INVICTUS INTERNAL MEDICINE LQ4: DIABETES MELLITUS

# QUESTION CHOICES RATIO REFERENCE

The Philippine In the Philippines National And Nutrition Health Survey (NNHeS) 2008 data set, the
DiabCare
NHAES 2008 (WHO A. 7.2 prevalence of DIABETES was found to be 7.2 %, a prevalence estimate that
2008 Vol 50
Criteria) statistics for B. 9.1 closely approximates the projections of the IDF for that year.
1 No. 1 Jan-
prevalence of C. 14.2 On the other hand, the prevalence of PRE-DIABETES in the 2008 Philippine
Mar. 2012 pp.
prediabetes in the D. 12 NNHeS was found to be 9.1% (ANSWER) and 14 % using the WHO and ADA
15
country is __% criteria respectively.

There are 2 broad

A. Age of onset
categories of DM is classified on the basis of the pathogenic process that leads to Harrison’s
B. Type of therapy
2 Diabetes, this hyperglycemia, as opposed to earlier criteria such as age of onset or type of 19th ed ch
C. Comorbid conditions
classification is therapy 417 p2399
D. Pathologic process
based on:

Maturity onset diabetes of the young (MODY) and monogenic diabetes are
subtypes of DM characterized by autosomal dominant inheritance， early onset
of hyperglycemia (usually <25 years; sometimes in neonatal period)， and
Maturity onset A. Autosomal recessive
impaired insulin secretion.
diabetes of the B. Onset 26-30 years old
Harrison’s
young (MODY) is a C. Insulin receptor can
3 Mutations in the insulin receptor cause a group of rare disorders characterized by 19th ed ch
sub-type of DM and cause DM type 2
severe insulin resistance. Several monogenic forms of DM have been identified. 417 p2400
one of these D. Affects Liver and
statements are true. Kidneys More than 10 different variants of MODY， caused by mutations in genes encoding
islet-enriched transcription factors or glucokinase. As their names imply these
transcription factors are expressed in the liver but also in other tissues
including the pancreatic islets and kidney.

Management
of
A. Home based glucose
Hyperglycemi
of 70-30mg/dl
a in
B. An HbA1C of <7% with
Hospitalized
previous episodes of
Which of the Glycemic targets in the non-critical care setting 3.1 We recommend a premeal Patients in
hypoglycemia
following is true glucose target of less than 140 mg/dl (7.8 mmol/liter) and a random BG of less Non-Critical
C. Admitted critically ill-
4 regarding glycemic than 180 mg/dl (10.0 mmol/liter) for the majority of hospitalized patients with non- Care Setting:
premeal glucose of
targets in a diabetic critical illness. An Endocrine
<140mg/dl
patient? Society
D. Admitted non
Clinical
critically ill patient-
Practice
random blood
Guideline
glucose <180mg/dl
P2
 Harrison’s
19th ed

• In the ADA and Harrison’s plasma glucose target = 80 – 130 mg/dL

• HbA1c of <7% is the goal however it should be without episodes of
hypoglycemia

A. Test patient’s HbA1c Unite for

A 45 yo female
B. Diagnose patient as Diabetes
came in for consult
diabetic and start on CPG for the
of an OGTT result of
metformin Diagnosis
200 mg/dL with BP,
C. Recommend weight and
5 weight and height of:
loss, diet and Management
145/90 mmHg, 75kg
exercise of Diabetes
and 5’5”. What is the Patient is diagnosed as DM based on the criteria. However, MNT and Lifestyle
D. Assure the patient that
next appropriate change should be the first option for treatment considering patient is newly
she has normal blood AACE & ADA
step? diagnosed.
glucose p 40
Lifestyle management is a fundamental aspect of diabetes care and includes
diabetes self-management education (DSME), diabetes self-management support
(DSMS), nutrition therapy, physical activity, smoking cessation counseling, and
psychosocial care.
 NOTE: According to Doc Bacot, though option B is correct in the thought that the
patient is diagnosed as DM – the hierarchy for management of DM should begin
with lifestyle and MNT before pharmacologic treatment.

