Subject: INTERNAL MEDICINE

Date: 01/14/2019

Internal Medicine Quiz 4: Diabetes

Questions Rationale

1. Type of maturity onset diabetes of the young Glucokinase catalyzes the formation of
caused by mutations in the enzyme responsible glucose-6-phosphate from glucose… (p. 2406, Harrison’s
for the formation of glucose-6-phosphate from Principle of Internal Medicine, 19th ed.)
glucose
A. MODY 1
B. MODY 2
C. MODY 3
D. MODY 4

2. Pacamalan, Pacatan Philippine Prevalence: ​5.4%

The Philippine NHAES 2013 statistics for prevalence of Male: 5.6%
prediabetes in the country is __% Female: 5.3%
Northern Mindanao: 3.5%
Source:
3. Which of the following is included in the ADA
guidelines when screening for patients with DM ?
A. Patients with IFG or IGT should be tested ​every 3
years
B. Women diagnosed with GDM should have lifelong
testing every 3 years
C. All individuals at age ​35​ years and above
D. If normal, testing should be repeated at a minimum of
5​-year interval
4. Features of DM type 1 are asymptomatic until what
percentage of beta cell destruction?
A. 50%
B. 70%
C. 90%
D. 100%
5. What is the main mechanism why Fasting Plasma
Glucose is increased in patients with DM?
A. Compensatory hyperinsulinemia
B. Impaired insulin secretion
C. Increased hepatic glucose production
D. Decreased peripheral glucose usage
Who should be screened ?
Testing for diabetes
1. All individuals at age ​45 years​ and above.
2. All adults who are overweight or obese (​BMI >25
kg/m2) ​(>23 kg/m2​ for Asians) + one or more
additional risk factor).
○ 1st degree relative​ with diabetes
○ High risk race​ or ethnicity
○ History of CVD
○ Hypertension (​>140/90​ mmHg)
○ HDL​ <35 mg/dL​ and/or TG​ >250 mg/dL
○ Polycystic ovarian syndrome
○ Physically inactivity
○ Clinical conditions associated with insulin
resistance ​(acanthosis nigricans, severe
obesity)
3. Patients with prediabetes should be tested ​yearly​.
4. Women diagnosed with GDM should have
lifelong testing every 3 years.
5. If ​normal​, testing should be repeated at a
minimum of ​3-year intervals.
6. Consideration of more frequent testing depending
on initial results and risk status.
Source: Powerpoint of Dr. Zaynab Abejuela
70% answer ani. Page 2403 upper right paragraph.
Please nalang ko screencap huhu
In case…​”beta cell mass is decreased by approx 50% in
individuals with long standing TYPE 2 DM…”
Source: Harrison’s 19th ed, Ch. 417, p. 2403
Same ang choices sa 5 ug 6?
Ang no. 6 nagcopy. Prevalence ang question sa 6.
Source: HAHAHAHAHAHA. . hoyyy #6 ​HONEST MISTAKE. MALI
AKONG NAMEMORIZE. LET ME CORRECT IT.hahaha
Ratio:
In the early stages of the disorder, glucose tolerance remains
near-normal, despite insulin resistance, because the
pancreatic beta cells compensate by increasing insulin output.
As insulin resistance and compensatory hyperinsulinemia
progress, the pancreatic islets in certain individuals are
unable to sustain the hyperinsulinemic state. IGT,
characterized by elevations in postprandial glucose, then
develops. A further decline in insulin secretion and an
increase in hepatic glucose production lead to overt diabetes
 with fasting hyperglycemia. Ultimately, beta cell failure
ensues.

Increased hepatic glucose output predominantly

accounts for increased FPG levels​, whereas decreased
peripheral glucose usage results in postprandial
hyperglycemia. (Harrison’s 19th ed p. 2404)

6. According to the 2013 National Nutrition and Health The ​Philippines​ National Health and Nutrition ​Survey
Survey, the Philippine prevalence of DM2 is (NNHeS) of ​2013​, has provided the latest health and
A. 5.4% disease score with ​prevalence rates​ of the major risk
B. 7.2% factors among adults ≥20 years of age: ​diabetes​ (5.4%),
C. 8.1% hypertension (22.3%), dyslipidemia, low HDL (71.3%),
D. 10.2% obesity​, BMI >25 kg/m​2​(31.1%), and smoking (25.4%).

