiodarone',\n options:['Digoxin','Disopyramide','Amiodarone','Bisoprolol'],\n exp:'Amiodarone causes multisystem adverse effects including: photosensitivity and slate-grey skin discoloration (lipofuscin deposits), peripheral neuropathy, hypo\/hyperthyroidism, pulmonary fibrosis, corneal microdeposits, and hepatotoxicity. It contains iodine (~37% by weight) and has an extremely long half-life of 40\u201355 days.'\n },\n {\n id:12,\n stem:'Which of the following are categorised under obstructive lung disease?\\n1. Bronchial asthma\\n2. Bronchiectasis\\n3. Bronchiolitis\\n4. Pulmonary sarcoidosis',\n correct:'1, 2 and 3',\n options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],\n exp:'Obstructive lung diseases include bronchial asthma, COPD (chronic bronchitis and emphysema), bronchiectasis, bronchiolitis, and cystic fibrosis. Pulmonary sarcoidosis causes RESTRICTIVE lung disease via bilateral hilar lymphadenopathy progressing to fibrosis with reduced lung volumes. Statement 4 is false.'\n },\n {\n id:13,\n stem:'Risk factors for development of COPD include which of the following?\\n1. Tobacco smoking\\n2. Recurrent infection\\n3. Coal dust exposure\\n4. High socio-economic status',\n correct:'1, 2 and 3',\n options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],\n exp:'COPD risk factors: tobacco smoking (single most important, ~80% of cases), occupational dust\/chemical exposure (coal, silica, cadmium), recurrent respiratory infections, air pollution, alpha-1 antitrypsin deficiency, and LOW socio-economic status. HIGH socio-economic status is PROTECTIVE. Statement 4 is false.'\n },\n {\n id:14,\n stem:'Which one of the following is NOT an aim of asthma therapy?',\n correct:'Minimal use of inhaled corticosteroid',\n options:['Peak expiratory flow circadian variation less than 20%','No emergency visits','Minimal use of inhaled corticosteroid','Minimal use of beta-2-agonists'],\n exp:'Goals of asthma therapy (GINA): minimal chronic symptoms, no exacerbations, no emergency visits, minimal SABA need, PEF circadian variation below 20%, and normal lung function. Inhaled corticosteroids (ICS) are the cornerstone of maintenance therapy and minimising ICS use is NOT a goal. Minimising SABA use IS a goal as frequent use signals poor control.'\n },\n {\n id:15,\n stem:'A 65-year-old male smoker is diagnosed with COPD. On pulmonary function testing, FEV1\/FVC is below 0.7 and FEV1 = 42% of predicted. The severity of airflow obstruction as per GOLD criteria is:',\n correct:'Severe',\n options:['Mild','Moderate','Severe','Very severe'],\n exp:'GOLD spirometric classification (post-bronchodilator FEV1\/FVC below 0.7): GOLD 1 Mild = FEV1 at or above 80%; GOLD 2 Moderate = FEV1 50\u201379%; GOLD 3 Severe = FEV1 30\u201349%; GOLD 4 Very severe = FEV1 below 30%. FEV1 at 42% falls in GOLD 3 (Severe) range.'\n },\n {\n id:16,\n stem:'A 40-year-old patient of bronchial asthma presents with acute severe breathlessness. Indications for giving assisted ventilation for acute severe asthma include which of the following?',\n correct:'PaO2 below 60 mm Hg, PaCO2 above 45 mm Hg',\n options:['PaO2 below 80 mm Hg, PaCO2 below 45 mm Hg','PaO2 above 60 mm Hg, PaCO2 above 45 mm Hg','PaO2 below 60 mm Hg, PaCO2 above 45 mm Hg','PaO2 below 80 mm Hg, PaCO2 above 45 mm Hg'],\n exp:'Indications for mechanical ventilation in severe asthma: PaO2 below 60 mmHg (hypoxaemia despite oxygen) AND PaCO2 above 45 mmHg (hypercapnia indicating respiratory muscle fatigue). In early asthma, hyperventilation causes low PaCO2. A rising PaCO2 to normal or above is an ominous sign of impending respiratory failure.'\n },\n {\n id:17,\n stem:'Which of the following are the non-metastatic extra-pulmonary manifestations of lung cancer?\\n1. Carcinoid syndrome\\n2. Nephrotic syndrome\\n3. Horner\\'s syndrome\\n4. Lambert-Eaton syndrome',\n correct:'2, 3 and 4',\n options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],\n exp:'Non-metastatic paraneoplastic and local manifestations of lung cancer include: Lambert-Eaton syndrome (SCLC), SIADH, Cushing syndrome, hypercalcaemia (squamous cell), Horner syndrome (Pancoast tumour), and nephrotic syndrome (membranous nephropathy). Carcinoid syndrome is a feature of carcinoid tumours, not a paraneoplastic feature of primary lung cancer. Statements 2, 3, and 4 are correct.'\n },\n {\n id:18,\n stem:'A 60-year-old obese person (110 kg) has excessive daytime sleepiness, morning headache, irritability, mood disturbances, dry mouth, nocturnal heartburn and diaphoresis of chest and neck. Which one of the following will be the best investigation to diagnose the patient?',\n correct:'Overnight Polysomnogram',\n options:['Ambulatory Blood Pressure Monitoring (ABPM)','24-hour Holter Monitoring','Echocardiography','Overnight Polysomnogram'],\n exp:'This picture of obese male with excessive daytime somnolence, morning headache (from nocturnal hypercapnia), nocturnal diaphoresis, dry mouth and heartburn is classic for Obstructive Sleep Apnoea. The gold standard investigation is overnight polysomnography (sleep study), which records the apnoea-hypopnoea index. AHI at or above 5\/hour confirms the diagnosis.'