Based on the results of the patient, he has positive FBS score so he is diagnosed
as DM however as stated in the notes repeat testing should be done on a
separate day within 2 weeks to confirm the diagnosis, except in the presence
of hyperglycemic crises, in which case the patient should be treated as having
diabetes.

Unite for
A 45 yo M with an A. Repeat the FBS after 1
Diabetes
FBS of 127 mg/dL year
CPG for the
claims to have been B. Repeat FBS within 2
Diagnosis
stressed during the weeks
and
week. He denies any C. Obtain plasma glucose
6 Management
weight loss, after a 75 g oral
of Diabetes
polydipsia and glucose challenge
polyuria. What is D. Start the patient on
Under
next step in non-pharmacologic
Screening for
management? treatment
DM

In addition to a complete physical examination, special attention should be given to

If the patient above DM-relevant aspects such as weight or BMI, retinal examination, orthostatic blood
is diagnosed with A. Foot Examination pressure, foot examination, peripheral pulses, and insulin injection sites.
UNITE/Dr.
diabetes, which of B. Influenza vaccine
7 Sevidal's
the following tests C. 2D echo At the time of diagnosis, the following complications are usually seen:
Lecture
should the patient do D. Opthalmologic Exam -peripheral neuropathy (20%)
immediately? -proteinuria (42%)
-retinopathy (2%)

Elena’s parents both Harrison’s

A. She has between 70 Type 2 DM has a strong genetic component. The concordance of type 2 DM in
8 have T2DM. She is 19th Edition,
and 90% risk identical twins is between 70 and 90%. Individuals with a parent with type 2 DM
worried she can p. 2404
 have the same fate B. She has 40% risk of have an increased risk of diabetes; if both parents have type 2 DM, the
as them. How much having DM2 risk approaches 40%.
risk does she have? C. She has 30% risk of
having DM2
D. As long as she is lean
and normotensive she
is not at risk

GDM has the

A. 5-10 Harrison’s
chance to progress GDM occurs in ~7% (range 1–14%) of pregnancies in the United States; most
B. 10-20 19th Edition,
9 to Diabetes in the women revert to normal glucose tolerance postpartum but have a substantial risk
C. 20-50 p. 2400,
next 10-20 years by (35–60%) of developing DM in the next 10–20 years.
D. 35-60 under GDM
__%.

Studies of individuals with serious mental illness, particularly schizophrenia and

A. They have poor health other thought disorders, show significantly increased rates of type 2 diabetes (93).
habits People with schizophrenia should be monitored for type 2 diabetes because
Screening for type 2 B. Schizophrenics are of the known comorbidity. Disordered thinking and judgment can be expected to
DM among compulsive eaters make it difficult to engage in behaviors that reduce risk factors for type 2 diabetes, Diabetes
10 schizophrenia C. Obesity is genetically such as restrained eating for weight management. Coordinated management of Care, Volume
patient is done linked to schizophrenia diabetes or prediabetes and serious mental illness is recommended to achieve 40, S30
mainly because: D. Antipsychotic drugs diabetes treatment targets. In addition, those taking second-generation
can cause (atypical) antipsychotics such as olanzapine require greater monitoring
hyperglycemia because of an increase in risk of type 2 diabetes associated with this
medication (94).

Which of the
following tests is the A. Fasting blood glucose
Harrison’s
estimate of plasma B. 2 hours postprandial The glycemic index is an estimate of the postprandial rise in the blood glucose
11 19th Edition,
glucose after C. OGTT when a certain amount of that food is consumed.
p. 2409
ingesting a certain D. Glycemic index
amount of food?
 A. Carbohydrate sources
high in protein should
be used to prevent
hypoglycemia
B. Fat quality appears
Which of the to be more important
following is than quantity Harrison’s
recommended C. Strong evidence 19th Edition,
12
medical nutrition supports the use of Chapter 418,
therapy for Diabetes cinnamon to treat page 2409
Mellitus? diabetes
D. Omega -3
supplementation helps
in the reduction of
cardiovascular risk
in high risk patients

