SMLE

IMPORTANT
NOTES

Please don't hesitate to contact us if you have any correction,

comments or suggestions.

[email protected]
 DR MOHTADI S NOTES FOR SMLE EXAM.

★ MEDICINE
★LIVER CYST.
1- H da id Li e C
Management depends on the ​ i e and imaging
fea e ​.
● Single, unilocular, anechoic with double line
sign or cyst with detached membrane (water-lily
sign):
➔ < 5 cm: Albendazole alone.
➔ > 6-10 cm: Combination albendazole +
PAIR (better), or PAIR alone.

2- Da gh e c m l i e a ed e e-
like, h ne c mb c :
surgery + albendazole.

3- La ge c >10cm c m lica ed:-

Surgery
4- Calcified c
Observation

➔ PAIR:
Puncture-aspiration-injection-reaspiration.
➔ C m lica ed mean : ​ruptured cyst, biliary
fistula, compressing vita organs, cyst with
secondary infection or hemorrhage.

★HIV a cia ed infec i n

➔ Pne m nia​ > pneumocystitis Carnii
➔ Dia hea​ > Cryptosporidium
➔ Re ini i ​, Blindness, Esophagitis > CMV
➔ Meningi i ​ > Cryptococcus
 DR MOHTADI S NOTES FOR SMLE EXAM.

★An imic bial f ch ice

= F ngi.
● Tinea e ic l ​ > topical antifungal (selenium
sulfide, ketoconazole or pyrithione zinc)
● Tinea c i /c i / edi ​> ​Topical terbinafine
● Tinea ca i i ( cal )​ > oral antifungal (griseofulvin,
terbinafine, itraconazole, fluconazole)
= Bac e ia.
● BV​> Metronidazole
● Chlam dia​ > ​Azithromycin and doxycycline​
● ​G n hea​ > ​single dose of IM ceftriaxone & oral
azithromycin
● Shigell i , Salm nella​ > Ciprofloxacin
● Cl idi m difficile​ > Vancomycin
● T n illi i & Sin i i ​> Amoxicillin/clavulanic acid
(augmentin)
● Ac e i i media​ > high dose amoxicillin (80 to 90
mg/ kg/day)
● Skin infec i n ​ ( e.g. impetigo, cellulitis or any
proven staph.aureus) > Oxacillin
● S hili , he ma ic fe e ​ > Penicillin G
(benzathine)
● P egnan i h UTI (c i i )​ >
○ 1st & 2nd trimester:​ (nitrofurantoin)
○ Third trimester:​ (cephalexin or amoxicillin)
● P egnan i h ( el ne h i i )​> IV ceftriaxone
● C e - e d m na ​ (ventilator acquired
pneumonia, fever with neutropenia) >
Piperacillin,Tecarcillin, Cefepime
● C e -MRSA​> Ceftaroline, Vancomycin, linezolid.
● Skin-MRSA​ >TMP/smx, doxycycline, clindamycin
● Meningi i :​-
● In ne na e​> ampicillin + (gentamicin or
cefotaxime)
● Infan & lde ​ ​> Ceftriaxone + vancomycin
● Elde l ​ ​> ceftriaxone + vancomycin +
ampicillin
DR MOHTADI S NOTES FOR SMLE EXAM.

★He a i i

He a i i A
➔ Se i n ?​ No
➔ Vaccine?​ Yes
➔ C a i e ea men ?​ No, usually self
limiting
➔ M de f an mi i n?​ Fecal-oral
➔ T e f he i ?​ RNA
➔ Ac e ch nic?​ Acute
➔ Ri k f ci h i He a cell la
ca cin ma? ​No

He a i i B
➔ Se i n ? ​Yes
➔ Vaccine? ​Yes
➔ C a i e ea men ?​ No
➔ M de f an mi i n?​ Blood , sexual
intercourse, mother to fetus sharing
needles
➔ T e f he i ? ​DNA
➔ Ac e ch nic? ​Both, but usually
chronic
➔ Ri k f ci h i He a cell la
ca cin ma?​ yes

He a i i C
➔ Se i n ? ​Yes
➔ Vaccine?​ No
➔ C a i e ea men ?​ Yes
➔ M de f an mi i n?​ same as B
➔ T e f he i ? ​RNA
➔ Ac e ch nic?​ Chronic
➔ Ri k f ci h i He a cell la
ca cin ma?​ yes
DR MOHTADI S NOTES FOR SMLE EXAM.

★COPD
● Pa h h i l g ​: Smoking destroys elastin
fibers.
Hi & clinicall :
➔ smoker.
➔ SOB worsening by exertion.
➔ Cough, sputum.
➔ barrel chest.
D :
➔ Spirometry: Decrease FEV1 and FVC
with increased TLC, incomplete
improvement after SABA.
:
➔ Improves mortality (Smoking cessation &
Oxygen therapy in those who Po2 < 55
or Sat<88%)
➔ Improves symptoms ( SABA,
anticholinergic agents)

Ac e COPD e ace ba i n:
➔ albuterol, ipratropium, steroids
➔ ih len m?​ Antibiotics
➔ Se e e i h e i a acid i ​?
Non-invasive MV.

