CMS 2022 Paper I \u2013 Part C (Q81\u2013Q120)<\/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#cms22p1c *,#cms22p1c *::before,#cms22p1c *::after{box-sizing:border-box;margin:0;padding:0}\n#cms22p1c{--ter:#1A5EA8;--ter-light:#2E82D5;--ter-pale:#EBF3FD;--teal:#1A3A5C;--teal-light:#24527F;--teal-pale:#E8F0F9;--ink:#1a1a1a;--ink-mid:#444;--ink-soft:#777;--line:#dde4ed;--bg:#f8fafd;--white:#ffffff;--correct:#1e6f46;--correct-bg:#eaf7ef;--correct-border:#43a047;--wrong:#b83232;--wrong-bg:#fdf0f0;--wrong-border:#e53935;--radius:10px;font-family:'Source Serif 4',Georgia,serif;font-size:16px;color:var(--ink);background:var(--bg);line-height:1.7;padding:0 0 48px}\n#cms22p1c .cq-sentinel{height:1px}\n#cms22p1c .cq-statusbar{position:fixed;top:0;left:0;right:0;z-index:99999;background:var(--white);border-bottom:2px solid var(--line);border-left:4px 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.cq-score-ring{width:110px;height:110px;border-radius:50%;background:conic-gradient(var(--ter) 0%,var(--line) 0%);display:flex;align-items:center;justify-content:center;margin:0 auto 20px;position:relative}\n#cms22p1c .cq-score-ring::before{content:'';position:absolute;width:86px;height:86px;border-radius:50%;background:var(--white)}\n#cms22p1c .cq-ring-inner{position:relative;display:flex;flex-direction:column;align-items:center;line-height:1.2}\n#cms22p1c .cq-ring-pct{font-family:'Playfair Display',serif;font-size:1.3rem;font-weight:700;color:var(--ter)}\n#cms22p1c .cq-ring-sub{font-size:0.6rem;color:var(--ink-soft);text-transform:uppercase;letter-spacing:0.05em}\n#cms22p1c .cq-score h2{font-family:'Playfair Display',serif;font-size:1.2rem;color:var(--ink);margin-bottom:8px}\n#cms22p1c .cq-net-line{font-size:1rem;color:var(--ter);font-weight:600;margin-bottom:6px}\n#cms22p1c .cq-verdict{font-size:0.85rem;color:var(--ink-soft);margin-bottom:20px}\n#cms22p1c .cq-score-bands{display:flex;justify-content:center;gap:10px;flex-wrap:wrap;font-size:0.8rem}\n#cms22p1c .cq-band{padding:4px 12px;border-radius:16px;font-weight:600}\n#cms22p1c .cq-band-c{background:var(--correct-bg);color:var(--correct)}\n#cms22p1c .cq-band-w{background:var(--wrong-bg);color:var(--wrong)}\n#cms22p1c .cq-band-s{background:var(--teal-pale);color:var(--teal)}\n#cms22p1c .cq-retry-btn{margin-top:22px;background:transparent;border:2px solid var(--ter);color:var(--ter);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#cms22p1c .cq-retry-btn:hover{background:var(--ter);color:var(--white)}\n@media(max-width:480px){#cms22p1c .cq-header h1{font-size:1.15rem}#cms22p1c .cq-qtext{font-size:0.88rem}#cms22p1c .cq-opt-text{font-size:0.84rem}}\n<\/style>\n<\/head>\n<body>\n<div id=\"cms22p1c\">\n <div class=\"cq-sentinel\" id=\"cms22p1c-sentinel\"><\/div>\n <div class=\"cq-statusbar\" id=\"cms22p1c-statusbar\">\n <div class=\"cq-sb-stats\">\n <div class=\"cq-timer-item\" id=\"cms22p1c-timer-item\">\u23f1 <strong id=\"cms22p1c-timer-display\">40:00<\/strong><\/div>\n <div class=\"cq-sb-item\">\u2705 <strong id=\"cms22p1c-sc\">0<\/strong><\/div>\n <div class=\"cq-sb-item\">\u274c <strong id=\"cms22p1c-sw\">0<\/strong><\/div>\n <div class=\"cq-sb-item\">\u23f3 <strong id=\"cms22p1c-sr\">40<\/strong> left<\/div>\n <div class=\"cq-sb-sep\"><\/div>\n <div class=\"cq-sb-item\">Net <strong id=\"cms22p1c-sn\">0<\/strong> \/ <strong id=\"cms22p1c-sm\">160<\/strong><\/div>\n <\/div>\n <div class=\"cq-sb-progress\"><div class=\"cq-sb-fill\" id=\"cms22p1c-fill\"><\/div><\/div>\n <\/div>\n <div class=\"cq-grace\" id=\"cms22p1c-grace\">\n <div class=\"cq-grace-box\">\n <h3>Time's Up!<\/h3><p>Submitting in<\/p>\n <div class=\"cq-grace-count\" id=\"cms22p1c-grace-count\">10<\/div>\n <button class=\"cq-grace-btn\" id=\"cms22p1c-grace-now\">Submit Now<\/button>\n <\/div>\n <\/div>\n <div class=\"cq-header\">\n <h1>Combined Medical Services Examination 2022<br>General Medicine & Paediatrics \u00b7 Paper I \u00b7 Part C<\/h1>\n <p>Infectious Disease \u00b7 Dermatology \u00b7 Psychiatry \u00b7 Emergency & Poisoning \u00b7 Paediatrics \u00b7 National Health Programmes<\/p>\n <div class=\"cq-meta\">\n <span class=\"cq-badge\">Questions 81 \u2013 120<\/span>\n <span class=\"cq-badge\">Options reshuffled<\/span>\n <button class=\"cq-timer-btn\" id=\"cms22p1c-timer-btn\">\u23f1 Start Timed Mode<\/button>\n <\/div>\n <\/div>\n <div class=\"cq-body\">\n <div id=\"cms22p1c-questions\"><\/div>\n <div class=\"cq-submit-wrap\"><button class=\"cq-btn\" id=\"cms22p1c-submit\">Submit Answers<\/button><\/div>\n <div class=\"cq-score\" id=\"cms22p1c-score\">\n <div class=\"cq-score-ring\" id=\"cms22p1c-ring\"><div class=\"cq-ring-inner\"><span class=\"cq-ring-pct\" id=\"cms22p1c-ring-pct\">0%<\/span><span class=\"cq-ring-sub\">score<\/span><\/div><\/div>\n <h2>Your Result<\/h2>\n <div class=\"cq-net-line\" id=\"cms22p1c-net-line\"><\/div>\n <div class=\"cq-verdict\" id=\"cms22p1c-verdict\"><\/div>\n <div class=\"cq-score-bands\">\n <span class=\"cq-band cq-band-c\" id=\"cms22p1c-ct-c\"><\/span>\n <span class=\"cq-band cq-band-w\" id=\"cms22p1c-ct-w\"><\/span>\n <span class=\"cq-band cq-band-s\" id=\"cms22p1c-ct-s\"><\/span>\n <\/div>\n <button class=\"cq-retry-btn\" id=\"cms22p1c-retry\">\u21ba Retry Quiz<\/button>\n <\/div>\n <\/div>\n<\/div>\n<script>\n(function(){\n 'use strict';\n const NS='cms22p1c',TOTAL=40,MAX=160,TIMER_SECS=2400,GRACE_SECS=10;\n const QUESTIONS=[\n {id:81,stem:'The first line investigation for diagnostic evaluation of patients with hypercalcaemia is',correct:'Serum i PTH levels',options:['24 hour urinary calcium excretion','Serum phosphate levels','Serum i PTH levels','Serum vitamin D levels'],exp:'The most common causes of hypercalcaemia are primary hyperparathyroidism (PHPT) and malignancy, accounting for >90% of cases. Intact PTH (iPTH) is the single most discriminating first-line test: in PHPT, iPTH is elevated or inappropriately normal despite hypercalcaemia; in malignancy-associated hypercalcaemia, iPTH is suppressed. This distinction guides all further investigation. Serum iPTH is the correct first-line test.'},\n {id:82,stem:\"Consider the following conditions:\\n1. Kaposi's sarcoma\\n2. Lymphoma\\n3. Tuberculosis\\n4. Persistent generalised lymphadenopathy\\nWhich of the above are causes of lymphadenopathy in a HIV positive patient?\",correct:'1, 2, 3 and 4',options:['1 and 3 only','2 and 3 only','1, 2 and 4 only','1, 2, 3 and 4'],exp:'All four are recognised causes of lymphadenopathy in HIV. Persistent generalised lymphadenopathy (PGL) is a direct manifestation of HIV itself (follicular hyperplasia). TB is the most common infectious cause of lymphadenopathy in HIV-positive patients in India. Non-Hodgkin lymphoma (and Hodgkin lymphoma) are AIDS-defining malignancies. Kaposi\\'s sarcoma (HHV-8 driven) causes lymph node, skin, and visceral involvement. All four are correct.'},\n {id:83,stem:'A patient receiving chemotherapy develops neutropenia. He presents with fever, cough, expectoration, chest pain and haemoptysis. His CT scan of chest reveals nodular infiltrates with halo sign and crescent sign. The most useful drug for treating him is',correct:'Voriconazole',options:['Colistin','Granulocyte Macrophage Colony','Voriconazole','Piperacillin-tazobactam'],exp:'Neutropenia + fever + CT halo sign (ground-glass halo around a nodule = early angioinvasive fungal disease) and air-crescent sign (late sign as infarcted tissue retracts) = invasive pulmonary aspergillosis (IPA). Voriconazole is the first-line treatment for IPA (IDSA\/ECMM guidelines), superior to amphotericin B in both efficacy and tolerability. Colistin treats MDR gram-negative bacteria. Piperacillin-tazobactam treats bacterial neutropenic sepsis.'},\n {id:84,stem:'A patient undergoes splenectomy after an accident. He will require oral prophylaxis against which of the following organisms?',correct:'Streptococcus pneumoniae',options:['Staphylococcus aureus','Escherichia coli','Streptococcus pneumoniae','Pneumocystis corinii'],exp:'The spleen is essential for clearance of encapsulated bacteria. Post-splenectomy patients are at lifelong risk of overwhelming post-splenectomy infection (OPSI). The three most important encapsulated organisms: Streptococcus pneumoniae (most common and most dangerous), Haemophilus influenzae type b, and Neisseria meningitidis. Management: vaccination against all three + lifelong oral penicillin V (or amoxicillin) prophylaxis.'},\n {id:85,stem:'A 30 year old male recently diagnosed with HIV presented with odynophagia. He was started on proton-pump inhibitor and an upper GI endoscopy was done. There were serpiginous ulcers in a normal surrounding mucosa in distal oesophagus. The most likely diagnosis is',correct:'Herpes simplex esophagitis',options:['Herpes simplex esophagitis','Gastro-esophageal reflux disease','Cytomegalovirus esophagitis','Candida esophagitis'],exp:'The key endoscopic discriminator: HSV oesophagitis causes multiple small, shallow, punched-out or serpiginous ulcers on a background of NORMAL-appearing mucosa. CMV oesophagitis produces one or a few large, deep, well-defined, solitary ulcers (often >1 cm) predominantly in the distal oesophagus. Candida oesophagitis shows white plaques\/pseudomembranes. GERD would not produce discrete ulcers in normal mucosa. Serpiginous ulcers with normal surrounding mucosa = HSV oesophagitis. Treatment: aciclovir.'},\n {id:86,stem:'Which one of the following statements regarding post gonococcal urethritis (PGU) is correct?',correct:'PGU refers to non-gonococcal urethritis in men treated earlier with single dose of penicillin',options:['Neisseria gonorrhoea is the most frequent cause of PGU in men','PGU refers to non-gonococcal urethritis in men treated earlier with single dose of penicillin','Combination therapy with azithromycin leads to resistance and should be avoided.','PGU usually occurs within one week after treatment of non-gonococcal urethritis.'],exp:'Post-gonococcal urethritis (PGU) occurs in men treated for gonorrhoea (typically with a single dose of penicillin or ampicillin, which eradicates N. gonorrhoeae but not co-infecting organisms) who subsequently develop persistent urethritis. PGU is caused by co-infecting agents \u2014 most commonly Chlamydia trachomatis, Ureaplasma urealyticum, or Mycoplasma genitalium. It typically appears 1\u20133 weeks after treatment of gonorrhoea. The correct definition is option (b).'