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Минздрав России Приказ 202н первичная медико-санитарная помощь текст Приказ 404н диспансеризация 1089н листок нетрудоспособности

outpatient chronic disease management

Research current Russian Federation official regulatory anchors relevant to an English study guide for a Polyclinic Therapy exam. Specifically Order of Ministry of Health No. 202n, 404n, 1089n, current procedures for dispensarization, sick leave, MSE/disability referral. Use authoritative official sources/web searches. Return concise factual corrections: order full title/date/current validity or replacements, core provisions, and caveats. Do not draft whole guide.

Create an accurate concise outline for all clinical/emergency items in the attached Russian Polyclinic Therapy 2024-2025 question list, in English. Cover outpatient diagnosis/treatment/followup/hospital referral and disease-specific temporary/permanent incapacity principles. Include safe Russian practice framing but avoid invented exact sick-leave durations. Need a structured content blueprint not citations. Return compactly organized by disease categories.

Which regulatory block should I verify in detail first?

mkdir -p "/tmp/workspace/polyclinic-therapy-guide/src" "/tmp/workspace/polyclinic-therapy-guide/output" && python3 - <<'PY' from docx import Document from docx.shared import Pt, Cm, RGBColor from docx.enum.text import WD_ALIGN_PARAGRAPH from docx.enum.section import WD_SECTION from docx.oxml import OxmlElement from docx.oxml.ns import qn from docx.enum.style import WD_STYLE_TYPE from docx.enum.table import WD_TABLE_ALIGNMENT from docx.enum.text import WD_BREAK from pathlib import Path out=Path('/tmp/workspace/polyclinic-therapy-guide/output/Polyclinic_Therapy_Russian_Medicine_Exam_Guide_2024_2025_English.docx') doc=Document() sec=doc.sections[0] sec.top_margin=Cm(1.7); sec.bottom_margin=Cm(1.7); sec.left_margin=Cm(2); sec.right_margin=Cm(2) styles=doc.styles styles['Normal'].font.name='Arial'; styles['Normal']._element.rPr.rFonts.set(qn('w:eastAsia'),'Arial'); styles['Normal'].font.size=Pt(9.5) for name,size,color in [('Title',21,'1F4E79'),('Heading 1',15,'1F4E79'),('Heading 2',12,'2F75B5'),('Heading 3',10.5,'2F75B5')]: s=styles[name]; s.font.name='Arial';s.font.size=Pt(size);s.font.bold=True;s.font.color.rgb=RGBColor.from_string(color) # footer footer=sec.footer.paragraphs[0]; footer.alignment=WD_ALIGN_PARAGRAPH.CENTER r=footer.add_run('Polyclinic Therapy Examination Guide | English | Russian Federation practice');r.font.size=Pt(8) def shade(cell, fill): tcPr=cell._tc.get_or_add_tcPr(); shd=OxmlElement('w:shd');shd.set(qn('w:fill'),fill);tcPr.append(shd) def bullets(items, level=0): for x in items: p=doc.add_paragraph(style='List Bullet' if level==0 else 'List Bullet 2');p.paragraph_format.space_after=Pt(1);p.add_run(x) def q(n,title,paras=None,bs=None): doc.add_heading(f'{n}. {title}',2) if paras: for x in paras: p=doc.add_paragraph(x);p.paragraph_format.space_after=Pt(3) if bs: bullets(bs) def page(): doc.add_page_break() # title p=doc.add_paragraph();p.alignment=WD_ALIGN_PARAGRAPH.CENTER r=p.add_run('POLYCLINIC THERAPY');r.bold=True;r.font.size=Pt(25);r.font.color.rgb=RGBColor(31,78,121) p=doc.add_paragraph();p.alignment=WD_ALIGN_PARAGRAPH.CENTER r=p.add_run('Examination Answers in English\nRussian Federation outpatient-care framework');r.font.size=Pt(14);r.bold=True p=doc.add_paragraph();p.alignment=WD_ALIGN_PARAGRAPH.CENTER;p.add_run('Based on the 2024-2025 question list supplied by the student\nUpdated legal note: October 2026').italic=True doc.add_heading('How to use this guide',1) doc.add_paragraph('This is an exam-oriented study guide. It uses the Russian terms polyclinic, district physician (uchastkovy therapist), dispensary observation, medical commission (VC), medical-social examination (MSE), and electronic certificate of incapacity for work (ELN). For a real patient, local institutional orders, current Russian clinical guidelines, and emergency-service protocols control.') doc.add_paragraph('The document answers all items. Repeated questions on incapacity are answered through a common assessment framework plus diagnosis-specific criteria. Drug doses are educational examples for trained clinicians, not self-treatment instructions.') doc.add_heading('Regulatory orientation',1) bullets([ 'Federal Law No. 323-FZ: fundamental principles of health protection and organization of medical care.', 'Ministry of Health Order No. 202n of 14 April 2025: organization of primary health care for adults. The course question may refer to the order applicable in 2024-2025; cite the version required by your department at the examination.', 'Ministry of Health Order No. 404n of 27 April 2021, as amended: procedure for preventive medical examination and dispensarization of specified adult groups.', 'Ministry of Health Order No. 1089n of 23 November 2021, as amended: conditions and procedure for formation of ELN and issuance of paper certificates in the exceptional statutory cases. It is in force through 1 March 2029.', 'Disability/MSE is governed by federal disability law, Government rules for recognizing a person as disabled, and current Ministry of Labour classification and criteria. MSE is a bureau, not the historical “MSEK” commission.' ]) doc.add_heading('Standard outpatient clinical algorithm',1) bullets(['Confirm urgency first: ABCDE, vital signs, oxygen saturation, glucose where relevant, ECG for cardiopulmonary symptoms.', 'Define syndrome and severity; identify red flags; obtain focused history, medicines, allergies, occupation and social risks.', 'Perform targeted examination and baseline laboratory/instrumental testing; make a working diagnosis and differential diagnosis.', 'Treat according to current clinical guidelines, educate the patient, document informed decisions, arrange follow-up and referral.', 'Assess temporary work incapacity individually: diagnosis alone is insufficient. Consider function, severity, complications, job hazards, response to therapy and prognosis.']) page();doc.add_heading('I. ORGANIZATION OF PRIMARY CARE, PREVENTION AND REHABILITATION',1) q(1,'Primary health care. Ministry of Health Order No. 202n.',bs=['Primary health care is the accessible first level of care. It includes prevention, diagnosis, treatment, medical rehabilitation, health education, palliative care and organization of referral.', 'It is delivered mainly on an outpatient basis and in day hospitals by territorial, general-practice/family, and specialized teams. Accessibility is territorial, appointment-based and, where needed, home-based.', 'Core principles: attachment of citizens to a medical organization/physician, continuity, prevention priority, routing, multidisciplinary work, quality and safety, and electronic documentation.', 'The physician must identify emergencies, stabilize the patient, call emergency medical services when indicated, and ensure transfer documentation.']) q(2,'Polyclinic: main tasks and structural organization.',bs=['Tasks: preventive examinations and dispensarization; diagnosis and ambulatory treatment; follow-up of chronic disease; vaccination and health education; rehabilitation; temporary-incapacity examination; referral and home care.', 'Typical structure: registry/call centre; district-physician departments; diagnostic units and laboratory; procedure rooms; specialists; prevention department/cabinet; emergency room; rehabilitation; day hospital; administrative and quality units.', 'Work is organized by patient flow: healthy/preventive, acute infectious, chronic, urgent, and home-visit streams. Infection-control separation is essential.']) q(3,'District physician (uchastkovy therapist): functional duties.',bs=['Provides first-contact adult internal-medicine care to the assigned population, including home visits when indicated.', 'Conducts examination, diagnosis, treatment, prevention, dispensary observation, counseling on risk