● M acc a e e ?​ PFT.
● Dec ea ed DLCO?​ Emphysema
● H m ni COPD e e i f ai fl
limi a i n ?​ FEV1

● COPD in ng n n- m ke ? ​alpha-1
antitrypsin deficiency.
● COPD n c n lled i h SABA? ​add
anticholinergic.
● COPD n c n lled i h SABA &
an ich line gic ?​ add ICS
DR MOHTADI S NOTES FOR SMLE EXAM.

Inhaled an icholinergic are he mo effec i e

he onl one ed in ac e e acerba ion i
I a ​.

When e gen he a ?
➔ Po2 < 55 or Sat < 88%
Or
➔ Po2 < 60 sat < 90% with right sided HF.

When c n ide in a i e MV?

➔ PaO2 < 40 mmhg
➔ Ph < 7.25.
➔ CO2 > 60 mmhg.
➔ Respiratory arrest.
➔ Cardiovascular collapse.
➔ Severe exacerbation with a lot of
secretions.

★ASTHMA MECHANICAL
VENTILATION
Ab l e indica i n f MV in e e e ac e
a hma:
➔ Coma.
➔ Respiratory or cardiac arrest.
➔ Refractory hypoxemia.

Rela i e indica i n :
➔ Inadequate response to initial.
management.
➔ Hypercapnia.
➔ Fatigue.
➔ Cardiovascular compromise.
DR MOHTADI S NOTES FOR SMLE EXAM.

★SLE

LAB
➔ M en i i e lab​ > ANA
➔ M ecific lab ​> anti-dsDNA,
anti-smith
Managemen .

ARTHRITIS:
➔ A h i i & mala a h​:
hydroxychloroquine
➔ E emel e e e fla e f
l a h i i :​ IV methylprednisolone

RENAL In l emen
➔ SLE i h mild ne h i i : ​corticosteroids
➔ SLE i h e e e ne h i i ( a idl
g e i e, diff e life a i e,
e ee ein ia and ac i e ine
edimen )​ :
corticosteroid + cyclophosphamide

CNS in l emen :
➔ SLE i h cen al ne em
manife a i n ( ei e, ganic b ain
nd me c ma):
IV cyclophosphamide & IV methylprednisolone
➔ Me h e a e a a hi ine :
steroid-sparing drugs

D g ind ced l : ​( c d ag ed b
A -H e AB)
● Hydrazine
● Isoniazid
● Chlorpromazine
● Procainamide
 DR MOHTADI S NOTES FOR SMLE EXAM.

★RHEUMATOID ARTHRITIS
#T be ed = a RA a e d be d g
e e d ea e ge (DMARD ).

● Wha he Be ini ial f m ma ic

c n l>
➔ Nsaids (they work immediately to
improve inflammation).
● ​The m im an in RA i e en
g e i n f he di ea e :
➔ Any patient with erosive disease or x-ray
changes or physical deformity needs at
least methotrexate to slow disease
progression, neither Nsaids nor steroids
stop RA progression.
● ​When e e id ?
➔ If acute flares not responding to Nsaids
or as a bridge when waiting DMARDS to
take effect, DMARDS are much slower in
onset of action than steroids.
● DMARDS i a h ge li , Wha he be
a i h?
➔ Methotrexate
● When e An i-TNF (e.g infli imab,
adalim mab) ?
➔ First-line In patient who is not responding
to methotrexate or couldn’t tolerate it.

D f ge c ee a e a PPD
bef e a g a -TNF, g ead
eac a f TB.
● Wha if a ien n me h e a e & an i-TNF
and ill n e nding?
➔ Consider rituximab or sulfasalazine.
 DR MOHTADI S NOTES FOR SMLE EXAM.

I a Q e

● Wha he m c mm n ca e f dea h in
RA​?
➔ Coronary artery disease.

Wha Fel nd me?

➔ RA
➔ Splenomegaly
➔ Neutropenia

Wha Ca lan nd me?

➔ RA
➔ Pneumoconiosis
➔ Lung nodule

★Infec i e End ca di i .
● Na i e​ = staph aureus
● IV ab e ​ = staph aureus
● P he ic
➔ Ea l ​ = staph.epidermidis
➔ La e ​= Strep.viridans
● Den al al ​= viridans

★BLOOD PRESSURE/ DSL +

DM.
Ta ge BP & Li id file in DM:

➔ Wi h CVD​: LDL < 100

➔ Wi h CVD​: LDL < 70
➔ T igl ce ide : ​ < 150
➔ BP: ​ of < 140/90 mmHg
 DR MOHTADI S NOTES FOR SMLE EXAM.

