Albania State Medical Exam (Provimi i Shtetit - Mjekësi) cheat sheet

Acute coronary syndrome: ST-elevation myocardial infarction requires reperfusion (primary PCI within 120 min of first medical contact) when symptoms <12 h.

Heart failure with reduced ejection fraction: four pillars are ACE inhibitor/ARB or ARNI, beta-blocker, mineralocorticoid receptor antagonist, and SGLT2 inhibitor.

Diabetic ketoacidosis: anion-gap acidosis, ketonemia, glucose usually >250 mg/dL; treatment is IV fluids, insulin infusion, and potassium replacement before insulin if K <3.3 mmol/L.

Community-acquired pneumonia severity can be stratified with CURB-65: confusion, urea >7 mmol/L, respiratory rate >=30, low blood pressure, age >=65; each item scores 1.

Hyponatremia: assess serum osmolality first; hypotonic hyponatremia is classified by volume status (hypo-, eu-, hypervolemic) and urine sodium guides cause.

Hyperkalemia with ECG changes (peaked T waves, wide QRS) is treated first with IV calcium gluconate for membrane stabilization, then insulin-glucose and beta-2 agonist.

Nephrotic syndrome: proteinuria >3.5 g/day, hypoalbuminemia, edema, hyperlipidemia; common causes include minimal change disease, membranous nephropathy, and focal segmental glomerulosclerosis.

Anemia classification by mean corpuscular volume: microcytic (iron deficiency, thalassemia, chronic disease), normocytic (acute blood loss, renal disease), macrocytic (B12/folate deficiency, alcohol).

Acute appendicitis: migration of pain to right lower quadrant, McBurney point tenderness, leukocytosis; Alvarado score >=7 supports operative management.

Acute cholecystitis: right upper quadrant pain, Murphy sign, fever, leukocytosis; ultrasound shows gallbladder wall thickening, pericholecystic fluid, or stones.

Bowel obstruction: colicky pain, vomiting, distension, absolute constipation; air-fluid levels on plain film; initial management is IV fluids and nasogastric decompression.

ATLS primary survey sequence: catastrophic hemorrhage control, Airway with cervical spine protection, Breathing, Circulation, Disability, Exposure.

Hernia: indirect inguinal hernia passes lateral to inferior epigastric vessels and through the deep ring; direct hernia passes medial to the vessels through Hesselbach triangle.

Thyroidectomy complications: recurrent laryngeal nerve injury (hoarseness), external branch of superior laryngeal nerve injury (voice fatigue), hypocalcemia from parathyroid injury.

Surgical site infection prevention: preoperative antibiotic prophylaxis within 60 min of incision, normothermia, glycemic control, and chlorhexidine-alcohol skin preparation.

Acute mesenteric ischemia: pain out of proportion to exam, lactate may be normal early; CT angiography is diagnostic and revascularization is time-critical.

Preeclampsia: new-onset hypertension after 20 weeks with proteinuria or end-organ dysfunction; severe features include BP >=160/110, platelets <100,000, elevated transaminases, pulmonary edema, visual or cerebral symptoms.

Eclampsia management: magnesium sulfate is first-line for seizure prophylaxis and treatment; loading dose 4-6 g IV followed by 1-2 g/h infusion.

Postpartum hemorrhage: most common cause is uterine atony; management sequence is uterine massage, oxytocin, then additional uterotonics, tranexamic acid, and surgical measures.

Gestational diabetes screening: 75 g oral glucose tolerance test at 24-28 weeks; diagnostic thresholds include fasting >=92, 1 h >=180, 2 h >=153 mg/dL (one or more abnormal).

Fetal heart rate interpretation: category III tracing includes absent baseline variability with recurrent late or variable decelerations or bradycardia, requiring immediate evaluation.

Ectopic pregnancy: risk factors include prior ectopic, tubal surgery, and pelvic inflammatory disease; diagnosis by quantitative beta-hCG and transvaginal ultrasound; treatment is methotrexate or surgery.

Cervical cancer screening: cytology every 3 years from age 21 or co-testing with HPV every 5 years from age 30; high-risk HPV types 16 and 18 carry highest risk.

Ovarian torsion: sudden unilateral pelvic pain with nausea and vomiting; ultrasound may show enlarged ovary with decreased Doppler flow; surgical detorsion is the treatment.

Neonatal resuscitation: dry, stimulate, warm; if apnea or heart rate <100, provide positive pressure ventilation; chest compressions at 3:1 ratio if heart rate <60 after effective ventilation.

Pediatric dehydration: mild <5%, moderate 5-10%, severe >10% weight loss; ORS is first-line for mild-moderate; IV isotonic fluid for severe or shock.