},\n {id:87,stem:'Which one of the following treatments is considered as Gold standard for brucellosis in adults?',correct:'Streptomycin and Doxycycline',options:['Streptomycin and Doxycycline','Azithromycin and Rifampin','Trimethoprim and Sulfamethoxazole','Amikacin and Ciprofloxacin'],exp:'The WHO-recommended gold standard treatment for brucellosis in adults is doxycycline 100 mg twice daily for 6 weeks PLUS streptomycin 1 g IM daily for the first 2\u20133 weeks. This combination has the lowest relapse rate (~5%). The alternative is doxycycline + rifampicin (oral, 6 weeks) \u2014 used when IM injections are impractical. Combination therapy is essential because monotherapy leads to high relapse rates due to intracellular persistence of Brucella.'},\n {id:88,stem:'Which one of the following has the highest risk of human immunodeficiency virus (HIV) transmission after single exposure to an HIV-infected source?',correct:'Blood transfusion',options:['Vaginal delivery','Vaginal intercourse','Blood transfusion','Percutaneous needle stick injury'],exp:'HIV transmission risk per single exposure: Blood transfusion with HIV-infected blood: ~90\u201395% \u2014 by far the highest risk. Mother-to-child (vaginal delivery without prophylaxis): ~10\u201330% per pregnancy. Receptive anal intercourse: ~0.5\u20133%. Vaginal intercourse (receptive): ~0.1\u20130.2%. Percutaneous needle-stick: ~0.3%. Blood transfusion carries the highest per-exposure risk because large volumes of cell-free and cell-associated virus are inoculated directly into the bloodstream, bypassing all mucosal barriers.'},\n {id:89,stem:'Consider the following statements with regard to vitamin C:\\n1. It is heat stable.\\n2. Normal platelets are poor in ascorbate.\\n3. Perifollicular hyperkeratosis is a clinical sign of scurvy.\\n4. Infants fed exclusively on boiled milk are vitamin C deficient.\\nWhich of the above statements are correct?',correct:'3 and 4',options:['1 and 2','2 and 3','1 and 4','3 and 4'],exp:\"Statement 1 is false \u2014 vitamin C is highly heat-labile; it is destroyed by cooking and boiling, which is clinically relevant. Statement 2 is false \u2014 platelets (and leucocytes) are rich in ascorbate, concentrating it 40\u201380\u00d7 higher than plasma; platelet ascorbate is a marker of tissue vitamin C status. Statement 3 is correct \u2014 perifollicular hyperkeratosis (follicular plugging with coiled 'corkscrew' hairs surrounded by hyperkeratotic papules) is a characteristic early sign of scurvy. Statement 4 is correct \u2014 cow's milk already has low vitamin C; boiling destroys the residual ascorbate. Infants fed boiled cow's milk are at high risk of infantile scurvy (Barlow's disease). Statements 3 and 4 are correct.\"},\n {id:90,stem:'Which of the following statements are correct in respect of vitamin D?\\n1. Skin exposure to sunlight is the main source\\n2. Deficiency of vitamin D causes distal muscle weakness\\n3. Vitamin D synthesis decreases in winter, as one moves away from equator\\n4. Body store accumulated during summer is consumed during winter',correct:'1, 3 and 4',options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],exp:'Statement 1 is correct \u2014 solar UVB irradiation (290\u2013315 nm) converts 7-dehydrocholesterol in the skin to cholecalciferol (vitamin D3), providing 80\u201390% of the body\\'s vitamin D. Statement 2 is false \u2014 vitamin D deficiency myopathy causes PROXIMAL muscle weakness (difficulty rising from a chair, climbing stairs), not distal. Statement 3 is correct \u2014 at higher latitudes, winter UVB is filtered by the atmosphere; synthesis is negligible north of ~35\u00b0N in winter months. Statement 4 is correct \u2014 excess vitamin D synthesised during summer is stored in adipose tissue and liver and consumed during winter. Statements 1, 3, and 4 are correct.'},\n {id:91,stem:'Which of the following are used in the treatment of Acne vulgaris?\\n1. Topical benzoyl peroxide\\n2. Topical antibiotics like clindamycin\\n3. Oral isotretinoin\\n4. Oral ivermectin',correct:'1, 2 and 3',options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],exp:'Topical benzoyl peroxide: bactericidal against C. acnes via oxidative stress; comedolytic; does not induce antibiotic resistance. Topical clindamycin: reduces C. acnes; always combined with benzoyl peroxide to prevent resistance. Oral isotretinoin (13-cis-retinoic acid): most effective for severe nodular\/cystic acne, targeting all four pathogenic factors. Oral ivermectin is used for scabies and strongyloidiasis \u2014 it has no role in acne vulgaris. Statements 1, 2, and 3 are correct.'},\n {id:92,stem:'Which one of the following is a cause of scarring alopecia?',correct:'Radiotherapy',options:['Androgenic alopecia','Alopecia Areata','Syphilis','Radiotherapy'],exp:'Non-scarring alopecias (reversible): androgenic alopecia (follicles remain viable), alopecia areata (T-cell-mediated but follicle bulb preserved), syphilitic alopecia (moth-eaten pattern, reversible with treatment). Scarring alopecias involve permanent destruction of follicular stem cells in the bulge region, replaced by fibrosis. Radiotherapy (ionising radiation) causes direct DNA damage to follicular stem cells, producing irreversible scarring alopecia at doses >45 Gy. Other causes: discoid lupus, lichen planopilaris.'},\n {id:93,stem:'Which of the following are used as mood stabilizers for treatment of bipolar disorder?\\n1. Valproic acid\\n2. Lamotrigine\\n3. Carbamazepine\\n4. Propranolol',correct:'1, 2 and 3',options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],exp:'Valproic acid: effective for acute mania, mixed states, and bipolar maintenance. Lamotrigine: particularly effective for bipolar depression and maintenance, preventing depressive episodes. Carbamazepine: approved for acute mania; used as second-line or when lithium is contraindicated. Propranolol is a \u03b2-blocker used for essential tremor, performance anxiety, and migraine prophylaxis \u2014 it has no mood-stabilising properties and is not used in bipolar disorder. Statements 1, 2, and 3 are correct.'},\n {id:94,stem:'An elderly alcoholic man who mainly eats a diet of maize and maize products presents with complaints of chronic diarrhoea, severe sunburn-like lesions on exposed parts and acute delirium. He is admitted. What is the likely diagnosis and its treatment?',correct:'Pellagra, Niacin therapy',options:[\"Celiac disease, Gluten free diet\",'Vitamin B 12 deficiency, Parenteral B 12 therapy','Pellagra, Niacin therapy',\"Whipple's disease, Doxycycline + Trimethoprim\"],exp:\"The classic triad of pellagra \u2014 the '3 Ds': Dermatitis (photosensitive skin lesions in sun-exposed areas, Casal's necklace), Diarrhoea, and Dementia (confusion, delirium) \u2014 is caused by niacin (vitamin B3) deficiency. Risk factors: maize-based diet (niacin in maize is in bound unabsorbable niacytin form) and alcoholism (poor dietary intake and impaired tryptophan-to-niacin conversion). Treatment: oral niacinamide (nicotinamide) 100\u2013300 mg\/day. A 4th D \u2014 Death \u2014 occurs without treatment.\"},\n {id:95,stem:'Which one of the following is an indication for self-injectable adrenaline (epinephrine)?',correct:'Anaphylaxis to allergens that are difficult to avoid',options:['Anaphylaxis to allergens that are difficult to avoid','Cardiogenic shock','Pheochromocytoma','Complete heart block'],exp:'Self-injectable adrenaline (auto-injector, e.g. EpiPen) is prescribed for patients at risk of future severe anaphylaxis who may not have immediate access to emergency care. The key indication is anaphylaxis to allergens that are difficult or impossible to avoid \u2014 e.g. venom allergy (bee, wasp), food allergy (peanuts, shellfish), latex allergy. Cardiogenic shock requires IV adrenaline in hospital. Pheochromocytoma is a contraindication. Complete heart block requires pacing or IV atropine.'},\n {id:96,stem:'Which of the following statements with regard to arterio-venous fistula in dialysis patient are correct?\\n1. Distension and thickening of vessel wall occurs\\n2. Formed upto a year before dialysis is contemplated\\n3. Leg veins are usually preferred\\n4. Synthetic graft may be used if fistula formation is not possible',correct:'1, 2 and 4',options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],exp:\"Statement 1 is correct \u2014 after AVF creation, the vein 'arterialises' under arterial pressure: vessel wall thickens and flow velocity increases. Statement 2 is correct \u2014 the AVF requires 4\u20136 weeks minimum for maturation; guidelines recommend planning 6\u201312 months before anticipated dialysis start. Statement 3 is false \u2014 arm veins (forearm radiocephalic, upper arm brachiocephalic) are strongly preferred; leg vein AVFs are specifically avoided due to poor accessibility, higher infection risk, and risk of limb ischaemia. Statement 4 is correct \u2014 when suitable native veins are unavailable, an arteriovenous graft (synthetic PTFE) is the next option. Statements 1, 2, and 4 are correct.\"},\n {id:97,stem:'An infant was born at 30 weeks of gestation and weighs 1\u00b72 kg at birth. Which of the following is the recommended initial feeding method?',correct:'Orogastric feeding',options:['Intravenous fluids only','Feeding by spoon and katori','Breastfeeding','Orogastric feeding'],exp:'A preterm infant born at 30 weeks has an immature suck-swallow-breathe reflex (matures at approximately 32\u201334 weeks). Direct breastfeeding and spoon\/katori feeding require coordinated suck-swallow reflex and would cause aspiration at 30 weeks. Expressed breast milk (EBM) is the preferred feed for all preterm infants. The route of delivery at 30 weeks is orogastric (or nasogastric) tube feeding of EBM. IV fluids alone are nutritionally insufficient for prolonged use. Orogastric feeding with expressed breast milk is the correct initial method.'},\n {id:98,stem:'A newborn delivered at 32 weeks gestation is started on spoon feeds after birth. On feeding with spoon, the baby demonstrates some spilling and coughing. What is the next step in management?',correct:'Orogastric or nasogastric tube feeding',options:['Orogastric or nasogastric tube feeding','Intravenous fluid therapy','Gastrostomy tube feeding','Breastfeeding'],exp:'At 32 weeks gestation, the suck-swallow-breathe coordination is still immature; spillage and coughing (aspiration risk) occur with spoon feeds. The appropriate next step is orogastric or nasogastric tube feeding of expressed breast milk, which bypasses the need for suck-swallow coordination and ensures safe, adequate caloric delivery. Gastrostomy is reserved for infants requiring prolonged enteral feeding (e.g. severe neurological impairment). IV fluids alone deprive the infant of enteral nutrition benefits.'