\n },\n {\n id:19,\n stem:'Which of the following drugs trigger bronchial asthma?\\n1. Sulfonamides\\n2. Aspirin\\n3. ACE inhibitors\\n4. Beta blockers',\n correct:'2, 3 and 4',\n options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],\n exp:'Drugs triggering asthma: Aspirin\/NSAIDs (inhibit COX, shifting arachidonic acid to leukotriene pathway causing bronchoconstriction), ACE inhibitors (bradykinin accumulation causes cough and bronchoconstriction), beta-blockers (block beta-2 receptors causing bronchoconstriction). Sulfonamides cause allergic reactions but are NOT established asthmagens. Statements 2, 3, and 4 are correct.'\n },\n {\n id:20,\n stem:'A patient with Crohn\\'s disease underwent ileal resection. Which of the following complications may develop?\\n1. Oxalate-rich renal calculi\\n2. Diarrhoea\\n3. Fat malabsorption\\n4. Hypernatraemia',\n correct:'1, 2 and 3',\n options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],\n exp:'Ileal resection consequences: (1) bile acid malabsorption causes fat malabsorption and steatorrhoea; (2) unabsorbed bile acids reaching colon cause secretory diarrhoea; (3) increased colonic oxalate absorption (normally bound by calcium in the ileum) causes hyperoxaluria and oxalate renal stones. Hypernatraemia is not a recognised complication. Statements 1, 2, and 3 are correct.'\n },\n {\n id:21,\n stem:'Protein-losing enteropathy due to obstruction of intestinal lymphatic vessels is seen in which of the following conditions?\\n1. Intestinal lymphangiectasia\\n2. Constrictive pericarditis\\n3. Eosinophilic gastroenteritis\\n4. Whipple\\'s disease',\n correct:'1, 2 and 4',\n options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],\n exp:'Protein-losing enteropathy due to lymphatic obstruction: intestinal lymphangiectasia (primary obstruction), constrictive pericarditis (raised venous pressure obstructs lymphatics), and Whipple\\'s disease (Tropheryma whipplei infects and blocks intestinal lymphatics with PAS-positive macrophages). Eosinophilic gastroenteritis causes PLE by mucosal damage, NOT lymphatic obstruction. Statements 1, 2, and 4 are correct.'\n },\n {\n id:22,\n stem:'Which one of the following viruses is associated with development of Acute Liver Failure and high mortality in pregnancy?',\n correct:'Hepatitis E virus',\n options:['Hepatitis A virus','Hepatitis E virus','Hepatitis C virus','Hepatitis B virus'],\n exp:'Hepatitis E virus (HEV) in pregnancy, particularly in the third trimester, carries a mortality rate of 15\u201325% due to fulminant hepatic failure. The mechanism may relate to hormone-mediated impairment of immune clearance. HEV is the leading cause of acute liver failure in pregnancy in India and other endemic regions.'\n },\n {\n id:23,\n stem:'Consider the following statements with regard to Anorexia of Aging:\\n1. Declining chemosensory function (smell and taste)\\n2. Reduced efficiency of chewing\\n3. Slowed gastric emptying\\n4. Alterations in the neuro-endocrine axis\\nWhich of the above statements are associated with early satiety and weight loss in the elderly?',\n correct:'1, 2, 3 and 4',\n options:['3 and 4 only','1, 2 and 4 only','1, 2, 3 and 4','1, 2 and 3 only'],\n exp:'All four mechanisms contribute to anorexia of ageing: reduced olfactory\/gustatory sensation decreases appetite, impaired dentition reduces food intake, delayed gastric emptying causes early satiety, and neuro-endocrine changes (increased CCK and leptin, decreased NPY and ghrelin) suppress appetite. All four statements are correct.'\n },\n {\n id:24,\n stem:'Consider the following statements:\\n1. Type-1 HRS is characterised by rapid deterioration in renal function within 1\u20132 weeks\\n2. Type-2 HRS is characterised by moderate and stable or slowly progressive renal dysfunction\\n3. HRS is seen in patients with large ascites in cirrhosis\\nWhich of the above statements is\/are correct?',\n correct:'1, 2 and 3',\n options:['1 only','3 only','1 and 2 only','1, 2 and 3'],\n exp:'All three statements about Hepato-Renal Syndrome are correct. HRS-1 (now HRS-AKI): rapid creatinine doubling to above 2.5 mg\/dL within 2 weeks with poor prognosis. HRS-2 (now HRS-CKD): steady moderate renal failure often with refractory ascites. HRS occurs in cirrhosis with ascites due to splanchnic vasodilation causing renal vasoconstriction.'