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1. Mr. Shields is a 42-year-old man with recently diagnosed type 2 diabetes. His initial blood
   pressure was 150/95 mm Hg.          Despite urging from his physician the patient refuses
   pharmacologic therapy for hypertension, instead insisting on a trial of lifestyle modification. After
   8 weeks his repeat blood pressure was 140/85 mm Hg.

    Which of the following statements is true?

    a) The observed blood pressure reduction if maintained over the long-term is associated with
       significant reduction in morbidity and mortality from cardiovascular conditions.
    b) The patient requires immediate pharmacologic therapy to lower blood pressure to JNC
       targets in order to appreciate significant change in deaths related to diabetes.
    c) The observed blood pressure reduction if maintained over the long-term is associated with a
       reduction in macro-vascular complications but not micro-vascular complications.
    d) The patient is at JNC target for blood pressure control in diabetics without evidence of end
       organ damage and should be followed closely to ensure he maintains this level of control.


Pharmacological blood pressure lowering in persons with diabetes mellitus
results in reductions in micro- and macro-vascular complications as well as in
deaths related to diabetes mellitus and overall mortality.

Correct answer: a


2. A 45 year old man presents with for follow-up evaluation of elevated blood pressures (noted on
   two previous examinations). On exam his blood pressure is again elevated at 150/90.
   Laboratory evaluation reveals a fasting glucose of 122.

    Which of the following is true in regards to antihypertensive drug therapy for this patient?

    a) Thiazide diuretics are contraindicated because they have been associated with an increased
       risk of developing diabetes mellitus.
    b) B-blockers are contraindicated because they have been associated with an increased risk of
       developing diabetes mellitus.
    c) ACE inhibitors and angiogenesis receptor blockers may decrease this patient’s risk of
       developing diabetes mellitus.
    d) Calcium channel blockers are contraindicated in metabolic syndrome.


Both thiazides and beta-blockers have been linked to an increased risk of
developing diabetes in persons initially free of diabetes who are treated with
these agents over the long-term. ACE inhibitors and ARBs have been shown in
several studies to reduce the risk of new diabetes cases by ~ 30%. ACE
inhibitors improve insulin sensitivity and, in some studies, have been associated
with increased risk of hypoglycemia, but typically do not affect fasting glucose
levels. Relative to beta-blockers, angiotensin receptor blockers have a reduced
risk of diabetes development in patients treated for hypertension (LIFE Study).
ACE inhibitors provide their greatest protection relative to calcium antagonists
and other agents in the setting of heavy proteinuria. ACE inhibitors do not appear
to preserve kidney function better than calcium antagonists in diabetics without
heavy proteinuria (ABCD study). Angiotensin receptor blockers protect the
kidney better (proteinuria, ESRD incidence, doubling of serum creatinine) than

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calcium antagonist-based regimens (IDNT study). There is no evidence that
calcium channel blocker adversely affect patients with the metabolic syndrome.

Correct answer: c


3. JW is a 56-year-old woman with diabetes mellitus for the last 10 years. Her glycemic control has
   been excellent since her diagnosis. Her body mass index (BMI) is 34 kg/m2. Though she follows
   a diabetic diet, her sodium intake remains relatively unrestricted. Blood pressure control has
   been poor ranging from 158 – 196 mm Hg systolic and between 70 – 92 mm Hg diastolic. Her
   current BP is 160/84 mm Hg. At present she takes naproxen (an NSAID) for joint aches,
   hydrochlorothiazide 25 mg once daily, and quinapril (an ACEI) 40 mg/d. Her estimated
   glomerular filtration rate is 40 ml/min/1.73 m2.

    At this point you would

    a) Discontinue naproxen therapy.
    b) Discontinue naproxen therapy and increase hydrochlorothiazide to 50 milligrams once daily.
    c) Discontinue naproxen therapy and hydrochlorothiazide; begin furosemide 40 milligrams once
       daily.
    d) Discontinue naproxen therapy and hydrochlorothiazide and begin metolazone 5 milligrams
       once daily.


Unrestricted dietary sodium intake antagonizes the BP lowering effect of most
antihypertensive drugs, especially agents with their primary locus of action on
the renin-angiotensin-system (ACE inhibitors, beta blockers, and angiotensin
receptor blockers). Thus, inadequate restriction of dietary sodium is a very
plausible culprit in this patient poor blood pressure control. NSAID therapy (not
aspirin), including the new COX-2 inhibitors, can cause salt and water retention
and antagonize blood pressure lowering of antihypertensive agents. Furosemide
is a very short-acting diuretic and is not prescribed optimally when used once
daily – bid – tid dosing is required for a sustained reduction in intravascular
volume. The level of kidney function determines the most appropriate diuretic.
Until the estimated GFR descends to the mid to low 40‟s, thiazide diuretics are
usually better choices than furosemide for BP lowering. Metolazaone, a very
long-acting thiazide like diuretic, also works well in persons with reduced kidney
function and has the added bonus of working well even in persons with good
kidney function.       Obesity has also been linked to poor BP lowering
responsiveness to antihypertensive drug therapy.           Therefore, it would be
appropriate to discontinue the NSAID and modify the choice of diuretic. It would
also be important to have the patient restrict her sodium intake.

Correct answer: d


4. All of the following patients require referral to an ophthalmologist except?

    a)   A patient with newly diagnosed Type 1 diabetes
    b)   A patient with newly diagnosed Type 2 diabetes
    c)   A patient with long standing Type 1 diabetes
    d)   A patient with long standing Type 2 diabetes



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The ADA Clinical Practice Guidelines recommend ophthalmologic evaluation for
all Type 1 diabetes who have had diabetes for at least 3 years and in all patients
with Type 2 diabetes. A major difference between type 1 and type 2 diabetes
mellitus is that many persons with type 2 diabetes have had the disease for many
years prior to diagnosis

Correct answer: a


5. Mrs. X is a 35-year-old African American woman who presents to the office with complaints of
   polyuria, polydipsia and intermittent blurred vision. She is overweight and states she was never
   able to lose the weight she gained with her pregnancy. Her son, now age 3, weighed 9 pounds 4
   ounces at birth.

    Which of the following tests could be used to diagnose diabetes in Mrs. X?

    a)   Fasting glucose of 140
    b)   1-hour post-prandial glucose of 190 mg/dl
    c)   A random glucose of 165
    d)   Hgb A1C of 10.0%

The revised criteria for diabetes mellitus include either 1) a casual glucose of
 > 200 mg/dl repeated on a subsequent day or 2) a casual glucose of > 200 mg/dl in a
patient with symptoms of diabetes (polyuria, polydipsia, and unexplained weight
loss) or 3) a fasting (no caloric intake for 8 hours) glucose of > 126 mg/dl confirmed
on a subsequent day. Normal fasting glucose is < 110 mg/dl. Fasting glucose of 110
– 125 mm Hg are considered impaired fasting glucose. In its early stages, diabetes
is a post-prandial rather than a fasting disease. That is, fasting glucose levels will
often be normal despite post-prandial elevations in glucose levels.            Although
hemoglobin A1C is elevated in many patients with diabetes and is used to document
metabolic control, there are no diagnostic criteria available for diabetes using this
measure. Thus, until the diagnosis of diabetes is made, there is no clear rationale
for ordering hemoglobin A1C levels. This test provides an integrated look at glucose
levels over the previous 2 – 3 months. Nevertheless, it is very likely that a
hemoglobin A1C of 8.0% does actually represent poor glycemic control and clinical
diabetes. A 1-hour postprandial glucose is not diagnostic of diabetes mellitus.

Correct answer: a


6. Mrs. X returns to the office to discuss the results of her blood work. The fasting glucose done last
   visit was 140 mg/dl. Her fasting glucose today is 160 mg/dl. During your discussion of her
   laboratory results Mrs. X. relates trying to diet and says that she lost five pounds since her last
   visit. She still, however, complains of polyuria and polydipsia. After a lengthy discussion the
   patient elects to begin medical therapy.

    Which of the following hypoglycemic drugs has been associated with weight gain?

    a)   Glargine Insulin
    b)   Sulfonylureas
    c)   Thiazolidinediones
    d)   All of the above




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Metformin has been associated with weight loss. Both sulfonylureas and insulin
have been associated with weight gain. TZDs have also been associated with
weight gain and edema however, redistribution of fat has been noted away from
the visceral depots to the subcutaneous region and peripheral depots. Though
she has lost 5 pounds, one concern is that this may not solely reflect her dietary
efforts but rather may be related to her persistently catabolic state attributable
to unabated hyperglycemia.

