Page 1 Ammar Naji SMLE Notes medicine & pedia

‫بسم اهلل الرحمن الرحيم‬

: ‫هذا امللف يشمل تجميع ألغلب النقاط في التخصصني‬

Medicine & Pediatric

SMLE Questions: July 2017 - October 12 2017 ‫ و‬SMLE Q bank 12th edition : ‫من‬

table of contents
ID ——————————————————————— Page 2
Allergy and immunology —————————————— Page 6
Cardiology ———————————————————— Page 7
Pulmonology ——————————————————— Page 9
Nephrology———————————————————— Page 10
GI ——————————————————————— Page 11
Rheumatology —————————————————— Page 14
Endocrine ———————————————————— Page 15
Neurology ———————————————————— Page 17
Hema-Onco ——————————————————— Page 18
General pediatrics ———————————————— Page 21
Genetic tables. —————————————————— Page 22

‫هذا العمل هو مجهود فردي والخطأ فيه وارد‬

‫في حال وجود اي اخطاء التواصل على االيميل‬
alyamani.ammar@gmail.com
Page 2 Ammar Naji SMLE Notes medicine & pedia

medicine: ID
Bilateral infiltration is caused by
- lower lobes : Mycoplasma (atypical pneumonia ): Tx: Azithromycin
- Butterfly appearance +HIV Dx: PCP(Pneumocystis carinii pneumonia)Tx: TMP/SMX:Trimethoprim/sulfamethoxazole

Respiratory
- S. aureus: Anti-staph (e.g.oxacillin, cloxacillin)
- If it comes with diarrhea —> legionella
Interstitial lung disease with small non necrotizing granuloma: hypersensitive pneumonitis or Sarcoidosis

RSV virus can be found in: Liver and Brain

Giardia: foul smelling fatty stool

biopsy: sickle shape parasite
Dx: 3 stool cultures, Best: stool immunoassay by ELISA.
Tx: Metronidazole

Giardiasis: foul smelling fatty stool

Ambiasiss: tenesmus , bloody stool
Ascariasis: cough with blood +vomiting bile stained

typhoid\Enteric fever\ salmonella typhi: abdominal pain fever headaches rose spot , constipation then diarrhea
Dx: 3 different blood cultures (Large volume) Tx: Ciprofloxacine

GI
Convulsion after GI infection: Shigella

Bloody diarrhea causes: (CHESS): Campylobacter, Hemorrhagic e.coli, Entamoeba histolytica, Salmonella, Shigella

food poisoning: Symptoms started within

1-6 hours —> staph. aureus
12-48 hours —> salmonella, e.coli
48-72 hours —> shigella, campylobacter
> 7 days —> giardiasis, amoebiasis

Rota virus: most common diarrhea in children, Dx: stool antigen, prophylaxis:Rota vaccine

Meningitis
Infants GEL: GBS, E.coli, Listeria Tx: amoxicillin and Cefotaxime
Children: N.Meningitidis, S.pneumoniae Tx: ceftrixone and vancomycin
meningitis close contact prophylaxis: rifampicin
meningitis and facial nerve palsy : lyme disease : borrelia burgdorferi

CNS
meningitis after Swimming in river lakes: Naegleria fowelri

most common foci of infection is frontal sinusitis leading to brain abscess.

Botulism: from honey ,

Adult descending paralysis CN first, face muscles abdominal cramps with nausea and vomiting upper limp weakness
infant : fatigue, not moving (floppy baby) or gaze from light direct on his eye

Rheumatic fever Tx: aspirin + penicillin, if cardiac involvement add steroid

prophylaxis: for 10 years or until 21 years whichever is longer
Cardio

- Penicillin G IM q 4weeks or daily Penicillin V

- if allergic to penicillin: azithromycin or erythromycin

Infective endocarditis: tooth: strep viridans (affect abnormal heart valves), drug abuse: S.aureus (affect normal heart
valves) Tx: IV vancomycin + IV gentamicin

renal stones with recurrent infection : struvite stone most common organs: proteus (Motile, positive urease and
oxidase negative)
genitourinary

Recurrent UTI prophylaxis TMP-SMX or nitrofurantoin Daily for six months

Syphilis 1ry painless ulcer 2ry: target rash (maculopapular rash all over the body but face sparing) 3ry: neural
symptoms present , Dx: initial: dark field microscope, best Fluorescent treponemal antibody absorption (FTA-ABS)

N.Gonorrhea: best Dx: Nucleic acid amplification testing (NAAT) then culture

Seprmtoicidal in condoms is a risk factor for Staph saprophyticus vaginal infection

Page 3 Ammar Naji SMLE Notes medicine & pedia

Hepatitis the structure of hepatitis viruses are as follow:

Hepatitis A virus (acute) (non-enveloped single-stranded RNA)
Hepatitis B virus (chronic) (enveloped double-stranded DNA) (the most common Hepatitis )
Hepatitis C virus (chronic) (enveloped single-stranded RNA)

TB best culture media :Löwenstein-Jensen medium, PPD test: >5mm positive, >10mm strong positive

Chronic infection
Positive PPD negative x-ray: give Isoniazid (INH) for 6-9 m
medications side effect
INH : peripheral Neuritis give pyridoxine (Vit B6)
Rifampisin: Rash + Red urine
Ethambotol:: optic neuritis
Streptomycin: hearing abnormally

HIV: (T helper Cells) Early symptomatic persistent generalized lymphadenopathy, AIDS: CD4<200
HIV Dx :ELisa is for screening, western blot is confirmatory
alternative cell reservoir for HIV (CD 4) :Monocytes, other T cells, macrophages
HIV + abdominal mass -> mostly non Hodgkin lymphoma
HIV + diffuse pasutle in skin and mouth or velvety skin rash -> Kaposi Sarcoma Tx: intralesinal chemotherapy
HIV: bilateral infiltration in lung : Pneumocystis carinii pneumonia(PCP) now called P.jirovecii

EBV: transmitted by saliva (kissing disease) tender cervical lymphadenopathy + splenomegaly Dx: monospot test

Other infections
associated with burkitt lymphoma
become worse when given amoxicillin,

Brucellosis: Farmer fever headache over weeks

Dog bite : history of rabies vaccine give two doses of rabies vaccine
no history of rabies vaccine give 3 doses of rabies vaccine + immunoglobulin

snake bite: immobilize limb, Wound irrigation/debridement + Anti-venom if appropriate.

candida
- inhaled steroids also have increased incidence of oral candidiasis Tx: Oral.nystatin.
- Candidimia Tx: Fluconazole, if K/C of liver disease Tx: Caspofungin
- Chronic mucocutanous candidiasis: repeated attacks of reddish rash and plaques in mouth
Sporotrichosis (Rose gardener’s disease)
- Budding yeast with branching hyphae
- injured from Rose thorn-> ulcer + ascending lymphangitis

Parasite

Fungal and parasite

Under cooked meat: Taenia saginata or Trichinellosis/Trichinosis
Under cooked pork: Tenia solium-
Soil :ascaris lumbricoids

Cutaneous leishmaniasis (also known as oriental sore, baghdad boil)i s the most common form of leish-maniasis
affecting humans caused by (e.g., L. major and L.tropica)
Visceral leishmaniasis (VL), also known as kala-azar caused by (e.g., L. infantum and L. donovani\

- Post–kala-azar dermal leishmaniasis: Develops months to years after the patient's recovery from visceral
leishmaniasis, with cutaneous lesions ranging from hypopigmented macules to erythematous papule and from nodules
to plaques; the lesions may be numerous and persist for decades.(common in India)

came from Africa: Sudan with fever headache and vomiting: Malaria Dx: Blood smear
Malaria prophylaxis Quinine 1week before traveling, until 6 week after returning

Yellow fever: came back from Africa with myalgia arthralgia (<6days, fever with unspecific symptoms)