\n },\n {\n id:25,\n stem:'Which one of the following is the serological marker of immunisation with Hepatitis B vaccine?',\n correct:'Anti-HBs',\n options:['HBsAg','Anti-HBs','HBcAg','Anti-HBc'],\n exp:'After Hepatitis B vaccination, only anti-HBs (antibody to HBsAg) is detectable. A titre at or above 10 mIU\/mL indicates protective immunity. Natural infection produces both anti-HBs AND anti-HBc. HBsAg indicates active infection. Anti-HBs alone therefore indicates vaccine-induced immunity.'\n },\n {\n id:26,\n stem:'Infection with which of the following organisms can cause a syndrome which is clinically indistinguishable from achalasia of the oesophagus?',\n correct:'Trypanosoma cruzi',\n options:['Trypanosoma cruzi','Schistosoma haematobium','Mycobacterium leprae','Plasmodium falciparum'],\n exp:'Trypanosoma cruzi (Chagas disease) destroys the myenteric plexus of Auerbach in the oesophagus, causing aperistalsis and failure of lower oesophageal sphincter relaxation. This produces a mega-oesophagus clinically identical to primary achalasia. Chagas disease also causes megacolon and cardiomyopathy, and is endemic in Central and South America.'\n },\n {\n id:27,\n stem:'Consider the following statements in respect of Helicobacter pylori:\\n1. It is a gram-positive, spiral-shaped bacterium\\n2. It uses an adhesion molecule (BabA) to bind to the Lewis b antigen on gastric epithelial cells\\n3. It produces urease enzyme that helps to raise the pH around the bacterium\\n4. It exclusively colonises only gastric-type epithelium',\n correct:'2, 3 and 4',\n options:['1, 2 and 3','1, 2 and 4','2, 3 and 4','1, 3 and 4'],\n exp:'H. pylori is gram-NEGATIVE, not gram-positive. Statement 1 is therefore false. Statements 2 (BabA adhesin binds Lewis b antigen), 3 (urease hydrolyses urea to ammonia, raising local pH for survival), and 4 (exclusively colonises gastric-type epithelium including gastric metaplasia in the duodenum) are all correct.'\n },\n {\n id:28,\n stem:'The quadruple therapy regime (OBMT regime) for Helicobacter pylori eradication comprises which of the following drugs?',\n correct:'Omeprazole, Bismuth subcitrate, Metronidazole, Tetracycline',\n options:['Omeprazole, Bismuth subcitrate, Metronidazole, Tetracycline','Ofloxacin, Bismuth subcitrate, Metronidazole, Tetracycline','Omeprazole, Beclomethasone, Metronidazole, Tacrolimus','Omeprazole, Beclomethasone, Mometasone, Tetracycline'],\n exp:'OBMT quadruple therapy: Omeprazole (PPI) + Bismuth subcitrate + Metronidazole + Tetracycline. This bismuth-based regimen is used in areas of high metronidazole resistance or as second-line after failed triple therapy. Bismuth directly kills H. pylori while tetracycline and metronidazole provide dual antibiotic coverage.'\n },\n {\n id:29,\n stem:'Cystic fibrosis disorder is:',\n correct:'Autosomal recessive',\n options:['Autosomal dominant','Autosomal recessive','X-linked dominant','X-linked recessive'],\n exp:'Cystic fibrosis is autosomal recessive, caused by mutations in the CFTR gene on chromosome 7q31. The most common mutation is F508del (deletion of phenylalanine at position 508). Carriers (heterozygotes) are unaffected. Both parents must be carriers for a child to be affected, with a 1 in 4 chance per pregnancy.'\n },\n {\n id:30,\n stem:'Which of the following diseases may be associated with Coeliac disease?\\n1. Type-2 Diabetes mellitus\\n2. IgA deficiency\\n3. Down syndrome\\n4. Turner\\'s syndrome',\n correct:'2, 3 and 4',\n options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],\n exp:'Coeliac disease associations: IgA deficiency (makes IgA anti-tTG falsely negative, requiring IgG tests), Down syndrome (5\u201312% prevalence), Turner syndrome (4\u20138%), Type 1 DM (autoimmune, not Type 2), thyroid disorders, and dermatitis herpetiformis. Type-2 DM is NOT a recognised association. 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Submitting in 10 Submit Now Combined Medical Services Examination 2021Paper I \u00b7 Part 1 Cardiology \u00b7 Respiratory \u00b7 Gastroenterology Questions 1 \u2013 30 Options reshuffled \u23f1 Start Timed Mode Submit Answers 0% score Your Result \u21ba Retry 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-36577","post","type-post","status-publish","format-standard","hentry","category-cms"],"yoast_head":"\n<title>CMS 2021 P1 Part-1 - 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\/15\/cms-2021-p1-part-1\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"CMS 2021 P1 Part-1 - atsixty\" \/>\n<meta property=\"og:description\" content=\"CMS 2021 Paper I \u2013 Part 1 (Q1\u2013Q30) \u23f1 30:00 \u2705 0 \u274c 0 \u23f3 30 left Net 0 \/ 120 Time's Up! 