factors, immunoprophylaxis and adherence.', 'Coordinates specialist consultations, investigations, hospitalization, rehabilitation, palliative services and social support.', 'Performs examination of temporary incapacity within authority, prepares records for the VC and MSE referral, and maintains medical confidentiality and documentation.']) q(4,'Documentation of the district physician. Passport of the district.',bs=['Medical documentation includes the outpatient record/electronic health record, visit notes, diagnoses and ICD coding, prescriptions, referrals, investigation results, consent/refusal, preventive and dispensary registers, ELN information and VC/MSE documents.', 'A district passport is an operational population profile: boundaries, attached population by age/sex, major chronic diseases and risk groups, disabled and homebound patients, mortality, vaccination/prevention indicators, staffing and social/environmental features.', 'Records must be timely, legible, factual, dated, signed electronically where applicable, and protect personal data.']) q(5,'Tasks and functions of the district physician.',bs=['Clinical function: diagnosis, treatment, emergency triage, referral and continuity after discharge.', 'Preventive function: risk assessment, dispensarization, screening, vaccination advocacy, counseling and patient schools.', 'Expert function: temporary incapacity assessment, VC participation, preparation of medical evidence for MSE.', 'Organizational function: analysis of district morbidity, quality/safety, infection control, rational medication use and coordination with nurses/social services.']) q(6,'Medical district, types. Rural medical care.',bs=['Districts may be territorial-therapeutic, general-practice/family, complex or specialized. The attached population and geography determine staffing and routing.', 'Rural care is staged: feldsher-midwife station or health post, rural outpatient clinic/physician practice, district or central district hospital, then intermunicipal/regional center.', 'Features: travel and communication barriers, lower specialist availability, greater home/visiting work, telemedicine where available, transport and evacuation planning, and active follow-up of vulnerable patients.']) q(7,'Polyclinic day hospital.',bs=['A day hospital provides planned treatment, diagnostics, rehabilitation and observation when 24-hour admission is unnecessary but ordinary outpatient care is insufficient.', 'Indications: stable conditions requiring infusions, parenteral therapy, monitored procedures, diagnostic observation, rehabilitation or therapy titration. Exclude unstable vital signs, acute surgical disease, active major bleeding, severe intoxication or need for continuous monitoring.', 'Workflow: referral/assessment, treatment plan and consent, daily assessment and documentation, emergency escalation plan, discharge summary and follow-up.']) q(8,'Principles of emergency care at the polyclinic stage.',bs=['Recognize time-critical conditions; use ABCDE; call emergency medical service early and do not delay transfer for nonessential tests.', 'Provide immediate monitoring, positioning, oxygen only for hypoxemia/respiratory distress, IV access and targeted first-line therapy within competence; reassess continuously.', 'Document onset, findings, ECG where relevant, drugs with route/time/dose, allergies and response; hand over using a structured method. Accompany if clinically necessary.', 'Avoid potentially harmful actions: do not give oral drugs/fluids in impaired consciousness or acute abdomen; do not attempt outpatient management of shock, severe hypoxemia, stroke signs or ongoing ACS.']) q(9,'Dispensarization: principles and legal basis.',bs=['Dispensarization is a periodic preventive examination aimed at early detection of chronic noncommunicable disease, cancer risk, major risk factors and conditions requiring follow-up.', 'Principles: population coverage, risk stratification, staged screening, informed voluntary participation, confidentiality, continuity, documented route to diagnosis/treatment, and quality monitoring.', 'Order No. 404n defines the adult procedure. Stage 1 is screening and risk assessment; Stage 2 contains indicated additional examination/consultation to clarify disease and determine follow-up.']) q(10,'Health groups. Order No. 404n.',bs=['Group I: no established chronic noncommunicable disease and no significant risk factors requiring dispensary observation.', 'Group II: no established chronic noncommunicable disease but modifiable risk factors or high/very high cardiovascular risk requiring preventive counseling and correction.', 'Group IIIa: chronic noncommunicable disease or need for dispensary observation/specialized care. Group IIIb: other diseases requiring dispensary observation.', 'The group determines prevention intensity and follow-up, not a label of disability or work incapacity.']) q(11,'Procedure for dispensarization of specified adult groups. Order No. 404n.',bs=['Stage 1: questionnaire, anthropometry, blood pressure, risk-factor assessment, age/sex-specific screening, basic tests and preventive counseling.', 'Stage 2: only when indicated by Stage 1 or symptoms. It may include specialist consultations, endoscopy, imaging, functional tests and additional laboratory testing.', 'The outcome is a health group, diagnosis or risk factor, brief preventive counseling, referral, and entry into dispensary observation where indicated.']) q(12,'Principles of dispensary work in a therapeutic district.',bs=['Create and regularly update disease and risk registers; identify patients from visits, discharge summaries, screening and diagnostic results.', 'Make an individual follow-up plan: target indicators, visits, tests, medication review, self-management education, rehabilitation and referral triggers.', 'Use active recall, home visits for patients with limited mobility, nurse participation, adherence review, and audit of complications, hospitalizations and mortality.']) q(13,'Healthy lifestyle. Health centres.',bs=['Healthy lifestyle measures: no tobacco/nicotine, healthy diet with salt/sugar reduction, regular physical activity, healthy weight, adequate sleep, moderation/avoidance of alcohol, vaccination, injury prevention and stress management.', 'Health centres provide risk-factor assessment, preventive counseling, motivation and individual/group programs. They do not replace diagnosis and treatment by the district physician.', 'Counseling should be brief, specific, measurable and repeated. Use motivational interviewing and referral for tobacco/alcohol dependence or mental-health care when needed.']) q(14,'Patient education programmes: asthma, pulmonary, cardiac and gastro schools. Example topics.',bs=['Asthma school: disease and triggers; inhaler technique; controller versus reliever treatment; written action plan; peak-flow/symptom monitoring; exacerbation red flags.', 'Pulmonary school: COPD physiology, smoking cessation, inhaler technique, vaccination, breathing/physical training, sputum/exacerbation action plan.', 'Cardiac school: BP self-monitoring, ischemic symptom action plan, medication adherence, salt and lipid control, activity/cardiac rehabilitation, anticoagulation safety where applicable.', 'Gastro school: diet pattern and symptom diary, alarm symptoms, medication safety including NSAID avoidance, H. pylori pathway where relevant, alcohol and weight management.']) q(15,'Follow-up after acute tonsillitis, pneumonia and glomerulonephritis.',bs=['Tonsillitis: assess clinical resolution, complications such as peritonsillar abscess or rheumatic features, and recurrent disease. Persistent fever, unilateral severe pain, airway symptoms or systemic toxicity need urgent ENT/hospital review.', 'Pneumonia: reassess symptoms, vital signs and SpO2; ensure clinical recovery and risk-factor control. Review imaging selectively, especially persistent symptoms or high cancer risk. Persistent hypoxemia, instability or nonresponse