★HEART FAILURE

Hea fail e managemen

➔ S lic EF le han 40%​ > ACE
➔ S lic EF le han 35% ​>
Spironolactone + ACE
➔ Dia lic ​> Diuretics, BB
➔ CHF​ > ACE, BB, Spironolactone
➔ Ac e m ma ic HF ​> Loop diuretic
(furosemide) and oxygen if hypoxic.

★D g Dec ea e The M ali

in HF
➔ ACEI/ARB
➔ BB ( metoprolol, Bisoprolol and
Carvedilol)
➔ Spironolactone or eplerenone (if Severe
systolic HF EF less than 35%)

★PE
➔ If able​ > Enoxaparin
➔ If able and an ic ag lan
c n aindica ed​ > consider IVC filter if
distal embolism confirmed
➔ If n able ​> thrombolytics
➔ If n able and h mb l ic
c n aindica ed ​> embolectomy
 DR MOHTADI S NOTES FOR SMLE EXAM.

★SVT managemen
Fi ​:
➔ Vagal valsalva maneuvers (carotid massage)
➔ IV adenosine
● If ineffec i e​: IV bb, diltiazem or
Verapamil.
● If all ineffec i e n able​:
Cardioversion

★ASD
➔ ASD if Asymptomatic and not severe >
follow-up.
➔ Otherwise surgical closure.

★Val la hea di ea e
➔ The best initial test for all valvular heart
disease is ​ech ca di g am​.
➔ T an e hageal ech ​ is generally
both more sensitive and specific than
an h acic ech .
➔ The most accurate test is
Ca he e i a i n

★RF f ca diac di ea e:
Maj i k f ca diac di ea e :
1-HTN
2-DM
3-Smoking
4-Hyperlipidemia
M c mm n > HTN
M dange > DM
 DR MOHTADI S NOTES FOR SMLE EXAM.

★MI
STEMI.
➔ aspirin, nitroglycerin, analgesia, BB
(aspirin and BB decrease mortality rate),
oxygen if hypoxic.
➔ he defini i e for STEMI i hrombol ic
or PCI.
➔ PCI is superior to thrombolytics but if not
available in the next 90 mins give
thrombolytics

N n-STEMI.
➔ Same but thrombolytics are
contraindicated, only ​PCI

➔ If infe i all MI​: Do right sided lead to

rule out posterior MI, give IVF, ​don gi e
morphine or ni rogl cerin​.

★Rhe ma ic fe e
Ab h la i in Rhe ma ic fe e :
➔ N ca diac in l emen :​ 5 years or till
the age of 21
➔ If i h ca diac in l emen b n
e id al damage:​ 10 years
➔ If i h e id al damage​: at least 10
years and until age of 40.
 DR MOHTADI S NOTES FOR SMLE EXAM.

★UC
Me alamine ef lce a i e c li i :
➔ E en i e c li i ac i e di ea e​:
better combination oral + topical
(suppositories or enema)
➔ Mild​ in ec m and 15 cm be nd anal
e ge​: Suppositories
➔ Mild​ f m ec m lenic fle e:
topical enema
T be ed:​ modera e o e ere di ea e
(combina ion oral and opical regardle he in ol ed
i e).
Sign & lab indica e e e e lce a i e c li i :
➔ 6 m e ​daily bloody bowel frequency.
➔ Stool volume ​m e​ than ​400g/d
➔ 37.8 C or more
➔ Hemoglobin ​< 10g/dL
➔ ESR ​> 30
➔ Serum albumin ​< 3g/dL
➔ X-ray (​Dila ed b el, h mb- in ing​)
➔ Sigmoidoscopy (​Ulce a i n, bl d in
l men​)

★C hn' di ea e
Managemen fc hn ic e

➔ Single < 5 cm i h an
c m lica i n ​> endoscopic dilatation.
➔ L ng 5 cm, m l i le, diff e
ec en ​ > Strictureplasty.
➔ C m lica ed m l i le ic e
i hin a h egmen f he b el,
in ile caecal j nc i n​ > Small bowel
resection
➔ C m lica i n mean​ > perforation,
abscess, fistula, or malignancy.
 DR MOHTADI S NOTES FOR SMLE EXAM.

★PITUITARY ADENOMA
● Ne e i h m nal le el:
If lac in ma​ > start Medical therapy
(​bromocriptine or cabergoline) ​cabergoline is
better​. ​

When d an hen idal e ec i n?

➔ Cushing or acromegaly.
➔ Non-functioning adenoma if more than
1cm or with compression sx.
➔ Prolactinoa not responding to medical
therapy.
➔ if with Hge > urgent neurosurgical
referral.

★METHOTREXATE
Managemen f ec ed me h e ae
he a ici :-

➔ Ne l e i en inc ea e in
an amina e ​ > Reduce methotrexate,
investigate
➔ 3 f ld inc ea e in an amina e ​ >
stop methotrexate, investigate.
 DR MOHTADI S NOTES FOR SMLE EXAM.