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var(--teal);color:var(--teal);border-radius:8px;padding:10px 28px;font-family:'Playfair Display',serif;font-size:0.95rem;font-weight:700;cursor:pointer;transition:background 0.2s,color 0.2s}\n#cms21p1a .cq-retry-btn:hover{background:var(--teal);color:var(--white)}\n@media(max-width:480px){\n #cms21p1a .cq-header h1{font-size:1.15rem}\n #cms21p1a .cq-qtext{font-size:0.88rem}\n #cms21p1a .cq-opt-text{font-size:0.84rem}\n}\n<\/style>\n<\/head>\n<body>\n<div id=\"cms21p1a\">\n\n <div class=\"cq-sentinel\" id=\"cms21p1a-sentinel\"><\/div>\n\n <div class=\"cq-statusbar\" id=\"cms21p1a-statusbar\">\n <div class=\"cq-sb-stats\">\n <div class=\"cq-timer-item\" id=\"cms21p1a-timer-item\">\u23f1 <strong id=\"cms21p1a-timer-display\">30:00<\/strong><\/div>\n <div class=\"cq-sb-item\">\u2705 <strong id=\"cms21p1a-sc\">0<\/strong><\/div>\n <div class=\"cq-sb-item\">\u274c <strong id=\"cms21p1a-sw\">0<\/strong><\/div>\n <div class=\"cq-sb-item\">\u23f3 <strong id=\"cms21p1a-sr\">30<\/strong> left<\/div>\n <div class=\"cq-sb-sep\"><\/div>\n <div class=\"cq-sb-item\">Net <strong id=\"cms21p1a-sn\">0<\/strong> \/ <strong id=\"cms21p1a-sm\">120<\/strong><\/div>\n <\/div>\n <div class=\"cq-sb-progress\"><div class=\"cq-sb-fill\" id=\"cms21p1a-fill\"><\/div><\/div>\n <\/div>\n\n <div class=\"cq-grace\" id=\"cms21p1a-grace\">\n <div class=\"cq-grace-box\">\n <h3>Time's Up!<\/h3>\n <p>Submitting in<\/p>\n <div class=\"cq-grace-count\" id=\"cms21p1a-grace-count\">10<\/div>\n <button class=\"cq-grace-btn\" id=\"cms21p1a-grace-now\">Submit Now<\/button>\n <\/div>\n <\/div>\n\n <div class=\"cq-header\">\n <h1>Combined Medical Services Examination 2021<br>Paper I \u00b7 Part 1<\/h1>\n <p>Cardiology \u00b7 Respiratory \u00b7 Gastroenterology<\/p>\n <div class=\"cq-meta\">\n <span class=\"cq-badge\">Questions 1 \u2013 30<\/span>\n <span class=\"cq-badge\">Options reshuffled<\/span>\n <button class=\"cq-timer-btn\" id=\"cms21p1a-timer-btn\">\u23f1 Start Timed Mode<\/button>\n <\/div>\n <\/div>\n\n <div class=\"cq-body\">\n <div id=\"cms21p1a-questions\"><\/div>\n <div class=\"cq-submit-wrap\">\n <button class=\"cq-btn\" id=\"cms21p1a-submit\">Submit Answers<\/button>\n <\/div>\n <div class=\"cq-score\" id=\"cms21p1a-score\">\n <div class=\"cq-score-ring\" id=\"cms21p1a-ring\">\n <div class=\"cq-ring-inner\">\n <span class=\"cq-ring-pct\" id=\"cms21p1a-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=\"cms21p1a-net-line\"><\/div>\n <div class=\"cq-verdict\" id=\"cms21p1a-verdict\"><\/div>\n <div class=\"cq-score-bands\">\n <span class=\"cq-band cq-band-c\" id=\"cms21p1a-ct-c\"><\/span>\n <span class=\"cq-band cq-band-w\" id=\"cms21p1a-ct-w\"><\/span>\n <span class=\"cq-band cq-band-s\" id=\"cms21p1a-ct-s\"><\/span>\n <\/div>\n <button class=\"cq-retry-btn\" id=\"cms21p1a-retry\">\u21ba Retry Quiz<\/button>\n <\/div>\n <\/div>\n\n<\/div>\n<script>\n(function(){\n 'use strict';\n const NS='cms21p1a', TOTAL=30, MAX=TOTAL*4;\n const TIMER_SECS=30*60;\n const GRACE_SECS=10;\n\n const QUESTIONS=[\n {\n id:1,\n stem:'A 60-year-old man comes to emergency with acute onset chest pain. The ECG shows ST depression and T wave inversion. Cardiac biomarkers in blood are not elevated. What will be the appropriate management?',\n correct:'Antiplatelets + LMW Heparin subcutaneous',\n options:['Oxygen + Aspirin + Ticagrelor + Metoprolol','Oxygen + Sublingual nitroglycerin + Antiplatelets + Streptokinase','Antiplatelets + LMW Heparin subcutaneous','Oxygen + Sublingual nitroglycerin + Digoxin'],\n exp:'ST depression + T wave inversion + negative biomarkers = NSTE-ACS (NSTEMI or unstable angina). Management is antiplatelet therapy + anticoagulation (LMWH). Thrombolysis (streptokinase) is contraindicated in NSTEMI. Digoxin has no role in ACS management.'\n },\n {\n id:2,\n stem:'A victim is found unconscious at the roadside. As a trained rescuer, after checking response and pulse, you decide on resuscitation. What is the recommended ratio of chest compression to ventilation during CPR?',\n correct:'30 : 2',\n options:['90 : 4','60 : 2','30 : 2','60 : 1'],\n exp:'Current AHA\/ERC guideline ratio for adult CPR (single or two rescuers) is 30 compressions to 2 rescue breaths. Compressions are delivered at 100\u2013120\/min to a depth of 5\u20136 cm. Minimising interruptions is the key principle.'\n },\n {\n id:3,\n stem:'Which one of the following is NOT a differential diagnosis of ST segment elevation in ECG?',\n correct:'Hypocalcaemia',\n options:['Acute pericarditis','Trauma to ventricles','Hypothermia','Hypocalcaemia'],\n exp:'ST elevation causes include: STEMI, acute pericarditis (saddle-shaped), hypothermia (Osborn\/J waves), ventricular trauma, Brugada syndrome, LV aneurysm, and early repolarisation. Hypocalcaemia causes QT prolongation, not ST elevation. Hypocalcaemia is therefore the EXCEPT answer.'