SMLE
IMPORTANT
NOTES
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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 [Link]) > 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 = [Link]
➔ La e = [Link]
● 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 :
● Pain
● Pallor
● Pulselessness
● Paresthesia
● Paralysis
● Poikilothermia (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 steroids 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.