requires urgent reassessment.', 'Acute glomerulonephritis: monitor BP, edema, urine sediment/proteinuria, creatinine/eGFR and electrolytes. Oliguria, pulmonary edema, severe hypertension, rising creatinine or hyperkalemia warrant urgent admission/nephrology.']) q(16,'Sanatoria in Russia and the Republic of Bashkortostan: indications, contraindications and therapeutic factors.',bs=['Sanatorium-resort treatment is a rehabilitation/prevention component after clinical stabilization. Common therapeutic factors include climate, balneotherapy/mineral waters, therapeutic mud, diet, graded exercise, physiotherapy and health education.', 'Indications: stable chronic cardiopulmonary, digestive, renal/metabolic or musculoskeletal disease when a defined rehabilitation goal exists and travel is safe. The destination is chosen by profile and local referral rules; Bashkortostan has balneological, climatic and mud-resort facilities.', 'General contraindications: acute illness/infection, exacerbation or decompensation, unstable angina/recent uncontrolled cardiac event, severe arrhythmia, active bleeding, advanced organ failure, active tuberculosis unless specialized, malignancy where contraindicated, and inability to travel safely.']) q(17,'Sick-leave certificate for diseases and injuries. Order No. 1089n.',bs=['An ELN documents temporary incapacity after an authorized medical examination. Paper certificates are exceptional and limited by law.', 'It may be issued for disease, injury, poisoning and other temporary-loss states, sanatorium treatment in statutory situations, care of a sick family member, quarantine, inpatient prosthetics, pregnancy/childbirth and adoption.', 'The treating clinician assesses incapacity, documents the basis and reviews the patient. Extension beyond the clinician’s authority requires the VC. Dates are based on clinical and occupational assessment, not a fixed diagnosis table.']) q(18,'Sick-leave certificate: functions and general rules.',bs=['Functions: medical evidence of temporary incapacity, legal basis for release from work, basis for insurance benefit administration, and a tool for continuity and control.', 'General rules: only authorized organizations/clinicians; examination and medical record precede issuance; electronic format is standard; data must be accurate and confidential.', 'Closure requires recovery or a safe return-to-work state, another lawful reason, or referral for further expert assessment.']) q(19,'Classification of incapacity. Clinical and occupational prognosis.',bs=['Temporary incapacity: a reversible impairment prevents safe performance of usual work for a limited time. It can be full or partial, depending on job and function.', 'Persistent incapacity/disability: durable impairments causing activity limitation and need for social protection, evaluated by MSE rather than diagnosis alone.', 'Clinical prognosis concerns expected recovery/health outcome. Occupational prognosis concerns ability to return to the former job, need for restrictions, retraining or permanent loss of work capacity.']) q(20,'Examination of temporary incapacity: criteria.',bs=['Assess disease severity, function, contagiousness, treatment burden, complication risk, response to treatment and work conditions such as driving, height, heat, heavy labor or public-contact work.', 'Temporary incapacity is justified when working would endanger the patient or others, impair treatment/recovery, or cannot be performed safely.', 'The decision must be individualized, supported by examination findings and a plan for review. The VC resolves prolonged, complex or disputed cases.']) q(21,'Medical commission (VC): composition and tasks.',bs=['The VC is a collegial body of the medical organization, established by the head. Composition follows local regulation and generally includes a chairperson, treating physician(s), relevant specialists and secretarial support.', 'Tasks include complex diagnostic/treatment decisions, quality/safety questions, extension and control of temporary-incapacity examination, referral preparation for MSE, assessment of rehabilitation/medical indications and review of disputes.', 'Its decision is recorded in the medical record and VC minutes/decision documentation.']) q(22,'Persistent incapacity: criteria.',bs=['A person may be referred for MSE when persistent disorders of body functions due to disease, injury or defect cause sustained activity limitations and require social-protection measures despite completed/ongoing rehabilitation potential.', 'Evidence includes objective clinical data, investigations, treatment and rehabilitation history, functional limitations, work conditions and prognosis.', 'Do not equate chronic disease, long absence, or a low eGFR alone with disability: severity and functional impact must be documented.']) q(23,'Persistent incapacity: categories of life activity.',bs=['MSE assesses limitation in self-care, independent movement, orientation, communication, behavior control, learning, work and, for children, age-appropriate development.', 'Each category is evaluated by degree of limitation using current federal criteria. This functional profile supports, but does not predetermine, disability group and rehabilitation needs.']) q(24,'Persistent incapacity: disability groups.',bs=['Group I: most severe persistent functional limitations with marked dependence on assistance/supervision.', 'Group II: severe limitations with reduced ability for self-care, mobility or work; assistance may be needed but not necessarily constant.', 'Group III: moderate persistent limitation, often including reduced work ability or need for adapted work conditions. A separate category applies to disabled children.', 'The bureau determines group, cause, duration, individual rehabilitation/habilitation programme and reassessment requirements under current rules.']) q(25,'MSE/MSEK: composition, tasks and documentation.',bs=['Use current term: bureau of medical-social examination (MSE). Its multidisciplinary assessment may involve physicians, rehabilitation and social-work expertise according to bureau structure.', 'Tasks: determine disability, functional limitations, rehabilitation/habilitation needs, vocational recommendations and social-protection measures; conduct reassessments and resolve expert questions.', 'Documentation includes the referral from the medical organization, clinical/examination records, investigation results, functional and occupational data, rehabilitation information, patient consent/notification and bureau decision.']) q(26,'Procedure for referral to MSE.',bs=['The medical organization completes diagnostic, treatment and rehabilitation measures to the extent clinically possible and confirms persistent impairment and limitation.', 'The treating physician prepares evidence; the VC considers referral where required by procedure; the organization sends the referral electronically or by the applicable route and informs the patient.', 'A refusal or inability of the medical organization to refer must be documented and the patient informed of lawful procedures for independent appeal/application.']) q(27,'MSE bureau composition and referral documentation.',bs=['The bureau structure includes expert personnel appropriate to the case and administrative support; it may examine records, the person in person, at home or in hospital where justified.', 'The referral must state diagnosis, course, complications, treatment response, objective findings, functional impairment, rehabilitation, occupation and working conditions, and the purpose of referral.', 'Avoid unsupported phrases such as “disabled”; describe measurable limitations and residual function.']) q(28,'Rehabilitation in the polyclinic: stages, goals and tasks.',bs=['Stages: acute inpatient stabilization; early post-acute/inpatient rehabilitation; outpatient/polyclinical rehabilitation; sanatorium/resort rehabilitation when indicated; long-term community/vocational support.', 