Batch Atlas
Whisper page
A. To increase insulin 3
uptake before exercise
A. INCORRECT If an individual is taking insulin and/or insulin secretagogues,
B. To ingest added http://www.nd
physical activity can cause hypoglycemia if medication dose or carb
carbohydrates if pre- ei.org/ADA-
consumption is not altered
In prescribing exercise blood glucose diabetes-
B. INCORRECT Added carbohydrate should be ingested when pre-exercise
individualized is <250mg/dL management-
13 glucose is <100 mg/dL (5.6 mmol/L)
physical activity, C. To avoid vigorous guidelines-
C. CORRECT Delay exercise if blood glucose is > 14 mmol/L (250mg/dL) and
ADA recommends: exercise if ketones lifestyle-
ketones are present;
are present changes-
D. INCORRECT Resistance training ≥2 times/wk (in absence of
D. Resistance exercise medical-
contraindications)
for patients with retinal nutrition-
neuropathy therapy-
physical-
activity.aspx.
 “Cardiovascular risk is lower and not equivalent in a younger individual with a brief
A. >35 years old Harrisons
Formal exercise duration of type 2 DM compared to an older individual with long standing type 2
B. > 5 yrs T2DM CH419 p2427
tolerance testing is DM...Because of the extremely high prevalence of underlying CVD in individuals
C. Microvascular Cardiovascul
14 not warranted in with diabetes (especially in type 2 DM), evidence of atherosclerotic vascular
complications in ar Morbidity
which of the disease (e.g. cardiac stress test) should be sought in an individual with diabetes
T2DM and Mortality
following individuals: who has symptoms suggestive of cardiac ischemia or peripheral or carotid arterial
D. Orthostatic dizziness paragraph 2
disease.”

A. Insulin
Most commonly
B. Glimepiride Metformin, if not contraindicated and if tolerated, is the preferred initial
15 used initial agent for UNITE
C. Metformin pharmacological agent for type 2 diabetes
type 2 DM
D. Acarbose

“(5) biguanides, α-glucosidase inhibitors, GLP-1 receptor

agonists, DPP-IV inhibitors, thiazolidinediones, and SLGT2 inhibitors
A. Biguanides
do not directly cause hypoglycemia” Harrison’s
Which of the follwing B. Sulfonylureas
- P. 2416 harrisons Principles of
antidiabetic drugs C. Alpha-glucosidase
16 “First-generation sulfonylureas (chlorpropamide, tolazamide, Internal
most commonly inhibitors
tolbutamide) have a longer half-life, a greater incidence of hypoglycemia,” Medicine,
cause hypoglycemia D. Dipeptidyl peptidase IV
- P. 2413 harrisons 19th ed
inhibitors
Same answer from previous ek ek

A. Glargine is an example
of short acting insulin
B. Usually the duration of
short acting insulin is
10-16 hrs
Which of the
C. Regular insulin has
following statements Harrison Ch
17 an onset of 30 min to
is true of short acting 418
1 hour and duration
insulin?
of 4-6 hrs
D. Some short acting
insulin has onset of
<25 min and peaks at
3-4 hrs
 A. The onset of action is
1-2h
B. It acts best as a single
agent
A. Onset is 2 to 4
C. It is best used in
Which of the ff is B. Usually paired with a short acting Harrison table
18 treating postprandial
true of basal insulin? C. Not for post prandial. Short acting is more appropriate 418.4
rise of blood sugar
D. Best answer. NPH is an example and peak is 4-10.
level
D. NPH is an example
and it peaks at 6-10 h

A. Just after a meal

Short-acting insulin B. >20 mins after a meal
Short-acting insulin is best injected within 15 minutes before a meal or just after a
19 analogue best C. >20 min before a meal ADA
meal
injected D. Depends on patient’s
preference

