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SMLE CONTENT OUTLINE
This outline provides a common organization of SMLE content. SMLE central committee continually
reviews the outline to ensure content is relevant to the practice of medicine. As practice guidelines
evolve or are introduced, the content on SMLE is reviewed and modified as needed.
The examination will emphasize certain parts of the outline, and no single examination will include
questions on all aspects. Questions may include content that is not included in this outline.
MEDICINE
CARDIOLOGY:
Coronary Artery Disease
Heart Failure
Atrial Fibrillation
Cardiovascular risk reduction
Valvular heart diseases
Pericarditis / myocarditis
PULMONARY:
Bronchial Asthma
COPD
Lung mass
Pleural effusion
Pulmonary embolism
GASTROENTEROLOGY:
Peptic ulcer disease
GERD
IBD
Celiac disease
Pancreatitis
April 2018 1
HEPATOLOGY:
Acute viral hepatitis
Acute non-viral hepatitis
Chronic viral hepatitis
Complications of Liver cirrhosis
Hepatocellular carcinoma
Ascending cholangitis
NEPHROLOGY:
Acute kidney injury
Chronic Kidney disease
Diagnosis of nephrotic syndrome
Hyper and hypokalemia
Hypo and hyper natremia
Primary HTN
Secondary HTN
ENDOCRINE:
Hypothyroidism
Hyperthyroidism
Diabetes (diagnosis)
Acute diabetic complications
Chronic diabetic complications
Prolactinoma
Adrenal insufficiency
Osteoporosis
RHEUMATOLOGY:
Rheumatoid arthritis
SLE
Osteoarthritis
Gout
Reactive arthritis
April 2018 2
HEMATOLOGY:
Iron deficiency anemia
Megaloblastic anemia
Hemolysis
Thrombotic disorders
Sickle cell disease
Anticoagulant Rx management
Thrombocytopenia
Acute leukemia (recognition)
INFECTIOUS DISEASES:
Pneumonia
Urinary tract infections
Tuberculosis
Brucellosis
Meningitis
Soft tissue / bone / joint infections
Infective endocarditis
Line related blood stream infections
H1N1
MERS-CoV
Chickenpox and shingles
Sexually transmitted infections (including HIV)
Malaria and dengue fever
NEUROLOGY:
Ischemic stroke
Hemorrhagic stroke
TIA
Seizure disorders
Multiple sclerosis
Spinal cord compression
Migraine
ONCOLOGY:
Lung cancer
Prostate cancer
Tumor lysis syndrome
Superior vena cava obstruction
Febrile neutropenia
April 2018 3
CRITICAL CARE:
Respiratory failure
Sepsis and septic shock
Hemorrhagic shock
Cardiac tamponade
Massive PE
Cardiogenic Shock
GERIATRICS:
Acute confusional state
Dementia
Falls
PSYCHIATRY:
Depression
Side effects of medications
Substance abuse
Bipolar disorder
Scizophrenia
April 2018 4
PAEDIATRICS
GENERAL PAEDIATRIC:
Gastroenteritis
Nephrotic syndrome
Febrile seizure
Bronchial asthma
Iron deficiency anemia
Bronchiolitis
Pneumonia
Otitis media
Cellulitis
Upper respiratory tract infections
Urinary tract infections
Celiac disease
Down syndrome
Acute renal failure
Henoch schonlein purpura
Constipation
Fluids and electrolytes disturbance
Rickets
Hypertension
Infantile colic
Celiac disease
Cerebral palsy
Undescended testis
Well baby
AMBULATORY:
Immunization
Development and behavior
Growth and growth disorders
Nutrition and nutritional disorders
Sequent
Failure to thrive
Enuresis
April 2018 5
CARDIOVASCULAR SYSTEM :
Congenital heart disease
Heart failure
Syncope
Rheumatic heart disease
RESPIRATORY SYSTEM:
Sinusitis
Adenotonsillitis
Pleural effusion
Laryngomalacia
Tracheomalacia
Cystic fibrosis
Croup
Tracheitis
GASTROINTESTINAL SYSTEM:
Cleft palate
Gastroesophageal reflux