Correct answer: d


7.   Mrs. Miller is a 25-year African American woman who was diagnosed to have Type 2 diabetes at
     her last office visit two months ago. At that time, her blood pressure was 144/86. She saw a
     dietician four weeks ago and began a low sodium ADA diet. Blood pressure at that time was
     reported to be 140/86. Today her blood pressure is 134/84.

     Which of the following is an appropriate treatment plan?

     a) This is an acceptable blood pressure; however her blood pressure should be closely
        monitored.
     b) The patient should now be started on a thiazide diuretic to achieve a target blood pressure of
        130/80
     c) Blood pressure should now be measured next visit to confirm the diagnosis of hypertension.
     d) The patient should be started on an ACEI to achieve a target blood pressure of 130/80
     e) It is reasonable to give this patient a trial of life style modification prior to initiating
        pharmacologic therapy.

This patient‟s hypertension has been confirmed on three separate office visits
thus answer c is incorrect.

Before initiating any kind of treatment plan for a patient with diabetes it is
important to define target goals for blood pressure control. Although 140/90 is an
acceptable goal for the general population, patients with diabetes have an
increased risk of adverse outcomes with even mildly elevated blood pressures. A
target BP level of <130/80 mm Hg is recommended (JNC VII, ADA, and ISHIB) for
patients with diabetes and no evidence of renal insufficiency or proteinuria.

Appropriate treatment for blood pressures of 130-139/80-89 includes lifestyle
modification such as weight reduction, reduction in dietary sodium, adopting the
DASH eating plan, increasing physical activity, and moderating alcohol
consumption. These interventions can decrease systolic blood pressure from 2-20
mmHg (JNC VII). Patients with blood pressures that are consistently above 130/80
mm Hg despite lifestyle modification should also be started on pharmacologic
treatment.

Correct answer: e


8. Which of the following medications has not been associated with potassium elevation in patients
   with diabetes?

     a) Thiazide diuretic
     b) NSAID
     c) ACE inhibitor
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    d) ARB

ACE inhibitors, angiotensin receptor blockers, and aldosterone antagonists all
can increase serum potassium.       There is some evidence that angiotensin
receptor blockers increase potassium less than ACE inhibitors do. Both thiazide
diuretic and loop diuretics may cause hypokalemia and are not known to cause
hyperkalemia under normal circumstances.       Calcium channel blockers are
unlikely to affect potassium homeostasis.

Correct answer: a


9. Mrs. Miller returns to the office to discuss her lipid profile. Her fasting LDL cholesterol is 110,
   HDL is 20, and triglycerides are 250.

    Which of the following is true?

    a)   Triglycerides are elevated, HDL is normal, and her LDL is at goal levels.
    b)   Triglycerides are normal, HDL is low, and her LDL is above goal levels.
    c)   Triglycerides are elevated, HDL is low, and her LDL is above goal levels.
    d)   Triglycerides are normal, HDL is normal, and her LDL is below goal levels.

ATP III recommended aggressive lipid lowering therapy for patients with an
absolute 10 year risk of clinical coronary disease of > 20%.        Patients with
diabetes are considered to have a “coronary heart disease equivalent.” The
NCEP/ATP III recommends a target LDL cholesterol of less than 100 for all
patients with diabetes whether or not clinical coronary disease is present. This
is the same LDL-C goal for persons with known coronary heart disease.
Triglyceride levels should be less than 150 mg/dl. Average HDL level for a middle-
aged woman is ~ 55mg/dl, so her HDL is low. In addition, and an HDL level <50 is
considered to be an independent risk factor for coronary artery disease.

Correct Answer: c


10. Which of the following medications should not be prescribed during pregnancy?

    a)   ACE inhibitors
    b)   Metformin
    c)   Acarbose
    d)   Insulin

Pregnancy in diabetic patients should be planned. Discussions with patients
should include planning for pregnancy and adjustment of medication to minimize
risks to the fetus while maintaining the health of the mother. ACE inhibitors are
category C in the first trimester (maternal benefit may outweigh fetal risk in
certain situations), but category D in later pregnancy, and should be discontinued
prior to pregnancy. Statins are pregnancy category X and should be discontinued
prior to conception or as soon as the woman is found to be pregnant.

Correct answer: a


11. Mrs. X’s HgbA1C at the time her pregnancy is diagnosed is 4.8%
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    Which of the following statements are true?

    a)       Mrs. X is no longer a diabetic
    b)       Mrs. X has an increased risk for delivering a diabetic infant.
    c)       Mrs. X’ baby has increased risk likelihood or having congenital malformations.
    d)       Mrs. X’s baby has a no increased likelihood of having congenital malformations.

The majority of pregnancies in women with diabetes are unplanned. This is very
unfortunate because maternal hyperglycemia is associated with an increased
rate of fetal malformations.

All women with diabetes and childbearing potential should be educated about the
need for good glucose control before pregnancy and instructed in effective
contraception at all times unless the patient is in good metabolic control and
actively trying to conceive. Hemoglobin A1C should be normal or as close to
normal as possible in an individual before conception is attempted.

Metformin and acarbose are pregnancy category B



  CATEGORY INTERPRETATION
         A           CONTROLLED STUDIES SHOW NO RISK. Adequate, well-controlled studies in
                     pregnant women have failed to demonstrate a risk to the fetus in any trimester of
                     pregnancy.
         B           NO EVIDENCE OF RISK IN HUMANS. Adequate, well-controlled studies in
                     pregnant women have not shown increased risk of fetal abnormalities despite
                     adverse findings in animals, or, in the absence of adequate human studies,
                     animal studies show no fetal risk. The chance of fetal harm is remote, but remains
                     a possibility.
         C           RISK CANNOT BE RULED OUT. Adequate, well-controlled human studies are
                     lacking, and animal studies have shown a risk to the fetus or are lacking as well.
                     There is a chance of fetal harm if the drug is administered during pregnancy; but
                     the potential benefits may outweigh the potential risks.
         D           POSITIVE EVIDENCE OF RISK. Studies in humans, or investigational or post-
                     marketing data, have demonstrated fetal risk. Nevertheless, potential benefits
                     from the use of the drug may outweigh the potential risk. For example, the drug
                     may be acceptable if needed in a life-threatening situation or serious disease for
                     which safer drugs cannot be used or are ineffective.
         X           CONTRAINDICATED IN PREGNANCY. Studies in animals or humans, or
                     investigational or post-marketing reports, have demonstrated positive evidence of
                     fetal abnormalities or risks which clearly outweighs any possible benefit to the
                     patient.

             NA = None assigned


Correct answer: d


12. A 40 year old woman with diet controlled Type 2 diabetes is seen for evaluation. After completing
    your history and physical examination and reviewing previous records you feel confidant the
    patient has no evidence of end-organ damage. Laboratory studies reveal a Hgb A1c of 6.5% and
    LDL cholesterol to be 120.
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    Which of the following would you recommend?

    a)   Begin clopidogrel to prevent cardiovascular events.
    b)   Begin 325 milligrams ASA daily to decrease cardiovascular events.
    c)   Begin aspirin and lovastatin
    d)   Begin lovastatin and clopidogrel to prevent cardiovascular events.

Aspirin (75-325 mg/d) is recommended in all adult patients with diabetes and
macrovascular disease. It should be considered in patients older than forty with
diabetes and possibly as young as thirty with additional cardiovascular risk
factors.   Aspirin is contraindicated in patients less than 21 years of age
secondary to concerns about Reyes Syndrome. Clopidogrel should be considered
in patients who are aspirin intolerant.

Correct answer: c


13. Mrs. X’s brother, age 50, presents to your office for an initial evaluation. She is asymptomatic.
    She is a large woman. Her weight is 189 and her calculated BMI is 30. Waist circumference is
    38 inches. Blood pressure is 135/88 mm Hg. Fasting glucose is 112 mg/dl, triglycerides are 175
    mg/dl, LDL is 130 mg/dl and HDL is 46 mg/dl. She wants to know if she has diabetes and is she
    at increased risk of a heart attack?

    At this point you would

    a)   Initiate life style modification
    b)   Initiate life style modification and begin ASA daily
    c)   Start the patient on pharmacologic therapy for hypertension as her target BP is 130/80
    d)   Diagnose the patient to have borderline Type 2 diabetes and begin an aggressive program of
         weight loss and exercise.

