North Macedonia Physician Licensing Exam cheat sheet

Acute coronary syndrome: serial high-sensitivity troponin at 0 and 1–3 h with ECG; ST elevation triggers immediate reperfusion, while non-ST-elevation cases are risk-stratified (GRACE) before invasive strategy.

Heart failure with reduced ejection fraction (≤40%) has mortality benefit from ARNI/ACE inhibitor, beta-blocker, mineralocorticoid antagonist and SGLT2 inhibitor - all four pillars are started early, not sequentially delayed.

Diabetic ketoacidosis: 0.9% saline resuscitation, insulin infusion 0.1 U/kg/h started after potassium is >3.3 mmol/L, and potassium replacement added once K <5.5 mmol/L with urine output.

Community-acquired pneumonia severity is scored with CURB-65 (confusion, urea >7 mmol/L, respiratory rate ≥30, low blood pressure, age ≥65); score ≥2 usually means admission.

Hyperkalemia with ECG changes: IV calcium gluconate stabilises the myocardium first, then insulin-glucose and salbutamol shift potassium intracellularly; dialysis is definitive when refractory.

Cirrhosis ascites is managed with spironolactone plus furosemide, sodium restriction and diagnostic paracentesis; ascitic neutrophil count ≥250/mm³ defines spontaneous bacterial peritonitis.

Anemia workup begins with MCV: microcytic points to iron deficiency, thalassemia or chronic disease; macrocytic to B12/folate deficiency, alcohol, hypothyroidism or myelodysplasia.

Acute pancreatitis diagnosis requires two of three: characteristic epigastric pain radiating to the back, lipase/amylase >3× upper limit, or imaging findings; early fluid resuscitation is the mainstay.

Acute appendicitis: migration of pain to the right lower quadrant with McBurney point tenderness and leukocytosis; Alvarado score ≥7 supports operative management.

Postoperative fever timing: within 48 h suggests atelectasis; days 3–5 urinary or line infection; days 5–7 anastomotic leak or surgical site infection; after day 7 deep abscess or thrombophlebitis.

Bowel obstruction: air-fluid levels and dilated loops on plain film; absence of gas distally plus peritonitis or strangulation signs mandates urgent laparotomy.

Trauma primary survey follows ABCDE (airway, breathing, circulation, disability, exposure); FAST ultrasound detects free intraperitoneal fluid in unstable patients.

Thyroidectomy risks: recurrent laryngeal nerve injury causes hoarseness, external branch of superior laryngeal nerve injury causes voice fatigue, and hypocalcemia from parathyroid devascularisation appears 24–72 h postoperatively.

Hernia strangulation signs: irreducible, tender, erythematous swelling with systemic toxicity and absent bowel sounds - requires emergency surgery, not manual reduction.

Cholecystitis: Murphy sign, right upper quadrant ultrasound showing wall thickening >3 mm and pericholecystic fluid; early laparoscopic cholecystectomy within 72 h is preferred.

Neonatal jaundice appearing within 24 h is always pathologic; unconjugated hyperbilirubinemia is treated with phototherapy, and exchange transfusion is used for levels near the exchange threshold or signs of acute bilirubin encephalopathy.

Pediatric dehydration is graded by WHO: some dehydration (two or more signs) uses oral rehydration solution 75 mL/kg over 4 h; severe dehydration needs IV Ringer lactate 100 mL/kg.

Growth assessment uses WHO/CDC percentile charts; crossing two major percentile lines downward over time warrants investigation for failure to thrive.

Kawasaki disease: fever ≥5 days plus 4 of 5 criteria (conjunctivitis, mucosal changes, rash, extremity changes, cervical lymphadenopathy); IVIG plus aspirin prevents coronary aneurysm.

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

Bronchiolitis in infants under 2 years is managed supportively with oxygen and hydration; routine bronchodilators, corticosteroids and antibiotics are not recommended.

Intussusception: intermittent colicky pain, vomiting, and red currant jelly stool; ultrasound shows a target sign, and air or contrast enema is both diagnostic and therapeutic.

Preeclampsia is defined as blood pressure ≥140/90 after 20 weeks with proteinuria or end-organ dysfunction; magnesium sulfate prevents and treats eclampsia, and delivery is the definitive treatment.