\n },\n {\n id:4,\n stem:'Which one of the following is a non-shockable rhythm in respect to use of AED (Automatic External Defibrillator)?',\n correct:'Pulseless electrical activity',\n options:['Monomorphic ventricular tachycardia','Polymorphic ventricular tachycardia','Ventricular fibrillation','Pulseless electrical activity'],\n exp:'AED\/defibrillation is indicated for shockable rhythms: VF and pulseless VT (both mono and polymorphic). Pulseless Electrical Activity (PEA) shows organised electrical activity without a perfusing pulse and is non-shockable. Treatment is CPR plus reversing the 4Hs and 4Ts. Asystole is also non-shockable.'\n },\n {\n id:5,\n stem:'A 50-year-old man reports to Emergency with breathlessness, palpitations and acute chest pain. On auscultation there is a systolic murmur at apex and ECG shows ST elevations in anterior chest leads. Which one of the following would be the next choice of investigation?',\n correct:'Cardiac marker troponin T\/I',\n options:['Cardiac marker troponin T\/I','Echocardiography','TMT','24-hour Holter monitoring'],\n exp:'ST elevation in anterior leads (V1\u2013V4) indicates likely anterior STEMI. The immediate next investigation is cardiac biomarkers (troponin T\/I) to confirm myocardial necrosis. TMT is contraindicated in acute MI. Biomarkers are the critical confirmatory step before initiating reperfusion therapy.'\n },\n {\n id:6,\n stem:'Which of the following electro-cardiographic findings are manifestations of digitalis intoxication?\\n1. Ventricular bigeminy\\n2. Ventricular tachycardia\\n3. Atrial flutter\\n4. Atrial tachycardia with variable block',\n correct:'1, 2 and 4',\n options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],\n exp:'Digitalis toxicity causes: ventricular bigeminy (very characteristic), ventricular tachycardia, atrial tachycardia with AV block (pathognomonic), and junctional tachycardia. Atrial flutter is NOT a recognised feature of digoxin toxicity. Statements 1, 2, and 4 are correct.'\n },\n {\n id:7,\n stem:'According to modified WHO classification of Heart Disease in Pregnancy, which cardiac lesion is a contraindication for pregnancy?',\n correct:'Pulmonary arterial hypertension',\n options:['Hypertrophic cardiomyopathy','Uncomplicated, small or mild pulmonary stenosis','Successfully repaired Tetralogy of Fallot','Pulmonary arterial hypertension'],\n exp:'WHO Class IV cardiac lesions are absolute contraindications to pregnancy (mortality risk above 25%). These include pulmonary arterial hypertension, severe systemic ventricular dysfunction (EF below 30%), and severe mitral stenosis. PAH carries the highest maternal mortality in pregnancy, approaching 30\u201350%.'\n },\n {\n id:8,\n stem:'A 35-year-old patient presents in Emergency with sudden onset palpitations. His heart rate is 150\/minute and reverts after carotid massage. The most probable diagnosis is:',\n correct:'Paroxysmal supraventricular tachycardia',\n options:['Paroxysmal supraventricular tachycardia','Ventricular tachycardia','Ventricular fibrillation','Atrial flutter with block'],\n exp:'Reversion to sinus rhythm with carotid sinus massage (vagal manoeuvre) is diagnostic of PSVT (AV nodal re-entrant tachycardia or AVRT). VT and VF do not respond to vagal manoeuvres. Atrial flutter may slow with increased AV block but does not typically terminate with carotid massage.'\n },\n {\n id:9,\n stem:'Which one of the following statements is correct regarding Opening Snap in cardiac auscultation?',\n correct:'It is a high-pitched diastolic sound.',\n options:['It is a high-pitched diastolic sound.','It is due to opening of stenosed aortic valve.','It indicates pulmonary arterial hypertension.','It precedes the aortic component of second heart sound.'],\n exp:'Opening Snap (OS) is a high-pitched, snapping diastolic sound caused by sudden tensing of the stiffened mitral valve leaflets at maximum excursion in mitral stenosis. It follows S2 (does not precede it). A shorter S2\u2013OS interval indicates more severe stenosis. It is NOT due to the aortic valve.'\n },\n {\n id:10,\n stem:'A 35-year-old labourer with recurrent chest pain (family history of similar complaint, brother died at 40) was prescribed sublingual nitroglycerin. After taking it, the chest pain INCREASED in intensity. Which one of the following is most likely?',\n correct:'Hypertrophic obstructive cardiomyopathy',\n options:['Hypertrophic obstructive cardiomyopathy','Chronic type A dissection of aorta','Degenerative mitral regurgitation','Sub-acute bacterial endocarditis involving aortic valve'],\n exp:'Nitroglycerin reduces preload (venous pooling) which reduces LV filling. In HOCM, reduced filling worsens dynamic outflow obstruction, increasing chest pain. This paradoxical worsening with nitrates combined with positive family history of sudden cardiac death in young age is classic for HOCM. Confirmed by echo showing asymmetric septal hypertrophy and systolic anterior motion of mitral valve.'