KSA Diabetes
20. A 56-year-old male is brought to the emergency department by ambulance with confusion and disorientation. His medical history includes type 2 diabetes and glaucoma. Laboratory Findings Arterial pH............7.25 (N 7.35-7.45) Blood glucose............240 mg/dL Serum sodium............129 mEq/L (N 136-145) Serum potassium............3.1 mEq/L (N 3.5-4.5) Serum chloride............95 mEq/L (N 98-107) Serum HCO3............7 mEq/L (N 22-29) Which one of the following is the most likely cause of his high anion gap metabolic acidosis?
A. Alcoholic Ketoacidosis
43. A 36-year-old male sees you for a health maintenance visit. Although his medical history is completely unremarkable he mentions that two of his cousins have been diagnosed with type 2 diabetes and asks if he should be screened for this. For patients in this age group, the American Diabetes Association recommends using BMI to determine whether screening is appropriate. Using a threshold of 23 kg/m2 is recommended for which one of the following ethnic groups?
A. Asian-American
31. An obese 48-year-old male with a 6-year history of type 2 diabetes asks about some weight loss plans that he read about in a magazine. He is currently taking metformin (Glucophage), 850 mg twice daily; sitagliptin (Januvia), 100 mg daily; and empagliflozin (Jardiance), 25 mg daily, but his hemoglobin A1c remains above 7.5%. His renal function is normal. Which one of the following diets would be LEAST appropriate for this patient?
A. Atkins (high fat, low carbohydrate)
18. Which one of the following lipid-lowering agents can worsen glycemic control?
A. Atorvastatin (Lipitor)
21. A 63-year-old male with a 10-year history of type 2 diabetes presents with a 3- to 4-day history of severe painful swelling of his scrotum and the adjacent skin, accompanied by fever and a foul-smelling discharge. An examination reveals a grossly edematous and tender scrotum that has necrotic-appearing patches of skin with palpable crepitations. Which one of the following diabetes medications has been linked to this type of scrotal infection?
A. Canagliflozin (Invokana)
29. A 64-year-old female with a 6-year history of type 2 diabetes presents with a 2-day history of malaise, dizziness, nausea, and vomiting. She has a temperature of 37.8°C (100.0°F), a blood pressure of 96/70 mm Hg, a pulse rate of 108 beats/min, and a respiratory rate of 20/min. The examination is otherwise unremarkable except for a BMI of 29 kg/m2 and dry mucous membranes. Laboratory Findings Serum sodium............135 mEq/L (N 135-145) Serum potassium............3.9 mEq/L (N 3.5-5.0) Serum chloride............103 mEq/L (N 100-108) CO2............15 mEq/L (N 24-30) Serum glucose............224 mg/dL Serum creatinine............0.67 mg/dL (N 0.6-1.5) BUN............20 mg/dL (N 8-25) Serum ketones............small amount present Arterial pH............7.12 (N 7.35-7.45) Hemoglobin A1c............7.4% Which one of the following antidiabetic agents is most likely to be associated with this presentation?
A. Canagliflozin (Invokana)
56. A morbidly obese 59-year-old male with a history of prediabetes indicates that despite multiple attempts at diet and exercise he has found it impossible to lose weight. Although his fasting glucose level has been stable at 118 mg/dL, his hemoglobin A1c has risen from 5.8% to 6.1% during the past year. Which one of the following has NOT been shown to reduce the risk of progression of impaired glucose tolerance to overt diabetes?
A. Canagliflozin (Invokana)
13. A 58-year-old male with type 2 diabetes has a blood pressure of 147/92 mm Hg. You start him on benazepril (Lotensin) and order a baseline serum creatinine level, which is 1.7 mg/dL (N 0.7-1.3). Two weeks later his blood pressure is 128/80 mm Hg, and his serum creatinine level is 2.1 mg/dL. His creatinine level is unchanged 1 week later. Which one of the following would be most appropriate at this point?
A. Continue benazepril at the same dosage
32. A 58-year-old male is diagnosed with type 2 diabetes. His medical history is notable for a long history of hypertension, stage 3 chronic kidney disease, low back pain, and osteoarthritis of his knees. His current medications are amlodipine (Norvasc), 10 mg daily; valsartan (Diovan), 180 mg daily; chlorthalidone, 25 mg daily; and simvastatin (Zocor), 40 mg daily. Laboratory findings are notable only for a hemoglobin A1c of 7.9%, a serum creatinine level of 1.5 mg/dL (N 0.7-1.3), and an estimated glomerular filtration rate of 51 mL/min/1.73 m2. Which one of the following would be beneficial for both renal protection and diabetes management?