},\n {id:99,stem:'A child speaks bisyllables like Ma-Ma and Ba-Ba. He is able to sit without support, and looks at the source of sound diagonally. His likely age is',correct:'6 months',options:['4 months','6 months','8 months','10 months'],exp:'Bisyllables (double consonants: ma-ma, ba-ba, da-da \u2014 non-specific use) is a 6-month speech milestone per standard Indian paediatric textbooks (Ghai). Indirect localisation of sound (looking towards a sound source obliquely\/diagonally, not directly) corresponds to the 4\u20136 month auditory developmental level. Sitting with partial support begins at 6 months; sitting without support is between 7\u20139 months in most texts, though some early achievers reach it at 6\u20137 months. The clustering of bisyllables + early sitting + indirect sound localisation places the developmental age at 6 months.'},\n {id:100,stem:'After sustaining a head injury, an 18 month old child displays eye opening only to pain, moans on painful stimuli and withdraws to painful stimuli. What is the modified Glasgow Coma Scale Score in this child?',correct:'8',options:['6','8','10','12'],exp:'Modified GCS for an 18-month-old: Eye opening (E): opens to pain only = 2. Verbal response (V): moaning to painful stimuli = 2 (incomprehensible sounds \/ abnormal vocalisation in paediatric modification). Motor response (M): withdraws from pain = 4 (normal flexion\/withdrawal). Total GCS = E2 + V2 + M4 = 8. A GCS of 8 defines severe TBI and is the threshold at which airway protection (intubation) is typically considered.'},\n {id:101,stem:'Which of the following are reversible causes of electromechanical dissociation seen in pulseless electrical activity?\\n1. Pericardial tamponade\\n2. Pulmonary thrombo-embolism\\n3. Hyperthermia\\n4. Hypokalemia',correct:'1, 2 and 4',options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],exp:'PEA is managed by identifying and reversing the underlying cause \u2014 the 4Hs and 4Ts. 4Hs: Hypoxia, Hypovolaemia, Hypo\/Hyperkalaemia, Hypothermia. 4Ts: Tension pneumothorax, Tamponade (cardiac), Toxins\/drugs, Thrombosis (pulmonary or coronary). Pericardial tamponade (1) is a classic 4T reversible cause. Pulmonary thrombo-embolism (2) is a 4T reversible cause. Hypokalemia (4) falls under the 4H category. Hyperthermia (3) is NOT in the standard 4H\/4T list \u2014 Hypothermia is a 4H cause, not hyperthermia. Statements 1, 2, and 4 are correct.'},\n {id:102,stem:'A 3-day old newborn presents with jaundice since birth. Examination reveals pallor and hepatosplenomegaly. The newborn also has a cephalhematoma. Which one of the following is the most important indicator to the diagnosis of pathologic jaundice?',correct:'Clinical jaundice since birth',options:['Pallor','Hepatosplenomegaly','Clinical jaundice since birth','Cephalhematoma'],exp:'The most important single indicator distinguishing pathological from physiological jaundice is the TIME of onset. Physiological neonatal jaundice appears on day 2\u20133 of life (never on day 1). Jaundice appearing within 24 hours of birth (since birth = day 1) is ALWAYS pathological by definition. Causes include haemolytic disease of the newborn (Rh incompatibility, ABO incompatibility), congenital infections, and sepsis. Jaundice since birth is the most important indicator of pathological jaundice.'},\n {id:103,stem:'What is the diagnosis of Autism Spectrum Disorder primarily based upon?',correct:'Clinical criteria only',options:['Clinical criteria only','Clinical criteria and genetic studies only','Clinical criteria and MRI brain only','Clinical criteria, genetic studies and MRI brain'],exp:'ASD is diagnosed entirely on clinical criteria \u2014 there is no confirmatory biomarker, genetic test, or neuroimaging finding that establishes the diagnosis. DSM-5 clinical criteria require: persistent deficits in social communication and social interaction AND restricted, repetitive patterns of behaviour, interests, or activities, with symptoms present in early developmental period, causing significant functional impairment. Genetic testing may identify treatable co-morbidities but does not establish the ASD diagnosis. The diagnosis is based on clinical criteria only.'},\n {id:104,stem:'According to the National AIDS Control Program, which one of the following drugs is given to newborns born to HIV-positive mothers to prevent mother to child transmission of HIV infection?',correct:'Nevirapine',options:['Nevirapine','Stavudine','Indinavir','Ritonavir'],exp:'Under the NACP and WHO guidelines for PMTCT of HIV: the infant born to an HIV-positive mother receives a single dose of nevirapine (NVP) immediately at birth (within 72 hours), followed by daily NVP syrup for 6 weeks. Nevirapine is an NNRTI with excellent oral bioavailability, good CNS penetration, and a long half-life \u2014 making it ideal for infant prophylaxis. Stavudine and the protease inhibitors (indinavir, ritonavir) are not used for this indication.'},\n {id:105,stem:'Which one of the following statements is correct in context of human breast milk?',correct:'Human milk contains omega 2 and omega 6 (very long chain) fatty acids',options:['The concentration of lactose is 5g\/dL','The protein content is higher than that in animal milk','Human milk does not contain taurine and cysteine like animal milk and formula milk','Human milk contains omega 2 and omega 6 (very long chain) fatty acids'],exp:'Option (a): Human breast milk lactose concentration is approximately 7 g\/dL \u2014 5 g\/dL is incorrect. Option (b): Human milk protein is approximately 0.9\u20131.2 g\/dL \u2014 lower than cow\\'s milk (~3.5 g\/dL); this is incorrect. Option (c): Human milk DOES contain taurine and cysteine in significant amounts \u2014 this statement is incorrect. Option (d): Human milk contains long-chain PUFAs: DHA (omega-3) and ARA (arachidonic acid, omega-6), which are critical for brain development and retinal maturation in neonates. Despite the typographical imprecision (\\'omega-2\\' should read \\'omega-3\\'), this is the most nearly correct statement and is the intended answer.'},\n {id:106,stem:'Which of the following are age appropriate language milestones in a normally developing 2 year old child?\\n1. Vocabulary of 50-100 words\\n2. Uses pronouns\\n3. Occasional repeating of words\\n4. Stating his name when asked',correct:'1, 2 and 4',options:['1, 2 and 3','1, 2 and 4','1 and 3 only','2, 3 and 4'],exp:'At 24 months: (1) Vocabulary of at least 50 words \u2014 correct. (2) Uses pronouns (I, me, you, mine emerge around 2 years) \u2014 correct. (3) Occasional word repetition (echolalia) is NOT a normal 2-year milestone; persistent echolalia is a red flag for ASD or developmental delay \u2014 statement 3 is not an expected normal milestone. (4) States own name when asked is expected by 2 years \u2014 correct. Statements 1, 2, and 4 are age-appropriate.'},\n {id:107,stem:'Which of the following tools are used for developmental screening?\\n1. Denver-II\\n2. Ages and Stages Questionnaire\\n3. Parents Evaluation of Developmental Status\\n4. Bayley Scale for Infant and Toddler Development',correct:'1, 2 and 3',options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],exp:'Developmental screening tools are brief instruments to identify children needing comprehensive evaluation. Denver-II (DDST-II) is the most widely used screening tool globally and in India. Ages and Stages Questionnaire (ASQ) is a validated parent-completed screening questionnaire. Parents\\' Evaluation of Developmental Status (PEDS) is a standardised parent-report screening tool. The Bayley Scales of Infant and Toddler Development (Bayley-III\/IV) is a comprehensive DIAGNOSTIC (standardised norm-referenced assessment) tool \u2014 it is NOT a screening tool. Statements 1, 2, and 3 are developmental screening tools.'},\n {id:108,stem:\"According to King's College criteria, which of the following are the indicators for referring to liver transplantation following acetaminophen toxicity?\\n1. Transaminase levels > 4000 IU\/L\\n2. Acidaemia (Serum pH < 7\u00b73) after adequate fluid resuscitation\\n3. Coagulopathy (INR > 6)\\n4. Renal dysfunction (creatinine > 3\u00b74 mg\/dL)\",correct:'2, 3 and 4',options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],exp:\"King's College Criteria for liver transplant referral in paracetamol-induced acute liver failure: Either (A) arterial pH <7.3 after adequate resuscitation OR (B) All three: PT >100 seconds (INR >6.5), creatinine >300 \u03bcmol\/L (~3.4 mg\/dL) indicating hepatorenal syndrome, AND grade III\u2013IV hepatic encephalopathy. Transaminase levels (statement 1) are NOT part of King's College Criteria \u2014 very high transaminases occur in many cases and do not independently predict non-survival. Statements 2, 3, and 4 are all King's College components.\"},\n {id:109,stem:'Which one of the following statements is correct about intra-dermal fractional Inactivated Polio Vaccine (fIPV) with respect to intramuscular (I\/M) IPV?',correct:'fIPV is one-fifth of the I\/M dose of IPV',options:['fIPV is one-tenth of the I\/M dose of IPV','fIPV is one-fifth of the I\/M dose of IPV','fIPV is half of the I\/M dose of the IPV','fIPV is three-fourth of the I\/M dose of IPV'],exp:'Fractional IPV (fIPV) is administered intradermally at a dose of 0.1 mL, which is exactly one-fifth of the standard intramuscular IPV dose of 0.5 mL. Intradermal delivery bypasses the deep muscle injection and still elicits adequate seroconversion because the dermis is rich in antigen-presenting cells (Langerhans cells). WHO and India\\'s UIP recommend two doses of fIPV at 6 weeks and 14 weeks. The correct answer is one-fifth of the I\/M dose.'},\n {id:110,stem:\"Which one of the following statements is correct regarding the Government of India program 'Home-based care of the young child'?\",correct:'The grassroots health worker makes 6 home visits',options:['It was started in 2014','The grassroots health worker is the Anganwadi worker','The grassroots health worker makes 6 home visits','The infant is monitored from 3 months to 15 months of age'],exp:'The Home Based Care for Young Child (HBYC) programme is an extension of HBNC under India\\'s NHM. It was started in 2011 (not 2014). The grassroots health worker delivering HBYC is the ASHA (Accredited Social Health Activist) \u2014 not the Anganwadi worker. ASHA makes 6 scheduled home visits at 3, 6, 9, 12, and 15 months of age (plus one earlier visit at 2 months in some program versions). The number of home visits made by the ASHA under HBYC is 6. Statement (c) is correct.'