\n },\n {\n id:11,\n stem:'A patient with atrial fibrillation on regular treatment presents with photosensitivity, skin discoloration and peripheral neuropathy. Which drug may be implicated?',\n correct:'Amiodarone',\n options:['Digoxin','Disopyramide','Amiodarone','Bisoprolol'],\n exp:'Amiodarone causes multisystem adverse effects including: photosensitivity and slate-grey skin discoloration (lipofuscin deposits), peripheral neuropathy, hypo\/hyperthyroidism, pulmonary fibrosis, corneal microdeposits, and hepatotoxicity. It contains iodine (~37% by weight) and has an extremely long half-life of 40\u201355 days.'\n },\n {\n id:12,\n stem:'Which of the following are categorised under obstructive lung disease?\\n1. Bronchial asthma\\n2. Bronchiectasis\\n3. Bronchiolitis\\n4. Pulmonary sarcoidosis',\n correct:'1, 2 and 3',\n options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],\n exp:'Obstructive lung diseases include bronchial asthma, COPD (chronic bronchitis and emphysema), bronchiectasis, bronchiolitis, and cystic fibrosis. Pulmonary sarcoidosis causes RESTRICTIVE lung disease via bilateral hilar lymphadenopathy progressing to fibrosis with reduced lung volumes. Statement 4 is false.'\n },\n {\n id:13,\n stem:'Risk factors for development of COPD include which of the following?\\n1. Tobacco smoking\\n2. Recurrent infection\\n3. Coal dust exposure\\n4. High socio-economic status',\n correct:'1, 2 and 3',\n options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],\n exp:'COPD risk factors: tobacco smoking (single most important, ~80% of cases), occupational dust\/chemical exposure (coal, silica, cadmium), recurrent respiratory infections, air pollution, alpha-1 antitrypsin deficiency, and LOW socio-economic status. HIGH socio-economic status is PROTECTIVE. Statement 4 is false.'\n },\n {\n id:14,\n stem:'Which one of the following is NOT an aim of asthma therapy?',\n correct:'Minimal use of inhaled corticosteroid',\n options:['Peak expiratory flow circadian variation less than 20%','No emergency visits','Minimal use of inhaled corticosteroid','Minimal use of beta-2-agonists'],\n exp:'Goals of asthma therapy (GINA): minimal chronic symptoms, no exacerbations, no emergency visits, minimal SABA need, PEF circadian variation below 20%, and normal lung function. Inhaled corticosteroids (ICS) are the cornerstone of maintenance therapy and minimising ICS use is NOT a goal. Minimising SABA use IS a goal as frequent use signals poor control.'\n },\n {\n id:15,\n stem:'A 65-year-old male smoker is diagnosed with COPD. On pulmonary function testing, FEV1\/FVC is below 0.7 and FEV1 = 42% of predicted. The severity of airflow obstruction as per GOLD criteria is:',\n correct:'Severe',\n options:['Mild','Moderate','Severe','Very severe'],\n exp:'GOLD spirometric classification (post-bronchodilator FEV1\/FVC below 0.7): GOLD 1 Mild = FEV1 at or above 80%; GOLD 2 Moderate = FEV1 50\u201379%; GOLD 3 Severe = FEV1 30\u201349%; GOLD 4 Very severe = FEV1 below 30%. FEV1 at 42% falls in GOLD 3 (Severe) range.'\n },\n {\n id:16,\n stem:'A 40-year-old patient of bronchial asthma presents with acute severe breathlessness. Indications for giving assisted ventilation for acute severe asthma include which of the following?',\n correct:'PaO2 below 60 mm Hg, PaCO2 above 45 mm Hg',\n options:['PaO2 below 80 mm Hg, PaCO2 below 45 mm Hg','PaO2 above 60 mm Hg, PaCO2 above 45 mm Hg','PaO2 below 60 mm Hg, PaCO2 above 45 mm Hg','PaO2 below 80 mm Hg, PaCO2 above 45 mm Hg'],\n exp:'Indications for mechanical ventilation in severe asthma: PaO2 below 60 mmHg (hypoxaemia despite oxygen) AND PaCO2 above 45 mmHg (hypercapnia indicating respiratory muscle fatigue). In early asthma, hyperventilation causes low PaCO2. A rising PaCO2 to normal or above is an ominous sign of impending respiratory failure.'\n },\n {\n id:17,\n stem:'Which of the following are the non-metastatic extra-pulmonary manifestations of lung cancer?\\n1. Carcinoid syndrome\\n2. Nephrotic syndrome\\n3. Horner\\'s syndrome\\n4. Lambert-Eaton syndrome',\n correct:'2, 3 and 4',\n options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],\n exp:'Non-metastatic paraneoplastic and local manifestations of lung cancer include: Lambert-Eaton syndrome (SCLC), SIADH, Cushing syndrome, hypercalcaemia (squamous cell), Horner syndrome (Pancoast tumour), and nephrotic syndrome (membranous nephropathy). Carcinoid syndrome is a feature of carcinoid tumours, not a paraneoplastic feature of primary lung cancer. Statements 2, 3, and 4 are correct.'