{"id":36727,"date":"2026-04-30T13:00:09","date_gmt":"2026-04-30T07:30:09","guid":{"rendered":"https:\/\/atsixty.com\/?p=36727"},"modified":"2026-04-30T13:00:51","modified_gmt":"2026-04-30T07:30:51","slug":"cms-2023-p1-part-a","status":"publish","type":"post","link":"https:\/\/atsixty.com\/index.php\/2026\/04\/30\/cms-2023-p1-part-a\/","title":{"rendered":"CMS 2023 P1 Part-A"},"content":{"rendered":"\n\n\n<link href=\"https:\/\/fonts.googleapis.com\/css2?family=Playfair+Display:wght@600;700&#038;family=Source+Serif+4:ital,wght@0,300;0,400;0,600;1,400&#038;display=swap\" rel=\"stylesheet\">\n\n<style>\n\/* \u2500\u2500 Namespace: cms23p1a \u2500\u2500 *\/\n#cms23p1a *,#cms23p1a *::before,#cms23p1a *::after{box-sizing:border-box;margin:0;padding:0}\n#cms23p1a{\n  --ter:#1A5EA8;--ter-light:#2E82D5;--ter-pale:#EBF3FD;\n  --teal:#1A3A5C;--teal-light:#24527F;--teal-pale:#E8F0F9;\n  --ink:#1a1a1a;--ink-mid:#444;--ink-soft:#777;\n  --line:#dde4ed;--bg:#f8fafd;--white:#ffffff;\n  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Display',serif;font-size:0.95rem;font-weight:700;cursor:pointer;transition:background 0.2s,color 0.2s}\n#cms23p1a .cq-retry-btn:hover{background:var(--ter);color:var(--white)}\n@media(max-width:480px){\n  #cms23p1a .cq-header h1{font-size:1.15rem}\n  #cms23p1a .cq-qtext{font-size:0.88rem}\n  #cms23p1a .cq-opt-text{font-size:0.84rem}\n}\n<\/style>\n\n<div id=\"cms23p1a\">\n\n  <div class=\"cq-sentinel\" id=\"cms23p1a-sentinel\"><\/div>\n\n  <div class=\"cq-statusbar\" id=\"cms23p1a-statusbar\">\n    <div class=\"cq-sb-stats\">\n      <div class=\"cq-timer-item\" id=\"cms23p1a-timer-item\">&#9201;&nbsp;<strong id=\"cms23p1a-timer-display\">40:00<\/strong><\/div>\n      <div class=\"cq-sb-item\">&#10003;&#65039;&nbsp;<strong id=\"cms23p1a-sc\">0<\/strong><\/div>\n      <div class=\"cq-sb-item\">&#10060;&nbsp;<strong id=\"cms23p1a-sw\">0<\/strong><\/div>\n      <div class=\"cq-sb-item\">&#9203;&nbsp;<strong id=\"cms23p1a-sr\">40<\/strong>&nbsp;left<\/div>\n      <div class=\"cq-sb-sep\"><\/div>\n      <div class=\"cq-sb-item\">Net&nbsp;<strong id=\"cms23p1a-sn\">0<\/strong>&nbsp;\/&nbsp;<strong id=\"cms23p1a-sm\">160<\/strong><\/div>\n    <\/div>\n    <div class=\"cq-sb-progress\"><div class=\"cq-sb-fill\" id=\"cms23p1a-fill\"><\/div><\/div>\n  <\/div>\n\n  <div class=\"cq-grace\" id=\"cms23p1a-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=\"cms23p1a-grace-count\">10<\/div>\n      <button class=\"cq-grace-btn\" id=\"cms23p1a-grace-now\">Submit Now<\/button>\n    <\/div>\n  <\/div>\n\n  <div class=\"cq-header\">\n    <h1>Combined Medical Services Examination 2023<br>General Medicine &amp; Paediatrics &nbsp;&middot;&nbsp; Paper I &nbsp;&middot;&nbsp; Part A<\/h1>\n    <p>Cardiology &nbsp;&middot;&nbsp; Respiratory &nbsp;&middot;&nbsp; Gastroenterology &amp; Hepatology &nbsp;&middot;&nbsp; Neurology &nbsp;&middot;&nbsp; Haematology<\/p>\n    <div class=\"cq-meta\">\n      <span class=\"cq-badge\">Questions 1 &ndash; 40<\/span>\n      <span class=\"cq-badge\">Options reshuffled<\/span>\n      <span class=\"cq-badge\">Score = c &times; 4 &minus; w<\/span>\n      <button class=\"cq-timer-btn\" id=\"cms23p1a-timer-btn\">&#9201; Start Timed Mode<\/button>\n    <\/div>\n  <\/div>\n\n  <div class=\"cq-body\">\n    <div id=\"cms23p1a-questions\"><\/div>\n    <div class=\"cq-submit-wrap\">\n      <button class=\"cq-btn\" id=\"cms23p1a-submit\">Submit Answers<\/button>\n    <\/div>\n    <div class=\"cq-score\" id=\"cms23p1a-score\">\n      <div class=\"cq-score-ring\" id=\"cms23p1a-ring\">\n        <div class=\"cq-ring-inner\">\n          <span class=\"cq-ring-pct\" id=\"cms23p1a-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=\"cms23p1a-net-line\"><\/div>\n      <div class=\"cq-verdict\" id=\"cms23p1a-verdict\"><\/div>\n      <div class=\"cq-score-bands\">\n        <span class=\"cq-band cq-band-c\" id=\"cms23p1a-ct-c\"><\/span>\n        <span class=\"cq-band cq-band-w\" id=\"cms23p1a-ct-w\"><\/span>\n        <span class=\"cq-band cq-band-s\" id=\"cms23p1a-ct-s\"><\/span>\n      <\/div>\n      <button class=\"cq-retry-btn\" id=\"cms23p1a-retry\">&#8634; Retry Quiz<\/button>\n    <\/div>\n  <\/div>\n\n<\/div>\n\n<script>\n(function(){\n  'use strict';\n  var NS='cms23p1a', TOTAL=40, MAX=TOTAL*4;\n  var TIMER_SECS=40*60, GRACE_SECS=10;\n\n  var QUESTIONS=[\n    {\n      id:1,\n      stem:'Thickened ventricular wall with normal diastolic function is a feature of',\n      correct:'athlete\\u0027s heart',\n      options:['hypertrophic cardiomyopathy','restrictive cardiomyopathy','endomyocardial fibrosis','athlete\\u0027s heart'],\n      exp:'Athlete\\u0027s heart (physiological cardiac remodelling) is characterised by concentric or eccentric LV hypertrophy (thickened walls) with preserved or even supranormal diastolic function \\u2014 the heart relaxes rapidly and completely. This is the key distinguishing feature from pathological hypertrophy. Hypertrophic cardiomyopathy shows asymmetric septal hypertrophy with impaired diastolic filling (diastolic dysfunction). Restrictive cardiomyopathy shows markedly impaired diastolic function with normal or near-normal wall thickness. Endomyocardial fibrosis impairs diastolic filling. Normal diastolic function with wall thickening = athlete\\u0027s heart.'\n    },\n    {\n      id:2,\n      stem:'In which of the following cases does paradoxical splitting occur?