},\n {id:111,stem:'In a child with high anion gap metabolic acidosis, poisoning with which of the following may be suspected?',correct:'Iron',options:['Iron','Digoxin','Rifampicin','Beta blockers'],exp:'High anion gap metabolic acidosis (HAGMA) in poisoning is caused by accumulation of unmeasured anions from toxic metabolites. Classic causes \u2014 MUDPILES mnemonic: Methanol, Uraemia, DKA, Propylene glycol, Isoniazid\/Iron, Lactic acidosis, Ethylene glycol, Salicylates. Iron poisoning causes HAGMA through: Fe\u00b2\u207a catalyses free radical generation (Fenton reaction) causing mitochondrial dysfunction and lactic acidosis; iron directly damages GI mucosa. Digoxin causes bradyarrhythmias. Rifampicin causes hepatotoxicity. Beta-blockers cause bradycardia. Iron is the correct answer.'},\n {id:112,stem:'Which one of the following is a \"Danger Sign\" for a newborn baby?',correct:'Respiratory rate more than 60\/min',options:['Temperature between 36\u00b70\u00b0C and 36\u00b75\u00b0C','Respiratory rate more than 60\/min','Heart rate of 120\/min','Weight loss of 8% within first week of life'],exp:'WHO\/IMNCI neonatal danger signs requiring urgent referral: not feeding well, convulsions, fast breathing (\u226560 breaths\/min), severe chest in-drawing, grunting, fever (\u226537.5\u00b0C) or hypothermia (<35.5\u00b0C), jaundice in first 24 hours or below umbilicus. Respiratory rate >60\/min is tachypnoea and a defined danger sign indicating possible pneumonia, sepsis, or respiratory distress. Heart rate of 120\/min is within the normal neonatal range (100\u2013160\/min). Weight loss of 8% is within normal physiological range (up to 10% is acceptable). Temperature 36.0\u201336.5\u00b0C is mild cold stress but the danger threshold is <35.5\u00b0C.'},\n {id:113,stem:'The codes given below represent specific type of permanent teeth:\\n1. Central and lateral incisors\\n2. Canines\\n3. Premolars\\n4. Molars\\nThe eruption of which of the following combinations will be close to menarche in girls?',correct:'3 and 4',options:['1 and 2','2 and 3','3 and 4','1 and 4'],exp:'Menarche in girls occurs at approximately 12\u201313 years of age. Permanent tooth eruption timeline: Central\/lateral incisors (1): 6\u20139 years. Canines (2): 9\u201312 years. Premolars (3): 10\u201312 years. 2nd Molars (4): 11\u201313 years. The teeth erupting closest to the time of menarche (~12\u201313 years) are the premolars (3) and the 2nd molars (4). Statements 3 and 4 correspond to the 11\u201313 year eruption window coinciding with menarche.'},\n {id:114,stem:'Urinary alkalinisation is used for enhancing excretion of which of the following poisoning?',correct:'Phenobarbitone',options:['Phenobarbitone','Alprazolam','Phenytoin','Lithium'],exp:'Urinary alkalinisation (IV sodium bicarbonate to maintain urine pH 7.5\u20138.0) enhances renal excretion of weak acids by ion trapping: at alkaline pH, the acid drug is in its ionised (charged) form which cannot be reabsorbed through the lipid-bilayer tubular membrane. Phenobarbitone (pKa ~7.3) is a weak acid \u2014 alkalinisation dramatically increases its renal clearance and is a treatment for phenobarbitone overdose. Salicylates are also treated this way. Alprazolam and phenytoin are not significantly excreted renally. Lithium excretion is handled by saline diuresis, not alkalinisation.'},\n {id:115,stem:'A 4 year old child is brought with a history of ingestion of 1 g of paracetamol two hours back. What should be the initial management?',correct:'Oral N-acetyl cysteine',options:['Induced vomiting','Gastric lavage','Oral N-acetyl cysteine','Alkaline diuresis'],exp:'For paracetamol overdose: N-acetylcysteine (NAC) is the specific antidote, maximally effective within 8\u201310 hours of ingestion. NAC replenishes hepatic glutathione stores, detoxifying the reactive metabolite NAPQI that causes hepatocellular necrosis. At 2 hours post-ingestion, oral NAC is the appropriate initial treatment. Induced vomiting risks aspiration and is no longer recommended. Gastric lavage has limited benefit after 1\u20132 hours. Alkaline diuresis is not indicated for paracetamol.'},\n {id:116,stem:'Antidote to reverse the muscarinic effects of organophosphate toxicity is',correct:'Atropine',options:['Pralidoxime aldoxime methiodide (PAM)','Atropine','Adrenaline','N-acetylcysteine'],exp:'Organophosphate poisoning inhibits acetylcholinesterase, causing ACh accumulation at both muscarinic and nicotinic synapses. Muscarinic effects (SLUDGE\/DUMBELS): salivation, lacrimation, urination, diarrhoea, bradycardia, bronchospasm, miosis \u2014 reversed by ATROPINE (competitive muscarinic receptor antagonist). Large IV doses of atropine are given until atropinisation is achieved (dry secretions, tachycardia, mydriasis). Pralidoxime (2-PAM) reactivates acetylcholinesterase by displacing the phosphate group \u2014 it reverses nicotinic effects and regenerates cholinesterase if given early (before \\'ageing\\'). PAM does not directly reverse muscarinic effects. Atropine is the antidote for muscarinic effects.'},\n {id:117,stem:'A 7 year old child is brought to the emergency with seizures and drowsiness. The child had been receiving some drugs for fever for the past two days. Child is found to be cyanosed with an oxygen saturation of 40% and unresponsive to oxygen therapy. Blood gas analysis reveals a normal PaO\u2082. Which drug intake may have caused the above condition?',correct:'Chloroquine',options:['Chloroquine','Amoxycillin-Clavulanic acid','Paracetamol','Mefenamic acid'],exp:'Cyanosis + SpO\u2082 40% + unresponsive to supplemental O\u2082 + NORMAL PaO\u2082 = hallmark of methaemoglobinaemia. MetHb contains Fe\u00b3\u207a (oxidised iron) and cannot carry O\u2082; pulse oximetry reads SpO\u2082 falsely low (~85%), blood appears chocolate-brown, and PaO\u2082 is normal because dissolved O\u2082 is unaffected. Chloroquine is a well-documented cause of drug-induced methaemoglobinaemia and can also cause convulsions and neurological toxicity in overdose. This child receiving drugs for fever, developing methaemoglobinaemia + seizures + cyanosis unresponsive to O\u2082 points to chloroquine. Treatment: methylene blue IV 1\u20132 mg\/kg.'},\n {id:118,stem:'Autism Spectrum Disorder is characterised by which of the following?\\n1. Onset before 3 years of age\\n2. Impaired verbal and gestural communication\\n3. Stereotypic and restrictive behavioural patterns\\n4. Tangential speech',correct:'1, 2 and 3',options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],exp:'ASD is characterised by two core domains (DSM-5): Domain A \u2014 Persistent deficits in social communication including impaired verbal and non-verbal (gestural) communication (statement 2). Domain B \u2014 Restricted, repetitive patterns of behaviour, interests, or activities (statement 3). Statement 1 (onset before 3 years) reflects classical DSM-IV criteria; DSM-5 states symptoms must be present in the early developmental period. Statement 4 (tangential speech) is a formal thought disorder feature seen in schizophrenia \u2014 the patient jumps from topic to unrelated topic \u2014 not characteristic of ASD. Statements 1, 2, and 3 are correct.'},\n {id:119,stem:'Which vaccines are stored in the top rack of the main refrigerator compartment at temperature of 4\u201310\u00b0C?',correct:'DPT, Hepatitis B, Measles, MMR vaccines',options:['DPT, Hepatitis B, Measles, MMR vaccines','DPT, TT, Hepatitis A vaccine','BCG, DPT and Typhoid','BCG, Measles and MMR vaccines'],exp:\"Under India's UIP cold chain guidelines, vaccines stored in the main refrigerator body (2\u20138\u00b0C, top racks 4\u201310\u00b0C) are those that must be kept cool but must NOT be frozen: DPT\/DT\/TT, Hepatitis B, Liquid pentavalent (DPTHibHepB), and measles-containing vaccines (measles, MMR). The freezer compartment (\u221220\u00b0C) is used for OPV. BCG is a lyophilised vaccine storable in either freezer or refrigerator. In the examination context, DPT, Hepatitis B, Measles, and MMR are the vaccines stored in the main refrigerator body \u2014 option (a) is the most comprehensive and correct answer.\"},\n {id:120,stem:\"Identification of '4Ds' is a key element of which National Health Programme?\",correct:'RBSK (Rashtriya Bal Swasthya Karyakram)',options:['IMNCI (Integrated Management of Childhood and Neonatal illness)','ICDS (Integrated Child Development Scheme)','RBSK (Rashtriya Bal Swasthya Karyakram)','JSSK (Janani Shishu Suraksha Karyakram)'],exp:\"The 4Ds in child health: Defects at Birth, Diseases (in children 0\u201318 years), Deficiencies, and Developmental Delays (including disabilities). These 4Ds are the four screening domains of the Rashtriya Bal Swasthya Karyakram (RBSK), launched by Government of India in 2013 under NHM. RBSK deploys mobile health teams to screen all children from birth to 18 years at schools and anganwadi centres for 30 conditions falling under the 4Ds. IMNCI focuses on management of sick children under 5. ICDS provides nutrition and early childhood education. JSSK provides entitlements for pregnant women and newborns.\"}\n ];\n\n const LETTERS=['A','B','C','D'];\n let userAnswers={},answered=0,shuffledOpts={};\n let timerRunning=false,timerRemaining=TIMER_SECS,timerInterval=null,graceInterval=null,quizSubmitted=false;\n function shuffle(arr){const a=arr.slice();for(let i=a.length-1;i>0;i--){const j=Math.floor(Math.random()*(i+1));[a[i],a[j]]=[a[j],a[i]];}return a;}\n function fmtTime(s){const m=Math.floor(s\/60),sec=s%60;return(m<10?'0':'')+m+':'+(sec<10?'0':'')+sec;}\n function startTimer(){\n if(timerRunning||quizSubmitted)return;timerRunning=true;\n const btn=document.getElementById(NS+'-timer-btn');btn.textContent='\u23f1 '+fmtTime(timerRemaining);btn.classList.add('running');\n document.getElementById(NS+'-timer-item').classList.add('active');\n timerInterval=setInterval(function(){\n timerRemaining--;const disp=fmtTime(timerRemaining);\n 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Display',serif;font-size:0.95rem;font-weight:700;cursor:pointer;transition:background 0.2s}\n#cms22p1c .cq-grace-btn:hover{background:#c62828}\n#cms22p1c .cq-header{background:var(--teal);color:var(--white);padding:28px 24px 22px;text-align:center}\n#cms22p1c .cq-header h1{font-family:'Playfair Display',serif;font-size:1.45rem;font-weight:700;letter-spacing:0.01em;line-height:1.3}\n#cms22p1c .cq-header p{font-size:0.85rem;opacity:0.85;margin-top:6px;font-style:italic}\n#cms22p1c .cq-meta{display:flex;justify-content:center;gap:16px;margin-top:14px;flex-wrap:wrap;align-items:center}\n#cms22p1c .cq-badge{background:rgba(255,255,255,0.15);border:1px solid rgba(255,255,255,0.3);border-radius:20px;padding:4px 14px;font-size:0.78rem;letter-spacing:0.03em}\n#cms22p1c .cq-timer-btn{background:transparent;border:1.5px solid rgba(255,255,255,0.7);color:var(--white);border-radius:20px;padding:4px 