A. Dapagliflozin (Farxiga)
42. Which one of the following types of insulin should never be mixed with any other form of insulin?
A. Insulin glargine
16. At a routine health maintenance visit, an obese 42-year-old male is found to have a fasting plasma glucose level of 118 mg/dL. Which one of the following is the most appropriate initial intervention for preventing or delaying the development of diabetes mellitus in this patient?
A. Lifestyle modification
50. An overweight 42-year-old female is diagnosed with type 2 diabetes on the basis of consecutive fasting plasma glucose levels of 138 mg/dL and 143 mg/dL. Her past medical history is notable only for a history of gestational diabetes 7 years ago during her second pregnancy. In addition to lifestyle intervention, American Diabetes Association guidelines recommend which one of the following as part of her initial management?
A. Metformin (Glucophage)
59. A 78-year-old male with a 15-year history of type 2 diabetes, hypertension, and hypercholesterolemia sees you for a routine follow-up visit. When evaluating his feet, which one of the following neurologic evaluations would be most useful for predicting the future occurrence of a diabetic foot ulcer?
A. Pressure sensation with Semmes-Weinstein monofilament (10 g)
60. An obese 55-year-old male with a history of pancreatitis and type 2 diabetes continues to have poor glycemic control despite being on metformin (Glucophage), basal insulin, empagliflozin (Jardiance), and pioglitazone (Actos). When told that his hemoglobin A1c is 9.5%, the patient indicates he is open to a trial of basal-bolus insulin therapy. Which one of the following insulin types would be most appropriate to prescribe as a bolus insulin if the patient will often find it necessary to delay eating until 20-30 minutes after the injection?
A. Regular insulin
28. A 52-year-old female with a BMI of 31 kg/m2 sees you for a routine health maintenance visit. Her family history is notable for type 2 diabetes in her mother and aunt. Her blood pressure is 136/88 mm Hg. Her history and a physical examination are otherwise unremarkable. Which one of the following hemoglobin A1c values would be the threshold for diagnosing diabetes mellitus in this patient?
B. 6.5%
51. A 61-year-old male with a history of type 2 diabetes, hypertension, and vascular claudication sees you for a follow-up visit. The diagnosis of vascular claudication was based on a right ankle-brachial index of 0.85. His current medications are ramipril (Altace), 10 mg daily; metformin (Glucophage), 850 mg twice daily; rosuvastatin (Crestor), 10 mg daily; and aspirin, 81 mg daily. A physical examination is notable for a callus on his right first toe. Other findings include absent sensation on 10-g monofilament testing and reduced vibration sensation using a 128-Hz tuning fork placed on the interphalangeal joint of the great toe. Laboratory testing is notable only for a hemoglobin A1c of 8.1%. Which one of the following antidiabetic agents should be AVOIDED in this patient because it is associated with a higher risk for amputation?
B. Canagliflozin (Invokana)
38. A 59-year-old male presents with a 2-month history of dyspnea on exertion. His medical history is significant for a long history of poorly controlled hypertension treated with lisinopril (Prinivil, Zestril), 20 mg daily; hydralazine, 25 mg twice daily; and chlorthalidone, 25 mg daily. He also has a 3-year history of type 2 diabetes treated with metformin (Glucophage), 500 mg twice daily, and glipizide (Glucotrol), 5 mg daily. A physical examination is notable for bibasilar rales, a soft S3 gallop, and 1+ pitting ankle edema. An echocardiogram reveals a left ventricular ejection fraction of 40%. Laboratory testing is notable for a BNP of 350 pg/mL (N <100) and a hemoglobin A1c of 7.9%. Which one of the following would be most appropriate to add to his regimen?