\n },\n {\n id:18,\n stem:'A 60-year-old obese person (110 kg) has excessive daytime sleepiness, morning headache, irritability, mood disturbances, dry mouth, nocturnal heartburn and diaphoresis of chest and neck. Which one of the following will be the best investigation to diagnose the patient?',\n correct:'Overnight Polysomnogram',\n options:['Ambulatory Blood Pressure Monitoring (ABPM)','24-hour Holter Monitoring','Echocardiography','Overnight Polysomnogram'],\n exp:'This picture of obese male with excessive daytime somnolence, morning headache (from nocturnal hypercapnia), nocturnal diaphoresis, dry mouth and heartburn is classic for Obstructive Sleep Apnoea. The gold standard investigation is overnight polysomnography (sleep study), which records the apnoea-hypopnoea index. AHI at or above 5\/hour confirms the diagnosis.'\n },\n {\n id:19,\n stem:'Which of the following drugs trigger bronchial asthma?\\n1. Sulfonamides\\n2. Aspirin\\n3. ACE inhibitors\\n4. Beta blockers',\n correct:'2, 3 and 4',\n options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],\n exp:'Drugs triggering asthma: Aspirin\/NSAIDs (inhibit COX, shifting arachidonic acid to leukotriene pathway causing bronchoconstriction), ACE inhibitors (bradykinin accumulation causes cough and bronchoconstriction), beta-blockers (block beta-2 receptors causing bronchoconstriction). Sulfonamides cause allergic reactions but are NOT established asthmagens. Statements 2, 3, and 4 are correct.'\n },\n {\n id:20,\n stem:'A patient with Crohn\\'s disease underwent ileal resection. Which of the following complications may develop?\\n1. Oxalate-rich renal calculi\\n2. Diarrhoea\\n3. Fat malabsorption\\n4. Hypernatraemia',\n correct:'1, 2 and 3',\n options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],\n exp:'Ileal resection consequences: (1) bile acid malabsorption causes fat malabsorption and steatorrhoea; (2) unabsorbed bile acids reaching colon cause secretory diarrhoea; (3) increased colonic oxalate absorption (normally bound by calcium in the ileum) causes hyperoxaluria and oxalate renal stones. Hypernatraemia is not a recognised complication. Statements 1, 2, and 3 are correct.'\n },\n {\n id:21,\n stem:'Protein-losing enteropathy due to obstruction of intestinal lymphatic vessels is seen in which of the following conditions?\\n1. Intestinal lymphangiectasia\\n2. Constrictive pericarditis\\n3. Eosinophilic gastroenteritis\\n4. Whipple\\'s disease',\n correct:'1, 2 and 4',\n options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],\n exp:'Protein-losing enteropathy due to lymphatic obstruction: intestinal lymphangiectasia (primary obstruction), constrictive pericarditis (raised venous pressure obstructs lymphatics), and Whipple\\'s disease (Tropheryma whipplei infects and blocks intestinal lymphatics with PAS-positive macrophages). Eosinophilic gastroenteritis causes PLE by mucosal damage, NOT lymphatic obstruction. Statements 1, 2, and 4 are correct.'\n },\n {\n id:22,\n stem:'Which one of the following viruses is associated with development of Acute Liver Failure and high mortality in pregnancy?',\n correct:'Hepatitis E virus',\n options:['Hepatitis A virus','Hepatitis E virus','Hepatitis C virus','Hepatitis B virus'],\n exp:'Hepatitis E virus (HEV) in pregnancy, particularly in the third trimester, carries a mortality rate of 15\u201325% due to fulminant hepatic failure. The mechanism may relate to hormone-mediated impairment of immune clearance. HEV is the leading cause of acute liver failure in pregnancy in India and other endemic regions.'\n },\n {\n id:23,\n stem:'Consider the following statements with regard to Anorexia of Aging:\\n1. Declining chemosensory function (smell and taste)\\n2. Reduced efficiency of chewing\\n3. Slowed gastric emptying\\n4. Alterations in the neuro-endocrine axis\\nWhich of the above statements are associated with early satiety and weight loss in the elderly?',\n correct:'1, 2, 3 and 4',\n options:['3 and 4 only','1, 2 and 4 only','1, 2, 3 and 4','1, 2 and 3 only'],\n exp:'All four mechanisms contribute to anorexia of ageing: reduced olfactory\/gustatory sensation decreases appetite, impaired dentition reduces food intake, delayed gastric emptying causes early satiety, and neuro-endocrine changes (increased CCK and leptin, decreased NPY and ghrelin) suppress appetite. All four statements are correct.'\n },\n {\n id:24,\n stem:'Consider the following statements:\\n1. Type-1 HRS is characterised by rapid deterioration in renal function within 1\u20132 weeks\\n2. Type-2 HRS is characterised by moderate and stable or slowly progressive renal dysfunction\\n3. HRS is seen in patients with large ascites in cirrhosis\\nWhich of the above statements is\/are correct?',\n correct:'1, 2 and 3',\n options:['1 only','3 only','1 and 2 only','1, 2 and 3'],\n exp:'All three statements about Hepato-Renal Syndrome are correct. HRS-1 (now HRS-AKI): rapid creatinine doubling to above 2.5 mg\/dL within 2 weeks with poor prognosis. HRS-2 (now HRS-CKD): steady moderate renal failure often with refractory ascites. HRS occurs in cirrhosis with ascites due to splanchnic vasodilation causing renal vasoconstriction.'