14px;font-family:'Source Serif 4',serif;font-size:0.78rem;cursor:pointer;letter-spacing:0.03em;transition:background 0.2s;display:flex;align-items:center;gap:6px}\n#cms22p1c .cq-timer-btn:hover{background:rgba(255,255,255,0.15)}\n#cms22p1c .cq-timer-btn.running{background:rgba(255,255,255,0.2);border-color:var(--white)}\n#cms22p1c .cq-body{max-width:760px;margin:0 auto;padding:0 16px}\n#cms22p1c .cq-card{background:var(--white);border:1px solid var(--line);border-radius:var(--radius);margin:24px 0;overflow:hidden;transition:box-shadow 0.2s}\n#cms22p1c .cq-card:hover{box-shadow:0 2px 12px rgba(26,94,168,0.1)}\n#cms22p1c .cq-qhead{background:var(--ter-pale);border-bottom:1px solid var(--line);padding:14px 18px;display:flex;gap:12px;align-items:flex-start}\n#cms22p1c .cq-qnum{flex-shrink:0;width:26px;height:26px;border-radius:50%;background:var(--ter);color:#fff;font-size:0.72rem;font-weight:700;display:flex;align-items:center;justify-content:center;margin-top:2px;transition:background 0.2s}\n#cms22p1c 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.cq-band-c{background:var(--correct-bg);color:var(--correct)}\n#cms22p1c .cq-band-w{background:var(--wrong-bg);color:var(--wrong)}\n#cms22p1c .cq-band-s{background:var(--teal-pale);color:var(--teal)}\n#cms22p1c .cq-retry-btn{margin-top:22px;background:transparent;border:2px solid var(--ter);color:var(--ter);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#cms22p1c .cq-retry-btn:hover{background:var(--ter);color:var(--white)}\n@media(max-width:480px){#cms22p1c .cq-header h1{font-size:1.15rem}#cms22p1c .cq-qtext{font-size:0.88rem}#cms22p1c .cq-opt-text{font-size:0.84rem}}\n<\/style>\n<\/head>\n<body>\n<div id=\"cms22p1c\">\n <div class=\"cq-sentinel\" id=\"cms22p1c-sentinel\"><\/div>\n <div class=\"cq-statusbar\" id=\"cms22p1c-statusbar\">\n <div class=\"cq-sb-stats\">\n <div class=\"cq-timer-item\" id=\"cms22p1c-timer-item\">\u23f1 <strong id=\"cms22p1c-timer-display\">40:00<\/strong><\/div>\n <div class=\"cq-sb-item\">\u2705 <strong id=\"cms22p1c-sc\">0<\/strong><\/div>\n <div class=\"cq-sb-item\">\u274c <strong id=\"cms22p1c-sw\">0<\/strong><\/div>\n <div class=\"cq-sb-item\">\u23f3 <strong id=\"cms22p1c-sr\">40<\/strong> left<\/div>\n <div class=\"cq-sb-sep\"><\/div>\n <div class=\"cq-sb-item\">Net <strong id=\"cms22p1c-sn\">0<\/strong> \/ <strong id=\"cms22p1c-sm\">160<\/strong><\/div>\n <\/div>\n <div class=\"cq-sb-progress\"><div class=\"cq-sb-fill\" id=\"cms22p1c-fill\"><\/div><\/div>\n <\/div>\n <div class=\"cq-grace\" id=\"cms22p1c-grace\">\n <div class=\"cq-grace-box\">\n <h3>Time's Up!<\/h3><p>Submitting in<\/p>\n <div class=\"cq-grace-count\" id=\"cms22p1c-grace-count\">10<\/div>\n <button class=\"cq-grace-btn\" id=\"cms22p1c-grace-now\">Submit Now<\/button>\n <\/div>\n <\/div>\n <div class=\"cq-header\">\n <h1>Combined Medical Services Examination 2022<br>General Medicine & Paediatrics \u00b7 Paper I \u00b7 Part C<\/h1>\n <p>Infectious Disease \u00b7 Dermatology \u00b7 Psychiatry \u00b7 Emergency & Poisoning \u00b7 Paediatrics \u00b7 National Health Programmes<\/p>\n <div class=\"cq-meta\">\n <span class=\"cq-badge\">Questions 81 \u2013 120<\/span>\n <span class=\"cq-badge\">Options reshuffled<\/span>\n <button class=\"cq-timer-btn\" id=\"cms22p1c-timer-btn\">\u23f1 Start Timed Mode<\/button>\n <\/div>\n <\/div>\n <div class=\"cq-body\">\n <div id=\"cms22p1c-questions\"><\/div>\n <div class=\"cq-submit-wrap\"><button class=\"cq-btn\" id=\"cms22p1c-submit\">Submit Answers<\/button><\/div>\n <div class=\"cq-score\" id=\"cms22p1c-score\">\n <div class=\"cq-score-ring\" id=\"cms22p1c-ring\"><div class=\"cq-ring-inner\"><span class=\"cq-ring-pct\" id=\"cms22p1c-ring-pct\">0%<\/span><span class=\"cq-ring-sub\">score<\/span><\/div><\/div>\n <h2>Your Result<\/h2>\n <div class=\"cq-net-line\" id=\"cms22p1c-net-line\"><\/div>\n <div class=\"cq-verdict\" id=\"cms22p1c-verdict\"><\/div>\n <div class=\"cq-score-bands\">\n <span class=\"cq-band cq-band-c\" id=\"cms22p1c-ct-c\"><\/span>\n <span class=\"cq-band cq-band-w\" id=\"cms22p1c-ct-w\"><\/span>\n <span class=\"cq-band cq-band-s\" id=\"cms22p1c-ct-s\"><\/span>\n <\/div>\n <button class=\"cq-retry-btn\" id=\"cms22p1c-retry\">\u21ba Retry Quiz<\/button>\n <\/div>\n <\/div>\n<\/div>\n<script>\n(function(){\n 'use strict';\n const NS='cms22p1c',TOTAL=40,MAX=160,TIMER_SECS=2400,GRACE_SECS=10;\n const QUESTIONS=[\n {id:81,stem:'The first line investigation for diagnostic evaluation of patients with hypercalcaemia is',correct:'Serum i PTH levels',options:['24 hour urinary calcium excretion','Serum phosphate levels','Serum i PTH levels','Serum vitamin D levels'],exp:'The most common causes of hypercalcaemia are primary hyperparathyroidism (PHPT) and malignancy, accounting for >90% of cases. Intact PTH (iPTH) is the single most discriminating first-line test: in PHPT, iPTH is elevated or inappropriately normal despite hypercalcaemia; in malignancy-associated hypercalcaemia, iPTH is suppressed. This distinction guides all further investigation. Serum iPTH is the correct first-line test.'},\n {id:82,stem:\"Consider the following conditions:\\n1. Kaposi's sarcoma\\n2. Lymphoma\\n3. Tuberculosis\\n4. Persistent generalised lymphadenopathy\\nWhich of the above are causes of lymphadenopathy in a HIV positive patient?\",correct:'1, 2, 3 and 4',options:['1 and 3 only','2 and 3 only','1, 2 and 4 only','1, 2, 3 and 4'],exp:'All four are recognised causes of lymphadenopathy in HIV. Persistent generalised lymphadenopathy (PGL) is a direct manifestation of HIV itself (follicular hyperplasia). TB is the most common infectious cause of lymphadenopathy in HIV-positive patients in India. Non-Hodgkin lymphoma (and Hodgkin lymphoma) are AIDS-defining malignancies. Kaposi\\'s sarcoma (HHV-8 driven) causes lymph node, skin, and visceral involvement. All four are correct.'},\n {id:83,stem:'A patient receiving chemotherapy develops neutropenia. He presents with fever, cough, expectoration, chest pain and haemoptysis. His CT scan of chest reveals nodular infiltrates with halo sign and crescent sign. The most useful drug for treating him is',correct:'Voriconazole',options:['Colistin','Granulocyte Macrophage Colony','Voriconazole','Piperacillin-tazobactam'],exp:'Neutropenia + fever + CT halo sign (ground-glass halo around a nodule = early angioinvasive fungal disease) and air-crescent sign (late sign as infarcted tissue retracts) = invasive pulmonary aspergillosis (IPA). Voriconazole is the first-line treatment for IPA (IDSA\/ECMM guidelines), superior to amphotericin B in both efficacy and tolerability. Colistin treats MDR gram-negative bacteria. Piperacillin-tazobactam treats bacterial neutropenic sepsis.'},\n {id:84,stem:'A patient undergoes splenectomy after an accident. He will require oral prophylaxis against which of the following organisms?',correct:'Streptococcus pneumoniae',options:['Staphylococcus aureus','Escherichia coli','Streptococcus pneumoniae','Pneumocystis corinii'],exp:'The spleen is essential for clearance of encapsulated bacteria. Post-splenectomy patients are at lifelong risk of overwhelming post-splenectomy infection (OPSI). The three most important encapsulated organisms: Streptococcus pneumoniae (most common and most dangerous), Haemophilus influenzae type b, and Neisseria meningitidis. Management: vaccination against all three + lifelong oral penicillin V (or amoxicillin) prophylaxis.'},\n {id:85,stem:'A 30 year old male recently diagnosed with HIV presented with odynophagia. He was started on proton-pump inhibitor and an upper GI endoscopy was done. There were serpiginous ulcers in a normal surrounding mucosa in distal oesophagus. The most likely diagnosis is',correct:'Herpes simplex esophagitis',options:['Herpes simplex esophagitis','Gastro-esophageal reflux disease','Cytomegalovirus esophagitis','Candida esophagitis'],exp:'The key endoscopic discriminator: HSV oesophagitis causes multiple small, shallow, punched-out or serpiginous ulcers on a background of NORMAL-appearing mucosa. CMV oesophagitis produces one or a few large, deep, well-defined, solitary ulcers (often >1 cm) predominantly in the distal oesophagus. Candida oesophagitis shows white plaques\/pseudomembranes. GERD would not produce discrete ulcers in normal mucosa. Serpiginous ulcers with normal surrounding mucosa = HSV oesophagitis. Treatment: aciclovir.'},\n {id:86,stem:'Which one of the following statements regarding post gonococcal urethritis (PGU) is correct?',correct:'PGU refers to non-gonococcal urethritis in men treated earlier with single dose of penicillin',options:['Neisseria gonorrhoea is the most frequent cause of PGU in men','PGU refers to non-gonococcal urethritis in men treated earlier with single dose of penicillin','Combination therapy with azithromycin leads to resistance and should be avoided.','PGU usually occurs within one week after treatment of non-gonococcal urethritis.'],exp:'Post-gonococcal urethritis (PGU) occurs in men treated for gonorrhoea (typically with a single dose of penicillin or ampicillin, which eradicates N. gonorrhoeae but not co-infecting organisms) who subsequently develop persistent urethritis. PGU is caused by co-infecting agents \u2014 most commonly Chlamydia trachomatis, Ureaplasma urealyticum, or Mycoplasma genitalium. It typically appears 1\u20133 weeks after treatment of gonorrhoea. The correct definition is option (b).'},\n {id:87,stem:'Which one of the following treatments is considered as Gold standard for brucellosis in adults?',correct:'Streptomycin and Doxycycline',options:['Streptomycin and Doxycycline','Azithromycin and Rifampin','Trimethoprim and Sulfamethoxazole','Amikacin and Ciprofloxacin'],exp:'The WHO-recommended gold standard treatment for brucellosis in adults is doxycycline 100 mg twice daily for 6 weeks PLUS streptomycin 1 g IM daily for the first 2\u20133 weeks. This combination has the lowest relapse rate (~5%). The alternative is doxycycline + rifampicin (oral, 6 weeks) \u2014 used when IM injections are impractical. Combination therapy is essential because monotherapy leads to high relapse rates due to intracellular persistence of Brucella.'},\n {id:88,stem:'Which one of the following has the highest risk of human immunodeficiency virus (HIV) transmission after single exposure to an HIV-infected source?',correct:'Blood transfusion',options:['Vaginal delivery','Vaginal intercourse','Blood transfusion','Percutaneous needle stick injury'],exp:'HIV transmission risk per single exposure: Blood transfusion with HIV-infected blood: ~90\u201395% \u2014 by far the highest risk. Mother-to-child (vaginal delivery without prophylaxis): ~10\u201330% per pregnancy. Receptive anal intercourse: ~0.5\u20133%. Vaginal intercourse (receptive): ~0.1\u20130.2%. Percutaneous needle-stick: ~0.3%. Blood transfusion carries the highest per-exposure risk because large volumes of cell-free and cell-associated virus are inoculated directly into the bloodstream, bypassing all mucosal barriers.'