B. Dapagliflozin (Farxiga)
53. An obese 77-year-old male sees you for a routine follow-up visit. He has a 20-year history of hypertension and a 12-year history of type 2 diabetes complicated by the development of microalbuminuria and proliferative diabetic retinopathy. He also has bilateral knee osteoarthritis and mild cognitive impairment. Although his diabetes had been adequately controlled with extended-release metformin (Glucophage XR), 500 mg twice daily, when his hemoglobin A1c recently rose to 7.7% you added extended-release glipizide (Glucotrol XL), 2.5 mg once daily in the morning. He reports that since then he has episodically experienced shakiness and hunger in the late morning, relieved by eating crackers. One of these episodes occurred during one of the walks he regularly takes with his wife before eating lunch. Which one of the following would be the most appropriate management?
B. Discontinuing glipizide and returning the patient to his previous drug regimen
11. A 63-year-old male with a 10-year history of type 2 diabetes and hypertension sees you for the first time. On examination he is found to have mild nonproliferative diabetic retinopathy with a few microaneurysms seen on ophthalmic examination. His current medications are simvastatin (Zocor), 40 mg daily; hydrochlorothiazide, 25 mg daily; lisinopril (Prinivil, Zestril), 10 mg daily; extended-release metformin (Glucophage XR), 1000 mg daily; extended-release glipizide (Glucotrol XL), 10 mg daily; and aspirin, 81 mg daily. Laboratory Findings Serum sodium............140 mEq/L (N 135-145) Serum potassium............4.3 mEq/L (N 3.5-5.0) Serum chloride............105 mEq/L (N 100-108) CO2............26 mEq/L (N 24-30) Serum creatinine............1.2 mg/dL (N 0.6-1.5) BUN............22 mg/dL (N 8-25) LDL-cholesterol............98 mg/dL HDL-cholesterol............39 mg/dL Triglycerides............245 mg/dL Hemoglobin A1c............7.7% The addition of which one of the following lipid-lowering agents has shown potential benefit for reducing the rate of progression of diabetic retinopathy in patients such as this?
B. Fenofibrate (Tricor)
54. A morbidly obese 55-year-old female is diagnosed with type 2 diabetes. She says that she has had problems with her weight since early childhood and that she has failed numerous commercial weight loss plans in the past, as well as fenfluramine/phentermine. Which one of the following agents is most likely to produce weight loss in patients with diabetes?
B. GLP-1 receptor agonists
10. A 42-year-old female with a BMI of 31 kg/m2 has a 3-week history of polyuria and polydipsia, accompanied by a 10-lb weight loss. Her fasting plasma glucose level is 320 mg/dL, and her hemoglobin A1c is 11.1%. Which one of the following single agents is most likely to reverse her glucose toxicity and improve her glycemic response?
B. Insulin
12. A 38-year-old patient with a 20-year history of type 1 diabetes is found to have reduced vibratory sensation in both feet, as well as reduced sensation to 10-g monofilament. Which one of the following exercise activities would NOT be recommended?
B. Jogging
49. A 62-year-old female sees you for the first time. Her past medical history is notable for a long history of type 2 diabetes and hypertension, and hospitalization a few months ago for a TIA and heart failure with preserved ejection fraction (HFpEF). Her current medications include: Hydrochlorothiazide, 25 mg daily Metoprolol succinate (Toprol-XL), 50 mg once daily Lisinopril (Prinivil, Zestril), 40 mg daily Metformin (Glucophage), 850 mg twice daily Rosuvastatin (Crestor), 20 mg daily Aspirin, 81 mg daily Notable findings on examination include a blood pressure of 135/84 mm Hg and a heart rate of 58 beats/min. Laboratory Findings Hemoglobin A1c............7.8% LDL-cholesterol............69 mg/dL HDL-cholesterol............35 mg/dL Triglycerides............210 mg/dL Estimated glomerular filtration rate............71 mL/min/1.73 m2 Which one of the following has been shown to reduce cardiovascular risk in patients such as this?
B. Liraglutide (Victoza)
37. A 29-year-old female with polycystic ovary syndrome with oligomenorrhea asks if you can prescribe a medication that would make her menses more regular. Her fasting glucose level is 100 mg/dL and her hemoglobin A1c is 5.9%. Which one of the following diabetes medications would be most appropriate for managing her oligomenorrhea?
