Medical Residency Independent Final Attestation (Kazakhstan) cheat sheet

Acute coronary syndrome: ST-elevation myocardial infarction requires reperfusion (primary PCI within 120 min of first medical contact, or fibrinolysis within 30 min if PCI unavailable) plus dual antiplatelet therapy, anticoagulation, and high-intensity statin.

Acute heart failure with pulmonary congestion: oxygen only if SpO2 <90%, intravenous loop diuretic (furosemide 20-40 mg IV), nitrates if systolic BP >110 mmHg, non-invasive ventilation for respiratory distress; avoid beta-blockers during acute decompensation.

Community-acquired pneumonia severity: CURB-65 (confusion, urea >7 mmol/L, respiratory rate >=30/min, systolic BP <90 or diastolic <=60 mmHg, age >=65) - 0-1 points outpatient, 2 points short inpatient, >=3 points consider intensive care.

Arterial hypertension in Kazakhstan follows ESC/ESH thresholds: office BP >=140/90 mmHg; target <130/80 mmHg if tolerated, individualised in frail elderly; first-line classes are ACE inhibitors/ARB, calcium channel blockers, thiazide-like diuretics, beta-blockers when indicated.

Type 2 diabetes: metformin first-line unless contraindicated (eGFR <30); HbA1c target <7% for most adults, <6.5% if achievable safely, <8% in limited life expectancy; add SGLT2 inhibitor or GLP-1 receptor agonist when atherosclerotic cardiovascular disease, heart failure, or chronic kidney disease is present.

Chronic obstructive pulmonary disease: diagnosis confirmed by post-bronchodilator FEV1/FVC <0.70; GOLD ABE grouping guides inhaled therapy - bronchodilator combination for group B, add inhaled corticosteroid for group E with eosinophils >=300 cells/microL.

Acute kidney injury: KDIGO staging by serum creatinine rise (>=26.5 micromol/L in 48 h or >=1.5x baseline in 7 days) and urine output (<0.5 mL/kg/h for 6 h = stage 1); stop nephrotoxins, assess volume status, and look for obstruction before diuresis.

Peptic ulcer disease with Helicobacter pylori: eradication with proton pump inhibitor-based triple or quadruple therapy, then confirm eradication by urea breath test or stool antigen at least 4 weeks after antibiotics and 2 weeks after PPI withdrawal.

Acute appendicitis: Alvarado score (migration of pain, anorexia, nausea/vomiting, tenderness right lower quadrant, rebound, fever >=37.3 C, leukocytosis, left shift) - score >=7 supports operative management; laparoscopic appendectomy is standard.

Acute cholecystitis: Tokyo Guidelines grade I-III; early laparoscopic cholecystectomy within 72 h of onset is preferred for grades I-II; percutaneous drainage for grade III or unfit patients.

Bowel obstruction: supine and erect abdominal radiographs show dilated loops and air-fluid levels; CT with contrast identifies transition point and strangulation. Signs of strangulation (fever, tachycardia, peritoneal signs, lactate rise) mandate urgent laparotomy.

Trauma primary survey follows ABCDE; haemorrhagic shock class III-IV requires massive transfusion protocol with balanced ratio (plasma:platelets:erythrocytes approximating 1:1:1) and permissive hypotension until surgical control.

Postoperative wound classification: clean, clean-contaminated, contaminated, dirty - determines antibiotic prophylaxis; single preoperative dose of cefazolin is standard for clean procedures.

Acute pancreatitis: diagnosis requires 2 of 3 (typical pain, serum lipase/amylase >3x upper limit, imaging); severity by modified Atlanta classification; early fluid resuscitation with balanced crystalloids, enteral nutrition when tolerated, no routine prophylactic antibiotics.

Thyroid nodule with suspicious ultrasound features (hypoechoic, irregular margins, microcalcifications, taller-than-wide) requires fine-needle aspiration biopsy; Bethesda category guides surgical extent.

Venous thromboembolism prophylaxis: Caprini score >=5 requires pharmacologic prophylaxis (low-molecular-weight heparin) unless contraindicated; mechanical prophylaxis for high bleeding risk.

Preeclampsia: BP >=140/90 mmHg after 20 weeks plus proteinuria >=300 mg/24 h or organ dysfunction; severe features include BP >=160/110, platelets <100,000, transaminases >2x normal, creatinine rise, pulmonary oedema, visual or cerebral symptoms - delivery is the definitive treatment.