Source: ​Philippines National Health and Nutrition Survey

(NNHeS) of 2013 (Google)

7. Which of the following acts primarily by decreasing

renal reabsorption of glucose?
A. Biguanides
B. Sulfonylureas
C. Thiazolidinediones
D​. ​SGLT2 inhibitors

Source: Diagnosis and Pharmacologic Management of Diabetes in the

Outpatient Clinic
Dr. Zaynab R. Abejuela
8. Which of the following provides prandial insulin
coverage?
A. NPH
B. Aspart
C. Glulisine
D. Glargine

It could be either Aspart or glulisine.

“Thus, insulin aspart, lispro, or glulisine is preferred over
regular insulin for prandial coverage”
Source: Harrison’s 19th, Ch. 418, p. 2411

9. Which of the ff has the side effects of weight gain,

edema, and heart failure?
A. sulfonylureas
B. meglitinides Source:
C. thiazolidinediones
D. insulin

10. Most important component in weight reduction for

patients with metabolic syndrome.
A. Increase physical activity
B. Caloric restriction
C. Behavior modification
D. Moderate reduction in dietary cholesterol
Source:

11. Dx with T2DM, criteria of FBS for dx:

A. ≥100 mg/dl
B. ≥126 mg/dl
C. ≥140 mg/dl Source:
D. ≥200 mg/dl
12. Case for 11-15:
The ADA recommended management for this patient's
dyslipidemia is
A. No intervention
B lifestyle modification only
C. Lifestyle + moderate intensity statin
D. ​Lifestyle + high intensity statin

*patient has ASCVD risk factors

Source:

13. Watanabe, Lumacang Source:

14.What is the primary goal of the patient's diabetes? Who’s the patient?
A. FBS <100
B. HbA1C<7 Ans: Prevent and delay complication
C. Postprandial glucose <180 ***emphasized by doc abejuela and naa sad sa reference
D. Prevent and delay complication
Source:

15. In the case of the patient above, without the other <40 since the patient is male
parameters, he would still be considered to have Male = <40
metabolic syndrome if his HDL is: Female <50
A. <40
B. >40
C. <50 Source:
D. >50

16. Most common type of Neuropathy in DM.

A. Autonomic Neuropathy
B. Mononeuropathy
C. Proximal neuropathy
D. Symmetric Polyneuropathy
Source:

17. ​True​ of screening and treatment of Diabetic
Nephropathy
A. Blood pressure should be ​< 120/80
B. Protein intake ​should be restricted​ in diabetic patients
with nephropathy
C. GFR should be estimated using serum creatinine
in all patients annually
D. Screening for nephropathy should ​commence 5 years
A. BP should be maintained at <140/90 mmHg.
B. ADA does not suggest restriction of protein intake
because studies have failed to show benefit.
C. Because some individuals with DM Type1 or
type2 have a decline in GFR in the absence of
albuminuria, ​annual​ measurement of serum
creatinine to estimate GFR should be
performed.
D. at the time of diagnosis for Type 2 DM
after the diagnosis​ of Type 2 DM Source:

18. Stage of retinopathy that has severe type Severe vision loss is primarily the result of progressive
a. Maculopathy diabetic retinopathy and clinically significant macular
b. Proliferative edema.
c. Background
d. Nonproliferative Source: Harrison 19th ed page 2424

19. FDA approved drug for pain associated with diabetic Two agents ​duloxetine​ and​ pregabalin​ have been
neuropathy? approved by FDA for pain associated with diabetic
A. celecoxib neuropathy.
b. ​duloxetine
c. gabapentin Source: Harrison’s 19th ed, Ch. 418, p. 2427
D. meperidine

20. ​What is the most common pattern of dyslipidemia in
DM?
A. Increases LDL, decreased HDL
B. Increased triglyceride, decreased HDL
C. Increased triglyceride, increased HDL
D. Increased triglyceride, increased LDL, decreased HDL
“The most common pattern of dyslipidemia is
hypertriglyceridemia and reduced high-density lipoprotein
(HDL) cholesterol levels”
Source: Harrison’s 19th ed, Ch. 418, p. 2428

