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id=\"qz-sr\">40<\/strong> left<\/div>\n <div class=\"qz-timer-wrap\">\n <div class=\"qz-timer\" id=\"qz-timer\">⏱ <strong id=\"qz-td\">40:00<\/strong><\/div>\n <div class=\"qz-stat net-score\">Net <strong id=\"qz-sn\">0<\/strong> \/ 160<\/div>\n <\/div>\n <\/div>\n <div class=\"qz-prog-track\"><div class=\"qz-prog-fill\" id=\"qz-fill\"><\/div><\/div>\n<\/div>\n\n<div class=\"qz-grace\" id=\"qz-grace\">\n <div class=\"qz-grace-box\">\n <h3>Time's Up!<\/h3><p>Submitting in<\/p>\n <div class=\"qz-grace-n\" id=\"qz-gn\">10<\/div>\n <button class=\"qz-grace-now\" id=\"qz-gnow\">Submit Now<\/button>\n <\/div>\n<\/div>\n\n<div class=\"qz-header\">\n <h1>Combined Medical Services Examination 2023<br>General Medicine & Paediatrics · Paper I · Part C<\/h1>\n <p>Hepatology · Nephrology · Haematology · Psychiatry · GI · Paediatrics · Vaccines<\/p>\n <div class=\"qz-meta\">\n <span class=\"qz-badge\">Questions 81–120<\/span>\n <span class=\"qz-badge\">Options reshuffled<\/span>\n <span class=\"qz-badge\">Score = c × 4 − w<\/span>\n <button class=\"qz-timer-btn\" id=\"qz-tbtn\">⏱ Start Timed Mode<\/button>\n <\/div>\n<\/div>\n\n<div class=\"qz-body\">\n <div id=\"qz-questions\"><\/div>\n <div class=\"qz-submit-wrap\">\n <button class=\"qz-submit\" id=\"qz-submit\">Submit Answers<\/button>\n <\/div>\n <div class=\"qz-result\" id=\"qz-result\">\n <div class=\"qz-ring\" id=\"qz-ring\">\n <div class=\"qz-ring-inner\">\n <div class=\"qz-ring-pct\" id=\"qz-rpct\">0%<\/div>\n <div class=\"qz-ring-sub\">score<\/div>\n <\/div>\n <\/div>\n <h2>Your Result<\/h2>\n <div class=\"qz-net\" id=\"qz-rnet\"><\/div>\n <div class=\"qz-verdict\" id=\"qz-rv\"><\/div>\n <div class=\"qz-bands\">\n <span class=\"qz-band bc\" id=\"qz-bc\"><\/span>\n <span class=\"qz-band bw\" id=\"qz-bw\"><\/span>\n <span class=\"qz-band bs\" id=\"qz-bs\"><\/span>\n <\/div>\n <button class=\"qz-retry\" id=\"qz-retry\">↺ Retry Quiz<\/button>\n <\/div>\n<\/div>\n\n<\/div>\n\n<script>\n(function(){\n\nvar TOTAL = 40, MAX = 160;\nvar TSECS = 2400, GSECS = 10;\nvar LTRS = [\"A\",\"B\",\"C\",\"D\"];\n\nvar QQ = [\n{id:81,\nstem:\"In serological investigation of hepatitis B virus infection, presence of hepatitis B e-antigen (HBeAg) is an indicator of\",\ncorrect:\"active replication of virus in the liver\",\nopts:[\"active replication of virus in the liver\",\"acute liver failure\",\"chronic infection with hepatitis B virus\",\"inactive carrier phase of infection\"],\nexp:\"HBeAg is a soluble secreted protein derived from the precore\/core region of the HBV genome. Its presence in serum is a marker of active viral replication and high infectivity. HBeAg-positive patients have very high HBV-DNA levels (10^7-10^9 IU\/mL) and are highly infectious. HBeAg seroconversion to anti-HBe is a key treatment endpoint. The inactive carrier state is characterised by HBsAg-positive, HBeAg-NEGATIVE (anti-HBe positive), low or undetectable HBV-DNA, and normal ALT. HBeAg indicates active viral replication.\"\n},\n{id:82,\nstem:\"Simultaneous infection with hepatitis B virus (HBV) and hepatitis D virus (HDV) followed by full recovery is associated with the appearance of\",\ncorrect:\"low titres of anti-HDV antibody, IgM type\",\nopts:[\"low titres of anti-HDV antibody, IgM type\",\"low titres of anti-HDV antibody, IgA type\",\"high titres of anti-HDV antibody, IgM type\",\"high titres of anti-HDV antibody, IgG type\"],\nexp:\"HDV (delta virus) is a defective RNA virus requiring HBsAg for its envelope. Co-infection (simultaneous acute HBV + HDV): usually self-limiting with full recovery in approximately 95% of cases. Serologically: LOW titre anti-HDV IgM (transient, brief), followed by brief IgG response that also wanes. The low-titre transient antibody response reflects the self-limiting nature of co-infection. Superinfection (HDV in chronic HBV carrier): leads to chronic delta hepatitis in 80-90% with HIGH-titre anti-HDV IgG persisting. Co-infection = low-titre brief antibody response; superinfection = high-titre persistent antibody with chronic disease.\"\n},\n{id:83,\nstem:\"Consider the following statements with regard to jaundice:<br>1. Presence of scleral icterus indicates a serum bilirubin level of at least 3 mg\/dL.<br>2. If the examiner suspects scleral icterus, second site to examine is underneath the tongue.<br>3. In long-standing jaundice, skin may become green due to reduction of bilirubin to biliverdin.<br>4. Sclerae have a particular affinity for bilirubin due to its high elastin content.<br>Which of the statements given above are correct?\",\ncorrect:\"2 and 4 only\",\nopts:[\"1 and 3 only\",\"2 and 4 only\",\"1, 2 and 4 only\",\"1, 2, 3 and 4\"],\nexp:\"Statement 1 FALSE: Scleral icterus becomes clinically detectable when serum bilirubin exceeds approximately 2 mg\/dL with careful inspection; the threshold is not 'at least 3 mg\/dL'. Statement 2 TRUE: After the sclerae, the next best site to detect early jaundice is the undersurface of the tongue (frenulum area) and hard palate. Statement 3 FALSE: In long-standing jaundice, bilirubin is OXIDISED to biliverdin (a green pigment), not reduced. Statement 4 TRUE: Sclerae have high elastin content, and bilirubin has a high affinity for elastin, which explains why sclerae become icteric early and prominently. Statements 2 and 4 only are correct.\"\n},\n{id:84,\nstem:\"Carotenoderma, due to ingestion of excessive amounts of carotene-containing fruits and vegetables, can be distinguished from jaundice by sparing of which of the following?\",\ncorrect:\"Sclerae\",\nopts:[\"Palms\",\"Soles\",\"Nasolabial folds\",\"Sclerae\"],\nexp:\"Carotenaemia causes yellow-orange discolouration of the skin (most prominent on palms, soles, nasolabial folds, and forehead) due to beta-carotene deposition in the stratum corneum. The critical distinguishing feature from jaundice: carotenaemia SPARES THE SCLERAE because carotene does NOT bind elastin and is deposited in skin lipid-rich layers only. In true jaundice (hyperbilirubinaemia), the sclerae are always icteric because bilirubin has high affinity for elastin. Yellow palms, soles, and nasolabial folds with white sclerae = carotenaemia. Yellow sclerae = always jaundice. Sclerae are spared in carotenaemia.\"\n},\n{id:85,\nstem:\"Meares-Stamey test is used in which one of the following clinical conditions?\",\ncorrect:\"Recurrent urinary tract infection in men\",\nopts:[\"Recurrent urinary tract infection in men\",\"Urinary tract infection in pregnant women\",\"Complicated cystitis in non-pregnant women\",\"Pelvic inflammatory disease\"],\nexp:\"The Meares-Stamey 4-glass test (or 2-glass pre-massage\/post-massage test) is a localisation test used to identify the source of infection or inflammation in the male lower urinary tract. Sequential collection of voided bladder urine (VB1 urethral, VB2 midstream bladder), expressed prostatic secretions (EPS), and post-massage urine (VB3 prostatic) is used to diagnose and localise chronic bacterial prostatitis, chronic pelvic pain syndrome, and to distinguish urethritis from prostatitis. It is specifically used in males with recurrent UTI or chronic pelvic pain symptoms. It has no application in female UTI or PID.\"\n},\n{id:86,\nstem:\"Which one of the following drugs is associated with calciphylaxis in chronic kidney disease patients?\",\ncorrect:\"Warfarin\",\nopts:[\"Calcium channel blocker\",\"Warfarin\",\"Non-calcium-based phosphate binder\",\"Thiazide diuretic\"],\nexp:\"Calciphylaxis (calcific uraemic arteriolopathy) is a devastating condition in CKD\/ESRD patients characterised by calcification of small and medium arterioles causing ischaemic skin necrosis. Warfarin is a well-established risk factor. The mechanism: warfarin inhibits Vitamin K-dependent carboxylation of Matrix Gla Protein (MGP), a potent inhibitor of vascular calcification. Without functional MGP, calcium-phosphate deposits accumulate in vessel walls, promoting calciphylaxis. This has led to use of Vitamin K supplementation and transition to alternative anticoagulants in at-risk patients. Warfarin is the drug most classically and specifically associated with calciphylaxis.\"\n},\n{id:87,\nstem:\"Consider the following pairs:<br>Urinary sediments seen in AKI : Diagnosis<br>1. RBC casts : Malignant hypertension<br>2. WBC casts : Pyelonephritis<br>3. Pigmented casts : Vasculitis<br>4. Granular casts : Myoglobinuria<br>How many of the pairs given above are correctly matched?\",\ncorrect:\"Only two pairs\",\nopts:[\"Only one pair\",\"Only two pairs\",\"Only three pairs\",\"All four pairs\"],\nexp:\"Pair 1 (RBC casts: Malignant hypertension) CORRECT: RBC casts indicate glomerular bleeding; malignant hypertension causes fibrinoid necrosis of glomerular arterioles with haematuria and RBC casts. Pair 2 (WBC casts: Pyelonephritis) CORRECT: WBC casts indicate renal parenchymal inflammation; seen in pyelonephritis and acute interstitial nephritis. Pair 3 (Pigmented casts: Vasculitis) INCORRECT: Pigmented (muddy-brown granular) casts are characteristic of acute tubular necrosis (ATN), not vasculitis. Vasculitis causes RBC casts. Pair 4 (Granular casts: Myoglobinuria) INCORRECT: In myoglobinuria (rhabdomyolysis), the casts are PIGMENTED casts (brown from haem pigment), not plain granular casts. Pairs 1 and 2 are correctly matched: only two pairs.\"\n},\n{id:88,\nstem:\"Which one of the following is the primary underlying mechanism of haemolysis in paroxysmal nocturnal haemoglobinuria (PNH)?\",\ncorrect:\"Complement-mediated destruction of CD59(-) red blood cells\",\nopts:[\"ABO incompatibility\",\"Red cell fragmentation\",\"Complement-mediated destruction of CD59(-) red blood cells\",\"Exotoxins produced by Clostridium perfringens\"],\nexp:\"PNH is caused by a somatic PIG-A gene mutation resulting in deficiency of GPI-anchored proteins on blood cell surfaces. The critical deficient proteins are CD55 (inhibits C3 and C5 convertases) and CD59 (prevents insertion of the Membrane Attack Complex C5b-9). Without CD55 and CD59, red blood cells are exquisitely sensitive to complement-mediated lysis. The primary mechanism is complement-mediated intravascular haemolysis of CD59-deficient red blood cells. The MAC (C5b-9) inserts into the RBC membrane causing lysis. This is why eculizumab (anti-C5 monoclonal antibody) is the specific and highly effective treatment for PNH.\"\n},\n{id:89,\nstem:\"Which one of the following is a clonal haematopoietic stem cell disorder in which phenotypically normal red blood cells, granulocytes and platelets accumulate in the absence of a recognizable physiological stimulus?\",\ncorrect:\"Polycythemia vera\",\nopts:[\"Mastocytosis\",\"Polycythemia vera\",\"Primary myelofibrosis\",\"Essential thrombocytosis\"],\nexp:\"Polycythaemia vera (PV) is a clonal myeloproliferative neoplasm caused by a JAK2 mutation (JAK2 V617F in approximately 95% of cases). PV is characterised by autonomous (stimulus-independent) proliferation of phenotypically normal erythroid, myeloid, and megakaryocytic cells, leading to elevated red cell mass, leukocytosis, and thrombocytosis without an appropriate physiological stimulus. The cells are morphologically normal but produced in excess due to constitutive JAK-STAT pathway activation. Essential thrombocytosis specifically affects platelets. Primary myelofibrosis involves fibrosis. Mastocytosis involves mast cells. PV is the correct answer.