},\n {id:89,stem:'Consider the following statements with regard to vitamin C:\\n1. It is heat stable.\\n2. Normal platelets are poor in ascorbate.\\n3. Perifollicular hyperkeratosis is a clinical sign of scurvy.\\n4. Infants fed exclusively on boiled milk are vitamin C deficient.\\nWhich of the above statements are correct?',correct:'3 and 4',options:['1 and 2','2 and 3','1 and 4','3 and 4'],exp:\"Statement 1 is false \u2014 vitamin C is highly heat-labile; it is destroyed by cooking and boiling, which is clinically relevant. Statement 2 is false \u2014 platelets (and leucocytes) are rich in ascorbate, concentrating it 40\u201380\u00d7 higher than plasma; platelet ascorbate is a marker of tissue vitamin C status. Statement 3 is correct \u2014 perifollicular hyperkeratosis (follicular plugging with coiled 'corkscrew' hairs surrounded by hyperkeratotic papules) is a characteristic early sign of scurvy. Statement 4 is correct \u2014 cow's milk already has low vitamin C; boiling destroys the residual ascorbate. Infants fed boiled cow's milk are at high risk of infantile scurvy (Barlow's disease). Statements 3 and 4 are correct.\"},\n {id:90,stem:'Which of the following statements are correct in respect of vitamin D?\\n1. Skin exposure to sunlight is the main source\\n2. Deficiency of vitamin D causes distal muscle weakness\\n3. Vitamin D synthesis decreases in winter, as one moves away from equator\\n4. Body store accumulated during summer is consumed during winter',correct:'1, 3 and 4',options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],exp:'Statement 1 is correct \u2014 solar UVB irradiation (290\u2013315 nm) converts 7-dehydrocholesterol in the skin to cholecalciferol (vitamin D3), providing 80\u201390% of the body\\'s vitamin D. Statement 2 is false \u2014 vitamin D deficiency myopathy causes PROXIMAL muscle weakness (difficulty rising from a chair, climbing stairs), not distal. Statement 3 is correct \u2014 at higher latitudes, winter UVB is filtered by the atmosphere; synthesis is negligible north of ~35\u00b0N in winter months. Statement 4 is correct \u2014 excess vitamin D synthesised during summer is stored in adipose tissue and liver and consumed during winter. Statements 1, 3, and 4 are correct.'},\n {id:91,stem:'Which of the following are used in the treatment of Acne vulgaris?\\n1. Topical benzoyl peroxide\\n2. Topical antibiotics like clindamycin\\n3. Oral isotretinoin\\n4. Oral ivermectin',correct:'1, 2 and 3',options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],exp:'Topical benzoyl peroxide: bactericidal against C. acnes via oxidative stress; comedolytic; does not induce antibiotic resistance. Topical clindamycin: reduces C. acnes; always combined with benzoyl peroxide to prevent resistance. Oral isotretinoin (13-cis-retinoic acid): most effective for severe nodular\/cystic acne, targeting all four pathogenic factors. Oral ivermectin is used for scabies and strongyloidiasis \u2014 it has no role in acne vulgaris. Statements 1, 2, and 3 are correct.'},\n {id:92,stem:'Which one of the following is a cause of scarring alopecia?',correct:'Radiotherapy',options:['Androgenic alopecia','Alopecia Areata','Syphilis','Radiotherapy'],exp:'Non-scarring alopecias (reversible): androgenic alopecia (follicles remain viable), alopecia areata (T-cell-mediated but follicle bulb preserved), syphilitic alopecia (moth-eaten pattern, reversible with treatment). Scarring alopecias involve permanent destruction of follicular stem cells in the bulge region, replaced by fibrosis. Radiotherapy (ionising radiation) causes direct DNA damage to follicular stem cells, producing irreversible scarring alopecia at doses >45 Gy. Other causes: discoid lupus, lichen planopilaris.'},\n {id:93,stem:'Which of the following are used as mood stabilizers for treatment of bipolar disorder?\\n1. Valproic acid\\n2. Lamotrigine\\n3. Carbamazepine\\n4. Propranolol',correct:'1, 2 and 3',options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],exp:'Valproic acid: effective for acute mania, mixed states, and bipolar maintenance. Lamotrigine: particularly effective for bipolar depression and maintenance, preventing depressive episodes. Carbamazepine: approved for acute mania; used as second-line or when lithium is contraindicated. Propranolol is a \u03b2-blocker used for essential tremor, performance anxiety, and migraine prophylaxis \u2014 it has no mood-stabilising properties and is not used in bipolar disorder. Statements 1, 2, and 3 are correct.'},\n {id:94,stem:'An elderly alcoholic man who mainly eats a diet of maize and maize products presents with complaints of chronic diarrhoea, severe sunburn-like lesions on exposed parts and acute delirium. He is admitted. What is the likely diagnosis and its treatment?',correct:'Pellagra, Niacin therapy',options:[\"Celiac disease, Gluten free diet\",'Vitamin B 12 deficiency, Parenteral B 12 therapy','Pellagra, Niacin therapy',\"Whipple's disease, Doxycycline + Trimethoprim\"],exp:\"The classic triad of pellagra \u2014 the '3 Ds': Dermatitis (photosensitive skin lesions in sun-exposed areas, Casal's necklace), Diarrhoea, and Dementia (confusion, delirium) \u2014 is caused by niacin (vitamin B3) deficiency. Risk factors: maize-based diet (niacin in maize is in bound unabsorbable niacytin form) and alcoholism (poor dietary intake and impaired tryptophan-to-niacin conversion). Treatment: oral niacinamide (nicotinamide) 100\u2013300 mg\/day. A 4th D \u2014 Death \u2014 occurs without treatment.\"},\n {id:95,stem:'Which one of the following is an indication for self-injectable adrenaline (epinephrine)?',correct:'Anaphylaxis to allergens that are difficult to avoid',options:['Anaphylaxis to allergens that are difficult to avoid','Cardiogenic shock','Pheochromocytoma','Complete heart block'],exp:'Self-injectable adrenaline (auto-injector, e.g. EpiPen) is prescribed for patients at risk of future severe anaphylaxis who may not have immediate access to emergency care. The key indication is anaphylaxis to allergens that are difficult or impossible to avoid \u2014 e.g. venom allergy (bee, wasp), food allergy (peanuts, shellfish), latex allergy. Cardiogenic shock requires IV adrenaline in hospital. Pheochromocytoma is a contraindication. Complete heart block requires pacing or IV atropine.'},\n {id:96,stem:'Which of the following statements with regard to arterio-venous fistula in dialysis patient are correct?\\n1. Distension and thickening of vessel wall occurs\\n2. Formed upto a year before dialysis is contemplated\\n3. Leg veins are usually preferred\\n4. Synthetic graft may be used if fistula formation is not possible',correct:'1, 2 and 4',options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],exp:\"Statement 1 is correct \u2014 after AVF creation, the vein 'arterialises' under arterial pressure: vessel wall thickens and flow velocity increases. Statement 2 is correct \u2014 the AVF requires 4\u20136 weeks minimum for maturation; guidelines recommend planning 6\u201312 months before anticipated dialysis start. Statement 3 is false \u2014 arm veins (forearm radiocephalic, upper arm brachiocephalic) are strongly preferred; leg vein AVFs are specifically avoided due to poor accessibility, higher infection risk, and risk of limb ischaemia. Statement 4 is correct \u2014 when suitable native veins are unavailable, an arteriovenous graft (synthetic PTFE) is the next option. Statements 1, 2, and 4 are correct.\"},\n {id:97,stem:'An infant was born at 30 weeks of gestation and weighs 1\u00b72 kg at birth. Which of the following is the recommended initial feeding method?',correct:'Orogastric feeding',options:['Intravenous fluids only','Feeding by spoon and katori','Breastfeeding','Orogastric feeding'],exp:'A preterm infant born at 30 weeks has an immature suck-swallow-breathe reflex (matures at approximately 32\u201334 weeks). Direct breastfeeding and spoon\/katori feeding require coordinated suck-swallow reflex and would cause aspiration at 30 weeks. Expressed breast milk (EBM) is the preferred feed for all preterm infants. The route of delivery at 30 weeks is orogastric (or nasogastric) tube feeding of EBM. IV fluids alone are nutritionally insufficient for prolonged use. Orogastric feeding with expressed breast milk is the correct initial method.'},\n {id:98,stem:'A newborn delivered at 32 weeks gestation is started on spoon feeds after birth. On feeding with spoon, the baby demonstrates some spilling and coughing. What is the next step in management?',correct:'Orogastric or nasogastric tube feeding',options:['Orogastric or nasogastric tube feeding','Intravenous fluid therapy','Gastrostomy tube feeding','Breastfeeding'],exp:'At 32 weeks gestation, the suck-swallow-breathe coordination is still immature; spillage and coughing (aspiration risk) occur with spoon feeds. The appropriate next step is orogastric or nasogastric tube feeding of expressed breast milk, which bypasses the need for suck-swallow coordination and ensures safe, adequate caloric delivery. Gastrostomy is reserved for infants requiring prolonged enteral feeding (e.g. severe neurological impairment). IV fluids alone deprive the infant of enteral nutrition benefits.'},\n {id:99,stem:'A child speaks bisyllables like Ma-Ma and Ba-Ba. He is able to sit without support, and looks at the source of sound diagonally. His likely age is',correct:'6 months',options:['4 months','6 months','8 months','10 months'],exp:'Bisyllables (double consonants: ma-ma, ba-ba, da-da \u2014 non-specific use) is a 6-month speech milestone per standard Indian paediatric textbooks (Ghai). Indirect localisation of sound (looking towards a sound source obliquely\/diagonally, not directly) corresponds to the 4\u20136 month auditory developmental level. Sitting with partial support begins at 6 months; sitting without support is between 7\u20139 months in most texts, though some early achievers reach it at 6\u20137 months. The clustering of bisyllables + early sitting + indirect sound localisation places the developmental age at 6 months.'