Schistosoma: headache, malaise, lymphadenopathy with absolute eosinophilia, Tx:Praziquantel

scotch tap is used in diagnosing: Pinworm (Enterobiasis)

Amoxacillin covers HELPS : H.pylori, E.coli, Listeria, Proteus, Shigella

antiviral that taken by inhalation: Zanamivir

contraindicated: Tetracycline(inhibits Ca and aluminium) and aluminum

vancomycin side effect side effect: red-man syndrome, ototoxic, nephrotoxic

chloramphenicol side effects :Aplastic anemia <1%

Page 4 Ammar Naji SMLE Notes medicine & pedia

Read about: hepatitis B Serology interpretation and meningitis CSF interpretation and bacteria classifications

most common most common

Disease Disease
Organism Organism

bronchiolitis RSV travelers' diarrhea E.coli

croup Parainfluenza virus Gastroenteritis pediatric Rotavirus

laryngotracheobronchitis Gastroenteritis adult Norovirus

epiglottis.. H.influenzae b Post antibiotic diarrhea C.diff

AOM S.pnemonia UTI E.coli

facial cellulitis (purbul) H.influenzae b Central line infection staph. epidermidis

cat bite Pasteurella-Multocida. intubation pneumonia Pseudomonas

Gas gangrene Clostridium perfringens

Organism/disease Treatment

Lung abscess Clindamycin + B-lactam (Ampicillin or ceftriaxone)

Atypical pneumonia (Mycoplasma or Legionella) Azithromycin

Shigella Amoxaciline

Enteric fever/ typhoid fever/salmonela typhy fluoroquinolones (Ciprofloxacine )

traveler diarrhea (E.coli) Ciprofloxacin

Giardia Metronidazole

Clostridium difficile Metronidazole

gunshot wound abdomen Metronidazole

cholera vibrio Doxycycline, epidemic prophylaxis tetracycliune

lymphangitis Doxycycline

bacterial Pharyngitis Penicillin G for 10 days

tonsillitis Amoxaciline

AOM Amoxaciline

Mastoiditis Vancomycin + ceftriaxone

Enterococcus infections Ampicillin resistant: Vancomycin

Enterococcus fragilis Metronidazole not available : Clindamycin

Necrotising faschitis piperacillin/tazobactam

Animal bite/human bite Augmantine + tetunus booster

N.Gonorrhea ceftriaxone

chlamydia Azithromycin (one dose) or Doxycycline 7 days

Pregnant: no doxycycline

Syphlis Penicillin G

HSV Acyclovir, if involving orbital area add topical Steroid

epididymo-orchitis (N.Gonorrhea ,chlamydia) Doxycyclin, can add ceftriaxone

Page 5 Ammar Naji SMLE Notes medicine & pedia

Bacterial vaginosis Metronidazole

Trichomaniasis Metronidazole

rheumatic fever Penicillin and aspirin

with cardiac symptoms add steroid

Infective endocarditis Vancomycin + gentamycin

Neonatal sepsis Ampicillin + Gentamycin

Rosacea Doxycycline -> erythromycin

Schistosoma Praziquantele

malaria: P. falciparum chloroquine or hydroxychloroquine

Pediatric: ID
Adenovirus: in gastroenteritis or URTI come with with conjunctivitis or coryza

Infant eye infection= copious, purulent discharge :

- less than 24 hrs => chemical conjunctivitis.
- less 1 week => Gonorrhea. Tx: (IV Ceftriaxone)
- less than 2 weeks => chlamydia Tx: (IV Ceftriaxone)
Ophthalmia neonatorum prophylaxis: erythromycin ointment

Child with bluster: Face or trunk or extremities: impetigo

Herpangia (HBV1): mouth ulcers (tonsillar and tung) and vesicles , lymphadenopathy

Congenital infections TORSH

Toxoplasmosis: (parasite from cat feces, meat ) brain calcification, hydrocephalus, chorioretinitis(blindness)
Rubella: blue berry muffin rash, cataract, deafness, cardiac anomalies , IUGR
syphilis: stillbirth, hydrops fetalis
HSV: IUGR, blind baby

Pediatric infections
Measles: rash from face to trunk + cough , coryza, mouth Koplik’s spots complication encephalitis
Rubella: rash from face to trunk tender lymphadenopathy (occipital, pre-auricular or retroauricular)
Rosacea: fever then rash in trunk then in face and limbs
Varicella zoster: chicken box vesicles different stages
Muumuus: parotid swilling, complication orchitis.
Coxsackie v: hand foot mouth vesicles (pillars and soft palate), can cause pericarditis
HSV: multi-nucleated giant cell mouth vesicles (gum bleeding)
EBV:(Infectious.mononucleosis) URTI, tender cervical lymphadenopathy, hepato splenomegaly, Dx:Monospot test

Vaccine
- influenza vaccine: Minimum age: 6 months, don't give if egg allergy present
- varicella: 13 years of age and older (who have never had chickenpox or received chickenpox vaccine) should get
two doses at least 28 days apart, if immunocompromised Pt with family member with chicken box give Varicella.Ig
- Psoriases don't give : varicella
- BCG vaccine: don't give if there is deficiency in IFN gamma
- Hepatitis B vaccine: type is recombinant
- OPV and IPV Both has serum antibodies
- Immune deficient Pt , you can give: influenza , Pneumococci, don't give Life attenuated vaccines
- HIV: the only Live attenuated vaccines can be given are MMR and varicella if CD4>200
- spleen removal vaccines : pneumococcal vaccine, meningococcal vaccine, Hemophilus influenza vaccine
- DTaP: don’t give if: post-previous vaccine anaphylaxis, Progressive neurologic disorder, severe acute illness
UPt oDate: Stable or resolved neurologic condition (eg, controlled idiopathic epilepsy, cerebral palsy, developmental
delay) are Not contraindications or precautions for DTaP vaccine

UTI Dx: urine analysis first + urine culture, if recurrent do U/S

Read about: Saudi vaccination schedule

Page 6 Ammar Naji SMLE Notes medicine & pedia

medicine: Allergy and immunology

T-cell immunodeficiency: (viral and mold infections )
- digeorge syndrome (22q11.2.deletion): dysmorphic features: wide spaced eyes, low sit ears, X-ray: absent
thymic shadow, present with recurrent fungal infections and PCP, lab; low lymphocyte and low Ca

B-cell (Immune globulin ) immunodeficiency: start after the age of 6 months(when mother antibodies is decreasing)
- agammaglobulinemia (x-linked) (Mutation in Bruton’s tyrosine kinase inhibitor)
6m old boys presenting with recurrent sinopulmonary infections: Dx: immune essay:no IgM, IgG, IgA, flow-cytrometry
no B-cell Tx: IVIG

SCID sever Combined immunodeficiency (no B-cell, T-cell) sever recurrent infection since birth die early

CGD Chronic granulomatous disease (NADPH oxidase defect )


(no phagocytosis ): recurrent abscess (skin, and visceral ) most commonly Aspergillus -> staph aureus

Wiskott–Aldrich syndrome (x- linked) : Eczema, Thrombocytopenia, recurrent infection,

hypersensitivity type 1:: Allergic, Anaphylaxis and Atopy : IgE mediated with mast cell release

hypersensitivity type 2: hemolytic anemia(ABO blood incompatibility)

bee sting type1 of hypersensitivity

swelling and redness for hours (Limited anaphylaxis): Antihistamines
tachycardia and SOB :SC epinephrine and IV antihistamin

pyodermagangrenosum is associated with Ulcerative colitis Tx :systemic steroid

Sjogren Syndrome: parotid swilling dryness Tx: artificial saliva

complication: Lymphocytic tissue infiltration

most common cause of itching 1st: Xerosis 2nd: Eczema

first immune responsible agent in the skin: Keratinocyte

Hyper IgM syndrome CD40L defect

Lip swelling for years: angioedema: C1 esterase inhibitor

ACEIs side affect :angioedema

Page 7 Ammar Naji SMLE Notes medicine & pedia

medicine: Cardiology
Myocardial Infarction (MI)
Initial test : ECG
Cardiac markers: CK-MB, Troponin(6 Hrs to rise) myoglobin(1h to rise)
ST elevation Tx: PCI if not tPA + aspirin and nitrates and beta blocker , ECG ST elevation + inverted T wave
nonST elevation Tx: heparin + aspirin and nitrates and beta blocker consider ( 6Pllb/lla|+ PCI )
For pain give: morphine
Most common complication: arrhythmia