THE ADA
A. Insulin
recommends this
B. biguanides Although not as effective as lifestyle interventions, drug therapy with metformin and
20 medication for those ADA
C. GLPT-1 acarbose (Precose) has been shown to prevent the progression of IGT to diabetes
who have impaired
D. Sulfonylureas
glucose intolerance

A. Insulin Mechanisms of Action

Diabetes drug that B. a- glucosidase
acts to decrease inhibitors A. Increase glucose utilization, decrease hepatic glucose production harrisons
21
glucose production C. Sulfonylureas B. Decrease GI glucose absorption Table 418-5
in the liver D. Dipeptidyl peptidase C. Increase insulin secretion
inhibitors D. Prolong endogenous GLP-1 action

A. Less Expensive
B. Less adverse effect When glycemic targets are not achieved with one drug given at Unite for
What is the value of C. Patient is more the maximum effective dose (optimal dose or half maximum), diabetes
22
multiple treatment? compliant to tx another drug from another pharmacologic class should be added CPG, page
D. More pathological rather than increasing the first drug to its maximum dose 31
target

Which of the
A. Sulfonylureas A. Sulfonylureas - increase insulin secretion
following acts
B. DPP4 inhibitors B. DPP4 inhibitors - prolong endogenous GLP-1 action Harrisons, pg.
primarily by
23 C. Thiazolidinediones C. Thiazolidinediones - decrease insulin resistance, increase glucose 2214
increasing the
D. Alpha Glucosidase utilization Table 418-5
body’s sensitivity to
inhibitors D. Alpha glucosidase inhibitors
insulin?

24 Which of the A. Sulfonylureas Agent-specific advantages of GLP-1 receptor agonist Harrison’s

 following drugs is B. GLP-1 receptor 1. Weight loss table 418-5
associated with agonist 2. Do not cause hypoglycemia
weight loss? C. Thiazolidone
D. DPP IV

A. Long acting only

Ideal regimen for B. Short acting + regular Basal insulin requirements are provided by long-acting (NPH insulin, insulin
Harrisons
insulin - dependent C. Long acting + rapid- glargine, or insulin detemir) insulin formulations. These are usually prescribed
25 chapt 418.
diabetes acting with short-acting insulin in an attempt to mimic
Pp2411
D. Long acting + physiologic insulin release with meals.
intermediate

A. Aspart
Which of the
B. Regular Unite for
26 following insulin
C. Glulisine diabetes CPG
provides basal level?
D. Glargine

DM patient
A. Measuring the ankle
complains of
brachial index
numbness of lower
B. Checking for dorsalis
extremities and Unite for
27 pedis pulse B or C, but since neurologic ang complaint and not CV related so, C?
difficulty walking. diabetes CPG
C. Testing for vibratory
Which of the
sense
following is
D. Order electromyogram
appropriate?
 A. Mononeuropathy
Most common type
B. Autonomic neuropathy The most common form of diabetic neuropathy is DISTAL SYMMETRIC Harrisons
of neuropathy in
28 C. Proximal neuropathy POLYNEUROPATHY. Most freq presents with distal sensory loss and pin, up to ch419 p.
DM?
D. Symmetrical distal 50% of patients do not have symptoms of neuropathy 2426
neuropathy

A. High LDL
harrisons
Most common B. Low HDL The most common pattern of dyslipidemia is hypertriglyceridemia and reduced
29 chapt 419
dyslipidemia in DM? C. High triglycerides high-density lipoprotein (HDL) cholesterol levels.
pp.2428
D. High cholesterol

A. Serum creatinine The first step in the screening and diagnosis of diabetic nephropathy is to measure Medscape:
B. Creatinine clearance albumin in a spot urine sample, collected either as the first urine in the morning or Diabetic
What is the most (eGFR) at random, for example, at the medical visit. This method is accurate, easy to Nephropathy:
30 sensitive test for dm C. Dipstick test for perform, and recommended by American Diabetes Association guidelines.The Diagnosis,
nephropathy? proteinuria results of albumin measurements in spot collections may be expressed as urinary Prevention,
D. Microalbumin/crea albumin concentration (mg/l) or as urinary albumin-to-creatinine ratio (mg/g or and
ratio mg/mmol). Treatment