},\n {id:100,stem:'After sustaining a head injury, an 18 month old child displays eye opening only to pain, moans on painful stimuli and withdraws to painful stimuli. What is the modified Glasgow Coma Scale Score in this child?',correct:'8',options:['6','8','10','12'],exp:'Modified GCS for an 18-month-old: Eye opening (E): opens to pain only = 2. Verbal response (V): moaning to painful stimuli = 2 (incomprehensible sounds \/ abnormal vocalisation in paediatric modification). Motor response (M): withdraws from pain = 4 (normal flexion\/withdrawal). Total GCS = E2 + V2 + M4 = 8. A GCS of 8 defines severe TBI and is the threshold at which airway protection (intubation) is typically considered.'},\n {id:101,stem:'Which of the following are reversible causes of electromechanical dissociation seen in pulseless electrical activity?\\n1. Pericardial tamponade\\n2. Pulmonary thrombo-embolism\\n3. Hyperthermia\\n4. Hypokalemia',correct:'1, 2 and 4',options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],exp:'PEA is managed by identifying and reversing the underlying cause \u2014 the 4Hs and 4Ts. 4Hs: Hypoxia, Hypovolaemia, Hypo\/Hyperkalaemia, Hypothermia. 4Ts: Tension pneumothorax, Tamponade (cardiac), Toxins\/drugs, Thrombosis (pulmonary or coronary). Pericardial tamponade (1) is a classic 4T reversible cause. Pulmonary thrombo-embolism (2) is a 4T reversible cause. Hypokalemia (4) falls under the 4H category. Hyperthermia (3) is NOT in the standard 4H\/4T list \u2014 Hypothermia is a 4H cause, not hyperthermia. Statements 1, 2, and 4 are correct.'},\n {id:102,stem:'A 3-day old newborn presents with jaundice since birth. Examination reveals pallor and hepatosplenomegaly. The newborn also has a cephalhematoma. Which one of the following is the most important indicator to the diagnosis of pathologic jaundice?',correct:'Clinical jaundice since birth',options:['Pallor','Hepatosplenomegaly','Clinical jaundice since birth','Cephalhematoma'],exp:'The most important single indicator distinguishing pathological from physiological jaundice is the TIME of onset. Physiological neonatal jaundice appears on day 2\u20133 of life (never on day 1). Jaundice appearing within 24 hours of birth (since birth = day 1) is ALWAYS pathological by definition. Causes include haemolytic disease of the newborn (Rh incompatibility, ABO incompatibility), congenital infections, and sepsis. Jaundice since birth is the most important indicator of pathological jaundice.'},\n {id:103,stem:'What is the diagnosis of Autism Spectrum Disorder primarily based upon?',correct:'Clinical criteria only',options:['Clinical criteria only','Clinical criteria and genetic studies only','Clinical criteria and MRI brain only','Clinical criteria, genetic studies and MRI brain'],exp:'ASD is diagnosed entirely on clinical criteria \u2014 there is no confirmatory biomarker, genetic test, or neuroimaging finding that establishes the diagnosis. DSM-5 clinical criteria require: persistent deficits in social communication and social interaction AND restricted, repetitive patterns of behaviour, interests, or activities, with symptoms present in early developmental period, causing significant functional impairment. Genetic testing may identify treatable co-morbidities but does not establish the ASD diagnosis. The diagnosis is based on clinical criteria only.'},\n {id:104,stem:'According to the National AIDS Control Program, which one of the following drugs is given to newborns born to HIV-positive mothers to prevent mother to child transmission of HIV infection?',correct:'Nevirapine',options:['Nevirapine','Stavudine','Indinavir','Ritonavir'],exp:'Under the NACP and WHO guidelines for PMTCT of HIV: the infant born to an HIV-positive mother receives a single dose of nevirapine (NVP) immediately at birth (within 72 hours), followed by daily NVP syrup for 6 weeks. Nevirapine is an NNRTI with excellent oral bioavailability, good CNS penetration, and a long half-life \u2014 making it ideal for infant prophylaxis. Stavudine and the protease inhibitors (indinavir, ritonavir) are not used for this indication.'},\n {id:105,stem:'Which one of the following statements is correct in context of human breast milk?',correct:'Human milk contains omega 2 and omega 6 (very long chain) fatty acids',options:['The concentration of lactose is 5g\/dL','The protein content is higher than that in animal milk','Human milk does not contain taurine and cysteine like animal milk and formula milk','Human milk contains omega 2 and omega 6 (very long chain) fatty acids'],exp:'Option (a): Human breast milk lactose concentration is approximately 7 g\/dL \u2014 5 g\/dL is incorrect. Option (b): Human milk protein is approximately 0.9\u20131.2 g\/dL \u2014 lower than cow\\'s milk (~3.5 g\/dL); this is incorrect. Option (c): Human milk DOES contain taurine and cysteine in significant amounts \u2014 this statement is incorrect. Option (d): Human milk contains long-chain PUFAs: DHA (omega-3) and ARA (arachidonic acid, omega-6), which are critical for brain development and retinal maturation in neonates. Despite the typographical imprecision (\\'omega-2\\' should read \\'omega-3\\'), this is the most nearly correct statement and is the intended answer.'},\n {id:106,stem:'Which of the following are age appropriate language milestones in a normally developing 2 year old child?\\n1. Vocabulary of 50-100 words\\n2. Uses pronouns\\n3. Occasional repeating of words\\n4. Stating his name when asked',correct:'1, 2 and 4',options:['1, 2 and 3','1, 2 and 4','1 and 3 only','2, 3 and 4'],exp:'At 24 months: (1) Vocabulary of at least 50 words \u2014 correct. (2) Uses pronouns (I, me, you, mine emerge around 2 years) \u2014 correct. (3) Occasional word repetition (echolalia) is NOT a normal 2-year milestone; persistent echolalia is a red flag for ASD or developmental delay \u2014 statement 3 is not an expected normal milestone. (4) States own name when asked is expected by 2 years \u2014 correct. Statements 1, 2, and 4 are age-appropriate.'},\n {id:107,stem:'Which of the following tools are used for developmental screening?\\n1. Denver-II\\n2. Ages and Stages Questionnaire\\n3. Parents Evaluation of Developmental Status\\n4. Bayley Scale for Infant and Toddler Development',correct:'1, 2 and 3',options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],exp:'Developmental screening tools are brief instruments to identify children needing comprehensive evaluation. Denver-II (DDST-II) is the most widely used screening tool globally and in India. Ages and Stages Questionnaire (ASQ) is a validated parent-completed screening questionnaire. Parents\\' Evaluation of Developmental Status (PEDS) is a standardised parent-report screening tool. The Bayley Scales of Infant and Toddler Development (Bayley-III\/IV) is a comprehensive DIAGNOSTIC (standardised norm-referenced assessment) tool \u2014 it is NOT a screening tool. Statements 1, 2, and 3 are developmental screening tools.'},\n {id:108,stem:\"According to King's College criteria, which of the following are the indicators for referring to liver transplantation following acetaminophen toxicity?\\n1. Transaminase levels > 4000 IU\/L\\n2. Acidaemia (Serum pH < 7\u00b73) after adequate fluid resuscitation\\n3. Coagulopathy (INR > 6)\\n4. Renal dysfunction (creatinine > 3\u00b74 mg\/dL)\",correct:'2, 3 and 4',options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],exp:\"King's College Criteria for liver transplant referral in paracetamol-induced acute liver failure: Either (A) arterial pH <7.3 after adequate resuscitation OR (B) All three: PT >100 seconds (INR >6.5), creatinine >300 \u03bcmol\/L (~3.4 mg\/dL) indicating hepatorenal syndrome, AND grade III\u2013IV hepatic encephalopathy. Transaminase levels (statement 1) are NOT part of King's College Criteria \u2014 very high transaminases occur in many cases and do not independently predict non-survival. Statements 2, 3, and 4 are all King's College components.\"},\n {id:109,stem:'Which one of the following statements is correct about intra-dermal fractional Inactivated Polio Vaccine (fIPV) with respect to intramuscular (I\/M) IPV?',correct:'fIPV is one-fifth of the I\/M dose of IPV',options:['fIPV is one-tenth of the I\/M dose of IPV','fIPV is one-fifth of the I\/M dose of IPV','fIPV is half of the I\/M dose of the IPV','fIPV is three-fourth of the I\/M dose of IPV'],exp:'Fractional IPV (fIPV) is administered intradermally at a dose of 0.1 mL, which is exactly one-fifth of the standard intramuscular IPV dose of 0.5 mL. Intradermal delivery bypasses the deep muscle injection and still elicits adequate seroconversion because the dermis is rich in antigen-presenting cells (Langerhans cells). WHO and India\\'s UIP recommend two doses of fIPV at 6 weeks and 14 weeks. The correct answer is one-fifth of the I\/M dose.'},\n {id:110,stem:\"Which one of the following statements is correct regarding the Government of India program 'Home-based care of the young child'?\",correct:'The grassroots health worker makes 6 home visits',options:['It was started in 2014','The grassroots health worker is the Anganwadi worker','The grassroots health worker makes 6 home visits','The infant is monitored from 3 months to 15 months of age'],exp:'The Home Based Care for Young Child (HBYC) programme is an extension of HBNC under India\\'s NHM. It was started in 2011 (not 2014). The grassroots health worker delivering HBYC is the ASHA (Accredited Social Health Activist) \u2014 not the Anganwadi worker. ASHA makes 6 scheduled home visits at 3, 6, 9, 12, and 15 months of age (plus one earlier visit at 2 months in some program versions). The number of home visits made by the ASHA under HBYC is 6. Statement (c) is correct.'},\n {id:111,stem:'In a child with high anion gap metabolic acidosis, poisoning with which of the following may be suspected?',correct:'Iron',options:['Iron','Digoxin','Rifampicin','Beta blockers'],exp:'High anion gap metabolic acidosis (HAGMA) in poisoning is caused by accumulation of unmeasured anions from toxic metabolites. Classic causes \u2014 MUDPILES mnemonic: Methanol, Uraemia, DKA, Propylene glycol, Isoniazid\/Iron, Lactic acidosis, Ethylene glycol, Salicylates. Iron poisoning causes HAGMA through: Fe\u00b2\u207a catalyses free radical generation (Fenton reaction) causing mitochondrial dysfunction and lactic acidosis; iron directly damages GI mucosa. Digoxin causes bradyarrhythmias. Rifampicin causes hepatotoxicity. Beta-blockers cause bradycardia. Iron is the correct answer.'