This patient appears to have the “metabolic syndrome.” Factors characteristic of
the metabolic syndrome include abdominal obesity (waist circumference of >40 in
men and >35 in women), atherogenic dyslipidemia (triglycerides >150, low HDL
<40 in men and <40 in women), elevated blood pressure (130-149/85-89), and
insulin resistance (fasting glucose 110-125). Although the metabolic syndrome is
not considered a coronary heart disease equivalent it is associated with an
increase risk for coronary heart disease. Furthermore, this patient is at increased
risk for diabetes. At this point life style modification is imperative. Exercise and
weight loss have been shown to decrease the likelihood of developing diabetes
mellitus. It is important to note although this patient‟s fasting glucose is in the
impaired fasting glucose range and is not diagnostic of diabetes mellitus.
However, after an oral glucose tolerance test, she may be found to actually have
diabetes mellitus. Thus, she might have diabetes and would be an excellent
candidate for oral glucose tolerance testing. Furthermore, diagnosing diabetes
would modify targets for blood pressure and lipids.

Correct answer: b

14. A 40 year old man with Type 2 diabetes wants to begin exercising. He has never been athletic
    and is interested in something easy and not too vigorous. After a thorough history and physical
    examination you find Mr. X to be mildly overweight (BMI 28) but otherwise healthy. His blood
    pressure is 128/80. HgbA1C is 6.9.

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    At this time you would advise Mr. X to

    a)   Start slow and gradually advance to a modest exercise program.
    b)   Order a 12 lead EKG, stress test and echocardiogram.
    c)   Order an exercise stress test.
    d)   Order a cardiac calcium scan.

There are no specific recommendations advocating the use of screening 12 lead
EKGs in asymptomatic diabetics. The ADA Clinical Practice Guidelines states
candidates for screening exercise stress testing include patients with either 1)
atypical cardiac symptoms, 2) an abnormal resting ECG, 3) a history or peripheral
or carotid occlusive disease, 4) sedentary lifestyle age >35 and plans to begin a
vigorous exercise program or 5) those with two or more risk factors noted above.
There is, however, no current evidence that exercise testing in asymptomatic
patients with risk factors improves prognosis.

It is advisable for sedentary patients to begin their exercise program slowly
before advancing to a vigorous program. If Mr. X wanted to proceed with a
vigorous program, a resting EKG and an exercise stress test are indicated.

Correct answer: a


15. Mr. X started walking every night after dinner. Recently he noticed some chest heaviness after
    walking for 2-3 minutes. He denies frank pain but states now unable to finish his walk.

    At this point you would

    a)   Schedule a exercise stress test
    b)   Obtain a lipid profile.
    c)   Initiate aspirin @ 325 mg per day
    d)   Initiate aspirin @ 325 mg per day, order a lipid profile and schedule a pharmacologic stress
         test.


Mr. X has a classic history of angina pectoris. It would be appropriate to begin
aspirin if this was not already done. In addition, assessment of lipids is
appropriate in all diabetics and in particular in patients with vascular disease. An
exercise stress test is may not achieve a high enough degree of sensitivity if the
patient cannot exercise. A pharmacological stress test would be an acceptable
alternative.

Correct answer: d


16. Mr. Phillips is a 65-year-old white man with a three-year history of Type 2 diabetes. He returns to
    the office for re-evaluation of his blood pressure. Three months ago his blood pressure was
    found to be 158/80. Today he is asymptomatic. He is currently following an 1800-calorie ADA
    diet. He has finally achieved ideal body weight. His last HgbA1C was 7.0%. Today his blood
    pressure is 136/80.

    Which of the following is true?

    a) This patient likely has white coat hypertension. No additional therapy is needed

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   b) It is likely that this patient will require at least two drugs of different classes to adequately
      control his blood pressure.
   c) This patient is doing well and should be encouraged to continue his present dietary program.
      Follow-up should be arranged in 3 months.
   d) This patient should be started on an ACE inhibitor to achieve a blood pressure of less than
      130/80.


Patients with diabetes are at increased risk for coronary events. Part of this risk
is related to associated cardiovascular risk factors such as hypertension.
Diabetics with hypertension have twice the risk of cardiovascular disease when
compared     with   non-diabetic    with   hypertension.      (Clinical   Practice
Recommendations 2005)

Lifestyle modification should be recommended for all patients with diabetes and
elevated blood pressure. This should include a low-sodium (< 2g/d), low-saturated
fat (< 10% to total daily fat intake), low-cholesterol diet. In addition, patients
should be strongly counseled to quit smoking restrict alcohol consumptions,
achieve ideal body weight and participate in regular aerobic exercise.

Multi-drug therapy is the rule to attain a goal blood pressure when the blood
pressure is above 15/10 mmHg above the target goal blood pressure. The target
blood pressure for diabetic patients is less than 130/80(JNC VII). One should not
settle for suboptimal control. ACE inhibitors or angiotensin receptor blockers are
the antihypertensive drugs of choice in persons with diabetes.



Correct answer: d


17. Mr. Johnson has long standing diabetes. His doctor recently moved out-of-state and he presents
    to you for evaluation and treatment of his hypertension. Despite taking enalapril 20 mg bid and
    amlodipine 10 mg q day his blood pressure remains 148/90. His EGFR is 58.

        Which of the following would not be recommended?

       a)   Obtain a spot urine for microalbumin
       b)   Obtain a 24 hour urine for protein and creatinine determination
       c)   Add a thiazide diuretic or metolazone.
       d)   Refill all current medications and wait for blood pressure to fall below goal.

Modest decreases in systolic blood pressure are associated with significant
decreases in any complications related to diabetes. Decreasing systolic blood
pressure in patients with Type 2 diabetes by 10 mmHg is associated with a 12%
reduction for any complication related to diabetes. Achieving target goals for
hypertension are important and one should not settle for near goals despite using
multiple medications. Nevertheless, target goals in diabetics are different for
patients with and without evidence of renal disease. The target goal for blood
pressure in diabetics with proteinuria > 1 gram/24 hours (spot urine protein/ creat
ratio > 0.66) is < 125/75 mm Hg. Thus testing for the presence of protinuria is
indicated in this patient. However, current recommendations are to check spot
urines rather than 24-hour urines to determine protein content. The urinary
protein/creatinine ratio is a good test when the total urinary protein excretion is >
                                                                                                     9
` 500 mg/day. Another alternative would be to measure the albumin:creatinine
ratio on a spot urine. First morning void urines are the best, however, random
urines are acceptable for spot albumin or protein measurements.

Most patients with diabetes and hypertension require multiple medications to
control blood pressure. Diuretics are essential to the multi-drug “cocktail” when
> 2 antihypertensive medications are prescribed.

The correct answer is d.


18. Mrs. Jones is a 50-year-old African American woman who presents for assistance with weight
    loss. She has always been overweight but gained 20 pounds after her husband died 3 months
    ago. She states she sits at home drinking lemonade and looking at the family album. Past
    medical history is unremarkable. On review of systems the patient is able to walk a flight of stairs
    without chest pain, pressure or shortness of breath. However, she does complain of having to go
    to the bathroom often and also of urinary incontinence which she attributes to having children.
    Her largest baby was 9 pounds. She does not smoke. Family history is positive for diabetes in
    her two sisters and mother, hypertension and coronary artery disease. Mrs. Jones weighs 180
    lbs. She is 5’4”. Blood pressure is 140/90 and pulse is 80. The remainder of the physical
    examination is within normal limits except for trace pedal edema. Laboratory analysis reveals a
    random glucose of 145 mg/dl, total cholesterol 210 mg/dl, LDL 125 mg/dl, HDL 50, mg/dl and TG
    175 mg/dl.

    At this point you would

    a) Educate the patient in lifestyle modification, and reevaluate blood pressure and lipids in 6
       weeks
    b) Measure fasting glucose, serum TSH level, electrolytes, BUN and creatinine, refer patient to
       a dietician
    c) Educate the patient in lifestyle modification, measure HgbA1c, serum TSH level, electrolytes,
       BUN and creatinine and arrange follow-up when labs are available.
    d) Educate the patient in lifestyle modification, measure fasting glucose, serum TSH level,
       electrolytes, BUN and creatinine and reevaluate in one month


This patient very likely has Type 2 diabetes mellitus. She has polyuria and
polydipsia and an elevated fasting glucose. (Normal fasting glucose < 126.)
However, she does not fit the strict definition of diabetes because she does not
have symptoms of diabetes and a casual glucose of >200. Furthermore, although
her fasting glucose > 126 it has not been confirmed on a subsequent visit. It is
important make the diagnosis of diabetes because it dictates specific target
goals for both serum lipid levels and blood pressure. The diagnosis can be
confirmed by repeat measurement of her fasting glucose on another day. Another
potential option would be to perform oral glucose tolerance testing.