B. Metformin (Glucophage)
6. An overweight, sedentary 71-year-old male presents with a 4-month history of burning pain in the soles of his feet that is most noticeable at night when he is lying in bed. His medical history includes a long history of type 2 diabetes, hypertension, and hypercholesterolemia. His current medications include metformin (Glucophage), 850 mg twice daily; exenatide (Bydureon), 2 mg subcutaneously weekly; valsartan (Diovan), 360 mg daily; hydrochlorothiazide, 25 mg daily; and rosuvastatin (Crestor), 10 mg daily. He quit smoking 40 years ago and does not drink alcohol. A physical examination is unremarkable except for some hyperesthesia of both feet, as well as reduced vibratory sensation. His protective sensation is intact in both feet and his pedal pulses are normal. Which one of the following would be LEAST effective for treating this patient's pain syndrome?
B. SSRIs
35. A 64-year-old female with type 2 diabetes is taking metformin (Glucophage), 1000 mg twice daily, and glyburide, 10 mg twice daily. Her hemoglobin A1c is 8.8%. You are considering switching her from glyburide to an SGLT2 inhibitor. Which one of the following is true regarding SGLT2 inhibitors?
B. Studies have shown that they reduce cardiovascular risk
46. A 75-year-old female sees you for a routine follow-up visit. Her medical history is notable for a 15-year history of type 2 diabetes and hypercholesterolemia. Her current medications include extended-release metformin (Glucophage XR), 2000 mg daily; extended-release glipizide (Glucotrol XL), 5 mg daily; atorvastatin (Lipitor), 20 mg daily; and aspirin, 81 mg daily. The patient's blood pressure is 128/78 mm Hg and her BMI is 29 kg/m2. A physical examination is otherwise unremarkable. Laboratory testing reveals a hemoglobin A1c of 7.3%, an LDL-cholesterol level of 95 mg/dL, an HDL-cholesterol level of 36 mg/dL, and a serum triglyceride level of 190 mg/dL. The patient tells you that she had one episode of mild chest discomfort while participating in an exercise program at the community center. An exercise nuclear stress test reveals findings suspicious for exercise-induced ischemia. Subsequent coronary angiography reveals an isolated 65% stenosis of the mid-right coronary artery. Which one of the following is true in this situation?
B. The atorvastatin dosage should be increased
52. An overweight 48-year-old male sees you to discuss the results of his laboratory tests, including a fasting glucose level of 110 mg/dL and a hemoglobin A1c of 5.9%. Which one of the following is the minimum recommended goal to reduce the risk of diabetes mellitus in a patient with impaired glucose tolerance?
B. Weight reduction of 5%-10%
4. A 71-year-old male is hospitalized for an infected foot ulcer. His medical history is notable for type 2 diabetes, hypertension, and chronic pancreatitis. His medications on admission include pancrelipase (Creon), 72,000 units with each meal; extended-release metformin (Glucophage XR), 500 mg four times daily; extended-release glipizide (Glucotrol XL), 5 mg daily; and benazepril (Lotensin), 40 mg daily. Insulin therapy is initiated for hyperglycemia with persistent blood glucose levels ≥200 mg/dL. Based on American Diabetes Association guidelines, which one of the following would be the most appropriate glycemic target for this patient during his hospitalization?
C. 140-180 mg/dL
17. A 66-year-old female sees you for a routine follow-up visit. Her past medical history is notable for type 2 diabetes and hypertension. Her current medications include extended-release metformin (Glucophage XR), 1000 mg daily; lisinopril (Prinivil, Zestril), 40 mg daily; and aspirin, 81 mg daily. A physical examination is unremarkable except for a BMI of 28 kg/m2, a blood pressure of 132/80 mm Hg, and a grade 2/6 midsystolic ejection murmur. The patient's hemoglobin A1c is 6.7%, her serum creatinine level is 1.5 mg/dL (N 0.6-1.1), and her estimated glomerular filtration rate is 51 mL/min/1.73 m2. An echocardiogram reveals moderate aortic sclerosis and concentric left ventricular hypertrophy with a left ventricular ejection fraction of 60%-65%. Based on current American Diabetes Association Guidelines, which one of the following would be most appropriate?
C. Add Liraglutide (Victoza)
5. An obese 53-year-old male with a history of type 2 diabetes sees you for the first time. He tells you that his previous physician had him see a dietician and started him on metformin (Glucophage), 500 mg twice daily. A copy of his most recent laboratory tests shows a hemoglobin A1c of 7.7%. He tells you that he has always been sedentary and asks if it would be worthwhile for him to join an exercise facility and begin an exercise program. Which one of the following statements would be accurate advice?