21. Which of the ff is the optimal Tx for diabetic

nephropathy?
Ans: ​Control of glycemia
Source: harrisons 19th p2425

22. ​True​ of screening for diabetic neuropathy:

A. T2DM​ should be tested within 5 yrs after onset
B. All pts should undergo 10g monofilament testing
every 6 months
C. ABI testing should be performed if there are
signs of PAD
D. The ​tuning fork test​ is used for temperature and
pin prick sensation of the extremities

23 What is the most effective therapy for diabetic
retinopathy?
A. Intensive glycemic control
B. Intensive BP control
C. Laser Photocoagulation
D. Prevention
24. Biological effect of activating advanced glycation end
products which contribute to the development of
complications in diabetes?
A. Increase anticoagulant activity
B. Decrease endothelial permeability
C. Increase protein breakdown
D. ​Increase ECM formation by fibroblast
25. Which of the following statements is true regarding
hypertension and diabetes?
A. They are more common in T1DM than in T2DM
B. Association is greater when microalbuminuria
is detected
C. Blood pressure treatment reduces risk of
developing macrovascular complications
D. Beta blockers are first line treatment
26. With regard to ​microalbuminuria​, which of the
following statements is true?
A. Conventional urine dipsticks are reliable in
diagnosing microalbuminuria
B. Once microalbuminuria develops, the pathologic
changes are irreversible
C. Microalbuminuria can remit to
normoalbuminuria without specific
interventions
D. Screening for microalbuminuria commences after
10 years of onset of T1DM
Source:
Treatment: Diabetic Retinopathy
“​The most effective therapy for diabetic retinopathy is
prevention​. ​Intensive glycemic and blood pressure
control will delay development or slow the progression of
retinopathy in individuals with either type 1 or type 2 DM.”
Source: Harrison’s 19th Ed. Chapter 419 Diabetic Mellitus:
Complications p.774
Source:
Ans: B
Ratio
A - false. More common in T2DM
C - false. Was it micro ba? :< i forgot
D - false. ACEI are the 1st line meds
Source:
Although the appearance of microalbuminuria in type 1
DM is an important risk factor for progression to
macroalbuminuria, only ~50% of individuals progress to
macroalbuminuria over the next 10 years.
In some individuals with type 1 diabetes and
microalbuminuria of short duration, the
microalbuminuria regresses.
Source: Harrison's Principles of Internal Medicine, 19E p.2425
27. Recommended first line of treatment for T2DM +
HPN + UACR >300
A. B-Blockers
B. Diuretics
C. ACEi
D. CCB

Source:

28. What is the blood pressure goal of a patient with

hypertension and DM?
a. Less than 120/80
b. Less than 130/80
c. Less than 140/90
d. Less than 150/90

Source:

29. In a patient with established DM, which medication is “The combination of an ACE inhibitor and an ARB is not
never taken together with ACE inhibitor? recommended and appears to be detrimental”
a. ARB
b. CCB
c. Thiazide Source: Harrison’s 19th ed, Ch. 418, p. 2426
d. inositol

30. Which of the following is used as a high-intensity

statin therapy?
a. Simvastatin
b. Pravastatin
c. Atorvastatin
d. Lovastatin
Source:

31. What level of LDL is considered a risk factor for

ASCVD?
A. 70 mg/dl
B. 80 Source:
C. 90
D. 100

32. What is the initial BP for dual therapy in hypertensive Ratio:

diabetic patients (nonverbatim)? Patients with confirmed office-based blood pressure ​≥ 160/100
A. 140/90 mmHg should, in addition to lifestyle therapy, have prompt
initiation and timely titration of two drugs or a single-pill
B. 150/90
combination of drugs ​demonstrated to reduce cardiovascular
 C. 160/90 events in patients with diabetes.
D. 170/90
(Also, refer to ​figure 9.1 in 2018 ADA Standards of Medical
Care in Diabetes)

Source: Ch 9 ​2018 ADA Standards of Medical Care in Diabetes

pp. S89-S90

33. Which of the following doses of rosuvastatin is used

as high intensity therapy for DM patients with ASCVD?
A. 5mg/dL
B. 10mg/dL
C. 15mg/dL
D. 20mg/dL

Source: Thank you, next.