Pyloric stenosis
Congenital Gastrointestinal anomalies
Foreign body ingestion
Peptic ulcer disease
Inflammatory bowel disease
Appendicitis
Intussusception
Chronic liver disease
Jaundice
MUSCULOSKELETAL SYSTEM:
Systemic lupus disease
Kawasaki Disease
Post infectious arthritis
Rheumatoid arthritis
INFECTIOUS DISEASES:
Brucella
Tuberculosis
April 2018 6
Osteomyelitis
Myositis
Cellulitis
Scarlet fever
Pharyngitis
Meningitis
Encephalitis
Malaria, enteric fever, leishmania
Dengue fever
CMV, EBV, HSV, HIV, hepatitis
Measles, mumps and rubella
Pertussis
Parasites (Ascaris, pinworms, giardiasis, amoeba)
Septic arthritis
Osteomyelitis
NEPHROLOGY:
Post streptococcal glomerulonephritis
Chronic kidney Disease
Congenital anomalies of kidney and genitourinary tract (CAKUT), (polycystic kidney
disease, Vesicourethral reflux, neurogenic bladder)
Hemolytic uremic syndrome
Renal tubular acidosis
ACUTE CARE:
Acute respiratory distress syndrome
Status asthmaticus
Status epilepticus
Shock
Arrhythmias
Drug ingestions (e.g. iron, acetaminophen)
Trauma
Testicular torsion
Peritonitis
Foreign body inhalation
HEMATOLOGY/ONCOLOGY:
Hemolytic anemias
Immune thrombocytopenic purpura
Hemoglobinopathies
Leukemia
Lymphoma
Retinoblastoma
April 2018 7
Willm’s tumor
Neuroblastoma
Nephroblastoma
Bleeding disorders
NEONATOLOGY:
Respiratory distress syndrome
Transient tachypnea of newborn
Intrauterine growth retardation
Meconium aspiration
Hemorrhagic diseases of newborn
ENDOCRINOLOGY:
Diabetes mellitus
Thyroid disorders
Diabetes insipidus
Panhypopituitarism
Short stature
Precious puberty
Ambiguous genitalia
Adrenal disorders
Obesity
GENETIC/METABOLIC:
Newborn screening
Hypoglycemia
Galactosemia
Phenylketonuria
Maple syrup disease
Turner syndrome
Marfan syndrome
ALLERGY/IMMUNOLOGY:
Atopic dermatitis
Allergic rhinitis
Primary immunodeficiencies
April 2018 8
OBSTETRICS AND GYNAECOLOGY
History & Examination
Ectopic Pregnancy
Spontaneous Abortion
Preeclampsia-Eclampsia
Third Trimester Bleeding
Preterm Labor
Preterm Rupture of Membranes
Postpartum Hemorrhage
Pap Smear & DNA Probe & Culture
Sexually Transmitted Infections and Urinary Tract Infections
Personal Interaction and Communication Skills
Normal and Abnormal Uterine Bleeding
Dysmenorrhea
Uterine Leiomyomas
Sexual Assault
Domestic Violence
Diagnosis and Management Plan
Maternal-Fetal Physiology
Preconception Care
Antepartum Care
Intrapartum Care
Immediate Care of the Newborn
Postpartum Care
Lactation
Medical and Surgical Complications of Pregnancy
Alloimmunization
Multifetal Gestation
Fetal Death
Abnormal Labor
Intrapartum Fetal Surveillance
Postpartum Infection
Anxiety and Depression
Post-term Pregnancy
Fetal Growth Abnormalities
Obstetrics Procedures
Family Planning
Induced Abortion
Vulvar and Vaginal Disease
Endometriosis
Chronic Pelvic Pain
Gynecological Procedures
Puberty
Amenorrhea
Hirsutism and Virilization
Menopause
Infertility
Premenstrual Syndrome and Premenstrual Dysphoric Disorder
April 2018 9
Legal and Ethics Issues in Obstetrics and Gynecology
Gestational Trophoblastic Neoplasia
Cervical Disease and Neoplasia
Endometrial Hyperlasia and Carcinoma
Ovarian Neoplasms
Preventive Care and Health Maintenance
Pelvic Organ Prolapse and Urinary Incontinence
Vulvar Neoplasms
Sexuality and Modes of Sexual Expression
April 2018 10
SURGERY
BASIC PRINCIPLES:
Surgical infection and antibiotics:
Systemic inflammatory response
Surgical infection prevention
Principles of antibiotics use in surgical patients
Surgical Site Infections
Intra-Abdominal Infections
Infections of the Skin and Soft Tissue
Preoperative assessment:
Preoperative evaluation
Risk assessment
Wound care:
Phases of wound healing
Factors affecting wound healing
Abnormal wound healing
Wound dressing
Post-operative complications:
Post-operative care
Postoperative fever
DVT
Complications of common procedures
GENERAL SURGERY:
Breast:
Mastalgia
Nipple discharge
Breast mass approach
Breast mass in pregnancy
Benign breast disorders: proliferative and non-proliferative disease, breast abscess,
mastitis
Breast cancer screening
Breast cancer
April 2018 11
Thyroid and parathyroid:
Neck mass evaluation
Thyroid nodule approach
Surgery for hyperthyroidism
Thyroid cancer
Complications of thyroidectomy
Primary hyperparathyroidism
2ndry hyperparathyroidism
Tertiary hyperparathyroidism
Adrenal:
Surgical hypertension
Incidental adrenal mass
GIT:
GERD
Corrosive esophageal injury
Swallowing foreign body
Esophageal cancer
Upper GI bleeding
Peptic Ulcer Disease
Surgical management of Obesity
Lower GI bleeding
Appendicitis
Bowel obstruction
Inflammatory Bowel Disease
Colon cancer screening
Colonic polyp
Colon cancer
Diverticular disease
PR bleeding
Anorectal conditions
Pilonidal sinus
Hepatobiliary:
Biliary colic
Acute cholecystitis
Obstructive jaundice
Cholangitis
Hydatid liver disease
Liver abscess
Acute Pancreatitis
Chronic pancreatitis
Pancreatic cancer
April 2018 12
Hernias:
Inguinal hernia
Incisional, Umbilical and epigastric hernias
Obstructed hernia
Rectus sheet hematoma
Vascular Surgery:
Diabetic foot
Peripheral arterial disease PAD
-Acute limb ischemia
-Chronic limb ischemia
-Critical limb ischemia
Venous Disorders
-Varicose veins
-Venous thromboembolism
Others
-Compartment syndrome
-Gangrene
-Dialysis vascular access
-Abdominal aortic aneurysms
Paediatric surgery:
Branchial cysts
Thyroglossal cyst
Pyloric stenosis
Diaphragmatic hernia
Tracheoesophageal fistula
Umbilical hernia
Undefended testicle
Hirschsprung disease
Wilms tumor
Neuroblastoma
Circumcision
April 2018 13
Plastic surgery:
Hand infections
Fingers injuries and amputations
Carpal tunnel syndrome
Upper limb nerve injuries evaluation
Cutaneous melanoma
Squamous cell carcinoma
Burn
Bed sore
Gastrointestinal Bleeding:
Upper GI bleeding, causes and surgical management
Lower GI bleeding causes and surgical management
Specific organ trauma:
liver
spleen
kidney and retroperitoneum
Esophageal, gastric and bowel trauma
Damage control surgery
Surgical ICU:
Abdominal compartment syndrome
Lung protective ventilation
Early and adequate nutrition
Restrictive blood transfusion
DVT and stress gastritis prophylaxis
Source control in septic patients
April 2018 14
SUBSPECIALTIES:
Urology:
Emergencies: Acute Urinary Retention, Testicular Torsion , hematuria, Fournier’s
Gangrene, Priapism
Infections: Cystitis ,Pyelonephritis , Prostatitis, Epididymo-orchitis
Lower Urinary Tract Obstruction: Benign Prostatic Hyperplasia, Urethral Stricture
Upper Urinary Tract Obstruction: Urolithiasis, Retroperitoneal Fibrosis
Pediatric Urology: Ureteropelvic Junction, Vesicoureteral Reflux, Ureteroceles, Posterior
Urethral Valve
Neurosurgery:
Raised intracranial pressure
Cerebrovascular diseases
Spinal cord compression
