1 Page Ammar Naji SMLE Notes Surgical

PART 2

‫بسم ا) الرحمن الرحيم‬

: ,‫غلب النقاط في التخصص‬9 ‫لف يشمل تجميع‬A‫هذا ا‬

GS, Orthopedic, ENT, Ophthalmology & ER

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

table of contents
General surgery—————————————————— Page 2
Orthopedic ———————————————————— Page 6
ENT——————————————————————— Page 9
Ophthalmology—————————————————— Page 10
Clinical Anatomy table——————————————— Page 14
Emergency medicine——————————————— Page 15

‫هذا العمل هو مجهود فردي والخطأ فيه وارد‬

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2 Page Ammar Naji SMLE Notes Surgical

‫يميل‬R‫في حال وجود اي اخطاء التواصل على ا‬

alyamani.ammar@gmail.com

General surgery
Plastic
Squamous Cell Carcinoma
- Long standing/reptitive skin injury
- eosinophilic inclusions
- volcano-like rolled outer edge
- Can happen as accompli cation of lichen sclerosis
Epidermal inclusion cyst(sebaceous cyst): nodule with central pore(black head), if symptomatic surgical removal
Scenario 2 : lump slowly growing for years with punctum in the middle that drain white foul smelling material

Basal cell carcinoma

develop in the nose
ulcer with rolled in edge

surgical site infection

Organism: fragilis or Clostridium perfringens,

fer
wound healing in inflammatory process: covered by epithelium

vit c difeciency will affect collagen synthesis stages of wound healing

Facial sutre removal day:5

ULCERS or
• Stage I: nonblanchable erythema present >1 h after pressure relief, skin intact
• Stage II: partial-thickness skin loss
• Stage III: full-thickness skin loss into subcutaneous tissue
• Stage IV: full-thickness skin loss into muscle, bone, tendon, or joint

Central line infection due to skin colonization

Surgical site infection due to staff hygiene

Erythema gyratum: is the Most common malignant lesion need to be removed

hidradenitis suppurativa.
- Painful nodules, manipulation yeilds drainage and pain improves after the discharge
- It affects groin and axilla

Fixed drug eruption:

- patches of redness and and sometimes surmounted by a blister
- Fade into hyperpgmented patches

Neuro surgery
most malignant brain tumor in adults: gliomas is the. Astrocytoma, Ependymoma: types of glioma.
children Medullablastoma
Most common primary tumor in the brain is meningioma (benign)

jugular foramen syndrome is involvement of the 9th , 10th , 11th cranial nerves

Most affected CN in ICP is 6 then optic

Subarachnoid hemorrhage: Worst headache + meningeal signs

High WBC & papilledema : leukemia CNC. Low WBC & Opsoclonus or Horner syndrome;

superficial temporal artery bleed : Connective tissue (2nd layer of the skull)

Dermatomes
T4: Nipple
T10: Umbilicus
L4: Knee

thoracic
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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.

Horizontal Fissure: 4th Intercostal Space OR inferior border of 4th Rib

Oblique Fissure: 6th Intercostal Space OR inferior border of the 6th Rib

achalasia.Tx: balloon expansion-> failed 3 times: myotomy

Diffuse esophageal spasm: corkscrew appearance, barium swallow

chronic reflux can cause -> Adenocarcinoma

Pharyngeal globus: Lump in throut barium enima and endoscopy all normal

PE: 5-7 days after surgery, Atelectasis one day after surgery

Cardiac valve repare

- Mtrial valve: Valvuloplasty
- Aortic valve: replacement

CABG indications:
- Three-vessel disease (LAD, LCX and RCA) with >70% stenosis in each vessel.
- Left main coronary disease with >50% stenosis

lung cancer
clara cell adenocarcinoma
Kaltusky: small cell carcinoma

Adenocarcinoma associated with anti epithelial cell receptor therapy

Brest-Endocrine
Brest masses and discharges
Fat necrosis: after trauma
Fibrocystic changes : pain flactuates with cycle; may be bilateraltx: FNA if blood biopsy
Fibroadenoma: mobile nontender mass, most common breast tumor in < 30 year
Intraductal papilloma: most common cause of bloody nipple discharge but mostly is serous discharge

Breast Cancer types

- invasive ductal carcinoma is the most common
- Invasive lobular carcinoma: 20% bilaterality.
- Paget disease: scaling of the nipple
- Inflammatory cancer: peud’o orange
Best prognostic indicator for breast cancer : LN involvement

skin dimpling in breast cancer: Cooper ligament

mastectomy : you will cut Pectorals major muscle

Parafollicular cell secrete: Medullary tumor

thyroid mass approach

TSH T4:
if TSH high or normal(hypothyroidism) -> FNA
Low TSH-> radio iodine -> if cold do FNA , if hot treat as hyperthyroidism

thyroid nodule-> TSH,T4 -> Radionuclide scan

thyroid cancer:
most common: Papillary cancer (Best prognosis), histopathology: psammoma bodies
Associated with Pheochromocytoma,

Multi-nodular goiter Tx: Radioactive iodine, if compression symptoms: surgery

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

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Most common parotid gland malignancy mucoepedermoid carcinoma, benign: pleomorphic adenoma

Fibrocystic Disease: in elderly + Discomfort not related to menstrual cycle Tx: Reassure,>6m medical
Fibrosystic changes :young pain with cycles , obsessive for the next cycle, then aspirate if blood do cytology
pathophsyolgy -> Apocrine metaplasia

Urology
Kidney level : T12-L3

Stone evacuation CT without contrast

renal mass evaluation CT with contrast

Renal stone
Calcium oxalate: most common
Struvite: infections, alkaline urine
Uric acid: radiolucent on KUB

papillary renal carcinoma Tx: Radical nephrecetomy for local disease

Interstitial cystitis: recurrent UTI not responding to Abx with negative cultures and submucosal petechia

bladder cancer Tx -> resection-> intravesical chemotherapy/immunotherapy (Mytomycin C or BCG)

1- Urge incontinence: Oxybutinin (Anticholinergic)

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

Urethral part could be injured during catheterization->Membranous urethra

urethral injury-> RUG-> Suprapubic Cath

saddle trauma-> anterior (bulbar) penile urethral injury

Epidedmo-orchitis unilateral testicular pain and fever+ UTI can be chronic

Tx: Males < 35: Treat for gonorrhea/chlamydia with ceftriaxone and doxycycline.
Older males: Treat as a urinary tract infection (E. coli) with levofloxacin.

Appendiceal Torsion: acute/sub acute pain in the Upper pole of testis , Blue dot sign
Testicular Torsion:acute pain<6h, tenderness, swilling of the testis no fever, absent cremasteric reflex Tx: Urgent
surgical exploration

varicocele: testicular pain, infertility ,bag of worms

hydrocele: painless scrotal swilling with positive treslumination

etiology: failure of obliteration of process vaginalis

Seminoma(Germ cell tumor): One cell type testicular mass, Radiosensitive

Embryonal cell carcinoma ( high AFP )

BPH: complication bilateral Hydronephrosism, Tx: Terazosin (alpha blocker)

acute Prostatitis: frequency, urgency, dysuria, tender prostate and felt BOGGY on DRE

prostate marker : PSA then acid phosphatase

Sex cord stromal tumor: Fibroma

Meigs syndrome: Fibroma+Pleural effusion+ ascites

pelvic abscess: Laparotomy

if posterio, midline, fluctuant, adherent to the periotoneum,: Posterior colpotomy

Cryptorchidism is the most common urological congenital male anomaly

vascular
DVT: post op enoxaparin,

abdominal aortic aneurysm.

- Aneurysms < 5 cm can be observed with serial annual imaging.
- Aneurysms ≥ 5 cm should have elective repair.
Thoracic aortic aneurysm: Asymptomatic lesions: Blood pressure management

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compartment syndrome: PAIN out of proportion

Pediatric
premature presented with abdominal distention and air on x-ray: Necrotizing enterocolitis

acute abdominal pain with para-umbilical mass post mild trauma: rectus sheath hematoma. Dx: Best CT

umblical hernia: repair after the age of 4y

volvulus: bilious vomiting: with obstruction Dx: barium Tx:flatus tube

Hepato biliary + upper GI+ colorectal

APPENDICITIS: mid abdominal pain-> RLQ WORSE with movement tenderness , anorexia TX: appendectomy +Abx
if >5d or mass Abx+ fluid surgery after a month
sub-hepatic appendix: appendicitis presented as right upper quadrant pain.:

Gallstone Dx:
Most common type :cholesterol, ,
Dx:U/S, most accurate test for acute cholysctitis: HIDA scan.
recurren with small stone Tx: ursodeoxycholic acid

Cholecystectomy is indicated in asymptomatic cholelithiasis if

- Sickle cell
- Porcelain
- Child

Fibrates increase gallstone risk. (It lowers TGs not cholesterol)

name of incision in open cholecystectomy: Kochar

Morphine can make a cholecystitis pain worse,

use IM Ketorolac (NSAID)

hernia direct: through the abdominal wall, indirect inguinal ring & testes

Indirect inguinal hernia: anterio-medial to the spermatic cord

inferior epigastric artery is medial to the Indirect inguinal hernia

Femoral hernias has highest risk for developing strangulated hernia

double wall sign of pneumoperitoneum : perforation

abdominal infection by enterococcus faecium, Rx? vancomycin

Budd Cherri syndrome ; hepatic veines obstruction>RUQ pain, ascites, hepatomegaly

Fiber, Vitamin D and Aspirin are protective factors for colon cancer

IBD :
- Pyoderma gangeronosum especially in UC
- Erythema nodosum especially in crohn’s

Heamorids are veins

best diagnostic for Meckel’s diverticulum: Meckel’s scan: (technetium-99m pertechnetate scanning)

acute pancreatitis: Cullen sign and Grey-Turner sign

Feeding: nasojejunal feeding

Chronic pancreatitis: Most accurate test: Secretin stimulation test

Pancreatic trauma: pancreatic enzyme will collected in: Omental bursa

Thrombophlebitis migrans can be a sign of malignancies such as pancreatic carcinoma

Enlarged medial superficial inguinal lymph nodes -> examin Anal area

anal fissure: Young pt have severe pain during defection followed by bleeding and relief after few hours :

Most common cause rectal bleeding in age 50 years : Diverticulosis

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hemorrhoid Tx: Sitz bath

inguinal canal is develop from the external oblique muscle: External spermatic fascia

small bowel obstruction the best diagnostic: Barium enema

Gardner syndrome have high risk for colorectal cancer

Orthopedic
Diseases
paget disease: High density bone in dexa+ easy break,

Osgood schlatter disease:pain in tibial tubercle he has just had growth spurt
Tx:

polymyalgia rheumatica:: Muscle tenderness

Subacromial bursitis one of the rotator cuff diseases: Hx: Night pain, weakness and loss of range of motion with
overhead activites, fell on outstretched arm-> inability to abduct and externally rotate the shoulder

adhesive capsulitis: STIFFNESS and pain in shoulder

olecranon bursitis: due to Repeated injury

Periosteal Reaction
- Ewing Sarcoma
- osteosarcoma
- osteomyelitis
stress fracture: running 20 km complaining of upper leg pain.

plantar fasciitis: sharp heel pain, worse in the morning, improves after walking

SCA + AVN Severe or > 8 year ——> surgery

legg calve perthes disease -> will cause (AVN)

mild hip flexion contracture at 10-20 degrees. painful/painless loss of abduction and internal rotation.
X-ray: destroyed fragmented femoral head.
Tx: <8 y No weight bearing >8 y surgery

Slipped capital femoral epiphysis(SCFE)

Pt can't bear weight with left hip external rotation, Obese
X-ray: medial slip of epiphysis, disrupted Klein’s line, doesn’t cross the femoral head
Tx:

DDH
limiting abduction
X-ray: broken shenton line, acetabular angle > 30, ossification centre outside the inner lower quadrant

Oncology
Ewing’s sarcoma: Onion skin is seen .Dx:MRI Tx: resection, chemotherapy, radiation.

Low back pain and lytic lesion biopsy shows schistocytes and giant cells? Giant cell Tumor of bone

Primary chondrosarcoma is seen in > 40 years old Most common location is the pelvis

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

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infections
Osteomyelitis MTB step 2
- ESR to follow response
- X-ray best initial
- MRI after X-rat
- Most accurate bone biopsy

metaphysis. is firstly affected in hematogenous osteomyelitis

Septic arthritisTx: IV antibiotics(2weeks)+serial needle aspiration. If hip or shoulder: surgical drain +Abx

Spine
scoliosis
orthopedic referral: > 20 degrees, surgery >40-45

most specific sign of osteoporosis: Decreased bone matrix and compression fractures

Spinal canal stenosis:back pain increased when walking downhill but relieved when walk-ing uphill

ankylosing spondylitis associated with ? uveitis as well as heart block

Patients with neurological deficits should have urgent MRI

post disease in the spine got abscess in the anterior chest wall, route of transmission: Anterior cutaneous

Fracture
Fractured bone increases ALP

open fracture: surgical irrigation, debridement and fixation.

open prediction and internal fixation

- overlapping
- Shortening > 2cm of middle third,
- comminuted fractures
- Ulnar and radial shaft

Falls onto an outstretched hand-> Colle's fracture

snuff box pain -> Scaphoid fracture
type of fracture that has several segments in the diaphysis:comminuted

Proximal tibial fracture -> MRI KNEE to evaluate the ligaments and meniscus

Best x ray to show fracture rib: Oblique

Injuries
Shoulder dislocation :Subacromial
- Anterior: abducted external rotated
- Posterior: adducted , internal rotation (common in epileptic patients )

Radial head sublaxation (Nursemaid’s elbow)

- Disrupted annular ligament
- Pronation position
- Treatment is reducation via supination technique or hyperpronation

Medial epicondylitis (golfer’s elbow):Difficulty in flexing the wrist Tx: NSAIDs, rest and physiotherapy

Lateral epicondylitis(Tennis elbow): elbow pain with resisted extension tenderness at medial epicondyle: reassure

BICEPS TENDINOPATHY : Patients with biceps tendinopathy typically have pain in the front of the shoulder that
worsens at night. Pain may increase with lifting, pulling, or repetitive overhead reaching.

carpal tunnel, median nerve injury , durkan carpal test Dx: nerve conduction Tx: splint in: Dorsiflexion

pregnancy induced carpal tunnel syndrome TX :night splint

quervain syndrome(+ve sign of Finkelstein test) Tx: NSAIDs, thumb SPICA (raised) splint and steroid injections

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hyperextension injury developed pain in

- The flexor digitorum profundus flexes the distal interphalangeal joint
- the flexor digitorum super-ficialis flexes the proximal interphalangeal joint

child sitting always in w: femoral anteversion (femoral torsion)

knee swelling only : X-ray (its always first in ortho) or aspiration

ACL: knee displaced to anterior, Dx: Lachman test positive

tibial collateral ligament injury-> Lateral blow to the knee, positive valgus stress test

Muscle spasm after run pain improves with streching the knee : Gastrocnemius muscle

Trauma -> ABI < 0.9: perform arterial duplex ultrasound or CT angiography
if arterial injury confirmed then consult vascular surgery. Orthobullets

Neuropraxia: nerve injury

Others
Muscle responsible of unlocking the knee: Populates

Back pain muscle relaxant: Metaxolone

Iliofemoral ligament is the strongest ligament of the hip joint and limits hyperextension of the hip

Vitamin D decrease fracture risk while aerobic exercise delay bone loss

Toe Dorsiflexion by Deep perineal N

Toe Plantar flexion by Tibial N

osteoporosis Tx: Alendronate (bisphosphonates)

spina stenosis: physiotherapy

Joint pain NSAID

Carpopedal spasm is due to low ca

Patellar femoral syndrome Knee pain increase by walking on the stairs relieved by walking on flat floor this pain
aggravated by contracting quadriceps muscle, what is the cause?

Joint pain(all other is normal): NSAID, if specific to a muscle movement

Back pain all other is normal : physiotherapy, x-ray, if neural abnormality, MRI
If trauma-> x-ray

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ENT
Ear
examine the ear: child Pull pinna Inferior backwards, Adult Pull pinna Superior backward

otitis Extrna: ear pain increases with pinna movement , auditory canal inflammation, normal tympanic membrane
Topical neomycin

otitis media : acute ear pain (most common symptom), redness and bulging of tympanic membrane
Organism: S.pneumonia, Tx: amoxcacilln if with effusion do :grommet tube(ventilation tube )
Complication: hearing loss(if recurent), Cholesteatoma, mastoiditis

Hemorrhagic vesicles on tympanic membrane: Bullous Myringitis

Cholesteatoma: a complication of AOM: abnormal epithelial growth: ear discharge hearing loss pain perforated TM
Tx: surgery : mastoidectomy ± tympanoplasty ± ossicular reconstruction

mastoiditis:a complication of AOM, tenderness and swelling behind the ear,->ear pushed down and forward
Tx: Vancomycin + ceftriaxone
Complication:Encephalitis,

- Otosclerosis : young with progressive loss of hearing, Normal tympanic membrane, and no evidence of middle ear
inflammation, can't hear her own voice
With a conductive hearing loss on Audiogram: Hearing loss at 2000 Hz + Air conduction below normal range.

loud sounds over an extended period of time-> noise induced SNHL

presbycusis (SNHL): most common hearing loss in adult + most common cause tinnitus
cells affected: Hair Cells

Meniere disease: recurrent vertigo (lasting hours to days) with auditory symptoms and nausea, vomiting,

Myrngiotomy: used in acute otitis media,

Grommet tube is a ventilation tube:otitis media with effusion

acoustic neuroma: hearing loss , dizziness , tinnitus, vertigo Dx:MRI

Hemorrhagic vesicles on tympanic membrane: Bullous Myringitis

Transverse temporal fractures: vestibular symptoms: vertigo, decreased hearing

Longitudinal temporal fracture: bleeding from ears

Nose
Nasal trauma:
CT only done when suspecting other facial fractures.

Trauma-> clear nasal discharge -> CSF leak + olfactory nerve will be affected

Epistaxis:
First thing: apply pressure
posterior oozing : spray anaesthetic or vasoconstrictor
epistaxis + obstruction angiofibroma
epistaxis due to going from cold to warm place: Tx: increase humdidity

Nasal obstruction
only fleshy mass: Nasal polyp
With blood: angiofibroma
with bad smell: foreign body -> x-ray head and chest
With enlarged turbinates: allergic rhinitis -> Intranasal corticosteroids
Unilateral + old age: cancer

Seiptal hematoma: Inscision and drainage

Diabetic Pt with dark color nasal discharge: zygomycosis. a.k.a Mucormycosis

sinusitis: Dx CT

fronciosis in the left side of the nose,-> Opthalmic vein drains into the cavernus sinus.-> orbital edema

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Throat
Postoperative parotitis is a well known entity which can develop in patients who undergo major abdom- inal surgery.

Head and neck

most common Parotid tumours:

Benign:Pleomorphic adenoma then hemangioma
Malignant: Mucoepidermoid

submandibular mass that increase in size with eating painful swelling : sialothiasis

Nasopahringeal carcinoma sore throat, palpable neck mass, hoarseness voice, hearing loss

most common site of paranasal sinus malignancy is in. Maxillary

Saccule: Vertical acceleration

Utricle: Linear acceleration
Semicircular canal: angular rotation

Ophtalmology
close angle glaucoma: painful sudden loss of vision high ocular pressure, halos
Acute Tx: IV acetazolamide (first) + timolol + topical pilocarpine
Chronic Tx Laser peripheral iridotomy
α1-agonists (Epinephrine) use is contraindicated due to Mydriasis side effect

Open angle glaucoma: painless loss of vision with optic disk cupping > 0.5
Tx: timolol ( contraindicated in Asthma/COPD, CHF)-> laser Trabeculectomy
can be caused by Long term use of topical steroid drops (steroid induced glaucoma)

red eye and tearing since birth Congenital glaucoma

cataract:
Opaque lens
surgery Complications: posterior subcapsular opacifications then Endophthalmitis

optic neuritis: Diplopia and decrease in visual acuity pain when moving the eye,
fundoscopy: optic disc swelling-> painful vision loss, Dx: MRI

Ptosis
can happen with 3rd CN palsy
Surgery only if visual field is obscured due to ptosis (Frontalis.suspension)
ptosis in Lacrimal gland tumor: Inferomedial direction

esotropia: Tx: if accommodated: Glasses.,

if not accommodated + the deviation is greater than 15 degree: Medial muscle recession

optic atrophy: loss of color vision

retinal detachment: neuroretina separates from the retinal pigment epithelium with accumulation of sub-retinal fluid

myopia
low-intermediate :LASIK & PRK
high: Phakic lens

to prevent dryness after laser refractive correction: block the punctua

post surgery in lacrimal gland: but a tube in Lacrimal duct (nasolacrima duct intubation)

Retinoblastoma: Leukocoria, strabismus, Fundoscopy: white or cream-colored masses often with prominent
intralesional blood vessels Tx:small tumors: Cryotherapy, or chemotherapy, advanced: enucleation
Scenario 2: Child opaque lens with signs of inflammation

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Iris neovascularization caused by:

proliferative diabetic retinopathy
Central retinal vein occlusion

light reflex
Afferent ---> optic nerve
Efferent ---> oculomotor nerve

Central retinal artery occlusion: Cherry red macula

Central retinal vein occlusion retinal hemorrhage, macular edema, cotton spot and venous engorgement, RAPD

Phencyclidine toxicity cause : both vertical , horizontal , rotatory nystagmus

eye hemangioma in neonate: surgery in 2weeks

Esotropia more than 15 : surgery

Retinal detachment Lower visual field loss with flashes and

Macular degeneration: Progressive painless vision loss Drusen spots

visual acuity: Snellen chart (stand with 6 Meters from the chart)

Phencyclidine toxicity cause : both vertical , horizontal , rotatory nystagmus

pterygium: will cause Corneal scarring then visual loss

drugs that causes Brown discoloration of eye: Lanatoprost and Thioridazine

Infections
keratitis :
can be caused after corneal trauma
parasite keratitis: Acanthamoeba-> Ring lesion in eye, complication: granulomtus encephalitis
Herpes simplex Keratitis: Dendritic corneal ulcer and Hypoesthetic cornea (decrease the corneal sensation of pain)
With contact lenses: pseudomonas aeruginosa, Acanthameba
Adenovirus: URTI+ conjunctivitis + epithelial nummular keratitis
Vit. A deficiency: -> Follicular Keratosis + Bitot's spots

Uveitis: inflammation iris and ciliary body: and decreased vision in photophobia ciliary flush, not fully reactive pupil
and floaters, (anterior uveitis: pain and redness),(posterior uveitis: painless) Tx:systemic corticosteroid

Orbital cellulitis:sudden onset, unilateral proptosis eye pain swelling. Limited painful eye movement

Cavernous sinus thrombosis is bilateral

Orbital Pseudotumor: Nonspecific Orbital Inflammation, commonly involves the extraocular muscles unilateral rapid-
onset painful proptosis and diplopia Tx: steroid

dacryocystitis: nasolacrimal duct infection Tx: Drain surgically

blephritis: Eyelid inflammation : secretions

chalazion: noninfectious obstruction of a meibomian glandin the eyelid soft tissues
stye: obstruction and infection of an eyelash(Zeis or Moll glands)

Entropion: Lid margin turned inward:

trichiasis : eyelashes turned inward:

Distichiasis: abnormal growth of lashes from the orifices of the meibomian glands on the posterior lamella of the
tarsal plate

conjunctivitis eye discharge:

- chlamydia Mucopurulent
- gonorrhea: Purulent
- Viral(adenovirus): watery discharge

eye redness and tearing

pABpilla: Allergic, Bacterial
Follicles: Viral and chlamydial.

bacterial conjunctivitis: tropical antibiotic, if neonate: systemic antibiotic

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Retinitis+ AIDS: CMV

Trauma
corneal ulcers (Corneal epithelial defects):redness, pain photophobia Tx:Double patch, Topical antibiotic(omintum are
better than drops), Cycloplegia

Orbital base fracture:with subconjunctival hemorrhage and weak upward gaze

eye trauma stain: fluorescein stain

foreign body sensation in his eye after splash: Topical antibiotic

eye involvement Systemic diseases

High ICP or Cavernous sinus aneurysm -> first Abducens(VI) nerve involvement, optic (II): Papilledema

Prolactinoma: eye: Bitemporal hemianopsia

TB ocular manifestations of > tuberculous uveitis

DM
commonest cause of iris neovascularization (rubeosis iridis)
can cause 2ry Open angle glaucoma

HTN
Grade I : mild arteriolar narrowing
Grade II : arteriovenous crossing
Grade III : retinal hemorrhage, exudate, cotton wool
Grade IV : papilledema

hemiplegic patient came with Upbeat nystagmus Where is the site of the lesion: Midbrain

SMLE clinical anatomy

UPPER LIMB

shoulder and mediastinal pleura

phrenic Nerve
injury: Hiatal hernia surgery: Anterior to scalenus anterior

shoulder abduction over 90degree + wing scapula, (neck stab) long thoracic Nerve(root)

shoulder abducttion, External rotation Axillary

injury: fracture humerus surgical neck (Upper trunk/Posterior cord of
biracial plexus)

thumb and index numbness and pain, thenar atrophy

Deformity: Ape hand,
Median Nerve
Injury: Supracondylar region, carpal tunnel
place: nerve between heads of pronator teres muscle

loss of adduction of fingers

Injury: Medial epicondyle Ulnar Nerve
Deformity: Partial claw

sensation in dorsum of the hand, extend extend his arm , wrist and fingers
Deformity: drop wrist Radial Nerve
Injury: Mid humerus(spiral) fracture

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tendon passes through lesser sciatic foramen Obturator Internus tendon

superficial palmar arch blood supply Ulnar artery

Trunk

breast cancer skin dimpling in Cooper ligament

appendix Superior Mesenteric Artery

up to proximal 2/3 of the transverse colon

Distal 1/3 of the transverse colon to upper rectum (no cecum) Inferior Mesenteric Artery

graft from rectus muscle inferior epigastric artery

medial to indirect inguinal hernia inferior epigastric artery

artery posterior to mid inguinal point Femoral artery

inguinal canal ligament Round ligament

legament prevent utraine prolapse utrosacral legament

not blocked by epidural anesthesia Rectum, Anterior vestibule

Dysmenorrhea uterine nerve.

testicular lymph node drainage para-aortic LN

Lower LIMB

gluteus area (buttock pain) and bladder blood supply Internal iliac artery

Hip abductors +IR: gluteus medius, the gluteus minimus + Trendelenburg gait Superior Gluteal Nerve

Hip Adductor: gluteus longus muscle, thigh medial sensation obturator Nerve

Hip lateral (external) rotation: gluteus maximus muscle

ligament that prevent overextension of hip Iliofemoral ligament

Knee flexion + Hip flexion sartorius muscle

Knee extension quadriceps femoris muscle

Posterior Leg compartment blood supply posterior tibial artery

(a branch of popliteal artery )

Foot dorsiflexion,
Common peroneal Nerve
injury: neck of fibula fracture

foot drop (loss of sensation in 1st & 2nd metatarsal joints) Deep Peronea Nerve

foot dorsiflex Tibialis anterior Nerve

Foot plantar flex, toe-foot walking Calcaneal (Achilles) ligament

injury: Superficial layer of the sole of the foot had transverse cut Abductor hallucis

Toe Plantar flexion (stand on his toes)

Tibial Nerve
Injury: tarsal tunnel syndrome

place: lateral to extensor hallucis longus dorsalis pedis artery

place: in front of medial malleolus great saphenous vein

flat foot, pain on foot after along walk Spring ligament

foot inversion injury: Talofibular

(anterior talofibular ligament)

foot eversion injury: deltoid ligament

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Head/ENT

Styloglosus muscle hypoglossal (XII) nerve

stylomastoid foramen trauma. Facial (Vll)

forehead muscle action Facial (Vll)

occipitofrontalis muscle paralysis Temporal branch from

Facial (Vll)

eye opening, if injury -> ptosis

Oculomotor(III)
most of eye movements, pupillary constriction

Nerve affect eye (eye closer) and ear Facial (Vll)

stapedius mescle (can’t tolerate loud noises) Facial (Vll)

skin of lower mandible and Lower part of the ear part of auricle Great Auricular nerve

pain with eating that radiate to the ear auriculotemporal nerve from
Trigeminal (V)

deafness + paralysis of tensor tympani muscle Mandibular division from

Trigeminal (V)

Nerve responsible for the sinuses Trigeminal (V)

Nerve responsible for the tonsils lesser palatine from maxillary from
Trigeminal (V)

throat, Middle ear ,

Glossopharyngeal (lX)
Senario: sore throat and refers ear pain

dysphagia (No gag reflex) + deviation of the uvula Vagus (X) opposite side of deviation

No gag reflex + normal uvula Glossopharyngeal (lX)

tongue Motor: hypoglossal (Xll) Anterior 2/3:

Posterior 1/3: sensory + taste:
Sensory: lingual from trigeminal
Glossopharyngeal(lX)
Taste: chorda tympani from facial

sensory of upper lip Infraorbital nerve

Central part of the lower lip and chin Submental LN

upper lip and lateral lower lip, cheeks, the lateral aspects of the nose, Submandibular LN

Lateral part of the face + eye Parotid LN

posterior inferior nasal septum blood supply sphenopalatine artery from

maxillary artery

Surgery complication

hysterectomy Ureteral injury

thyroidectomy recurrent laryngeal nerve injury

PDA surgery Left Recurrent Laryngeal Nerve injury

surgery to stomach that rapped Vagal nerve

her around the esophagus

BPH. Surgery injured the prostatic plexus-> Erectile Dysfunction

mastectomy: you will cut Pectorals major muscle-> adduction and medial rotation loss

appendectomy. Gonadal vessels injury

supradrelenectomy inferior vena cava

‫نسخة غير مكتملة‬

15 Page Ammar Naji SMLE Notes Surgical

embolize the splenic artery Stomach fundus

Metastasis

From To
Breast cancer anterior axillary LN

Colorectal Liver

Liver Stomach

Stomach lung

Thyroid, Breast. Kidneys & bone

Prostate

screening
cervical ca: normal 21-29:q1-3y, ASCUS: :<30 in 6m, >30y do hpv-dna discontinuing > 60-70 with 3
pap smear >30:q5y Other abnormalities : colposcopy or more normal Pap smear.

colon grade A: 50-75

Colonoscopy: colon cancer: every 10 or 5 sigmoidscopy, 1year after surgery
high grade hyperplasia after 1 yr then every 3-5 yrs
UC; every 1-2 y after 8y of onset of pan-colitis

Breast 45-54 every year, >55 every 2y, self exam monthly (3-5d post cycle)
(mammogram better than self exam in detecting abnormally by 2y)

DM screening: normal repeat after pre-diabetic: yearly diabetic:HbA1c every 3

3 years, months

DM: Optha screening: Type 1 DM: annually beginning 5 years after onset of DM
Type 2 DM: annually beginning at time of diagnosis

BP Normal BP + No Co-morbidities: in 3years

Normal BP + Co-morbidities in 1year
high BP No symptoms No Co-morbidities: repeat in 6 months
Comorbidities (HF… etc) repeat in 3 months

Emergency medicine
Nail hematoma Tx; painless no action, painful: evacuate hematoma

Abdominal trauma:
- FAST or DPL is indicated in unstable blunt trauma
- CT is indicated in stable blunt trauma
- Exploratory laparotomy in penetrating trauma if shock or peritoneal signs present

CT scan in trauma: to detect retropretoinum hemorrhage

Contraindication for gastric lavage

1- caustics (drain cleaners): burning of esophagus and oropharynx
2- Altered mental status: may cause aspiration

airway
- Nasopharyngeal airway is contraindicated in facial trauma
- An oropharyngeal airway is for use only in unconscious patients. (Absent gag reflex)

difficulty in intubation -> jaw thrust.

hypoxia after intubation: DOPES: Displacement of the endotracheal tube (ETT) Obstruction of the ETT Patient
especially pneumothorax; also: pulmonary embolism, pulmonary edema

‫نسخة غير مكتملة‬

16 Page Ammar Naji SMLE Notes Surgical

Intubation in asthmatic Pt
Ketamine in status asthmaticus and hemodynamically unstable.
- Propofol – Propofol is the intravenous (IV) induction agent of choice for the hemodynamically stable asthmatic patient

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.

foreign body inhalation mostly: right bronchus , Tx: bronchoscope

partial obstruction Hyperinflation and mediastinal shift
complete obstruction Atelectasis (unable to cough or speak)

bee sting type1 of hypersensitivity

1st: Remove stinger and watch the pt
swelling and redness for hours (Limited anaphylaxis): Antihistamines
tachycardia and SOB :SC epinephrine and IV antihistamin

heat stoke if body temperature higher than 41.1°C Tx: cooling, if hypotension: iv fluid

Mild burn : cool tab water (not ice or cold)

epinephrine MOA: inhibit mast cell release (leukotrine and histamine)

Toxicology
Aspirin toxicity: Respiratory alkalosis followed by metabolic acidosis Tx: Alkalinization of urine

TCA toxicity :3C’s : Convulsions, Coma, Cardiotoxicity (arrhythmia)

Digoxin toxicity: palpitation diaphoresis and ECG shows arrhythmia Dx: Fb immunoglbulin level

alcohol-use disorder Tx: psychological + naltrexone or disulfiram

alcohol withdrawal Tx: Diazepam + Thiamine

heroin withdrawal Tx: Methadone

wild mushroom. RNA polymerase II Will be inhabited

DRUG SYMPTOMS antidotes

Opioid, ‫هبوط‬ Hypothermia Hypotension Respiratory depression Dilated or Naloxone (secure airway first)
constricted pupils (pinpoint in opioid) CNS depression

Anticholinergic ‫مفلسع‬ Hyperthermia Dilated pupils, Dry skin, Vasodilation Agitation/ Supportive care
hallucinations Ileus Urinary retention Tachycardia Physostigmine

Sympathomymetic Same as Anticholinergic but with Diaphoresis

Cholinergic ‫مخرخر‬ Diaphoresis, Diarrhea, Decreased BP, Urination, Emesis, Atropin,

organophosphates Excitation of skeletal muscle Miosis Lacrimation Salivation, if sever: Praldoxime(oxime)
Seizures Bronchospasm, Bronchorrhea, Bradycardia

Cannabis palpitation, euphoria, visual hallucinations

Drug Antidote Drug Antidote

Acetaminophen N-acetylcysteine Cocaine supportive care no beta

(within 8h of ingestion ) blocker

Benzodiazepines Flumazenil Heparin Protamine sulfate

Iron deforaxamine lead succimer

Cyanide Sodium nitrate Isonazide Pyridoxine ,

MTX folnelic acid metoclopromide Benzotropine

MgSo4 Ca glutamate digoxin Digibind

‫نسخة غير مكتملة‬