SMLE 2019

TH
17 OF DECEMBER

Glory Team

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

suggestions.

[email protected]

Medicine: 2-6
Surgery: 7-11
Pediatric: 12-15
OB/GYN: 16-18
Glory Group 17th December

★ Medicine
● Diagnostic (or high yield ) test to reach dx of RA:
A. ANA
B. Anti CCP
Answer is: B
➔ Non‑specific parameters
○ ↑ Inflammatory markers: ​CRP​, ​ESR
○ Anemia of chronic disease
➔ Serology (specific parameters)
○ ACPA (e.g., ​anti-CCP​ ;)
■ Specificity​ > 90%
○ Rheumatoid factor (RF)
■ IgM​ ​autoantibodies​ against the F
​ c region​ of ​IgG
■ Low ​specificity

● Pt had ​massive hemoptysis​ caused by TB bronchiectasis and was treated,

X-ray provided: there is collection in upper right lung, your immediate
management :
A. Put him on Right lateral position
B. Chest physiotherapy
Answer is: A
➔ In massive hemoptysis: initially Patient must be placed in the lateral decubitus
position (over the affected side)

● 77 years old female pt, have bilateral cerumen in her ears, examination
showed (Rinne test positive on both sides, Weber lateralization to left) Dx:
A. all options in Left ear
B. one option in Right ear
Answer is:
➔ Positive renin: indicates normal or sensorineural hearing loss.
➔ Weber shift to right: so it’s either right conductive or sensorineural.
➔ Positive renin excluded conductive: it’s left sensorineural HL
Glory Group 17th December
● Typical presentation of cushing syndrome (moon face, stria, obesity...) but
on lab result: low ACTH and low Cortisol 8:00 am, Dx:
A. Cushing syndrome
B. Others difficult names
Answer is: ​Could be iatrogenic, if ACTH low and cortisol high > go for adrenal

● Presentation of CAH, asking the mode of inheritance:

A. AR
Answer is: A

● Psychiatry case: female tried to cut her wrists, her mood changes suddenly
in clinic, caused problem btw the doctor and the nurse, most likely
personality disorder:
A. Anti-social
B. Borderline
C. Schezoid
Answer is: B

● Asymptomatic female complains of only spider veins on the anterior aspect

of her rt thigh, and asking for a cosmetic treatment, there is no varicose
veins, only those spider veins, you will offer:
A. sclerotherapy
B. endovenous ablation
C. surgical stripping and ligation
D. some medications (combination of two)
Answer is: A

● Patient with jaundice and ​fleiser keiser ring​, they gave laps and
ceruloplasmin value i don't remember, what is the treatment ??
A. Penicillamine
Answer is: A

● Case of drug abuser with ​painless hand ulcers​ or ​papules ​I don’t really
remember, + something in retina and splinter hge:
A. Bacterial endocarditis
B. Syphilis
Answer is: A, we are assuming janeway lesions in the hands. (osler nodes; painful,
janeway lesion: painless)
IF U DONT REMEMBER DO U THINK ILL :(
Glory Group 17th December

● Iong case scenario, asking about symptoms (non-caseating granuloma)

with which disease
A. Crohn’s
B. IBS
C. UC
Answer is : A

● pt with cough, hemoptysis, and SOB, PDD -ve, L.N show caseating
granuloma
A. anti TB
Answer is:​ What’s the question? If pulmonary TB suspected go for sputum culture and
CXR after isolation.

● Child Asthma he is on albuterol when needed Recently he is complaining

of multiple episodes of SOB night time 6 or 8 times per month What do u
want to add to his medication
A. Salbutamol with ICS
B. Formoterol with ICS
C. Montelukast
D. Aminophylline
Answer is: B ​He is already on SABA And he has moderate persistent asthma > so
LABA +ICS
Glory Group 17th December
● Young female in 30s with jaundice and yellow sclera started 2 weeks ago.
No flapping tremor or stigmata of liver failure. LFTs: High AST(1400),
ALT(1300), GGT (70?), Bilirubin High direct and indirect, US: biliary
strictures and dilatation, What is Most appropriate management
A. discharge with F/U
B. admit and start iv dextrose
C. order PT & INR
D. refer to liver transplant
Answer: C

● Young female with isolated ​Elevated liver enzyme​ only she is

asymptomatic, what is your management
A. Colonoscopy
B. Reassurance
C. Order ANA

Answer is:

● Elderly 80 years old admitted to hospital as a case of pneumonia 2 days

ago now she is confused and agitated Vitals Temp 38 RR high I can't recall
exactly HR was 100 O sat 95 ​what is the nurse should do
A. Ask for on call resident and give her haloperidol
B. Elevate the bed and give her oxygen
C. Call the family to set and watch
Answer is: B
IN PREVIOUS RECALL: ​Copd elderly admitted exerberation at night became aggressive
disoriented what the nurse should do first:
a. Call the duty dr for lorazepam iv
b. Restrain her
c. Call family sit beside her
d. Elevate the head of bed put nasal O2 oxygen try to orient her about place and time
Glory Group 17th December
● what appropriate method to collect urine to do culture ( appropriate and
reliable)?
A. mid stream
B. subrapabic aspiration
C. cystoscopic aspiration
Answer is: A But best is C

● Sick euthyroid syndrome ?

A. low T3, T4 and high reverse T3
Answer is: A

● 19yr old man with bloody diarrhea, pain at iliac fossa which show this
episode at previous but little blood spotting dx?
A. UC
B. Chrons
C. diverticulosis
D. ischemic colitis
Answer is: ​incomplete but most likely A

● which group should screened to asymptomatic bacteriuria?

A. diabetic
B. pregnant
C. before surgery
D. malignancy not sure
Answer is: B

● Pt in ICU with necrotizing pancreatitis for 4 weeks what metabolic response

will be present in this Pt
A. Hypoglycemia
B. Lipolysis
C. Decrease insulin resistance
D. Decrease gluconeogenesis
Answer is: B

● Pt complaining of epigastric burn for 6 month increase when lying down,

and when he left wight he feels better taste in his mouth
A. Perforated peptic ulcer
B. Esophagitis
C. Pancreatitis
D. Gastritis
Answer is: B
Glory Group 17th December

★ Surgery
● Trauma pt, and they mentioned typical s&s of tension pneumothorax, his
GCS is 8​, what is your ​next​ step in management:
A. intubation
B. Needle thoracostomy
Answer is: B

● Typical case of appendicitis by history and

examination, x ray showed fecalith (pic
provided) your next step:
A. order non contrast CT
B. appendectomy
Answer is: B

● woman post lap cholecystectomy not sure

for duration present with SOB, (manifestation
of atelectasis) and need mx?
A. bronchodilator
B. abx
C. secnti something
Answer is: ​incentive spirometry

● Case with S&S of pancreatitis but amylase was high but not even reach
double normal value, what is the best initial investigation
A. Urine amylase
B. CT scan
C. US
Answer is: C
​ ancreatiti​s​.
​Ultrasound (most useful initial test)​: ​indicated in all patients with acute p

● Hard sign of vascular injury:

A. Palpable thrill
B. Weak pulse
C. Changed the color of the limb
Answer is: A
Glory Group 17th December
● girl 17 yrs not menstruated with breast develop but scant pubic and axillary
hair with increase in testosterone in scenario?
A. DHEA
B. 17 hydroxy
Answer is: A

● pt with left flank pain us or x-ray show firm mass in the lumbar region ask
about investigation?
A. MRI
B. CT
Answer is: incomplete, how can X-ray detect the consistency of tumor ? Firm on
X-ray?!!!

● Perianal ​swelling tender​ didn't mention worm or not there is no

leukocytosis ​no fever​?
A. Hematoma
B. Abscess
Answer is: A

● Pt was playing football and he fell on his knee and develop swelling in his
tibia
Answer is: osgood-schlatter disease

● 30 yr old male with unilateral inguinal hernia open with mesh 3 weeks,
come with pain radiate to thigh and paresthesia ?
A. nerve block
B. remove mesh and neurectomy
C. Systemic anti inflammatory
Answer is: C

● pt fall from height 4 meters stable but complain of severe bilateral heel best
mx?
A. pain killer
B. radiology on 2 foot
Answer is: ​first check pulse then painkiller.
Glory Group 17th December

● Old patient with RLQ pain; on examination there is mass 3x3 + he is taking
anticoagulant for atrial fibrillation. On CT there is mass on right rectus
muscle 3x3 enhancing. What is the management ??
A. Surgical excision
B. Embolization
Answer is: ​ THIS IS RECTUS SHEATH HEMATOMA
➔ stop anticoagulants
➔ analgesia & observation
➔ FFP & vit.k if severe bleeding
➔ Embolization if unstable

● Patient with appendicitis and ​abscess, reaching the abdominal wall​ , what
is the management ??
A. Open drainage
B. Percutaneous drainage
C. Open appendectomy with drainage
D. Laparoscopic appendectomy with drainage
Answer is: B

● Patient had an accident lost 25%blood loss...what is expected to decrease?

A. Pulse pressure
B. GCS
C. Urine output
Answer is: A

➔ Class 1: Volume loss up to 15% of total blood volume, approximately 750 mL.
Heart rate is minimally elevated or normal. Typically, there is no change in blood
pressure, pulse pressure, or respiratory rate.
➔ Class 2: Volume loss from​ 15% to 30% ​of total blood volume, from 750 mL to
1500 mL. Heart rate and respiratory rate become elevated (100 BPM to 120
BPM, 20 RR to 24 RR). ​Pulse pressure begins to narrow,​ but systolic blood
pressure may be unchanged to slightly decreased.
➔ Class 3: Volume loss from 30% to 40% of total blood volume, from 1500 mL to
2000 mL. A significant drop in blood pressure and changes in mental status
occur. Heart rate and respiratory rate are significantly elevated (more than 120
BPM). Urine output declines. Capillary refill is delayed.
➔ Class 4: Volume loss over 40% of total blood volume. Hypotension with narrow
pulse pressure (less than 25 mmHg). Tachycardia becomes more pronounced
(more than 120 BPM), and mental status becomes increasingly altered. ​Urine
output is minimal or absent​. Capillary refill is delayed.
Glory Group 17th December
● Vulvar carcinoma in situ Tx
A. Vulvectomy
B. Superficial local excision
C. Radiochemotherapy
Answer is:​Carcinoma in site > one those accepted
● WLE
● Laser surgery
● Skinning vulvectomy

● Pt did surgery in sinuses I don't remember the name later he developed

numbness in lower lid and upper lip, what is nerve injuries
A. Infraorbital
B. Infratrociolar
C. External nasal
Answer is: A

● Patient had penetrating knife-injury to the neck, he’s awake and alert O2 sat
87%. What’s the best management:
A. Intubate
B. O2 mask
C. Cricothyroidotomy
D. Tracheostomy
Answer is: B

● Patient had painful itchy lump in anus, then ruptured and developed
discharge. What’s your diagnosis:
A. Anal abscess
B. Anal fistula
Answer is: B
➔ Ruptured​ abscess >> fistula
➔ Abscess​ >> mass or swelling, pain, tenderness, redness and purulent
discharge, usually with fever or leukocytosis.
➔ Hematoma​ >> painful mass only.
➔ Hemorrhoids ​>> painless, prolapsed mass with bleeding; becomes painful when
thrombosed​.
➔ Fissure​ >> pain (during and after defecation) bleeding

● 42 years old female complaining of bilateral GSV varicose vein for 3 years,
what is the most appropriate management ?
A. Endovascular ablation
B. Sclerotherapy
C. GSV ligation and strpping
Answer is: A
Glory Group 17th December
● Patient was hit on abdomen 4 days ago. Found to have small wound with
semi-purulent discharge, what’s the most appropriate management?
A. CT of abdomen
B. Send for laparotomy
C. Culture the discharge
Answer is: A

● Elderly with ELECTIVE hernia repair On admission patient Sx of right HF

and hyperthermia what to do :
A. open repair now
B. don’t repair unless obstructed
C. Lap no
D. delay and do it when Sx relieved
Answer is: D

● Pt came with cholecystitis symptoms for 1 day;

A. early lap chole
B. 2-3m lap chole
C. ERCP
Answer is: A

● Female patient with fresh blood per rectum colonoscopy was normal.
Tech99 showed angiodysplasia in left colon, whats next best management:
A. Something ablation
B. Resection of left side colon
C. Some medical therapy
Answer is: ​argon cautery
Glory Group 17th December

★ Pediatric
● 6 or 7 years old child presented with DKA, newly diagnosed DM type 1,
what is the most important element to ensure compliance
A. Health educator referral
B. Provide written management plan
C. Involve child in group type 1 DM
D. Listen carefully to child Questions and concerns
Answer is:
IN PREVIOUS RECALL: 7 years old child brought to the ER with DKA. What is the best
to do after ER treatment?
A. Listen to his concerns about DKA and its management
B. Supply child and family with a written plan of care
C. Send the Child to special care services

● Q about eczema what is true regarding treatment:

A. Ointment highly depend on provider and pt predilection
B. Strong soap is better than non soap
Answer is: A

● Pediatric pt had congenital diaphragmatic hernia, (they did resuscitations

in delivery room) what is the immediate management after stabilizing the
pt:
A. large NGT
B. Surgical repair
Answer is: A

● Case about child mother complaining he is not eating well and he looks
shorter than his classmates he is anemic and I calculate BMI was 17, Wt is
25 Kg, Ht is 120 cm growth hormone level is normal but ILGF is low was 19
What is the most appropriate management
A. Growth hormone
B. Give him high calorie diet
Answer is: B
Glory Group 17th December

● Case about child has diarrhea for 3 month sometimes with blood he has
joint pain not mention stiffness He is anemic and febrile 38
A. Chronic dysentery
B. Crohn's disease
Answer is: UC

● breast milk ig
A. igA
B. IgM
C. igG
D. igE
Answer is: A

● Most accurate diagnostic test for pertussis:

A. Blood culture
B. Nasopharyngeal PCR
Answer is: B
Test from secretions in Nasopharyngeal (culture or PCR) are most commonly used to
diagnose pertussis, but not blood culture.

● 18 month old boy, irritability and cry, can’t move his right leg, on
examination knee is swollen, red and range of motion significantly affected,
he has fever (typical septic arthritis) what is the most important test to
reach your dx:
A. Blood culture
B. Joint fluid analysis
C. Knee x ray
D. CBC
Answer is: B

● What is the best modality to evaluate coronary arteries after Kawasaki??

A. CTA
B. MRA
C. ECHO
D. Cardiac catheterization
Answer is: C
Glory Group 17th December
● Mother brought her boy who’s complaining of vesicles that rupture and
turn to honey colored crust, on his face arms and trunk, asking about when
to allow him to go back to daycare, what you will till her:
A. it is contagious and return to daycare in 3 days
B. it is contagious and return to daycare after they dry
C. it’s not contagious and return to daycare
D. it’s not contagious and (something)
Answer is: B

● Croup case, asking what auscultation findings on examination:

A. inspiratory sound due to subglottic narrowing
Answer is: A

● Supracondylar humerus pediatric fracture, with absent pulse, your

management: (no closed reduction!)
A. Early K-wire
B. Surgical exploration
Answer is: B

● Child with​ lethargy only.​ Labs: hgb 8; what is the management??

A. Oral ferrous
B. Blood transfusion
C. Oral magnesium
D. IM iron
Answer is: A

● Child 3 yo, with pain of leg.exam showed mild swelling. X ray showed
sclerotic lesion at distal tibia. Most likely diagnosis:
A. Osteosarcoma
B. Chondrosarcoma
C. Periosteal sarcoma
D. Ewing sarcoma
Answer is: A

🦴
➔ Most common primary bone tumor in pedia is osteosarcoma (typical sites is distal
femur, proximal tibia usually starts with pain. Then decrease range of motion
or limbing.
➔ Osteosarcoma usually around the knee > distal femur and proximal tibia
➔ Second most common is ewing’s sarcoma, starts with pain less likely affect
movement, verrrry malignant
Glory Group 17th December
➔ Ewing > more than one site, most commonly in long bones, but osteosarcoma
more common in general.
➔ WHAT DO U WANT

● Kid with vesicular rash and small lymphadenopathy and fever....most likely
organism?
A. Varicella
B. Herpes zoster
C. EBV
Answer is: A

🍁
● baby born after 3d mother c/o urine smell burned sugar?
A. maple baby
B. PKU
Answer is: A, ​Maple syrup urine disease

● patient with asthma symptoms not respond to bronchodilators with FTT

and has 2 of his family asthmatic. which give this child Clinical pic of CF ?
A. not responding to bronchodilator
B. the family history of asthma
C. FTT
Answer is: C
Glory Group 17th December

