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12-A 61-year-old man is due to undergo his first screening colonoscopy. His medical history is significant for hypertension, and he is currently taking lisinopril and amlodipine. The patient denies headache and chest pain. His blood pressure today is 160/100 mm Hg. What is the next step in the management of this patient? A-Schedule the patient for colonoscopy

B-Retake the patient’s blood pressure
C-Optimize blood pressure control
D-Refer for cardiology consultation
F-Cancel the colonoscopy and get a CT colonoscopy

Ans: C. controlling systolic hypertension reduces perioperative cardiac complications, and systolic hypertension should be controlled prior to any elective surgery. There is no need to repeat the blood pressure reading. The patient cannot have the colonoscopy yet due to his uncontrolled blood pressure.

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*Patient on warfarin presents with intracranial hemorrhage, which of the following will most rapidly reverse the anticoagulation in this patient ?*

A) Fresh frozen plasma
B) IV vitamin K
C) IV desmopressin
D) Prothrombin complex concentrate

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Q2-A 64 year’s old man is placed on Lisinopril as a part of managing CAD in association of ejection fraction 25% and symptoms of breathlessness. Although he has rales some times in the lung examination. Patient is asymptomatic now. Physical examination showed minimal pedal edema. His Potassium level is high which is high on repeat examination. His ECG is normal.
How would you best manage this patient?

A-Add kayexalate (Potassium binding resin)
B-Insulin glucose
C-Stop Lisinopril
D-Switch Lisinopril to candisartan
E-Switch Lisinopril to Hydralazine and nitrates



Ans: E. Although cough is the most common adverse effect of ACEI (Lisinopril), they may also cause hyperkalemia.you can not just switch ACEI to ARBs, since both medication cause Hyperkalaemia because of their effect on inhibiting aldosterone. Aldosterone  normal function to excrete potassium from distal tubules.
Hydralazine is direct acting arteriolar vasodilator. Hydralazine will decrease afterload and has been shown to clear mortality benefit in patient with systolic dysfunction. Hydralazine should be used with nitrates to dilate the coronary arteries so the blood is not stolen away from coronary perfusion when after load is decrease with use of hydrazine.

Q3-Which of the following is most common adverse effect of statin medication?

A-Rhabdomyolysis
B-Liver dysfunction
C-Renal dysfunction
D-Encephalopathy
E-Hyperkalaemia



Ans: B. at least 1% of patient taking statin will develop elevation of liver transaminase to the level where you will need to discontinue the medications.elevation of CPK level,rhabdomyolysis and  or myositis occurs in less than 0.1% patients and rare to have stop medication because of myositis.there is no recommendation to routinely monitor all patient with CPK in absence of symptoms.on the other hand all patients on statin should be monitore routinely for liver enzymes even in absence of any symptoms.

Q4-70 year’s old woman comes to the emergency room with crushing substernal chest pain for the last hour. The pain radiates to left arm and associated with anxiety, diaphoresis and nausea. She describes pain as “sore” and dull and clinches her fist in front of her chest. She has a history of hypertension.
What is most likely to be found in this patient?

A->10 mmof hg decrease blood pressure on inspiration
B-Increase jugualar venous pressure on inhalation
C-Triphasic scratchy sound on auscultation
D-S4 gallops








Ans: D. Acute coronary syndrome associated with S4 gallops because of ischemia leading to noncompliance of left ventricle. The S4 gallop is the sound of atrial systole as blood is ejected from atria into a stiff ventricle.
A decrease in blood pressure more than 10mmof hg during inspiration is pulsus paradoxus and is associated with cardiac temponade.
An increase in JVP on inspiration is kussmaul sign seen in most oftenly seen with constrictive pericarditis or restrictive cardiomyopathies.
A triphasic patchy sound seen in pericardial rub.
Although pericarditis can occur as a complicationof myocardial infarction (Dressler’s Syndrome), this would not occur for several days after Myocardial infarction and is much rarer than simple ventricular ischemia.