★Ace amin hen

Ace amin hen ( a ace am l) ici
S age :
➔ 1 ​: Asymptomatic or GI symptoms.
➔ 2nd​: hepatotoxicity starts, RUQ pain, LFT’s start to
rise.
➔ 3 d​: hepatic failure & encephalopathy, LFT’s peaks
+ signs & symptoms of hepatic failure.
➔ 4 h​: Full recovery or death.

Managemen :
➔ activated charcoal
➔ should be given early, at 1-2 hours
post-ingestion, after that no need.

➔ Se m a ace am l le el​ :
◆ you should measure paracetamol level to plot it in
The Rumack-Matthew nomogram then determine
either to give the antidote or no.
◆ Serum paracetamol ​le el eak 4 h af e
inge i n​ so If patient came immediately after
ingestion order paracetamol level after 4 hours.

➔ If he came ​4 h m e​ after ingestion order

serum paracetamol level immediately.
➔ If he came ​7 h af e ​ingestion with symptoms
or history suggests toxic dose start antidote
immediately !!!!
➔ because hepatic injury usually starts at 8 hours
post-ingestion and it’s better to give an antidote
before 8 hours otherwise patient may lose his liver
while you are waiting for the results.

Sa N-ace lc eine:
➔ Minimum toxic dose is 7-10g, so if you have a
definitive history of toxic dose ingestion you can
start antidote based on history.

li e an lan :
➔ It is the definitive management if patient ends up
with fulminant hepatitis or hepatic failure.
DR MOHTADI S NOTES FOR SMLE EXAM.

★T m l i nd me
➔ Hyperkalemia
➔ Hyperphosphatemia
➔ Hyperuricemia
➔ H calcemia
➔ high blood urea nitrogen (BUN)

★C anial ne e al

➔ All intraocular muscles supplied by ​3 d

(oculomotor) ​e cep perior obliq e b 4 h,
and la eral rec b 6 h.
Re e be ( S 4-LR6)

➔ All Intraocular muscles pulls the eye towards its

side except obliques pushes to the opposite
side.
Re e be Ob e=O e

➔ So ​6 h​ ​(abducent) palsy: ​affected eye will go

toward the nose (esotropia), unable to abduct.

➔ If ​4 h​ nerve palsy​ double-vision + patients

characteristically tilt their head down.

➔ 3 d​ nerve palsy : ​down and out position in the

affected eye(exotropia) + ptosis + dilated pupil
(mydriasis)
DR MOHTADI S NOTES FOR SMLE EXAM.

★Rei e nd me ( eac i e
a hii )

i an a oimm ne reac ion occ rring af er an

infec ion, par ic larl ho e in he rogeni al or
ga roin e inal rac . ​

H emembe he cla ic iad

○ conjunctivitis, cannot see. ​
○ urethritis, cannot pee.
○ arthritis, cannot climb a tree. ​
Managemen
○ Antibiotics ​if there's an active infection
such as STD’s (chlamydia).
○ N aid ​, for pain and joint inflammation.

★Demen ia

➔ Va c la demen ia
● Vascular risk factors (Obesity, DM, HTN,
Smoking).
● Progressive dementia.
● Neuroimaging:Hyperintense in white
matter and periventricular area.

➔ Le b die demen ia
● Hallucinations and parkinsonism.

➔ F n em al demen ia
● Personality changes.

➔ NPH
● Ataxia.
● Urinary incontinence.
● Dilated ventricles with normal ICP.
 DR MOHTADI S NOTES FOR SMLE EXAM.

★ SURGERY
★ - fe e
➔ 0-2 da > ​atelectasis or pneumonia.
➔ 3-5 da >​ UTI.
➔ 5-7 da ​ ​>​ DVT.
➔ 7 da ​ ​>​ wound infection.
➔ 8-15 da ​ ​>​ drug fever or deep abscess.

★THYROID
Th id n d le
➔ Fi ​ > TFT
➔ If TFT n mal ​> FNA
➔ I TFT h e f nc i ning​ > thyroid Scan
● If can h
○ H ​ > ​this is toxic
hyperfunctioning nodule
start antithyroid therapy or
surgical excision.
○ C ld​ > FNA.

★He a bilia
When d e ch lec ec m indica ed in
a m ma ic gall ne ?

➔ hematological disease ​( ickle- hal)

➔ calcified gallbladder ​(high i k f cance )
➔ very large stone ​( i k f cance & fi la)
➔ immunocompromised patient.
DR MOHTADI S NOTES FOR SMLE EXAM.

★Mi i i nd me​ gallstone in the

cystic duct causing compression of the common
hepatic duct

★Ac e bilia anc ea i i

Fi
➔ resuscitation specially IVF.
Then
➔ ERCP (stone extraction) followed by lap
chole.