★ Obstetrics & Gynecology

● Female patient after delivery (days) start having s&s of heart failure (
orthopnea, dyspnea, lower limb edema ...ect) , didn’t mention her vitals,
what is the most likely Dx:
A. Viral myocarditis
B. Peripartum cardiomyopathy
C. Infective endocarditis
Answer is: B

● Pregnant in her 36wk, c/o abdominal pain, on examination tender uterus,

Fundal height 38 wk. What is the next test:
A. Abdominal US
B. CTG
Answer is: A, ​In other recall it was​ c​ oncealed abruptio placenta > next step is
Cardiotocography, if not diagnosed > A

● pregnant on labour 1/5 of head felt abdominal , no epidural anesthesia,

HEAD at ​+2 ​station?
A. ventose
B. CS
C. observe after two hours
Answer is: ​VENTOSE, if prolonged labor.

● Pregnant lady in labour, dilatation and effacement in active stage, you felt
the mouth, lips, nose, eyes (face presentation) , how to proceed :
A. Emergency CS
B. Augmentation
Answer is:
Mento anterior > VD
Mento posterior > CS

● Pregnant female pt in her 1st trimester , came with dysuria and frequency,
Abx:
A. Augmentin
B. Cipro
C. Nitro
Answer is: C
Glory Group 17th December
● case do 3 pap before normal. she is smoker pap now show low grade
dysplasia
A. colposcopy
B. repeat pap 1yr
C. resection and ablation
Answer is: ​DEPENDS ON AGE.

● Which of the following is appropriate to diagnose endometriosis??

A. Diagnostic laparoscopy
B. US
C. MRI
Answer is: A

● 17 y female , gymnast, tanner stage 5 , but no menses . What is the cause

of primary amenorrhea?
A. Hypogonadal hypogonadism
B. Vaginal septum
C. Gonadal agenesis
D. Androgen insensitivity
Answer is: B

● Female first visit plans to conceive, no complaints… what’s the best

diagnostic test?
A. Pelvic digital exam
B. Pelvic ultrasound
C. Can't recall the rest
Answer is: Diagnostic test for what?

● Female pregnant...complain of right abdominal pain (did not specify upper

or lower) ​positive tenderness and rebound​. What's the most likely
diagnosis? (no labs or images were done)
A. Pancreatitis
B. Cholecystitis
C. Appendicitis
Answer is: C

● 27 yrs done pap since 3yrs with good and come now for routine check?
A. reassurance
B. repeat pap now
C. other options were with cytology
Answer is: B
Glory Group 17th December
● 41 years old pregnant GA 36 Week presented with abdominal pain no
bleeding, on examination there is tender and tense uterus, there is no hx of
trauma within 48 hours, didn't mention CTG or hx of fibroid
A. Red degeneration
B. Placenta abruption
C. Other excluded by me
Answer is: A

● fibroid in old age which increased with endometrial thickness

A. leiomyosarcoma
Answer is: A

● 32 years old with menorrhagia she not complaining of pain or anything else
Her ​BMI is 41​ No hx of ovarian or endometrial ca what is the most
appropriate next step
A. Hysterectomy
B. MRI pelvis
C. Embolization
D. Endometrial biopsy
Answer is: D
Glory Group 17th December

Ethics & Biostatistics

● Child abuse, what’s next step?
A. Observe, Gathering information, referral, follow up
B. Observe, referral, Gathering information,, follow up
C. Observe, document, report, follow up .
D. Observe, document, report, self care
Answer is: C

Incredible work, incredible people!

Keep it up!

______________________________________________________________________

Commonly Mistaken Question

● Old man k/c of DM, HTN, and chronic claudication. Now came with a 4-hour
history of lower limb pain, palpable femoral pulse but absent pulse of
popliteal and below the left leg. Associated with delay in distal pulse
(dorsalis) of right leg. How would you manage?
A. Catheter thrombolysis
B. Femoral thrombectomy
C. Heparinization and observation
Answer is: ​C,​ since it is mild only diminished pulse by palpating it.
❖ Acute limb ischemia > give heparin even before imaging
❖ In general if u didn’t feel the pulse go for arterial Doppler as initial fast non
invasive procedure to confirm absent pulse
❖ Venous duplex is the best initial for any venous disease (DVT, varicose, venous
ulcer + lymphedema)
❖ CTA > the best for arterial insufficiency and acute limb ischemia.