Free Practice Questions for Avicenna TSMU State Graduation Examination — General Medicine / Имтиҳони хатми давлатӣ (ИХД)

Explanation: A Mentzer index below 13 favors beta-thalassemia trait: marrow output of small red cells is preserved, so the RBC count is normal or high despite marked microcytosis. A normal ferritin shows that iron stores are adequate, which argues against iron deficiency. Hemoglobin electrophoresis showing a raised HbA2 confirms the diagnosis.

Explanation: Current EULAR recommendations make methotrexate the anchor conventional synthetic DMARD and part of the first treatment strategy in active rheumatoid arthritis, started as soon as the diagnosis is made. Folic acid reduces its gastrointestinal and hepatic side effects. Short-term glucocorticoids may bridge the period until methotrexate takes effect, and biologic agents are added when the treatment target is not reached.

Explanation: Isolated thrombocytopenia with a normal smear and normal coagulation in an otherwise well adult suggests primary immune thrombocytopenia (ITP). For newly diagnosed adults with a platelet count below 30 x 10^9/L or bleeding, corticosteroids are first-line therapy, with intravenous immunoglobulin added when a rapid rise is needed. Second-line options include thrombopoietin receptor agonists, rituximab and splenectomy.

Explanation: This is chronic myeloid leukemia in chronic phase: massive splenomegaly, neutrophilic leukocytosis with all stages of maturation, basophilia and the Philadelphia chromosome t(9;22). The BCR::ABL1 fusion gene encodes a constitutively active tyrosine kinase, and tyrosine kinase inhibitors such as imatinib (or second-generation dasatinib or nilotinib) are first-line therapy. They achieve durable hematologic, cytogenetic and molecular responses in most patients.

Explanation: This is an acute inferior ST-elevation myocardial infarction, usually from right coronary artery occlusion. When primary PCI can be delivered promptly, it is the preferred reperfusion strategy. ESC guidance aims for wire crossing within 60 minutes of diagnosis when the patient presents to a PCI centre, and ACC/AHA uses a door-to-device target of 90 minutes or less.

Explanation: Current ESC and ACC/AHA guidelines build HFrEF treatment on four pillars that each reduce mortality and hospitalization: an ACE inhibitor/ARB or ARNI, an evidence-based beta-blocker, a mineralocorticoid receptor antagonist and an SGLT2 inhibitor. Dapagliflozin and empagliflozin benefit patients with or without diabetes, so this patient should receive one.

Explanation: In the ESH/ESC office classification, grade 1 hypertension is a systolic pressure of 140–159 mmHg and/or diastolic 90–99 mmHg, confirmed on repeated measurements. Grade 2 is 160–179 and/or 100–109 mmHg, and grade 3 is 180 mmHg or more systolic and/or 110 mmHg or more diastolic.

Explanation: Atria and ventricles beating independently at different rates (AV dissociation), with a slow broad-complex escape rhythm, is complete heart block. The slow ventricular rate causes cerebral hypoperfusion and Morgagni–Adams–Stokes syncope. Atropine, isoprenaline or temporary pacing can bridge an emergency, but permanent pacemaker implantation is the definitive treatment.

Explanation: CURB-65 gives one point each for confusion, urea above 7 mmol/L, respiratory rate of 30/min or more, systolic BP below 90 or diastolic 60 mmHg or less, and age 65 or over. This patient scores for urea, respiratory rate and age, a total of 3. A score of 3 or more indicates severe pneumonia with high mortality risk, requiring hospital admission and assessment for intensive care.

Explanation: The GOLD report defines persistent airflow limitation in COPD as a post-bronchodilator FEV1/FVC ratio below 0.70 in a patient with compatible symptoms and exposures. The FEV1 percentage of predicted is then used to grade the severity of airflow limitation.