'Goals: restore or compensate function, prevent complications/relapse, return to independent life and safe work, improve quality of life and adherence.', 'Tasks: functional assessment, individualized programme, exercise/physical therapy, medication optimization, education, psychological/social support, assistive devices, monitoring and specialist referral.']) q(29,'Sanatorium-resort stage of rehabilitation in internal diseases.',bs=['Only after stabilization and risk assessment. It builds exercise tolerance, self-management and lifestyle change through climate/balneological/physical factors, diet, graded training and education.', 'The referral must specify diagnosis, current status, contraindications, medications, allowable exertion, target outcomes and monitoring requirements.']) q(30,'Prolonged low-grade fever in outpatient practice.',bs=['Confirm true persistent fever with a reliable temperature record and review drugs, factitious causes and normal variation. Take history for infections, TB contacts, travel, exposures, dental/ENT sources, autoimmune symptoms, malignancy and weight loss.', 'Examine fully. Initial testing is guided by symptoms but commonly includes CBC, ESR/CRP, urinalysis, renal/liver tests, chest imaging and targeted microbiology; further imaging/serology is not “shotgun” testing.', 'Red flags: weight loss, night sweats, lymphadenopathy, organomegaly, new murmur, immunosuppression, severe headache/neurologic signs, or progressive illness. Refer/admit according to severity.']) q(31,'Somatic disease in older and senile patients.',bs=['Presentation is often atypical: infection may cause delirium/falls, MI may be painless, and dehydration/heart failure can evolve quickly. Multimorbidity, frailty, cognitive/sensory impairment and social isolation alter care.', 'Use comprehensive geriatric assessment: function, cognition, mood, falls, nutrition, continence, social support and medication review.', 'Start low and go slow where appropriate, but do not undertreat. Avoid polypharmacy, renal-dose errors, anticholinergic burden and unsafe hypotension; simplify regimen and ensure caregiver education.']) q(32,'Somatic disease during pregnancy.',bs=['Pregnancy changes physiology and drug risk. Confirm gestational age, obstetric history, maternal severity and fetal status; coordinate early with obstetric care.', 'Prefer non-drug measures and medicines with established pregnancy safety. Avoid teratogens and drugs contraindicated by trimester; do not stop essential chronic therapy without specialist advice.', 'Urgent referral/admission for severe hypertension/pre-eclampsia symptoms, dyspnea/hypoxemia, thromboembolism suspicion, significant bleeding, sepsis, severe abdominal pain or reduced fetal movement.']) page();doc.add_heading('II. OUTPATIENT INTERNAL MEDICINE',1) # disease entries function def disease(n,title,dx,manage,refer,follow): q(n,title,bs=[f'Diagnosis/assessment: {dx}',f'Outpatient management: {manage}',f'Urgent referral/hospitalization: {refer}',f'Follow-up/prevention: {follow}']) disease(33,'Acute respiratory viral infections (ARVI).','Acute upper-airway symptoms, fever and exposure history; assess RR, SpO2, lung findings and risk factors. Exclude pneumonia, influenza/COVID-19 when clinically relevant, bacterial focal infection and sepsis.','Rest, fluids, antipyretic such as paracetamol if needed, saline nasal care and symptom relief. Antibiotics do not treat uncomplicated viral ARVI. Infection-control advice and work isolation follow current rules.','Dyspnea, SpO2 reduction, confusion, persistent high fever/toxicity, dehydration, chest pain, high-risk comorbidity or suspected pneumonia.','Review if worsening or no expected improvement; vaccination, hand hygiene, ventilation, smoking cessation and control of chronic disease.') disease(34,'Influenza.','Sudden fever, myalgia, headache and respiratory syndrome during circulation; assess pneumonia and high-risk pregnancy, elderly, chronic disease or immunosuppression. Confirm testing when it changes management/public health action.','Early antiviral treatment is considered per current Russian guidance, especially in high-risk or severe cases. Supportive care; no routine antibiotics.','Respiratory failure, altered consciousness, hemodynamic instability, bacterial pneumonia, severe dehydration, pregnancy with significant illness.','Annual vaccination is principal prevention. Reassess complications and return to activity only after clinical recovery.') disease(35,'Community-acquired pneumonia.','Cough, fever, dyspnea, pleuritic pain and focal signs; measure SpO2, RR, BP, mental status. Chest radiography confirms in most cases; CBC/CRP and microbiology are selective. Use a validated severity assessment with clinical judgment.','Outpatient therapy only if stable, able to take oral medication, adherent and with safe follow-up. Empirical antibiotic choice follows current Russian CAP guidance, local resistance, allergy and comorbidity. Support fluids/antipyretic and smoking cessation.','Hypoxemia, RR elevation, hypotension, confusion, sepsis, multilobar disease, inability to take oral therapy, decompensated comorbidity or poor social support.','Clinical review within 48-72 h or sooner; investigate nonresponse. Follow-up imaging is selective for persistent symptoms/high malignancy risk.') disease(36,'Chronic obstructive pulmonary disease (COPD).','Confirm persistent airflow obstruction by post-bronchodilator spirometry. Assess symptoms, exacerbations, smoking/biomass exposure, SpO2 and comorbidities.','Smoking cessation, vaccination, inhaler technique and pulmonary rehabilitation are core. Inhaled bronchodilator treatment is individualized by symptoms/exacerbations; add inhaled corticosteroid only when indicated by guideline phenotype/risk.','Severe exacerbation, marked dyspnea, cyanosis, confusion, SpO2 low, acute hypercapnia suspicion, new arrhythmia/chest pain or inadequate home support.','Regular symptom/exacerbation review, spirometry, inhaler adherence and action plan. Assess need for long-term oxygen only after stable formal evaluation.') disease(37,'Bronchial asthma.','Variable respiratory symptoms plus objective variable expiratory airflow limitation. Assess control, exacerbation history, inhaler technique, adherence, allergens, NSAID/beta-blocker triggers and differential diagnoses.','All adults need inhaled corticosteroid-containing therapy. Step treatment up/down after checking technique/adherence and risk. Give written action plan and teach reliever use.','Severe attack, inability to speak full sentences, silent chest, exhaustion, altered consciousness, hypoxemia, poor response to initial bronchodilator, or prior near-fatal asthma.','Assess control at planned visits; review technique, triggers, peak-flow/action plan, vaccination and comorbid rhinitis/obesity.') disease(38,'Pyelonephritis.','Fever/flank pain with urinary symptoms and pyuria/bacteriuria. Obtain urinalysis and urine culture before antibiotics if feasible; assess pregnancy, obstruction, sepsis and renal function.','Uncomplicated stable cases may receive guideline-concordant oral antibiotics adjusted to culture and renal function, fluids and analgesia. Men, pregnancy, obstruction or systemic illness need lower threshold for specialist/hospital care.','Sepsis, vomiting/inability to hydrate, obstruction/stone with infection, pregnancy, acute kidney injury, immunosuppression or no response.','Confirm symptom resolution; address stones, reflux, diabetes, urinary obstruction and recurrence. Do not treat asymptomatic bacteriuria except in indicated groups such as pregnancy.') disease(39,'Glomerulonephritis.','Suspect with hematuria, proteinuria, edema, hypertension and reduced eGFR. Urinalysis with microscopy, quantitative protein, creatinine/electrolytes, albumin, complements/serology and renal ultrasound are guided by syndrome.','Control BP and volume, avoid nephrotoxins, adjust doses and urgently involve nephrology. Immunosuppression