MI localization:
Anterior MI:V1-V6. Left anterior defending artery (LAD)
Inferior MI: ll, llll, aVF. Right coronary artery (RCA)
Lateral MI: I,aVL,V5-V6. Left circumflex (LCX)

History of MI: -> acutely hemodynamic unstable + harsh systolic murmur: Rupture of papillary muscle(MR)

MI+ bradycardia + hypotension :atropin + Pacemaker

History of MI, with vague chest pain, normal ECG

- stress test
- can't exercise: perfusion cardiac scan

angina while sleeping : Prinzmetal (variant) angina

asymptomatic Pt with Hx of transit angina + ECG shows AF: Give anticoagulation after calculating CHADSVAS score

Heart Failure HF :
Tx: acute -> lasix (furosemide )+ ACEI + O2 + Correcting underlying cause
Chronic:-> lasix (furosemide )+ ACEI + beta blocker
Drugs that prolongs survival in HF
- ACEIs, B blockers, Spironolactone

2nd degree AV block: pacemaker if not Atropine

coarctation of aorta : radio-femoral delay or a difference in the PB between upper and lower limbs, come with PDA
Dx: Best initial: X-ray, diagnostic: echo
Tx: prostaglandin to keep the PDA open
Complication: aortic dissection

Endocarditis with negative bacterial culture : SLE (Libman-Sacks endocarditis)

Infective endocarditis (IE): Dx: 2 major or 1major + 3minor or 5minor

major: 2+ve blood culture, endocardial vegetation,
minor: fever>38.5 , vascular & immunological phenomena as septic emboli , jane-way lesion , osler's nodes , roth spot
organism: tooth: strep viridans (affect heart valves), drug abuse: S.aureus (affect norma; heart valves)
Tx: IV vancomycin + IV gentamicin: for 4-6 weeks
complication Most common valvular abnormality: Mitral Regurgitation, the least common is ASD
Risk factor: cyanotic heart disease is the most common cause of endocarditis,

pericarditis: friction rub, diffuse ST elevation: Tx: aspirin, if acute with Pericardial tamponade: Pericardiocentesis,
Dressler's syndrome is a type of pericarditis

Myocarditis: Hx of URTI (Coxsackie B)-> ,orthopnea , pulmonary edema, high troponin Tx:supportive can add steroid

Pericardial tamponade: low BP, muffled heart sound, raised JVP

Carotid stenosis:in Carotid Doppler <70% antiplatelate >70% stenting

Aortic stenosis: syncope.(due to systemic hypotension) sever < 1 cm: Surgical repair
murmur:Crescendo-decrescendo: Systolic Ejection,
Can cause: LBBB

aortic regurgitation: Tx: Nifedipine best for delaying the surgery

Mitral stenosis: hemoptysis, flushed cheeks, orthopnea, SOB, palpation

murmur: Opening snap + Mid diastolic murmur, Severe MS if < 1.5 cm: Valve replacement
can present with Dysphagia due to large Left atrium pressing on oesophagus

Mitral Regurgitation.Valve replacement is indicated when the heart starts to dilate.

Page 8 Ammar Naji SMLE Notes medicine & pedia

Leg pain
Claudication: increased by walking. Relief by rest
DVT: long trip or post surgery or after delivery with leg pain and swilling
Acute limp ischemia/peripheral vascular-disease: unilateral leg swelling loss of hair, pallor, pain

DVT: Dx:duplex to calf muscle, Tx: LMWH and Warfarin, prophylaxis: LMWH
if pregnant: LMWH until 36 weeks. After that switch to un-fractionated heparin

Lipid
High risk category (CVD, PVD, stroke, DM) —> LDL < 2.6
Moderate risk —> LDL < 3.4
Low risk —> LDL < 4.2
protective from heart diseases: HDL
more risk for CAD: LDL
Medications
high lipid: Statin (Statin, liver toxic, muscle weakness, don't give in pregnancy) and do LFT before prescribing
High: TGs: Fibrate
Low HDL: Niacin

recurrent palpitations ECG : Supraventricular tachycardia

ECG with Canon wave: ventricular tachycardia

Monomorphic ventricular tachycardia is a wide complex tachycardia

drug that cause thrombolytic action: streptokinase ,tpa

Drugs MOA:
ACEI: decrease afterload and preload
ca channel blockers: decrease cardiac output and decrease peripheral resistance
phytosterol: Decrease plasma cholesterol
Aspirin: inhibit the production of Thromboxane A2

Drug side affect:

Amiodraone (anti arrhythmic): : hyper pigmentation
Digoxin: Hyperkalemia
Clonidine (alpha-agonist antihypertensive): can cause severe hypertension when stopped abruptly

Pediatric: Cardiology
the diagnostic test for most of the congenital heart diseases is echocardiography

congenital heart disease most common presentation is heart murmur

ASD (ostium secundum defect): S2 split, RBBB Tx <8 mm observe

VSD: pan systolic murmur Tx: follow at 12-month if asymptomatic no intervention, can cause cyanosis in later life

PDA: Cardiac defect with a communication between aortic arch and pulmonary vessels

Tetralogy of fallot: Ventricular Septal Defect (VSD) + Overriding of the aorta + Pulmonary Stenosis + Right Ventricular
Hypertrophy (RVH)
On X-ray: boot-shaped heart and dark lung fields

Cyanotic Heart Disease: 5T’s

- Transposition of the great vessels TGA: neonate cyanotic with murmur , RVH, RAD, VSD x-ray shows egg on string
appearance Tx:PGE1, NSIAD is contraindicated)
- Truncus arteriosus
- Tricuspid atresia
- Tetralogy of Fallot(
- Total anomalous pulmonary venous return

Down syndrome heart disease: atrioventricular septal defect

Marfan syndrome: (thin, tall and has chest deformity): heart: can have aortic dissection or arterial aneurism rupture

Family history of premature cardiac diseases : do lipid profile

Infant HR >220BPM: suggests Supraventricular Tachycardia. Attempt Vagal maneuvers and consider IV adenosine.
Page 9 Ammar Naji SMLE Notes medicine & pedia

medicine: pulmonology
Asthma
Acute Tx: ventolin + O2 + systemic steroid (can add Short Acting Anticholinergic (Ipratonium))
On-going Tx: SABA PRN -> add inhaled steroid -> Add LABA Montelukast-> max dose -> add systemic steroid
best investigation for determine severity of asthma: PEFR = Peak Expiratory Flow Rate

COPD:
Acute Tx: SABA(ventolin) or/And Short Acting Anticholinergic (Ipratonium: decrease bronchial secretion)
Can add systemic steroid and O2 and consider intubation , if infection add antibiotic
On-going Tx : Short acting bronchodilators or long acting -> short +LONG -> add inhaled steroid
bronchodilators :(beta agonist or Anticholinergic )

venral (allergic) conjunctivitis come with asthma

Allergic pneumonitis: Pt experiencing cough and wheezing and respiratory symptoms related to a specific place

lobar pneumonia: in auscultation: bronchial breathing

Atypical pneumonia: present with headache, malaise, and low-grade fever with mild respiratory symptoms (cough -
SOB) and bilateral lower lobe pneumonia, organism: Mycoplasma. (if with diarrhea: Legionella) Tx: Azithromycin