According to the NCEP/ATP III guidelines, patients with elevated lipids should be
evaluated for secondary causes of dyslipidemia including diabetes. Other causes
of secondary dyslipidemia include hypothyroidism, chronic renal failure and
obstructive liver disease. Therefore, measure of TSH and renal function would
indeed be appropriate for this patient.

Consultation with a dietician is recommended as part of a prescription for
“therapeutic lifestyle modification.” Therapeutic lifestyle modification is
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appropriate for both hypertension and dyslipidemia. However, according to the
NCEP/ATP III guidelines, lifestyle modification for 6 weeks is appropriate. This
should be followed by reevaluation of LDL-C and either, intensification of
therapeutic lifestyle changes (TLC), or initiation of medical therapy. In addition,
if this patient is in fact diagnosed with diabetes (confirmation of elevated fasting
glucose on a subsequent visit,) then the patient should be treated with both TLC
and pharmacologic therapy to achieve a blood pressure of < 130/80 mm Hg.
Lifestyle modification alone is only recommended for diabetics with blood
pressure of 130-139/80-89 and only for a maximum of three months. The target
goals outlined in NCEP/ATP III and JNC VI for patients with diabetics are
recommended to modify the elevated risk for cardiovascular disease associated
with diabetes.

Correct answer: d


19. Mr. Reynolds has longstanding type 2 diabetes. Urine for microalbuminuria demonstrated 380
    micrograms per milligram of creatinine. Today his blood pressure is 166/92 and his creatinine is
    1.6 mg/dl.

   Which of the following statements are true?

   a) Diuretic therapy is indicated to reduce albuminuria.
   b) Reduction of blood pressure is important to capture the reversible component of
      microalbuminuria.
   c) Initiation of an ARB will delay the progression of nephropathy
   d) Treatment with an ACE will delay the progression to microalbuminuria

ACE inhibitors slow progression of diabetic nephropathy in both Type 1 and Type
2 diabetes. ACE inhibitors decrease glomerular capillary pressure by decreasing
arterial pressure and selectively dilating the efferent glomerular more so than the
afferent arteriole. ARBS have recently been shown to decrease progression of
diabetic nephropathy in persons with type 2 diabetes mellitus. ARB's do have a
stronger database that ACE inhibitors supporting their use in diabetic
nephropathy, especially heavy (more than microalbuminuria) proteinuria patients.

There are no long-term studies of the effect of alpha-blockers, loop diuretics or
centrally acting agents on the long-term complications of diabetics.
Nevertheless, the overwhelming evidence is in favor of obtaining blood pressure
control as an effective means for preventing micro- and macro-vascular
complications. These drugs should be used as adjunctive therapy to better
studied drugs in persons with diabetes such angiotensin receptor blockers, ACE
inhibitors, calcium antagonists, and thiazide diuretics.     Diuretics are also
important drugs when attempting to control blood pressure in complex (>2) drug
regimens to combat the expansion of extracellular fluid volume that antagonizes
blood pressure lowering with many antihypertensive agents.

Dihydropyridine calcium blockers selectively dilate afferent arterioles and can
result in increase in intraglomerular pressures. For this reason they are not
favored in the management of hypertension in diabetics with severe reductions in
kidney function or with proteinuria – unless there is simultaneous use of an ARB
or an ACE.      The RENAAL study demonstrated the safety of adding a
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dihydropyridine calcium antagonist to losartan, an ARB, in person with diabetic
nephropathy and heavy proteinuria. There was no diminution of the effect of the
ARB on preservation of kidney function when this combination was used. Though
rate-lowering calcium antagonists such as verapamil and diltiazem theoretically
cause less preferential dilation of the afferent arteriole, there are no long-term
clinical studies showing their impact on clinical outcomes such as doubling of
serum creatinine or development of ESRD .

This patient already has microalbuminuria. Therefore the correct answer is

Correct answer: c


20. Mr. Reynolds is a 40 year old man. He was started on hydrochlorothiazide and an ACE inhibitor
    three weeks ago. He returns to clinic four weeks later. At this visit his blood pressure is 150/90
    mm Hg (down from 160/90). He is however, complaining of some dizziness, especially early in
    the morning that comes and goes throughout the remainder of the day.

    At this point you would you would…

    a)   Discontinue his antihypertensive medication and reevaluate his blood pressure in one month.
    b)   Reassure him.
    c)   Discontinue the diuretic but continue the ACE inhibitor.
    d)   Evaluate him for pheochromocytoma.

Overall, it is often very difficult to control blood pressure in diabetics with
nephropathy. It also takes 4 - 6 or sometimes 8 weeks to see the maximal blood
pressure lowering effect when a drug is prescribed. He has only been on his dual
therapy for a few weeks. Given the height of his BP elevation above his goal BP
(<130/80 mm Hg) you can up-titrate his medication, add another drug, or watch his
BP on his current dose for a few more weeks. It is very likely that he will need
another second drug; yet gradually lowering blood pressure will minimize side
effects as blood pressure is reduced. On the other hand, at eight weeks it is
unlikely that his BP will have fallen to goal with either watching him for a few more
weeks or up titrating his medication dose. This is a judgment call –however, there
is no immediate payoff in lowering BP too rapidly. If it takes you three or four
months to get his BP to goal, you shouldn't worry. Thus, reassuring him is fine.
Patients frequently require multiple medications to achieve blood pressure targets.
Generally a diuretic should be added to an ACE or ARB prior to adding a calcium
blocker, except where contraindicated.          Diabetic patients should always have
orthostatic blood pressure changes measured given their propensity to autonomic
neuropathy. There is no reason to stop his current medication or to evaluate him
for pheochromocytoma. His dizziness might be related to his blood pressure
elevation, to the fall in his blood pressure, or his medication.

Correct answer: b

21. Mr. Santiago is a 40-year old man with a ten-year history of diabetes mellitus, hypertension and
    hypercholesterolemia and recently diagnosed coronary heart disease. His medications include
    metformin, a statin, metoprolol, chlorthalidone, and ACE inhibitor. He saw the ophthalmologist
    you referred him to last week and has the consultative report for you to see. According to the
    ophthalmologist he has “non-proliferative retinopathy” with evidence of dot and blot hemorrhages.

                                                                                                   12
    Which of the following medications are contraindicated in Mr. Santiago?

    a)   Aspirin
    b)   Clopidorgrel
    c)   Sildenafil
    d)   None of the above

The Early Treatment of Diabetic Retinopathy Study (ETDRS) investigated whether
aspirin (650 mg/day) could retard the progression of retinopathy. After examining
progression of retinopathy, development of vitreous hemorrhage, or duration of
vitreous hemorrhage, aspirin was shown to have no effect on retinopathy. There
are no ocular contraindications to the use of aspirin when required for
cardiovascular disease or other medical indications.

Correct answer: d


22. A 64 year old patient has Type 2 Diabetes and microalbuminuria. Which of the following
    interventions will reduce urinary albumin excretion?

    a)   Increased sodium intake
    b)   Use of an ACE inhibitor
    c)   Reduction in potassium intake
    d)   Enhanced fluid intake
    e)   All of the above

ACE inhibitors and ARB's reduce urinary protein excretion. However, they cannot
maximally reduce urinary albumin excretion in the setting of unrestricted sodium
intake.   Decreased sodium intake will act with ACE and ARBS to reduce
proteinuria. Increased adiposity elevates urinary protein excretion. Decreasing
adiposity will decrease urinary albumin excretion. Therefore, Glycemic control is
well established as an effective strategy to reduce urinary protein excretion.
Other effective strategies to reduce proteinuria include smoking cessation and
lowering of blood pressure.

Correct answer: b


23. A patient presents for follow-up evaluation. She is 45 years old and has long standing Type 2
    diabetes, hypertension and hyperlipidemia. Her blood pressure today is 160/92 mm Hg a level
    that is similar to previously documented clinical visits. Her calculated BMI is 30 kg/m2. Fasting
    glucose is 280 mg/dl. Her hemoglobin A1C is 11.8%. Her lipid profile is: LDL cholesterol is 145
    mg/dl, HDL cholesterol is 44 mg/dl and triglycerides are 300.

    At this point you would

    a) Begin lifestyle modification, and initiate treatment for diabetes with metformin.
    b) Begin lifestyle modification, pharmacologic treatment for hypertension, metformin, a
       thiazolidinedione, a statin and aspirin.
    c) Begin lifestyle modification, pharmacologic treatment for hypertension, sulfonyluria and a
       statin.
    d) First control her diabetes and then discuss treatment for her hypertension and
       hyperlipidemia.



                                                                                                  13
According to JNC VII, all patients with diabetes and Stage 2 hypertension should
be started on pharmacologic therapy. Furthermore, although the ADA practice
Guidelines recommends repeat blood pressure measurement in one month to
confirm hypertension, they recommend immediate pharmacologic treatment for
all patient with blood pressures >160/100 without waiting an additional month to
confirm. Lifestyle modification should also be provided concurrently.

The NCEP/ATP III guidelines recommend lifestyle modification for 6 weeks after
which response to therapy should be evaluated. In patients with coronary heart
disease (CH) or (CHD) equivalents including diabetes, intensive lifestyle therapy
and maximal control of other risk factors should be started. The most recent
ADA practice guidelines 2005 recommend patients over 40 with total cholesterol
> 135 be started on a statin to achieve an LDL reduction of 30-40% regardless of
baseline LDL. The primary goal is an LDL of < 100

When choosing treatment regimens for patients with diabetes it is important to
consider the effects of treatment on weight. Sulfonylureas are associated with
weight gain. In the absence of contraindications, it is therefore reasonable to
start patients with BMI > 25 who have moderate hyperglycemia (fasting glucose
140 to <200) on metformin as it is not associated with significant weight gain.
Finally patients with moderate to severe fasting hyperglycemia will likely require
two agents to achieve euglycemia.

Correct answer: b


24. Mrs. Z comes in for evaluation of her diabetes. You have not seen her for several years. She
    states her glucoses are very well controlled now on BID NPH insulin. Her glucose flow sheets
    confirm this. In fact, her glucose levels are now all under 160 mg/dl whereas chart review
    indicates her glucose levels in the past had always been well above 250 mg/dl. There has been
    no significant change in dietary intake or physical activity in the last several years. She now
    experiences hypoglycemic episodes 2 to 3 times per week whereas this rarely ever occurred prior
    to 1 year ago. PMH is remarkable for longstanding poorly controlled hypertension, hyperlipidemia
    and smoking. Today Mrs. Z weighs 239 pounds. (Previous weight 180). Her blood pressure is
    188/100 mm Hg. Her fasting glucose is 145 mg/dl.

   Which of the following lab panels are likely to belong to Mrs. Z?

   a)    Random glucose 160, HgbA1c 7.0%, Na 138, K 5.0, Cl 100, bicarb CO2 18, creat 1.5
   b)    Random glucose 220, HgbA1c 10.0%, Na 138, K 5.0, Cl 100, bicarb CO2 18, creat 1.5
   c)    Random glucose 160, HgbA1c 7.0%, Na 138, K 5.0, Cl 104, bicarb CO2 24, creat 0.8
   d)    Random glucose 220, HgbA1c 10.0%, Na 138, K 5.0, Cl 100, bicarb CO2 18, creat .8

As patients develop renal insufficiency it is not uncommon to see glycemic
control improve. The kidney clears insulin and therefore insulin remains in the
circulation longer. Although it is possible Mrs. Z is finally following all your
recommendations the fact that her weight has not decreased but rather
increased suggests that insulin sensitivity is unlikely to have improved. Finally,
Mrs. Z may be lying but is more likely that she is developing renal insufficiency.
Persons without diabetes who have chronic kidney disease appear to have an
increased risk of developing diabetes mellitus.

Correct answer: a
                                                                                                 14
25. In patients with Type 2 diabetes receiving statins for lipid lowering, which of the following is to be
    expected?

    a)   Reduction in proteinuria
    b)   Reduction in stroke risk
    c)   Enhanced erectile function
    d)   Improved glycemic control

Statins reduce both coronary and stroke risk. Unfortunately they have not been
shown to reduce the likelihood of erectile dysfunction in patients with
established ED or to enhance erectile function. Although theoretically they might
since they improve endothelial function. Also, statins might reduce urinary
albumin excretion also because of their ability to improve endothelial function.
One study suggested that statins lowered the risk of future diabetes but no
studies have shown improved glycemic control with statins.

Correct answer: b


26. Which of the following blood pressure phenotypes is most common in patients with diabetes
mellitus?

    a)   Systolic >140 and diastolic >90 with normal pulse pressure
    b)   Systolic pressure 130-140, Diastolic <80, pulse pressure >40
    c)   Systolic > 140, diastolic blood pressure 70-90, pulse pressure > 40
    d)   None of the above are correct

Persons with diabetes mellitus have predominantly SBP elevations compared to
persons without diabetes DBP levels are either the same or slightly lower than
non-diabetics. Thus, pulse pressure, the difference between SBP and DBP, is
greater in persons with diabetes than in non-diabetics. Diabetes represents a
premature aging of the vascular system with arterial stiffening and reduced
arterial compliance that occurs years earlier than in non-diabetics.

Correct answer: c


27. RR is a 47-year-old white man with fasting plasma glucose levels consistently in the 115 - 125
    mg/dl range. He weighs 230 pounds and is 5' 8" tall.

    At this point you would

    a) Inform the patient he has borderline diabetes and refer him to a dietician for instruction in a
       1500 calorie ADA diet.
    b) Inform the patient he has borderline diabetes and initiate treatment with metformin
    c) Inform the patient he has borderline diabetes and initiate treatment with a sulfonylurea
    d) Inform the patient he has impaired glucose tolerance and advise him to begin a 1500 calorie
       ADFA diet.
    e) Inform the patient he has impaired fasting glucose and advise lifestyle modification and
       strongly consider referring him or an oral glucose tolerance test

Correct answer: Normal fasting glucose is < 100 mg/dl, impaired fasting glucose
is 100-125 and diabetes is diagnosed when glucose is persistently > 126 mg/dl.
Lifestyle modifications including appropriate physical activity, weight loss, and

                                                                                                       15
calorie restriction should be encouraged to promote weight loss to a healthier
body weight.

Correct answer: e


PD is a 32-year-old woman who is in her 20th week of pregnancy with her first child. She has not had any
prenatal visits. Her fasting glucose levels, however, have been at the upper limits of normal (~ 95 mg/dl). A 75
gram oral glucose tolerance test is obtained after a 12 hour fast. Her fasting plasma glucose was 128 mg/dl and
her 1-hour post-glucose load plasma glucose was 188 mg/dl and her 2- hour post-load glucose was 160 mg/dl.
Prior to this pregnancy her fasting glucose values were all normal at her annual physicals.

28. How would you classify her OGTT?

    a)   She has normal glucose tolerance
    b)   She has gestational diabetes
    c)   She has developed type 2 diabetes mellitus
    d)   None of the above

Correct answer: According to the ADA 2005 guideline, “gestational diabetes
mellitus (GMD) is defined as any degree of glucose intolerance with onset or first
recognition during pregnancy. The definition applies regardless of whether
insulin or only diet modification is used for treatment or whether the condition
persists after pregnancy. It does not exclude the possible that unrecognized
glucose intolerance may have antedated or begun concomitantly with the
pregnancy.” Normal fasting plasma glucose is < 95 mg/dl, 1-hour post-load
glucose should be < 180 mg/dl, and 2-hour post-load glucose should be < 155
mg/dl. When two or more of these values are either met or exceeded in a woman
where the first evidence of impaired glucose tolerance is occurring during this
pregnancy, then the diagnosis of gestational diabetes mellitus is made. Glucose
tolerance typically deteriorates during the third trimester of pregnancy. Women,
who are not at low-risk for GDM, should be screened at the first prenatal visit and
retested at 24 - 28 weeks of gestation. Women at low risk of GDM including
women who are < 25 years, are of normal body weight, have no first degree
relative with DM, no history of abnormal glucose tolerance or poor obstetrical
outcome and women who are not members of a racial or ethnic group with high
diabetes prevalence do not require testing for gestational diabetes. Given that
this patient is Hispanic, she should have been screened at her first prenatal visit.

