North Macedonia Physician Licensing Exam (Стручен испит за доктори на медицина) Feed

Question

A 58-year-old male presents to the emergency department with acute crushing retrosternal chest pain radiating to his left jaw and diaphoresis. An immediate 12-lead ECG demonstrates ST-segment elevation of 2.5 mm in leads V1 through V4 with reciprocal ST depression in leads II, III, and aVF. Which coronary artery is most likely occluded?

Internal Medicine

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A 66-year-old female with a history of ischemic heart disease is admitted with severe dyspnea, orthopnea, and pink frothy sputum. Physical examination reveals blood pressure of 175/100 mmHg, pulse of 115 bpm, bilateral diffuse pulmonary crackles extending to the upper zones, and third heart sound (S3 gallop). What is the most appropriate initial pharmacological combination in this patient?

Internal Medicine

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According to current European hypertension guidance, what is the usual initial pharmacological strategy for most adults with confirmed hypertension who require drug treatment?

Internal Medicine

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A 71-year-old male with a history of hypertension and type 2 diabetes mellitus presents with newly detected non-valvular atrial fibrillation. He has no prior history of stroke or heart failure. What is his CHA2DS2-VASc score, and what is the recommended stroke prevention strategy?

Internal Medicine

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A 68-year-old female presents to the clinic with fever, productive cough with rust-colored sputum, and right pleuritic chest pain. Vital signs: BP 100/62 mmHg, HR 102 bpm, RR 32 breaths/min, temperature 38.8 °C. Laboratory testing reveals normal serum urea of 5.8 mmol/L (urea <=7 mmol/L). She is alert and fully oriented. What is her CURB-65 score, and what is the appropriate clinical management disposition?

Internal Medicine

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A 64-year-old male with severe chronic obstructive pulmonary disease (COPD) presents with increased dyspnea, increased sputum volume, and purulence. Arterial blood gas on room air shows: pH 7.33, PaCO2 56 mmHg, PaO2 54 mmHg, HCO3- 29 mmol/L. When administering oxygen therapy, what is the target oxygen saturation (SpO2) to avoid hypercapnic respiratory failure?

Internal Medicine

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A 24-year-old female presents to the urgent care clinic with an acute severe asthma attack. She is speaking in short phrases, has a respiratory rate of 28 breaths/min, pulse of 118 bpm, and peak expiratory flow (PEF) of 45% of predicted. What is the immediate first-line pharmacological treatment?

Internal Medicine

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A 52-year-old woman presents 10 days after total hip replacement with sudden dyspnea and obstructive shock. Bedside echocardiography shows acute right-ventricular dilatation and hypokinesis, making high-risk pulmonary embolism the leading diagnosis. What is the appropriate immediate reperfusion approach?

Internal Medicine

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A 54-year-old male with a history of chronic NSAID use for osteoarthritis presents with hematemesis and melena. Vital signs show BP 95/60 mmHg and HR 110 bpm. After initial fluid resuscitation, urgent upper endoscopy reveals a 1.5 cm duodenal ulcer with an active spurting arterial bleed (Forrest Ia). What is the appropriate initial endoscopic and pharmacological intervention?

Internal Medicine

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A 42-year-old male with a history of alcohol abuse presents with severe epigastric pain radiating to his back, accompanied by nausea and persistent vomiting. Physical examination reveals epigastric tenderness and guarding. Laboratory evaluation shows serum amylase 1,240 U/L and serum lipase 2,850 U/L (reference <60 U/L). What is the most critical initial therapeutic intervention within the first 24 hours of admission?

Internal Medicine

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A 59-year-old male with decompensated hepatitis C cirrhosis and chronic ascites presents with low-grade fever, diffuse abdominal discomfort, and altered mental status. Diagnostic paracentesis is performed. Ascitic fluid analysis reveals an absolute polymorphonuclear (PMN) neutrophil count of 380 cells/mm3. What is the diagnosis and the standard empiric first-line antibiotic treatment?