- hypersensitive pneumonitis or Sarcoidosis: Interstitial lung disease with small non necrotizing granuloma
- TB causes caseating “necrotizing” granulomas
Parapneumonic effusion empyema: Pt with pneumonia treated with antibiotic weeks later came with effusion:
Dx: Thoracocentesis, Tx: chest tube drainage for the empyema

Green sputum: Pseudomonas, H.influenza or pneumococcal species

bronchiectasis : H. influenzae is a common organism

Add Chest physiotherapy to the medical treatment

most common cause of chronic cough in adult: postnasal drip

obstructive sleep apnea: type of breathing Cheyne–Stokes respiration

most common cause: Obesity, Most effective Tx: C-pap, if not helpful ->Modafinil

Alpha 1 Antitrypsin deficiency: young, cirrhosis, panacniar emphysema

Asbestos: Hx of weight loss and dyspnea factory worker x-ray: bilateral lung fibrosis

horner syndrome (ptosis ,anhidrosis, miosis) site of the tumor Tumor :apex of the lung

SVC syndrome: upper limb edema , intercostals vein engorgement ,Lung cancer or a lesion compressing on the
Median mediastinum

Hamartoma: lung nodule with: popcorn calcification or calcium and fat

Lung carcinoma in-situ: <3cm, adenocarcinoma, absence of papillary or micropapillary patterns, no invasive features

Squamous cell carcinoma: (histopathology: polygonal cells)

high keratin, affect smokers, Pt have high Ca levels (PTH related peptide for lung ca)

small cell carcinoma: can have SIADH post chemotherapy Tx: Water restriction, if Sever: Hypertonic saline

Smoking increase risk of: lung and bladder cancer

Pediatric: Pulmonology
bronchiolitis(RSV): SOB, cough Tx:supportive: O2, IV fluid, Physiotherapy, ribavirin(side affect anemia) can be given

Croup/laryngotracheobronchitis:(Parainfluenza virus)barking cough, horsiness(dysphonia), stridor, diagnosed

Clinically. X-ray:steeple sign Tx: epinephrin + steroid can help

Epiglottitis: drowling of saliva(sitting in Tripod position ), x-ray: thump sign, Tx: intubation, Abx: Ceftriaxone.

allergic rhinitis recurrent nasal congestion, rhinorrhea, sneezing, tearing eyes

pertussis Dx: . Nasopharyngeal swab

Page 10 Ammar Naji SMLE Notes medicine & pedia

inhaled Corticosteroids can cause

- growth retardation
- oral thrush tx: Oral nystatin.

Cystic Fibrosis: recurrent infection(URTI with pseudomonas), greasy diarrhea, slow growing, Dx: sweat chloride test
chance of his sibling of becoming a carrier: 2:4, do sweat chloride test for other siblings too

RDS: seen in prematurity, X-ray Air bronchogram, atelectasis, ground glass. Tx: Oxygen
due to surfactants deficiency (Dipalmitoylphosphatidylcholine)

Pneumocyte Type I: 97% of alveolar surfaces

Pneumocyte Type II: Secrete pulmonary surfactant , decreasing alveolar surface tension

medicine: Nephrology
HTN treatment A: ACEI
HTN Tx <55y :A, >55y:B or C, step2 A+B or A+C. Step3 A+B+C B: thiazide
HTN + migrane -> B blocker C: Ca chanel blocker
HTN + BPH -> prazosin (alpha blocker)
HTN + DM -> ACEI
HTN + gout -> ACEI (thiazide is contraindicated in gout)

Malignant hypertension > 180/120.

uncontrolled HTN-> kidney: Increase hyalinization of arterioles

The most common cause for secondary hypertension is renal disease

The most common cause of Renal failure is diabetes

Renal artery stenosis: screening: Doppler U/S, Dx: CT-angio

- unilateral: HTN
- bilateral: fluid overload + no urine azotemia (would cause HTN and decreased GFR)
nephrotic: proteinuria, edema (generalized depend on severity ) ± Macroscopic hematuria Tx:prednisone
nephritic (Glomerulonephritis):hematuria, proteinuria, edema, and often hypertension Tx: depend on the etiology

Minimal change disease (nephrotic syndrome:) LM: normal, EM: fusion of foot process, average age :2 years old

Polycystic kidney disease: bilateral abdominal mass with loin pain & hematuria (biopsy showing multiple cysts)

Poststreptococcal glomerulonephritis: 1-3 wk post pharynx or skin infection Dx: ASOT, anti-DNAse, LOW C3
Tx: Diuretic (thiazide)
IgA Nephropathy: <7 days post URT,I Normal C3, Tx:steroid

Reiter's syndrome Arthritis, Conjunctivitis, Urethritis (with negative culture) Tx:NSAID

Renal cancer most common symptom: painless Hematuria

Renal cell carcinoma gene: VHL,

Renal stone:
Calcium oxalate: most common
Struvite: recurrent infections
Uric acid: radiolucent stone on US

1- Urge incontinence: Oxybutinin (Anticholinergic)

2- Stress incontinence: (Pelvic prolapse): Kegel exercise -> surgery

acute urinary retention : 1st thing to do is foley catheter and urine culture

Hyperkalemia: palpitations, muscle weakness, muscle stiffness -> arrhythmia, Tx:ca gluconate
Hyokalemia: muscle weakness, diarrhea, irritability

hypercalcemia Tx: IV fluid + Furosemide

Hypocalcemia Tx: IV fluid+ ca+ replace Mg if low.

hypomagnesaemia First symptoms : hyperreflexia

Page 11 Ammar Naji SMLE Notes medicine & pedia

Low Na + dehydration (Hypovolemic hyponatremia) Tx:Normal saline (moderate) Hypertonic saline (severe)
Low Na + volume overload (Hypervolemic hyponatremia) Tx: Fluid restriction + loop diuretics

vomiting -> Metabolic alkalosis (low Na + Low K)

anion gap = Na - ( Cl + HCO3 )

inulin used to measure GFR: because its freely filtered by the kidney

Read about: Acid-base imbalance

Pediatric: Nephrology
Wegener's granulomatosis: renal bleeding + URTI ± hemoptysis + dysmorphic features (Saddle nose)
Goodpasture syndrome: Renal and lung bleeding(hemoptysis & hematuria): anti GBM antibodies

Alport syndrom: disease that damages the tiny blood vessels in your kidneys,+ Hearing loss

HTN in a child: More than 95th percentile

epididydimitis: scrotal pain, examination is normal, US normal , urine analysis show pyuria
Tx: cefixime and doxycycline or azithromycine

hematuria assessment : do urine analysis first

child with enuresis: Dx:first urinalysis (to exclude UTI),

medicine: GI
Esophageal cancer
- Proximal 2/3 —> squamous cell carcinoma.

- Distal 1/3 —> adenocarcinoma (Barret).

Peptic ulcer: Dx:Endoscopy

RISK factors: NSAID
Tx: Triple therapy: PPI, amoxicillin, and clarithromycin
NSAID induced ulcer: prophylaxis and Tx: Misoprostol
Monitor the treatment: urea breath test or stool test for H. pylori
Peptic ulcer medication that causes: Gynacomastia, erectile dysfunction and decrease lipido: Cimetidine

Celecoxib is a NSAIDS with low risk for gastritis.

perforated duodenal ulcer: acute epigastric pain-> generalized, X-ray Free air under diaphragm

chronic pancreatitis: chronic episodic attacks of epigastric pain radiating to the back, Steatorrhea, CT: calcification

acute pancreatitis epigastric pain and tenderness, high amylase, lipase, Tx:IV fluid +NPO

severe diarrhea and vomiting -> hypotension :decrease extracellular fluid

Bowel obstruction:
- Upper intestinal obstruction —> vomiting
- Lower intestinal obstruction —> pain
- Large bowel obstruction —> distention.
- Complete bowel obstruction —> absolute constipation.
flagellated protozoa :absorption is prevented -> diarrhea

IBD
UC: ulceration cell type: T CELL, sigmoidoscopy see fragile mucosa of rectum and spot blood
Crohn’s: Idiopathic : skip lesion , transmural ulcers.