Eclampsia and severe preeclampsia: magnesium sulfate loading 4-6 g IV over 15-20 min then 1-2 g/h; monitor reflexes, respiratory rate, urine output; antidote calcium gluconate 10% 10 mL IV.

Postpartum haemorrhage: >500 mL after vaginal or >1000 mL after caesarean delivery; stepwise approach - uterine massage, oxytocin, tranexamic acid 1 g IV within 3 h, then carboprost/balloon tamponade, uterine artery embolisation or laparotomy.

Gestational diabetes screening: 75 g oral glucose tolerance test at 24-28 weeks; thresholds fasting >=5.1, 1 h >=10.0, 2 h >=8.5 mmol/L - any one value confirms diagnosis.

Rhesus prophylaxis: anti-D immunoglobulin 300 micrograms at 28 weeks and within 72 h of delivery of an Rh-positive infant, plus after abortion, amniocentesis, or antepartum haemorrhage in Rh-negative unsensitised women.

Fetal heart rate interpretation: baseline 110-160/min; late decelerations indicate uteroplacental insufficiency requiring intrauterine resuscitation (left lateral position, oxygen, stop oxytocin, tocolysis); variable decelerations suggest cord compression.

Cervical cancer screening: cytology (Pap test) every 3 years from age 21-30, or HPV testing every 5 years from age 30; colposcopy for abnormal results; HPV vaccination prevents types 16 and 18.

Ectopic pregnancy: transvaginal ultrasound and serial beta-hCG; discriminatory zone ~1500-3500 IU/L; methotrexate for stable unruptured cases meeting criteria, surgery for rupture or haemodynamic instability.

Neonatal resuscitation: dry, stimulate, assess tone/breathing/heart rate; positive pressure ventilation for apnoea or heart rate <100/min; chest compressions if heart rate <60/min after effective ventilation; 3:1 compression-to-ventilation ratio.

Apgar score assessed at 1 and 5 minutes: Appearance, Pulse, Grimace, Activity, Respiration - each 0-2; score does not define asphyxia and should not guide resuscitation decisions.

Neonatal jaundice: phototherapy thresholds depend on age in hours, gestational age, and risk factors; exchange transfusion for severe hyperbilirubinaemia or signs of acute bilirubin encephalopathy; always check direct bilirubin before prolonged phototherapy.

Paediatric dehydration: WHO classification - no dehydration, some dehydration (2 or more signs: restless, sunken eyes, thirsty, skin pinch slow), severe dehydration (lethargy, sunken eyes, unable to drink, skin pinch very slow) requiring IV Ringer's lactate 100 mL/kg.

Acute respiratory infection in children: fast breathing thresholds are >=60/min under 2 months, >=50/min for 2-11 months, >=40/min for 1-5 years; pneumonia with danger signs requires hospital referral and parenteral antibiotics.

Kazakhstan national immunisation schedule includes BCG at birth, hepatitis B at birth, DTP (pertussis, diphtheria, tetanus) from 2 months, polio, MMR at 12 months and 6 years, and revaccination against diphtheria and tetanus at 6, 12, and 16 years.

Febrile seizures: simple if generalised, <15 min, once in 24 h, in a child 6 months-5 years without CNS infection; no routine long-term anticonvulsants; antipyretics do not prevent recurrence.

Growth assessment uses WHO/CDC percentile or z-score charts; weight-for-age, length/height-for-age, and weight-for-length/height - z-score below -2 indicates undernutrition or stunting and requires evaluation.

Cardiopulmonary resuscitation (adult): compressions 100-120/min at depth 5-6 cm, full recoil, minimal interruptions; ratio 30:2 without advanced airway, continuous compressions with ventilation every 6 s once advanced airway is placed; defibrillate shockable rhythms immediately.

Reversible causes of cardiac arrest (4 H and 4 T): hypoxia, hypovolaemia, hypo/hyperkalaemia and metabolic, hypothermia; thrombosis, tamponade, tension pneumothorax, toxins.

Anaphylaxis: intramuscular adrenaline 0.5 mg (1:1000) into the anterolateral thigh, repeat every 5 min; remove trigger, high-flow oxygen, IV crystalloid bolus, adjuncts (antihistamine, glucocorticoid) are secondary.