\\n1. Severe aortic stenosis\\n2. Right bundle branch block\\n3. Right ventricular pacing\\n4. Hypertrophic obstructive cardiomyopathy\\nSelect the correct answer using the code given below.',\n      correct:'1, 3 and 4',\n      options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],\n      exp:'Paradoxical (reversed) splitting of S2 occurs when A2 is delayed beyond P2, so the split is heard on expiration (not inspiration). Causes are those that delay aortic valve closure: LBBB (the classic cause), severe aortic stenosis (prolonged LV ejection), HOCM (prolonged LV ejection due to dynamic obstruction), and right ventricular pacing (which creates an LBBB activation pattern). Right bundle branch block causes WIDE splitting (P2 delayed, not A2) \\u2014 the opposite \\u2014 so it does NOT cause paradoxical splitting. Statements 1, 3, and 4 are correct.'\n    },\n    {\n      id:3,\n      stem:'A patient with peripheral oedema has the following findings on clinical examination: A soft systolic murmur at the lower left sternal border with raised JVP showing prominent C-V wave. The murmur increases in intensity on deep inspiration. The most likely valvular abnormality is',\n      correct:'tricuspid regurgitation',\n      options:['ventricular septal defect','mitral regurgitation','tricuspid regurgitation','mitral valve prolapse'],\n      exp:'The clinical triad described is pathognomonic of tricuspid regurgitation (TR): (1) pansystolic murmur at the lower left sternal border (tricuspid area); (2) Carvallo\\u0027s sign \\u2014 the murmur increases on deep inspiration (increased venous return augments right heart flow); (3) prominent C-V wave in the JVP (systolic regurgitant wave from RV into RA, merging the C and V waves into a large CV wave); (4) peripheral oedema from right heart failure. Mitral regurgitation murmur does NOT increase with inspiration. VSD murmur is harsh. Mitral valve prolapse is a mid-systolic click with late systolic murmur.'\n    },\n    {\n      id:4,\n      stem:'Kussmaul\\u0027s sign is a clinical feature of',\n      correct:'constrictive pericarditis',\n      options:['constrictive pericarditis','hypertrophic obstructive cardiomyopathy','anteroseptal myocardial infarction','dilated cardiomyopathy'],\n      exp:'Kussmaul\\u0027s sign is a paradoxical rise in jugular venous pressure on inspiration (normally JVP falls on inspiration). In constrictive pericarditis, the rigid fibrocalcific pericardium cannot expand to accommodate the increased venous return during inspiration, forcing JVP upward. It is also seen in restrictive cardiomyopathy, right heart failure, and massive pericardial effusion with tamponade. It is NOT a feature of HOCM, STEMI, or dilated cardiomyopathy. Constrictive pericarditis is the classic teaching answer.'\n    },\n    {\n      id:5,\n      stem:'A patient has a cardiac murmur that is best heard at the right second intercostal space. It increases with expiration. Also, the murmur reduces in intensity during sustained handgrip but increases in intensity on inhalation of amyl nitrite. The likely lesion is',\n      correct:'hypertrophic obstructive cardiomyopathy',\n      options:['ventricular septal defect','aortic stenosis','hypertrophic obstructive cardiomyopathy','mitral regurgitation'],\n      exp:'Two bedside manoeuvres identify HOCM: (1) Handgrip increases LV afterload and preload \\u2014 larger LV cavity \\u2192 reduced dynamic obstruction \\u2192 murmur SOFTER; (2) Amyl nitrite inhalation reduces preload and afterload \\u2192 smaller LV cavity \\u2192 worsened obstruction \\u2192 murmur LOUDER. These are the opposite responses to aortic stenosis (handgrip louder, amyl nitrite softer). The murmur of HOCM can radiate to the aortic area (right 2nd ICS) mimicking AS, but the dynamic manoeuvre responses clinch the diagnosis. Answer: HOCM.'\n    },\n    {\n      id:6,\n      stem:'In the modified Duke criteria for infective endocarditis, which one of the following is NOT a major criterion?',\n      correct:'Roth\\u0027s spots',\n      options:['New partial dehiscence of prosthetic valve','Positive blood culture','Roth\\u0027s spots','New valvular regurgitation'],\n      exp:'Modified Duke major criteria: (1) Positive blood cultures \\u2014 typical organisms in \\u22652 sets, or persistently positive, or single positive for Coxiella; (2) Evidence of endocardial involvement \\u2014 positive echocardiogram (oscillating mass, abscess, new prosthetic valve dehiscence) OR new valvular regurgitation. Roth\\u0027s spots (flame-shaped retinal haemorrhages with pale centres) are an immunological phenomenon \\u2014 a MINOR criterion in the modified Duke classification. They are NOT a major criterion. New partial dehiscence of prosthetic valve and new valvular regurgitation are major criteria.'\n    },\n    {\n      id:7,\n      stem:'Which one of the following diseases affects predominantly large arteries?',\n      correct:'Giant cell arteritis',\n      options:['Granulomatosis with polyangiitis','Polyarteritis nodosa','Giant cell arteritis','Eosinophilic granulomatosis with polyangiitis'],\n      exp:'Vasculitides are classified by vessel size. Large vessel: Giant cell arteritis (temporal arteritis \\u2014 affects aorta and its major branches, temporal artery) and Takayasu arteritis. Medium vessel: Polyarteritis nodosa (medium muscular arteries, spares lungs), Kawasaki disease. Small vessel: Granulomatosis with polyangiitis (GPA\/Wegener\\u0027s), Microscopic polyangiitis, Eosinophilic granulomatosis with polyangiitis (EGPA\/Churg-Strauss), IgA vasculitis (HSP). Giant cell arteritis is the large artery vasculitis among the options.'\n    },\n    {\n      id:8,\n      stem:'Osborn waves in ECG show prolonged repolarization with a distinctive convex elevation of the J point. These waves are associated with',\n      correct:'systemic hypothermia',\n      options:['systemic hypothermia','acute pericarditis','acute myocarditis','Brugada syndrome'],\n      exp:'Osborn waves (J waves) are pathognomonic of systemic hypothermia (core temperature typically < 30\\u00b0C). They appear as a positive deflection at the J point (junction of QRS and ST segment), most prominent in leads V4\\u2013V6 and inferior leads. The amplitude increases as core temperature falls. Other ECG features of hypothermia: bradycardia, prolonged PR\/QRS\/QT, muscle tremor artefact, and ultimately ventricular fibrillation at < 28\\u00b0C. Brugada syndrome shows a right bundle branch block-like pattern with ST elevation in V1\\u2013V3 (Type 1 coved pattern) \\u2014 not Osborn waves.'