Internal Medicine

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A 70-kg postoperative patient develops oliguria. Over the past 6 hours, his total urine output has been 140 mL. Baseline serum creatinine was 85 µmol/L (0.96 mg/dL) and has risen to 180 µmol/L (2.0 mg/dL). Urinalysis shows specific gravity >1.025, urine sodium 12 mmol/L, and a fractional excretion of sodium (FeNa) of 0.6%. What stage and category of acute kidney injury (AKI) does this represent?

Internal Medicine

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A 62-year-old female with long-standing type 2 diabetes has an estimated glomerular filtration rate (eGFR) of 42 mL/min/1.73 m2 and a confirmed urine albumin-to-creatinine ratio (ACR) of 180 mg/g. According to KDIGO staging of chronic kidney disease (CKD), how is her condition classified?

Internal Medicine

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A 19-year-old male with newly diagnosed type 1 diabetes presents with nausea, vomiting, abdominal pain, deep rapid breathing (Kussmaul respiration), and a fruity breath odor. Laboratory results show: blood glucose 24.2 mmol/L (436 mg/dL), arterial pH 7.18, serum bicarbonate 11 mmol/L, positive serum ketones, and serum potassium 4.8 mmol/L. What is the fundamental initial fluid and insulin protocol?

Internal Medicine

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Which of the following laboratory findings meets the established diagnostic criteria for diabetes mellitus in an asymptomatic patient, provided it is confirmed on repeat testing?

Internal Medicine

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A 32-year-old female presents with weight loss, heat intolerance, palpitation, fine tremor, and bilateral exophthalmos. Thyroid examination reveals a diffusely enlarged, non-tender goiter with an audible vascular bruit. Laboratory testing reveals suppressed serum TSH (<0.01 mIU/L) and elevated free thyroxine (FT4). What is the underlying pathophysiology and the most specific diagnostic antibody?

Internal Medicine

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A 26-year-old female undergoes routine blood testing. Results show: hemoglobin 98 g/L (9.8 g/dL), mean corpuscular volume (MCV) 64 fL, red blood cell count (RBC) 5.8 x 10^12/L, and red cell distribution width (RDW) 12.5% (normal). The calculated Mentzer index (MCV / RBC count) is 11.0 (64 / 5.8). What is the most likely diagnosis?

Internal Medicine

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A 21-year-old male presents with periumbilical abdominal pain that began 14 hours ago and has now migrated to the right lower quadrant. On physical examination, there is localized tenderness and guarding at McBurney's point. Deep palpation of the left lower quadrant elicits sharp pain in the right lower quadrant. What is the name of this clinical sign and the most probable diagnosis?

Surgery

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A 46-year-old female presents with constant right upper quadrant pain, nausea, vomiting, and low-grade fever following a fatty meal. Physical examination demonstrates an abrupt arrest of inspiration upon deep palpation of the right upper quadrant below the costal margin. Abdominal ultrasound shows gallstones, a thickened gallbladder wall of 5 mm, and pericholecystic fluid. What is the diagnosis and the standard surgical management?

Surgery

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A 65-year-old male with a history of prior open appendectomy and left hemicolectomy presents with diffuse crampy abdominal pain, prominent abdominal distension, vomiting of feculent material, and failure to pass flatus or stool for 48 hours. An erect plain abdominal radiograph demonstrates multiple central air-fluid levels and dilated bowel loops with plicae circulares (valvulae conniventes). What is the diagnosis?

Surgery

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A 48-year-old male with a history of recurrent epigastric burning presents to the emergency room with sudden-onset, agonizing abdominal pain that started 2 hours ago. On examination, the patient lies motionless with knees flexed; his abdomen is severely tender throughout with diffuse involuntary board-like muscular rigidity. An erect chest radiograph shows a crescent of free air beneath the right hemidiaphragm. What is the diagnosis and the immediate definitive surgical intervention?

Surgery

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During surgical repair of a groin hernia, the surgeon identifies the hernia sac protruding through Hesselbach's triangle medial to the inferior epigastric vessels. What type of hernia is this, and how does it compare anatomically to an indirect inguinal hernia?