34. Target HDL in females with diabetes according to Ans: 50mg/dL - FEMALES
ADA? greater than? 40mg/dL - males

A. 30 mg/dl Source:
B. 40 mg/dl
C. 50mg/dl
D. 60 mg/dl

35. Which of the following is recommended by ADA in Recommendations:

managing dyslipidemia in diabetic patients? ● Lifestyle modification focusing on weight loss (inf
A. Use ​of trans fat indicated);
B. Reduction of saturated fat ● Reduction​ of saturated fat, trans fat, and
C. Avoid ​dietary n-3 fatty acids cholesterol intake
D. Use of ​moderate ​intensity statins with ● Increase​ of dietary n-3 fatty acids, viscous fiber,
atherosclerotic cardiovascular disease in all ages and plant stanols/sterols intake;
● Increase​ physical activity should be recommended
to improve lipid profile in patients with diabetes
D: Should be ​high​-intensity
Source:

36. ADA recommended Medical Nutrition Therapy

(MNT):
Ans: ​Fat quality appears to be far more important Source:
than quantity
37. According to the latest ADA recommendations, less
stringent A1C goals is advised to patients who have
______.
A. Extensive co-morbid conditions
B. Long life expectancy
C. Newly diagnosed diabetes
D. No risk for cardiovascular disease

Source: Standards of Medical Care in Diabetes 2018. Diabetes Care

2018 Jan; 41 (Supplement 1) S60

38. In prescribing individualized physical activity, ADA C. CORRECT /delay exercise if blood glucose is >14
recommends: mmol/L and ketones are present
A. To increase insulin uptake ​before ​exercise
B. To ingest added carbohydrates if pre-exercise
blood glucose is ​<250mg/dL
C. To avoid vigorous exercise if ketones are
present
D. Resistance exercise for patients with ​retinal
neuropathy

Source:
39. What is the initial therapy used in treating patients
with type 2 DM?
A. Insulin
B. Glimepiride
C. Metformin
D. Acarbose

Source:

40. Which of the following antidiabetic drugs most

commonly cause ​hypoglycemia​:
A.Biguanides
B. ​Sulfonylureas
C. Alpha-glucosidase inhibitors Source:
D. Dipeptidyl peptidase IV inhibitors (​neutral sa all)

41. Which of the following will provide basal insulin

coverage?
a. Regular
b. Aspart
c. Glulisine
d. Glargine

“Basal insulin requirements are provided by long-acting

(NPH insulin, insulin glargine, or insulin detemir) insulin
formations.”
Source: Harrison’s 19th ed, Ch. 418, p. 2411

42. Which of the ff diabetic medications would be “Agents associated with weight loss include metformin,
favorable for patient in terms of weight loss? alpha-glucosidase inhibitors, GLP-1 agonists​, and
A. Sulfonylureas amylin mimetics. Dipeptidyl peptidase 4 inhibitors appear
B. GLP-1 agonists to be weight neutral. Unlike these agents, insulin
C. Alpha glucosidase inhibitors secretagogues, thiazolidinediones, and insulin have often
D. Thiazolidinedione been associated with weight gain.”