\n    },\n    {\n      id:9,\n      stem:'A decline in total lung capacity to less than 80% of patient\\u0027s predictive value is an indication of',\n      correct:'restrictive lung disease',\n      options:['restrictive lung disease','obstructive lung disease','pulmonary artery hypertension','pulmonary embolism'],\n      exp:'Total lung capacity (TLC) < 80% of predicted defines restrictive lung disease on spirometry\/plethysmography. Restriction means the lungs cannot expand to normal total volume \\u2014 caused by interstitial fibrosis (IPF), chest wall disease (kyphoscoliosis, obesity), neuromuscular weakness, or pleural disease. In obstructive lung disease (COPD, asthma), TLC is normal or increased (due to air trapping\/hyperinflation). Pulmonary artery hypertension and pulmonary embolism affect vasculature and do not primarily reduce TLC.'\n    },\n    {\n      id:10,\n      stem:'A 28-year male is suspected of having hypertrophic obstructive cardiomyopathy (HOCM). Which of the following statements are likely to be true on his examination?\\n1. Maneuvers that decrease LV preload will cause the murmur to intensify.\\n2. Maneuvers that decrease LV afterload will cause decrease in intensity of murmur.\\n3. Murmur of HOCM becomes softer with passive leg raising.\\n4. Murmur of HOCM becomes louder with squatting.\\nSelect the correct answer using the code given below.',\n      correct:'1 and 3',\n      options:['1 and 3','2 and 3','2 and 4','1 and 4'],\n      exp:'HOCM murmur behaviour: The dynamic outflow tract obstruction worsens when the LV cavity is smaller (less preload) and improves when the cavity is larger (more preload\/afterload). Statement 1 TRUE: decreased preload (Valsalva, standing) \\u2192 smaller LV \\u2192 worse obstruction \\u2192 louder murmur. Statement 2 FALSE: decreased afterload \\u2192 LV empties more readily \\u2192 smaller LV \\u2192 worse obstruction \\u2192 LOUDER murmur (not softer). Statement 3 TRUE: passive leg raising increases venous return\/preload \\u2192 larger LV \\u2192 less obstruction \\u2192 murmur softer. Statement 4 FALSE: squatting increases both preload and afterload \\u2192 larger LV \\u2192 murmur SOFTER (not louder). Statements 1 and 3 are correct.'\n    },\n    {\n      id:11,\n      stem:'A 56-year male, chronic heavy smoker, presented with breathlessness. On examination, pulse: 96\/minute, BP: 112\/70 mm Hg and a pansystolic murmur is showing Carvallo\\u0027s sign with murmur getting louder on deep inspiration. Which one of the following statements is true regarding examination of JVP in him?',\n      correct:'V wave and C wave merge.',\n      options:['V wave is attenuated.','C wave is attenuated and V wave is accentuated.','V wave and C wave merge.','V wave and C wave merge and Y descent is blunted.'],\n      exp:'In tricuspid regurgitation (confirmed by Carvallo\\u0027s sign in this COPD\/cor pulmonale patient), the regurgitant systolic jet into the right atrium merges the C wave (tricuspid valve closure) and V wave (venous filling) into a single large positive systolic wave \\u2014 the C-V fusion wave. This is the characteristic JVP finding in TR. The Y descent is typically sharp (rapid RA emptying when tricuspid valve opens). Blunted Y descent is seen in cardiac tamponade or tricuspid stenosis. V wave attenuation would be seen in conditions reducing RA filling.'\n    },\n    {\n      id:12,\n      stem:'Which one of the following is a manifestation of vascular phenomenon in modified Duke criteria?',\n      correct:'Janeway\\u0027s lesions',\n      options:['Osler\\u0027s node','Roth\\u0027s spots','Janeway\\u0027s lesions','Glomerulonephritis'],\n      exp:'Modified Duke minor criteria include immunological phenomena (Osler\\u0027s nodes, Roth\\u0027s spots, rheumatoid factor, glomerulonephritis) and vascular phenomena. Vascular phenomena: major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial haemorrhage, conjunctival haemorrhages, and Janeway\\u0027s lesions. Janeway\\u0027s lesions are painless erythematous or haemorrhagic macules on the palms and soles \\u2014 they result from septic emboli (vascular phenomenon). Osler\\u0027s nodes (painful, tender nodules on fingertips) are immunological. Roth\\u0027s spots = immunological. Glomerulonephritis = immunological.'\n    },\n    {\n      id:13,\n      stem:'The volume of air remaining in the lungs after a normal expiration is called',\n      correct:'functional residual capacity',\n      options:['expiratory residual volume','functional residual capacity','residual volume','vital capacity'],\n      exp:'Functional Residual Capacity (FRC) = the volume of air remaining in the lungs at the end of a normal, passive (tidal) expiration. FRC = ERV (expiratory reserve volume) + RV (residual volume). It represents the resting equilibrium position of the respiratory system where outward chest wall recoil balances inward lung recoil. Residual volume (RV) is the air remaining after maximal forced expiration. Vital capacity = the maximum volume exhaled after maximal inhalation. FRC is the correct answer.'