Entrapment neuropathy
Cranial & spinal infection
Hydrocephalus
Degenerative disc disease
Congenital anomalies
Brain tumors
Orthopedic:
Trauma: Open fracture treatment, Compartment syndrome
Principles of fracture/ dislocation management
Oncology: Osteosarcoma, Ewing's sarcoma, Chondrosarcoma
Birth injuries
Developmental diseases
ENT:
Epistaxis
Otitis externa
Otitis media
Sinusitis
Tonsillitis
Acoustic neuroma
Foreign body
Disorders of balance
Hearing loss
April 2018 15
Ophthalmology:
Infectious and inflammatory disorders: blepharitis; conjunctivitis , uveitis
endophthalmitis; iridocyclitis; periorbital cellulitis; uveitis
Neoplasms: melanoma; retinoblastoma
Cataract
Glaucoma
Lacrimal system disorders
Refractive disorders
Disorders of the retina: diabetic retinopathy; papilledema; retinal detachment; retinitis
pigmentosa; retinal hemorrhage, amaurosis fugax,
Visual impairment/blindness, night blindness, Sudden loss of vision
Traumatic and mechanical disorders: corneal abrasion, ulcer; dislocated lens; foreign
body in eye, laceration of the eyelid; subconjunctival hemorrhage
April 2018 16
PATIENT SAFETY, PREVENTIVE MEDICINE, & ETHICS
ETHICS:
Informed Consent
DNR/DNI
Organ Donation
Abortion
Breaking Bad News
DAMA
Authorship and Plagiarism
Patient Privacy
Proper HIM
Abuse (spouse, child and elderly)
Conflict of Interest
Social Media Practices/Technology
Confidentiality
Sick Leave
Second opinions
Medico-legal Issues/Whistleblowing
Death Certificate
Identity Theft
Fertility Ethics
Plastic Surgery/Bariatric/Obesity
Communications with peers' patients
Bullying and Abuse
Impaired Physicians
PATIENT SAFETY:
Clinical Privileges
Patient /Community Education
Medications Safety
Infectious Prevention and Control
Surgical Safety
Emergency Preparedness
Continues Professional development
Inter-professional communication
International patient safety goals
Blood Transfusion safety
Radiation Safety
Patient Empowerment
Communication with patient and family
Institute of Medicine Quality dimensions
Diagnostic Errors
Venous thromboembolism prophylaxis
April 2018 17
PREVENTIVE:
Nutrition / Obesity
Exercise
Travel medicine
Risk factors (NCDs) Assessment and modifications
Smoking
Environmental
-Temp (hyperthermia, heat stroke)
-Metals (lead)
Venomous bites and stings
Reportable diseases
Outbreaks
Herd immunity
Immunization (Child, Adult)
Disease screening (Cancer, CVD, DM, HTN, AAA)
Mental Health
Principles of screening (validity, test parameters, criteria for screening test)
Sleep Medicine
Preventive Cardiology
Adolescent health
Geriatric medicine
Women Health
April 2018 18
Report of the Incidence and Prevalence of Diseases and other Health
Related Issues in Saudi Arabia
A study for the SMLE Blueprint Project
Heba AlManea
Assessment Executive Specialist, SCFHS
Dr Abdulmohsen Al-Zalabani
Associate Professor, Epidemiology & Community Medicine, Taibah University
Dr Fadi Munshi
Executive Director of Assessment, SCFHS
1
November 2017
Overview and Purpose of the Review
Presently, the Saudi Medical Licensure Examination (SMLE) must be passed as part of the
process leading to practice in Saudi Arabia. The intent of the SMLE is to assess the medical
knowledge and clinical decision-making ability of a candidate at an entry-level general
practitioner whom are expected to provide safe and effective patient care for the Saudi Nation.