\"\n},\n{id:90,\nstem:\"Which of the following insulins has a cloudy preparation and requires resuspension prior to injection?\",\ncorrect:\"Lente\",\nopts:[\"Lente\",\"Glargine\",\"Detemir\",\"Degludec\"],\nexp:\"Lente insulin (insulin zinc suspension) is a cloudy, intermediate-acting insulin preparation containing insulin-zinc crystals in suspension. The zinc-insulin complexes settle to the bottom, so the vial must be gently rolled\/resuspended before each injection to ensure uniform dosing. NPH (isophane) insulin is another classic cloudy insulin requiring resuspension. Clear (transparent) insulins: all rapid-acting analogues (aspart, lispro, glulisine), short-acting regular insulin, and all modern long-acting analogues (glargine, detemir, degludec) are clear solutions that do NOT require resuspension. Lente is the correct answer.\"\n},\n{id:91,\nstem:\"Which of the following statements are correct with regard to anorexia nervosa?<br>1. The illness is often precipitated by weight loss.<br>2. Food avoidance is common.<br>3. Body image is intact and there is no fear of weight gain.<br>4. Downy hair (lanugo) may develop on back, forearms and cheeks.<br>Select the correct answer using the code given below.\",\ncorrect:\"2 and 4\",\nopts:[\"1, 2 and 3\",\"1, 2 and 4\",\"1, 3 and 4\",\"2 and 4\"],\nexp:\"Statement 1 FALSE: Anorexia nervosa is typically precipitated by intentional dieting\/food restriction, NOT by weight loss as an external precipitant. Statement 2 TRUE: Food avoidance, restriction, and selective eating are core behavioural features driven by intense fear of weight gain. Statement 3 FALSE: Body image disturbance and intense fear of gaining weight are CORE DIAGNOSTIC CRITERIA (DSM-5); body image is profoundly disturbed, not intact. Statement 4 TRUE: Lanugo (fine downy hair covering the body) is a classic physical sign of severe anorexia nervosa seen on the back, face, forearms, and abdomen; an adaptive response to hypothermia from loss of body fat. Statements 2 and 4 are correct.\"\n},\n{id:92,\nstem:\"Which of the following are adverse effects of loop-acting and thiazide diuretics?<br>1. Metabolic acidosis<br>2. Hypovolaemia<br>3. Hyponatraemia<br>4. Hypokalaemia<br>Select the correct answer using the code given below.\",\ncorrect:\"2, 3 and 4\",\nopts:[\"1, 2 and 3\",\"1, 2 and 4\",\"1, 3 and 4\",\"2, 3 and 4\"],\nexp:\"Loop and thiazide diuretics are both kaliuretic diuretics with shared adverse effects. Hypovolaemia (2): fluid depletion from excess diuresis. Hyponatraemia (3): particularly with thiazides which maintain free water reabsorption in the collecting duct; thiazides cause more profound hyponatraemia than loop diuretics. Hypokalaemia (4): urinary potassium wasting from increased distal tubular flow and aldosterone activation. Both cause metabolic ALKALOSIS (not acidosis) via volume contraction (stimulating H+ secretion), hypokalaemia (K+ shifts out of cells, H+ enters), and hydrogen ion loss. Statement 1 (metabolic acidosis) is INCORRECT; these drugs cause ALKALOSIS. Statements 2, 3, and 4 are correct.\"\n},\n{id:93,\nstem:\"Which one of the following statements is correct with regard to peptic ulcer prophylaxis?\",\ncorrect:\"Proton-pump inhibitors (PPIs) are effective at reducing the incidence of ulceration.\",\nopts:[\"Stress ulceration during clinical illness is uncommon.\",\"Ulcer prophylaxis should be continued once absorption of enteral feed is established.\",\"Proton-pump inhibitors (PPIs) are effective at reducing the incidence of ulceration.\",\"PPIs when used with antibiotics may decrease the risk of Clostridium difficile infection.\"],\nexp:\"Statement (a) FALSE: Stress ulceration is COMMON in critically ill patients (mechanical ventilation, coagulopathy, major trauma, burns) and is a major cause of upper GI bleeding in ICUs. Statement (b) FALSE: Ulcer prophylaxis can generally be DISCONTINUED once enteral nutrition is established; enteral feeding raises gastric pH and provides mucosal protection. Statement (c) TRUE: PPIs effectively suppress gastric acid, raising gastric pH above 4, which prevents stress ulceration and is the standard prophylaxis in ICU patients at risk. Statement (d) FALSE: PPIs combined with antibiotics actually INCREASE the risk of C. difficile infection by disrupting normal gut flora. Option (c) is the only correct statement.\"\n},\n{id:94,\nstem:\"Which of the following are the features of post-lumbar puncture headache?<br>1. Dull aching occipitofrontal headache<br>2. Worse on waking but improves during the day<br>3. Recumbency usually improves the headache within minutes<br>Select the correct answer using the code given below.\",\ncorrect:\"1 and 3 only\",\nopts:[\"1 and 2 only\",\"2 and 3 only\",\"1 and 3 only\",\"1, 2 and 3\"],\nexp:\"Post-lumbar puncture headache (PDPH) is caused by CSF leakage through the dural puncture site, reducing CSF volume and intracranial pressure, causing traction on pain-sensitive intracranial structures when upright. Classic features: Statement 1 TRUE: Dull, aching, bilateral occipitofrontal headache. Statement 2 FALSE: PDPH is characteristically WORSE on SITTING UP or STANDING and BETTER when LYING DOWN. It is the classic orthostatic headache. Statement 3 TRUE: Recumbency (lying flat) rapidly improves or abolishes the headache within minutes by restoring CSF pressure and relieving traction on pain-sensitive structures. Statements 1 and 3 are correct.\"\n},\n{id:95,\nstem:\"Which of the following are correct with regard to alpha-1-antitrypsin deficiency?<br>1. Prolonged jaundice in neonatal period<br>2. Pulmonary emphysema in adulthood<br>3. Panniculitis is seen rarely<br>4. Autosomal dominant disorder<br>Select the correct answer using the code given below.\",\ncorrect:\"1, 2 and 3\",\nopts:[\"1, 2 and 3\",\"1, 2 and 4\",\"1, 3 and 4\",\"2, 3 and 4\"],\nexp:\"Alpha-1-antitrypsin (AAT) deficiency (PIZZ genotype): Statement 1 TRUE: Neonatal cholestasis\/prolonged jaundice is a classic hepatic manifestation; AAT accumulates as misfolded polymer in hepatocytes causing ER stress and neonatal jaundice. Statement 2 TRUE: Panacinar emphysema (predominantly lower lobe) develops in adulthood due to uninhibited neutrophil elastase destroying alveolar walls; smoking dramatically accelerates emphysema. Statement 3 TRUE: Panniculitis (necrotising inflammation of subcutaneous fat) is a rare but recognised manifestation. Statement 4 FALSE: AAT deficiency follows AUTOSOMAL RECESSIVE (codominant) inheritance, NOT autosomal dominant. The PiZZ homozygous state causes severe deficiency. Statements 1, 2, and 3 are correct.\"\n},\n{id:96,\nstem:\"Which of the following drugs can cause granulomatous liver injury?<br>1. Carbamazepine<br>2. Allopurinol<br>3. Diltiazem<br>4. Acetaminophen<br>Select the correct answer using the code given below.\",\ncorrect:\"1, 2 and 3\",\nopts:[\"1, 2 and 3\",\"1, 2 and 4\",\"1, 3 and 4\",\"2, 3 and 4\"],\nexp:\"Drug-induced granulomatous hepatitis involves formation of non-caseating granulomas in the liver. Classic causative drugs: Carbamazepine (anticonvulsant): well-recognised cause of granulomatous hepatitis as part of hypersensitivity reactions. Allopurinol (xanthine oxidase inhibitor): a classic cause, often with systemic hypersensitivity syndrome. Diltiazem (calcium channel blocker): documented cause of granulomatous hepatitis. Other causes: quinidine, hydralazine, phenytoin, sulfonamides, isoniazid. Acetaminophen (paracetamol) causes CENTRILOBULAR NECROSIS (zone 3 hepatocellular necrosis) via toxic NAPQI metabolite, NOT granulomatous hepatitis. Statements 1, 2, and 3 are correct.\"\n},\n{id:97,\nstem:\"Which of the following are the five essential components of nurturing care?<br>1. Health<br>2. Nutrition<br>3. Breastfeeding<br>4. Responsive caregiving<br>5. Early learning<br>6. Immunization<br>7. Safety and security<br>8. Supplementation<br>Select the correct answer using the code given below.\",\ncorrect:\"1, 2, 4, 5 and 7\",\nopts:[\"1, 2, 4, 5 and 7\",\"1, 2, 3, 4 and 5\",\"1, 4, 6, 7 and 8\",\"2, 3, 5, 6 and 8\"],\nexp:\"The WHO\/UNICEF Nurturing Care Framework (2018) defines five essential components: (1) Good health; (2) Adequate nutrition; (4) Responsive caregiving (sensitive, responsive interactions between caregivers and children that promote social-emotional development); (5) Opportunities for early learning (stimulation, play, communication); (7) Safety and security (protecting children from harm, stress, and adversity). Breastfeeding is a component of nutrition, not a separate domain. Immunization is part of health. Supplementation is part of nutrition. The five domains are Health, Nutrition, Responsive caregiving, Early learning, and Safety and security. Statements 1, 2, 4, 5, and 7 are correct.\"\n},\n{id:98,\nstem:\"A full-term baby born with birth weight of 2000 g comes for well-baby visit at two months of age. Which of the following nutritional supplements would you advise?\",\ncorrect:\"Iron orally 2 mg\/kg\/day up to 1 year of age\",\nopts:[\"Vitamin D orally 200 IU\/day up to 3 months of age\",\"Vitamin D orally 200 IU\/day up to 1 year of age\",\"Iron orally 2 mg\/kg\/day up to 3 months of age\",\"Iron orally 2 mg\/kg\/day up to 1 year of age\"],\nexp:\"A full-term low birth weight (LBW) infant (birth weight 2000 g, below 2500 g) has reduced iron stores at birth (iron is accumulated primarily in the last trimester). IAP and National guidelines recommend: Iron supplementation for full-term LBW infants: oral elemental iron 2 mg\/kg\/day starting at 2 months of age (when maternal iron stores become depleted) and continued until 1 year of age. This prevents iron deficiency anaemia in LBW infants during rapid postnatal growth. Vitamin D (400 IU\/day) is recommended for all breastfed infants but the key supplement for a 2-month-old LBW baby at the well-baby visit is iron 2 mg\/kg\/day up to 1 year.\"\n},\n{id:99,\nstem:\"Which of the following are common problems in babies with intrauterine growth restriction delivered at term gestation?<br>1. Hypothermia<br>2. Hypoglycaemia<br>3. Hypocalcaemia<br>Select the correct answer using the code given below.\",\ncorrect:\"1, 2 and 3\",\nopts:[\"1 and 2 only\",\"2 and 3 only\",\"1 and 3 only\",\"1, 2 and 3\"],\nexp:\"IUGR\/SGA infants at term face multiple metabolic complications due to reduced fat, glycogen stores, and immature thermoregulation: Hypothermia (1): IUGR infants have reduced subcutaneous fat (insulation) and reduced brown adipose tissue (thermogenesis), making them highly vulnerable to hypothermia. Hypoglycaemia (2): IUGR infants have reduced hepatic glycogen stores and impaired gluconeogenesis; hypoglycaemia is very common and must be monitored closely. Hypocalcaemia (3): IUGR infants have lower calcium stores and impaired parathyroid response, predisposing to neonatal hypocalcaemia. All three are correct well-recognised complications of IUGR at term.\"\n},\n{id:100,\nstem:\"Which one of the following statements is correct regarding a normal newborn's growth?\",\ncorrect:\"Birth weight is regained by 7-10 days of age.\",\nopts:[\"Weight loss may be 8-10% of birth weight in the initial two weeks of life.\",\"Birth weight is regained by 7-10 days of age.\",\"Birth weight is regained within first week of life.\",\"Weight loss may be 12-15% of birth weight in the initial two weeks of life.\"],\nexp:\"Normal newborn weight changes: Initial physiological weight loss occurs in the first 3-4 days of life due to passage of meconium, insensible water losses, and establishment of feeding. Normal weight loss: 7-10% of birth weight (weight loss greater than 10% is excessive). Birth weight is normally REGAINED by 7-10 days of age. Option (a) mentions 8-10% which is within range but the two-week timeframe is incorrect (loss occurs in first 3-4 days). Option (c) 'within first week' is too early for most infants. Weight loss of 12-15% (option d) is abnormal. Option (b) birth weight regained by 7-10 days is the correct statement.\"\n},\n{id:101,\nstem:\"For developmental assessment of a baby, grasp is best assessed by offering the child\",\ncorrect:\"red pellets\",\nopts:[\"a red ring\",\"a red cube\",\"red pellets\",\"multicoloured pellets\"],\nexp:\"Developmental assessment of hand grasp uses standardised objects of specific sizes to elicit different grasp patterns. Red pellets (small, approximately 3 mm) are specifically used to test the development of PINCER GRASP (inferior pincer at 8-9 months, neat\/superior pincer grasp at 9-12 months). The small size of the pellet necessitates a precise pincer grasp (thumb and index finger tip opposition) rather than a raking or palmar grasp. A red ring tests gross grasp and transfer. A red cube tests palmar\/pincer grasp transition. Red pellets are used to assess fine motor pincer grasp development in the Denver Developmental Screening Test.\"\n},\n{id:102,\nstem:\"Urinary alkalinization as a method for enhancing excretion for poisoning is aimed at achieving\",\ncorrect:\"urine pH 7.5-8\",\nopts:[\"serum pH 7.5-8\",\"urine pH 7.5-8\",\"serum pH > 8\",\"urine pH > 8\"],\nexp:\"Urinary alkalinisation enhances renal excretion of weak acids (salicylates, phenobarbitone) by ion trapping: at alkaline urine pH, the acid drug is ionised and cannot be reabsorbed across the tubular epithelium, so it is excreted in urine. The TARGET urine pH is 7.5-8.0 (achieved by IV sodium bicarbonate infusion with careful monitoring). It is NOT aimed at altering serum pH (targeting serum pH 7.5-8 would cause dangerous systemic alkalosis). Urine pH greater than 8 is unnecessarily aggressive and risks precipitation of calcium phosphate in tubules. The correct target is urine pH 7.5-8.\"\n},\n{id:103,\nstem:\"Exchange transfusion as a method to enhance excretion of poison is indicated in\",\ncorrect:\"methemoglobinemia\",\nopts:[\"methemoglobinemia\",\"carbamazepine poisoning\",\"theophylline poisoning\",\"barbiturate poisoning\"],\nexp:\"Exchange transfusion replaces the patient's blood with donor blood, removing the toxin-laden red cells or plasma. It is specifically indicated when the toxic substance is carried within red blood cells and cannot be effectively removed by dialysis or haemoperfusion. Methaemoglobinaemia (from oxidising agents - dapsone, primaquine, nitrites, chloroquine): when metHb levels are very high (typically greater than 70%) and methylene blue has failed or is contraindicated (e.g., G6PD deficiency), exchange transfusion replaces metHb-containing red cells with normal oxyhaemoglobin-containing donor red cells. Carbamazepine, theophylline, and barbiturate are better removed by haemoperfusion or haemodialysis.\"\n},\n{id:104,\nstem:\"In case of a child with an acute poisoning by ingestion, activated charcoal may be used in which one of the following situations?\",\ncorrect:\"Antiepileptic ingestion\",\nopts:[\"Iron ingestion\",\"Antiepileptic ingestion\",\"Corrosive ingestion\",\"Lithium ingestion\"],\nexp:\"Activated charcoal (AC) works by adsorbing ingested toxins in the GI tract, preventing absorption. Antiepileptic drugs (carbamazepine, phenobarbitone, valproate, phenytoin) are well adsorbed by activated charcoal; MDAC enhances elimination of carbamazepine and phenobarbitone. Contraindications\/ineffective: Iron (heavy metal, not adsorbed by AC; deferoxamine chelation is used). Corrosives (acids\/alkalis: AC is ineffective and worsens mucosal damage; also obscures endoscopic assessment). Lithium (ionic metal compound: not adsorbed by AC; sodium polystyrene sulphonate or haemodialysis used). Antiepileptic ingestion is the correct answer.\"\n},\n{id:105,\nstem:\"Which of the following genetic causes are commonly associated with autism spectrum disorders?<br>1. Angelman syndrome<br>2. Fragile X syndrome<br>3. Tuberous sclerosis<br>4. Williams syndrome<br>Select the correct answer using the code given below.\",\ncorrect:\"1, 2 and 3\",\nopts:[\"1, 2 and 3\",\"1, 2 and 4\",\"1, 3 and 4\",\"2, 3 and 4\"],\nexp:\"Genetic conditions commonly associated with ASD: Angelman syndrome (UBE3A mutation): ASD features in approximately 50-80% of cases. Fragile X syndrome (FMR1 CGG repeat expansion): the most common single-gene cause of inherited intellectual disability and ASD; approximately 30% of males with Fragile X have ASD. Tuberous sclerosis complex (TSC1\/TSC2 mutations): ASD occurs in approximately 40-50% of TSC patients. Williams syndrome (deletion 7q11.23): characterised by HYPERSOCIABILITY and a friendly personality; it is associated with OPPOSITE social behaviours to ASD and is NOT commonly associated with ASD. Statements 1, 2, and 3 are correct.\"\n},\n{id:106,\nstem:\"To reduce the risk of neural tube defects in the baby, which of the following are recommended?\",\ncorrect:\"Folate supplements, from one month before conception to three months after\",\nopts:[\"Folate supplements, from one month before conception to three months after\",\"Folate supplements, from confirmation of pregnancy to the end of first trimester\",\"Zinc supplements, from one month before conception to three months after\",\"Zinc supplements, from confirmation of pregnancy to the end of first trimester\"],\nexp:\"Neural tube defects (NTDs: anencephaly, spina bifida) result from failure of neural tube closure at 3-4 weeks of gestation, often before pregnancy is confirmed. Prevention: FOLATE (folic acid) supplementation is the established evidence-based intervention. Timing: supplementation must BEGIN at least 1 MONTH BEFORE CONCEPTION (pre-conceptual) to ensure adequate folate status at the time of neural tube closure (which occurs before many women know they are pregnant) and continued through the FIRST TRIMESTER (up to 12 weeks). Dose: 0.4-0.5 mg\/day (standard risk) or 4-5 mg\/day (high risk). Zinc supplements are not the established intervention for NTD prevention. Option (a) is correct.\"\n},\n{id:107,\nstem:\"Vaccine-associated poliomyelitis is chiefly seen with which of the following strains of oral poliovirus?\",\ncorrect:\"OPV 2\",\nopts:[\"OPV 1 only\",\"OPV 2\",\"OPV 3 only\",\"Both OPV 1 and OPV 3\"],\nexp:\"Vaccine-associated paralytic poliomyelitis (VAPP) is a rare complication of oral poliovirus vaccine (OPV). Among the three poliovirus serotypes, TYPE 2 (OPV 2) is responsible for the MAJORITY of VAPP cases and also for circulating vaccine-derived poliovirus (cVDPV) outbreaks. Wild poliovirus type 2 was eradicated in 1999, and the trivalent OPV (tOPV) was replaced with bivalent OPV (bOPV types 1+3) globally in 2016 to eliminate the type 2 VAPP risk. OPV type 2 is the correct answer.\"\n},\n{id:108,\nstem:\"Which one of the following is categorized as a specific learning disability?\",\ncorrect:\"Dysgraphia\",\nopts:[\"Dysgraphia\",\"Dystonia\",\"Dysthymia\",\"Dysphoria\"],\nexp:\"Specific learning disabilities (SpLD) are neurodevelopmental disorders affecting acquisition of reading, writing, or mathematical skills despite normal intelligence. The three main SpLDs (DSM-5): Dyslexia (impaired reading), Dysgraphia (impaired written expression and handwriting), Dyscalculia (impaired mathematics). Dystonia is a movement disorder (neurological), not a learning disability. Dysthymia is a chronic depressive mood disorder (psychiatric), not a learning disability. Dysphoria is a state of unease (mood symptom), not a learning disability category. Dysgraphia is the only specific learning disability among the options.\"\n},\n{id:109,\nstem:\"A baby is delivered at 34 weeks' gestation and found to be apnoeic at birth. After performing the initial steps of resuscitation, the baby is still apnoeic. The next step should be\",\ncorrect:\"positive pressure ventilation using 30% oxygen\",\nopts:[\"tactile stimulation\",\"positive pressure ventilation using 30% oxygen\",\"positive pressure ventilation using 100% oxygen\",\"chest compression\"],\nexp:\"NRP\/ILCOR 2020 guidelines for preterm neonatal resuscitation: After the initial steps (warmth, drying\/stimulation, clearing airway, repositioning), if the baby remains apnoeic, the next step is POSITIVE PRESSURE VENTILATION (PPV). For preterm infants (less than 35 weeks), PPV should be initiated with 21-30% oxygen. Starting with 30% FiO2 is recommended because hyperoxia in preterm infants causes oxygen toxicity, free radical injury to the developing brain, lungs, and retina. Tactile stimulation has already been performed in the initial steps. Chest compressions are indicated only if heart rate remains below 60 bpm despite 30 seconds of effective PPV. PPV with 30% oxygen is the correct next step.\"\n},\n{id:110,\nstem:\"A child requires detailed developmental evaluation if the developmental quotient is below\",\ncorrect:\"70%\",\nopts:[\"70%\",\"75%\",\"80%\",\"85%\"],\nexp:\"The Developmental Quotient (DQ) = (Developmental Age \/ Chronological Age) x 100. A DQ below 70 indicates significant developmental delay and requires comprehensive multidisciplinary developmental evaluation. This threshold corresponds to the definition of intellectual disability (IQ below 70, approximately 2 standard deviations below the mean). A DQ of 70-85 indicates borderline developmental delay warranting close monitoring and therapeutic intervention. A DQ above 85 is generally within the normal range. The threshold for referring a child for detailed developmental evaluation is a DQ below 70%.\"\n},\n{id:111,\nstem:\"The upper limit of age for attainment of visual fixation or following is\",\ncorrect:\"2 months\",\nopts:[\"birth\",\"1 month\",\"2 months\",\"3 months\"],\nexp:\"Visual fixation (fixing gaze on an object or face) is present from birth and becomes consistent by 4-6 weeks. Visual following (tracking a moving object) begins by 4-6 weeks and is well-established by 6-8 weeks. The UPPER LIMIT of normal age for attaining visual fixation or following is 2 months (8 weeks). Absence of visual fixation and following beyond 2 months is a RED FLAG requiring urgent ophthalmological and neurological assessment to exclude visual impairment (cataracts, retinal pathology), cortical visual impairment, or significant developmental delay. The upper limit is 2 months.\"\n},\n{id:112,\nstem:\"A child develops 'stranger anxiety' at\",\ncorrect:\"6-7 months\",\nopts:[\"2-3 months\",\"4-5 months\",\"6-7 months\",\"8-9 months\"],\nexp:\"Stranger anxiety (fear of unfamiliar people, manifesting as distress, crying, or clinging to the caregiver when approached by strangers) is a normal developmental milestone reflecting the child's developing ability to distinguish familiar from unfamiliar faces and deepening attachment to primary caregivers. Standard developmental textbooks (Ghai, Nelson) place the onset of stranger anxiety at 6-7 months of age. The peak is typically at 8-12 months. Social smile begins at 6 weeks; selective social smile by 3-4 months; stranger anxiety by 6-7 months. The correct answer is 6-7 months.\"\n},\n{id:113,\nstem:\"Consider the following statements with respect to developmental milestones at 9 months of age:<br>1. At this age, child develops immature pincer grasp.<br>2. At this age, child can say bisyllables (mama, dada, etc.).<br>3. At this age, child can wave bye-bye.<br>Which of the statements given above are correct?\",\ncorrect:\"1 and 3 only\",\nopts:[\"1 and 2 only\",\"2 and 3 only\",\"1 and 3 only\",\"1, 2 and 3\"],\nexp:\"Developmental milestones at 9 months: Fine motor: IMMATURE PINCER GRASP (inferior pincer using distal pad of thumb and index finger) develops at 8-9 months. Neat\/superior pincer (fingertip to fingertip) develops at 9-12 months. Statement 1 TRUE. Language: Bisyllables (mama, dada) as NON-SPECIFIC vocalisations begin at approximately 6 MONTHS. At 9 months, bisyllables are being used but this is not a NEW 9-month milestone; it begins at 6 months. Statement 2 is NOT specifically a new 9-month milestone. Social: Waving bye-bye is a 9-month social milestone. Statement 3 TRUE. Statements 1 and 3 only are correct.\"\n},\n{id:114,\nstem:\"What are the upper age limits by which a child should start walking alone, and be able to speak single words?\",\ncorrect:\"18 months, 18 months respectively\",\nopts:[\"12 months, 15 months respectively\",\"15 months, 18 months respectively\",\"15 months, 15 months respectively\",\"18 months, 18 months respectively\"],\nexp:\"Upper limits (red flag thresholds) for developmental milestones: Independent walking should be achieved by 18 months. A child not walking independently by 18 months requires evaluation for motor delay (cerebral palsy, neuromuscular disease). Single meaningful words should be spoken by 18 months. A child with no single meaningful words by 18 months requires evaluation for speech-language delay, hearing impairment, or ASD. Note: most children ACHIEVE walking at 12-13 months and single words at 10-14 months; these 18-month figures are the UPPER LIMITS (2 standard deviations below mean) used as red flag thresholds per standard Indian paediatric developmental guidelines (Ghai). Both upper limits are 18 months.\"\n},\n{id:115,\nstem:\"A child presents to the emergency following ingestion of around 20 mL of kerosene oil about 40 minutes back. The child appears stable. Which one of the following measures should be done for the management of the child?\",\ncorrect:\"Radiography\",\nopts:[\"Gastric lavage\",\"Oxygen therapy\",\"Intravenous steroids\",\"Radiography\"],\nexp:\"Kerosene (hydrocarbon) ingestion management: Gastric lavage and induced vomiting are ABSOLUTELY CONTRAINDICATED in kerosene ingestion. The primary risk is ASPIRATION PNEUMONITIS from the low-viscosity hydrocarbon entering the lungs; inducing vomiting or lavage massively increases aspiration risk. The amount (20 mL) is relatively small and systemic toxicity is unlikely. The child is STABLE. Management: reassurance, observation, and CHEST X-RAY (radiography) to detect early aspiration pneumonitis (bilateral lower lobe infiltrates appearing within 2-8 hours). Activated charcoal is ineffective for hydrocarbons. Oxygen therapy and steroids are used only if aspiration pneumonitis develops. Radiography is the correct initial step.\"\n},\n{id:116,\nstem:\"The event related to vaccination which can be contraindication for the next vaccination of similar\/identical type is\",\ncorrect:\"encephalopathy following DPT vaccine\",\nopts:[\"syncope following MMR vaccine\",\"encephalopathy following DPT vaccine\",\"abscess at injection site after DPT vaccine\",\"gastroenteritis following MMR vaccine\"],\nexp:\"True contraindication (absolute) to further doses of the SAME vaccine: encephalopathy (acute encephalopathy not attributable to another cause) occurring within 7 days of DPT\/DTP vaccination is an absolute contraindication to further doses of pertussis-containing vaccine. Whole-cell pertussis component has been associated with rare serious neurological adverse events. Other listed events: Syncope (vasovagal fainting) after MMR is common and NOT a contraindication to repeat vaccination. Injection-site abscess after DPT requires investigation but is not a contraindication per se. Gastroenteritis after MMR is a coincidental event. Encephalopathy following DPT vaccine is the correct contraindication.\"\n},\n{id:117,\nstem:\"Which of the following events could be caused or precipitated by an active component of vaccine?<br>1. Anaphylaxis after measles vaccine<br>2. Encephalopathy after DPT vaccine<br>3. Adenitis following BCG vaccine<br>4. Gastroenteritis following MMR vaccine<br>Select the correct answer using the code given below.\",\ncorrect:\"1, 2 and 3\",\nopts:[\"1, 2 and 3\",\"1, 2 and 4\",\"1, 3 and 4\",\"2, 3 and 4\"],\nexp:\"AEFI caused by the active vaccine component: Anaphylaxis after measles vaccine is a true vaccine reaction to vaccine antigens or constituents (gelatin stabiliser, neomycin, egg protein). Encephalopathy after DPT vaccine is a rare but recognised serious vaccine reaction to the pertussis component of whole-cell DPT. Adenitis (suppurative lymphadenitis) following BCG vaccine is a local vaccine reaction where the live attenuated Mycobacterium bovis causes regional axillary lymphadenitis. Gastroenteritis following MMR vaccine is NOT a recognised adverse effect of MMR vaccine components; it is a coincidental infection. Statements 1, 2, and 3 are correct.\"\n},\n{id:118,\nstem:\"Which one of the following can be used for developmental screening for use in community to identify children (aged 0-6 years) with developmental delay?\",\ncorrect:\"Trivandrum Development Screening Chart\",\nopts:[\"Revised Denver Development Screening Test (Denver II)\",\"Ages and Stages Questionnaire (ASQ-3)\",\"Phatak's Baroda Development Screening Test\",\"Trivandrum Development Screening Chart\"],\nexp:\"The question asks for a COMMUNITY-LEVEL developmental screening tool specifically designed for use in India for children 0-6 years. The Trivandrum Development Screening Chart (TDSC) was developed at the Child Development Centre, Trivandrum, Kerala, specifically designed for use by community health workers (ANMs, ASHAs) in India. It is simple, culturally adapted, and practical for use at the community level in resource-limited settings. Denver II requires trained personnel and more time. ASQ-3 is a parent-completed questionnaire used globally. Phatak's Baroda test is more suited to clinical settings. Trivandrum Development Screening Chart is the specifically India-adapted community-level screening tool.\"\n},\n{id:119,\nstem:\"According to the WHO clinical criteria, which of the following clinical signs are indicative of 'severe pneumonia or very severe disease' in children aged 2 months to 5 years?<br>1. Convulsions<br>2. Lower chest indrawing<br>3. Inability to feed<br>4. Stridor<br>Select the correct answer using the code given below.\",\ncorrect:\"1, 2 and 4\",\nopts:[\"1, 2 and 3\",\"1, 2 and 4\",\"1, 3 and 4\",\"2, 3 and 4\"],\nexp:\"WHO\/IMNCI classification for children aged 2 months to 5 years: SEVERE PNEUMONIA: lower chest indrawing (subcostal recession) requires hospital admission and IV antibiotics. VERY SEVERE DISEASE (general danger signs): inability to drink\/feed, vomiting everything, convulsions, abnormally sleepy\/unconscious, stridor when calm. Inability to feed is classified as a general danger sign of very severe disease but is NOT specific to severe pneumonia. Lower chest indrawing is the hallmark of severe pneumonia specifically. Convulsions and stridor when calm are danger signs of very severe disease. The WHO clinical criteria for severe pneumonia or very severe disease associated with pneumonia: lower chest indrawing, convulsions, stridor when calm. Statements 1, 2, and 4 are correct.\"\n},\n{id:120,\nstem:\"An eleven-month-old unimmunized child comes for immunization. Which vaccines should be given in this visit?\",\ncorrect:\"OPV, DPT, MR and Hepatitis B vaccines\",\nopts:[\"BCG, OPV, DPT and Hepatitis B vaccines\",\"OPV, DPT and MR vaccines only\",\"BCG, DPT and MR vaccines\",\"OPV, DPT, MR and Hepatitis B vaccines\"],\nexp:\"An 11-month-old completely unimmunized child requires catch-up immunisation per India's Universal Immunisation Programme (UIP) schedule. The child has missed: OPV (0, 6, 10, 14 weeks doses), DPT (6, 10, 14 weeks doses), Hepatitis B (birth, 6, 10, 14 weeks doses). MR\/Measles vaccine is due at 9-12 months and is NOW due at 11 months. At this single visit: OPV + DPT + MR + Hepatitis B should be given. BCG is given at birth through 1 year but the primary priority at 11 months catch-up is OPV, DPT, MR, and Hepatitis B. Option (d) OPV, DPT, MR and Hepatitis B vaccines is correct.\"\n}\n];\n\nvar ans = {}, done = 0, sopts = {};\nvar trun = false, trem = TSECS, tiv = null, giv = null, subm = false;\n\nfunction g(id){ return document.getElementById(id); }\n\nfunction fmt(s){\n var m = Math.floor(s\/60), sc = s%60;\n return (m<10?\"0\":\"\")+m+\":\"+(sc<10?\"0\":\"\")+sc;\n}\n\nfunction shuf(a){\n var b=a.slice(), i, j, t;\n for(i=b.length-1;i>0;i--){j=Math.floor(Math.random()*(i+1));t=b[i];b[i]=b[j];b[j]=t;}\n return b;\n}\n\nfunction stats(){\n var c=0, w=0, k;\n for(k in ans){ if(ans[k]===\"c\") c++; else w++; }\n var net = c*4 - w;\n g(\"qz-sc\").textContent = c;\n g(\"qz-sw\").textContent = w;\n g(\"qz-sr\").textContent = TOTAL - done;\n g(\"qz-sn\").textContent = (net>=0 ? \"+\":\"\")+net;\n g(\"qz-fill\").style.width = (done\/TOTAL*100)+\"%\";\n}\n\nfunction pick(qid, oi){\n if(ans[qid] !== undefined || subm) return;\n var q = null, k;\n for(k=0;k<QQ.length;k++){ if(QQ[k].id===qid){ q=QQ[k]; break; } }\n if(!q) return;\n var op = sopts[qid];\n var isok = op[oi] === q.correct;\n ans[qid] = isok ? 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Submitting in 10 Submit Now Combined Medical Services Examination 2023General Medicine & Paediatrics · Paper I · Part C Hepatology · Nephrology · Haematology · Psychiatry · GI · Paediatrics · Vaccines Questions 81–120… <\/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-36736","post","type-post","status-publish","format-standard","hentry","category-cms"],"yoast_head":"\n<title>CMS 2023 P1 Part-C - 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\/05\/02\/cms-2023-p1-part-c\/\" \/>\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-C - atsixty\" \/>\n<meta property=\"og:description\" content=\"CMS 2023 | General Medicine & Paediatrics | Paper I | Part A ✓️ 0 ❌ 0 ⏳ 40 left ⏱ 40:00 Net 0 \/ 160 Time's Up! 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{"id":36736,"date":"2026-05-02T07:47:05","date_gmt":"2026-05-02T02:17:05","guid":{"rendered":"https:\/\/atsixty.com\/?p=36736"},"modified":"2026-05-02T07:47:24","modified_gmt":"2026-05-02T02:17:24","slug":"cms-2023-p1-part-c","status":"publish","type":"post","link":"https:\/\/atsixty.com\/index.php\/2026\/05\/02\/cms-2023-p1-part-c\/","title":{"rendered":"CMS 2023 P1 Part-C"},"content":{"rendered":"\n\n\n\n\n\n\n\nCMS 2023 | General Medicine & Paediatrics | Paper I | Part A<\/title>\n<link href=\"https:\/\/fonts.googleapis.com\/css2?family=Playfair+Display:wght@600;700&family=Source+Serif+4:ital,wght@0,400;0,600;1,400&display=swap\" rel=\"stylesheet\">\n<style>\n*,*::before,*::after{box-sizing:border-box;margin:0;padding:0}\n:root{\n --blue:#1A5EA8;--blue-lt:#2E82D5;--blue-pale:#EBF3FD;\n --navy:#1A3A5C;--navy-lt:#24527F;--navy-pale:#E8F0F9;\n --ink:#1a1a1a;--ink-mid:#444;--ink-soft:#777;\n --line:#dde4ed;--bg:#f8fafd;--white:#ffffff;\n --ok:#1e6f46;--ok-bg:#eaf7ef;--ok-bd:#43a047;\n 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Display\",serif;font-size:1.15rem;color:var(--bad);margin-bottom:8px}\n.qz-grace-box p{font-size:0.85rem;color:var(--ink-mid);margin-bottom:14px}\n.qz-grace-n{font-family:\"Playfair Display\",serif;font-size:2.8rem;font-weight:700;color:var(--bad);line-height:1;margin-bottom:16px}\n.qz-grace-now{background:var(--bad);color:#fff;border:none;border-radius:8px;padding:10px 24px;font-family:\"Playfair Display\",serif;font-size:0.9rem;font-weight:700;cursor:pointer}\n.qz-grace-now:hover{background:#c62828}\n\n@media(max-width:480px){\n .qz-header h1{font-size:1.05rem}\n .qz-stem{font-size:0.87rem}\n .qz-opt-txt{font-size:0.84rem}\n .qz-prog-stats{font-size:0.68rem}\n}\n<\/style>\n<\/head>\n<body>\n<div id=\"cms23p1a\">\n\n<div class=\"qz-prog-bar\" id=\"qz-prog-bar\">\n <div class=\"qz-prog-stats\">\n <div class=\"qz-stat\">✓️ <strong id=\"qz-sc\">0<\/strong><\/div>\n <div class=\"qz-stat\">❌ <strong id=\"qz-sw\">0<\/strong><\/div>\n <div class=\"qz-stat\">⏳ <strong id=\"qz-sr\">40<\/strong> left<\/div>\n <div class=\"qz-timer-wrap\">\n <div class=\"qz-timer\" id=\"qz-timer\">⏱ <strong id=\"qz-td\">40:00<\/strong><\/div>\n <div class=\"qz-stat net-score\">Net <strong id=\"qz-sn\">0<\/strong> \/ 160<\/div>\n <\/div>\n <\/div>\n <div class=\"qz-prog-track\"><div class=\"qz-prog-fill\" id=\"qz-fill\"><\/div><\/div>\n<\/div>\n\n<div class=\"qz-grace\" id=\"qz-grace\">\n <div class=\"qz-grace-box\">\n <h3>Time's Up!<\/h3><p>Submitting in<\/p>\n <div class=\"qz-grace-n\" id=\"qz-gn\">10<\/div>\n <button class=\"qz-grace-now\" id=\"qz-gnow\">Submit Now<\/button>\n <\/div>\n<\/div>\n\n<div class=\"qz-header\">\n <h1>Combined Medical Services Examination 2023<br>General Medicine & Paediatrics · Paper I · Part C<\/h1>\n <p>Hepatology · Nephrology · Haematology · Psychiatry · GI · Paediatrics · Vaccines<\/p>\n <div class=\"qz-meta\">\n <span class=\"qz-badge\">Questions 81–120<\/span>\n <span class=\"qz-badge\">Options reshuffled<\/span>\n <span class=\"qz-badge\">Score = c × 4 − w<\/span>\n <button class=\"qz-timer-btn\" id=\"qz-tbtn\">⏱ Start Timed Mode<\/button>\n <\/div>\n<\/div>\n\n<div class=\"qz-body\">\n <div id=\"qz-questions\"><\/div>\n <div class=\"qz-submit-wrap\">\n <button class=\"qz-submit\" id=\"qz-submit\">Submit Answers<\/button>\n <\/div>\n <div class=\"qz-result\" id=\"qz-result\">\n <div class=\"qz-ring\" id=\"qz-ring\">\n <div class=\"qz-ring-inner\">\n <div class=\"qz-ring-pct\" id=\"qz-rpct\">0%<\/div>\n <div class=\"qz-ring-sub\">score<\/div>\n <\/div>\n <\/div>\n <h2>Your Result<\/h2>\n <div class=\"qz-net\" id=\"qz-rnet\"><\/div>\n <div class=\"qz-verdict\" id=\"qz-rv\"><\/div>\n <div class=\"qz-bands\">\n <span class=\"qz-band bc\" id=\"qz-bc\"><\/span>\n <span class=\"qz-band bw\" id=\"qz-bw\"><\/span>\n <span class=\"qz-band bs\" id=\"qz-bs\"><\/span>\n <\/div>\n <button class=\"qz-retry\" id=\"qz-retry\">↺ Retry Quiz<\/button>\n <\/div>\n<\/div>\n\n<\/div>\n\n<script>\n(function(){\n\nvar TOTAL = 40, MAX = 160;\nvar TSECS = 2400, GSECS = 10;\nvar LTRS = [\"A\",\"B\",\"C\",\"D\"];\n\nvar QQ = [\n{id:81,\nstem:\"In serological investigation of hepatitis B virus infection, presence of hepatitis B e-antigen (HBeAg) is an indicator of\",\ncorrect:\"active replication of virus in the liver\",\nopts:[\"active replication of virus in the liver\",\"acute liver failure\",\"chronic infection with hepatitis B virus\",\"inactive carrier phase of infection\"],\nexp:\"HBeAg is a soluble secreted protein derived from the precore\/core region of the HBV genome. Its presence in serum is a marker of active viral replication and high infectivity. HBeAg-positive patients have very high HBV-DNA levels (10^7-10^9 IU\/mL) and are highly infectious. HBeAg seroconversion to anti-HBe is a key treatment endpoint. The inactive carrier state is characterised by HBsAg-positive, HBeAg-NEGATIVE (anti-HBe positive), low or undetectable HBV-DNA, and normal ALT. HBeAg indicates active viral replication.\"\n},\n{id:82,\nstem:\"Simultaneous infection with hepatitis B virus (HBV) and hepatitis D virus (HDV) followed by full recovery is associated with the appearance of\",\ncorrect:\"low titres of anti-HDV antibody, IgM type\",\nopts:[\"low titres of anti-HDV antibody, IgM type\",\"low titres of anti-HDV antibody, IgA type\",\"high titres of anti-HDV antibody, IgM type\",\"high titres of anti-HDV antibody, IgG type\"],\nexp:\"HDV (delta virus) is a defective RNA virus requiring HBsAg for its envelope. Co-infection (simultaneous acute HBV + HDV): usually self-limiting with full recovery in approximately 95% of cases. Serologically: LOW titre anti-HDV IgM (transient, brief), followed by brief IgG response that also wanes. The low-titre transient antibody response reflects the self-limiting nature of co-infection. Superinfection (HDV in chronic HBV carrier): leads to chronic delta hepatitis in 80-90% with HIGH-titre anti-HDV IgG persisting. Co-infection = low-titre brief antibody response; superinfection = high-titre persistent antibody with chronic disease.\"\n},\n{id:83,\nstem:\"Consider the following statements with regard to jaundice:<br>1. Presence of scleral icterus indicates a serum bilirubin level of at least 3 mg\/dL.<br>2. If the examiner suspects scleral icterus, second site to examine is underneath the tongue.<br>3. In long-standing jaundice, skin may become green due to reduction of bilirubin to biliverdin.<br>4. Sclerae have a particular affinity for bilirubin due to its high elastin content.<br>Which of the statements given above are correct?\",\ncorrect:\"2 and 4 only\",\nopts:[\"1 and 3 only\",\"2 and 4 only\",\"1, 2 and 4 only\",\"1, 2, 3 and 4\"],\nexp:\"Statement 1 FALSE: Scleral icterus becomes clinically detectable when serum bilirubin exceeds approximately 2 mg\/dL with careful inspection; the threshold is not 'at least 3 mg\/dL'. Statement 2 TRUE: After the sclerae, the next best site to detect early jaundice is the undersurface of the tongue (frenulum area) and hard palate. Statement 3 FALSE: In long-standing jaundice, bilirubin is OXIDISED to biliverdin (a green pigment), not reduced. Statement 4 TRUE: Sclerae have high elastin content, and bilirubin has a high affinity for elastin, which explains why sclerae become icteric early and prominently. Statements 2 and 4 only are correct.\"\n},\n{id:84,\nstem:\"Carotenoderma, due to ingestion of excessive amounts of carotene-containing fruits and vegetables, can be distinguished from jaundice by sparing of which of the following?\",\ncorrect:\"Sclerae\",\nopts:[\"Palms\",\"Soles\",\"Nasolabial folds\",\"Sclerae\"],\nexp:\"Carotenaemia causes yellow-orange discolouration of the skin (most prominent on palms, soles, nasolabial folds, and forehead) due to beta-carotene deposition in the stratum corneum. The critical distinguishing feature from jaundice: carotenaemia SPARES THE SCLERAE because carotene does NOT bind elastin and is deposited in skin lipid-rich layers only. In true jaundice (hyperbilirubinaemia), the sclerae are always icteric because bilirubin has high affinity for elastin. Yellow palms, soles, and nasolabial folds with white sclerae = carotenaemia. Yellow sclerae = always jaundice. Sclerae are spared in carotenaemia.\"\n},\n{id:85,\nstem:\"Meares-Stamey test is used in which one of the following clinical conditions?\",\ncorrect:\"Recurrent urinary tract infection in men\",\nopts:[\"Recurrent urinary tract infection in men\",\"Urinary tract infection in pregnant women\",\"Complicated cystitis in non-pregnant women\",\"Pelvic inflammatory disease\"],\nexp:\"The Meares-Stamey 4-glass test (or 2-glass pre-massage\/post-massage test) is a localisation test used to identify the source of infection or inflammation in the male lower urinary tract. Sequential collection of voided bladder urine (VB1 urethral, VB2 midstream bladder), expressed prostatic secretions (EPS), and post-massage urine (VB3 prostatic) is used to diagnose and localise chronic bacterial prostatitis, chronic pelvic pain syndrome, and to distinguish urethritis from prostatitis. It is specifically used in males with recurrent UTI or chronic pelvic pain symptoms. It has no application in female UTI or PID.\"\n},\n{id:86,\nstem:\"Which one of the following drugs is associated with calciphylaxis in chronic kidney disease patients?\",\ncorrect:\"Warfarin\",\nopts:[\"Calcium channel blocker\",\"Warfarin\",\"Non-calcium-based phosphate binder\",\"Thiazide diuretic\"],\nexp:\"Calciphylaxis (calcific uraemic arteriolopathy) is a devastating condition in CKD\/ESRD patients characterised by calcification of small and medium arterioles causing ischaemic skin necrosis. Warfarin is a well-established risk factor. The mechanism: warfarin inhibits Vitamin K-dependent carboxylation of Matrix Gla Protein (MGP), a potent inhibitor of vascular calcification. Without functional MGP, calcium-phosphate deposits accumulate in vessel walls, promoting calciphylaxis. This has led to use of Vitamin K supplementation and transition to alternative anticoagulants in at-risk patients. Warfarin is the drug most classically and specifically associated with calciphylaxis.\"\n},\n{id:87,\nstem:\"Consider the following pairs:<br>Urinary sediments seen in AKI : Diagnosis<br>1. RBC casts : Malignant hypertension<br>2. WBC casts : Pyelonephritis<br>3. Pigmented casts : Vasculitis<br>4. Granular casts : Myoglobinuria<br>How many of the pairs given above are correctly matched?\",\ncorrect:\"Only two pairs\",\nopts:[\"Only one pair\",\"Only two pairs\",\"Only three pairs\",\"All four pairs\"],\nexp:\"Pair 1 (RBC casts: Malignant hypertension) CORRECT: RBC casts indicate glomerular bleeding; malignant hypertension causes fibrinoid necrosis of glomerular arterioles with haematuria and RBC casts. Pair 2 (WBC casts: Pyelonephritis) CORRECT: WBC casts indicate renal parenchymal inflammation; seen in pyelonephritis and acute interstitial nephritis. Pair 3 (Pigmented casts: Vasculitis) INCORRECT: Pigmented (muddy-brown granular) casts are characteristic of acute tubular necrosis (ATN), not vasculitis. Vasculitis causes RBC casts. Pair 4 (Granular casts: Myoglobinuria) INCORRECT: In myoglobinuria (rhabdomyolysis), the casts are PIGMENTED casts (brown from haem pigment), not plain granular casts. Pairs 1 and 2 are correctly matched: only two pairs.\"\n},\n{id:88,\nstem:\"Which one of the following is the primary underlying mechanism of haemolysis in paroxysmal nocturnal haemoglobinuria (PNH)?\",\ncorrect:\"Complement-mediated destruction of CD59(-) red blood cells\",\nopts:[\"ABO incompatibility\",\"Red cell fragmentation\",\"Complement-mediated destruction of CD59(-) red blood cells\",\"Exotoxins produced by Clostridium perfringens\"],\nexp:\"PNH is caused by a somatic PIG-A gene mutation resulting in deficiency of GPI-anchored proteins on blood cell surfaces. The critical deficient proteins are CD55 (inhibits C3 and C5 convertases) and CD59 (prevents insertion of the Membrane Attack Complex C5b-9). Without CD55 and CD59, red blood cells are exquisitely sensitive to complement-mediated lysis. The primary mechanism is complement-mediated intravascular haemolysis of CD59-deficient red blood cells. The MAC (C5b-9) inserts into the RBC membrane causing lysis. This is why eculizumab (anti-C5 monoclonal antibody) is the specific and highly effective treatment for PNH.\"\n},\n{id:89,\nstem:\"Which one of the following is a clonal haematopoietic stem cell disorder in which phenotypically normal red blood cells, granulocytes and platelets accumulate in the absence of a recognizable physiological stimulus?\",\ncorrect:\"Polycythemia vera\",\nopts:[\"Mastocytosis\",\"Polycythemia vera\",\"Primary myelofibrosis\",\"Essential thrombocytosis\"],\nexp:\"Polycythaemia vera (PV) is a clonal myeloproliferative neoplasm caused by a JAK2 mutation (JAK2 V617F in approximately 95% of cases). PV is characterised by autonomous (stimulus-independent) proliferation of phenotypically normal erythroid, myeloid, and megakaryocytic cells, leading to elevated red cell mass, leukocytosis, and thrombocytosis without an appropriate physiological stimulus. The cells are morphologically normal but produced in excess due to constitutive JAK-STAT pathway activation. Essential thrombocytosis specifically affects platelets. Primary myelofibrosis involves fibrosis. Mastocytosis involves mast cells. PV is the correct answer.\"\n},\n{id:90,\nstem:\"Which of the following insulins has a cloudy preparation and requires resuspension prior to injection?\",\ncorrect:\"Lente\",\nopts:[\"Lente\",\"Glargine\",\"Detemir\",\"Degludec\"],\nexp:\"Lente insulin (insulin zinc suspension) is a cloudy, intermediate-acting insulin preparation containing insulin-zinc crystals in suspension. The zinc-insulin complexes settle to the bottom, so the vial must be gently rolled\/resuspended before each injection to ensure uniform dosing. NPH (isophane) insulin is another classic cloudy insulin requiring resuspension. Clear (transparent) insulins: all rapid-acting analogues (aspart, lispro, glulisine), short-acting regular insulin, and all modern long-acting analogues (glargine, detemir, degludec) are clear solutions that do NOT require resuspension. Lente is the correct answer.\"\n},\n{id:91,\nstem:\"Which of the following statements are correct with regard to anorexia nervosa?<br>1. The illness is often precipitated by weight loss.<br>2. Food avoidance is common.<br>3. Body image is intact and there is no fear of weight gain.<br>4. Downy hair (lanugo) may develop on back, forearms and cheeks.<br>Select the correct answer using the code given below.\",\ncorrect:\"2 and 4\",\nopts:[\"1, 2 and 3\",\"1, 2 and 4\",\"1, 3 and 4\",\"2 and 4\"],\nexp:\"Statement 1 FALSE: Anorexia nervosa is typically precipitated by intentional dieting\/food restriction, NOT by weight loss as an external precipitant. Statement 2 TRUE: Food avoidance, restriction, and selective eating are core behavioural features driven by intense fear of weight gain. Statement 3 FALSE: Body image disturbance and intense fear of gaining weight are CORE DIAGNOSTIC CRITERIA (DSM-5); body image is profoundly disturbed, not intact. Statement 4 TRUE: Lanugo (fine downy hair covering the body) is a classic physical sign of severe anorexia nervosa seen on the back, face, forearms, and abdomen; an adaptive response to hypothermia from loss of body fat. Statements 2 and 4 are correct.\"\n},\n{id:92,\nstem:\"Which of the following are adverse effects of loop-acting and thiazide diuretics?<br>1. Metabolic acidosis<br>2. Hypovolaemia<br>3. Hyponatraemia<br>4. Hypokalaemia<br>Select the correct answer using the code given below.\",\ncorrect:\"2, 3 and 4\",\nopts:[\"1, 2 and 3\",\"1, 2 and 4\",\"1, 3 and 4\",\"2, 3 and 4\"],\nexp:\"Loop and thiazide diuretics are both kaliuretic diuretics with shared adverse effects. Hypovolaemia (2): fluid depletion from excess diuresis. Hyponatraemia (3): particularly with thiazides which maintain free water reabsorption in the collecting duct; thiazides cause more profound hyponatraemia than loop diuretics. Hypokalaemia (4): urinary potassium wasting from increased distal tubular flow and aldosterone activation. Both cause metabolic ALKALOSIS (not acidosis) via volume contraction (stimulating H+ secretion), hypokalaemia (K+ shifts out of cells, H+ enters), and hydrogen ion loss. Statement 1 (metabolic acidosis) is INCORRECT; these drugs cause ALKALOSIS. Statements 2, 3, and 4 are correct.\"\n},\n{id:93,\nstem:\"Which one of the following statements is correct with regard to peptic ulcer prophylaxis?\",\ncorrect:\"Proton-pump inhibitors (PPIs) are effective at reducing the incidence of ulceration.\",\nopts:[\"Stress ulceration during clinical illness is uncommon.\",\"Ulcer prophylaxis should be continued once absorption of enteral feed is established.\",\"Proton-pump inhibitors (PPIs) are effective at reducing the incidence of ulceration.\",\"PPIs when used with antibiotics may decrease the risk of Clostridium difficile infection.\"],\nexp:\"Statement (a) FALSE: Stress ulceration is COMMON in critically ill patients (mechanical ventilation, coagulopathy, major trauma, burns) and is a major cause of upper GI bleeding in ICUs. Statement (b) FALSE: Ulcer prophylaxis can generally be DISCONTINUED once enteral nutrition is established; enteral feeding raises gastric pH and provides mucosal protection. Statement (c) TRUE: PPIs effectively suppress gastric acid, raising gastric pH above 4, which prevents stress ulceration and is the standard prophylaxis in ICU patients at risk. Statement (d) FALSE: PPIs combined with antibiotics actually INCREASE the risk of C. difficile infection by disrupting normal gut flora. Option (c) is the only correct statement.\"\n},\n{id:94,\nstem:\"Which of the following are the features of post-lumbar puncture headache?<br>1. Dull aching occipitofrontal headache<br>2. Worse on waking but improves during the day<br>3. Recumbency usually improves the headache within minutes<br>Select the correct answer using the code given below.\",\ncorrect:\"1 and 3 only\",\nopts:[\"1 and 2 only\",\"2 and 3 only\",\"1 and 3 only\",\"1, 2 and 3\"],\nexp:\"Post-lumbar puncture headache (PDPH) is caused by CSF leakage through the dural puncture site, reducing CSF volume and intracranial pressure, causing traction on pain-sensitive intracranial structures when upright. Classic features: Statement 1 TRUE: Dull, aching, bilateral occipitofrontal headache. Statement 2 FALSE: PDPH is characteristically WORSE on SITTING UP or STANDING and BETTER when LYING DOWN. It is the classic orthostatic headache. Statement 3 TRUE: Recumbency (lying flat) rapidly improves or abolishes the headache within minutes by restoring CSF pressure and relieving traction on pain-sensitive structures. Statements 1 and 3 are correct.\"\n},\n{id:95,\nstem:\"Which of the following are correct with regard to alpha-1-antitrypsin deficiency?<br>1. Prolonged jaundice in neonatal period<br>2. Pulmonary emphysema in adulthood<br>3. Panniculitis is seen rarely<br>4. Autosomal dominant disorder<br>Select the correct answer using the code given below.\",\ncorrect:\"1, 2 and 3\",\nopts:[\"1, 2 and 3\",\"1, 2 and 4\",\"1, 3 and 4\",\"2, 3 and 4\"],\nexp:\"Alpha-1-antitrypsin (AAT) deficiency (PIZZ genotype): Statement 1 TRUE: Neonatal cholestasis\/prolonged jaundice is a classic hepatic manifestation; AAT accumulates as misfolded polymer in hepatocytes causing ER stress and neonatal jaundice. Statement 2 TRUE: Panacinar emphysema (predominantly lower lobe) develops in adulthood due to uninhibited neutrophil elastase destroying alveolar walls; smoking dramatically accelerates emphysema. Statement 3 TRUE: Panniculitis (necrotising inflammation of subcutaneous fat) is a rare but recognised manifestation. Statement 4 FALSE: AAT deficiency follows AUTOSOMAL RECESSIVE (codominant) inheritance, NOT autosomal dominant. The PiZZ homozygous state causes severe deficiency. Statements 1, 2, and 3 are correct.\"\n},\n{id:96,\nstem:\"Which of the following drugs can cause granulomatous liver injury?<br>1. Carbamazepine<br>2. Allopurinol<br>3. Diltiazem<br>4. Acetaminophen<br>Select the correct answer using the code given below.\",\ncorrect:\"1, 2 and 3\",\nopts:[\"1, 2 and 3\",\"1, 2 and 4\",\"1, 3 and 4\",\"2, 3 and 4\"],\nexp:\"Drug-induced granulomatous hepatitis involves formation of non-caseating granulomas in the liver. Classic causative drugs: Carbamazepine (anticonvulsant): well-recognised cause of granulomatous hepatitis as part of hypersensitivity reactions. Allopurinol (xanthine oxidase inhibitor): a classic cause, often with systemic hypersensitivity syndrome. Diltiazem (calcium channel blocker): documented cause of granulomatous hepatitis. Other causes: quinidine, hydralazine, phenytoin, sulfonamides, isoniazid. Acetaminophen (paracetamol) causes CENTRILOBULAR NECROSIS (zone 3 hepatocellular necrosis) via toxic NAPQI metabolite, NOT granulomatous hepatitis. Statements 1, 2, and 3 are correct.\"\n},\n{id:97,\nstem:\"Which of the following are the five essential components of nurturing care?<br>1. Health<br>2. Nutrition<br>3. Breastfeeding<br>4. Responsive caregiving<br>5. Early learning<br>6. Immunization<br>7. Safety and security<br>8. Supplementation<br>Select the correct answer using the code given below.\",\ncorrect:\"1, 2, 4, 5 and 7\",\nopts:[\"1, 2, 4, 5 and 7\",\"1, 2, 3, 4 and 5\",\"1, 4, 6, 7 and 8\",\"2, 3, 5, 6 and 8\"],\nexp:\"The WHO\/UNICEF Nurturing Care Framework (2018) defines five essential components: (1) Good health; (2) Adequate nutrition; (4) Responsive caregiving (sensitive, responsive interactions between caregivers and children that promote social-emotional development); (5) Opportunities for early learning (stimulation, play, communication); (7) Safety and security (protecting children from harm, stress, and adversity). Breastfeeding is a component of nutrition, not a separate domain. Immunization is part of health. Supplementation is part of nutrition. The five domains are Health, Nutrition, Responsive caregiving, Early learning, and Safety and security. Statements 1, 2, 4, 5, and 7 are correct.\"\n},\n{id:98,\nstem:\"A full-term baby born with birth weight of 2000 g comes for well-baby visit at two months of age. Which of the following nutritional supplements would you advise?\",\ncorrect:\"Iron orally 2 mg\/kg\/day up to 1 year of age\",\nopts:[\"Vitamin D orally 200 IU\/day up to 3 months of age\",\"Vitamin D orally 200 IU\/day up to 1 year of age\",\"Iron orally 2 mg\/kg\/day up to 3 months of age\",\"Iron orally 2 mg\/kg\/day up to 1 year of age\"],\nexp:\"A full-term low birth weight (LBW) infant (birth weight 2000 g, below 2500 g) has reduced iron stores at birth (iron is accumulated primarily in the last trimester). IAP and National guidelines recommend: Iron supplementation for full-term LBW infants: oral elemental iron 2 mg\/kg\/day starting at 2 months of age (when maternal iron stores become depleted) and continued until 1 year of age. This prevents iron deficiency anaemia in LBW infants during rapid postnatal growth. Vitamin D (400 IU\/day) is recommended for all breastfed infants but the key supplement for a 2-month-old LBW baby at the well-baby visit is iron 2 mg\/kg\/day up to 1 year.\"\n},\n{id:99,\nstem:\"Which of the following are common problems in babies with intrauterine growth restriction delivered at term gestation?<br>1. Hypothermia<br>2. Hypoglycaemia<br>3. Hypocalcaemia<br>Select the correct answer using the code given below.\",\ncorrect:\"1, 2 and 3\",\nopts:[\"1 and 2 only\",\"2 and 3 only\",\"1 and 3 only\",\"1, 2 and 3\"],\nexp:\"IUGR\/SGA infants at term face multiple metabolic complications due to reduced fat, glycogen stores, and immature thermoregulation: Hypothermia (1): IUGR infants have reduced subcutaneous fat (insulation) and reduced brown adipose tissue (thermogenesis), making them highly vulnerable to hypothermia. Hypoglycaemia (2): IUGR infants have reduced hepatic glycogen stores and impaired gluconeogenesis; hypoglycaemia is very common and must be monitored closely. Hypocalcaemia (3): IUGR infants have lower calcium stores and impaired parathyroid response, predisposing to neonatal hypocalcaemia. All three are correct well-recognised complications of IUGR at term.\"\n},\n{id:100,\nstem:\"Which one of the following statements is correct regarding a normal newborn's growth?\",\ncorrect:\"Birth weight is regained by 7-10 days of age.\",\nopts:[\"Weight loss may be 8-10% of birth weight in the initial two weeks of life.\",\"Birth weight is regained by 7-10 days of age.\",\"Birth weight is regained within first week of life.\",\"Weight loss may be 12-15% of birth weight in the initial two weeks of life.\"],\nexp:\"Normal newborn weight changes: Initial physiological weight loss occurs in the first 3-4 days of life due to passage of meconium, insensible water losses, and establishment of feeding. Normal weight loss: 7-10% of birth weight (weight loss greater than 10% is excessive). Birth weight is normally REGAINED by 7-10 days of age. Option (a) mentions 8-10% which is within range but the two-week timeframe is incorrect (loss occurs in first 3-4 days). Option (c) 'within first week' is too early for most infants. Weight loss of 12-15% (option d) is abnormal. Option (b) birth weight regained by 7-10 days is the correct statement.\"\n},\n{id:101,\nstem:\"For developmental assessment of a baby, grasp is best assessed by offering the child\",\ncorrect:\"red pellets\",\nopts:[\"a red ring\",\"a red cube\",\"red pellets\",\"multicoloured pellets\"],\nexp:\"Developmental assessment of hand grasp uses standardised objects of specific sizes to elicit different grasp patterns. Red pellets (small, approximately 3 mm) are specifically used to test the development of PINCER GRASP (inferior pincer at 8-9 months, neat\/superior pincer grasp at 9-12 months). The small size of the pellet necessitates a precise pincer grasp (thumb and index finger tip opposition) rather than a raking or palmar grasp. A red ring tests gross grasp and transfer. A red cube tests palmar\/pincer grasp transition. Red pellets are used to assess fine motor pincer grasp development in the Denver Developmental Screening Test.\"\n},\n{id:102,\nstem:\"Urinary alkalinization as a method for enhancing excretion for poisoning is aimed at achieving\",\ncorrect:\"urine pH 7.5-8\",\nopts:[\"serum pH 7.5-8\",\"urine pH 7.5-8\",\"serum pH > 8\",\"urine pH > 8\"],\nexp:\"Urinary alkalinisation enhances renal excretion of weak acids (salicylates, phenobarbitone) by ion trapping: at alkaline urine pH, the acid drug is ionised and cannot be reabsorbed across the tubular epithelium, so it is excreted in urine. The TARGET urine pH is 7.5-8.0 (achieved by IV sodium bicarbonate infusion with careful monitoring). It is NOT aimed at altering serum pH (targeting serum pH 7.5-8 would cause dangerous systemic alkalosis). Urine pH greater than 8 is unnecessarily aggressive and risks precipitation of calcium phosphate in tubules. The correct target is urine pH 7.5-8.\"\n},\n{id:103,\nstem:\"Exchange transfusion as a method to enhance excretion of poison is indicated in\",\ncorrect:\"methemoglobinemia\",\nopts:[\"methemoglobinemia\",\"carbamazepine poisoning\",\"theophylline poisoning\",\"barbiturate poisoning\"],\nexp:\"Exchange transfusion replaces the patient's blood with donor blood, removing the toxin-laden red cells or plasma. It is specifically indicated when the toxic substance is carried within red blood cells and cannot be effectively removed by dialysis or haemoperfusion. Methaemoglobinaemia (from oxidising agents - dapsone, primaquine, nitrites, chloroquine): when metHb levels are very high (typically greater than 70%) and methylene blue has failed or is contraindicated (e.g., G6PD deficiency), exchange transfusion replaces metHb-containing red cells with normal oxyhaemoglobin-containing donor red cells. Carbamazepine, theophylline, and barbiturate are better removed by haemoperfusion or haemodialysis.\"\n},\n{id:104,\nstem:\"In case of a child with an acute poisoning by ingestion, activated charcoal may be used in which one of the following situations?\",\ncorrect:\"Antiepileptic ingestion\",\nopts:[\"Iron ingestion\",\"Antiepileptic ingestion\",\"Corrosive ingestion\",\"Lithium ingestion\"],\nexp:\"Activated charcoal (AC) works by adsorbing ingested toxins in the GI tract, preventing absorption. Antiepileptic drugs (carbamazepine, phenobarbitone, valproate, phenytoin) are well adsorbed by activated charcoal; MDAC enhances elimination of carbamazepine and phenobarbitone. Contraindications\/ineffective: Iron (heavy metal, not adsorbed by AC; deferoxamine chelation is used). Corrosives (acids\/alkalis: AC is ineffective and worsens mucosal damage; also obscures endoscopic assessment). Lithium (ionic metal compound: not adsorbed by AC; sodium polystyrene sulphonate or haemodialysis used). Antiepileptic ingestion is the correct answer.\"\n},\n{id:105,\nstem:\"Which of the following genetic causes are commonly associated with autism spectrum disorders?<br>1. Angelman syndrome<br>2. Fragile X syndrome<br>3. Tuberous sclerosis<br>4. Williams syndrome<br>Select the correct answer using the code given below.\",\ncorrect:\"1, 2 and 3\",\nopts:[\"1, 2 and 3\",\"1, 2 and 4\",\"1, 3 and 4\",\"2, 3 and 4\"],\nexp:\"Genetic conditions commonly associated with ASD: Angelman syndrome (UBE3A mutation): ASD features in approximately 50-80% of cases. Fragile X syndrome (FMR1 CGG repeat expansion): the most common single-gene cause of inherited intellectual disability and ASD; approximately 30% of males with Fragile X have ASD. Tuberous sclerosis complex (TSC1\/TSC2 mutations): ASD occurs in approximately 40-50% of TSC patients. Williams syndrome (deletion 7q11.23): characterised by HYPERSOCIABILITY and a friendly personality; it is associated with OPPOSITE social behaviours to ASD and is NOT commonly associated with ASD. Statements 1, 2, and 3 are correct.\"\n},\n{id:106,\nstem:\"To reduce the risk of neural tube defects in the baby, which of the following are recommended?\",\ncorrect:\"Folate supplements, from one month before conception to three months after\",\nopts:[\"Folate supplements, from one month before conception to three months after\",\"Folate supplements, from confirmation of pregnancy to the end of first trimester\",\"Zinc supplements, from one month before conception to three months after\",\"Zinc supplements, from confirmation of pregnancy to the end of first trimester\"],\nexp:\"Neural tube defects (NTDs: anencephaly, spina bifida) result from failure of neural tube closure at 3-4 weeks of gestation, often before pregnancy is confirmed. Prevention: FOLATE (folic acid) supplementation is the established evidence-based intervention. Timing: supplementation must BEGIN at least 1 MONTH BEFORE CONCEPTION (pre-conceptual) to ensure adequate folate status at the time of neural tube closure (which occurs before many women know they are pregnant) and continued through the FIRST TRIMESTER (up to 12 weeks). Dose: 0.4-0.5 mg\/day (standard risk) or 4-5 mg\/day (high risk). Zinc supplements are not the established intervention for NTD prevention. Option (a) is correct.\"\n},\n{id:107,\nstem:\"Vaccine-associated poliomyelitis is chiefly seen with which of the following strains of oral poliovirus?\",\ncorrect:\"OPV 2\",\nopts:[\"OPV 1 only\",\"OPV 2\",\"OPV 3 only\",\"Both OPV 1 and OPV 3\"],\nexp:\"Vaccine-associated paralytic poliomyelitis (VAPP) is a rare complication of oral poliovirus vaccine (OPV). Among the three poliovirus serotypes, TYPE 2 (OPV 2) is responsible for the MAJORITY of VAPP cases and also for circulating vaccine-derived poliovirus (cVDPV) outbreaks. Wild poliovirus type 2 was eradicated in 1999, and the trivalent OPV (tOPV) was replaced with bivalent OPV (bOPV types 1+3) globally in 2016 to eliminate the type 2 VAPP risk. OPV type 2 is the correct answer.\"\n},\n{id:108,\nstem:\"Which one of the following is categorized as a specific learning disability?\",\ncorrect:\"Dysgraphia\",\nopts:[\"Dysgraphia\",\"Dystonia\",\"Dysthymia\",\"Dysphoria\"],\nexp:\"Specific learning disabilities (SpLD) are neurodevelopmental disorders affecting acquisition of reading, writing, or mathematical skills despite normal intelligence. The three main SpLDs (DSM-5): Dyslexia (impaired reading), Dysgraphia (impaired written expression and handwriting), Dyscalculia (impaired mathematics). Dystonia is a movement disorder (neurological), not a learning disability. Dysthymia is a chronic depressive mood disorder (psychiatric), not a learning disability. Dysphoria is a state of unease (mood symptom), not a learning disability category. Dysgraphia is the only specific learning disability among the options.\"\n},\n{id:109,\nstem:\"A baby is delivered at 34 weeks' gestation and found to be apnoeic at birth. After performing the initial steps of resuscitation, the baby is still apnoeic. The next step should be\",\ncorrect:\"positive pressure ventilation using 30% oxygen\",\nopts:[\"tactile stimulation\",\"positive pressure ventilation using 30% oxygen\",\"positive pressure ventilation using 100% oxygen\",\"chest compression\"],\nexp:\"NRP\/ILCOR 2020 guidelines for preterm neonatal resuscitation: After the initial steps (warmth, drying\/stimulation, clearing airway, repositioning), if the baby remains apnoeic, the next step is POSITIVE PRESSURE VENTILATION (PPV). For preterm infants (less than 35 weeks), PPV should be initiated with 21-30% oxygen. Starting with 30% FiO2 is recommended because hyperoxia in preterm infants causes oxygen toxicity, free radical injury to the developing brain, lungs, and retina. Tactile stimulation has already been performed in the initial steps. Chest compressions are indicated only if heart rate remains below 60 bpm despite 30 seconds of effective PPV. PPV with 30% oxygen is the correct next step.\"\n},\n{id:110,\nstem:\"A child requires detailed developmental evaluation if the developmental quotient is below\",\ncorrect:\"70%\",\nopts:[\"70%\",\"75%\",\"80%\",\"85%\"],\nexp:\"The Developmental Quotient (DQ) = (Developmental Age \/ Chronological Age) x 100. A DQ below 70 indicates significant developmental delay and requires comprehensive multidisciplinary developmental evaluation. This threshold corresponds to the definition of intellectual disability (IQ below 70, approximately 2 standard deviations below the mean). A DQ of 70-85 indicates borderline developmental delay warranting close monitoring and therapeutic intervention. A DQ above 85 is generally within the normal range. The threshold for referring a child for detailed developmental evaluation is a DQ below 70%.\"\n},\n{id:111,\nstem:\"The upper limit of age for attainment of visual fixation or following is\",\ncorrect:\"2 months\",\nopts:[\"birth\",\"1 month\",\"2 months\",\"3 months\"],\nexp:\"Visual fixation (fixing gaze on an object or face) is present from birth and becomes consistent by 4-6 weeks. Visual following (tracking a moving object) begins by 4-6 weeks and is well-established by 6-8 weeks. The UPPER LIMIT of normal age for attaining visual fixation or following is 2 months (8 weeks). Absence of visual fixation and following beyond 2 months is a RED FLAG requiring urgent ophthalmological and neurological assessment to exclude visual impairment (cataracts, retinal pathology), cortical visual impairment, or significant developmental delay. The upper limit is 2 months.\"\n},\n{id:112,\nstem:\"A child develops 'stranger anxiety' at\",\ncorrect:\"6-7 months\",\nopts:[\"2-3 months\",\"4-5 months\",\"6-7 months\",\"8-9 months\"],\nexp:\"Stranger anxiety (fear of unfamiliar people, manifesting as distress, crying, or clinging to the caregiver when approached by strangers) is a normal developmental milestone reflecting the child's developing ability to distinguish familiar from unfamiliar faces and deepening attachment to primary caregivers. Standard developmental textbooks (Ghai, Nelson) place the onset of stranger anxiety at 6-7 months of age. The peak is typically at 8-12 months. Social smile begins at 6 weeks; selective social smile by 3-4 months; stranger anxiety by 6-7 months. The correct answer is 6-7 months.\"\n},\n{id:113,\nstem:\"Consider the following statements with respect to developmental milestones at 9 months of age:<br>1. At this age, child develops immature pincer grasp.<br>2. At this age, child can say bisyllables (mama, dada, etc.).<br>3. At this age, child can wave bye-bye.<br>Which of the statements given above are correct?\",\ncorrect:\"1 and 3 only\",\nopts:[\"1 and 2 only\",\"2 and 3 only\",\"1 and 3 only\",\"1, 2 and 3\"],\nexp:\"Developmental milestones at 9 months: Fine motor: IMMATURE PINCER GRASP (inferior pincer using distal pad of thumb and index finger) develops at 8-9 months. Neat\/superior pincer (fingertip to fingertip) develops at 9-12 months. Statement 1 TRUE. Language: Bisyllables (mama, dada) as NON-SPECIFIC vocalisations begin at approximately 6 MONTHS. At 9 months, bisyllables are being used but this is not a NEW 9-month milestone; it begins at 6 months. Statement 2 is NOT specifically a new 9-month milestone. Social: Waving bye-bye is a 9-month social milestone. Statement 3 TRUE. Statements 1 and 3 only are correct.\"\n},\n{id:114,\nstem:\"What are the upper age limits by which a child should start walking alone, and be able to speak single words?\",\ncorrect:\"18 months, 18 months respectively\",\nopts:[\"12 months, 15 months respectively\",\"15 months, 18 months respectively\",\"15 months, 15 months respectively\",\"18 months, 18 months respectively\"],\nexp:\"Upper limits (red flag thresholds) for developmental milestones: Independent walking should be achieved by 18 months. A child not walking independently by 18 months requires evaluation for motor delay (cerebral palsy, neuromuscular disease). Single meaningful words should be spoken by 18 months. A child with no single meaningful words by 18 months requires evaluation for speech-language delay, hearing impairment, or ASD. Note: most children ACHIEVE walking at 12-13 months and single words at 10-14 months; these 18-month figures are the UPPER LIMITS (2 standard deviations below mean) used as red flag thresholds per standard Indian paediatric developmental guidelines (Ghai). Both upper limits are 18 months.\"\n},\n{id:115,\nstem:\"A child presents to the emergency following ingestion of around 20 mL of kerosene oil about 40 minutes back. The child appears stable. Which one of the following measures should be done for the management of the child?\",\ncorrect:\"Radiography\",\nopts:[\"Gastric lavage\",\"Oxygen therapy\",\"Intravenous steroids\",\"Radiography\"],\nexp:\"Kerosene (hydrocarbon) ingestion management: Gastric lavage and induced vomiting are ABSOLUTELY CONTRAINDICATED in kerosene ingestion. The primary risk is ASPIRATION PNEUMONITIS from the low-viscosity hydrocarbon entering the lungs; inducing vomiting or lavage massively increases aspiration risk. The amount (20 mL) is relatively small and systemic toxicity is unlikely. The child is STABLE. Management: reassurance, observation, and CHEST X-RAY (radiography) to detect early aspiration pneumonitis (bilateral lower lobe infiltrates appearing within 2-8 hours). Activated charcoal is ineffective for hydrocarbons. Oxygen therapy and steroids are used only if aspiration pneumonitis develops. Radiography is the correct initial step.\"\n},\n{id:116,\nstem:\"The event related to vaccination which can be contraindication for the next vaccination of similar\/identical type is\",\ncorrect:\"encephalopathy following DPT vaccine\",\nopts:[\"syncope following MMR vaccine\",\"encephalopathy following DPT vaccine\",\"abscess at injection site after DPT vaccine\",\"gastroenteritis following MMR vaccine\"],\nexp:\"True contraindication (absolute) to further doses of the SAME vaccine: encephalopathy (acute encephalopathy not attributable to another cause) occurring within 7 days of DPT\/DTP vaccination is an absolute contraindication to further doses of pertussis-containing vaccine. Whole-cell pertussis component has been associated with rare serious neurological adverse events. Other listed events: Syncope (vasovagal fainting) after MMR is common and NOT a contraindication to repeat vaccination. Injection-site abscess after DPT requires investigation but is not a contraindication per se. Gastroenteritis after MMR is a coincidental event. Encephalopathy following DPT vaccine is the correct contraindication.\"\n},\n{id:117,\nstem:\"Which of the following events could be caused or precipitated by an active component of vaccine?<br>1. Anaphylaxis after measles vaccine<br>2. Encephalopathy after DPT vaccine<br>3. Adenitis following BCG vaccine<br>4. Gastroenteritis following MMR vaccine<br>Select the correct answer using the code given below.\",\ncorrect:\"1, 2 and 3\",\nopts:[\"1, 2 and 3\",\"1, 2 and 4\",\"1, 3 and 4\",\"2, 3 and 4\"],\nexp:\"AEFI caused by the active vaccine component: Anaphylaxis after measles vaccine is a true vaccine reaction to vaccine antigens or constituents (gelatin stabiliser, neomycin, egg protein). Encephalopathy after DPT vaccine is a rare but recognised serious vaccine reaction to the pertussis component of whole-cell DPT. Adenitis (suppurative lymphadenitis) following BCG vaccine is a local vaccine reaction where the live attenuated Mycobacterium bovis causes regional axillary lymphadenitis. Gastroenteritis following MMR vaccine is NOT a recognised adverse effect of MMR vaccine components; it is a coincidental infection. Statements 1, 2, and 3 are correct.\"\n},\n{id:118,\nstem:\"Which one of the following can be used for developmental screening for use in community to identify children (aged 0-6 years) with developmental delay?\",\ncorrect:\"Trivandrum Development Screening Chart\",\nopts:[\"Revised Denver Development Screening Test (Denver II)\",\"Ages and Stages Questionnaire (ASQ-3)\",\"Phatak's Baroda Development Screening Test\",\"Trivandrum Development Screening Chart\"],\nexp:\"The question asks for a COMMUNITY-LEVEL developmental screening tool specifically designed for use in India for children 0-6 years. The Trivandrum Development Screening Chart (TDSC) was developed at the Child Development Centre, Trivandrum, Kerala, specifically designed for use by community health workers (ANMs, ASHAs) in India. It is simple, culturally adapted, and practical for use at the community level in resource-limited settings. Denver II requires trained personnel and more time. ASQ-3 is a parent-completed questionnaire used globally. Phatak's Baroda test is more suited to clinical settings. Trivandrum Development Screening Chart is the specifically India-adapted community-level screening tool.\"\n},\n{id:119,\nstem:\"According to the WHO clinical criteria, which of the following clinical signs are indicative of 'severe pneumonia or very severe disease' in children aged 2 months to 5 years?<br>1. Convulsions<br>2. Lower chest indrawing<br>3. Inability to feed<br>4. Stridor<br>Select the correct answer using the code given below.\",\ncorrect:\"1, 2 and 4\",\nopts:[\"1, 2 and 3\",\"1, 2 and 4\",\"1, 3 and 4\",\"2, 3 and 4\"],\nexp:\"WHO\/IMNCI classification for children aged 2 months to 5 years: SEVERE PNEUMONIA: lower chest indrawing (subcostal recession) requires hospital admission and IV antibiotics. VERY SEVERE DISEASE (general danger signs): inability to drink\/feed, vomiting everything, convulsions, abnormally sleepy\/unconscious, stridor when calm. Inability to feed is classified as a general danger sign of very severe disease but is NOT specific to severe pneumonia. Lower chest indrawing is the hallmark of severe pneumonia specifically. Convulsions and stridor when calm are danger signs of very severe disease. The WHO clinical criteria for severe pneumonia or very severe disease associated with pneumonia: lower chest indrawing, convulsions, stridor when calm. Statements 1, 2, and 4 are correct.\"\n},\n{id:120,\nstem:\"An eleven-month-old unimmunized child comes for immunization. Which vaccines should be given in this visit?\",\ncorrect:\"OPV, DPT, MR and Hepatitis B vaccines\",\nopts:[\"BCG, OPV, DPT and Hepatitis B vaccines\",\"OPV, DPT and MR vaccines only\",\"BCG, DPT and MR vaccines\",\"OPV, DPT, MR and Hepatitis B vaccines\"],\nexp:\"An 11-month-old completely unimmunized child requires catch-up immunisation per India's Universal Immunisation Programme (UIP) schedule. The child has missed: OPV (0, 6, 10, 14 weeks doses), DPT (6, 10, 14 weeks doses), Hepatitis B (birth, 6, 10, 14 weeks doses). MR\/Measles vaccine is due at 9-12 months and is NOW due at 11 months. At this single visit: OPV + DPT + MR + Hepatitis B should be given. BCG is given at birth through 1 year but the primary priority at 11 months catch-up is OPV, DPT, MR, and Hepatitis B. Option (d) OPV, DPT, MR and Hepatitis B vaccines is correct.\"\n}\n];\n\nvar ans = {}, done = 0, sopts = {};\nvar trun = false, trem = TSECS, tiv = null, giv = null, subm = false;\n\nfunction g(id){ return document.getElementById(id); }\n\nfunction fmt(s){\n var m = Math.floor(s\/60), sc = s%60;\n return (m<10?\"0\":\"\")+m+\":\"+(sc<10?\"0\":\"\")+sc;\n}\n\nfunction shuf(a){\n var b=a.slice(), i, j, t;\n for(i=b.length-1;i>0;i--){j=Math.floor(Math.random()*(i+1));t=b[i];b[i]=b[j];b[j]=t;}\n return b;\n}\n\nfunction stats(){\n var c=0, w=0, k;\n for(k in ans){ if(ans[k]===\"c\") c++; else w++; }\n var net = c*4 - w;\n g(\"qz-sc\").textContent = c;\n g(\"qz-sw\").textContent = w;\n g(\"qz-sr\").textContent = TOTAL - done;\n g(\"qz-sn\").textContent = (net>=0 ? \"+\":\"\")+net;\n g(\"qz-fill\").style.width = (done\/TOTAL*100)+\"%\";\n}\n\nfunction pick(qid, oi){\n if(ans[qid] !== undefined || subm) return;\n var q = null, k;\n for(k=0;k<QQ.length;k++){ if(QQ[k].id===qid){ q=QQ[k]; break; } }\n if(!q) return;\n var op = sopts[qid];\n var isok = op[oi] === q.correct;\n ans[qid] = isok ? 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