\n },\n {\n id:25,\n stem:'Which one of the following is the serological marker of immunisation with Hepatitis B vaccine?',\n correct:'Anti-HBs',\n options:['HBsAg','Anti-HBs','HBcAg','Anti-HBc'],\n exp:'After Hepatitis B vaccination, only anti-HBs (antibody to HBsAg) is detectable. A titre at or above 10 mIU\/mL indicates protective immunity. Natural infection produces both anti-HBs AND anti-HBc. HBsAg indicates active infection. Anti-HBs alone therefore indicates vaccine-induced immunity.'\n },\n {\n id:26,\n stem:'Infection with which of the following organisms can cause a syndrome which is clinically indistinguishable from achalasia of the oesophagus?',\n correct:'Trypanosoma cruzi',\n options:['Trypanosoma cruzi','Schistosoma haematobium','Mycobacterium leprae','Plasmodium falciparum'],\n exp:'Trypanosoma cruzi (Chagas disease) destroys the myenteric plexus of Auerbach in the oesophagus, causing aperistalsis and failure of lower oesophageal sphincter relaxation. This produces a mega-oesophagus clinically identical to primary achalasia. Chagas disease also causes megacolon and cardiomyopathy, and is endemic in Central and South America.'\n },\n {\n id:27,\n stem:'Consider the following statements in respect of Helicobacter pylori:\\n1. It is a gram-positive, spiral-shaped bacterium\\n2. It uses an adhesion molecule (BabA) to bind to the Lewis b antigen on gastric epithelial cells\\n3. It produces urease enzyme that helps to raise the pH around the bacterium\\n4. It exclusively colonises only gastric-type epithelium',\n correct:'2, 3 and 4',\n options:['1, 2 and 3','1, 2 and 4','2, 3 and 4','1, 3 and 4'],\n exp:'H. pylori is gram-NEGATIVE, not gram-positive. Statement 1 is therefore false. Statements 2 (BabA adhesin binds Lewis b antigen), 3 (urease hydrolyses urea to ammonia, raising local pH for survival), and 4 (exclusively colonises gastric-type epithelium including gastric metaplasia in the duodenum) are all correct.'\n },\n {\n id:28,\n stem:'The quadruple therapy regime (OBMT regime) for Helicobacter pylori eradication comprises which of the following drugs?',\n correct:'Omeprazole, Bismuth subcitrate, Metronidazole, Tetracycline',\n options:['Omeprazole, Bismuth subcitrate, Metronidazole, Tetracycline','Ofloxacin, Bismuth subcitrate, Metronidazole, Tetracycline','Omeprazole, Beclomethasone, Metronidazole, Tacrolimus','Omeprazole, Beclomethasone, Mometasone, Tetracycline'],\n exp:'OBMT quadruple therapy: Omeprazole (PPI) + Bismuth subcitrate + Metronidazole + Tetracycline. This bismuth-based regimen is used in areas of high metronidazole resistance or as second-line after failed triple therapy. Bismuth directly kills H. pylori while tetracycline and metronidazole provide dual antibiotic coverage.'\n },\n {\n id:29,\n stem:'Cystic fibrosis disorder is:',\n correct:'Autosomal recessive',\n options:['Autosomal dominant','Autosomal recessive','X-linked dominant','X-linked recessive'],\n exp:'Cystic fibrosis is autosomal recessive, caused by mutations in the CFTR gene on chromosome 7q31. The most common mutation is F508del (deletion of phenylalanine at position 508). Carriers (heterozygotes) are unaffected. Both parents must be carriers for a child to be affected, with a 1 in 4 chance per pregnancy.'\n },\n {\n id:30,\n stem:'Which of the following diseases may be associated with Coeliac disease?\\n1. Type-2 Diabetes mellitus\\n2. IgA deficiency\\n3. Down syndrome\\n4. Turner\\'s syndrome',\n correct:'2, 3 and 4',\n options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],\n exp:'Coeliac disease associations: IgA deficiency (makes IgA anti-tTG falsely negative, requiring IgG tests), Down syndrome (5\u201312% prevalence), Turner syndrome (4\u20138%), Type 1 DM (autoimmune, not Type 2), thyroid disorders, and dermatitis herpetiformis. Type-2 DM is NOT a recognised association. Statements 2, 3, and 4 are correct.'\n }\n ];\n\n \/* \u2500\u2500 Utilities \u2500\u2500 *\/\n const LETTERS=['A','B','C','D'];\n let userAnswers={}, answered=0, shuffledOpts={};\n let timerRunning=false, timerRemaining=TIMER_SECS;\n let timerInterval=null, graceInterval=null, quizSubmitted=false;\n\n function shuffle(arr){\n const a=arr.slice();\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 fmtTime(s){\n const m=Math.floor(s\/60),sec=s%60;\n return (m<10?'0':'')+m+':'+(sec<10?'0':'')+sec;\n }\n\n \/* \u2500\u2500 Timer \u2500\u2500 *\/\n function startTimer(){\n if(timerRunning||quizSubmitted)return;\n timerRunning=true;\n const btn=document.getElementById(NS+'-timer-btn');\n btn.textContent='\u23f1 '+fmtTime(timerRemaining);btn.classList.add('running');\n document.getElementById(NS+'-timer-item').classList.add('active');\n timerInterval=setInterval(function(){\n timerRemaining--;\n const 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