Surgery

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A 74-year-old female with a history of chronic atrial fibrillation and peripheral vascular disease presents with agonizing, poorly localized periumbilical abdominal pain of 4 hours duration. On physical examination, the abdomen is soft and non-distended with minimal tenderness, completely out of proportion to the patient's excruciating distress. Laboratory tests show serum lactate of 4.2 mmol/L (elevated) and marked leukocytosis. What is the most likely diagnosis, and what is the definitive diagnostic modality?

Surgery

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According to the Advanced Trauma Life Support (ATLS) protocol, what is the correct and prioritized sequence for the primary survey and initial resuscitation in an acutely injured polytrauma patient?

Surgery

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A 28-year-old male is brought to the emergency department 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 78%. Examination reveals absent breath sounds and hyperresonance on the right hemithorax, distended jugular veins, and tracheal deviation to the left. What is the immediate life-saving management before obtaining any imaging?

Surgery

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A 35-year-old trauma victim with blunt pelvic and splenic injuries has an estimated acute blood loss of 1,700 mL (approximately 35% of his circulating blood volume). He presents with a heart rate of 128 bpm, blood pressure of 84/55 mmHg, respiratory rate of 32/min, cold pale extremities, and marked confusion. According to the ATLS classification of hemorrhagic shock, which class of shock is this, and what is the fluid resuscitation requirement?

Surgery

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A 22-year-old male sustains a blow to the temporal region during a sports match. He experienced a brief loss of consciousness for 2 minutes, followed by a complete recovery of normal consciousness for 3 hours (lucid interval). He then rapidly deteriorates with severe headache, vomiting, progressive obtundation, and a dilated, non-reactive right pupil. A non-contrast head CT scan shows a biconvex (lenticular), hyperdense extra-axial collection adjacent to the squama of the right temporal bone. What vessel is ruptured?

Surgery

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A physician evaluates an unresponsive head-trauma patient. The patient opens his eyes to pain, makes incomprehensible sounds, and shows abnormal flexion to pain. What is the Glasgow Coma Scale score, and what airway action is appropriate after rapid assessment of oxygenation and airway reflexes?

Surgery

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A 70-kg adult male suffers deep second- and third-degree thermal burns covering his entire anterior chest and abdomen (18% TBSA) and the entirety of both upper extremities (9% + 9% = 18% TBSA), for a total burn surface area of 36% TBSA. Using the standard Parkland formula (4 mL x body weight in kg x % TBSA), what is the total volume of Ringer's lactate required in the first 24 hours, and what volume must be infused during the first 8 hours post-injury?

Surgery

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According to surgical infection prevention guidelines, what is the optimal timing for the administration of prophylactic intravenous antibiotics prior to a surgical incision?

Surgery

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A 62-year-old male with a BMI of 32 kg/m2 undergoes an elective open right hemicolectomy for colon adenocarcinoma. According to the Caprini risk assessment model, he is at high risk for venous thromboembolism (VTE). What is the recommended postoperative thromboprophylaxis protocol?

Surgery

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During an elective right hemicolectomy, the surgeon enters the colon under controlled conditions. There is no gross spillage, acute inflammation, or break in sterile technique. How should this operative wound be classified?

Surgery

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A 68-year-old male presents with sudden, excruciating pain in his right leg of 3 hours duration. Physical examination reveals that the right foot and lower calf are pale, cold to the touch, and mottled. Femoral, popliteal, dorsalis pedis, and posterior tibial pulses are completely absent on the right, but normal on the left. The patient has diminished sensation over the dorsum of the foot. What is the diagnosis, and what is the immediate initial medical action?

Surgery

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A 72-year-old male with an obstructing adenocarcinoma of the sigmoid colon presents with acute complete large bowel obstruction, marked abdominal distension, and signs of impending cecal perforation (cecal diameter 11 cm on CT). What emergency surgical procedure is classically indicated in a critically ill patient with an obstructing left colon lesion and peritoneal contamination?

Surgery

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A newborn infant is assessed at 1 minute of life: heart rate is 120 bpm, respiratory effort shows a vigorous strong cry, muscle tone shows active motion and flexed extremities, reflex irritability shows prompt sneezing upon bulb suctioning, and skin color reveals a pink body with cyanotic hands and feet (acrocyanosis). What is this infant's calculated APGAR score?