Hx of atrial fibrillation came with severe generalized abdominal pain :Mesenteric ischemia

Hepatitis A biopsy after the resolution of disease will be normal

Hepatitis B vaccine: is recombinant vaccine

Page 12 Ammar Naji SMLE Notes medicine & pedia

Most common symptom with hepatitis C : Loss of appetite (Vague constitutional symptoms)

First sign of portal HTN: splenomegaly

Chronic alcohol: AST>ALT 2:1, high GGT, blood: High MCV with no Megaloblasts

acute live failure: severe decline in live function characterized by coagulation abnormality (INR >1.5) &
encephalopathy in setting of previously normal liver.

high Indirect bilirubin with normal LFT: Hemolytic or Crigler-Najjar syndrome or Gilbert syndrome
high direct bilirubin with normal LFT : Dubin-Johnson syndrome, Rotor syndrome

Pt had jaundice -> his color turned green: Oxidation of bilirubin

Primary biliary cirrhosis: female: autoimmune against bile duct-> itching jaundice xanzlasma,
Dx: high ALP, GGT do biopsy Tx: Ursodeoxycholic acid, best Liver transplant

Primary sclerosing cholangitis: male fibrosis and narrow bile duct, no symptoms Dx: ERCP, come with IBD,
Tx: Liver transplant

Wilson disease (high copper): jaundice and confusion(negative hepatitis ), Kayser fleischer ring,
Dx:Slit lamp test & penicillamine copper if not present Serum ceruloplasmin level
Tx: Penicillamine and zinc, sever cases Liver transplant

zollinger ellison syndrome

Triad of: tumor of pancreas + gastric acid hyper-secretion + peptic ulcer.

Whipple disease: Tx: Long term antibiotic (1year)

plummer vinson syndrome: Dysphagia, Esophageal webs, Iron deficiency anemia Tx:iron replacement

aphthus ulcer: come IBD and celiac

Renal cancer staging: CT

cervical cancer: staging: MRI

large ovarian cyst Dull anteriorly Resonant laterally

ascites Resonant anteriorly Dull laterally

Intercostal spase
- Tension pneumothorax: 2nd mid clavicular line (using NEEDLE THORACOSTOMY)
- Chest tube: 5th ant. axillary line
- Live need biopsy: 7th mid axillary line
- Thoracocentesis: 8th-10th mid axillary line.

Hiccups: give Chlorpromazine

barium swallow :
Corkscrew appearance: diffuse esophageal spasm
bird like appearance : achalasia

vitamin B1 (Thiamin) deficiency: (rice diet only) can cause:

beriberi: symmetrical peripheral neuropathy( sensory and motor impairments)
Wernicke-Korsakoff syndrome: mental state changes (acute confusion), ataxia, and ocular abnormalities (nystagmus)
vitamin B3 deficiency: 3D Diarrhea, Dermaitis, Dementia
vitamin B12 deficiency:(gastric surgery or vegetarian diet) , Parietal cells (vit B12 absorption) in the Terminal ileum
peripheral neuropathy(numbness and soak and gloves distribution),stomatitis، glossitis, Macrocytic anemia with
megaloblast , can cause: Clinical dementia
vitamin C deficiency: ecchymoses, bleeding gum, petechiae

Celiac Duodenum proximal jejunum

Meckel’s diverticulum Lower ilium
crohns Ileocecal area
Brunner's glands Submucosal duodenum
Parietal cells (vit B12 absorption) Terminal ileum
Goblet cells Ascending colon

paneth cell: secret defensins

Aluminum: constipation
Mg: diarrhea
Page 13 Ammar Naji SMLE Notes medicine & pedia

Metoclopromide to decrease the N/V associated with opioids.

Pediatric: GI
Neonate: abdominal distention and constipation: do x-ray

Pyloric stenosis: non-bilious projectile vomiting + Olive mass, can have Hypochloremic metabolic alkalosis
Dx: initial is abdominal US. Most accurate is upper GI series

intussusception: sudden abdominal pain bloody diarrhea, jelly stool

Dx:US showing donut sign Tx: first IV fluid -> air enema or Barium enema

Hirschsprung: abdominal distension and constipation since birth (not passing meconium ),
initially do X-ray to exclude other causes for constipation, Dx:barium enema, rectal biopsy, Tx: leveling colosytomy

bilious vomiting: with obstruction: malrotation (volvulus) ,WITHOUT intestinal obstruction: Duodenal.atresia

Duodenal.atresia: x-ray will show double bubble sign.(intestinal obstruction)

Celiac: flat buttocks, malabsorption, Failure to thrive, mostly affecting: Duodenum proximal jejunum
Dx: Intestine biopsy, Tx: gluten free diet :Rice is safe

Kwashiorkor disease: High carb, low protein diet -> fair coiled hair and abdominal distention,

Formula milk or cow milk: more protein

breast feeding milk: more carb

Hepatitis A virus: common in children, acute, hepatomegaly jaundice, abdominal pain,

biopsy after the resolution of disease will be normal

Duodenal hematoma: blunt trauma-> upper bowel obstruction

X-ray duodenal coiled spring sign: Tx: NGT decompression + TPN

Constipation + developmental delay

Gitelmann k low, Mg low and Ca high
bartter k low, Mg normal and Ca low ,Na low cl low , NaCl reabsorption is defective

devolved vomiting and jaundice after fruit juice: Fructose intolerance

foreign body ingestion: battery : upper Gi endoscope, small objects: serial x-rays
foreign body aspiration mostly: right bronchus , Tx: bronchoscope

congenital diaphragmatic hernia: no breath sound in the left Side and the heart sound heard in right side, scaphoid-
appearing abdomen

neonates may lose up to 10 percent of their birth weight in the first few days of life

infantile colic: due to decreased peristalsis: reassurance, do warm baths

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medicine: Rheumatology
OA: m stiffness <30min, old age, unilateral, X-ray: osteophytes, Heberden (DIP)and bwatcher(PIP)
RA: m stiffness >30min, young age, symmetrical , X-ray:synovitis, swan neck , Boutonniere, joint affected PIP & MCP

osteoarthritis OA: Tx: Physiotherapy to strengthen muscles( high impact low repetition). -> pain drug

Rheumatoid Arthritis (RA):

Tx DAMARD: Methotrexate (MTX) -> add steroid
marker Anti-cyclic citrullinated peptide. (Anti-CCP), genetic HLA-DR4
TNF-alpha released from synovial fluid -> loss of bones in joint
Boutonniere deformity:Flexion of PIP joint & hyperextension of DIP
swan neck: hyperextension of PIP joint & Flexion of DIP

juvenile idiopathic arthritis(Still's disease) Tx: NSAIDs, intra-articular corticosteroid -> methotrexate, corticosteroids

Gout :1st metatarsal joint pain, redness and erythema High temperatures
Acute Tx: NSAID, -> Intra Articular steroid -> colchicine
Prevention of future attacks Tx: xanthenia oxidase inhibitor (alloprinal)
HTN + Gout treat gout with intra Articular steroid steroid , Treat HTN with ACEI
CONTRAINDICTION : thiazide , aspirin , Naiacin

Gout: monosodium urate crystal

Pseudogout: ca pyrophosphate crystal

osteogenesis imperfecta: Defective Type I collagen-> blue sclera + multiple fracture

Osteoporosis: DEXSA: < -2.5 Tx: biophosphanate can add + vit.D + ca

Paget disease: High ALP, Osteolytic lesions on x-ray, osteoporosis skull

Knee swilling initial-> x-ray, if there is Hx of trauma -> knee aspiration

polymyalgia rheumatica: pain & stiffness of symmetrical proximal muscles, tender muscles, no weakness or atrophy,
high ESR

fibromyalgia: joint pain, Normal blood workup.with trigger points on palpation, Depression and anxiety are common.

giant cell arteritis: headache-> LOSS OF VISON, Tx: steroid

Behcet Vasculitis: oralral/genital ulcers, abdominal pain/diarrhea and arthritis of large joints, affect young males 

Tx: Steroids, resistant : Azathioprine , Cholacine, genetic :HLA B51

SLE
markers: Anti-dna (most specific ) Anti Smith, ANA, Anti phosphlibd
most important Prognostic factor: renal involvement

Latent SLE or incomplete lupus: Undifferentiated connective tissue disease (UCTD) It is diagnosed when there is
evidence of an existing autoimmune condition(ANA, ESR) which does not meet the criteria for any specific
autoimmune disease

Scleroderma: CREST Calcinosis, Raynaud’s phenomenon, Esophageal dysfunction, Sclerodactyly, Telangiectasia:

markers:, Anti-topoisomerase I:Anti-SCL-70(diffuse systemic sclerosis ), Anti Centromere(limited disease, CREST),

Dermatomyositis: Proximal muscle weakness, Heliotrope rash (periorbital), Gottron’s papules., risk of malignancy

Drug side affect

biophosphanate: can cause esophagitis

Read about: synovial fluid interpretation

Page 15 Ammar Naji SMLE Notes medicine & pedia

medicine: Endocrine
DM medications:
First line : metaformin
2nd line: metaformin + Sulfonylurea (glipizide, Chlorpropamide) or metaformin+ pioglitazone , metaformin +Gliptin
3nd line: metaformin + Sulfonylurea + pioglitazone
surgery or pregnancy shift to insulin
anti-diabetic regime that resembles the normal physiology: ASPART AND GLARGINE

DM medications side MOA

metformin: decrees hepatic gluconeogenesis, increase Muscle uptake of glucose, increase insulin sensitivity
Incretin: Stimulate insulin secretion
glipizide :Increase insulin secretions from pancreas

DM medications side affect

Sulfonylurea (glipizide, Chlorpropamide): wight gain+ hypoglycemia
pioglitazone, may cause or exacerbate heart failure

Adiponectin: hormone increases body cells sensitivity and response to insulin

DM affect on wound healing: limit phagocytosis

Target HbA1c of DM2 <7 in pregnant <6

DM neuropathic pain Tx: Pregabalin (Lyrica)

DM neohpropathy: after a mean duration of diabetes of 15 years, with highest drop in GFR after 20 years
(screening stat after 5yers of diagnosis in DM1)
Early stages check for microalbuminuria, late stages: Albumin/creatinine spot ratio.

DM+ hemoptysis with fungal infection :Zygomycetes

DM +Calf redness: cellulitis
DM+ painful back swelling has multiple dis-charges: carbuncle
DM+ over flow incontinence: Diabetic neuropathy

DM Pt with papule no itching pink pale not respond for antifungal :Granuloma annulare Tx: no need

thyroid Nodule :mass start with US symptoms start with TSH -> if US high suspicion: FNA

thyroid nodule Increase in iodine uptake: Iodine radiotherapy

Multi-nodular goiter: radioidonie

if with obstructive symptoms or pregnant or child: surgery

Thyroid mass with intracellular amyloid deposit :Medalley

thyroid storm Tx: beta blocker

Hyperthyroidism meds
More rapid action : Propylthiouracil
Can cause pancytopenia (infections) : Methimazole
in pregnancy increase dose by 30% and use Propylthiouracil

hyperthyroidism, with palpitation : Atrial fibrillation

Hashimoto thyroiditis
- increases the risk of non hodgkin lymphoma
- Histology: Hurthle cells

Cretinism: low iodine Tx: for the community: iodine supplement, individual cases levothyroxine

primary hyperparathyroidism: high Ca, high PTH, low phosphate

high prolactin : exclude Prolactinoma (pituitary tumor) Dx: MRI Tx: dopamine agonist :Cabergoline

low prolactin MRI will show: EMPTY SELLA TRUCICA

Cushing syndrome Dx; 24 h urinary cortisol (more accurate) or Low dose dexamethasone suppression test
to know the cause: ACTH level( if low scan adrenal, if high -> MRI brain)
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pheochromocytoma episodic high PB, Dx: high urine catecholamine Tx: alpha blocker : phenoxybenzamine

hyperaldosteronism(conns): high Na, Low K, high Bp

Addison's disease: Low Na, high K

SIADH: : Low Na, Normal K low serum osmolality, high Urine osmolality
diabetes insipidus high Na, Normal K high serum osmolality, low Urine osmolality,
Psychogenic Polydipsia: Low Na, Normal K high serum osmolality, low Urine osmolality,

hyperaldosteronism: Dx:Renin aldosterone ratio, 1ry or 2ry: aldosterone suppression test Tx:Spironolactone

Adrenal gland
Glomerulosa —> mineralocorticoids (aldosterone)
Fasiculata —> glucocorticoids (cortisol)
Reticularis —> androgens (DHEA, androstenedione)

parotid swilling:
Asymptomatic: Parotid CA
bilateral, missed vaccine: Mumps
Swollen, painful uni or bilateral : parotitis
Post surgery, unilateral parotid swelling lab cloudy saliva: bacterial sialadenitis
submanidibular swilling, Pain and swelling related after meals: Sialolithiasis
swollen parotid and salivary gland with dry eye and dry mouth: sjogren's syndrome Tx:Artificial eye and saliva drops

MSH Melanocyte stimulating hormone released from Anterior lobe of pituitary

Pediatric: Endocrine
Pediatric Pt presented with acute symPt oms of DM check urine analysis for DKA

DKA
Most common cause adult: infection children: Missing insulin dose
predominant ketone is: Acetoacetate
early mechanism to restore blood pH:Excretion of CO2 through lungs.
Tx: IV fluids-> insulin-> potassium replacement

Hypoglycemia attack Tx:IM.glucagon.

unilateral gynecomastia in adolescent males is normal

Puppetry
Average age for girls: 10 and a half years old.
Average age for boys: 11 and a half to 12 years old. (earliest sign: Enlarged testes)

precocious puberty: when having puberty changes before the age of 8 years

Screening: leuteinizing hormone LH (high) best: GnRH -> MRI

Mullerian agenesis: secondary sexual characteristics but has no vagina

short stature (growth retardation): 1st see parents hight (if not similar)->
Lab: GH, IGF-1 (somatomedin C) if low: give GH
If normal Lab: Constitutional growth delay

Mid parental height (used to expect height potential)

Boy = (Paternal height + Maternal height + 13 cm)/2

Girls= (Paternal height + maternal height - 13 cm)/2

in girls: the spine stops growing after the onset of menarche by 24 months.

Obesity in childhood Tx: lifestyle modification

congenital adrenal hyperplasia: present with Ambiguous genitalia, Dehydration, hyperkalemia

21-hydroxylase deficiency Dx: high 17-hydroxyprogesterone (Hormone) Tx: hydrocortisone
the Pt will have: bone age more than chronological age

Congenital hypothyroidism: never cries, Umbilical hernia, Distended Abdomen and large protruded tongue

Athlete with weight gain and bad.breath: Anabolic steroid

Page 17 Ammar Naji SMLE Notes medicine & pedia

medicine: Neurology
Stroke: Dx: Brain.CT
<4.5 h tPA + heparin (VTE prophylaxis) +aspirin after 24h
>4.5 h aspirin + heparin (VTE prophylaxis)
Venous Thromboembolism(VTE): heparin or warfarin
prevention: of 2nd stroke/stroke in Atrial Fibrillation : warfarin

Uncontrolled hypertension appears to be the most important risk factor for recurrent hemorrhage

hyper-coagulable state Most common cause of ischemic stroke in females:

Acute Intracranial hemorrhage

blood pressure below 130 mmHg may cause ischemia and worsen neurologic injury.

Extradural hematoma: mostly from middle meningeal artery

Hemiplegia: paralysis in one entire side of the body (left or right)

Diplegia: paralysis in lower limbs
Quadriplegia: paralysis in all 4 limbs

intracranial tumors:
Malignant: Gliomas include: Astrocytomas, Ependymomas, Glioblastomamultiforme, Medulloblastomas.
Benign:Meningiomas

Epilepsy,
receptors most likely is stimulated glutamate
Tx: Carbamizabine or valporic acid or keppra
Status epilepticus: benzo-> phenytoin-> phenoparbital (induse coma),
Absent seizure: child Ethosuximide, >10y valporic acid, (fentanyl will induce seizure)

Headache
- Migraine: chronic unilateral headache associated with nausea, vomiting, photophobia, aura, lasting for hours,
Dx: clinical diagnosis Tx: triptan, prophylaxis is b blocker. If asthma : amitriptyline, if Pt doesn’t want medical Tx:
biofeedback therapy
- Cluster: Tx: O2 prophylaxis: Ca chanel blocker (Verapamil)
- Tension : band like distribution
- giant cell arteritis:, Headache when combing hair, tender vessel on temporal area-> LOSS OF VISON, Tx: steroid
high ICP: headache ,vomiting, blurred vision, cranial nerve affected: 6th CN palsy then optic

trigeminal neuralgia: Carbamazepine

Parkinsonism Tx: Levodopa, antiviral used: amantadine

Myasthenia gravis: diplopia, ptosis, blurred vision, difficulty chewing weakness worse at the end of the day, it affect
Acetylcholine receptors.
Tx: Acute: plasmapheresis ± IVIG on-going: pyridostigmine

Multiple sclerosis: episodes of focal neurological damage that come and go (e.g: optic neuritis )
CSF: IGg + irregular bands, Dx: MRI Tx: IV steroid

Botulism: descending paralysis CN first, face muscles abdominal cramps with nausea and vomiting upper limp
symmetrical weakness, lower limbs

Myotonic macular dystrophy : muscle wasting difficulty in swallowing, frontal baldness, cataract,

Duchenne: Gower sign, Pseudohypertrophy, dilated cardiomyopathy

Alzheimer's disease
Tx: donepezil, galantamine, and rivastigmine
developed hallucinations : Haloperidol

carpal tunnel syndrome: median nerve Dx:Durkan’s carpal test Tx: hyperextension

Temporal lobe: smell and hearing

Occipital lobe: vison
Page 18 Ammar Naji SMLE Notes medicine & pedia

Drug side affect

TCA: 3Cs Convulsion, Cardiotoxicity and Coma
phenytoin: gingival hyperplasia, hirsutism, folic acid deficiency
Tacrine (Alzheimer’s drugs): hepatotoxic
Metoclopromide: dystonia

Read about: Glasco coma score (GCS) , cranial nerves

Pediatric: Neurology
cerebral palsy: developmental delay (crossed legs), prematurity is the most common cause

Guillain Barre syndrome: post URTI infection(campylobacter)-> Ascending paralysis with hyporeflexia -> respiratory
failure, can have cranial nerve involvement
cell affected: Schwann cells CSF: high protein Dx: nerve conduction study Tx:IVIG or plasmapheresis

autism: is always alone, doesn’t own any toys and doesn’t play with others: Interpersonally

medicine: Hema-Onco
Most common intra-abdominal tumor
infancy: Neuroblastoma (adrenal)
Children: Wilms tumor (kidney) Pt might have aniridia (absence of the iris)

most common Parotid tumours:

Benign:Pleomorphic adenoma then hemangioma
Malignant: Mucoepidermoid

Hodgkin lymphoma: histopathology: Reed Sternberg cell, Tx: chemo+radiation(ABVD+XRT) types:

- Nodular Sclerosis (MOST COMMON) fibrosis and collagen envelopes
- Mixed cellularity: has pleomorphic background (eosinophils, neutrophils, and histiocytes)
- Lymphocyte predominance: background infiltrate of lymphocytes
- Lymphocyte depleted: worst prognosis
Burkitt lymphoma: gene: C-myc, more common in africans, come with EBV, histopathology: starry sky appearance

ALL (most common in children)

CP: fatigue, weakness, lymphadenopathy

Lab: low Hgb high WBC, CALLA +ve (Common acute lymphoblastic leukemia antigen)

Diagnosis: flow cytometry of bone marrow biopsy showing >20% blasts

Tx: chemotherapy+ intrathecal methotrexate

AML: (most common in adult )

CP: pale, ecchymoses, weakness, lymphadenopathy

Lab: low Hgb high WBC with(neutropenia causes ecchymoses)

Diagnosis: flow cytomtry (myloxidase) bone marrow (>20% blast) blood film (blast, aure rods comon in M3)

Tx chemotherapy

Subtype : M3 promyelocytic leukemia: DIC, aure rods in blood film Tx add tretinoin to chemo

CLL:

Stages : 1 high WBC (mostly lymphocytes) 2: lymphadenopathy 3:hepatosplenomegaly 4thrombocytopenia

Diagnosis: clinical + WBC + hypogammaglubulinemia

Tx: no symptoms Observation

SymPt omatic: chemo(fludrabine)

CML
CP: Asymptomatic mostly, splenomegaly , generalized weakness, itching

gene :Philadelphia chromosome t(9;22

Dx: high WBC (mostly neutrophils) cytogenesis: Philadelphia chromosome

Tx: tyrosine kinase inhibitor

Bone marrow transplant is the definitive treatment of All leukemias but you need to try other methods first
Page 19 Ammar Naji SMLE Notes medicine & pedia

multiple myeloma (CRAB): high Ca (poor prognosis), Renal fallure, Anemia, Bone litc lesion
Dx: Protei electrophoresis: for M protein. Blood: ROULEAU FORMATION

anemia of chronic disease: normochromic normocytic

iron deficiency anemia IDA :, most common cause is: chronic blood loss
Tx: oral iron if gastritis/upper GI bleeding: IV iron, best form for iron supplement: Ferttin, if significant or acute
bleeding: packed RBCs
Monitor treatment by: Reticulocyte Count and Hb level
vitamin C: increases the metabolization/absorption of iron

hemolytic anemia: high Un-conjugated bilirubin, high LDL, high reticulocyte

SCA: limp pain : VOC (Hand–foot syndrome), painful hip: AVN, SOB+chest pain: acute chest syndrome(most
common cause of death ), hyposplenism (infarction), penis pain(Priapism.), blood film: Inclusion bodies +joly bodies
Tx: acute: IV fluid+ analgesia ± blood transfusion, ongoing: hydroxyurea (increase HbF)
HIGH PROTEIN LEVEL: will have false positive test
SCA + parvovirus B19: Aplastic anemia
recurrent cholecystitis: cholecystectomy

Beta Thalassemia: common in the Mediterranean Sea Area, genetic defect: missense or nonsense mutation

alcohol anemia: High MCV with no Megaloblasts

Aplastic anemia: low platelets, low RBCs and low WBCs, causes: chemo therapy, Meds side affects

chronic gastritis (bleeding): IV iron

Haemophilia: factor (VIII) or (IX) deficiency : deep bleeding (Hemarthrosis) Dx: high aPTT

ITP: petechiae + low platelets

HUS Hemolitc urimec syndrome: petechiae + low platelets +schistocyte+ renal failure Tx: if sever Plasmapheresis
TTP= HUS + fever and/ or altered mental status, blood:(fragmented RBC schistocyte), gene mutation ADAMTS13
HSP: petechiae + normal platelets, abdominal pain, arthritis, IgA Tx: mostly resolves spontaneously, severe: steroid

ITP Tx: bleeding IVIG ± platelate transfusion

Not bleeding only petechiae PLT: adult >30, child>20 observe
: adult <30, child<20 corticosteroid

DIC and thrombosis Tx: both heparine and FFP

Spherocytosis (Ankyrin deficienc): multiple blood transfusions and splenomegaly, Dx: increased osmotic fragility

Warfarin toxicity:- INR >5: stop warfarin give vitamin K

- bleeding: vitamin K, heavy bleeding:FFP
Heparin toxicity: HIT(LowPLT): D/C heparin + argatroban (non-heparin anticoagulant )

hemochromatosis Dx: Transferrin saturation level Tx: IV.deferoxamine

iron toxicity Tx: IV.deferoxamine

Polycythemia vera: high RBC -> Hyperviscosity-> blurred vision And headache Tx:Phlebotomy

prothrombin time (PT ) (warfarin ): measure the functioning of factors I, II, V, VII, and X
partial prothrombin time (PTT) (heparin): measure the functioning of factors VIII, IX, XI, XII, and VWF
prolonged bleeding time: VON WILLEBRAND (VWF)

vWD management: DDAVP(Desmopressin) or Factor VIII, if not in the choices: Cryoprecipitate

post blood transfusion fever (Non-hemolytic): due to the WBCs in blood

- <38C, continue with transfusion but decrease rate and give antipyretics
- >38C, stop transfusion, give antipyretics and anti-histamine
prevention : leuko-reduction to reduce the number of leukocytes transfused.

blood transfusion hemolytic reaction: fever, chills, hypotension, back or flank pain, dyspnea, hemoglobinuria->
acute renal failure (<24 h) and DIC, Tx: stop transfusion, IV fluids

Allergic Non-hemolytic Transfusion Reactions(IgA deficiency): allergy -> anaphylaxis after blood transfusion,Tx: IM
epinephrine, antihistamine

Heparin MOA binds to the enzyme inhibitor antithrombin III

Read about: electrophoresis interpretations ,lymphoma staging

Page 20 Ammar Naji SMLE Notes medicine & pedia

Pediatric: hema-onco
Bleeding from umbilical cord: factor 13 deficiency or vitamins K deficiency

Vitamin k dependent factors

factors II (prothrombin), VII, IX and X ,proteins C, S and Z

hydrops fetalis in alfa thalassemia: Normal 2 beta abnormal 4 alpha

painless neck mass mostly lymphoma

Page 21 Ammar Naji SMLE Notes medicine & pedia

Pediatric: General
Turner syndrome: 45X, Webbing of the neck coarctation of aorta, hypothyroidism, horseshoe kidney

Fragile X syndrome: mental retardation Macrogonadisim (large testes)

Prader Willi syndrome: FFT -> obese, short , hand deformity , mental retard

Rett syndrome: decreased in head growth, weird hand movements, expressive end receptive language skills and lost
his interest in his social environment

Nureofibromatosis: Café au lait spots in face and neck, Axillary freckling

kawasaki: >5days fever, cracked lip, strawberry tung, pericarditis, rash Tx: IVIG

Rickets-> vitamin D deficiency

hyposphatemic rickets: child with: (Low PO4, Normal Ca, Dec or normal ALP)

Most common cause of FTT: psychosocial

a child with yellowish occlusive area of the teeth Tx: Fluride supplement

school boy with an itchy scalp, 10 other classmates are affected: Pediculosis capitis

W-Setting habit in a child will cause Internal Femoral Torsion

greasy rash: Seborrheic dermatitis Tx: topical. corticosteroids

rash spear the folds-> Diaper rash Tx: Barrier cream with frequent change of dipper

rash doesn't spear the folds, Satellite lesions -> candidal diaper dermatitis Tx: Topical nystatin

Cavernous hemangioma most commonly spread to: Liver and CNS

infantile hemangiomas :do not require any medical or surgical intervention

newborn with hemangioma affecting the eye: surgery should be done in 2-3 weeks

bad smell: nose+(unilateral obstruction):foreign body, throat Tonsilloliths,

Jaundice
- first 24 hours of life is ALWAYS Pathological Sepsis or Hemolytic causes(Spherocytosis, G6PD deficiency,
Pyruvate Kinase Deficiency do COOMBS test)
- 24h - 2 weeks: physiological or breast feeding jaundice
- Prolonged physiological jaundice associated with hypothyroidism and GIT obstruction
breast feeding
mother using phyntoin dose not affect breast feeding mothers
mother with HCV don't stop breast feeding except if there is a cracked nipple
All vaccines are safe in breast feeding

bilateral renal agenesis-> oligohydramnios

in CPR for infant (asystole) Tx: Epinephrine

phenyleketonuria: deficient enzyme: phenylalanine hydroxylase (PAH)

immunoglobulin from his mother-> Passive neutral immunity

Dehydration mild <5%, 5-10% moderate, >10 severe

Tx: mild and moderate oral rehydration, sever or continues vomiting IV fluid

oral rehydration solution: Rehydration phase: 50-100mL/kg for the first 4 hours. then Maintenance

Maintenance
- Per day : 100cc/kg for the first 10kg, 50cc/kg for the 2nd 10kg , 20cc/kg for the rest of the weight [1000, 500,200]
- Per hour : 4cc/kg for the first 10kg, 2cc/kg for the 2nd 10kg , 1cc/kg for the rest of the weight [40, 20,10]
————————————————————————————————————————————————————————————————————————————————————————-

Fluid Deficit :% x 10 x Kgs

Page 22 Ammar Naji SMLE Notes medicine & pedia

Read about apgar score and developmental milestones and assessment of dehydration

Disese Mode of inheritance

Hereditary chronic pancreatitis Autosomal dominant

RH- D Autosomal dominant

Marfan syndrome Autosomal dominant

neurofibromatosis type 1 Autosomal dominant

Ehlers-Danlos syndrome Autosomal dominant (mostly)

polycystic kidney disease(chormosome 16) Autosomal dominant adult.(MC)(chr 16p)

Autosomal recessive infancy (chr 4q)

progressive familial intrahepatic Autosomal recessive

cholestasis

Cystic fibrosis Autosomal recessive

Wilson’s Disease Autosomal recessive

anemias : sickle, thalassemia, fanconi Autosomal recessive

G6PD X-linked

Haemophilia X-linked

Agammaglobulinemia X-linked

Wiskott Aldrich Syndrome X-linked

Duchenne X-linked
Page 23 Ammar Naji SMLE Notes medicine & pedia

Disease Gene/marker/chromosome
Brest CA BRCA1 or BRCA2 or TP53

ovarian cancer CA125

Pancreatic ca: CA19, Ki-Ras

colorectal cancer APC, CEA

and familial adenomatous polyps:

Kidney CA VHL (von Hippel Lindau) MET, TSC

suprarenal/ adrenal CA p53

And Li-Fraumeni syndrome

CML BCR-ABL

CML Philadelphia chromosomes chromosome 22 t(9;22)

Follicular B cell lymphoma: BCL2

burkhits lymphoma C-myc

Hodgkin lymphoma NF-κB

HCC : high AFP

Choriocarcinoma: high b-hCG:

Cystic fibrosis chromosome 7 long q arm

Crohn’s Disease chromosome 16 nad 12

HPV HPV 16 (most common) and HPV 18

Gilbert’s Syndrome UGT1A1 on Chromosome 2q37

Wilson’s ATP7B

Hereditary angioedema C1 esterase inhibitor Deficiency

(SERPING1 gene)

neurofibromatosis NF1 chromosome 17 q11.2

Agammaglobulinemia CD 19 and 20

Celiac HLA-DQ2,8

Digeorge syndrome 22q11.2.deletion