➔ Ab n indica ed nle ​severe necrotizing

pancreatitis.
➔ Mild m de a e:​ lap chole in same
admission.
➔ Se e e:​ lap chole in ​4-6 weeks.
➔ if In e able . ​ Endoscopic sphincterotomy

★A e ial lce managemen

➔ All patients ​ h ld m king,​ and

control of diabetes, hypertension, and
hyperlipidaemia.
➔ Revascularization ​angi la
➔ Non-healing ulceration, gangrene, rest
pain >​ ​S ge ( all am a i n)

★Ven lce managemen

➔ Compressions
◆ If ​failed​ > shave therapy (excision
of the whole ulcer)
● f ll ed b ​ skin grafting,
or skin grafting alone.
 DR MOHTADI S NOTES FOR SMLE EXAM.

★GI bleeding
In e iga i n f i ible GI bleeding ih
hem d namicall able:

➔ Upper & lower endoscopy, source of bleeding

found?
◆ Ye ​ > Treat
◆ N ​> wireless endoscopy capsule/ double
balloon endoscopy.
➔ i ele end c ca le/ d ble ball n
end c n a ailable?​ ​CT enterography
➔ if ce nkn n & i ible bleeding
affec ing hem d namic e ima ed
bleeding f 0.5ml/min >​ ​Angiography

Managemen f e GI bleeding:

➔ Fi : ​Always stabilize the patient with IV fluids,

send blood for Basic labs & coagulation profile.
➔ hen, ​endoscopy: If bleeding source is peptic
ulcer (most common) > injection of epinephrine
around bleeding point + thermal hemostasis.
➔ If bleeding ce i e hageal a ice ​> IV
octreotide followed by endoscopic ligation or
sclerotherapy.
➔ Pe i en ec en a ice bleeding?
● Consider transjugular intrahepatic
portosystemic shunt (TIPS), balloon
tamponade, Liver transplant.

➔ L ng em dec ea e he i k f
ec en a ice bleed?
● BB
● Nitrates
● follow up
DR MOHTADI S NOTES FOR SMLE EXAM.

★GIST (Ga in e inal

mal m )
➔ gical e ec i n f he m if:
● more than ​2 cm​, or
● less than ​2 cm b highl ici
such as bleeding or ulceration.

➔ If ​le ​ than ​2 cm​ and looks benign > follow up

➔ Gist with metastasis > tyrosine kinase inhibitors

(imatinib)

★Pene a ing abd minal

a ma
*** Al a a b ABC a ach

➔ Pa ien able​ > wound exploration

● if superficial > ​ b e a i n
● If not clear > ​CT

➔ Eme genc e l a la a m If
● Evisceration
● Signs of peritonitis
● Hemodynamic instability
● Free air under the diaphragm
 DR MOHTADI S NOTES FOR SMLE EXAM.

★Bl n abd minal a ma

Sa i h ABC

● S able​: CT
◆ if nega i e​ > observation
● Un able​ > FAST only.

Eme genc La a m :
● unstable.
● signs of peritonitis.
● positive FAST.

★G n h ene a ing inj

➔ Always Laparotomy after stabilization

★S gical i e infec i n
➔ Fi ​ > evaluate surgical wound by ​inspection

➔ If he e ign f infec i n​ (purulent

discharge, erythema, tenderness, then wound
exploration if ​ e ficial​ > ​clean, drain pus,
dressing and you may give abx

➔ If dee c llec i n ec ed ​> ​order CT

➔ If mall c llec i n le han 4 cm​ > ​abx
➔ If la ge 4cm and m e​ > ​percutaneous
drainage + abx
➔ If ign f e i ni i ​ > ​Laparotomy
 DR MOHTADI S NOTES FOR SMLE EXAM.

Pe i he al a e di ea e
(Acute & chronic limb ischemia)

★ACUTE LIMB ISCHEMIA

➔ M c mm n ca e f ac e limb i chemia
i Emb l f m hea igin.

➔ P e en a i n
S dden leg ain i h me f 6P :
● P​ain
● P​allor
● P​ulselessness
● P​aresthesia
● P​aralysis
● P​oikilothermia (cold skin)

➔ Diagn i
● Ini iall ​ = duplex US, (ABI)
● Be ​ = CTA.
● The ​m acc a e​ is angiogram, but
unnecessary unless revascularization will
be done.

➔ ​T ea men
● He a in​ ( immediately before
imaging)
● Re a c la i a i n​ (usually
embolectomy)
 DR MOHTADI S NOTES FOR SMLE EXAM.

★ACUTE ON TOP OF CHRONIC

LIMB ISCHEMIA

➔ If a ien came i h ​bila e al​ ac e limb

i chemia he ha a ​hi ​ f ch nic limb
i chemia ​>> You should consider ​It acute on
top of chronic​ ​which is due to thrombosis not
embolus

➔ T ea men ​ is same but revascularization will be

(​ b ec ca e e d ec ed
b ​)

Th mbec m ca he e di ec ed h mb l i ?

➔ Th mbec m ​is safe and effective as a

primary treatment for ​acute limb ischemia​ ​with a
similar clinical outcome compared to ​ca he e
h mb l i ​.

➔ Choice of rea men ho ld ill be on a

ca e-b -ca e ba i .

