SMLE exam: free questions, blueprint and pass score

Results: A scaled score on a 200-800 reporting scale, with a statement of results and a feedback report comparing you with other test takers - announced 2-6 weeks after the test window closes.

Attempts: You may sit each licensure exam up to four times a year, counted from your first attempt, until you pass. You cannot sit twice in the same testing window - the second sitting counts as an attempt and its result is void. Arriving more than 30 minutes late also counts as an attempt unless SCFHS accepts a documented reason. After passing, you get two further attempts to improve your score, for residency selection.

1. Question 1Medicinemedium

   A 22-year-old man with type 1 diabetes presents with vomiting and abdominal pain. Glucose is 31 mmol/L, pH 7.10, bicarbonate 9 mmol/L, ketones strongly positive and potassium 3.0 mmol/L. IV 0.9% saline has been started. What is the most appropriate next step?

   1. AStart a fixed-rate IV insulin infusion immediately
   2. BGive IV potassium replacement and hold insulin until potassium is at least 3.3 mmol/L
   3. CGive IV sodium bicarbonate to correct the acidosis
   4. DGive a subcutaneous dose of long-acting insulin
   Show answer and explanation▾

   Answer: B. Give IV potassium replacement and hold insulin until potassium is at least 3.3 mmol/L

   Insulin drives potassium into cells, so starting it when potassium is below 3.3 mmol/L risks dangerous hypokalaemia and arrhythmia. Potassium is replaced first while fluids continue. Bicarbonate is not indicated at pH 7.10, and long-acting subcutaneous insulin does not treat DKA.

   Reference: ADA Consensus Report: Hyperglycemic Crises in Adults With Diabetes (2024)

2. Question 2Medicinemedium

   A 72-year-old woman with hypertension and type 2 diabetes is found to have non-valvular atrial fibrillation. Her eGFR is 70 mL/min and she has no bleeding history. What is the best long-term strategy to prevent stroke?

   1. AAspirin 81 mg daily
   2. BA direct oral anticoagulant such as apixaban
   3. CNo antithrombotic therapy
   4. DAspirin plus clopidogrel
   Show answer and explanation▾

   Answer: B. A direct oral anticoagulant such as apixaban

   Age 65-74, hypertension and diabetes give her a high stroke-risk score, so oral anticoagulation is recommended, and a DOAC is preferred over warfarin in non-valvular AF. Aspirin alone or dual antiplatelet therapy is less effective at preventing stroke and still causes bleeding.

   Reference: 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation

3. Question 3Medicinemedium

   A 45-year-old woman develops pleuritic chest pain and breathlessness two days after a 12-hour flight. Heart rate is 112/min, blood pressure 128/80 mmHg and SpO2 93% on air. Her two-level Wells score is 6 (PE likely). What is the most appropriate next investigation?

   1. AD-dimer, and image only if it is raised
   2. BCT pulmonary angiography
   3. CChest X-ray, and reassure if it is normal
   4. DLower-limb venous Doppler before any chest imaging
   Show answer and explanation▾

   Answer: B. CT pulmonary angiography

   When PE is likely on the Wells score, the next step is imaging with CT pulmonary angiography; a negative D-dimer cannot safely exclude PE at high pre-test probability. A normal chest X-ray does not exclude PE, and leg Doppler is reserved for when CTPA is contraindicated or unavailable.

   Reference: NICE Guideline NG158: Venous thromboembolic diseases (2020, updated 2023)

4. Question 4Medicineeasy

   A 66-year-old man with chronic kidney disease has a potassium of 7.1 mmol/L. His ECG shows peaked T waves and a widened QRS complex. What should be given first?

   1. AIV calcium gluconate
   2. BIV insulin with glucose
   3. COral calcium resonium
   4. DIV furosemide
   Show answer and explanation▾

   Answer: A. IV calcium gluconate

   With ECG changes, IV calcium is given first to stabilise the myocardium; it does not lower potassium. Insulin with glucose then shifts potassium into cells, and binders or diuretics remove it more slowly.

   Reference: UK Kidney Association Clinical Practice Guideline: Treatment of Acute Hyperkalaemia in Adults (2020)

5. Question 5Medicinemedium

   A 34-year-old man from a rural area has had three weeks of intermittent fever, drenching sweats, low back pain and fatigue. He regularly drinks unpasteurised camel milk. Examination shows mild hepatosplenomegaly. What is the most likely diagnosis?