Sepsis and septic shock (Sepsis-3): suspected infection plus SOFA increase >=2 points; septic shock requires vasopressors to maintain MAP >=65 mmHg and lactate >2 mmol/L despite fluid resuscitation; start broad-spectrum antibiotics within 1 h.

Acute respiratory distress syndrome (Berlin definition): onset within 1 week, bilateral opacities, not fully explained by cardiac failure, PaO2/FiO2 <=300 mmHg with PEEP >=5 cm H2O; lung-protective ventilation with tidal volume 6 mL/kg predicted body weight.

Status epilepticus: benzodiazepine first line (diazepam 10 mg IV or midazolam 10 mg IM), then second-line (levetiracetam, valproate, phenytoin); refractory cases require anaesthetic doses and intubation.

Opioid overdose: naloxone 0.4-2 mg IV/IM titrated to respiratory rate, repeated every 2-3 min as needed; monitor for re-narcotisation because naloxone half-life is shorter than most opioids.

Trauma and haemorrhage: permissive hypotension (systolic 80-90 mmHg) until surgical control in penetrating trauma without traumatic brain injury; tranexamic acid 1 g IV within 3 h of injury followed by 1 g over 8 h.

Tuberculosis: diagnosis by sputum smear, culture (gold standard), and nucleic acid amplification (Xpert MTB/RIF); standard regimen 2 months HRZE plus 4 months HRE; adherence monitored by DOTS; drug resistance requires susceptibility-guided regimens.

HIV: screen with ELISA, confirm with Western blot or nucleic acid test; start antiretroviral therapy regardless of CD4 count; monitor viral load and CD4; post-exposure prophylaxis within 72 h for 28 days.

Viral hepatitis B and C: HBsAg indicates current infection; anti-HCV with HCV RNA confirms viraemia; direct-acting antivirals achieve cure in >95% of HCV cases; HBV vaccination is the primary prevention.

Acute intestinal infections: epidemiological history, stool culture and PCR panel; oral rehydration is the mainstay; antibiotics reserved for invasive disease, severe cases, or high-risk patients; report to sanitary-epidemiological service per Kazakh regulations.

Measles and rubella: airborne precautions, notification within 24 h, post-exposure vaccination or immunoglobulin for susceptible contacts; vaccination remains the cornerstone of elimination.

Epidemiological measures: incidence, prevalence, morbidity, mortality; relative risk and odds ratio for association; herd immunity threshold = 1 - 1/R0 (e.g. R0 12 for measles requires ~92% coverage).

Healthcare-associated infections: standard precautions, hand hygiene (WHO 5 moments), sterilisation control, surveillance of surgical site and catheter-related infections; report outbreaks to the sanitary-epidemiological service.

Tick-borne infections in Kazakhstan: tick-borne encephalitis and Lyme borreliosis; prevention by protective clothing, repellents, and vaccination against tick-borne encephalitis in endemic regions.

The healthcare system is regulated by the Code of the Republic of Kazakhstan 'On Public Health and the Healthcare System' (2009, with subsequent amendments); it defines the guaranteed volume of free medical care (GBP) and the compulsory social health insurance (OSMS) package.

OSMS (obligatory social medical insurance) is funded by employer and state contributions; citizens and legal residents are entitled to a defined package of services; the Social Health Insurance Fund administers payments to providers.

Primary health care is delivered through polyclinics and rural outpatient facilities; the gatekeeper function and referral system determine access to specialised and inpatient care.

Medical documentation: primary accounting forms and statistical reporting are mandatory; medical confidentiality is protected by law, with disclosure permitted only in cases defined by legislation (e.g. threat to public health, court order).

Informed voluntary consent is required before any medical intervention; emergency intervention without consent is permitted when the patient's condition threatens life and consent cannot be obtained, with documentation and notification of relatives or officials.

Medical errors and adverse events are subject to internal investigation and, where applicable, forensic medical examination; patients may claim compensation for harm to health through the courts.

Sanitary-epidemiological welfare is supervised by the state sanitary-epidemiological service; notifiable infectious diseases and occupational diseases must be reported within established timeframes.

Quality control of medical services is carried out through licensing, accreditation of healthcare organisations, and internal/external expert review of medical care quality.