\n    },\n    {\n      id:14,\n      stem:'The investigation of choice for early follow-up in patients treated for anti-H. pylori drugs is',\n      correct:'urea breath test',\n      options:['urea breath test','rapid urease test','stool H. pylori antigen test','serology for H. pylori'],\n      exp:'The urea breath test (UBT) is the investigation of choice for confirming H. pylori eradication after treatment. The patient ingests labelled urea (\\u00b9\\u00b3C or \\u00b9\\u2074C); if H. pylori is present, its urease splits the urea and labelled CO\\u2082 is detected in exhaled breath. It should be performed at least 4 weeks after completing antibiotics and 2 weeks after stopping PPIs. Advantages: non-invasive, high sensitivity and specificity (~95%), whole-stomach sampling. Serology remains positive for months\/years after eradication and cannot confirm cure. Rapid urease test requires endoscopy biopsy. Stool antigen test is also valid but UBT is the gold standard for follow-up.'\n    },\n    {\n      id:15,\n      stem:'The most common non-pancreatic site for tumour distribution in Zollinger-Ellison syndrome is',\n      correct:'duodenum',\n      options:['duodenum','ovaries','stomach','liver'],\n      exp:'In Zollinger-Ellison syndrome (ZES), the gastrinoma arises in the pancreas in approximately 25\\u201340% of cases. Among extra-pancreatic locations, the duodenum is the most common site, accounting for 50\\u201370% of sporadic gastrinomas. The gastrinoma triangle (Passaro\\u0027s triangle) is defined by the junction of the cystic and common bile ducts (superiorly), the junction of the 2nd and 3rd portions of the duodenum (inferiorly), and the neck of the pancreas. Most sporadic gastrinomas are found within this triangle. MEN-1 associated gastrinomas are frequently duodenal, often multiple and small. Duodenum is the correct answer.'\n    },\n    {\n      id:16,\n      stem:'Which of the following are the risk factors for the acquisition of hepatitis C infection?\\n1. Faeco-oral transmission\\n2. Intravenous drug abuse\\n3. Vertical transmission\\n4. Sharing toothbrush and razors\\nSelect the correct answer using the code given below.',\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:'HCV is transmitted predominantly via blood-to-blood contact. Intravenous drug abuse (sharing needles) is the leading route of HCV transmission in developed countries. Vertical transmission from HCV-positive mother to neonate occurs in approximately 5% of pregnancies (higher if maternal HIV co-infection). Sharing toothbrushes and razors involves percutaneous\/permucosal blood exposure and is a recognised risk factor. Faeco-oral transmission is NOT a route for HCV (unlike HAV and HEV). HCV is NOT transmitted via contaminated food or water. Statement 1 is false. Statements 2, 3, and 4 are correct.'\n    },\n    {\n      id:17,\n      stem:'The most common cause of shock in severe acute pancreatitis (SAP) is',\n      correct:'hypovolemic shock resulting from third space loss',\n      options:['hypovolemic shock resulting from third space loss','septic shock resulting from infected pancreatic necrosis','cardiogenic shock resulting from SIRS','abdominal compartment syndrome'],\n      exp:'In the early phase of severe acute pancreatitis, massive third-space fluid sequestration occurs \\u2014 plasma leaks into the retroperitoneum, peritoneal cavity, and bowel wall due to the inflammatory capillary leak syndrome triggered by activated pancreatic enzymes. This results in intravascular volume depletion and hypovolemic shock, which is the most common cause of shock in SAP. Septic shock (from infected necrosis) is a later complication (usually after week 2). Aggressive IV fluid resuscitation (lactated Ringer\\u0027s preferred) in the first 24\\u201348 hours is the cornerstone of SAP management.'\n    },\n    {\n      id:18,\n      stem:'The most common causative agent for spontaneous bacterial peritonitis is',\n      correct:'Escherichia coli',\n      options:['Escherichia coli','Enterococcus sp.','Staphylococcus aureus','Streptococcus viridans'],\n      exp:'Spontaneous bacterial peritonitis (SBP) occurs in cirrhotic patients with ascites when gut bacteria translocate across the intestinal wall into the ascitic fluid. The organisms responsible are enteric gram-negative bacilli that translocate from the gut lumen. Escherichia coli is the most common causative organism (~40\\u201350%), followed by Klebsiella pneumoniae and Streptococcus pneumoniae. SBP is typically monomicrobial. Diagnosis: ascitic fluid neutrophil count \\u2265 250\/mm\\u00b3. Treatment: cefotaxime IV + IV albumin (to prevent hepatorenal syndrome). Prophylaxis: norfloxacin or ciprofloxacin in high-risk cirrhotics.'\n    },\n    {\n      id:19,\n      stem:'The serologic marker detectable during the \\u0027window\\u0027 period of hepatitis B infection is',\n      correct:'anti-HBc IgM',\n      options:['anti-HBsAb','anti-HBc IgG','anti-HBc IgM','HBeAg'],\n      exp:'The serological window period in acute HBV infection is the interval when HBsAg has become undetectable but anti-HBs (protective antibody) has not yet appeared. During this window, the ONLY detectable serological marker is anti-HBc IgM (IgM antibody to hepatitis B core antigen). Anti-HBc IgM is the diagnostic marker of acute HBV infection. It appears in the prodromal phase, peaks during acute illness, and declines over 3\\u20136 months. Anti-HBc IgG persists lifelong and indicates past or chronic infection. HBeAg disappears before HBsAg in resolving infection. In the window period, anti-HBc IgM is the only positive marker.'\n    },\n    {\n      id:20,\n      stem:'A 14-year boy came with chronic diarrhoea and malnutrition. The physician suspected celiac disease. Which of the following are correct in his diagnostic workup?\\n1. Presence of IgA antiendomysial antibody\\n2. Absence of reduced height of villi on intestinal biopsy\\n3. Increased lymphocytes in lamina propria in small intestine biopsy\\n4. Absence of tTG antibody in serum\\nSelect the correct answer using the code given below.',\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:'Celiac disease diagnostic features: IgA anti-endomysial antibody (EMA) is highly specific (\\u226595%) for celiac and its presence strongly supports the diagnosis \\u2014 statement 1 correct. On intestinal biopsy, villous atrophy (reduced height of villi \/ blunting) is the hallmark lesion; the examiner intends statement 2 to indicate that reduced height of villi is NOT absent (i.e., villous atrophy IS present, confirming celiac) \\u2014 statement 2 correct in this context. Increased intraepithelial and lamina propria lymphocytes with crypt hyperplasia are characteristic Marsh lesions \\u2014 statement 3 correct. Anti-tTG antibodies are ELEVATED (not absent) in celiac \\u2014 statement 4 is false (absence of tTG would argue against celiac). Statements 1, 2, and 3 are the correct diagnostic features.'\n    },\n    {\n      id:21,\n      stem:'Which of the following statements are correct for the treatment of chronic hepatitis B with pegylated interferon (PEG-IFN)?\\n1. PEG-IFN is poorly tolerated drug as compared to nucleoside analogues.\\n2. Resistance to treatment with PEG-IFN is more common than nucleoside analogues.\\n3. PEG-IFN is not useful in patients of cirrhosis.\\n4. PEG-IFN is administered every week for 48 weeks.\\nSelect the correct answer using the code given below.',\n      correct:'1, 3 and 4',\n      options:['1, 3 and 4','1, 2 and 3','2 and 4','1 and 3 only'],\n      exp:'Statement 1 TRUE: PEG-IFN has significant adverse effects (flu-like symptoms, cytopenias, depression, autoimmune reactions) making it poorly tolerated vs nucleoside\/nucleotide analogues (NAs). Statement 2 FALSE: Resistance to PEG-IFN does NOT occur (it acts via immune mechanisms, not direct antiviral binding \\u2014 no resistance mutations). NAs (lamivudine, adefovir, older agents) develop resistance; newer NAs (tenofovir, entecavir) have minimal resistance. Statement 3 TRUE: PEG-IFN is contraindicated in decompensated cirrhosis (Child-Pugh B\/C) \\u2014 risk of hepatic decompensation. Statement 4 TRUE: Standard PEG-IFN dosing for HBV is 180 mcg SC weekly for 48 weeks. Statements 1, 3, and 4 are correct.'\n    },\n    {\n      id:22,\n      stem:'Which of the following are recommended for management of tumour lysis syndrome?\\n1. Urinary alkalinisation\\n2. Intravenous fluids\\n3. Rasburicase\\n4. Febuxostat\\nSelect the correct answer using the code given below.',\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:'Current guidelines for tumour lysis syndrome (TLS) management: Intravenous fluids (aggressive hydration 2\\u20133 L\/m\\u00b2\/day) \\u2014 cornerstone, promotes uric acid and phosphate excretion. Rasburicase (recombinant urate oxidase) \\u2014 converts uric acid to allantoin (more soluble), the treatment of choice for established hyperuricaemia in TLS. Febuxostat (xanthine oxidase inhibitor) \\u2014 used for TLS prophylaxis when allopurinol is not tolerated. Urinary alkalinisation (sodium bicarbonate) was previously recommended with allopurinol to increase uric acid solubility, but is now discouraged: it promotes calcium phosphate precipitation in tubules (worsening TLS nephropathy) and is contraindicated with rasburicase (allantoin precipitates in alkaline urine). Current guidelines do NOT recommend urinary alkalinisation. Statements 2, 3, and 4 are correct.'\n    },\n    {\n      id:23,\n      stem:'Focal seizures may be associated with which of the following?\\n1. Jacksonian march\\n2. Todd\\u0027s paralysis\\n3. Epilepsia partialis continua\\nSelect the correct answer using the code given below.',\n      correct:'1, 2 and 3',\n      options:['1 and 2 only','2 and 3 only','1 and 3 only','1, 2 and 3'],\n      exp:'All three are features specifically associated with focal (partial) seizures. Jacksonian march: focal motor seizure beginning in one part of the body (e.g., thumb, corner of mouth) and spreading sequentially along the motor homunculus \\u2014 reflects focal spread of ictal activity through the primary motor cortex. Todd\\u0027s paralysis (post-ictal paresis): transient focal weakness (minutes to hours) following a focal motor seizure, due to neuronal exhaustion in the motor cortex. Epilepsia partialis continua (Kojewnikow syndrome): continuous focal motor seizure (clonic jerking) lasting hours to days without loss of consciousness \\u2014 a form of focal status epilepticus. All three are correct.'\n    },\n    {\n      id:24,\n      stem:'Typical absence seizures are characterized by',\n      correct:'abrupt 3 Hz spike-and-slow wave discharges on EEG',\n      options:['abrupt 3 Hz spike-and-slow wave discharges on EEG','postictal confusion in children','multifocal structural abnormalities of brain','less responsiveness to anticonvulsants as compared to atypical absence seizures'],\n      exp:'Typical absence seizures (childhood absence epilepsy) have a pathognomonic EEG pattern: bilateral, synchronous, symmetric 3 Hz (2.5\\u20134 Hz) spike-and-slow wave complexes, arising abruptly on a normal background and terminating equally abruptly. Clinically: brief (5\\u201330 seconds) staring spells with loss of awareness, no aura, NO postictal confusion (the child resumes activity immediately \\u2014 distinguishing from focal seizures). No structural brain abnormality is present. Typical absence seizures respond WELL to ethosuximide (drug of choice), valproate, or lamotrigine. Atypical absence (Lennox-Gastaut) is less responsive to treatment. Option (a) is the only correct statement.'\n    },\n    {\n      id:25,\n      stem:'Which of the following are contraindications to thrombolysis in acute ischemic stroke?\\n1. Recent head injury\\n2. Recent MI\\n3. Hypertension > 150\/100 mm Hg\\n4. GI bleeding in last 3 weeks\\nSelect the correct answer using the code given below.',\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:'Absolute contraindications to IV tPA (alteplase) for acute ischemic stroke include: intracranial\/intraspinal surgery or serious head trauma in previous 3 months, prior ischemic stroke within 3 months, history of intracranial haemorrhage, recent MI (within 3 months \\u2014 risk of pericardial haemorrhage\/cardiac rupture), active internal bleeding (including GI bleeding within 21 days), and BP > 185\/110 mmHg that cannot be controlled. The threshold BP contraindication is > 185\/110 mmHg \\u2014 NOT 150\/100 mmHg. A BP of 150\/100 is entirely acceptable for thrombolysis (the target is to lower BP only if > 185\/110 before and during tPA). Statement 3 (hypertension > 150\/100) is NOT a contraindication. Statements 1, 2, and 4 are correct contraindications.'\n    },\n    {\n      id:26,\n      stem:'Which one of the following distinguishes axonal degeneration from segmental demyelination on electrophysiological studies?',\n      correct:'Distal latency is normal in axonal degeneration and prolonged in segmental demyelination.',\n      options:[\n        'Distal latency is normal in axonal degeneration and prolonged in segmental demyelination.',\n        'Conduction velocity is slow in axonal degeneration and normal in segmental demyelination.',\n        'Conduction block is present in axonal degeneration and absent in segmental demyelination.',\n        'Temporal dispersion is prominent in axonal degeneration and absent in segmental demyelination.'\n      ],\n      exp:'The key electrophysiological distinction: In axonal neuropathy, the myelin sheath is intact so conduction velocity and distal latency are relatively PRESERVED (normal or mildly reduced due to loss of the fastest large fibres); the main finding is reduced CMAP\/SNAP amplitude. In demyelinating neuropathy (e.g. GBS, CIDP), the myelin is damaged causing slowed conduction: PROLONGED distal latency, slowed NCV (< 75% of lower normal limit), conduction block, and temporal dispersion. Conduction block and temporal dispersion are features of demyelination (not axonal degeneration). Option (a) correctly states: distal latency normal in axonal degeneration, prolonged in segmental demyelination.'\n    },\n    {\n      id:27,\n      stem:'Which one of the following drugs helps to maintain abstinence by reducing craving for alcohol?',\n      correct:'Acamprosate',\n      options:['Apomorphine','Acamprosate','Atropine','Azathioprine'],\n      exp:'Acamprosate (calcium acetylhomotaurinate) is a structural analogue of GABA that modulates glutamate (NMDA receptor antagonism) and GABA neurotransmission. It reduces the craving and protracted withdrawal discomfort (anxiety, dysphoria, insomnia) associated with alcohol abstinence, helping to maintain sobriety. It does not cause aversion reactions. Naltrexone (opioid antagonist) also reduces craving by blocking alcohol-induced dopamine release. Disulfiram causes aversion (acetaldehyde accumulation) not craving reduction. Apomorphine is a dopamine agonist used in Parkinson\\u0027s disease. Acamprosate is the correct answer for reducing alcohol craving.'\n    },\n    {\n      id:28,\n      stem:'The BCR-ABL 1 oncoprotein exhibits constitutive activity of which one of the following enzymes?',\n      correct:'Tyrosine kinase',\n      options:['Alanine kinase','Tyrosine kinase','Leucine kinase','Cysteine kinase'],\n      exp:'The Philadelphia chromosome [t(9;22)(q34;q11)] results from reciprocal translocation between chromosomes 9 and 22, fusing the BCR gene to the ABL1 proto-oncogene. The BCR-ABL1 fusion protein is a constitutively active TYROSINE KINASE \\u2014 it phosphorylates downstream substrates continuously without the normal regulation by growth factor ligand binding. This drives uncontrolled proliferation and resistance to apoptosis in CML haematopoietic stem cells. This is the therapeutic target of imatinib (Gleevec) and subsequent TKIs. Tyrosine kinase is the correct answer.'\n    },\n    {\n      id:29,\n      stem:'Imatinib, Dasatinib, Nilotinib and Ponatinib are examples of which class of drugs?',\n      correct:'Tyrosine kinase inhibitors',\n      options:['Interferons','Monovalent antibodies','Bivalent antibodies','Tyrosine kinase inhibitors'],\n      exp:'All four drugs are BCR-ABL tyrosine kinase inhibitors (TKIs) used in the treatment of chronic myeloid leukaemia (CML) and Philadelphia chromosome-positive ALL. Imatinib (Gleevec) was the first-generation TKI (revolutionary drug, validated the targeted therapy concept). Dasatinib and nilotinib are second-generation TKIs with activity against imatinib-resistant mutants. Ponatinib is a third-generation TKI specifically designed to overcome the T315I \\u201cgatekeeper\\u201d mutation resistant to all other TKIs. They are small-molecule inhibitors (not antibodies). The class is tyrosine kinase inhibitors.'\n    },\n    {\n      id:30,\n      stem:'Helicobacter pylori infection is associated with the development of which one of the following lymphoid malignancies?',\n      correct:'Mucosa-associated lymphoid tissue lymphoma',\n      options:['Burkitt\\u0027s lymphoma','Hodgkin\\u0027s lymphoma','Mucosa-associated lymphoid tissue lymphoma','Adult T-cell leukemia\/lymphoma'],\n      exp:'H. pylori infection drives the development of gastric MALT (mucosa-associated lymphoid tissue) lymphoma. The pathogenesis: H. pylori-driven chronic inflammation leads to acquisition of B-cell lymphoid tissue (normally absent in the gastric mucosa), which undergoes antigen-driven clonal expansion. In early-stage MALT lymphoma, H. pylori eradication therapy alone achieves complete remission in ~75% of cases. Advanced cases acquire chromosomal translocations [t(11;18)] making them H. pylori-independent. Burkitt\\u0027s lymphoma is associated with EBV. Adult T-cell leukaemia\/lymphoma is associated with HTLV-1. Hodgkin\\u0027s lymphoma is associated with EBV in some cases.'\n    },\n    {\n      id:31,\n      stem:'The Duffy antigen system serves as receptor for which one of the following protozoal parasites?',\n      correct:'Plasmodium vivax',\n      options:['Giardia lamblia','Plasmodium vivax','Entamoeba histolytica','Balantidium coli'],\n      exp:'The Duffy antigen (DARC \\u2014 Duffy Antigen Receptor for Chemokines, now called ACKR1) on the surface of red blood cells is the obligate receptor used by Plasmodium vivax merozoites to invade erythrocytes via the Duffy-binding protein (DBP). Individuals who are Duffy-negative (common in West Africa, Fy(a-b-) genotype) are naturally resistant to P. vivax infection \\u2014 this explains the near-absence of P. vivax in sub-Saharan Africa. This receptor is not used by P. falciparum (which uses glycophorin A\/B and Band 3). No other protozoa listed use the Duffy antigen.'\n    },\n    {\n      id:32,\n      stem:'With regard to transfusion therapy, cryoprecipitate is a rich source of which of the following?\\n1. Fibrinogen\\n2. Clotting factor VIII\\n3. Clotting factor IX\\n4. von Willebrand factor\\nSelect the correct answer using the code given below.',\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:'Cryoprecipitate is prepared by thawing fresh frozen plasma at 1\\u20136\\u00b0C and collecting the cold-insoluble precipitate. It is rich in: fibrinogen (the primary indication \\u2014 for hypofibrinogenaemia in DIC, massive haemorrhage), Factor VIII (used in haemophilia A before recombinant products), von Willebrand factor (used in von Willebrand disease), Factor XIII (fibrin stabilising factor), and fibronectin. Factor IX is NOT in cryoprecipitate \\u2014 it is present in FFP and Factor IX concentrate. Cryoprecipitate is NOT the source for haemophilia B (Factor IX deficiency). Statements 1, 2, and 4 are correct.'\n    },\n    {\n      id:33,\n      stem:'Which of the following viruses can be transmitted via transfusion of infected blood?\\n1. Hepatitis B virus\\n2. Hepatitis C virus\\n3. Human immunodeficiency virus\\n4. Parvovirus B19\\nSelect the correct answer using the code given below.',\n      correct:'1, 2, 3 and 4',\n      options:['1 and 3 only','2 and 4 only','1, 2 and 3 only','1, 2, 3 and 4'],\n      exp:'All four viruses are recognised transfusion-transmitted pathogens. HBV, HCV, and HIV are the three major transfusion-transmitted infections for which mandatory blood screening is performed globally. Parvovirus B19 is also transmissible by transfusion \\u2014 it is a small, non-enveloped DNA virus resistant to pathogen inactivation methods used for lipid-enveloped viruses; it is clinically significant in immunocompromised patients (causing pure red cell aplasia) and those with chronic haemolytic anaemias (causing aplastic crisis). NAT (nucleic acid testing) for B19 is used for plasma-derived products. All four are transfusion-transmitted. Statements 1, 2, 3, and 4 are all correct.'\n    },\n    {\n      id:34,\n      stem:'Which one of the following correctly describes the mode of inheritance of haemophilia B?',\n      correct:'X-linked recessive',\n      options:['Autosomal dominant','Autosomal recessive','X-linked dominant','X-linked recessive'],\n      exp:'Haemophilia B (Christmas disease) is caused by deficiency of clotting Factor IX due to mutations in the F9 gene located on the X chromosome (Xq27.1). It follows X-linked recessive inheritance: affected males (XY) have one defective X chromosome and manifest the disease; females (XX) are carriers and are usually unaffected (unless lyonisation causes significant Factor IX deficiency). Sons of carrier females have a 50% chance of being affected; daughters have a 50% chance of being carriers. This is identical in pattern to haemophilia A (Factor VIII deficiency, also X-linked recessive). X-linked recessive is the correct answer.'\n    },\n    {\n      id:35,\n      stem:'Which one of the following conditions characteristically may present with a triad of haemolysis, pancytopenia and venous thrombosis?',\n      correct:'Paroxysmal nocturnal haemoglobinuria',\n      options:['Glucose-6-phosphate dehydrogenase deficiency','Hereditary spherocytosis','Haemolytic uremic syndrome','Paroxysmal nocturnal haemoglobinuria'],\n      exp:'Paroxysmal nocturnal haemoglobinuria (PNH) is a clonal stem cell disorder caused by a somatic mutation in the PIG-A gene, resulting in deficiency of GPI-anchored complement-regulatory proteins (CD55, CD59) on blood cell surfaces. The classic triad: (1) Intravascular haemolysis (complement-mediated, CD59 deficiency) \\u2014 causing haemoglobinuria and anaemia; (2) Pancytopenia (underlying bone marrow failure \\u2014 aplastic anaemia); (3) Venous thrombosis in unusual sites (hepatic veins \\u2014 Budd-Chiari syndrome, portal, mesenteric, cerebral veins) \\u2014 the leading cause of death in PNH. Eculizumab (anti-C5 antibody) is the specific treatment. PNH is the correct answer.'\n    },\n    {\n      id:36,\n      stem:'Which one of the following is associated with low MCV of red blood cells?',\n      correct:'Thalassaemia',\n      options:['Thalassaemia','Vitamin B12 deficiency anaemia','Folate deficiency anaemia','Sickle cell anaemia'],\n      exp:'Mean corpuscular volume (MCV) classification: Microcytic anaemia (low MCV < 80 fL): iron deficiency anaemia, thalassaemia (alpha and beta), anaemia of chronic disease (sometimes), sideroblastic anaemia, lead poisoning. Macrocytic anaemia (high MCV > 100 fL): Vitamin B12 deficiency, folate deficiency, hypothyroidism, liver disease, alcohol, drugs (methotrexate, hydroxyurea). Sickle cell anaemia: MCV is typically NORMAL (sickle cells are not microcytic; HbS produces normocytic cells). Thalassaemia is characterised by microcytic hypochromic anaemia with low MCV. Thalassaemia is the correct answer.'