   1. ABrucellosis
   2. BTyphoid fever
   3. CInfectious mononucleosis
   4. DAcute viral hepatitis
   Show answer and explanation▾

   Answer: A. Brucellosis

   Undulant fever, sweats, back pain (sacroiliitis or spondylitis) and hepatosplenomegaly after drinking unpasteurised milk is the classic picture of brucellosis, which is endemic in the region. Typhoid is food- or water-borne without this exposure pattern, and mononucleosis and hepatitis do not explain the milk exposure or back pain.

   Reference: Harrison's Principles of Internal Medicine, 21st ed. (2022)

6. Question 6Obstetrics and Gynaecologyeasy

   Ten minutes after a vaginal delivery, a woman is bleeding heavily and the uterus feels soft and boggy. Uterine massage has been started. Which drug is the first-line uterotonic?

   1. AOxytocin
   2. BCarboprost
   3. CTranexamic acid alone
   4. DNifedipine
   Show answer and explanation▾

   Answer: A. Oxytocin

   Uterine atony is the commonest cause of postpartum haemorrhage, and IV oxytocin is the first-line uterotonic. Carboprost and ergometrine are second-line, and tranexamic acid is given in addition to uterotonics, not instead of them. Nifedipine relaxes the uterus.

   Reference: WHO Recommendations for the Prevention and Treatment of Postpartum Haemorrhage (2012)

7. Question 7Obstetrics and Gynaecologyeasy

   A woman at 33 weeks of gestation has blood pressure 166/112 mmHg, a severe headache and 3+ proteinuria. Antihypertensive treatment has been started. Which drug should be given to prevent eclamptic seizures?

   1. APhenytoin
   2. BDiazepam
   3. CMagnesium sulfate
   4. DLevetiracetam
   Show answer and explanation▾

   Answer: C. Magnesium sulfate

   Magnesium sulfate is the drug of choice for preventing and treating eclamptic seizures and is more effective than phenytoin or diazepam. Monitor reflexes, respiratory rate and urine output for toxicity.

   Reference: ACOG Practice Bulletin No. 222: Gestational Hypertension and Preeclampsia (2020)

8. Question 8Obstetrics and Gynaecologyeasy

   A pregnant woman with no history of diabetes and normal early-pregnancy glucose asks when she will be screened for gestational diabetes. When is the 75 g oral glucose tolerance test usually performed?

   1. AAt the booking visit only
   2. BAt 24-28 weeks of gestation
   3. CAt 36-38 weeks of gestation
   4. DOnly after delivery
   Show answer and explanation▾

   Answer: B. At 24-28 weeks of gestation

   Women without known diabetes are screened at 24-28 weeks, when insulin resistance of pregnancy has developed. Earlier testing is for women with risk factors, and testing at 36 weeks is too late to change outcomes.

   Reference: ADA Standards of Care in Diabetes: Management of Diabetes in Pregnancy (2024)

9. Question 9Obstetrics and Gynaecologymedium

   A 24-year-old woman has irregular periods, hirsutism and polycystic ovaries on ultrasound. She does not want to conceive at present and asks for help with her cycles and hair growth. What is the first-line pharmacological treatment?

   1. ACombined oral contraceptive pill
   2. BClomiphene citrate
   3. CLetrozole
   4. DSpironolactone alone
   Show answer and explanation▾

   Answer: A. Combined oral contraceptive pill

   For women with PCOS who are not trying to conceive, the combined oral contraceptive pill is first line for menstrual irregularity and hirsutism. Clomiphene and letrozole induce ovulation for fertility. Anti-androgens such as spironolactone are added if the pill alone is not enough, and need reliable contraception.

   Reference: International Evidence-based Guideline for the Assessment and Management of Polycystic Ovary Syndrome (2023)

10. Question 10Pediatricseasy

    A 4-month-old infant has two days of coryza, cough and wheeze, with fine crackles on auscultation. He is feeding over half his usual amount, SpO2 is 95% on air and there is mild subcostal recession. What is the most appropriate management?

    1. ANebulised salbutamol every 4 hours
    2. BOral prednisolone for 3 days
    3. CSupportive care with nasal suction, feeding support and safety-net advice
    4. DOral amoxicillin
    Show answer and explanation▾

    Answer: C. Supportive care with nasal suction, feeding support and safety-net advice

    Bronchiolitis is viral and self-limiting; management is supportive. Bronchodilators, corticosteroids and antibiotics do not improve outcomes and are not recommended. Admission is needed for low saturations, poor feeding or worsening work of breathing.

    Reference: AAP Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis (2014)

11. Question 11Pediatricsmedium

    A 3-year-old has had fever for six days with bilateral non-purulent conjunctivitis, cracked red lips, a polymorphous rash and swollen hands and feet. What is the most important treatment to reduce the risk of complications?