A. Hemorrhage is the “Establishing that strict glycemic control reduces the risk of macrovascular
hallmark of diabetic complications of diabetes has proved much more elusive than the beneficial effects
retinopathy on microvascular complications such as retinopathy and renal disease.”
Which of the B. Insulin resistance is
Harrison’s
31 following statements the pathologic process A. WRONG. The appearance of neovascularization in response to retinal
19th Ed
is true? of DM 1 hypoxemia (not hemorrhage) is the hallmark of proliferative diabetic
C. 25% of complications retinopathy
develop in type 2 DM B. WRONG. Should be type 2 DM
patients C. WRONG. Should be 50%. 50% (not 25% of T2DM are diagnosed with
 D. There is no proof or complications
evidence that
controlling glycemic
index can prevent
macrovascular
complications

The etiology of diabetes in an individual with new-onset disease can usually be

assigned on the basis of clinical criteria.

Individuals with type 1 DM tend to have the following characteristics:

(1) onset of disease prior to age 30 years

(2) lean body habitus
Patient has new A. Age (3) requirement of insulin as the initial therapy
onset of DM. Which B. Habitus (4) propensity to develop ketoacidosis Harrison’s
32 of the following most C. Ketoacidosis (5) an increased risk of other autoimmune disorders such as autoimmune thyroid 19th ed
likely point to type 1 D. Family history of disease, adrenal insufficiency, pernicious anemia, celiac disease, and vitiligo.
than type 2 DM? diabetes
Individuals with type 2 DM often exhibit the following features:

(1) develop diabetes after the age of 30 years

(2) are usually obese (80% are obese, but elderly individuals may be lean
(3) may not require insulin therapy initially
(4) may have associated conditions such as insulin resistance， hypertension,
cardiovascular disease, dyslipidemia, or PCOS.

A male patient with a 6 year history was brought to the
ER because of unresponsiveness. He was seen a
month ago because of slight pedal edema. An
antidiabetic was prescribed along with diuretics and
lab tests were requested. He took the meds for a
week, did not do the tests and was lost to follow-up.
Three days ago, he had a finger prick for glucose
during a free clinic and was told the result was high.
33
He took the meds leftover from the previous
prescription regularly for 3 days. He also decreased
his food intake and skipped evening meals to control
his blood sugar. He was unresponsive the next
morning.
This problem is likely the result of which of the
following?
A. Hypoglycemia
B. Accelerated atherosclerosis
C. Hyperosmolar state
D. Insufficient blood glucose control
Hypoglycemia
From the case:
-brought to the ER because of unresponsiveness
Harrisons
- took antidiabetic medications
Page 2420,
- decreased his food intake and skipped evening meals
2431
- unresponsive the next morning
*Neuroglycopenic manifestations of hypoglycemia are the direct result of CNS
glucose deprivation (behavioral changes, confusion, fatigue, seizure, loss of
consciousness and if severe, death)
*Hypoglycemia is most commonly caused by drugs used to treat DM or by
exposure to other drugs, including alcohol
*Conventional risk factor for hypoglycemia in diabetes:
→ influx of exogenous glucose is reduced (e.g., during an overnight fast or
 after missed meals or snacks)

Hyperosmolar state
*Prototypical patient with HHS is an elderly with type 2 DM, with a several week
history of polyuria, weight loss and diminished oral intake that culminates in mental
confusion, lethargy or coma.
*PE reflects profound dehydration and hyperosmolality and reveals hypotension,
tachycardia, and altered mental status.
*Often precipitated by serious, concurrent illnes such as MI or stroke, sepsis and
pneumonia

In SMBG, a small drop of blood and an easily detectable enzymatic reaction allow
A. Serum sodium
measurement of the capillary plasma glucose. Many glucose monitors can rapidly
What initial test will B. Plasma glucose
and accurately measure glucose (calibrated to provide plasma glucose value even
34 be most useful in the C. Spinal CT scan compi
though blood glucose is measured) in small amounts of blood (3–10 μL) obtained
above case? D. Capillary blood
from the fingertip; alternative testing sites (e.g., forearm) are less reliable,
glucose
especially when the blood glucose is changing rapidly (postprandially).

A. GDM
B. DM T1
A 38 year old pregnant woman, now on her 2nd C. DM T2
trimester was referred to you by her OB for D. Other Types of DM
management of her elevated blood glucose. She is a
known diabetic for 3 years, on metformin 500 mg TID Harrisons,
35 • Diabetes diagnosed at the initial prenatal visit should be classified as overt
prior to pregnancy with good glycemic control. Upon page 2400
diabetes rather than GDM.
learning that she is pregnant, she stopped her
• Overt diabetes can either be DM type 1, type 2 or other types. Since the
metformin but did not bother to visit any of her doctors
patient is taking Metformin, an oral hypoglycemic agent, probably she has
for glucose management. The patient has:
DM type 2.
• Glucose intolerance developing DURING pregnancy is classified as GDM.

A. Insulin
38 yo woman, 2nd tri, elevated bg. Diabetic 3yrs B. Metformin
metformin 500mg tid. Upon learning she was C. Acarbose
module 33 IM
36 pregnant, stopped metformin and did not visit any of D. Gliclazide
DM whis
her doctors. What is the ideal medication for her at this
time? The efficacy and safety of insulin have made it the standard for treatment of
diabetes during pregnancy

31 y.o with T1DM, A. Abdominal pain is

with Epigastric pain,
nausea and B. Hypotension results
37
vomiting. PE (+):
Labored breathing
with fruity odor.
DKA:
usually severe
Abdominal pain may be severe and can resemble acute pancreatitis or ruptured
viscus. Hypotension can occur because of volume depletion in combination with harrison’s
from volume depletion
peripheral vasodilatation. Kussmaul respirations and a fruity odor on the patient’s
and peripheral
breath (secondary to metabolic acidosis and increased acetone) are classic signs
vasoconstriction
 C. Labored breathing of the disorder. Cerebral edema, an extremely serious complication of DKA, is
Which of the ff. Is results from mixed seen most frequently in children.
true of the patient? acidosis
D. Cerebral edema is
a very common
manifestation in his
age

https://www.
medicinenet.c
om/hyperkale
One example of potassium shift causing hyperkalemia is diabetic ketoacidosis. mia/article.ht
Insulin is vital to patients with type 1 diabetes. Without insulin, patients with type 1 m
A. Increased renal diabetes can develop severely elevated blood glucose levels. Lack of insulin also
reabsorption causes the breakdown of fat cells, with the release of ketones into the blood,
Which of the ff
B. Decreased GI loss turning the blood acidic (hence the term ketoacidosis). The acidosis and high Also
38 increases serum
C. Extracellular shift of glucose levels in the blood work together to cause fluid and potassium to mentioned by
potassium level?
K+ move out of the cells into the blood circulation. Patients with diabetes often Doc Sevidal
D. Intracellular …. also have diminished kidney capacity to excrete potassium into urine. The and Doc
combination of potassium shift out of cells and diminished urine potassium Basang in
excretion causes hyperkalemia. their
respective
lectures in the
past