Correct answer: b


29. Which of the following is not true regarding gestational diabetes mellitus?

    a)   GDM is a risk factor for perinatal morbidity and mortality
    b)   GDM is a risk factor for development of diabetes mellitus later in life
    c)   GDM is a risk factor for prolonged gestation
    d)   GDM is a risk factor for cesarean section

GDM is a risk factor for all of the above. GDM accounts for ~ 90% of the diabetes
encountered during pregnancy. 6-weeks post delivery the mother should be
reclassified according to standard criteria - normal, impaired fasting glucose,
impaired glucose tolerance, or diabetes mellitus.
                                                                                                             16
Correct answer: c

30. Which of the following patients should be screened for diabetes?

    a)   A 35 year old Native American with BMI of 22 kg/m2
    b)   A 30 year white woman who is physically inactive with a BMI of 34 kg/m2
    c)   A 40 year old African American woman with BMI of 24
    d)   A 28 year old African American man who is physically active and has a BMI of 28


Testing for diabetes should be considered in all individuals at age 45 years and
above, particularly in those with a BMI >25 kg/m2 and if normal should be
repeated a 3 year intervals. Testing should be considered at a younger age in
individuals who area overweight (BMI > 25 kg/m2 and have additional risk factors
as follows:

        are habitually physically inactive
        have a first degree relative with diabetes
        are member of a high risk group (e.g. African American, Latino, Native
         American, Asian American, Pacific Islander
         persons with first degree relatives with diabetes
        women who have delivered a baby > 9 pounds or were diagnosed with
         gestational diabetes mellitus
        are, hypertensives (> 140/90)
        have an HDL cholesterol level , 35 mg/dl or a triglyceride level . 250
        have PCOS
        on previous testing had IGT or IFG
        Have other clinical conditions associate with insulin resistance (acnthosis
         nigrican)
        Have history of vascular

Correct answer: b



31. JC is a 55 year white old man with known chronic kidney insufficiency, presumably secondary to
    poorly controlled hypertension and diabetes mellitus. His primary care physician recently initiated
    treatment with 4 mg once daily of trandolapril, an ACE inhibitor. His current medications
    additionally include HCTZ 12.5 mg/d, amlodipine 10 mg/d, acetaminophen 1000 mg every 6
                                                                                              2
    hours, and prn ranitidine. His estimated glomerular filtration rate is 37 ml/min/1.73 m (serum
    creat 2 mg/dl). 6 weeks after initiating ACE inhibitor, his creatinine rises to 3.3 mg/dl. Prior to
    starting his ACE inhibitor, his BP had ranged between 160 -188/78 – 92 mm Hg. His BP is
    currently 176/84 mm Hg. He has no intercurrent illness ness to report.

    The least liklely explanation for his rise in serum creatinine is:

    a)   Hyperglycemia
    b)   Bilateral “critical” renal artery stenosis
    c)   ranitidine
    d)   acetominphen

This man has chronic kidney insufficiency. In persons with reduced kidney mass,
auto-regulation of renal blood flow and glomerular filtration rate is abnormal. That is,

                                                                                                    17
instead of the normal sigmoidal relationship between systemic blood pressure and
GFR, there is a more linear relationship. Thus, renal perfusion pressure is more
closely linked to GFR than in normal kidneys. Stated another way, the normal auto-
regulation of renal blood flow and GFR are disrupted. When GFR and renal blood flow
auto-regulation are abnormal, abrupt and/or sizeable drops in BP can cause reductions
in GFR and therefore elevations in serum creatinine. In chronic kidney disease the
remaining nephrons also over-express COX-2. The over-expression of this enzyme
leads to the production of vasodilatory prostaglandins (dilates glomerular afferent
arteriole) and also augments angiotensin II synthesis (constricts glomerular efferent
arteriole); this leads to increased glomerular pressure that, if maintained over the
long-term, causes renal injury and loss of kidney function. In the setting of bilateral –
not typically unilateral – critical renal artery stenosis, drops in BP as well as initiation
of ACE inhibitor therapy can lead to global reductions in GFR and elevations in serum
creat. There is, however, no evidence that this man has experienced a significant
drop in BP. NSAID‟s including COX-2 inhibitors can lead to reductions in global GFR,
so ibuprofen is a viable suspect.           Ranitidine is unlikely to have caused the
deterioration in kidney function.         The most likely explanation for his acute
deterioration in kidney function is that the bilaterally critically stenosed renal arteries
were highly dependent on vasodilatory prostaglandins and ang II to maintain GFR in
the underperfused nephrons. The ACE inhibitor, maybe in conjunction with the NSAID,
interrupted this compensatory set of mechanisms leading to global reductions in GFR.
Overdiuresis is the most common cause of deteriorations in kidney function in persons
with chronic kidney disease after initiating ACE inhibitor therapy. However, with a GFR
below the mid-40‟s, the low-dose thiazide he had been prescribed is not likely to have
caused much, if any, diuresis. Thiazides are typically ineffective when the GFR drops
much below the mid 40‟s.

Best answer: b


32. RA is a 48-year-old person with long-standing diabetes mellitus for the last 10 years. Over the
    last 3 years eight hemoglobin A1C’s have ranged between 8 – 9.9%. His blood pressure has
    ranged 156–190 / 78–96 mm Hg during this same time frame.               He currently takes two
    antihypertensive medications – atenolol 50 mg once daily and doxazosin 4 mg once daily. He
    rarely misses taking his antihypertensive medications. A 24-hour urine recently showed 1.2
    grams of protein.

   Which of the following is least likely to improve his blood pressure control?

   a)   Encouraging dietary sodium restriction.
   b)   Discontinuing doxazosin, and add an ACE- inhibitor along with a diuretic.
   c)   Adding an ACE inhibitor and a diuretic.
   d)   Discontinue doxazosin and adding an ARB and a diuretic.

Diuretics enhance the blood pressure lowering effect of virtually all
antihypertensive drug classes.         Furthermore, when taking more than 2
antihypertensive drugs, if a diuretic was not one of the first two drugs, in most
instances it must be the third drug if BP lowering is to be effective. Because of his
diabetes, he is a good candidate for an ACE inhibitor or an ARB. In type 2 diabetes
the data is strongest (RENAAL, IDNT trials) for angiotensin receptor blockers than
ACE inhibitors for preventing progressive loss of kidney function. Nevertheless,
though the database is less significant for ACEI in type 2 diabetic nephropathy;

                                                                                                18
there is no physiological reason for these agents not to forestall progressive
nephropathy in type 2 diabetes. In persons with type 1 diabetes mellitus, the data
on forestalling progressive nephropathy belongs to the ACE inhibitors; however,
there is little reason to believe that angiotensin receptor blockers wouldn‟t be
effective in this setting – despite the fact that the database for their use in type 1
diabetes mellitus is far less robust than for ACE inhibitors.         Dietary sodium
restriction will lower blood pressure. However, the major problem is getting the
patient to restrict sodium. Thus of the choices available, choice „„a” is the least
likely to lead to improvement his blood pressure control.

Best answer: a


33. TT is a 52 year old woman with long-standing diabetes mellitus. Her glycemic control has been
    quite good over the years. Over the past 3 years, a review of her chart documents no
    hemoglobin A1C’s above 7%. She experiences hypoglycemia episodes ~ twice weekly. After a
    recent myocardial infarction, she was placed on a beta-blocker. She read information on the
    internet that has led her to be concerned about some of the potential adverse effects of beta
    blockers.

        Which of the following may occur as a consequence of taking a beta-blocker?

        a)   Weight loss
        b)   Absent or blunted tachycardia during hypoglycemia
        c)   Absence of sweating with hypoglycemia
        d)   Warm extremities

Beta-blockers can cause weight gain, blunting of the tachycardic response during
hypoglycemia and cool extremities.         Sweating with hypoglycemia is a
sympathetic cholinergic function and is thus unaffected by beta-blockers.

Best answer: b

34. Which of the following is the best answer?

        a) The goal blood pressure level in persons with diabetes is < 140/90 mm Hg.
        b) If hemoglobin A1C is 6.4% during a clinic visit, intensification of diabetes drug therapy
           is indicated.
        c) In persons with diabetes, systolic blood pressure is very close to that of age- and sex-
           matched persons without diabetes, however, diastolic blood pressure is usually much
           higher in persons with diabetes compared to persons without diabetes
        d) Goal LDL-cholesterol in persons with diabetes mellitus is < 130 mg/dl.
        e) Lowering blood pressure is a proven way to reduce the need for retinal laser surgery to
            treat neovascularization.

The goal BP according to the American Diabetes Association (ADA) is < 130/80
mm hg. According to the JNC VII report, the goal BP for persons with diabetes is
< 130/80 mm Hg. Hemoglobin A1C > 7% is an indication for intensification of
diabetes therapy. Compared to persons without diabetes, persons with diabetes
mellitus tend to have much higher systolic blood pressure levels but similar to
slightly lower diastolic blood pressures. The goal LDL-C is < 100 mg/dl in persons
with diabetes. Both glycemic control and effective BP lowering are proven ways
to reduce the risk of microvascular disease (e.g., nephropathy, retinopathy).



                                                                                                 19
Best answer: e


35. NX is a 48-year-old African American woman with a 14 year history of diabetes mellitus. She has
    never experienced DKA nor hyperosmolar coma. Her most recent serum creatinine was 1.4
                                       2
    mg/dl (EGFR ~ 50 ml/min/1.73 m ). She has chosen you as her primary care physician. During
    your initial visit you note that her BP is 166/68 mm Hg. Her physical examination reveals
    background retinopathy, and evidence of left ventricular enlargement. She also has loss of
    sensation over the plantar surface of the foot. Her stool guaiac is negative. Previous BP levels
    and blood counts according to her old medical records are essentially unchanged. She has had
    repeated dipstick positive proteinuria (1+), although her urinary protein has never been quantified.
    Her current hemoglobin is 10.8 mg/dl (reticulocyte count 1%, MCV 84, Iron studies normal) Her
    current medications include verapamil SR 240 mg once daily, ASA 81 mg/d, and HCTZ 25 mg/d.

    Which of the following statements is correct?

    a)   A screening colonoscopy should be ordered.
    b)   The patient should be started in iron and folic acid.
    c)   The patient should have three stool guaiacs performed.
    d)   The patient hemoglobin is normal for her.

 Diabetes and reduced kidney function both cause anemia. Diabetes has been linked
to an earlier expression of anemia at reduced, though higher GFR‟s, than persons with
reduced GFR but no diabetes. The anemia of reduced kidney function, particularly in
persons with diabetes, begins to be manifest at GFR‟s of ~60 ml/min/1.73 m2.
Nonetheless is prudent to exclude intermittent GI bleeding. If these are positive the
patient deserves a diagnostic colonoscopy.

Best answer: c


36. In a patient with a strong family history of diabetes which approach for establishing the diagnosis
    of diabetes mellitus is most likely to confirm the diagnosis of diabetes mellitus in its earliest
    stages?

         a)   Measuring hemoglobin A1C
         b)   Fasting plasma glucose
         c)   Oral glucose tolerance testing
         d)   Measuring glycated hemoglobin

Though hemoglobin A1C is used to follow the course of therapeutic response to
diabetes therapy, no diagnostic criteria are available for using this test to
diagnose diabetes mellitus. Diagnostic criteria definitely exist for fasting plasma
glucose, however, in its earliest stages, diabetes mellitus is more readily
detected in the post-prandial than in the fasting state. Some labs measure and
report glycated hemoglobin levels (always higher than hemoglobin A1C levels),
however, diagnostic criteria for diabetes mellitus do not exist for this lab test.
Oral glucose tolerance testing is most likely to detect diabetes mellitus in its
earliest stages.

Correct answer: c


37. VB is a 58 year old overweight woman with a 15-year history of diabetes mellitus. Over the
    years, she has taken multiple oral hypoglycemic agents and for many years had very good
                                                                                                     20
    control of her fasting and post-prandial glucose levels. There has been no evidence of
    retinopathy, although she developed microalbuminuria ~ 3 years ago. Her medical records now
    indicate a progressive rise in her fasting and post-prandial blood sugars. Her hemoglobin A1C
    levels have risen from 6.1% to 8.8% over the last 18 months with no change in diet, stable
    medications, and no evidence of intercurrent infections or other identifiable stressors. Her weight,
    diet, and physical activity levels have remained relative constant over the last 2 years. Current
    medications include metformin 2550 mg/d (taken in divided doses), pioglitazone 45 mg/d,
    enalapril 20 mg bid, amlodipine 5 mg/d, ASA 325 mg/d, and lamisil 250 mg once daily. She says
    that she takes her medications every day and rarely misses any doses.

    The most likely explanation for her deterioration in glucose tolerance is?

    a)   Increasing insulin resistance
    b)   Progressive insulinopenia
    c)   The patient is not being entirely truthful
    d)   Her antihypertensive medication

The natural history of persons with Type 2 Diabetes Mellitus is progressive loss of
pancreatic beta-cell insulin secretion.     Some patients will clearly become
insulinopenic and may even develop symptoms such of polyuria, polydipsia,
polyphagia, weight loss, and visual symptoms if their hyperglycemia becomes
severe enough. Insulin resistance, per se, is not a sufficient cause for diabetes
mellitus – unless pancreatic insulin secretion is also abnormal. Furthermore, in
this lady there is no evidence that some of the main causes of insulin resistance
such as physical inactivity, high-fat diet, and weight gain have changed much
over the last several years. Her antihypertensive medications have no effect
(amlodipine, dihydropyridine calcium antagonist) on glucose tolerance or actually
improve glucose tolerance (enalparil, an ACE inhibitor). ACE inhibitors typically
do not change fasting glucose levels, however, they do improve glucose
tolerance and have been implicated as contributing to the risk of hypoglycemia.

Correct answer: b

38. Which of the following drug(s) is/are contraindicated in diabetics?

    a)   thiazide diuretics
    b)   dilantin
    c)   nicotinic acid
    d)   doxazosin
    e)   None of the above

Thiazide and other potassium-wasting diuretics may precipitate diabetes or
worsen glycemic control and/or glucose tolerance.       Nevertheless, they are
important agents in the management of hypertension in patients with diabetes.
Beta-blockers can also worsen glucose tolerance and have been linked to an
increased risk of developing diabetes mellitus. ACE inhibitors appear to reduce
the long-term risk of developing diabetes mellitus by ~30% and improve insulin
sensitivity though not fasting glucose in persons with diabetes. Virtually every
authoritative body recommends an ACE inhibitor (or an ARB)in persons with
diabetes. Nicotinic acid or niacin also can worsen glucose tolerance, and for
these reason are cautiously used in the management of lipid abnormalities in
persons with diabetes. Alpha-interferon also can cause worsening glucose
tolerance. Other drugs that may worsen glucose tolerance or cause diabetes
include pentamidine, glucocorticoids, and thyroid hormone. Doxazosin, an alpha
                                                                                                     21
adrenergic blocker, improves insulin sensitivity and glucose tolerance, and
therefore has an opposite effect on glucose tolerance and levels compared to the
other drugs discussed. However, none of the above drugs are “contraindicated” in
diabetics. As always thgough the therapeutic benefit must out weigh the risk.

Correct answer: e


39. KL is a 44-year-old woman with diabetes mellitus for the past 5 years. She once experienced
    diabetic ketoacidosis during a bout of pyelonephritis complicated by sepsis. KL also smoked for
    50-pack years and has severe hypercholesterolemia (LDL-C 200 mg/dl), low HDL cholesterol (34
    mg/dl) and elevated fasting triglycerides (280 – 440 mg/dl). Three years ago she experienced an
    anterior wall myocardial infarction. Cardiac catheterization showed severe LAD stenosis that was
    amenable to angioplasty with stent placement and 40 – 70% patchy stenosis of her right coronary
    artery. Serial ejection fractions have ranged from 30 – 38% over the last 18 months. Her major
    complaint today is progressive shortness of breath. She experiences significant SOB with only
    minimal physical exertion. Hemoglobin A1C levels have ranged from 8.8 – 11.2% over the last
                                                                           2
    18 months. Her estimated glomerular filtration rate is 40 ml/min/1.73 m .

   Current medications include ASA 325 mg once daily, lipitor 40 mg @ HS, quinapril 40 mg bid,
   felodipine 10 mg once daily, glucotrol XL 10 once daily, and pioglitazone 30 mg once daily.

   Vitals show a BP of 150/72 in the seated position without significant orthostatic change, pulse
   rate of 88 beats per minute (regular), respirations of 18/minute

   Physical examination is normal except for a fourth heart sound, bilateral lower lung field rales that
   do not clear with cough extending ~ ¼ way up, mild elevation of her jugular venous pressure @
   45 degrees, bilateral femoral bruits, and 3 + lower extremity edema extending to the level of the
   knees.

       Which of the following is true?

       a) She has class III heart failure symptoms.
       b) The most logical drug to add to her diabetes treatment regimen, after reinforcing dietary
          counseling, is metformin.
       c) The drug in her current regimen that should definitely be discontinued is glucotrol.
       d) Her lower extremity edema is predominantly from her heart failure.
       e) HCTZ/triamterene should be prescribed.