Source: ADA 2018, S67

43. What is the significance of waist circumference as a
risk factor of metabolic syndrome?
A. Directly relates to BMI
B. Indirectly measures visceral adiposity
C. Directly measures insulin resistance
D. Indirectly measures subcutaneous fat
44. The most accepted hypothesis of metabolic
syndrome?
A. Genetic defect in fat metabolism
B. Dysregulation in adrenal function
C. Insulin resistance
D. Dysfunction in glucose metabolism
45. Best management for Metabolic Syndrome?
a. Metformin
b. Weight loss
c. Blood pressure control
d. Reduction of cholesterol
46. Mang Ben Aguilar 56 year old came in to ER due to
chest pain, first in onset. ECG tracing revealed
anterolateral wall myocardial infarction. Metformin was
taken for weight loss and Imidapril for controlled
hypertension. Capillary blood glucose result is 156 mg/dl.
As part of the comprehensive diabetic management and
care plan, he is entitled to the following?
1.​ ​Screen dental infection
2.​ ​Cancer surveillance and screening
3.​ ​Recheck FBS after two weeks
D. Check serum TSH
Ans: A. 1,2,& 3
47. Mang Ben, follow up FBS 132, OGTT 210
1. 1st gen sulfonylureas over metformin despite side effect
2. Weight bearing exercise to lower BG
3. Delay exercise if BG >180 or <100 mg/dL
4. HbA1c goal of 8%
Answer: D. 4 only
48. What is the most practical approach in deciding the
medications used to treat Mang Ben?
1.​ ​Since his capillary blood sugar is <200, oral anti
diabetic agents may be initiated, ideally metformin
2.​ ​If he can afford, antidiabetic medications that less
precipitate heart failure may be taken such as
thiazolidiname
3.​ ​Regular insulin may be started immediately to
“Central adiposity is a key feature of the syndrome, and
the syndrome’s prevalence reflects the strong relationship
between waist circumference and increasing adiposity.”
“Measurement of the waist circumference is a surrogate
for visceral adipose tissue and should be performed in the
horizontal plane above the iliac crest.”
Source: Harrison’s 19th ed Ch. 422, p. 2449 and Ch. 416, p. 2392
Insulin Resistance
The most accepted and unifying hypothesis to describe
the pathophysiology of the metabolic syndrome is insulin
resistance
Source: Harrison’s
Source: Harison’s 19th ed
Ratio: Patients with DM should be ​screened for dental
infections​. Patients with diabetes should be encouraged to
undergo recommended age- and ​sex-appropriate cancer
screening​s and to reduce their modifiable cancer risk factors
(obesity, smoking, and physical inactivity).
Among ASYMPTOMATIC individuals with positive results, any
of the three tests should be​ REPEATED within two week​s for
confirmation.
Source: ADA
Source:
Source:
1. CORRECT. Oral antidiabetic agent should be initiated
starting at a threshold of no greater than 180 mg/dL
2. INCORECT. In patients with symptomatic heart failure,
thiazolidinamide treatment should not be used.
3. CORRECT. The earlier the insulins may be initiated, the
more beta cells may be preserved.
4. INCORRECT. Improve glycemic control reduces
 preserve beta cell function
4. Diabetic retinopathy should be excluded as improvement in
glycemic control may worsen retinopathies initially
Ans: ​B. 1 & 3
49. Outpatient follow-up with Mang Ben should include
the following:
1. Foot exam to assess blood flow, sensation to be
conducted every 2 years
2. Management of diabetic neuropathy is a diagnosis
of exclusion
3. Microalbuminuria test should be conducted every 6
months after the time of first diagnosis for DM Type 2
4. Once there is diabetic nephropathy, patient most
likely also has retinopathy
Answer: C. 2 & 4
50. ​Optimal care of all cardiovascular risk factors is the key to
manage him best. What is your realistic goals to help curtail
another cardiac event from occuring?
1. Statins should be started regardless of Mang Ben's
LDL cholesterol levels
2. ​Beta blockers are given even if it may increase
glycemic levels
3. Screening for dyslipidemia and hypertension should
be done annually
4. Target blood pressure of 140/90mmHG using
ARBS or ACE inhibitors as first line
anti-hypertensive agents
Answer: B 2& 4
microvascular complications of diabetes even if it does not
improve macrovascular complications.
1. WRONG. Comprehensive foot evaluation is done at
least ​ANNUALLY​ not every 2 years
2. CORRECT. Verbatim siya sa ADA na book under
Neuropathy
3. WRONG. At least ​ONCE A YEAR​, assess urinary
albumin and estimated GFR in patients with T1DM with
duration of >5 years, in all patients with T2DM, and in all
patients with comorbid hypertension.
4. CORRECT.
Source: ADA 2018
1. Wrong. Statin use should only be considered when
triglyceride level is >204mg/dl and HDL level of <34
mg/dl.
2. Correct. In patients with prior myocardial infarction,
b-blockers should be continued for at least 2 years after
the event.
3. Wrong. Blood pressure should be measured at each
routine visit.
4. Correct. Most patients with diabetes and hypertension
should be treated to a systolic blood pressure goal of
<140 mmHg and a diastolic blood pressure goal of <90
mmHg.
Source: