Hamoud’s Approach

Venous thromboembolism (VTE) First, assess the likelihood of the patient having DVT and/or PE. If high risk, go for imaging directly. Prioritize management in unstable patients. If low risk, order D-dimer -> positive? Compression US if suspected DVT, and CTPA if suspected PE. US inconclusive for DVT? Choose CTPA as it can accurately diagnose both DVT and PE. What if the patient is pregnant or can’t handle radiation? V/Q scan. Skip US if PE is suspected. An ECG showing sinus tachycardia is an exam keyword for PE. Severe dyspnea, syncope, hypotension, raised JVP, and cyanosis are the hallmarks of massive (saddle) PE. Patients may also present in cardiogenic shock. In general, treatment is commenced with a a therapeutic dose of LMWH. If unavailable? Fondaparinux is an alternative (not in pregnant). UFH is used in patients with CKD. Massive PE and/or unstable? Thrombolysis. If C/I, embolectomy. Phlegmasia Cerulea Dolens -> Limb threatening case of DVT that mimics ALI by having ischemic changes. Treated with thrombolysis. If C/I with a history of stroke or recent surgery <10 days, IVC filter is appropriate. A typical case of DVT is initially treated with LMWH for at least 5 days, followed by a long term oral anticoagulant such as warfarin. Anticoagulants should be continued for 3 months, 6 months if associated with cancer, and for life if recurrent. If an anticoagulant isn’t sufficient and patient has recurrent attacks, choose IVC filter. I made some changes to the approach and elaborated further. According to the SCFHS handbook, VTE is classified as a medical condition, so my references here are mainly Harrison and Davidson.

Spontaneous Pneumothorax Primary -> up to 2cm, observation and oxygenation. Bigger? Aspiration. Failed? Chest tube. Secondary -> up to 2cm, aspiration. Failed or bigger? Chest tube. If hemodynamically unstable or bilateral? Immediately choose chest tube. If post RTA? Needle decompression as it’s a case of tension pneumothorax. Suspect a secondary cause with underlying lung disease.

سؤال يستحق التفكير وننصحكم بالتدبر به؟ نرى كثير يقولون تكرر الاختبار من هذا وذاك ( المصادر) طيب وبالنهاية؟ درجات غير مرتفعة!؟ لماذا ؟ شيكوا وراجعوا تصحيح التجميعات ( المصادر) خصوصاً اللي تكرر ذكرها لأن للاسف كثيييييير طريقتهم في المذاكرة : *هذا ماوجدنا عليه آباءنا* باختصار دامه تكرار وذكر (المرجع) ليش درجتك نازله بالنهاية وغير مرضية ؟! ختاماً : راجعوا حلول واجابات الملفات الموصى بها لجميع التخصصات فلا يجتمع تكراً عالي جداً ودرجات نازلة الا في مراجع حلولها غير دقيقة. الله يوفقكم ❤️

Pediatric Surgery Intestinal atresia -> Neonate, bilious vomiting, and associated with congenital anomalies such as polyhydramnois. Peritonitis occurs if perforated. Xray, and IV fluids prior to surgery. Pyloric stenosis -> Below 4 months old. Projectile non-bilious vomiting, postprandial, progressive weight loss, olive mass, severe electrolyte imbalance. US. IV fluid prior to pylorotomy. Hirschsprung -> Bilious vomiting, enterocolitis, abdominal distention, passes meconium on the 2nd day, empty rectum then gush of foul smelling stool comes out on DRE. ABC then refer for surgery. Biopsy shows absence of ganglion cells. Midgut volvulus -> Bilious vomiting, tenderness, bloody stool, and patient may appear septic. Upper GI series is the highest diagnostic test as it shows absence of the typical C-loop. Surgical treatment. Intussusception -> ileocecal obstruction. Colicky pain, blood-stained mucus jelly stool, palpable sausage mass, and target sign on US. ABC to correct imbalance. Reduction is attempted by pneumatic enema as it is both therapeutic and diagnostic. Surgery if failed or peritonitis, or if an adult case. Meckel’s diverticulum -> Painless bright blood in the diaper with minimal information. Nuclear scan. My references: Nelson and Illustrated.