    1. AIV immunoglobulin with aspirin
    2. BOral amoxicillin
    3. CIV ceftriaxone
    4. DOral antihistamines
    Show answer and explanation▾

    Answer: A. IV immunoglobulin with aspirin

    This is Kawasaki disease. IV immunoglobulin, given within the first 10 days of illness, with aspirin, reduces the risk of coronary artery aneurysms. Antibiotics and antihistamines do not treat the vasculitis.

    Reference: AHA Scientific Statement: Diagnosis, Treatment, and Long-Term Management of Kawasaki Disease (2017)

12. Question 12Pediatricsmedium

    A term baby is noticed to be jaundiced at 18 hours of age. She is feeding well and otherwise appears well. What is the most appropriate next step?

    1. AReassure and review at day 3
    2. BAdvise exposure to sunlight at home
    3. CMeasure the serum bilirubin urgently
    4. DStop breastfeeding and start formula
    Show answer and explanation▾

    Answer: C. Measure the serum bilirubin urgently

    Jaundice in the first 24 hours of life is always pathological until proven otherwise, often haemolysis, so serum bilirubin is measured urgently, within 2 hours. Sunlight is not a treatment, and breastfeeding should continue.

    Reference: NICE Clinical Guideline CG98: Jaundice in Newborn Babies Under 28 Days (2010, updated 2023)

13. Question 13Surgeryeasy

    A motorcyclist arrives after a high-speed collision. He is unresponsive, with snoring respirations and an obvious open fracture of the left tibia. What is the first priority?

    1. ASplint the tibial fracture
    2. BSecure the airway while restricting cervical spine movement
    3. CObtain a CT scan of the head
    4. DInsert two large-bore cannulas
    Show answer and explanation▾

    Answer: B. Secure the airway while restricting cervical spine movement

    The primary survey starts with A: airway maintenance with restriction of cervical spine motion. Snoring respirations mean a partly obstructed airway. Circulation, imaging and fracture care come after the airway is secure.

    Reference: ATLS Advanced Trauma Life Support Student Course Manual, 10th ed. (2018)

14. Question 14Surgeryeasy

    A 42-year-old woman has 24 hours of constant right upper quadrant pain, fever of 38.4 °C and a positive Murphy's sign. Bilirubin is normal. What is the best initial imaging test?

    1. AAbdominal ultrasound
    2. BERCP
    3. CPlain abdominal X-ray
    4. DMRCP
    Show answer and explanation▾

    Answer: A. Abdominal ultrasound

    Ultrasound is the first-line test for suspected acute cholecystitis, showing gallstones, wall thickening and a sonographic Murphy's sign. ERCP is for bile duct stones with obstruction or cholangitis, MRCP for suspected duct stones, and a plain film shows only a minority of gallstones.

    Reference: Tokyo Guidelines 2018: Diagnostic Criteria and Severity Grading of Acute Cholecystitis

15. Question 15Surgeryeasy

    A 46-year-old woman presents with a 2 cm firm, painless lump in her right breast, found one week ago. What is the standard approach to diagnosis?

    1. ARepeat examination after her next period
    2. BTriple assessment: clinical examination, imaging and core needle biopsy
    3. CMammography alone, and biopsy only if it is abnormal
    4. DImmediate wide local excision
    Show answer and explanation▾

    Answer: B. Triple assessment: clinical examination, imaging and core needle biopsy

    A discrete breast lump at this age needs triple assessment: clinical examination, imaging (mammography with ultrasound) and tissue diagnosis by core biopsy. A normal mammogram does not exclude cancer, and surgery comes only after diagnosis.

    Reference: Bailey & Love's Short Practice of Surgery, 28th ed. (2023)

1. 1

   Check you are eligible

   MBBS or equivalent, or in your internship year, or one year from graduation.

2. 2

   Apply through SCFHS's e-application

   SCFHS processes the application and issues a scheduling permit with your eligibility period. You receive an email with instructions for accessing it.

3. 3

   Book with Prometric

   Use the permit to schedule a date at an SCFHS-approved Prometric centre, in Saudi Arabia or abroad. Scheduling may not be open more than three months ahead, and SCFHS sets the testing windows.

4. 4

   Bring your permit and ID

   Centres open at 7:30 a.m. Bring the scheduling permit, on paper or on your phone, and a passport (or a national or residence ID in Saudi Arabia) with your name exactly as it appears on the permit.

5. 5

   Wait for your results

   Results are released 2-6 weeks after the testing window closes, as a statement of results and a feedback report comparing you with other candidates.