Albania State Exam — Physician (Provimi i Shtetit për Profesionin e Rregulluar të Mjekut) Feed

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A 58-year-old male with a history of hypertension and hyperlipidemia presents to the emergency department with 90 minutes of severe, crushing substernal chest pain radiating to his left jaw and diaphoresis. An immediate 12-lead ECG demonstrates 3 mm ST-segment elevation in leads V1 through V4. The nearest percutaneous coronary intervention (PCI)-capable hospital is 25 minutes away. What is the most appropriate initial reperfusion strategy for this patient?

Internal Medicine

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A 64-year-old female with ischemic cardiomyopathy presents for routine follow-up. Transthoracic echocardiography reveals a left ventricular ejection fraction (LVEF) of 32%. Her current medications are lisinopril 20 mg daily, carvedilol 25 mg twice daily, and furosemide 40 mg daily. She remains in NYHA Class II functional status. Which medication addition represents the fourth pillar of guideline-directed medical therapy (GDMT) to reduce cardiovascular mortality in heart failure with reduced ejection fraction?

Internal Medicine

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A 72-year-old male with hypertension, type 2 diabetes mellitus, and a prior ischemic stroke is diagnosed with non-valvular atrial fibrillation. Physical examination reveals an irregularly irregular pulse at 88 beats/min. What is the most appropriate long-term management strategy to prevent thromboembolic stroke in this patient?

Internal Medicine

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A 45-year-old male with a history of intravenous drug use presents with high fever, night sweats, dyspnea, and painful erythematous nodules on the pads of his fingers (Osler nodes). A new holosystolic murmur is auscultated at the lower left sternal border that increases with inspiration. Which diagnostic finding fulfills a Major Duke Criterion for the diagnosis of infective endocarditis?

Internal Medicine

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A 68-year-old male presents to the clinic with fever, productive cough with rust-colored sputum, and pleuritic right-sided chest pain. Vital signs show BP 125/80 mmHg, HR 92 bpm, RR 22 breaths/min, and oxygen saturation 96% on room air. He is fully alert and oriented (Glasgow Coma Scale 15). Blood urea nitrogen (BUN) is 14 mg/dL (5.0 mmol/L). Chest X-ray reveals right lower lobe consolidation. Based on the CURB-65 score, what is the most appropriate management setting for this patient?

Internal Medicine

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A 66-year-old male with severe chronic obstructive pulmonary disease (COPD) presents to the emergency department with increased dyspnea, increased sputum volume, and sputum purulence (Anthonisen Type 1 exacerbation). Arterial blood gas on room air shows: pH 7.31, PaCO2 56 mmHg, PaO2 54 mmHg, and HCO3- 28 mEq/L. What is the most appropriate initial oxygenation and ventilatory management?

Internal Medicine

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A 24-year-old female with moderate persistent asthma reports using her short-acting beta-2 agonist (SABA) inhaler 4 to 5 times per week and waking up with wheezing twice a month. She is currently taking low-dose inhaled budesonide daily. According to GINA guidelines, what is the most appropriate next step in her pharmacotherapy?

Internal Medicine

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A 48-year-old woman who underwent total knee arthroplasty 10 days ago presents with sudden-onset pleuritic chest pain, dyspnea, and tachycardia (HR 115 bpm). Her blood pressure is 120/75 mmHg and RR is 24/min. Her modified Wells score for pulmonary embolism is calculated as 6.0 (high probability). What is the definitive diagnostic imaging modality of choice?

Internal Medicine

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A 42-year-old male is diagnosed with a duodenal ulcer, and a gastric mucosal biopsy is positive for Helicobacter pylori on rapid urease testing. He has no known drug allergies. What is the recommended first-line quadruple eradication therapy in regions with high clarithromycin resistance?

Internal Medicine

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A 40-year-old female presents with severe epigastric pain radiating to her back, nausea, and persistent vomiting following a heavy meal. Serum lipase is 1,450 U/L (reference < 60 U/L). Abdominal ultrasound demonstrates cholelithiasis without common bile duct dilation. What is the cornerstone of initial medical management during the first 24 hours of acute pancreatitis?