66yo man, worsening abdominal pain over the last week, the pain started as vague lower abdominal discomfort associated with nausea, anorehia and constipation, this morning he has sudden severe lower abdominal pain accompanied by lightheadedness and an episode of vomiting, the pain initially improved but then gradually intensified to involve the entire abdomen, his medical history is significant for coronary artery disease and appendectomy, bowel sounds diminished, the abdomen is diffusely tender with guarding and rebound tenderness, abdominal imaging is most likely reveal which of the following findings in this patient? a. dilated small bowel with a transition zone b. embolic occlusion of the mesenteric artery c. free air in the peritoneal cavity d. hematoma surrounding the abdominal aorta C. The question is specifically asking about potential findings on simple imaging with the details provided, not the diagnosis. Many signs of peritonitis are in the question, so abdominal imaging through a quick x-ray will surely reveal pneumoperitoneum due to the perforation. As for the cause, the case is going with mesentric occlusion which causes severe pain out of proportion to physical findings. Not an SMLE question. I posted it since it’s decent for learning an important concept in the exam.

صباح الخير. انا ادري ان الكل متشتت بخصوص نصائح الامتياز، لكن عندي نصيحة بسيطة. على مدار السنين السابقة كثير قدموا الشهور الاختيارية في يناير و فبراير، و هذي اكبر غلطة من وجهة نظري الشخصية. فكرة ال golden months كونها في شهور متاخرة جدا بحجة ان السنتر الفلاني اللي تبونه بيتذكركم تتكرر باستمرار. اول نقطة، اذا تركتوا انطباع كويس صدقوني ما تفرق متى رحتوا لهم. عندهم قائمة اطباء امتياز اشتغلوا معهم و اللي نال اعجابهم بياخذونه سواء الفترة كانت قريبه او بعيدة. ثاني نقطة، كثير يدخل شهر يناير متحمس و يبدا يشك في التخصص مع اول اسبوع للدوام، و في نفس الوقت بوابة التقديم تسكر بدري في نفس الشهر. لا تحطون أنفسكم في هذا الموقف لانه منتشر. طبعا سبب اخر لتأخير الشهور الاختيارية هو اختبار الهيئة. ممكن من اول محاولة تكتب لكم الدرجة اللي تطمحون لها، او يمكن ثالث محاولة. لكن الاستعداد للاختبار يكون اسهل و اسهل مع كل محاولة، لانكم فقط تراجعون اغلب الوقت مع نسبة اسئلة جديدة. فلذلك انا اشوف شهر نوفمبر و ديسمبر فترة ممتازة للشهور الاختيارية. أسأل الله لكم التوفيق.

Some of the most common causes of lower GI bleeding: Diverticulosis -> most common cause of lower GI bleeding. Abnormal mucosa on colonoscopy. IBD is also diagnosed through a colonoscopy, hence why it’s often the preferred initial investigation in general. Angiodysplasia -> may have inconclusive findings on colonoscopy when done initially. CT-A is the test of choice, but if not available choose nuclear scan/TC99. Ischemia -> severe manifestation often unresponsive to resuscitation, so it will need CT-A to rapidly assess the bleeding vessels for further management. Old women presented with lower gi bleeding on examination diffusely tender abdomen pr exam showing fresh blood patient is unstable despite receiving blood Bp70/50 What is the most appropriate management: A. laparotomy B. Angiography C. Urgent colonoscopy D. Observe B. A patient with refractory instability and active bleeding in urgent need for angioembolization. If the patient had been stabilized after resuscitative measures, we’d go for a colonoscopy instead. In the rare patient who has continuous bleeding from an obscure source, only then do we go for a laparotomy.

Here are two questions on hernia that I believe I answered incorrectly last time: 76 male reducible inguinal hernia with moderate pain. Mx? A- Open with mesh B- simple repair C- Non- surgical procedure A. “although watchful waiting may be appropriate for individuals with asymptomatic hernias or for elderly patients with minimally symptomatic hernias as the risk for acute incarceration or strangulation is very low - when followed for 7 to 10 years, approximately 70% of male patients who elect for inguinal hernia observation will undergo operative repair, with the likelihood of undergoing repair being higher for men older than 65 years when compared to younger men, and the most common indication for operation was pain rather than acute strangulation.” - Washington Manual of Surgery Female with small femoral hernia, most appropriate Mx: A. laproscopic repair B. simple open remai C. mesh open repair D. observation A. Uncomplicated femoral hernias are repaired laparoscopically with traditional TAPP or TEP approaches.