Postpartum hemorrhage is most often caused by uterine atony; management sequence is uterine massage, oxytocin, then ergometrine, carboprost or misoprostol, and tranexamic acid within 3 h.

Antepartum fetal surveillance: non-stress test is reactive with two accelerations in 20 min; a biophysical profile score ≤4 warrants delivery assessment.

Gestational diabetes screening is done at 24–28 weeks with an oral glucose tolerance test; targets are fasting <5.1 mmol/L and 1-h postprandial <7.8 mmol/L.

Ectopic pregnancy: a positive pregnancy test with no intrauterine sac and an adnexal mass plus free fluid on ultrasound; hemodynamically unstable patients need surgery, stable ones may receive methotrexate.

Cervical cancer screening starts at age 21–25 with cytology every 3 years or HPV testing every 5 years; high-risk HPV 16 and 18 drive most cases.

Ovarian torsion presents with sudden unilateral pelvic pain, nausea and vomiting; Doppler may be normal, so clinical suspicion guides laparoscopy.

Incidence measures new cases per population at risk per time; prevalence measures all existing cases and equals incidence × average duration for stable diseases.

Sensitivity = TP/(TP+FN); specificity = TN/(TN+FP); positive predictive value depends on prevalence, so screening in low-prevalence populations yields many false positives.

Relative risk is used in cohort studies (a/(a+b) ÷ c/(c+d)); odds ratio approximates it in case-control studies and is interpreted as an estimate of association.

Attributable risk (risk difference) = incidence in exposed − incidence in unexposed; it estimates the excess disease burden caused by exposure.

Herd immunity threshold = 1 − 1/R0; measles with R0 around 12–18 requires roughly 92–95% two-dose coverage.

Randomised controlled trials minimise confounding through randomisation, while blinding reduces observer and reporting bias; intention-to-treat analysis preserves randomisation benefits.

North Macedonia's Law on Health Protection governs patient rights, informed consent, confidentiality and the right to a second opinion; the Health Insurance Fund finances compulsory coverage.

Pharmacokinetics: volume of distribution = dose/plasma concentration; clearance = rate of elimination/plasma concentration; half-life = 0.693 × Vd/clearance.

Zero-order kinetics means a constant amount is eliminated per unit time regardless of concentration (ethanol, phenytoin at high doses, aspirin at high doses), so small dose increases can cause toxicity.

CYP450 interactions: CYP3A4 inhibitors (macrolides, azoles, grapefruit) raise levels of statins, calcium channel blockers and tacrolimus; inducers (rifampicin, carbamazepine) lower them.

Aminoglycosides and vancomycin are nephrotoxic and ototoxic; therapeutic drug monitoring of trough levels prevents accumulation in renal impairment.

Warfarin inhibits vitamin K epoxide reductase; effect is monitored by INR, reversed by vitamin K and prothrombin complex concentrate in major bleeding.

ACE inhibitors cause dry cough via bradykinin accumulation and are contraindicated in pregnancy and bilateral renal artery stenosis; ARBs avoid the cough.

Beta-lactam allergy is often over-reported; direct oral provocation or skin testing is preferred before switching to broader-spectrum alternatives to limit resistance.

Cell injury becomes irreversible when mitochondrial ATP falls below a critical threshold, membrane integrity is lost, and calcium influx activates proteases and phospholipases.

Acute inflammation: vasodilation, increased vascular permeability, and neutrophil emigration via margination, rolling, adhesion and transmigration; chronic inflammation features macrophages and lymphocytes.

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

Apoptosis is energy-dependent and caspase-mediated with cell shrinkage and no inflammation, in contrast to necrosis.

Neoplasia: tumour suppressor genes (TP53, RB, APC) lose function with both alleles affected, while oncogenes (RAS, MYC, HER2) gain function with a single mutation.

Amyloid is a misfolded beta-pleated protein deposit staining apple-green birefringence with Congo red under polarised light.

Shock pathophysiology: hypovolemic and cardiogenic shock show low cardiac output with high systemic vascular resistance; septic and anaphylactic shock show low resistance with warm skin initially.

Informed consent requires capacity, adequate disclosure of risks and alternatives, comprehension, and voluntariness; documented refusal by a capacitated patient must be respected.

Four principles: autonomy, beneficence, non-maleficence, justice; when they conflict, autonomy generally prevails for capacitated adults.

Confidentiality may be breached only when legally required (reportable infectious disease, suspected child abuse) or when there is a specific serious threat to an identifiable person.

Decisions for incapacitated patients follow advance directives, then a legally authorised surrogate, then best-interest assessment; emergency treatment may proceed without consent when life-threatening.

Physicians must not treat family members for serious conditions or enter dual relationships that impair objectivity; conflicts of interest must be disclosed.

Medical error disclosure: patients should be told about harmful errors, and honest disclosure is an ethical duty distinct from legal liability.

Euthanasia and physician-assisted death are not legal in North Macedonia; withdrawing futile treatment and providing palliative sedation are ethically distinct and permitted.

Adult cardiac arrest: high-quality chest compressions at 100–120/min with 5–6 cm depth, minimally interrupted, and early defibrillation for shockable rhythms (VF/pulseless VT).

Anaphylaxis: intramuscular adrenaline 0.5 mg (1:1000) into the anterolateral thigh, repeated after 5 min if needed; antihistamines and steroids are adjuncts only.

Sepsis bundle: measure lactate, draw blood cultures, give broad-spectrum antibiotics within 1 h, and start 30 mL/kg crystalloid for hypotension or lactate ≥4 mmol/L.

Status epilepticus: benzodiazepine first (midazolam, lorazepam), then a second-line anticonvulsant (levetiracetam, valproate, phenytoin); refractory cases need anaesthesia with intubation.

Acute asthma severity: inability to speak, silent chest, SpO2 <92% and peak flow <33% predicted indicate life-threatening attack; give oxygen, nebulised salbutamol and ipratropium plus systemic steroids.

Opioid overdose: titrate naloxone to restore breathing, not full consciousness; re-sedation is common because naloxone half-life is shorter than most opioids.

Acute upper airway obstruction: stridor, drooling and tripod position suggest epiglottitis; do not inspect the throat forcibly - prepare for controlled intubation in theatre.

Primary care uses a biopsychosocial model: screen for red flags while exploring the patient's ideas, concerns and expectations within a time-limited consultation.

Hypertension in primary care: confirm with repeated office readings or ambulatory monitoring; start treatment with a thiazide, ACE inhibitor/ARB or calcium channel blocker, often combined.

Antibiotic stewardship: uncomplicated acute bronchitis, viral upper respiratory infection and most acute otitis media do not require antibiotics; use a delayed prescription strategy when appropriate.

Cardiovascular risk is estimated with validated charts (SCORE) using age, sex, smoking, blood pressure and lipids; statin therapy is offered above the risk threshold.

Depression screening uses PHQ-9 or two-question screening; brief psychological therapy and SSRIs are first-line for moderate depression, with follow-up at 2–4 weeks.

Immunisation schedules are delivered in primary care; missed doses are caught up rather than restarted, and contraindications must be verified before each dose.

Referral criteria: unexplained weight loss, new focal neurological deficit, suspected malignancy red flags and suicidal ideation require urgent onward referral, not watchful waiting.

Acute ischaemic stroke within 4.5 h of onset may receive IV thrombolysis after excluding haemorrhage on CT; large-vessel occlusion may need mechanical thrombectomy within 24 h in selected patients.

Stroke localisation: middle cerebral artery - contralateral face/arm weakness and aphasia; posterior circulation - vertigo, diplopia, ataxia and crossed sensory findings.

Headache red flags (SNOOP): sudden onset, new after age 50, fever or neck stiffness, focal deficit, papilledema, pregnancy, or a change in established headache pattern.

Multiple sclerosis: dissemination in time and space; MRI shows periventricular, juxtacortical and infratentorial demyelinating lesions, and oligoclonal bands appear in CSF.

Parkinson disease is diagnosed clinically by bradykinesia plus rest tremor or rigidity; levodopa remains the most effective symptomatic treatment.

Psychosis: first-episode assessment excludes substance use, delirium and organic causes; antipsychotics are started at low dose with metabolic monitoring.

Serotonin syndrome versus neuroleptic malignant syndrome: serotonin syndrome has hyperreflexia, clonus and mydriasis; NMS has lead-pipe rigidity, bradyreflexia and raised creatine kinase.