Algorithm
Management of this
For hyperglycemia and ketonemia/ketonuria. Hyperglycemi
patient include. A. Fluids 1-3L 0.45% NS
c crises in
Refer to case #37 for 2-3 h
A. Complete initial evaluation and start IV fluids 1.0 L of 0.9% NaCl per hour adult patients
B. Insulin drip and
B. Insulin:regular IV route 0.1 U/kg/bwt as bolus with diabetes
39 bolus 1.0 u/kg
C. If low bicarb check ph if <6.9 administer 100 mmol in 400 ml H20 +20 meq Kcl care vol 32
Kani ba, DKA ni C. Bicarbonate for low
infuse for 2 hrs number 7 july
siya. Kailangan ug bicarb
D. When serum glucose reaches 200 mg/dl (DKA) or 350 (HHS) change to 5% 2009
katong lab values D. D5NSS if 250-300
dextrose with .45%nacl at 150-250 ml/h
from the previous glucose
Harrison’s
numbers.
 Significance of Ketone Measurements
● b-hydroxybutyrate can only be measured using specialized equipment not
Source:
What is the most available in most in-house laboratories
A. Serum osmolality
reliable index in ● During recovery, results from the nitroprusside test might wrongly indicate
B. Urine ketones Doc Sevidal
40 measuring the that the ketone concentration is not improving or is even getting worse
C. Urine glucose and Doc
response to ● The best biochemical indicator of resolution of keto-acid excess is
D. Serum anion gap Basang’s
treatment? simply the anion gap
Lectures
● There is no rationale for follow-up ketone measurements after the initial
measurement has returned high

1. Screen dental infection

Mang Ben Aguilar 56 year old came in to ER due to 2. Cancer surveillance and screening
chest pain, firsr in onset. ECG tracing revealed 3. Recheck FBS after two weeks
anterolateral wall myocardial infarction. Metformin was 4. Check serum TSH
taken for weightloss and Imidapril for controlled
41 hypertension. Capillary blood glucose result is 156 Ratio: Patients with DM should be screened for dental infections. Patients with ADA
mg/dl. diabetes should be encouraged to undergo recommended age- and sex-
appropriate cancer screenings and to reduce their modifiable cancer risk factors
As part of the comprehensive diabetic management (obesity, smoking, and physical inactivity). Among ASYMPTOMATIC individuals
and care plan, he is entitled to the following? with positive results, any of the three tests should be REPEATED within two weeks
for confirmation.
 D. 4 only. HBA1c goal of 8% without hypoglycemia
1. 1st gen sulfonylureas over
metformin despite side
Mang Ben, Less stringent A1C goals (such as ,8%) may be appropriate for patients with a
effect
follow up history of severe hypoglycemia, limited life expectancy, advanced microvascular or
2. Weight bearing exercise to
42 FBS 132, OGTT macrovascular
lower BG
210 complications, extensive comorbid conditions, or long-standing
3. Delay exercise if BG >180
diabetes in whom the general goal is difficult to attain despite diabetes self-
or <100 mg/dL
management education, appropriate glucose monitoring, and effective doses of
4. HbA1c goal of 8%
multiple glucose-lowering agents including insulin

1. Since his capillary blood

sugar is <200, oral anti
diabetic agents may be
initiated, ideally
metformin
What is the most 2. If he can afford, 1. CORRECT. Oral antidiabetic agent should be initiated starting at a
practical antidiabetic medications threshold of no greater than 180 mg/dL
approach in that less precipitate heart 2. INCORECT. In patients with symptomatic heart failure, thiazolidinamide
deciding the failure may be taken such treatment should not be used.
DM
43 medications as thiazolidiname 3. CORRECT. The earlier the insulins may be initiated, the more beta cells
Compliation
used to treat 3. Regular insulin may be may be preserved.
Mang Ben started immediately to 4. INCORRECT. Improve glycemic control reduces microvascular
Aguilar? preserve beta cell complications of diabetes even if it does not improve macrovascular
function complications.
4. Diabetic retinopathy should
be excluded as
improvement in glycemic
control may worsen
retinopathies initially