Internal Medicine

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A 54-year-old male with alcoholic cirrhosis and refractory ascites develops low-grade fever, diffuse abdominal discomfort, and altered mental status. Abdominal examination demonstrates shifting dullness and mild generalized tenderness. Diagnostic paracentesis is performed. Which ascitic fluid analysis finding confirms the diagnosis of Spontaneous Bacterial Peritonitis (SBP)?

Internal Medicine

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A 28-year-old male presents with recurrent bloody diarrhea, tenesmus, and crampy lower abdominal pain for 4 months. Colonoscopy reveals continuous, circumferential mucosal erythema, loss of vascular pattern, and friability extending from the anal verge up to the splenic flexure, with abrupt transition to normal mucosa. Biopsies show crypt architectural distortion, cryptitis, and crypt abscesses confined to the mucosa and submucosa. What is the most likely diagnosis?

Internal Medicine

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An 80-year-old female is admitted with severe gastroenteritis and poor fluid intake. Her serum creatinine has risen from a baseline of 0.8 mg/dL to 2.4 mg/dL over 48 hours. Urinalysis reveals no protein, no red blood cells, and a few hyaline casts. Which urinary diagnostic parameter most strongly supports a diagnosis of prerenal acute kidney injury over acute tubular necrosis (ATN)?

Internal Medicine

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A 56-year-old male with Stage 4 Chronic Kidney Disease (eGFR 22 mL/min/1.73 m²) undergoes laboratory evaluation. Which combination of mineral and bone metabolism laboratory values is characteristic of secondary hyperparathyroidism in advanced CKD?

Internal Medicine

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A 32-year-old female presents with progressive bilateral lower extremity edema and periorbital swelling. Laboratory workup reveals: 24-hour urinary protein 5.2 g/day, serum albumin 2.1 g/dL, total cholesterol 360 mg/dL, serum creatinine 0.9 mg/dL, and normal complement levels (C3, C4). Urinalysis shows 4+ protein, oval fat bodies, and no hematuria. Which clinical condition best represents this constellation of findings?

Internal Medicine

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A 62-year-old male with a 10-year history of Type 2 Diabetes Mellitus and established Atherosclerotic Cardiovascular Disease (prior myocardial infarction) has an HbA1c of 8.6% despite metformin 1,000 mg twice daily. His eGFR is 55 mL/min/1.73 m² and urine albumin-to-creatinine ratio is 180 mg/g. According to ADA and ESC guidelines, which second-line antidiabetic class with proven cardiovascular and renal mortality benefit should be added next?

Internal Medicine

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A 21-year-old female with Type 1 Diabetes Mellitus presents to the emergency department with abdominal pain, Kussmaul respirations, and vomiting. Initial lab tests show: blood glucose 480 mg/dL, arterial pH 7.15, serum bicarbonate 10 mEq/L, anion gap 24 mEq/L, and serum potassium 3.1 mEq/L. What is the most critical initial management rule regarding insulin administration in this patient?

Internal Medicine

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A 45-year-old female presents with fatigue, constipation, cold intolerance, and 6 kg weight gain over 6 months. Physical examination reveals delayed deep tendon reflex relaxation, dry coarse skin, and a diffusely enlarged, non-tender thyroid gland. Serum TSH is 18.5 mIU/L (reference 0.4-4.0 mIU/L) and free T4 is 0.4 ng/dL (reference 0.8-1.8 ng/dL). Anti-thyroperoxidase (anti-TPO) antibodies are strongly positive. What is the definitive treatment of choice?

Internal Medicine

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A 38-year-old male is evaluated for refractory hypertension (BP 175/105 mmHg despite triple-agent antihypertensive therapy including an ACE inhibitor, calcium channel blocker, and thiazide). Routine blood tests reveal a serum potassium of 2.9 mEq/L (reference 3.5-5.0 mEq/L). Screening reveals an elevated plasma aldosterone concentration (PAC) of 32 ng/dL and a suppressed plasma renin activity (PRA) of 0.4 ng/mL/h, yielding an aldosterone-to-renin ratio (ARR) of 80 (normal < 20). What is the next most appropriate confirmatory test?

Internal Medicine

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A 35-year-old male presents with a 6-week history of productive cough, low-grade evening fevers, drenching night sweats, and 7 kg involuntary weight loss. Sputum smear is positive for acid-fast bacilli (AFB) and GeneXpert MTB/RIF confirms rifampicin-sensitive Mycobacterium tuberculosis. What is the standard first-line treatment regimen and duration for drug-susceptible pulmonary tuberculosis?

Internal Medicine

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A 70-year-old female is admitted with urosepsis. Vital signs are: BP 78/45 mmHg (MAP 56 mmHg), HR 122 bpm, RR 26/min, SpO2 93%, and temperature 39.1°C. Serum lactate is 4.2 mmol/L. She has received 30 mL/kg of IV crystalloids over the past hour, but her blood pressure remains 80/48 mmHg (MAP 58 mmHg). What is the first-choice vasopressor to restore and maintain a target Mean Arterial Pressure (MAP) >= 65 mmHg?

Internal Medicine

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A 22-year-old college student presents with high fever, severe headache, photophobia, and neck stiffness for 18 hours. Physical exam reveals positive Kernig and Brudzinski signs and scattered petechial lesions on the lower extremities. Lumbar puncture is performed immediately. Which cerebrospinal fluid (CSF) profile is most indicative of acute bacterial meningitis?

Internal Medicine

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A 44-year-old female presents with bilateral, symmetric pain and swelling of the proximal interphalangeal (PIP) and metacarpophalangeal (MCP) joints, accompanied by morning stiffness lasting over 90 minutes for the past 3 months. Laboratory evaluation reveals positive anti-cyclic citrullinated peptide (anti-CCP) antibodies and rheumatoid factor (RF). What is the first-line conventional synthetic disease-modifying antirheumatic drug (csDMARD) of choice?

Internal Medicine

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A 26-year-old female presents with malar rash, polyarthritis, photosensitivity, and oral ulcers. Laboratory testing confirms positive antinuclear antibodies (ANA 1:1280) and high-titer anti-double-stranded DNA (anti-dsDNA) antibodies. Urinalysis reveals 3+ proteinuria, hematuria with dysmorphic RBCs, and red blood cell casts. Serum complement levels (C3 and C4) are severely depressed. What is the most critical diagnostic procedure to guide therapy and prognosis?

Internal Medicine

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A 23-year-old asymptomatic male of Mediterranean descent undergoes routine pre-employment blood testing. Complete blood count shows: Hemoglobin 11.2 g/dL, MCV 62 fL (microcytic), MCH 20 pg, RBC count 6.2 x 10^12/L (elevated), and RDW 12.8% (normal). Serum ferritin is normal at 150 ng/mL. Hemoglobin electrophoresis shows HbA 94.5%, HbA2 5.2% (elevated, reference 2.0-3.5%), and HbF 0.3%. What is the diagnosis?

Internal Medicine

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A 19-year-old male presents to the surgical clinic with periumbilical pain that began 14 hours ago and has now migrated to the right lower quadrant. On examination, he is febrile (38.2°C) with localized tenderness, muscle guarding, and rebound tenderness at McBurney's point. Rovsing's sign and psoas sign are positive. White blood cell count is 14,800/mm³ with 82% neutrophils. What is the most appropriate management?

General Surgery

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A 46-year-old obese female presents with severe continuous right upper quadrant pain, nausea, and vomiting that started after a fatty dinner 12 hours ago. On physical examination, she demonstrates inspiratory arrest during deep palpation of the right subcostal margin (positive Murphy sign). Temperature is 38.4°C and WBC is 13,500/mm³. Transabdominal ultrasound shows gallbladder wall thickening (5 mm), pericholecystic fluid, and gallstones impacted in the gallbladder neck. What is the definitive management of choice?

General Surgery

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A 74-year-old male presents to the emergency department with high spiking fevers with rigors, jaundice, right upper quadrant pain, profound hypotension (BP 80/50 mmHg), and acute confusion. Laboratory tests reveal total bilirubin 6.8 mg/dL, alkaline phosphatase 450 U/L, and WBC 22,000/mm³. Abdominal ultrasound shows marked common bile duct dilation (16 mm) with an impacted choledochal stone. What is the diagnosis and the most urgent therapeutic intervention?

General Surgery

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A 60-year-old female with a history of open hysterectomy presents with crampy abdominal pain, obstipation, nausea, and bilious vomiting for 24 hours. Physical examination reveals abdominal distension, hyperactive high-pitched tinkling bowel sounds, and surgical scars on the lower midline. Plain abdominal radiography demonstrates multiple air-fluid levels in a 'stepladder' pattern with dilated small bowel loops and absence of gas in the colon. What is the most likely diagnosis and underlying etiology?

General Surgery

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A 52-year-old male with a history of chronic NSAID use for osteoarthritis presents with sudden-onset, excruciating, generalized abdominal pain that started 2 hours ago. On physical examination, he is lying completely still. His abdomen is rigid and 'board-like' with involuntary guarding and diffuse rebound tenderness. Upright chest radiography reveals crescent-shaped free air under the right hemidiaphragm (pneumoperitoneum). What is the initial operative procedure of choice?

General Surgery

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A 65-year-old male presents with a painless bulge in his right groin that appears upon standing and heavy lifting and disappears when lying supine. Anatomically, the hernia sac protrudes directly through Hesselbach's triangle, medial to the inferior epigastric vessels. Which type of groin hernia is this?

General Surgery

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A 68-year-old male presents with a 3-day history of left lower quadrant abdominal pain, low-grade fever (38.1°C), constipation, and anorexia. On physical examination, there is localized tenderness and palpable fullness in the left iliac fossa without generalized peritonitis. Contrast-enhanced abdominal CT confirms sigmoid diverticulitis with localized pericolonic fat stranding and a small 2 cm pericolonic abscess (Hinchey Stage Ia). What is the most appropriate initial management?

General Surgery

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A 50-year-old average-risk male presents to his primary care physician to discuss colorectal cancer screening. He has no gastrointestinal symptoms and no personal or family history of colorectal neoplasms. According to international preventive guidelines, what is the recommended screening strategy using screening colonoscopy?

General Surgery

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A 28-year-old unrestrained driver arrives at the trauma bay following a high-speed motor vehicle collision. He is severely dyspneic, cyanotic, and agitated. Vital signs: BP 70/40 mmHg, HR 138 bpm, RR 36/min, SpO2 82%. Physical exam reveals absent breath sounds over the right hemithorax, hyperresonance to percussion on the right, distended neck veins, and tracheal deviation to the left. What is the immediate life-saving intervention?

General Surgery

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A 34-year-old male polytrauma patient with open pelvic fractures and massive intra-abdominal hemorrhage arrives in hemorrhagic shock (Class IV shock: HR 145 bpm, BP 65/40 mmHg, base deficit -12 mEq/L, lactate 6.5 mmol/L). While initiating damage control surgery, what is the recommended protocol for blood component resuscitation in massive transfusion?

General Surgery

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A 22-year-old male presents following blunt abdominal trauma from a bicycle handlebar injury to his left upper quadrant. On arrival, he is hemodynamically stable: BP 122/78 mmHg, HR 76 bpm. Abdominal CT with intravenous contrast demonstrates a Grade III splenic laceration with a 3 cm subcapsular hematoma and moderate hemoperitoneum, with no active intravenous contrast extravasation (no 'blush'). What is the standard management strategy?

General Surgery

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A 72-year-old male with a history of benign prostatic hyperplasia (BPH) presents to the emergency department in extreme distress, unable to void for 14 hours following the use of an over-the-counter antihistamine. Physical examination reveals a tender, dull, distended bladder extending up to the umbilicus. What is the immediate first-line management?