35 years old male has GERD with no alarm symptoms he is on esmoprazole 20 mg not satisfied ? Next step ? A- Life style modification B- Double the dose C- Endoscopy A. We can’t assume the patient started lifestyle modifications simply because they are using medication. If that doesn’t work, raise the PPI dose to 40mg, and if still not controlled proceed for endoscopy, then it depends: If no findings -> 24h Esophageal pH testing as the gold standard for GERD. If positive findings -> exclude motility disorders by doing manometry. Then proceed for nissen fundoplication for surgical treatment of GERD.

Progressive dysphagia to both solids and liquids? Case of achalasia. The initial test for hypermotility disorders is barium swallow as it would show bird’s peak appearance in achalasia (corkscrew appearance if intermittent dysphagia primarily with liquids). The definitive investigation is manometry. A young patient with no red flags has dysphagia to solids only? Go for barium swallow again to check for an esophageal stricture. If red flags such as unintentional weight loss or anemia are present and the patient is above 50 years old, go for an endoscopy with biopsy to look for cancer. K/C of GERD presents with sudden onset of red flags? Endoscopy again. Some questions below: 45 years old male presented to  the gastro clinic with history of  dysphagia toboth solid and  liquid for one year. Associated  with regurgitation of food. What is the best diagnostic test? A. Barium swallow B. OGD C. Manometry D. CT abdomen C. Progressive dysphagia to both liquids and solids without red flags and the patient is also younger than 50 years old. An elevated ESR is likely. Patient presented with dysphagia to liquids more than solid Which is the most appropriate initial investigation? A- endoscopy B- barium swallow C- US D- biopsy B is the initial test. 55 years old male with history of GERD for 10 years controlled on PPI. Presented to the hospital with recent history of dysphagia to solid food. What is the best next step? A. OGD B. CT abdomen C. Manometry D. Barium swallow A.

باذن الله النسخة المحدثة من الملف بحاول اشتغل عليها خلال الاشهر القادمة. حاليًا مشغول لكن بحاول ارجع في اقرب وقت عشانكم و بحط رابط حسابي على القناة عشان استفساراتكم لاحقًا. لا تنتظرون الملف الجديد، من الحين شدوا حيلكم في المذاكرة من جميع المصادر الموجودة في التلقرام و توكلوا على الله لان بنك الاسئلة ثابت بأفكاره و مواضيعه.

الحمدلله الذي بنعمته تتم الصالحات تم ترشيحي في رغبتي الاولى

للانترن الجدد: الحمدلله يبدوا ان الامور في السليم. اثناء استعدادكم للاختبار في الاشهر القادمة ركزوا على فهم الافكار ولا تحفظون فقط لان هذا الشي يضيعكم عند تشابه الاسئلة و تغيير المعطيات. من وجهة نظري: انسو فكرة ان فيه بنك اسئلة يتغير بشكل كبير او يبقى ثابت، ذاكروا المواضيع الاساسية بتركيز (مدسن، اوبي، بيديا، سيرجري) و بعدها امسكوا تجميعات ٣ اشهر مع التصحيح بانفسكم بناءً على المذاكرة السابقة و توكلوا على الله.