Kawasaki disease: fever >=5 days plus 4 of 5 criteria (rash, conjunctivitis, mucosal changes, extremity changes, cervical lymphadenopathy); treat with IVIG and aspirin.

Bronchiolitis: most common cause is respiratory syncytial virus; treatment is supportive (oxygen, hydration); bronchodilators and corticosteroids are not routinely recommended.

Growth assessment: use WHO growth standards for children under 5 and local/national charts thereafter; crossing two major percentile lines warrants evaluation.

Febrile seizures: simple if generalized, <15 min, once in 24 h, age 6 months-5 years; no routine EEG or long-term anticonvulsant needed.

Intussusception: intermittent colicky abdominal pain, vomiting, bloody stool (currant jelly), sausage-shaped mass; air or contrast enema is diagnostic and therapeutic.

Pediatric dosing: weight-based (mg/kg); check maximum adult dose; use actual body weight for most drugs, and renal dosing adjusted for creatinine clearance.

Incidence measures new cases per population at risk per time; prevalence measures all existing cases at a point or period.

Relative risk = incidence in exposed / incidence in unexposed; attributable risk = incidence in exposed minus incidence in unexposed.

Odds ratio approximates relative risk when the outcome is rare (<10%); case-control studies estimate odds ratio.

Sensitivity = true positives / (true positives + false negatives); specificity = true negatives / (true negatives + false positives).

Positive predictive value depends on prevalence: PPV = (sensitivity x prevalence) / [(sensitivity x prevalence) + ((1-specificity) x (1-prevalence))].

Herd immunity threshold = 1 - (1/R0); higher R0 requires higher vaccination coverage.

Screening programs require a valid test, an accepted treatment for detected disease, and adequate follow-up; lead-time bias can falsely inflate survival.

Albanian health legislation: the Law on Health (1994, amended) establishes the national health system; mandatory health insurance is administered by the Health Insurance Institute (ISKSH).

Pharmacokinetics: bioavailability (F), volume of distribution (Vd = dose / plasma concentration), clearance (CL = dose rate / steady-state concentration), half-life t1/2 = 0.693 x Vd / CL.

Loading dose = (Vd x target concentration) / bioavailability; maintenance dose = (CL x target concentration) / bioavailability.

Cytochrome P450: CYP3A4 metabolizes most drugs; inhibitors include macrolides, azoles, grapefruit; inducers include rifampicin, carbamazepine, phenytoin, St John's wort.

Paracetamol overdose: N-acetylcysteine is the antidote; Rumack-Matthew nomogram guides treatment based on timed serum level; risk of hepatotoxicity rises with dose >150 mg/kg.

Organophosphate poisoning: SLUDGE syndrome (salivation, lacrimation, urination, diarrhea, GI cramping, emesis) plus bradycardia and miosis; atropine is antidote, pralidoxime for nicotinic effects.

Opioid overdose: pinpoint pupils, respiratory depression, coma; naloxone is the antidote and may require repeat dosing due to short half-life.

Warfarin reversal: vitamin K for stable patients; prothrombin complex concentrate for major bleeding; target INR for most indications is 2-3.

Digoxin toxicity: nausea, visual changes (yellow-green halos), bradyarrhythmias; risk increased by hypokalemia and renal impairment; antidote is digoxin-specific antibody fragments.

Cell injury: reversible injury shows cellular swelling and fatty change; irreversible injury shows membrane damage, mitochondrial dysfunction, and nuclear changes (pyknosis, karyorrhexis, karyolysis).

Inflammation: acute response involves vasodilation, increased vascular permeability, and neutrophil recruitment; chronic inflammation features macrophages, lymphocytes, and fibrosis.

Necrosis types: coagulative (ischemia), liquefactive (brain, abscess), caseous (tuberculosis), fat (pancreatitis), fibrinoid (vasculitis).

Apoptosis is energy-dependent, caspase-mediated, and does not incite inflammation; pathways are intrinsic (mitochondrial) and extrinsic (death receptor).

Tumor suppressor genes: TP53 (guardian of the genome), RB, APC, BRCA1/2; loss of both alleles (two-hit hypothesis) is required for loss of function.

Oncogenes: RAS, MYC, HER2, BCR-ABL; activation by mutation, amplification, or translocation.

Shock: hypovolemic, cardiogenic, distributive (septic, anaphylactic, neurogenic), and obstructive; lactic acidosis reflects tissue hypoperfusion.

Atherosclerosis pathogenesis: endothelial injury, LDL accumulation and oxidation, monocyte recruitment, foam cell formation, smooth muscle proliferation, and plaque complication.

Hypertension diagnosis: office BP >=140/90 mmHg confirmed on repeated visits; home or ambulatory monitoring is preferred to exclude white-coat hypertension.