She does not have heart failure symptoms at rest (class IV), however, given the
appearance of he heart failure symptoms with minimal exertion, this is consistent
with class III heart failure. Her glycemic control has been poor and her kidney
function is significantly depressed. Both class III heart failure and reduced
kidney function are contraindications to metformin – there is an increased risk in
these settings of lactic acidosis. There is no compelling reason to discontinue
glucotrol at this time.    Her physical exam suggests that she indeed has both
right and left sided heart failure. Thus, the right-sided heart failure has likely
contributed to her lower extremity edema. However, assigning right sided heart
failure the predominant role in her edema cannot be done with confidence. Both
felodpine (a dihyrdopyridine calcium antagonist) and pioglitazone can cause
edema, though the underlying mechanisms are different.                  Furthermore,
pioglitazone is a known cause of fluid retention/volume expansion and is therfore
contraindicated in class III – IV heart failure. Multiple causes of lower extremity
edema can be identified. Given that her estimated GFR is below the mid 40‟s, a
thiazide diuretic, especially at low dose, is unlikely to be effective in initiating a

                                                                                                     22
diuresis or in controlling blood pressure. A higher dose diuretic (bid furosemide
or metolazone, for example) would effectively diurese her and help her attain
better BP control. Improved BP control might improve her cardiac performance
as well.

Correct answer: a


40. Mr. Khan is a 58 year man with Type 2 Diabetes and coronary heart disease. He has a strong
    family history of early coronary heart and sudden death. His sugars are currently well controlled
    on diet and an alpha glucosidase inhibitor and metformin. His LDL cholesterol is 99 on a statin.
    Triglycerides are 200 and his HDL cholesterol is 23. He takes ASA 325 milligrams daily.

         Which of the following approaches would optimize his lipid profile?

         a)   Advise the patient to drink 4 four alcoholic beverages daily.
         b)   Begin Niacin 250 milligrams bid and gradually titrate to 1000 milligrams per day.
         c)   Begin a vigorous exercise program
         d)   Start Folic acid 1 milligram daily

This patient has a low HDL level. There are various ways to increase HDL.
Although alcohol has been shown to increase HDL levels recommending four
alcoholic beverages a day would not be advised.         Niacin increases HDL
cholesterol, lowers LDL cholesterol and triglycerides. Adding niacin to statins
has been shown to slow the progression of atherosclerosis (Arterial Biology for the
Investigation of the Treatment Effects of Reducing Cholesterol (ARBITER 2 Trial). Niacin
can be used safely in diabetic patients.       Exercise can increase HDL levels but
recommending a “vigorous” exercise program in a patient with CAD would not be
advisable. Niacin

Correct answer: b



41. Mr. N is a 45 man who was diagnosed to have diabetes more than 12 years ago. His GFR is 40.
    Four months ago he underwent stent placement for occlusion of his LAD. He also has
    proliferative retinopathy which was treated by laser 2 years ago. He is doing well today although
    he mentions he is having some burning discomfort of his feet for the last two months. His
    glycemic control has been excellent; fasting glucoses range between 110 and 125 and post
    prandial glucoses are never higher than 160.

    At this visit you would:

    a)   Order an ankle brachial index test
    b)   Test sensation with a 10 g monofilament
    c)   Order nerve conduction tests
    d)   Test sensation to pain and temperature, vibration, and light touch with a cotton wisp

This patient‟s symptoms are suggestive of peripheral neuropathy. The best initial
way to evaluate this patient is to assess sensation using a 10 g monofilament.
Testing for sensation to pain, temperature, vibration and light touch are
appropriate but will not be as sensitive or reproducible as testing sensation with
the monofilament. Nerve conduction tests will diagnoses peripheral neuropathy
but are not recommended as part of a standard office evaluation. The ankle


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brachial index is recommended to evaluate for arterial insufficiency not
neuropathy. would define might be helpful

Correct answer: b

42. Mr. N’s sensation is found to be intact to all modalities. Which of the following statements is true?

    a) Mr. N should be instructed in use of the monofilament so that he can asses his sensation and
       participate in reducing his risk of ulceration and amputation
    b) Mr. N has had diabetes for more than 10 years and is at increased risk for amputation
    c) Mr. N has a normal sensory examination and is therefore not at increased risk for diabetic
       food ulcer
    d) Mr. N has a normal sensory examination and is therefore not at increased risk for risk of
       amputation

Correct answer: b

43. Mr. U presents for a follow visit for diabetes. He takes metformin 1000 milligrams twice daily and
    self-monitors his blood glucose. Fasting and pre-prandial glucose are all less than 130. HgbA1c
    is 8%.

    At this point you would

    a) Continue the metformin and have the patient come backing in six months for another
       HgBA1c.
    b) Add a TZD.
    c) Repeat the HgBA1c as it is very unlikely that to have such a high value with the fasting and
       pre-prandial values described
    d) Discontinue metformin and begin a sulfonylurea to achieve a HgBA1c of <7%

Metformin does not require endogenous insulin secretion to be effective Insulin
secretion typically declines over time even in persons with Type 2 Diabetes
Mellitus. Checking post prandial glucose is great but what this patient mostly
needs is combination oral hypoglycemic therapy and/or a radical change in diet.

Correct answer: b


44. Which of the following tests is not a component of an initial comprehensive evaluation in an
    asymptomatic 30 year old patient with newly diagnosed Type 1 diabetes?

    a)   HgBA1c
    b)   Fasting lipid profile
    c)   Thyroid-stimulating hormone (TSH)
    d)   Test for microalbuminuria

Correct answer: d

45. Which of the following statement is true?

    e) Patients with diabetes who are older than 40 years of age should take ASA for primary
       prevention of myocardial infarction
    f) Patients with diabetes who are older than 40 years of age should take ASA daily for primary
       prevention of retinopathy
    g) Patients with diabetes and proliferative retinopathy should not take ASA if because it
       increases the risk of retinal hemorrhage
    h) Patients with diabetes should take ASA daily to prevent microalbuminuria

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Correct answer: a


46. Which of the following should be performed at every routine diabetes visit?

    a)   Comprehensive foot examination
    b)   Measurement of capillary glucose
    c)   Measurement of blood pressure
    d)   Measurement of HgbA1c

Correct answer: c

47. A 45 year woman with type 2 diabetes is found to have a single blood pressure measurement of
    160/80. There is evidence of left atrial enlargement and left ventricular hypertrophy on EKG. At
    this point you would

    a)   Arrange follow-up in one month to repeat her blood pressure
    b)   Arrange follow-up in one week to repeat her blood pressure
    c)   Begin chlorthalidone 25 milligrams daily
    d)   Begin chlorthalidone 25 milligrams and lisinopril 10 milligrams daily and arrange follow-up in
         one month

This is a tough problem. With evidence of target organ injury present it becomes easy to justify
treatment after one visit. There is no evidence to support this treatment strategy. However, the ADA
did adopt a recommendation to intimate immediate pharmacologic treatment for diabetic patients with
a single systolic blood pressures > 160 or diastolic blood pressures >100. The blood pressures is >
20/10 over goal so two drugs are needed. The ACE inhibitor should definitely be used.

Correct answer: d


48. Mrs. Z was recently diagnosed with type 2 diabetes. She completed diabetes education classes
    and is following a 1500 calorie ADA diet. At this point you would recommend she

    a)   Measure capillary blood glucose twice daily
    b)   Measure fasting and post-prandial capillary blood glucose daily
    c)   Measure capillary blood glucose three or more times daily
    d)   None of the above

The role of SMBG in stable diet-treated patients with type 2 diabetes is not known.
Daily SMBG is especially important for patients treated with insulin to monitor for and prevent
asymptomatic hypoglycemia and hyperglycemia. For most patients with type 1 diabetes and
pregnant women taking insulin, SMBG is recommended three or more times daily

Correct answer: d


49. Which of the following statements is correct?

    a. A thorough foot examination should be performed annually in diabetics annually to identify
       high risk foot conditions
    b. A thorough foot examination should be performed every visit in diabetics to identify evidence
       of increased plantar pressure (calluses, corns etc.)
    c. A thorough foot examination should be performed quarterly in diabetics to identify evidence of
       neuropathy
    d. A thorough foot examination should be performed biannually in diabetics to identify evidence
       of peripheral vascular disease

Correct answer: a
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