مختصر اول اسبوع من مارس ظهرت بنوك جديدة باسئلة مختلفه و فيها نسب تكرار من قبل لكن تختلف من شخص إلى اخر و البنك مسألة توفيق ممكن يجيك بنك مكرر 90٪ و ممكن يجيك بنك جديد بتكرار اقل. لدفعة القادمة الاستعداد للاختبار بالفهم و ليس الحفظ افضل طريقة تصحح البنوك السابقه بنفسك لايوجد افكار جديدة كلياً او مواضيع جديده كلها نفس السابق فقط أسئلة الأخلاقيات أصبحت سيناريو من الواقع المهني ما احد يعرف الجواب الصحيح تماماً لانه كل شخص يفهم السؤال و الموقف من جهته Silent

مختصر اول اسبوع من مارس ظهرت بنوك جديدة باسئلة مختلفه و فيها نسب تكرار من قبل لكن تختلف من شخص إلى اخر و البنك مسألة توفيق ممكن يجيك بنك مكرر 90٪ و ممكن يجيك بنك جديد بتكرار اقل. لدفعة القادمة الاستعداد للاختبار بالفهم و ليس الحفظ افضل طريقة تصحح البنوك السابقه بنفسك لايوجد افكار جديدة كلياً او مواضيع جديده كلها نفس السابق فقط أسئلة الأخلاقيات أصبحت سيناريو من الواقع المهني ما احد يعرف الجواب الصحيح تماماً لانه كل شخص يفهم السؤال و الموقف من جهته Silent

للانترن الجدد: الحمدلله يبدو ان الامور تمام. اثناء استعدادكم للاختبار في الاشهر القادمة ركزوا على فهم الافكار فقط ولا تحفظون لان هذا الشي يضيعكم لين تغيرت معطيات السؤال. من وجهة نظري: انسوا فكرة ان فيه شيء اسمه بنك اسئلة يتغير بشكل كبير او يبقى ثابت، ذاكروا المواضيع الاساسية بتركيز (مدسن، اوبي، بيديا، سيرجري) و بعدها امسكوا تجميعات ٣ اشهر مع التصحيح بانفسكم بناءً على المذاكرة السابقة و توكلوا على الله.

Patient with history of left leg pain when walking 200m. Came now with acute pain in the left leg. O/E: leg is cold and pale. Left leg pulses: femoral intact, popliteal and distal pulses NOT intact. Right leg: femoral and popliteal intact. Distal pulses not intact. Which of the following is the most appropriate management? A. CT angiography B. Above knee amputation C. Catheter directed thrombolysis D. Heparin and observe This patient had PAD then presented with ALI in the form of bilateral arterial thrombosis, but there are no signs of critical limb ischemia which would indicate amputation so B is excluded. D is incorrect because I definitely would not administer heparin and then “observe” the patient, we would immediately move on to another step in the full approach. A is also incorrect because the patient needs urgent revascularization so we can skip CT-A making the answer C. The first line treatment in ALI is typically catheter thrombolysis unless they give history of a cardiac cause or show A-fib on an ECG, so in that case we would choose embolectomy. If D was simply “Heparin” it would be correct as it’s the first step in any ALI case.

تحديث بسيط على بعض الشروحات و السؤال اللي ذكرته فوق. النسخة القادمة في شهر جون تقريبا باذن الله.

27-year-old obese woman presents with right iliac fossa pain associated with anorexia, nausea, and vomiting. On examination, there is moderate right iliac fossa tenderness. Labs showed: leukocytosis, what is the most appropriate management? I’m posting this question here since people are conflicted on the answer so I’ll provide my point of view. A case of (RIF) acute abdomen most likely suggestive of appendicitis with an Alvarado score of 6. Typically, CT scan is the initial choice in most of these cases if we’re following the guidelines which are the basis for standardized exams. Real life practice varies and some surgeons have different wildly approaches in general. In other words, initially we would also go for CT with contrast as well when it comes to LIF pain for instance (suspected diverticulitis). In our question though, it’s about a female patient so it’s safer to choose US in an emergency scenario if we can’t order a pregnancy test, but the patient is obese and US is largely useless for obese patients. That leaves us with laparoscopy and CT scan as our most likely choices. We would go with laparoscopy if the Alvarado score was 7-10, and CT if it’s less than that. I don’t think the question wants us to assume the patient is pregnant as it very well could be trying to tell if you know the Alvarado scoring system as it’s 6 in our case therefore the answer is CT. The question could be missing additional details in the full recall: (pregnancy test: negative / the score is actually 7. Maybe the patient has fever? Left shift?). But with this scenario? CT scan makes far more sense based on what I typed as the question specified most appropriate management, not the very next step you want to do. If the question had pregnancy test, go for it.