C. Combined aerobic and resistance training results in greater glycemic improvement than either method alone
40. An obese 47-year-old female with a 5-year history of impaired fasting glucose sees you for a routine follow-up visit. Her condition has been managed with lifestyle intervention and metformin (Glucophage), 1000 mg twice daily. She is upset that she has gained 5 kg (11 lb) during the past year even though she has continued her previous exercise routine and has not changed her diet. Her hemoglobin A1c is now 7.2%. A friend of hers has experienced success with semaglutide (Ozempic), a GLP-1 receptor agonist, and the patient asks if this would be an option for her. Laboratory testing at this visit includes a normal TSH level. Which one of the following is NOT a mechanism of action of GLP-1 receptor agonists?
C. Enhancing insulin sensitivity of muscle
23. An obese 52-year-old male has a 4-month history of early satiety, nausea, and bloating with occasional vomiting. His past medical history is notable for a 10-year history of type 2 diabetes with moderate nonproliferative retinopathy and diabetic nephropathy with albuminuria. He reports that over the past year he has experienced tingling in both feet as well as erectile dysfunction. His current medications include extended-release metformin (Glucophage XR), 1000 mg daily, and atorvastatin (Lipitor), 10 mg daily. On examination his blood pressure is 150/100 mm Hg supine and 120/80 mm Hg upright. He has reduced sensation to pinprick and vibration in his feet. His hemoglobin A1c is 8.9%. Upper gastrointestinal endoscopy is notable only for some food residue despite the preceding overnight fast. Which one of the following diabetes medications should be AVOIDED in this patient?
C. Exenatide (Bydureon, Byetta)
39. Which one of the following is true regarding the effects of lifestyle on insulin resistance?
C. Exercise has been shown to enhance insulin action in skeletal muscle
48. Which one of the following endocrinopathies is NOT associated with diabetes mellitus?
C. Gastrinoma
7. A 71-year-old male presents early on a Saturday morning to the urgent care clinic you are staffing. He describes a 1-week history of episodic sweating, feelings of hunger, and tremor that are relieved by eating. He reports that he has type 2 diabetes and has taken metformin (Glucophage) for years, and that his physician recently added a new diabetes medication because his hemoglobin A1c rose above 7.5%. He did not bring his medications with him and you are unable to access his records because the electronic medical record system is undergoing routine maintenance and an update. Which one of the following diabetes medications would be most likely to cause this patient's symptoms?
C. Glyburide
44. An overweight 48-year-old female sees you for a routine follow-up visit. Her medical history is notable for type 2 diabetes, dysmenorrhea, and osteoarthritis in her left knee. Her current medications include metformin (Glucophage), 850 mg twice daily; extended-release glipizide (Glucotrol XL), 5 mg daily; atorvastatin (Lipitor), 40 mg daily; and ibuprofen as need for arthritis pain. She also began taking vitamin E, 800 IU daily, about a year ago. The patient is surprised to learn that her hemoglobin A1c has risen to 7.9%, from 6.8% 6 months ago, despite the fact that she has lost 3 kg (7 lb). Based on her home glucose monitoring log, her fasting and prandial glucose levels have consistently been below 130 mg/dL and 170 mg/dL, respectively. Which one of the following is the most likely cause of the rise in this patient's hemoglobin A1c?
C. Iron deficiency anemia
58. A 37-year-old male with type 2 diabetes controlled with diet is found to have an LDL-cholesterol level of 101 mg/dL, an HDL-cholesterol level of 45 mg/dL, and a serum triglyceride level of 350 mg/dL. He would like to reduce his triglycerides but does not want to take a prescription medication. In addition to lifestyle changes, which one of the following could help lower his serum triglyceride levels?
C. Omega-3 fatty acids
25. An obese 60-year-old male with a 10-year history of type 2 diabetes and hypertension sees you for a routine follow-up visit. His current medications include extended-release metformin (Glucophage XR), 1500 mg daily; valsartan (Diovan), 320 mg daily; atorvastatin (Lipitor), 40 mg daily; and aspirin, 81 mg daily. He reports having one glass of wine on the weekend only. This past week he underwent a workup for vague right-sided upper abdominal pain. Ultrasonography of the right upper quadrant revealed mild hepatic steatosis and laboratory testing revealed normal aminotransferases. His FIB-4 score is 1.03. Which one of the following statements is true?