Pediatrics

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During resuscitation of a newly delivered term infant, the team provides warmth, dries the infant, positions the airway, stimulates breathing, and suctions only because visible secretions are obstructing the airway. At 30 seconds of life, the infant remains apneic with a heart rate of 70 bpm. What is the immediate next step?

Pediatrics

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A full-term male infant is noted to have visible jaundice on his face and chest at 14 hours of life. The mother's blood type is O Rh-negative and the infant's blood type is A Rh-positive. Total serum bilirubin is 135 µmol/L (7.9 mg/dL). Which of the following statements regarding this infant's jaundice is correct?

Pediatrics

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Which feeding and vitamin D plan is appropriate for a healthy term infant who is exclusively breastfed?

Pediatrics

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During a routine well-child developmental examination of a 9-month-old infant, which set of developmental milestones is normally expected for this age?

Pediatrics

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A 4-year-old unimmunized child presents with high fever (39.5 °C), severe hacking cough, rhinorrhea, and bilateral conjunctivitis with photophobia. On oral examination, tiny white, pinpoint lesions surrounded by an erythematous halo are visualized on the buccal mucosa opposite the lower molars. Two days later, a reddish maculopapular rash appears at the hairline and behind the ears, spreading cephalocaudally to the trunk and extremities. What is the diagnosis and the pathognomonic oral enanthem?

Pediatrics

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A 5-year-old child presents with low-grade fever, malaise, and an intensely pruritic rash that started on the scalp and trunk and has spread to the face and limbs. Physical examination reveals lesions at various simultaneous stages of development: erythematous macules, papules, thin-walled clear vesicles on an erythematous base ('dewdrops on a rose petal'), and crusted scabs. What is the diagnosis, and which common antipyretic must be strictly avoided?

Pediatrics

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An 18-month-old boy is brought to the pediatric emergency service at 2:00 AM with a harsh, barking 'seal-like' cough, hoarseness, and inspiratory stridor that worsens with agitation. He has a low-grade fever of 38.0 °C and no drooling or difficulty swallowing. On room air, his SpO2 is 96%. What is the most likely pathogen and the evidence-based first-line medical therapy for this condition (croup)?

Pediatrics

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A 5-month-old infant presents during the winter season with a 2-day history of clear rhinorrhea and low-grade fever, progressing to tachypnea (RR 62/min), intercostal retractions, and bilateral expiratory wheezes and diffuse fine crackles on chest auscultation. SpO2 is 93% on room air. According to international and national pediatric guidelines, what is the cornerstone of management for acute viral bronchiolitis?

Pediatrics

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A 3-year-old unimmunized girl is brought to the emergency department in severe toxic respiratory distress. She has a high fever of 39.8 °C, sits upright leaning forward with her neck hyperextended and chin thrust forward (tripod position), and is drooling saliva because she cannot swallow. Her voice is muffled ('hot potato voice'), and she has soft inspiratory stridor. What is the immediate, most critical clinical directive?

Pediatrics

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A 10-kg, 14-month-old toddler presents with severe acute gastroenteritis, vomiting, and watery diarrhea for 3 days. On physical examination: the infant is lethargic and floppy, fontanelle and eyes are deeply sunken, tears are absent, mucous membranes are parched, skin pinch retracts very slowly (>2 seconds), and radial pulse is weak and rapid. According to WHO criteria, what is the classification of dehydration and the immediate fluid resuscitation protocol?

Pediatrics

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A previously healthy 20-month-old girl experiences a generalized tonic-clonic convulsion lasting 3 minutes during an acute spike in body temperature to 39.2 °C secondary to acute otitis media. Upon arrival at the clinic 20 minutes later, the child is conscious, interactive, has a normal neurological examination, and exhibits no focal deficits. Which of the following defines this event, and what is the appropriate management?

Pediatrics

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A 3-year-old child (body weight 15 kg) is brought to the resuscitation room with ongoing generalized tonic-clonic convulsive activity that has lasted continuously for 8 minutes without cessation. Vascular access is not yet established. According to pediatric status epilepticus resuscitation guidelines, what is the first-line medication and route of choice to terminate the seizure?

Pediatrics

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