➔ Patients ​ e i ing ick e a c la i a i n

i h c n aindica i n f h mb l i ​ may
benefit from ​thrombectomy​ more.
➔ Ca he e h mb l i ​ can be the treatment of
choice in patients with complex crural diseases.
➔ S he c ncl i n​: if patient condition is
severe​ or he is ​going to critical limb ischemia
such as rest pain, loss of sensation, motor
weakness > ​thrombectomy would be better.
DR MOHTADI S NOTES FOR SMLE EXAM.

★CHRONIC LIMB ISCHEMIA

➔ Maj i k
● DM
● Hypertension
● Smoking
● Hyperlipidemia

➔ P e en a i n
● Leg pain in the calves on exertion,
relieved by rest. (Intermittent
claudication)

➔ Se e ei a cia ed i h l f
● Hair
● Sweet glands
● The skin become smooth & shiny.

➔ Diagn i
● The ​be ini ial ​is ​ABI​ (ankle-brachial
index).
➔ N mal ABI i > 0.9
➔ if less than 0.9 then disease is
present.

➔ T ea men
● Lifestyle modification (smoking
cessation, control DM & HTN, weight
loss).
● Cilostazol
● Aspirin
● Statins(LDL goal <70)

➔ Fail e f All medical he a

● Bypass Surgery
DR MOHTADI S NOTES FOR SMLE EXAM.

★HERNIA
➔ Pedia ic he nia​ > Lap Herniotomy
◆ Umbilical​ > observe till 5y old

➔ Ad l he nia:
◆ Small he nia​ (less than 2 cm)
herniorrhaphy
◆ La ge inci i nal he nia​ >
● Lap hernioplasty (with mesh)
● Open if complicated (specially
strangulated)

➔ Rec en he nia: ​ if first one by lap do open, if

first one by open do Lap
 DR MOHTADI S NOTES FOR SMLE EXAM.

★ PEDIATRIC
★ Im an mile ne
● Smiles: ​2m
● No head lag, Raking grasp, Reaches object,
rolls ​from​ prone to supine: ​4m
● Sits without support , transfer object hand to
hand, holds bottle, rolls from supine to prone:
6m
● Creep-crawling: ​7m
● Normal Crawling : ​8-9m
● Stands, starts pincer grasp, waves bye-bye,
play peek-a-boo, say dada mama non-specific:
9-10m
● Fear of strangers, mature pincer grasp: ​10m
● Walks, imitates others, say dada mama specific,
say one-two other words: ​1 ea
● Walks backward, says three to six words: ​15m
● Runs, kick a ball, say at least six words: ​18m
● Walks up and down stairs, washes hands,
brushes teeth, copies line: ​2 ea
● Ride tricycle, Talks 3-words sentences: ​3 ea
● Hops on one foot, copies , name colors, tells a
story:​ 4 ea
● Heel to toe walk, copies◼, Counts:​ 5 ea
● Copies , begins to understand right & left: ​6
ea
References: Nelson & illustrated textbooks of pediatrics.
DR MOHTADI S NOTES FOR SMLE EXAM.

★VSD
➔ The m c mm n c ngeni al hea
di ea e VSD :
◆ Small​ VSD often close
n ane l ​ in the first two
years of life.
◆ La ge​ VSD require surgical repair
within the ​1 ea .

★CROUP
➔ Mild > ​ e id​.
➔ Moderate to severe (rest stridor) >
e ine h ine​.
➔ If not responde give ​e ine h ine again.
➔ If still not respond ENT & ICU
consultation.

★P ning accina i n
➔ Patient on​ low-dose systemic steroids ​for less
than 14 days > ​gi e him all accine .
➔ Patient on​ high dose systemic steroid​s for more
than 14 days > ​dela all li e accine f 1
m n h.
➔ Patient on other ​immunosuppressive drugs​ >
dela li e accine f 3 m n h .
➔ Patient on ​biologics cytokine inhibitors​ > ​Dela
MMR & Va icella 6 m n h .
➔ Patient received IVIG​ > ​dela MMR & Va icella
f 8m nh .
➔ Patient received blood transfusion​: ​dela MMR
& a icella f :-=
● Packed RBCs: 3m
● Whole blood: 6m
● Plasma & Platelets: 7m
➔ children have family members with primary or
secondary immune deficiency: ​gi e him all
e ce OPV.
DR MOHTADI S NOTES FOR SMLE EXAM.

★B ki l m h ma
● Af ican​ child with neck mass> think about
Burkitt lymphoma
im an fac :-
➔ Most significant risk​ EBV infec i n
➔ Gene :​ C-m c
➔ microscopic findings: ​ a k
a ea ance
➔ Treatment: intensive ​chem he a ​.

★Thala emia
● - hala aemia ai : ​HbA2 >4%.
○ Slightly anemic, ​l MCV and MCH
○ Clinically ​a ​ymptomatic.

● hala aemia in e media ​: high HbF.

○ Anemic​ (symptoms usually develop
when the hemoglobin level remains
below 7.0 g/dL)
○ Very ​l MCV and MCH
○ Splenomegaly
○ Variable bone changes
○ Variable transfusion dependency.

● hala aemia maj ​: HbF >90%

(un-transfused).
Se e e haem l ic anaemia,
Ve l MCV and MCH
○ Hepatosplenomegaly,
○ Chronic transfusion dependency.
DR MOHTADI S NOTES FOR SMLE EXAM.

★Pedia ic ca ic inge i n
➔ Bleaching if asymptomatic > ​ b e e
➔ Drain > ​end c ega dle
m m

★CONGENITAL HEART
DISEASE
➔ Newborn with ​PDA​ > indomethacin or
ibuprofen
➔ Newborn with ​c an ic​ heart disease >
prostaglandin infusion

➔ Acute ​TOF​ hypoxic spells >

● Place the child knee-chest
position, oxygen
● Then sedation with opioids
consider ketamine & propranolol.
● Definitive TOF management >
surgical repair in 3-4m.

➔ An ac e e ace ba i n f HF, ign

f fl id e l ad ​> Loop diuretics
(furosemide) and oxygen if hypoxic

★ Itching, bleeding, offensive smell >

f eign b d .

★ if with lacerations or urinary, stool

incontenince > ​ e al ab e
 DR MOHTADI S NOTES FOR SMLE EXAM.

★ OBG
★BREAST CANCER
1- In a i e in ad c al b ea ca cin ma​ ​(most
common breast cancer)
➔ B ea -c n e ing ea men (E ci i n f
m i h afe ma gin f n mal i e)
● Suitable for tumor ​< 4cm
● With​ l m h n de clea ance ​if sentinel
node biopsy is positive.
● Give​ e a i e adi he a ​ (RT)

2-In ad c al b ea ca cin ma
➔ M dified adical ma ec m ​ ​(entire breast is
removed, including the skin, areola, nipple, and
most axillary lymph nodes, but the pectoralis
major muscle is spared)
➔ Indica i n:
● Tumor more than​ 4 cm.
● Widespread disease or those who
choose this treatment.
● If SLB +ve do clearance
➔ Radi he a nl if:
● > 3 LN​ involvement, Lymphatic/vascular
invasion.

★UTI in egnanc
➔ Cystitis first & second trimester
○ Ni am icillin
➔ Cystitis third trimester
Am icillin ce hale in
➔ Pyelonephritis>
IV cef ia ne
 DR MOHTADI S NOTES FOR SMLE EXAM.

★FETAL DEMISE
Managemen f fe al demi e:

● N DIC e en

➔ Delivery may best be ​defe ed​ for a number of

days to allow for an appropriate grief response
to begin.
➔ Or if the patient ​ i he ​ conservative
management, ​follow weekly serial DIC
laboratory tests​.
➔ 90% ​ of patients start spontaneous labor after 2
weeks.

M de f deli e

◆ If < 23 eek ​ & no fetal autopsy is

indicated: dilatation and evacuation
(D&E)
◆ If 23 eek ​ : Induction of labor with
vaginal prostaglandin.

Ce arean deli er i almo ne er appropria e for dead

fe .

★HTN
● Ch nic HTN​: HTN before 20 weeks of GA.
● Ge a i nal HTN​: diagnosed after 20 weeks.
● P eeclam ia:​ gestational HTN with
proteinuria.
● HTN S e im ed eeclam ia​: chronic
HTN then after 20 weeks proteinuria.
● Eclam ia​: seizure
 DR MOHTADI S NOTES FOR SMLE EXAM.

★BREAST MASS
➔ After history and clinical examination.
➔ patient ​less than 30​ ? ​Ul a nd
➔ patient ​30 or older​ ? ​Mamm g am
➔ Suspicious​ on mammogram results?
C e needle bi

C ic n Ul a nd FNA e l :
➔ Clear fluids? ​Rea e & f ll
➔ Residual mass or Bloody? ​C e needle
bi

S lid n l a nd e l :
➔ Likely benign? ​T ea a needed
➔ suspicious? ​C e bi

★H e h idi m in
egnanc

➔ First trimester ​PTU

➔ Second and third ​me hima le
DR MOHTADI S NOTES FOR SMLE EXAM.

★Amen hea
P ima Amen hea

M lle ian Agene i T iad

➔ Primary amenorrhea
➔ (+) breasts but (–) uterus
➔ (+) pubic and axillary hair

And gen In en i i i
➔ Primary amenorrhea
➔ (+) breasts but (–) uterus
➔ (–) pubic and axillary hair

G nadal D gene i
➔ Primary amenorrhea
➔ (–) breasts but (+) uterus
➔ ↑ FSH levels

H halamic Pi i a Fail e
➔ Primary amenorrhea
➔ (–) breasts but (+) uterus
➔ ↓ FSH levels

★C n aindica i n f ECV
➔ Severe oligohydramnios.
➔ Nonreassuring fetal monitoring test results.
➔ Hyperextended fetal head.
➔ Significant fetal or uterine anomaly (eg,
hydrocephalus, septate uterus).
➔ Abruptio placenta
➔ Active labor with fetal descent
➔ Multiple gestation.
➔ previous classical CS
➔ any indication for CS.
 DR MOHTADI S NOTES FOR SMLE EXAM.