C. The diagnosis of NASH can only be made with a liver biopsy
47. A 68-year-old female with long-standing type 2 diabetes and hypertension sees you for an annual follow-up visit. Her current medications are metformin (Glucophage), 850 mg twice daily; glipizide (Glucotrol), 10 mg daily; atorvastatin (Lipitor), 40 mg daily; lisinopril (Prinivil, Zestril), 20 mg daily; and aspirin, 81 mg daily. She eats a well balanced diet. Which vitamin deficiency is most likely to occur in this patient?
C. Vitamin B12
2. An obese 58-year-old male comes to your office with a 2-week history of fatigue associated with polyuria, polydipsia, and weight loss. You suspect he has type 2 diabetes. This diagnosis would be corroborated by a random glucose level greater than or equal to a threshold of
D. 200 mg/dL
55. A 39-year-old Hispanic male with a BMI of 32 kg/m2 sees you for a routine health maintenance visit. On examination he is found to have a waist circumference of 104 cm (41 in) and a blood pressure of 132/86 mm Hg. Based on the National Cholesterol Education Program guidelines, which one of the following additional findings would meet the criteria for metabolic syndrome?
D. A serum triglyceride level of 180 mg/dL
27. A 45-year-old male with a 10-year history of type 2 diabetes is diagnosed with hypertension. He does not smoke and his current medications include extended-release metformin (Glucophage XR), 1500 mg daily; sitagliptin (Januvia), 100 mg daily; simvastatin (Zocor), 40 mg daily; and aspirin, 81 mg daily. His average blood pressure at a visit last week and today is 154/94 mm Hg. His urine albumin level is 30 µg/mg creatinine. His total cholesterol level is 200 mg/dL, his LDL-cholesterol level is 90 mg/dL, and his HDL-cholesterol level is 52 mg/dL. His 10-year American Heart Association cardiovascular risk score is 10.5%. Which one of the following is true regarding treatment recommendations for this patient?
D. ADA guidelines recommend initiating therapy with either an ACE inhibitor or an angiotensin receptor blocker
45. A 55-year-old male sees you for a routine visit. His past medical history is notable for an 8-year history of diabetes mellitus and a past history of hypercholesterolemia. His current medications are atorvastatin (Lipitor), 20 mg daily; extended-release metformin (Glucophage XR), 1000 mg daily; and aspirin, 81 mg daily. His serum creatinine level is 1.3 mg/dL (N 0.7-1.3) and his estimated glomerular filtration rate is 61 mL/min/1.73 m2. On examination he has a blood pressure of 124/80 mm Hg. His hemoglobin A1c is 6.7%. A spot urine sample contains 40 µg albumin/mg creatinine. At a follow-up visit 6 months later he has an albumin/creatinine ratio of 48 µg/mg on a spot urine sample. Which one of the following would be most appropriate?
D. Begin an angiotensin receptor blocker
8. A 55-year-old male with type 2 diabetes presents with a history of reduced libido and erectile dysfunction. He has not seen a physician for many years. On examination you note bronze-colored skin, hepatomegaly, and mild testicular atrophy. A nonfasting laboratory workup reveals the following serum levels: Glucose............250 mg/dL AST............260 U/L (N 10-40) ALT............210 U/L (N 10-55) FSH............5.0 mIU/mL (N 1.0-12.0) LH............8.1 mIU/mL (N 2.0-12.0) Testosterone............180 ng/mL (N 280-1250) Which one of the following is the most likely diagnosis?
D. Hemachromatosis
57. A 60-year-old groundskeeper is brought to the emergency department unconscious after being found in his apartment by his brother. His vital signs include a rectal temperature of 38.1°C (100.6°F), a blood pressure of 96/70 mm Hg, a pulse rate of 128 beats/min, and a respiratory rate of 15/min. An examination is otherwise unremarkable except for very dry skin and mucous membranes. Laboratory Findings Serum sodium............150 mEq/L (N 135-145) Serum potassium............3.1 mEq/L (N 3.5-5.0) Serum chloride............112 mEq/L (N 100-108) CO2............26 mEq/L (N 24-30) Serum glucose............1080 mg/dL Serum creatinine............4.0 mg/dL (N 0.6-1.5) BUN............70 mg/dL (N 8-25) Serum ketones............small amount present Which one of the following is the most likely diagnosis?
D. Hyperosmolar, hyperglycemic state
3. A 66-year-old male who was hospitalized because of a TIA 3 months ago sees you for a follow-up visit. His past medical history is notable for impaired fasting glucose and hypertension. His current medications include valsartan (Diovan), 160 mg daily; rosuvastatin (Crestor), 20 mg daily; and aspirin, 81 mg daily. On examination his BMI is 30 kg/m2, his blood pressure is 134/86 mm Hg, and he has brown, velvety, hyperkeratotic plaques on the back of his neck and in his axillae. Laboratory studies are notable for an LDL-cholesterol level of 85 mg/dL, an HDL-cholesterol level of 35 mg/dL, and a serum triglyceride level of 174 mg/dL. His hemoglobin A1c is 7.1%. Which one of the following agents may reduce his risk for stroke and myocardial infarction?
D. Pioglitazone (Actos)
14. A 67-year-old male presents with a 3-month history of heaviness and fatigue in his right lower thigh and calf when he walks more than three to four blocks. His medical history is notable for hypertension and type 2 diabetes. His current medications include simvastatin (Zocor), 40 mg daily; amlodipine (Norvasc), 10 mg daily; lisinopril (Prinivil, Zestril), 10 mg daily; extended-release metformin (Glucophage XR), 1500 mg daily; canagliflozin (Invokana), 300 mg daily; and aspirin, 81 mg daily. He smokes half a pack of cigarettes a day. A physical examination is notable for a normal blood pressure and reduced pedal pulses on the right. His resting ankle-brachial index is 0.80 at the right dorsalis pedis. You recommend that he stop smoking. Which one of the following would also be appropriate in the management of his peripheral artery disease?
D. Prescribing a structured exercise program to improve functional status and walking distance
36. Microalbuminuria is strongly linked to which one of the following complications of diabetes mellitus?
D. Progressive nephropathy
24. An overweight 50-year-old female with newly diagnosed type 2 diabetes asks you about dietary measures she might use to control her blood glucose. Which one of the following would be accurate advice regarding carbohydrate intake and diabetes?
D. Reducing overall carbohydrate intake for individuals with diabetes has the most evidence for improving glycemia
22. A 16-year-old male has a 1-week history of polyuria, polydipsia, and polyphagia. On laboratory evaluation he is found to have a serum glucose level of 270 mg/dL, a serum bicarbonate level of 9 mEq/L (N 22-26), a serum pH of 7.0 (N 7.35-7.45), and a serum potassium level of 4.0 mEq/L (N 3.5-5.0). Which one of the following most accurately describes this patient's total body potassium?
D. Severe deficiency
A 43-year-old female sees you for a routine follow-up visit. Her medical history is notable only for a 2-year history of type 2 diabetes treated with metformin (Glucophage), 500 mg twice daily, before breakfast and dinner. She takes no other medications and does not smoke. Her family history is notable for her mother having a heart attack at age 58. A physical examination is unremarkable, and her blood pressure is 128/76 mm Hg. Laboratory evaluation reveals a serum creatinine level of 0.8 mg/dL (N 0.6-1.5) with an estimated glomerular filtration rate of 92 mL/min/1.73 m2, a hemoglobin A1c of 6.6%, and no microalbuminuria. Her lipid profile includes a total cholesterol level of 200 mg/dL, an LDL-cholesterol level of 105 mg/dL, an HDL-cholesterol level of 42 mg/dL, and a serum triglyceride level of 220 mg/dL. Her 10-year American Heart Association cardiovascular risk score is 3.5%. According to current American Diabetes Association guidelines, which one of the following would be most appropriate to prescribe at this visit?
E. A statin
41. A 39-year-old female with type 2 diabetes develops microalbuminuria and is started on enalapril (Vasotec). At a follow-up visit 2 months later an electrolyte panel reveals an unchanged serum creatinine level of 1.4 mg/dL (N 0.6-1.1), but her potassium level has risen from a baseline of 4.0 mEq/L to a level of 5.4 mEq/L (N 3.5-5.0). Which one of the following is the most likely cause of her potassium elevation?