depends on biopsy-defined/subtype diagnosis, not empirical outpatient use.','Rapidly rising creatinine, oliguria/anuria, hyperkalemia, pulmonary edema, hypertensive emergency, nephritic/nephrotic severe syndrome or systemic vasculitis features.','Monitor BP, eGFR, potassium, urinalysis/proteinuria and cardiovascular/renal risk; nephrology-led long-term care.') disease(40,'Hypertensive disease.','Diagnose by repeated standardized office measurements, preferably confirm with home/ambulatory BP. Assess total CV risk, target-organ damage and secondary causes when indicated.','Lifestyle: salt reduction, weight management, physical activity, alcohol/tobacco reduction. Drug therapy is individualized, usually combination treatment when required; monitor BP, creatinine and potassium.','Hypertensive emergency with acute target-organ damage: neurologic deficit, ACS, pulmonary edema, aortic syndrome, AKI, eclampsia. Do not rapidly lower uncomplicated elevated BP.','Home BP diary, adherence and adverse-effect review; screen/manage lipid, diabetes, CKD and smoking.') disease(41,'Ischemic heart disease (IHD).','Characterize chest pain and functional limitation; obtain ECG, risk profile and appropriate noninvasive/anatomic testing. Distinguish stable angina from acute coronary syndrome.','Lifestyle, antianginal therapy, antiplatelet/lipid-lowering therapy and risk-factor control are individualized. Revascularization evaluation is needed for high-risk anatomy/ischemia or uncontrolled symptoms.','Acute/prolonged resting chest pain, dynamic ECG changes, syncope, acute HF, arrhythmia or ACS suspicion: emergency transfer.','Monitor symptoms, BP/lipids, adherence, exercise/rehabilitation and medication adverse effects.') disease(42,'Polyclinic rehabilitation after myocardial infarction.','Begin after stabilization: assess symptoms, ECG/echo data, EF, HF/arrhythmia, functional capacity, psychosocial state, employment demands and medication adherence.','Phased supervised aerobic activity, cardiac education, smoking cessation, diet, cardiac secondary prevention and psychological/occupational support. Maintain guideline secondary-prevention medicines unless contraindicated.','Recurrent chest pain, syncope, HF decompensation, sustained arrhythmia, hypotension or poor exercise tolerance requires urgent review.','Individual return-to-work decision depends on LV function, ischemia, arrhythmias, job risk and rehabilitation outcome.') disease(43,'Myocarditis.','Suspect after viral/systemic illness with chest pain, dyspnea, palpitations, syncope, troponin/ECG changes or new LV dysfunction. Echo and cardiac MRI are key; exclude ACS.','Restrict exercise. Management targets HF/arrhythmia; etiology-specific/immunosuppressive therapy requires specialist evidence.','Hemodynamic instability, syncope, sustained ventricular arrhythmia, high-grade block, acute HF, significant troponin/chest pain or suspected fulminant myocarditis.','Cardiology follow-up with ECG, echo and functional assessment. Return to strenuous exercise only after specialist clearance.') disease(44,'Cardiomyopathy.','Classify dilated, hypertrophic, restrictive/infiltrative or arrhythmogenic phenotype using history, ECG, echo, MRI/genetics when indicated; assess HF, arrhythmia and sudden-death risk.','Guideline HF therapy for reduced EF; phenotype-specific therapy, family screening and device/rhythm management by cardiology.','Syncope, sustained arrhythmia, acute HF/pulmonary edema, chest pain/ischemia or high-risk hypertrophic cardiomyopathy symptoms.','Serial echo/ECG, family counseling where inherited, medication and device follow-up; occupation/sport restrictions individualized.') disease(45,'Iron-deficiency anemia (IDA).','Confirm anemia and iron deficiency (ferritin interpreted with inflammation, transferrin saturation). Search for source: menstrual, GI bleeding, malabsorption, diet, renal/other disease.','Oral iron is usual first-line if tolerated; IV iron is selective. Treat the cause, not only the Hb. Do not delay GI/gynecologic investigation when indicated.','Hemodynamic instability, suspected active bleeding, severe symptomatic anemia, angina/heart failure, syncope or need for transfusion assessment.','Check Hb response and replenish iron stores; verify source control and recurrence prevention.') disease(46,'Vitamin B12-deficiency anemia.','Macrocytosis may be absent. Test B12, CBC/smear and consider methylmalonic acid/homocysteine where available; assess neurologic signs and cause such as pernicious anemia, gastric/ileal disease or diet.','Replace B12 by guideline route/regimen; treat cause and coexisting folate/iron deficiency. Do not give folate alone when B12 deficiency is possible because neurologic injury may progress.','Severe anemia with instability, profound neurologic symptoms, pancytopenia/diagnostic uncertainty or suspected hematologic malignancy.','Monitor reticulocyte/Hb response, neurologic recovery and lifelong replacement when cause is irreversible.') disease(47,'Rheumatoid arthritis.','Persistent inflammatory symmetric small-joint synovitis, morning stiffness, raised inflammatory markers, RF/anti-CCP and imaging support diagnosis. Exclude septic/crystal arthritis.','Early rheumatology referral and treat-to-target disease-modifying therapy are required. NSAIDs/short glucocorticoids are bridging only when appropriate; exercise, vaccination and CV/bone-risk care matter.','Septic arthritis suspicion, rapidly progressive disability, vasculitis, cervical spine neurologic signs, severe drug toxicity or systemic complications.','Monitor disease activity, function, CBC/liver/renal safety tests and medication-specific infection screening.') disease(48,'Osteoarthritis.','Mechanical pain, brief stiffness, activity limitation and characteristic exam/imaging. Exclude inflammatory arthritis, fracture, infection and referred pain.','Education, therapeutic exercise, weight reduction if indicated, assistive devices and topical/oral analgesia with risk assessment. Injections/surgical referral are selective.','Hot swollen joint with fever, trauma/fracture suspicion, acute neurovascular deficit or rapidly destructive disease.','Function-focused follow-up, fall prevention, work adaptation and joint-replacement referral for severe refractory pain/disability.') disease(49,'Gout.','Acute monoarthritis often affects first MTP; confirm crystals when possible. Measure urate, renal function and comorbidities, but urate can be normal during a flare. Exclude septic arthritis.','Treat flare early with NSAID, colchicine or glucocorticoid chosen for comorbidity. Long-term urate-lowering therapy is indicated for recurrent flares, tophi, CKD/urolithiasis or high burden, titrated to serum-urate target with prophylaxis.','Septic arthritis uncertainty, fever/systemic toxicity, uncontrolled pain, AKI or complex comorbidity.','Diet/alcohol and weight counseling, medication review (diuretics), renal/CV risk care, urate monitoring and adherence.') disease(50,'Gastroesophageal reflux disease (GERD).','Typical heartburn/regurgitation; assess alarm symptoms: dysphagia, bleeding, anemia, weight loss, persistent vomiting, older-onset concerning symptoms. Consider cardiac pain first where appropriate.','Weight reduction if relevant, avoid late meals/trigger pattern, elevate head of bed. Time-limited proton-pump inhibitor trial is typical; optimize adherence/timing before labeling refractory.','GI bleeding, progressive dysphagia, food impaction, severe chest pain or alarm symptoms require urgent/endoscopic evaluation.','Step down to lowest effective treatment after control; endoscopy/referral for alarms, persistent symptoms or Barrett-risk assessment.') disease(51,'Chronic gastritis.','Often requires etiologic confirmation: H. pylori, autoimmune gastritis, chemical/NSAID injury. Symptoms alone do not establish diagnosis. Check anemia/B12/iron where indicated and endoscopy for alarms.','Test-and-treat H. pylori according to local regimen and confirm eradication when indicated. Avoid NSAIDs/alcohol irritants; acid suppression for symptoms when appropriate.','Bleeding, perforation symptoms, weight loss, anemia, persistent vomiting, dysphagia, mass/ulcer suspicion.','Monitor eradication and nutritional consequences of atrophic/autoimmune gastritis; surveillance follows endoscopic pathology risk.') disease(52,'Peptic ulcer disease of stomach and duodenum.','Endoscopy establishes gastric ulcer diagnosis and biopsy rules out malignancy; test for H. pylori and review NSAID/antiplatelet use.','Eradicate H. pylori where present, stop/modify ulcerogenic drugs where possible, prescribe PPI healing therapy and protect high-risk patients if NSAID unavoidable.','Hematemesis/melena, shock, severe sudden abdominal pain/peritonitis, persistent vomiting/obstruction or cancer concern.','Confirm H. pylori eradication after appropriate interval; gastric ulcers often need endoscopic healing confirmation.') disease(53,'Chronic pancreatitis.','Recurrent/persistent epigastric pain, exocrine insufficiency, diabetes and imaging changes. Evaluate alcohol, smoking, gallstone/metabolic/hereditary causes; exclude pancreatic cancer in new/progressive symptoms.','Alcohol abstinence and smoking cessation, dietary counseling, analgesia strategy, pancreatic enzyme replacement for exocrine insufficiency and diabetes/nutrition management. Endoscopic/surgical options are specialist decisions.','Acute severe pain, fever, jaundice/cholangitis, vomiting/dehydration, GI bleeding, obstruction, weight loss or malignancy suspicion.','Monitor weight, stools/nutrition, fat-soluble vitamin risk, glucose and pain/opioid safety.') disease(54,'Irritable bowel syndrome (IBS).','Recurrent abdominal pain related to defecation with change in stool frequency/form, after excluding alarm features and plausible organic disease. Screen selectively for celiac/inflammation based on phenotype.','Explain gut-brain interaction, diet trial such as tailored fiber/low-FODMAP under guidance, exercise/sleep and psychological therapy. Treat constipation, diarrhea or pain by subtype.','Bleeding, nocturnal symptoms, fever, anemia, weight loss, onset later in life, family history of colorectal cancer/IBD, mass or inflammatory markers.','Planned review avoids repeated low-yield testing; validate symptoms and address anxiety/depression.') disease(55,'Chronic cholecystitis.','Assess biliary-type pain and ultrasound for stones/sludge/wall changes; test liver enzymes and pancreatic markers if complications suspected. Differentiate dyspepsia, ulcer, cardiac and pancreatic pain.','Dietary regularity and avoidance of individual fatty triggers; symptomatic therapy is limited. Symptomatic gallstones usually require planned surgical consultation rather than indefinite medication.','Fever/jaundice, persistent severe RUQ pain, hypotension/confusion, cholangitis, pancreatitis or peritonitis signs.','Surgical follow-up for symptomatic cholelithiasis; address obesity/metabolic risk.') disease(56,'Liver cirrhosis.','Establish cause and stage compensated/decompensated disease. Assess synthetic function, CBC, renal function, ultrasound/portal-hypertension signs and screen for HCC/varices according to specialist pathway.','Treat etiology where possible, absolute alcohol abstinence, nutrition/sarcopenia care, vaccination and complication prevention. Ascites/encephalopathy/variceal prophylaxis require guideline and specialist oversight.','GI bleeding, encephalopathy, sepsis, jaundice with acute deterioration, tense ascites/respiratory compromise, AKI/hepatorenal syndrome or severe hyponatremia.','Regular hepatology follow-up, HCC surveillance, variceal pathway, transplant evaluation for decompensation.') page();doc.add_heading('III. WORK-CAPACITY ASSESSMENT BY DIAGNOSIS',1) doc.add_paragraph('For Questions 57-78, always state the common legal-expert principle: certify temporary incapacity only when the acute state or functional limitation prevents safe work; reassess clinically; involve the VC in prolonged/complex cases; refer to MSE for documented persistent functional disorders and life-activity limitation after appropriate treatment/rehabilitation. The following are criteria, not automatic durations.') incap=[ ('ARVI','Temporary incapacity is appropriate for fever/intoxication, contagiousness, significant respiratory symptoms, complications or unsafe work. Persistent incapacity is unusual; investigate another disorder if prolonged.'), ('Pneumonia','Temporary incapacity covers active infection, hypoxemia, fever, weakness and recovery incompatible with work. MSE is considered only for persistent respiratory impairment, chronic complications or severe comorbidity causing sustained limitation.'), ('COPD','Temporary incapacity during moderate/severe exacerbation, acute respiratory failure or therapy escalation. MSE depends on sustained airflow limitation, chronic respiratory failure, exercise tolerance, exacerbation burden and hazardous/heavy occupation.'), ('Asthma','Temporary incapacity for exacerbation, inadequate control, systemic therapy/urgent observation, or exposures that provoke attacks. MSE for persistent uncontrolled severe asthma with enduring functional/work limitation despite optimized treatment.'), ('Chronic pyelonephritis','Temporary incapacity during febrile exacerbation, pain, impaired renal function or parenteral treatment. MSE requires persistent CKD, hypertension, recurrent complicated infection or functional limitation despite care.'), ('Chronic glomerulonephritis','Temporary incapacity during active nephritic/nephrotic exacerbation, edema, uncontrolled BP or AKI. MSE is based on CKD stage, persistent proteinuria/complications, treatment burden and life-activity impact.'), ('Hypertensive disease','Temporary incapacity for hypertensive crisis/acute target-organ injury or severe uncontrolled BP requiring evaluation. MSE only with persistent organ damage and substantial functional limitation, not BP diagnosis alone.'), ('IHD','Temporary incapacity for unstable symptoms, ACS, revascularization recovery or medication adjustment affecting safety. MSE considers persistent angina class, LV dysfunction/HF, ischemia, arrhythmia and inability to perform job demands.'), ('Myocardial infarction','Temporary incapacity throughout acute treatment and individualized rehabilitation. MSE may be appropriate for persistent HF, angina, serious arrhythmia, markedly reduced exercise tolerance or contraindicated high-risk work.'), ('Myocarditis','Temporary incapacity during active inflammation, chest symptoms, arrhythmia/HF and exercise restriction. MSE is exceptional but considered for chronic cardiomyopathy, HF, conduction disorder or persistent function loss.'), ('Cardiomyopathy','Temporary incapacity during decompensation, arrhythmia evaluation/intervention or HF exacerbation. MSE relies on persistent HF, syncope/arrhythmias, exercise capacity, device needs and work restrictions.'), ('Iron-deficiency anemia','Temporary incapacity when symptomatic anemia, active blood loss, severe weakness/dyspnea or diagnostic/therapeutic procedures prevent safe work. MSE is unusual unless cause/complication produces durable impairment.'), ('B12-deficiency anemia','Temporary incapacity for severe anemia, neurologic deficit or work-up/treatment. MSE depends on persistent neurologic disability or irreversible underlying disease, not B12 deficiency alone.'), ('Rheumatoid arthritis','Temporary incapacity during high inflammatory activity, flare, major treatment adjustment or surgery. MSE considers persistent joint dysfunction, deformity, systemic disease, self-care/mobility and vocational limitation.'), ('Osteoarthritis','Temporary incapacity during severe pain/synovitis, functional loss, joint replacement and rehabilitation. MSE depends on sustained mobility/self-care/work impairment after treatment and realistic adaptation.'), ('Gout','Temporary incapacity during acute flare with inability to walk/use limb