★LABOR
Fi age (la en ) ​> ​0-5 cm ce ical

➔ P l nged la en ha e
● more than 20 h in nullipara, more
than 14 h in multipara.
➔ Managemen f l nged la en
ha e​:
● rest & rehydration.
● oxytocin if hypotonic contractions.
➔ CS for urgent problems only.

Fi age (ac i e) ​> 6 cm f ll dila ed

➔ P l nged ac i e ha e
● If dilation 1 cm over two hours in
active phase,
➔ Managemen f l nged ac i e
ha e​:
● oxytocin with amniotomy.
➔ Ac i e ha e a e : ed
memb ane i h
● No cervical change for ≥4 hours
despite adequate contractions.
● Or No cervical change for ≥6
hours with inadequate
contractions.
➔ Managemen f a e ed ac i e age
● Depends on contractions
(Adequate contractions should
occur every 2-3 min.)
● If contractions are hypotonic > ​IV
cin.
● If contractions are adequate > ​CS
 DR MOHTADI S NOTES FOR SMLE EXAM.

Sec nd age ​> ​ f m f ll dila ed ill deli e f

he bab .
➔ P l nged ec nd age
◆ In n lli a a ​> 3h of pushing.
◆ In m l i a a​ > 2h of pushing.
◆ Wi h e id al ​> add 1 more hour.

➔ Managemen f l nged ec nd
age:
● If contractions are hypotonic > ​IV
cin
● If contractions are adequate >
head is not engaged ?
eme genc ce a ean ec i n
● head is engaged? ​ b e ic
f ce a ac m​.

★Vaginal di cha ge
mic c e anal i
➔ ​ e d h hae
P h hae​ >
Candida, treated by fluconazole.
➔ ​Flagella ed, an, a a i e ​>
Trichomonas, treated by metronidazole &
for (husband also)
➔ ​Cl e cell ​> BV, treated by
metronidazole

➔ g een ell di cha ge​, foul or fishy

smell, itching = trichomoniasis
➔ No itching, foul or fishy smell, ​g e ​ in
color = BV
➔ Whi i h Chee ​ ​discharge and thick,
itching but no smell= Candida
 DR MOHTADI S NOTES FOR SMLE EXAM.

★P ima PPH
If b i k bleeding bl d e e falling hea
a e i ing

➔ Re ci a e fi
● 2 large-bore IV
● Oxygen by mask
● Monitor BP, pulse, urine
output, then search and
treat the cause.

➔ if i al a e g d&n f e bleeding
● start bimanual uterine
massage, oxytocin, IV
fluids.

➔ If find he e f & b gg > hi i

e ine a n
● carboprost or misoprostol.

➔ If n a n
e l e geni al ac & e f
lace a i n :
○ if you find suture and drain
hematoma.
If n lace a i n
● inspect the placenta:
○ if retained placental tissue:
remove manually or with
D&C or medically.

★Bi h c e
➔ score​ 6 ​favorable: ​ cin
➔ score ​ 3​ unfavorable: ​ce ical i ening
DR MOHTADI S NOTES FOR SMLE EXAM.

★PREVENTION
➔ P im dial e en i n​ ​> when you prevent the
risk factors
ً ‫ز ﻟﻤﺎ ﻧﻤﻨﻊ اﻟﺘﺪﺧ ﻦ واﻟﻜﺤ ل ﺑﺎﻟﺴﻌ د ﺔ ﻣﺜ‬

➔ P ima e en i n​ > you are trying to prevent

disease.
‫ز ﻣﺜ ً ﻟﻤﺎ ﻧﺴ ﺣﻤ ت ﺗﻄ ﻋ ﺔ ﻋﻦ ﻋ اﻣﻞ اﻟﺨﻄ ره‬
‫ ﻧﺤﺎول ﻧ ﻋ اﻟﻨﺎس ﻋﻦ‬،‫ﻟ ﺻﺎﺑﻪ ﺑﺎﻟﺴﻜﺮ او اﻣﺮاض اﻟﻘﻠﺐ‬
‫ﻣﺮض ﻣﻌ ﻦ وﻛ ﻒ ﺘﻔﺎدوﻧﻪ او اﻋﻄ ﺗﻄﻌ ﻤﺎت‬.

➔ Sec nda e en i n​ > early detection of

disease (screening tests)

➔ Te ia e en i n​ ​> disease is already here,

and we are trying to minimize complications

➔ Q a e na e en i n​ ​> when we are trying to

protect patient from invasive medical
intervention and offering ethically acceptable
process.