The primary purpose of this report is to review and summarize the frequency of most
responsible diagnoses as seen in the Saudi context by using existing data. This includes data
from Ministry of Health (MOH) statistical book. The data includes common cases, and
operations witnessed in MOH hospitals during 2015-2016. Another source is a Global Burden of
Disease study that includes lists of the top conditions/diseases with the greatest burden on the
population health in Saudi Arabia reported by the Institute of Health Metrics and Evaluation.
The inclusion of these prevalent conditions in medical licensure examinations would help
ensure that doctors are adequately prepared to treat today’s Saudi population’s major health
concerns.
As a secondary purpose, this report includes a review of certain areas of importance for the
practice of medicine which may not be well represented by patient presentations/diagnoses,
such as population health (in Hajj seasons), Patient Safety issues and Medical Malpractice
issues.
2
November 2017
A Snapshot of Health Care in Saudi Arabia
In 2016, the population of Saudi Arabia was over 31 million individuals, all of whom require
health care services in some capacity. In 2016, children and youth under 15 years of age
represent (30.35%) of the Saudi population; adults 15 to 64 years of age represent 65.46%;
whereas seniors over the age of 65 comprise 4.17% of the population. In 2016, Ministry of
Health Statistical yearbook reported the total number of visits to the primary health care
centers, private, general and polyclinics in 2016 was nearly 138 Million visits; 3451377 cases
represented the total number of inpatients in the hospitals of all health sectors: 49.4% of them
were in MOH hospitals. The statistical yearbook also reported 49,817,811 visits to Health
centers and 64,346,910 visits to Outpatients of MOH hospitals.
In 2016, the MOH published its annual statistical book detailing health activities and services
provided across Saudi Arabia. The report outlines cases related to complications of pregnancy,
children, and gynecology, MOH hospitals, injury cases by type of injury, gynecology operations
in MOH hospitals by type of operations, deliveries in MOH hospitals by type of delivery,
operations in MOH hospitals by hospital sections and cases of malignant tumors registered in
KFSHRC Riyadh & Jeddah. The report, also, includes lists of most common causes of premature
mortality and conditions with the highest burden. Findings from this report will contribute to
our knowledge of incidence and prevalence of disease in Saudi Arabia.
Studying statistics of such cases and conditions will contribute to the drafting of a framework
that outlines what should be included and assessed by establishing the grounds of our
knowledge of incidence and prevalence of disease in Saudi Arabia. SMLE will focus on such
cases and conditions which will be seen frequently by future doctors. (See Tables 1-8 in
Appendix 1).
3
November 2017
Health of the Population (Hajj Season)
Public health refers to a population-health based approach. The public health aims to monitor
health status, promote health, and prevent diseases and injuries through various activities
including population health assessment, health protection, and emergency preparedness.
It is noteworthy that MOH pursues its program “Safe Surgery Saves Lives” (SSSL), which
features providing free specialized healthcare services, including open-heart surgeries, cardiac
catheterization, kidney blood and peritoneal dialysis, alimentary endoscopy, obstetrical cases,
in addition to other specialized services needed by pilgrim patients.
In 2017, More than 29,000 health practitioners - including various medical, technical and
administrative groups - were commissioned under Hajj Manpower Program. Physicians, nurses
and allied health personnel constituted 76% of the assigned manpower. In average, a physician
served 425 pilgrims.
Nevertheless, there are many steps being taken to enhance public health practice in Saudi
Arabia. The future vision is that “all physicians graduating from Saudi medical schools should be
able to practice medicine with the concepts of public health as key elements in their day-to-day
activities, as well as seeing themselves as a key component of the public health system”.
4
November 2017
Patient Safety
To provide safe care to patients, it is important for physicians to have clear understanding of
safety issues and patient safety concepts. The Canadian Patient Safety Institute (CPSI) has
developed a safety competencies framework to help health professionals to improve the health
of their patients. Six overarching competencies have been developed to enhance safe practices:
(1) contribute to a culture of patient safety, (2) work in teams for patient safety, (3)
communicate effectively for patient safety, (4) manage safety risks, (5) optimize human and
environmental factors, and (6) recognize, respond to and disclose adverse events. The
competencies describe the knowledge, skills, and behavior necessary for the safe care of
patients.