or systemic complications. MSE is rare, considered for tophaceous destructive disease, severe CKD or persistent disability.'), ('GERD','Temporary incapacity is usually short and symptom-driven, for severe esophagitis/complication or diagnostic intervention. MSE is rare unless severe complication causes persistent limitation.'), ('Chronic gastritis','Temporary incapacity for severe exacerbation, bleeding/anemia or required investigation. MSE is generally not indicated unless an underlying disease creates durable impairment.'), ('Peptic ulcer disease','Temporary incapacity for exacerbation, bleeding, perforation/operation and recovery. MSE may be considered after major surgery or persistent severe complication with functional impact.'), ('Chronic pancreatitis','Temporary incapacity for exacerbation, severe pain, malnutrition, diabetes instability or procedures. MSE considers persistent exocrine/endocrine failure, pain, complications and functional limitation.'), ('Chronic cholecystitis/cholelithiasis','Temporary incapacity for biliary colic, acute inflammation/complications or cholecystectomy recovery. MSE only for rare persistent complications affecting function.'), ('Cirrhosis','Temporary incapacity for decompensation or treatment of complications. MSE is frequently relevant in decompensated cirrhosis due to persistent organ dysfunction, encephalopathy, ascites, bleeding risk and limited work capacity.')] for i,(name,text) in enumerate(incap,57): q(i,f'Criteria of temporary and persistent incapacity: {name}.',bs=[text,'Document objective severity, job hazards, treatment response and functional restrictions. Do not use a fixed duration without reassessment.']) q(79,'Medical-social examination: criteria used in MSE.',bs=['The MSE evaluates persistent disorders of body functions, degree of life-activity limitation, need for social-protection measures, rehabilitation potential and vocational consequences.', 'The referral must present a complete, objective longitudinal record. The bureau applies current official classifications and criteria, which can change; use the current version in an examination answer.']) page();doc.add_heading('IV. PREHOSPITAL EMERGENCY CARE AND EDUCATIONAL PRESCRIPTION EXAMPLES',1) doc.add_paragraph('All items below begin with: assess ABCDE, monitor ECG/BP/SpO2, establish IV access where needed, check glucose when altered consciousness is present, call emergency medical service, document time and response, and arrange immediate transfer when a time-critical diagnosis is possible. Doses are adult educational examples and require adjustment for contraindications, local protocol and scope of practice. “Rx” examples are not legal prescriptions for unsupervised use.') def emergency(n,title,steps,rx): q(n,title,bs=['Immediate actions: '+steps,'Academic medication example: '+rx,'Transfer: continue monitoring and structured handover; do not delay evacuation for completion of outpatient testing.']) emergency(80,'Acute coronary syndrome at the prehospital stage.','Rest, ECG within minutes, repeat if nondiagnostic; aspirin chew if no allergy/active bleeding; nitroglycerin only if BP adequate and no PDE-5 inhibitor/relevant RV infarction concern; oxygen only if hypoxemic; analgesia per EMS protocol. Activate PCI-capable pathway.','Rx: Acidi acetylsalicylici 150-300 mg p.o. chew once. Rp.: Tab. Acidi acetylsalicylici 0.1 N. 3. D.S. Chew 1-3 tablets once for suspected ACS if no contraindication; emergency transfer.') emergency(81,'Myocardial infarction at the prehospital stage.','Treat as ACS with immediate reperfusion routing. Obtain ECG, treat life-threatening arrhythmia/shock/pulmonary edema by protocol; do not permit self-transport.','Rx: as ACS aspirin above. Nitroglycerin is conditional, not routine in hypotension/shock. Anticoagulant/P2Y12/opioid decisions follow EMS/PCI protocol.') emergency(82,'Hypertensive crisis at the prehospital stage.','Determine whether acute target-organ damage exists. For emergency, controlled reduction under monitored protocol and hospital transfer. For markedly elevated BP without injury, repeat measurement, treat oral medication cautiously and arrange prompt review; avoid precipitous BP fall.','Rx example only when clinically appropriate and ordered: Captoprili 12.5-25 mg p.o. once. Rp.: Tab. Captoprili 0.025 N. 1. D.S. Take 1/2-1 tablet orally once under medical supervision. Not for pregnancy, shock or suspected bilateral renal-artery stenosis.') emergency(83,'Cardiogenic shock.','Call resuscitation/EMS, supine position if no pulmonary edema, airway/oxygenation support, ECG, cautious fluids only if RV infarction/hypovolemia suspected and no congestion, urgent reperfusion and vasopressor/inotrope by critical-care team.','Rx: no routine outpatient prescription. Noradrenaline and inotropes require monitored IV titration by emergency/critical-care personnel.') emergency(84,'Acute pulmonary edema.','Sit upright with legs dependent if tolerated, noninvasive ventilation/oxygen for hypoxemia, ECG, treat precipitant. Nitrates only with adequate BP; IV loop diuretic if volume overload. Immediate hospital transfer.','Rx: Furosemidi 20-40 mg i.v. slowly may be used by trained clinician when congestion is present. Rp.: Sol. Furosemidi 1% - 2 ml. D.t.d. N. 5 in amp. S. For IV use by medical personnel only.') emergency(85,'Sinus bradycardia.','Treat only if symptomatic/unstable: hypotension, shock, ischemic chest pain, acute HF, syncope/altered consciousness. ECG, correct reversible causes, pacing readiness.','Rx: Atropini sulfatis 0.5 mg i.v.; repeat per resuscitation protocol to total 3 mg if needed. Rp.: Sol. Atropini sulfatis 0.1% - 1 ml. D.t.d. N. 10 in amp. S. IV use by trained personnel only.') emergency(86,'Second- or third-degree AV block.','Treat unstable bradycardia: monitoring, atropine may help nodal block but is often ineffective in infranodal/high-grade block; immediate transcutaneous pacing and emergency transfer.','Rx: Atropini sulfatis as above while preparing pacing, only in monitored setting. Do not delay pacing/transfer.') emergency(87,'Frequent ventricular extrasystoles.','Assess instability, ischemia, QT/electrolytes, drug toxicity and structural heart disease. ECG and emergency transfer for runs, syncope, chest pain, HF or suspected VT. Avoid reflex antiarrhythmic prescribing.','Rx: no universal outpatient antiarrhythmic. Correct reversible cause and manage per EMS/cardiology protocol.') emergency(88,'Paroxysm of atrial fibrillation.','Assess instability. If shock, ischemia, pulmonary edema or altered consciousness: immediate electrical cardioversion by emergency team. If stable, rate/rhythm strategy and anticoagulation depend on onset, duration, comorbidity and protocol.','Rx: no one-size-fits-all prescription. Beta-blocker/diltiazem/amiodarone selection requires ECG, BP, EF and contraindication assessment.') emergency(89,'Paroxysmal supraventricular tachycardia.','If stable, attempt vagal manoeuvres. If regular narrow-complex SVT persists, adenosine under monitoring may be used. Unstable patient needs synchronized cardioversion.','Rx: Adenosini 6 mg rapid i.v. bolus followed by flush; if necessary, protocol repeat. Rp.: Sol. Adenosini 3 mg/ml - 2 ml. D.t.d. N. 6 in amp. S. IV emergency use by trained personnel only.') emergency(90,'Syncope.','Lay supine, elevate legs, check airway/breathing, BP, pulse, glucose, ECG and pregnancy/bleeding context. Differentiate reflex syncope from arrhythmia, ACS, PE, hemorrhage, seizure and stroke.','Rx: no routine medication. Give oral/IV glucose only for confirmed/suspected hypoglycemia according to consciousness and protocol; transfer for red flags.') emergency(91,'Acute asthma attack.','Assess ability to speak, RR, pulse, SpO2, PEF if feasible. Repeated inhaled short-acting beta2-agonist via spacer/nebulizer, oxygen for hypoxemia, early systemic corticosteroid; add ipratropium in severe attack.','Rx: Salbutamoli 100 micrograms/dose, 4-10 inhalations via spacer, repeat per protocol. Prednisoloni 40-50 mg p.o. once when able, per clinician protocol.') emergency(92,'Status asthmaticus.','A life-threatening refractory exacerbation: resuscitation/EMS, high-flow oxygen targeted to saturation, repeated bronchodilator plus ipratropium, systemic corticosteroid, consider IV magnesium sulfate by protocol, prepare ventilatory support.','Rx: Magnesii sulfatis 2 g i.v. over 20 min may be used for severe refractory asthma by trained team. No outpatient management.') emergency(93,'Gastrointestinal bleeding.','ABC, two large-bore IV lines, NPO, hemodynamic assessment, crossmatch/fluids per protocol, review anticoagulants, urgent transfer/endoscopy pathway. Do not give oral medications/food.','Rx: Pantoprazoli 80 mg i.v. bolus may be used in suspected upper GI bleed per protocol. Rp.: Pantoprazoli 40 mg pulv. N. 1. S. IV use by medical personnel only.') emergency(94,'Biliary colic.','Assess for acute cholecystitis, cholangitis and pancreatitis. NPO, analgesia/antiemetic, examination and urgent referral if fever/jaundice/persistent pain.','Rx: Diclofenaci 75 mg i.m. once may be used if no renal failure, ulcer/GI bleeding, anticoagulant risk or allergy. Rp.: Sol. Diclofenaci 2.5% - 3 ml. D.t.d. N. 5 in amp. S. IM by medical personnel only.') emergency(95,'Acute abdomen.','ABC, urgent surgical assessment/transfer, NPO, IV access/fluids, analgesia and antiemetic as protocol. Do not use laxatives, enemas, food, heating pads or delay with repeated outpatient tests.','Rx: analgesia should not be withheld if surgical evaluation is arranged; e.g., Fentanyli 0.05 mg/ml - 2 ml i.v. titrated only by qualified emergency personnel.') emergency(96,'Renal colic.','Assess pain, fever, sepsis, solitary kidney, pregnancy, anuria/AKI and obstruction. NSAID analgesia if safe; urgent urology transfer for infection or obstruction risk.','Rx: Diclofenaci 75 mg i.m. once if not contraindicated, as above. Avoid NSAIDs in significant AKI/advanced CKD, active GI bleed or relevant allergy.') emergency(97,'Anaphylactic shock.','Immediately give IM adrenaline in mid-anterolateral thigh, lay patient supine with legs raised unless respiratory distress requires position of comfort, call EMS, airway/oxygen/IV fluids, repeat adrenaline as needed. Antihistamines/steroids are adjuncts, never substitutes.','Rx: Sol. Epinephrini 1 mg/ml (0.1%) - 0.5 ml i.m. adult, repeat every 5 min if needed. Rp.: Sol. Epinephrini hydrochloridi 0.1% - 1 ml. D.t.d. N. 10 in amp. S. IM emergency use only.') emergency(98,'Angioedema (Quincke edema).','Assess airway continuously. Stridor, voice change, tongue/floor-of-mouth swelling or dyspnea requires emergency airway-capable transfer. Treat as anaphylaxis if allergic/systemic features. Bradykinin-mediated ACE-inhibitor angioedema may not respond to antihistamines/steroids.','Rx: If anaphylaxis criteria or airway compromise suspected, adrenaline IM as above. Stop suspected ACE inhibitor and transfer urgently.') page();doc.add_heading('V. COVID-19: EXAM-ORIENTED OUTPATIENT ANSWERS',1) doc.add_paragraph('The course list includes COVID-19. Local epidemiology and Russian Ministry/Rospotrebnadzor instructions have changed repeatedly. Use current infection-control and clinical guidance in practice; the following describes a safe clinical approach.') q(99,'History and epidemiological history in suspected COVID-19.',bs=['Record onset and trajectory, fever, cough, sore throat/rhinorrhea, dyspnea, chest pain, loss/change of smell/taste, diarrhea, confusion and home SpO2 if available.', 'Ask about confirmed/probable contacts, household/outbreak exposure, travel or congregate settings, occupation, prior infection and vaccination, and ability to isolate.', 'Identify high-risk status: age, pregnancy, obesity, chronic lung/heart/kidney/liver disease, diabetes, cancer/immunosuppression and current medicines. Ask red flags immediately.']) q(100,'General and special laboratory/instrumental plan for COVID-19.',bs=['Clinical assessment: temperature, RR, HR, BP, mental status and SpO2 at rest, with exertional assessment only if safe.', 'Etiologic testing follows current local availability/indication: antigen test and/or NAAT/PCR. A negative early test does not override high clinical suspicion.', 'CBC, CRP, renal/liver tests, glucose, coagulation markers and blood gas are indicated by severity and management needs, not all mild cases. Chest radiograph/CT is reserved for suspected lower-respiratory involvement or complication; CT is not a screening test for uncomplicated infection.']) q(101,'Hospitalization criteria in established COVID-19.',bs=['Need for supplemental oxygen, low or falling SpO2, increased work of breathing/tachypnea, hemodynamic instability, altered consciousness, inability to maintain hydration/oral medication, or evidence of severe pneumonia/sepsis.', 'Also consider high-risk patient with clinical deterioration, decompensated comorbidity, pregnancy with significant illness, unsafe home situation or inability to ensure monitoring.', 'Decide by trajectory and clinical assessment, not imaging alone. Arrange emergency transfer rather than routine referral if unstable.']) q(102,'Algorithm of hospitalization for suspected COVID-19.',bs=['Place mask on patient if tolerated, separate from others, use staff PPE according to current infection-control policy and notify the receiving/EMS service.', 'Stabilize ABCs, record vital signs/SpO2 and treatment, communicate suspected infection and severity, and arrange medically appropriate transport.', 'Disinfect exposed clinical area/equipment according to current policy; document contacts only as required by applicable public-health rules.']) q(103,'Principles of home outpatient care for confirmed COVID-19.',bs=['Select only clinically stable patients with adequate home support, communication and ability to monitor/worsening access. Provide a clear safety-net plan.', 'Symptom management, hydration, rest, continuation of essential chronic medications unless clinician advises otherwise, and antiviral therapy only if currently indicated and started within its appropriate window.', 'Explain red flags: worsening dyspnea, persistent chest pain, confusion, cyanosis, low/falling SpO2, inability to drink or severe weakness. Arrange scheduled contact/reassessment based on risk.']) q(104,'Disinfection plan for prevention of coronavirus infection.',bs=['Hand hygiene, respiratory etiquette, adequate ventilation, regular cleaning of high-touch surfaces and shared equipment with approved disinfectant, and appropriate waste/laundry handling.', 'Use PPE and patient separation in healthcare settings according to risk. Cleaning staff need training in dilution/contact time and safe removal of PPE.', 'Avoid disproven practices such as spraying disinfectant on people. Follow current Russian sanitary/public-health instructions for outbreaks and medical organizations.']) doc.add_heading('References for examination preparation',1) bullets(['Ministry of Health of the Russian Federation Order No. 202n of 14 April 2025, organization of primary health care for adults.', 'Ministry of Health Order No. 404n of 27 April 2021, procedure for preventive examination and dispensarization of specified adult groups, current amendments.', 'Ministry of Health Order No. 1089n of 23 November 2021, conditions and procedure for ELN formation and paper sick-leave issuance, current amendments.', 'Federal Law No. 323-FZ, Federal Law No. 181-FZ, and current MSE rules/classification criteria.', 'Current Russian clinical guidelines and local emergency medical service protocols for each disease.']) doc.save(out) print(out, out.stat().st_size) PY python3 - <<'PY' from docx import Document p='/tmp/workspace/polyclinic-therapy-guide/output/Polyclinic_Therapy_Russian_Medicine_Exam_Guide_2024_2025_English.docx' d=Document(p) heads=[x.text for x in d.paragraphs if x.style.name=='Heading 2'] print('heading2 count',len(heads),'first',heads[:2],'last',heads[-3:]) PY