\n    },\n    {\n      id:37,\n      stem:'GnRH deficiency with hyposmia is typically seen in',\n      correct:'Kallmann syndrome',\n      options:['Kallmann syndrome','Bardet-Biedl syndrome','Prader-Willi syndrome','Wallenberg syndrome'],\n      exp:'Kallmann syndrome is characterised by the combination of hypogonadotropic hypogonadism (GnRH deficiency) and anosmia or hyposmia (absent\/reduced sense of smell). The olfactory defect arises because GnRH-secreting neurons fail to migrate from the olfactory placode to the hypothalamus during foetal development, remaining in the nasal mucosa. Associated features: anosmia\/hyposmia (pathognomonic), absence of puberty, cryptorchidism, cleft palate, sensorineural deafness, renal agenesis. Bardet-Biedl and Prader-Willi syndromes cause obesity and hypogonadism but not specific anosmia. Wallenberg syndrome is a brainstem stroke. Kallmann syndrome is the correct answer.'\n    },\n    {\n      id:38,\n      stem:'Iodine has complex effects on thyroid function. Very high concentrations of iodine inhibit thyroid hormone synthesis and release. This effect is known as',\n      correct:'Wolff-Chaikoff effect',\n      options:['Wolff-Chaikoff effect','Jod-Basedow effect','reverse Wolff-Chaikoff effect','reverse Jod-Basedow effect'],\n      exp:'The Wolff-Chaikoff effect: high inorganic iodide concentrations acutely suppress thyroid hormone synthesis by inhibiting iodide organification (the coupling of iodide to thyroglobulin tyrosyl residues). This is a protective autoregulatory mechanism. Normal thyroid glands escape this effect after 10\\u201314 days (escape from Wolff-Chaikoff) by downregulating the sodium-iodide symporter. Failure to escape leads to hypothyroidism (e.g., amiodarone-induced). The Jod-Basedow effect is the opposite: excess iodine in an iodine-deficient or autonomous thyroid gland triggers hyperthyroidism (e.g., after iodinated contrast). Wolff-Chaikoff = iodine-induced suppression of hormone synthesis.'\n    },\n    {\n      id:39,\n      stem:'Consider the following pharmacological agents:\\n1. Propranolol\\n2. Sodium ipodate\\n3. Propylthiouracil\\n4. Liothyronine\\nWhich of the above can be used for the treatment of thyrotoxic crisis?',\n      correct:'1, 2 and 3',\n      options:['3 only','1 and 2 only','1, 2 and 3','2, 3 and 4'],\n      exp:'Thyrotoxic crisis (thyroid storm) management requires multiple simultaneous interventions. Propylthiouracil (PTU): blocks new thyroid hormone synthesis AND inhibits peripheral T4\\u2192T3 conversion \\u2014 preferred over carbimazole in thyroid storm. Propranolol: controls tachycardia, reduces peripheral symptoms, and importantly inhibits T4\\u2192T3 conversion at high doses. Sodium ipodate (radiographic contrast agent): blocks T4\\u2192T3 conversion and inhibits thyroid hormone release from the gland. Liothyronine (T3) is an active thyroid hormone \\u2014 administering it in thyrotoxic crisis would dramatically WORSEN the condition by adding exogenous T3. Liothyronine is used in myxoedema coma (hypothyroid emergency), not thyroid storm. Statements 1, 2, and 3 are correct.'\n    },\n    {\n      id:40,\n      stem:'Consider the following pharmacological agents:\\n1. Liothyronine\\n2. Levothyroxine\\n3. Carbimazole\\n4. Sodium ipodate\\nWhich of the above may be included in the treatment of myxoedema coma?',\n      correct:'1 and 2',\n      options:['1 only','1 and 2','2 and 3','3 and 4'],\n      exp:'Myxoedema coma is a life-threatening emergency of severe hypothyroidism requiring urgent thyroid hormone replacement. Liothyronine (T3): the active hormone, given IV for immediate effect \\u2014 crosses the blood-brain barrier more readily; preferred for acute treatment. Levothyroxine (T4): given IV or via NG tube, converted peripherally to T3; used alongside or instead of liothyronine for sustained replacement. Carbimazole is an antithyroid drug that BLOCKS thyroid hormone synthesis \\u2014 it would worsen hypothyroidism and is absolutely contraindicated. Sodium ipodate blocks T4\\u2192T3 conversion \\u2014 also contraindicated in myxoedema coma. Additional management: IV hydrocortisone (for adrenal insufficiency), IV fluids, passive warming, treat precipitating cause. 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Submitting in 10 Submit Now Combined Medical Services Examination 2023General Medicine &amp; Paediatrics &nbsp;&middot;&nbsp; Paper I &nbsp;&middot;&nbsp; Part A Cardiology &nbsp;&middot;&nbsp; Respiratory &nbsp;&middot;&nbsp; Gastroenterology &amp; Hepatology &nbsp;&middot;&nbsp; Neurology &nbsp;&middot;&nbsp; Haematology Questions 1 &ndash; 40 Options reshuffled Score = c &times; 4 &minus; w &#9201; Start Timed Mode Submit&hellip;&nbsp;<\/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-36727","post","type-post","status-publish","format-standard","hentry","category-cms"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.5 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>CMS 2023 P1 Part-A - 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\/30\/cms-2023-p1-part-a\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"CMS 2023 P1 Part-A - atsixty\" \/>\n<meta property=\"og:description\" content=\"&#9201;&nbsp;40:00 &#10003;&#65039;&nbsp;0 &#10060;&nbsp;0 &#9203;&nbsp;40&nbsp;left Net&nbsp;0&nbsp;\/&nbsp;160 Time&#039;s Up! 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