Recently, the American College of Physicians has published patient safety strategies which the
authors strongly recommend be adopted. Although these strategies are proposed for an
American patient population, they are in keeping with prior research from the CPSI.
The Saudi Patient Safety Center (SPSC) is a national body that aims to raise awareness and
knowledge of patient, strengthen and improve the culture of best practices in patient safety in
all health institutions, study and research to improve the quality of health facilities.
SPSC will frequently issues patient safety alerts with recommendation action items. SMLE will
include common patient safety issues, as familiarity with published strategies are required to
further improve the health of their patients.
5
November 2017
Medical Malpractice
In an effort to reduce medical malpractice, the General Directorate of Forensic Medicine Centers
at MOH has issued a statistical report about the Medical Malpractice in Saudi Arabia. The report
tackled the specialties of the convicted practitioners concluded by the forensic health centers
during the years 1434 H – 1437 H.
The data manifested that the practitioners specialized in OB/GYN were the most likely to be
convicted of malpractice during the last four years. Following them were practitioners
specialized in general surgery in the years 1434 H - 01436 H. Internal Medical practitioners
came in third place in the years 1434 and 1436.
By shedding light on the most common medical malpractices in Saudi Arabia, the SMLE may
play a vital role in addressing the systemic malfunctions in order to ensure the safe practice of
general practitioners.
Summary
The intent of the SMLE is to assess the medical knowledge and clinical decision-making
ability of a candidate at an entry-level general practitioner. This review outlines the most
common cases and conditions in the Saudi population. It also provides information about other
health related issues that are necessary for the improvement of Saudis’ health and establishing
the SMLE blueprint.
6
November 2017
Appendix 1
Table 1: Cases related to complications of pregnancy and childbirth, MOH Hospitals
7
November 2017
Table 2: Total Injury Cases in the Kingdom by type of injury (1436 H)
8
November 2017
Table 3: Some Gynecology Operations in MOH Hospitals by Type of Operations (1437 H)
9
November 2017
Table 4: Deliveries in MOH Hospitals by Type of Delivery
Normal deliveries
Cesarean section
Ventouse
Other
Breech
Forceps
10
November 2017
Table 5: Operations in MOH Hospitals by Hospital Sections (1436 H)
Sections # Cases
General 119981
OBS\GYN 116123
Ophthalmology 82345
Orthopedics 55472
ENT 28452
Plastic 20974
Urology 18400
Pediatrics 18291
Others 13768
Faciodental 13085
Cardiac, Chest & vascular 9442
Neurology 7901
11
November 2017
Table 6: Cases of Malignant Tumors Registered in KFSHRC Riyadh & Jeddah
Breast
Thyroid gland
NHL-lymph
Leukemia
Brain & C.N.S
Hodgkin’s
Oral cavity
Liver
Lung
Bladder
Nasopharynx
Soft tissue
Ovary
Esophagus
12
November 2017
Table 7: Top 10 causes of premature mortality
13
November 2017
Table 8: Top 10 risk factors contributing to DALY*
Dietary risks
Air pollution
Tobacco smoke
Occupational risks
*DALY (disability-adjusted life year): summary measure used to give an indication of the burden
of disease
14
November 2017
Table 9: Specialties of convicted malpractice practitioners concluded by the Forensic Health
Centers (MOH) during The Years 1434 H – 1437 H
200
180
160
140
120
100
80
60 1437 H
40
20 1436 H
0
Anesthesia &…
Oral Maxillofacial…
1435 H
Cardiology
ENT
Urology
Pediatrics
OB/GYN
Plastic Surgery
Other Surgeries
Midwifery
Radiology
Other Specialties
General Surgery
INT Medicine
Hematology
Dental Surgery
Neurosurgery
Orthopedic Surgery
Ophthalmology
Dermatology
1434 H
15
November 2017