Type 2 diabetes: first-line pharmacotherapy is metformin plus lifestyle; add SGLT2 inhibitor or GLP-1 receptor agonist when atherosclerotic cardiovascular disease, heart failure, or chronic kidney disease is present.

Primary prevention of cardiovascular disease: use validated risk scores (e.g., SCORE2) to guide statin and antihypertensive therapy.

Depression screening: PHQ-9 or PHQ-2; positive screen requires diagnostic interview and suicide risk assessment.

Antibiotic stewardship in primary care: avoid antibiotics for uncomplicated viral upper respiratory infections; use narrow-spectrum agents when indicated.

Contraception counseling: combined oral contraceptives are contraindicated in migraine with aura, uncontrolled hypertension, and history of venous thromboembolism.

Childhood immunization schedules should follow the national immunization calendar; missed doses are resumed without restarting the series.

Chronic disease follow-up: monitor HbA1c every 3-6 months, blood pressure at each visit, and renal function (eGFR, urine albumin) at least annually in diabetes.

Cardiac arrest: high-quality CPR with compressions at 100-120/min, depth 5-6 cm, full recoil, minimal interruptions; defibrillate shockable rhythms (VF, pulseless VT) as soon as possible.

Advanced airway: after intubation, capnography confirms placement; waveform capnography also monitors CPR quality and return of spontaneous circulation.

Sepsis: initiate broad-spectrum antibiotics within 1 hour of recognition, obtain blood cultures before antibiotics, and give 30 mL/kg crystalloid for hypotension or lactate >=4 mmol/L.

Anaphylaxis: intramuscular epinephrine 0.3-0.5 mg (1 mg/mL) into the anterolateral thigh, repeated every 5-15 min as needed; adjuncts include fluids, oxygen, antihistamines, and corticosteroids.

Acute stroke: non-contrast CT excludes hemorrhage; intravenous thrombolysis within 4.5 hours of symptom onset for eligible patients; thrombectomy up to 24 hours in selected large vessel occlusion.

Acute severe asthma: oxygen to target saturation, repeated inhaled short-acting beta-2 agonist, ipratropium, systemic corticosteroids; consider magnesium sulfate for severe cases.

Tension pneumothorax: immediate needle decompression then tube thoracostomy; do not delay for imaging in an unstable patient.

Glasgow Coma Scale: eye (1-4), verbal (1-5), motor (1-6); score <=8 indicates need to assess airway protection and consider intubation.

First-line pharmacotherapy for major depressive disorder includes SSRIs, SNRIs, and mirtazapine; response is assessed at 4-6 weeks, and treatment continues at least 6-12 months after remission.

Serotonin syndrome: clonus, hyperreflexia, agitation, hyperthermia; caused by serotonergic agents; treatment is discontinuation and supportive care, with benzodiazepines for severe cases.

Neuroleptic malignant syndrome: rigidity, hyperthermia, autonomic instability, elevated creatine kinase; treat by stopping the antipsychotic, supportive care, and dantrolene or bromocriptine.

Acute ischemic stroke: thrombolysis window up to 4.5 hours; time is brain; blood pressure threshold for treatment is generally <185/110 mmHg before thrombolysis.

Status epilepticus: first-line benzodiazepine (lorazepam or diazepam), then second-line anticonvulsant (levetiracetam, valproate, or phenytoin); refractory cases need anesthetic agents.

Migraine: diagnosis is clinical; acute treatment with NSAIDs or triptans; prophylaxis with beta-blockers, topiramate, or amitriptyline when attacks are frequent.

Parkinson disease: cardinal features are bradykinesia, rigidity, resting tremor, and postural instability; levodopa-carbidopa is the most effective symptomatic treatment.

Multiple sclerosis: relapsing-remitting course is most common; MRI shows periventricular, juxtacortical, infratentorial, and spinal cord lesions; acute relapse treated with high-dose corticosteroids.

Informed consent requires capacity, adequate disclosure of risks, benefits, and alternatives, and voluntary decision without coercion.

Capacity assessment: patient can understand information, appreciate consequences, reason about options, and communicate a choice.

Confidentiality may be breached only when required by law or when there is serious risk to the patient or others (e.g., reportable infectious diseases, imminent harm).

Medical confidentiality is protected by the Albanian Code of Medical Ethics and the Law on Health; disclosure requires patient consent except in legally defined exceptions.

End-of-life care: respect patient autonomy, provide palliative care, and avoid futile interventions; advance directives should guide decisions where recognized.

Research ethics: institutional review board approval, informed consent, and risk minimization are required for studies involving human participants.

Professional boundaries: avoid dual relationships and conflicts of interest; disclose financial interests and obtain informed consent for procedures performed by trainees.

Reporting obligations: suspected child abuse, certain communicable diseases, and gunshot wounds are typically mandatory reports under national law.