E. Hyporeninemic hypoaldosteronism
9. A 67-year-old male sees you 6 months after he was hospitalized with a non-ST-elevation myocardial infarction. He also has a history of hypertension and type 2 diabetes. His current medications are rosuvastatin (Crestor), 40 mg daily; benazepril (Lotensin), 20 mg daily; metoprolol, 25 mg twice daily; aspirin, 81 mg daily; and clopidogrel (Plavix), 75 mg daily. His fasting lipid profile reveals a total cholesterol level of 198 mg/dL, an LDL-cholesterol level of 70 mg/dL, an HDL-cholesterol level of 40 mg/dL, and a serum triglyceride level of 375 mg/dL. Adding which one of the following agents is recommended by the American Diabetes Association to further reduce his cardiovascular risk?
E. Icosapent ethyl (Vascepa), 4 g daily
1. A 35-year-old male sees you for a routine health maintenance visit. He has gained a few pounds over the past few years. He is 173 cm (68 in) tall and weighs 82 kg (181 lb), giving him a BMI of 27 kg/m2.According to current American Diabetes Association guidelines, which one of the following additional factors would warrant screening him for prediabetes and diabetes?
E. Physical inactivity
15. A 16-year-old female is admitted to the hospital with a 1-week history of polyuria, polydipsia, and polyphagia. On examination she is lethargic and volume-depleted and her breath smells of acetone. Her blood pressure is 96/70 mm Hg, her pulse rate is 120 beats/min, and she has Kussmaul respirations at a rate of 32/min. Laboratory Findings Serum glucose............525 mg/dL Serum sodium............122 mEq/L (N 135-145) Serum potassium............3.1 mEq/L (N 3.5-5.0) Serum chloride............95 mEq/L (N 100-108) CO2............7 mEq/L (N 24-30) Arterial blood gases pH............7.10 (N 7.35-7.45) pCO2............15 mm Hg (N 35-45) pO2............98 mm Hg (N 80-100) After initiation of intravenous fluid therapy, which one of the following should be given next?
E. Potassium
19. A 72-year-old female with a history of hypertension, stage 4 chronic kidney disease, heart failure, and recurrent urinary tract infections is found to have type 2 diabetes. A trial of dietary therapy is unsuccessful. Her laboratory evaluation is notable for a random glucose level of 240 mg/dL, a hemoglobin A1c of 8.2%, macroalbuminuria, and a serum creatinine level of 3.4 mg/dL. Which one of the following diabetes agents would be most appropriate?
E. Repaglinide (Prandin)
30. A 62-year-old female has a 5-year history of type 2 diabetes and a 2-year history of poorly controlled hypertension. Her current medications are olmesartan medoxomil (Benicar), 40 mg daily; amlodipine (Norvasc), 10 mg daily; chlorthalidone, 25 mg daily; extended-release metformin (Glucophage XR), 850 mg twice daily; and liraglutide (Victoza), 1.2 mg subcutaneously daily. A physical examination is notable for a blood pressure of 150/94 mm Hg. Laboratory Findings Serum sodium............140 mEq/L (N 135-145) Serum potassium............3.9 mEq/L (N 3.5-5.0) Serum chloride............108 mEq/L (N 100-108) CO2............26 mEq/L (N 24-30) Serum creatinine............1.4 mg/dL (N 0.6-1.5) BUN............29 mg/dL (N 8-25) Hemoglobin A1c............6.7% The American Diabetes Association recommends which one of the following to improve control of this patient's blood pressure?
E. Spironolactone (Aldactone)
33. A mildly obese 56-year-old female sees you for follow-up of type 2 diabetes which was diagnosed earlier in the year. She is taking metformin (Glucophage XR), 2000 mg daily. Her most recent hemoglobin A1c was 7.9% and she expresses an interest in starting linagliptin (Tradjenta), a DPP-4 inhibitor that her brother takes. Which one of the following statements about DPP-4 inhibitors is true?
E. They will not increase her risk for hypoglycemia
34. A 45-year-old male with a long history of type 2 diabetes expresses an interest in starting a regular exercise program. Which one of the following complications related to diabetes would preclude him from engaging in a powerlifting program?
c. Moderate nonproliferative diabetic retinopathy