},\n {id:112,stem:'Which one of the following is a \"Danger Sign\" for a newborn baby?',correct:'Respiratory rate more than 60\/min',options:['Temperature between 36\u00b70\u00b0C and 36\u00b75\u00b0C','Respiratory rate more than 60\/min','Heart rate of 120\/min','Weight loss of 8% within first week of life'],exp:'WHO\/IMNCI neonatal danger signs requiring urgent referral: not feeding well, convulsions, fast breathing (\u226560 breaths\/min), severe chest in-drawing, grunting, fever (\u226537.5\u00b0C) or hypothermia (<35.5\u00b0C), jaundice in first 24 hours or below umbilicus. Respiratory rate >60\/min is tachypnoea and a defined danger sign indicating possible pneumonia, sepsis, or respiratory distress. Heart rate of 120\/min is within the normal neonatal range (100\u2013160\/min). Weight loss of 8% is within normal physiological range (up to 10% is acceptable). Temperature 36.0\u201336.5\u00b0C is mild cold stress but the danger threshold is <35.5\u00b0C.'},\n {id:113,stem:'The codes given below represent specific type of permanent teeth:\\n1. Central and lateral incisors\\n2. Canines\\n3. Premolars\\n4. Molars\\nThe eruption of which of the following combinations will be close to menarche in girls?',correct:'3 and 4',options:['1 and 2','2 and 3','3 and 4','1 and 4'],exp:'Menarche in girls occurs at approximately 12\u201313 years of age. Permanent tooth eruption timeline: Central\/lateral incisors (1): 6\u20139 years. Canines (2): 9\u201312 years. Premolars (3): 10\u201312 years. 2nd Molars (4): 11\u201313 years. The teeth erupting closest to the time of menarche (~12\u201313 years) are the premolars (3) and the 2nd molars (4). Statements 3 and 4 correspond to the 11\u201313 year eruption window coinciding with menarche.'},\n {id:114,stem:'Urinary alkalinisation is used for enhancing excretion of which of the following poisoning?',correct:'Phenobarbitone',options:['Phenobarbitone','Alprazolam','Phenytoin','Lithium'],exp:'Urinary alkalinisation (IV sodium bicarbonate to maintain urine pH 7.5\u20138.0) enhances renal excretion of weak acids by ion trapping: at alkaline pH, the acid drug is in its ionised (charged) form which cannot be reabsorbed through the lipid-bilayer tubular membrane. Phenobarbitone (pKa ~7.3) is a weak acid \u2014 alkalinisation dramatically increases its renal clearance and is a treatment for phenobarbitone overdose. Salicylates are also treated this way. Alprazolam and phenytoin are not significantly excreted renally. Lithium excretion is handled by saline diuresis, not alkalinisation.'},\n {id:115,stem:'A 4 year old child is brought with a history of ingestion of 1 g of paracetamol two hours back. What should be the initial management?',correct:'Oral N-acetyl cysteine',options:['Induced vomiting','Gastric lavage','Oral N-acetyl cysteine','Alkaline diuresis'],exp:'For paracetamol overdose: N-acetylcysteine (NAC) is the specific antidote, maximally effective within 8\u201310 hours of ingestion. NAC replenishes hepatic glutathione stores, detoxifying the reactive metabolite NAPQI that causes hepatocellular necrosis. At 2 hours post-ingestion, oral NAC is the appropriate initial treatment. Induced vomiting risks aspiration and is no longer recommended. Gastric lavage has limited benefit after 1\u20132 hours. Alkaline diuresis is not indicated for paracetamol.'},\n {id:116,stem:'Antidote to reverse the muscarinic effects of organophosphate toxicity is',correct:'Atropine',options:['Pralidoxime aldoxime methiodide (PAM)','Atropine','Adrenaline','N-acetylcysteine'],exp:'Organophosphate poisoning inhibits acetylcholinesterase, causing ACh accumulation at both muscarinic and nicotinic synapses. Muscarinic effects (SLUDGE\/DUMBELS): salivation, lacrimation, urination, diarrhoea, bradycardia, bronchospasm, miosis \u2014 reversed by ATROPINE (competitive muscarinic receptor antagonist). Large IV doses of atropine are given until atropinisation is achieved (dry secretions, tachycardia, mydriasis). Pralidoxime (2-PAM) reactivates acetylcholinesterase by displacing the phosphate group \u2014 it reverses nicotinic effects and regenerates cholinesterase if given early (before \\'ageing\\'). PAM does not directly reverse muscarinic effects. Atropine is the antidote for muscarinic effects.'},\n {id:117,stem:'A 7 year old child is brought to the emergency with seizures and drowsiness. The child had been receiving some drugs for fever for the past two days. Child is found to be cyanosed with an oxygen saturation of 40% and unresponsive to oxygen therapy. Blood gas analysis reveals a normal PaO\u2082. Which drug intake may have caused the above condition?',correct:'Chloroquine',options:['Chloroquine','Amoxycillin-Clavulanic acid','Paracetamol','Mefenamic acid'],exp:'Cyanosis + SpO\u2082 40% + unresponsive to supplemental O\u2082 + NORMAL PaO\u2082 = hallmark of methaemoglobinaemia. MetHb contains Fe\u00b3\u207a (oxidised iron) and cannot carry O\u2082; pulse oximetry reads SpO\u2082 falsely low (~85%), blood appears chocolate-brown, and PaO\u2082 is normal because dissolved O\u2082 is unaffected. Chloroquine is a well-documented cause of drug-induced methaemoglobinaemia and can also cause convulsions and neurological toxicity in overdose. This child receiving drugs for fever, developing methaemoglobinaemia + seizures + cyanosis unresponsive to O\u2082 points to chloroquine. Treatment: methylene blue IV 1\u20132 mg\/kg.'},\n {id:118,stem:'Autism Spectrum Disorder is characterised by which of the following?\\n1. Onset before 3 years of age\\n2. Impaired verbal and gestural communication\\n3. Stereotypic and restrictive behavioural patterns\\n4. Tangential speech',correct:'1, 2 and 3',options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],exp:'ASD is characterised by two core domains (DSM-5): Domain A \u2014 Persistent deficits in social communication including impaired verbal and non-verbal (gestural) communication (statement 2). Domain B \u2014 Restricted, repetitive patterns of behaviour, interests, or activities (statement 3). Statement 1 (onset before 3 years) reflects classical DSM-IV criteria; DSM-5 states symptoms must be present in the early developmental period. Statement 4 (tangential speech) is a formal thought disorder feature seen in schizophrenia \u2014 the patient jumps from topic to unrelated topic \u2014 not characteristic of ASD. Statements 1, 2, and 3 are correct.'},\n {id:119,stem:'Which vaccines are stored in the top rack of the main refrigerator compartment at temperature of 4\u201310\u00b0C?',correct:'DPT, Hepatitis B, Measles, MMR vaccines',options:['DPT, Hepatitis B, Measles, MMR vaccines','DPT, TT, Hepatitis A vaccine','BCG, DPT and Typhoid','BCG, Measles and MMR vaccines'],exp:\"Under India's UIP cold chain guidelines, vaccines stored in the main refrigerator body (2\u20138\u00b0C, top racks 4\u201310\u00b0C) are those that must be kept cool but must NOT be frozen: DPT\/DT\/TT, Hepatitis B, Liquid pentavalent (DPTHibHepB), and measles-containing vaccines (measles, MMR). The freezer compartment (\u221220\u00b0C) is used for OPV. BCG is a lyophilised vaccine storable in either freezer or refrigerator. In the examination context, DPT, Hepatitis B, Measles, and MMR are the vaccines stored in the main refrigerator body \u2014 option (a) is the most comprehensive and correct answer.\"},\n {id:120,stem:\"Identification of '4Ds' is a key element of which National Health Programme?\",correct:'RBSK (Rashtriya Bal Swasthya Karyakram)',options:['IMNCI (Integrated Management of Childhood and Neonatal illness)','ICDS (Integrated Child Development Scheme)','RBSK (Rashtriya Bal Swasthya Karyakram)','JSSK (Janani Shishu Suraksha Karyakram)'],exp:\"The 4Ds in child health: Defects at Birth, Diseases (in children 0\u201318 years), Deficiencies, and Developmental Delays (including disabilities). These 4Ds are the four screening domains of the Rashtriya Bal Swasthya Karyakram (RBSK), launched by Government of India in 2013 under NHM. RBSK deploys mobile health teams to screen all children from birth to 18 years at schools and anganwadi centres for 30 conditions falling under the 4Ds. IMNCI focuses on management of sick children under 5. ICDS provides nutrition and early childhood education. JSSK provides entitlements for pregnant women and newborns.\"}\n ];\n\n const LETTERS=['A','B','C','D'];\n let userAnswers={},answered=0,shuffledOpts={};\n let timerRunning=false,timerRemaining=TIMER_SECS,timerInterval=null,graceInterval=null,quizSubmitted=false;\n function shuffle(arr){const a=arr.slice();for(let i=a.length-1;i>0;i--){const j=Math.floor(Math.random()*(i+1));[a[i],a[j]]=[a[j],a[i]];}return a;}\n function fmtTime(s){const m=Math.floor(s\/60),sec=s%60;return(m<10?'0':'')+m+':'+(sec<10?'0':'')+sec;}\n function startTimer(){\n if(timerRunning||quizSubmitted)return;timerRunning=true;\n const btn=document.getElementById(NS+'-timer-btn');btn.textContent='\u23f1 '+fmtTime(timerRemaining);btn.classList.add('running');\n document.getElementById(NS+'-timer-item').classList.add('active');\n timerInterval=setInterval(function(){\n timerRemaining--;const disp=fmtTime(timerRemaining);\n document.getElementById(NS+'-timer-display').textContent=disp;document.getElementById(NS+'-timer-btn').textContent='\u23f1 '+disp;\n if(timerRemaining<=300)document.getElementById(NS+'-timer-item').classList.add('warning');\n if(timerRemaining<=0){clearInterval(timerInterval);timerInterval=null;triggerGrace();}\n },1000);\n }\n function stopTimer(){if(timerInterval){clearInterval(timerInterval);timerInterval=null;}timerRunning=false;}\n function triggerGrace(){\n if(quizSubmitted)return;let count=GRACE_SECS;\n document.getElementById(NS+'-grace-count').textContent=count;document.getElementById(NS+'-grace').classList.add('show');\n graceInterval=setInterval(function(){count--;document.getElementById(NS+'-grace-count').textContent=count;if(count<=0){clearInterval(graceInterval);graceInterval=null;dismissGrace();showScore();}},1000);\n }\n function dismissGrace(){document.getElementById(NS+'-grace').classList.remove('show');if(graceInterval){clearInterval(graceInterval);graceInterval=null;}}\n function updateStats(){\n const c=Object.values(userAnswers).filter(v=>v==='correct').length;\n const w=Object.values(userAnswers).filter(v=>v==='wrong').length;\n const net=(c*4)-w;\n document.getElementById(NS+'-sc').textContent=c;document.getElementById(NS+'-sw').textContent=w;\n document.getElementById(NS+'-sr').textContent=TOTAL-answered;\n document.getElementById(NS+'-sn').textContent=net>=0?'+'+net:net;\n document.getElementById(NS+'-sm').textContent=MAX;\n document.getElementById(NS+'-fill').style.width=(answered\/TOTAL*100)+'%';\n }\n function pick(qid,oi){\n if(userAnswers[qid]!==undefined||quizSubmitted)return;\n const q=QUESTIONS.find(x=>x.id===qid);\n const opts=shuffledOpts[qid],correct=opts[oi]===q.correct;\n userAnswers[qid]=correct?'correct':'wrong';answered++;\n opts.forEach(function(o,i){\n const 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