General Surgery

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A 35-year-old male presents with sudden, severe, colicky right flank pain radiating to his groin, accompanied by nausea and microscopic hematuria. Vital signs: BP 130/85 mmHg, HR 90 bpm, afebrile (36.8°C). Non-contrast computed tomography (NCCT) of the abdomen and pelvis confirms a 4 mm calculus in the distal right ureter without significant hydronephrosis or perinephric stranding. What is the most appropriate initial management?

General Surgery

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A 15-year-old boy wakes up with sudden, severe left scrotal pain and swelling accompanied by nausea and vomiting. Physical examination reveals an exquisitely tender, swollen, high-riding left testis with a horizontal lie. The cremasteric reflex is absent on the left. Color Doppler ultrasound demonstrates absent vascular blood flow to the left testis. What is the definitive management and time window to salvage the testicle?

General Surgery

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A 66-year-old male presents for health maintenance. Digital rectal examination (DRE) reveals a hard, irregular, non-tender nodule in the right peripheral zone of the prostate. Serum Prostate-Specific Antigen (PSA) is 12.4 ng/mL (reference < 4.0 ng/mL). What is the definitive diagnostic procedure to confirm or exclude prostate cancer?

General Surgery

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A 71-year-old male with a 45 pack-year smoking history collapses with sudden-onset tearing lower back and abdominal pain. In the emergency department, his blood pressure is 75/40 mmHg and HR is 120 bpm. On physical examination, a prominent, pulsatile, expansile mid-abdominal mass is palpable. Bedside point-of-care ultrasound demonstrates an infrarenal abdominal aorta measuring 6.8 cm in diameter with free retroperitoneal fluid. What is the diagnosis and immediate management plan?

General Surgery

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A 68-year-old female with chronic atrial fibrillation presents with sudden-onset, severe pain in her right leg that started 3 hours ago. On physical examination, the right lower extremity is cold, pale, and pulseless (absent dorsalis pedis and posterior tibial pulses). She reports numbness in her toes, and light touch sensation is decreased. What clinical syndrome is present and what is the immediate intervention?

General Surgery

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A 54-year-old postmenopausal female discovers a painless, hard, non-mobile 2 cm mass in the upper outer quadrant of her left breast. There is overlying skin tethering but no nipple discharge. What constitutes the mandatory 'Triple Assessment' protocol for definitive breast lump evaluation?

General Surgery

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A 62-year-old male who underwent an open sigmoid colectomy 5 days ago develops fever (38.8°C), tachycardia, and worsening wound pain. Physical examination of the abdominal incision reveals spreading erythema extending 4 cm beyond the margins, marked local warmth, induration, and purulent discharge between the surgical staples. What is the most important initial management step for this superficial/deep surgical site infection (SSI)?

General Surgery

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A 65-year-old female is scheduled for total hip arthroplasty. She has no active bleeding, no coagulopathy, and normal renal function (eGFR 85 mL/min/1.73 m²). According to international surgical thromboprophylaxis guidelines (e.g., ACCP/NICE), what is the standard recommended pharmacological venous thromboembolism (VTE) prophylaxis regimen?

General Surgery

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A male infant is delivered at 39 weeks of gestation. At 1 minute after birth, the assessment reveals: heart rate 110 bpm, vigorous crying with active respiratory effort, active movement of all extremities, grimacing and coughing to suction catheter, and pink body with cyanotic hands and feet (acrocyanosis). What is the calculated APGAR score at 1 minute?

Pediatrics

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A 3-day-old breastfed full-term male newborn presents with cutaneous jaundice extending from his face down to his mid-abdomen. He is nursing vigorously every 2.5 hours, producing 6 wet diapers and 4 yellow stools daily. Vital signs are normal, and physical exam is unremarkable. Serum total bilirubin is 11.5 mg/dL (unconjugated fraction 11.0 mg/dL, conjugated fraction 0.5 mg/dL). Hemoglobin is 16.5 g/dL and blood types of mother and baby are both O positive. What is the most likely diagnosis and appropriate management?

Pediatrics

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