Pharmacokinetics: bioavailability (F), volume of distribution (Vd), clearance (Cl), half-life t1/2 = 0.693 x Vd / Cl; steady state reached after approximately 4-5 half-lives; loading dose = Vd x target concentration / F.

Cytochrome P450 interactions: CYP3A4 inhibitors (clarithromycin, ketoconazole, grapefruit juice) raise levels of statins, calcium channel blockers, and immunosuppressants; inducers (rifampicin, carbamazepine, phenytoin) lower them.

Warfarin: monitor INR; target 2.0-3.0 for most indications, 2.5-3.5 for mechanical mitral valves; vitamin K is the antidote; many drug and food interactions; direct oral anticoagulants are alternatives with fewer interactions.

Aminoglycosides and vancomycin require therapeutic drug monitoring because of nephrotoxicity and ototoxicity; trough levels guide dosing; adjust for renal function.

Rational prescribing principles: correct diagnosis, evidence-based first-line agent, appropriate dose and duration, consideration of comorbidity, renal and hepatic function, pregnancy and lactation, and cost-effectiveness.

Antimicrobial stewardship: prescribe only for bacterial infection, choose narrowest effective spectrum, use local resistance data, complete the prescribed course, and avoid unnecessary prophylaxis; WHO AWaRe classification (Access, Watch, Reserve).

Adverse drug reactions: Type A (dose-dependent, predictable) and Type B (idiosyncratic, unpredictable); reporting to the pharmacovigilance system is mandatory for serious reactions.

Prescription requirements in Kazakhstan: prescriptions are written on approved forms with the international non-proprietary name, dose, regimen, and prescriber details; controlled substances require special accounting and storage.

Chest radiograph interpretation: systematic review of airway, bones, cardiac silhouette, diaphragm, effusion, fields (lungs), gastric bubble, hila; silhouette sign localises opacity to adjacent structure.

CT is first-line for suspected pulmonary embolism (CT pulmonary angiography), acute stroke (non-contrast CT to exclude haemorrhage), and renal colic (non-contrast CT); MRI is preferred for soft tissue, spinal cord, and brain pathology.

Ultrasound: first-line for abdominal pain in pregnancy, suspected gallstones, renal obstruction, and deep vein thrombosis; operator-dependent and limited by body habitus and gas.

Laboratory reference intervals: complete blood count, basic metabolic panel, liver enzymes; interpret results against age- and sex-specific reference ranges and consider pre-analytical errors (haemolysis, wrong tube, fasting status).

Cardiac biomarkers: high-sensitivity troponin is the preferred marker of myocardial injury; serial measurement with 0/1 h or 0/3 h algorithms; BNP/NT-proBNP supports heart failure diagnosis.

Microbiological diagnostics: culture before antibiotics, Gram stain for rapid orientation, PCR for rapid detection; blood cultures from two sites before antimicrobial therapy in suspected sepsis.

Radiation safety: justify every examination (ALARA principle), use the lowest dose achieving diagnostic quality; avoid unnecessary CT in children and pregnant women; shield gonads and thyroid where appropriate.

Point-of-care testing (glucose, INR, blood gas, rapid antigen tests) requires quality control and documentation; results must be interpreted in clinical context.

Four principles of biomedical ethics: autonomy, beneficence, non-maleficence, justice; these guide resolution of clinical dilemmas and are reflected in Kazakh healthcare legislation.

Informed consent requires capacity, adequate information (diagnosis, proposed intervention, risks, alternatives, consequences of refusal), voluntariness, and documentation; the patient may withdraw consent at any time.

Medical confidentiality: disclosure only with patient consent or when required by law (notifiable diseases, threat to third parties, court order); discuss cases only with involved healthcare professionals.

Breaking bad news: SPIKES protocol - Setting, Perception, Invitation, Knowledge, Emotions, Strategy and summary; use clear language, allow silence, and confirm understanding.

Communication with relatives: identify the patient's authorised representative; respect the patient's wishes about disclosure; document decisions in the medical record.

Conflict of interest and gifts: accept only items of nominal value; declare financial relationships with pharmaceutical companies; prescribing must be based on clinical indication, not incentives.

Medical error disclosure: inform the patient honestly, document the event, report through internal channels, and participate in root-cause analysis; concealment violates ethical and legal norms.

Professional boundaries: maintain respectful communication with colleagues and patients, avoid discrimination, and follow the code of medical ethics adopted by the professional association and the Ministry of Health.

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