(1-2) AACE &

1. Foot exam to assess blood ADA.
flow, sensation to be Standards of
conducted every 2 years 1. INCORRECT. Perform a comprehensive foot evaluation at least annually to Medical Cate
Outpatient 2. Management of diabetic identify risk factors for ulces and amputations. in Diabetes -
follow-up with neuropathy is a 2. CORRECT. Diabetic neuropathy is a diagnosis of exlusion. Nondiabetic 2017.
Mang Ben diagnosis of exclusion neuropathies may be present in patients with diabetes and may be Microvascular
should include 3. microalbuminuria test treatable. complications
44
the following: should be conducted every 3. INCORRECT. An annual microalbuminurua measurement us advised and footcare.
6 months after the time of individuals with T1 or T2DM. Screening should commence at the yome of pp S93, S95
first diagnosis for T2DM diagnosis of T2DM. (3-
4. Once there is diabetic 4. CORRECT. Individuals with diabetic nepheopathy commonly have diabetic 4)Harrison’s.
nephropathy, patient retinopathy. Chap 419,
most likely also has DM:
retinopathy Compliacatio
ns. pp 2424-5
 1. Statins should be started
Optimal care of
regardless of Mang Ben's Diabetes
all
LDL cholesterol levels Care:
cardiovascular
2. Beta blockers are given A. Wrong. Statin use should only be considered when triglyceride level is Standards of
risk factors is
even if it may increase >204mg/dl and HDL level of <34 mg/dl. Medical Care
the key to
glycemic levels B. Correct. In patients with prior myocardial infarction, b-blockers should be in Diabetes-
manage him
3. Screening for dyslipidemia continued for at least 2 years after the event. 2017
45 best. What is
and hypertension should C. Wrong. Blood pressure should be measured at each routine visit. Diabetes
your realistic
be done annually D. Correct. Most patients with diabetes and hypertension should be treated Care:
goals to help
4. Target blood pressure of to a systolic blood pressure goal of <140 mmHg and a diastolic blood Standards of
curtail another
140/90mmHG using pressure goal of <90 mmHg. Medical Care
cardiac even
ARBS or ACE inhibitors in Diabetes-
from occuring?
as first line anti- 2017
hypertensive agents

Less stringent Hba1c goals (such as 8%) may be appopriate for patients with
Which of the
1. Extensive comorbidities severe hypoglycemia, limited life expectancy, advanced microvascular or
following allows
2. Long life expectancy macrovascular complications, extensive comorbid conditions or long
46 less stringent WBL
3. Long Standing DM standing DM, to whom the general goal is difficult to attain despite diabetes self
Hba1c
4. No CVD risk management education, appopriate glucose monitoring, and effective doses of
monitoring?
multiple glucose lowering agents including insulin.

Ominous Octet organs:

Pancreas = decreased insulin and amylin, increased glucagon secretion
Which of the 1. Lungs
Intestines = Incretin effect
following organs 2. Brain
Kidneys = increase glucose reabsorption
47 is/are involved in 3. Heart Ref: wbl
Muscles = decreased glucose uptake
the ominous 4. Liver
Brain = transmitter dysfunction
octet?
Liver = Increased glucose production
Adipocytes = increased lypolysis

1. Volume depletion
2. Excess of
counterregulatory
Kussmaul breathing is a deep and labored breathing pattern often associated with
hormones increase
These features severe metabolic acidosis, particularly diabetic ketoacidosis (DKA).
lipolysis
48 distinguish DKA
3. Precipitated by
from HHS: DKA results from relative or absolute insulin deficiency combined with
infectionand insulin
counterregulatory hormone excess, both are necessary for DKA to develop
deficiency
4. Nausea, vomiting,
Kussmaul respiration

What are the 1. DKA

49 diabetic 2. Hypoglycemic Coma Source: Doc
Asked from Doc Bacot . :-(
emergency 3. HHS Bacot
conditions? 4. Septic Shock
 The following
Reference:
drugs affect 1. Alpha antagonist Drug- or chemical-induced—glucocorticoids, vacor (a rodenticide), pentamidine,
Harrisons,
glycemic level 2. Nicotinis acid nicotinic acid, diazoxide, β-adrenergic agonists, thiazides, calcineurin and mTOR
50 19th ed,
by antagonizing 3. Glucocorticoids inhibitors, hydantoins, asparaginase, α-interferon, protease inhibitors,
Table 417-1,
or intefering with 4. Antifungal agents antipsychotics (atypicals and others), epinephrine
page 2399
insulin function: