Pyetje-Davidson’s Erëblin Lahu

Diabeti dhe komplikimet l 2021 tiple

Choice Questions
20.1. A 110-kg 57 year old man presents with
1-month history of lethargy, urinary frequency
and increased thirst. He has been dieting for
years but only recently has managed to lose
10 kg with little effort. What would be the
simplest test that could make the diagnosis?
A. Autoantibodies to glutamic acid
decarboxylase (GAD), protein tyrosine
phosphatase islet antigen-2 (IA-2) and zinc
transporter 8 (ZnT8)
B. Capillary blood glucose
C. Fasting venous blood glucose
D. Oral glucose tolerance test (OGTT)
E. Random venous blood glucose

20.2. A 49 year old black woman with a body

mass index (BMI) of 42 kg/m2 presents with a
6-month history of fatigue and lethargy. Over
the past few days she has become increasingly
thirsty, is getting up at night to pass urine and
has experienced some dysuria. On admission,
blood glucose was measured at 40 mmoi/L
(720 mg/dl) with ketones of 4 mmoi/L and
bicarbonate 12 mmoi/L. She is treated for
diabetic ketoacidosis (DKA), but what is the
most likely underlying diagnosis?
A. Impaired glucose tolerance
B. Latent autoimmune diabetes of adulthood
(LADA)
C. Metabolic syndrome
D. Type 1 diabetes mellitus
E. Type 2 diabetes mellitus

20.3. The most common monogenic forms of

diabetes are caused by defects in insulin
secretion. Maturity-onset diabetes of the young
(MODY) commonly develops under the age of
25 and is dominantly inherited. One form of
MODY is due to mutation in glucokinase. How
should these patients be managed?
A. Basal insulin
B. Biguanide (metformin) alone
C. Diet alone
D. No treatment required
E. Sulphonylurea with meals

20.4. The diabetes team were asked to review

a hyperglycaemic 37 year old man on the
surgical ward who presented with abdomir:ml
pain, general lethargy, weight loss and pal~
loose bowel motions. He has been in hodpital a
number of times with upper abdominal pain
with a normal abdominal ultrasound scan. He
has a family history of type 2 diabetes mellitus.
He recently lost his job as a taxi driver as there
was concern after he came to work smelling
strongly of alcohol and was found to be above
the legal limit to drive. Mean corpuscular
volume (MCV) was raised on blood tests from
3 years ago. On admission he had a blood
glucose of 20 rnmoi/L (360 mg/dl) with
ketones of 3 mrnoi/L .and bicarbonate
20 mmoi/L. What is the most likely
diagnosis?
A. Impaired glucose tolerance
B.LADA
C. Monogenic diabete$
D. Pancreatic insuffi9iency
E. Type 2 diabetes mellitus

20.5. DKA is a medical emergency in people

with type 1 diabetes. What is the most
common mechanism of death in DKA in
children and adolescents?
A. Acute respiratory distress syndrome
B. Cerebral oedema
c. Hypokalaemia
D. Pneumonia
E. Septic shock

20.6. A 57 year old woman with a 5-year history

of diet-controlled diabetes is struggling to make
any further changes to her lifestyle. Her HbA1c
is above target. What would be the best
first-line pharmacological therapy?
A. Biguanide (e.g. metformin)
B. Dipeptidyl peptidase-4 (DPP-4) inhibitor (e.g.
sitagliptin)
C. Insulin
D. Sodium and glucose co-transporter 2
(SGLT2) inhibitor (e.g. empagliflozin)
E. Sulphonylurea (e.g. gliclazide)

20.7. A 47 year old man with type 2 diabetes

has been treated with a biguanide (metformin)
and a sulphonylurea (gliclazide) for a number of
years. Unfortunately his glycaemic control has
deteriorated and his doctor is considering
adding in a thiazolidinedione (pioglitazone).
What is its mechanism of action?
A. Activation of peroxisome
proliferator-activated receptor y (PPARy) in
adipocytes
B. Delays carbohydrate absorption
C. Prevents breakdown of incretin hormones
D. Promotion of ~-cell insulin secretion
E. Sensitises tissues to insulin

20.8. A 58 year old obese woman with an

8-year history of type 2 diabetes and an HbA1c
80 mmol/mol (9.5%) attends the diabetes clinic.
She is recommended to start a glucagon-like
peptide-1 (GLP-1) agonist. What are the
possible side effects?
A. Bladder cancer
B. Genital fungal infections
C. Hypoglycaemia
D. Pancreatitis
E. Weight gain

20.9. A 24 year woman with type 1 diabetes is

attending the antenatal clinic. She is 16 weeks
pregnant and is concerned. that her baby is
big for gestation. What is the most likely
mechanism for this?
A. Fetal hypoinsulinaemia
B. Genetic factors
C. Hypertension
D. Maternal hyperglycaemia
E. Pregnancy-induced hyperphagia
20.1 0. A 38 year old man with poorly controlled
type 1 diabetes suddenly develops double
vision. On examination he is unable to abduct
his left eye. He undergoes an urgent CT scan
of his brain, which is normal. What is the most
likely diagnosis?
A. Brain tumour
B. Diabetic mononeuropathy
C. Giant cell arteritis
D. Graves' eye disease
E. Stroke

20.11. A 21 year old student attends her family

physician feeling generally unwell with a 3-day
history of vomiting. She has been trying to lose
weight and has been on a low-fat diet and
started to exercise daily. She felt unwell with
diarrhoea and vomiting for 3 days following a
seafood meal. The family physician checked a
blood glucose level, which was 5.2 mmoi/L
(94 mg/dl) and urine dipstick showed glucose
trace and ketones 3+.
What is the most likely cause of ketonuria?
A. Diabetic ketoacidosis
B. Fasting
C. High-carbohydrate diet
D. Repeated vomiting
E. Strenuous exercise

20.12. A 52 year old English lorry driver with

type 1 diabetes returns to clinic for his annual
review. HbA1c is stable at 62 mmol!mol (7.8%)
and he reports no hypoglycaemic episodes. He
is well aware of the need to check his glucose
prior to driving and does so; however, he does
not keep a record of them. Which of the
following is legally required in the UK for people
prescribed insulin to enable them to drive a
heavy goods vehicle?
A. Annual driving test
B. Annual review with 3 months' glucose meter
readings
C. Biannual diabetes review
D. Continuous glucose monitoring
E. Retinal screening
20.13. A 56 year old woman has type 2 diabetes.
She also has non-alcohotic fatty liver disease
(NAFLD), arthritis, coeliac disease, mild visual
impairment and chronic obstructive pulmonary
disease (COPD). She smokes up to 20 cigarettes
a day. Which of the following conditions has a
pathophysiological link and is more common in
individuals with type 2 diabetes?
A. Coeliac disease
B. COPD
C. NAFLD
D. Optic atrophy
E. Rheumatoid arthritis

20.14. A 67 year old female has had type 1

diabetes for 50 years. She has an HbA1c of
42 mmol/mol (6%) and is very strict about her
diet. She was admitted for an elective total hip
replacement. On the day of surgery, she was
found by the junior doctor to be very drowsy
with a capillary blood glucose of 2.2 mmoi/L
(40 mg/dl). What should ideally happen next?
A. Cancel theatre
B. Intravenous (IV) access and 1 00 ml of 20%
dextrose and repeat blood glucose in 15
minutes
C. IV access and 1 00 ml of 50% dextrose
D. IV access and 200 ml of 20% dextrose
E. Withhold insulin for rest of day

20.15. A woman at 20 weeks' gestation

undergoes a 75-g oral glucose tolerance test
with the following results: 0 minutes =
5.6 mmoi/L (1 01 mg/dl); 120 minutes =
9.2 mmoi/L (166 mg/dl). According to the
National Institute for Clinical Excellence (NICE)
guidelines, what should be the immediate
management?
A. Dietary modification
B. GLP-1 receptor agonist
C. Insulin
D. Metformin
E. Sulphonylurea, e.g. glibenclamide
20.16. A frail 93 year old man with type 1
diabetes for 46 years attends for review. His
HbA1c is 69 mmol/mol (8.5%). Blood pressure
is 152/82 mmHg for which he is taking an
angiotensin-converting enzyme (ACE) inhibitor
(ramipril) and a calcium channel blocker
(amlodipine). He has mild background diabetic
retinopathy. Which of these treatment targets is
most appropriate in this scenario?
A. Avoidance of hypoglycaemia
B. HbA1c of 48 mmol/mol (6.5%) or less
C. HbA1c of 58 mmol/mol (7.5%) or less
D. Microvascular disease prevention
E. No need to monitor blood glucose in view of
his age

20.11. A 32 year old woman attends the

antenatal clinic for her booking scan. She is 12
weeks pregnant with twins and has been
struggling with 'morning sickness'. She has a
BMI of 36 kg/m2 and undergoes an OGTI, the
results of which are: fasting plasma glucose
4.8 mmoi/L (86 mg/dl); 2-hour plasma glucose
7.0 mmoi/L (126 mg/dl).
As part of her routine checks the midwife
dips her urine and she has 2+ ketones. What is
the most likely diagnosis?
A. Diabetic ketoacidosis
B. Gestational diabetes
C. Hyperemesis gravidarum
D. Normal physiological response in pregnancy
E. Undiagnosed type 2 diabetes

20.18. A 51 year old man with type 1 diabetes

returns to the foot clinic. He attends for regular
review as he has an ulcer on his left heel. He
has been on a walking holiday to the Amalfi
c;oast for 2 weeks. The podiatrist asks for a
medical' review as he is concerned that the left
foot is now warm and swollen. The ulceration
looks much improved and the patient feels well.
X-ray does not reveal any obvious bony
abnormality. What is the most likely diagnosis?
A. Acute Charcot arthropathy
B. Deep vein thrombosis (DVT)
C. Dry gangrene
D. Gout
E. Osteomyelitis

20.19. A 47 year old woman with type 1

diabetes attends for annual review. She denies
any significant hypoglycaemia. Her results are
as follows: HbA1c 46 mmol/mol (6.4%); blood
pressure (BP) 152/98 mmHg (average of 3);
weight 61 kg (BMI 24 kg/m2); urinalysis: +
glucose, trace nitrites, albumin: creatinine ratio
(ACR) 5 mg/rnrnol (previously early morning
sample 6.2 mg/mmol); total cholesterol
3.8 mmoi/L (147 mg/dl).
Current medication: basal analogue insulin
(glargine), bolus/rapid-acting analogue insulin
(NovoRapid), ACE inhibitor (lisinopril), statin
(simvastatin).
Which result is it most important to act
upon? '
A. Blood pressure
B. Cholesterol
C. HbA,c
D. Urinalysis
E. Weight

20.20. James is a 19 year old man from Ireland;

he has a family history of diabetes. His mother
developed diabetes later in life; he is unsure if
she required insulin but she often attended the
hospital. She died suddenly when he was
young. James is an active man but has recently
been hindered by general malaise, lethargy and
pain in his knees. He has had a steroid injection
into his left knee with little improvement. The
following tests have been carried out:
Haemoglobin 145 g/L Anti-GAD antibody:
(14.5 g/dL) negative
White blood cell count Anti-IA-2 antibody:
6.2 x 109/L negative
Urea 5.2 mmoi/L Antineutrophil
(31 mg/dL) cytoplasmic
Creatinine 62 JJmoi/L antibody
(0.70 mg/dL) (ANCA): negative
Glucose 11.4 mmoi/L Ferritin 1137 j.Jg/L
(205 mg/dL)
HbA1c 51 mmol/mol
(6.8%)
What is the most likely diagnosis?
A. Hereditary haemochromatosis
B. MODY
C. Steroid-induced diabetes
D. Type 1 diabetes
E. Type 2 diabetes

20.21. Insulin is the main regulator of glucose

metabolism and storage. It is secreted from
pancreatic ~ cells. These cells regulate blood
glucose concentrations by coupling glucose
with insulin secretion. Glucose enters the
pancreatic ~ cells by facilitated diffusion down
its concentration gradient through cell
membrane glucose transporters (GLUTs).
Through which GLUT does glucose enter
pancreatic ~ cells?
A. GLUT1
B. GLUT2
C. GLUT3
D. GLUT4
E. GLUT5

20.22. Blood glucose is tightly regulated in order

to provide a constant supply of glucose to the
central nervous system. Following ingestion of
a meal containing carbohydrate, which of the
following is most likely to occur in the normal
physiological state?
A. Inhibition of GLP-1 release
B. Inhibition of insulin release
C. Stimulation of glucagon release
D. Stimulation of hepatic gluconeogenesis
E. Stimulation of hepatic glucose uptake

20.23. A 59 year old man with a BMI of 29 kg/

m2 is admitted to hospital with pleuritic chest
pain and a productive cough and is found to
have pneumonia. He has no history of diabetes
and takes no regular medication. As part of his
admission investigations, a plasma glucose is
found to be 10.0 mmoi/L (180 mg/dL). Which
of the following is the most appropriate
management?
A. Blood glucose monitoring with fasting
plasma glucose after recovery from infection
B. Commence treatment with liraglutide
C. Commence treatment with metformin
D. No further assessment of glycaemic control
E. Variable-rate intravenous insulin infusion

20.24. A 70 year old woman attends her family

physician complaining of excessive thirst and
fatigue. A random venous glucose is
13.2 mmoi/L (238 mg/dL), confirming a
diagnosis of diabetes. She takes a number of
medications for hypertension, ischaemic heart
disease and polymyalgia rheumatica. Which of
the following medications can precipitate
hyperglycaemia?
A. ACE inhibitor (e.g. ramipril)
B. Aspirin
C. Calcium channel blocker (e.g. amlodipine)
D. Nitrate (e.g. isosorbide mononitrate)
E. Steroid (e.g. prednisolone)

20.25. An 18 year old female with type 1

diabetes is admitted with suspected
pyelonephritis. She has not taken any insulin for
24 hours during her acute illness. Her initial
blood tests include: plasma glucose 24 mmoi/L
(432 mg/dL), bicarbonate 12 mmoi/L and
ketones 5.5 mmoi/L. Which electrolyte will most
likely require regular monitoring and aggressive
intravenous supplementation?
A. Bicarbonate
B. Calcium
C. Magnesium
D. Phosphate
E. Potassium

20.26. A 75 year old male with no prior diagnosis

of diabetes is admitted to hospital because he
has become progressively more drowsy and
unwell since being started on oral amoxicillinby
his family physician for a suspected chest
infection 2 weeks ago. He appears clinically
dehydrated. His initial blood tests include:
plasma glucose 55 mmoi/L (991 mg/dl),
ketones 0.1 mmoi!L, sodium 149 mmoi/L and
serum osmolality 368 mmol!kg. Which of the
following statements is correct with regard to the
management of this patient?
A. A solution of 10% dextrose is the initial
intravenous fluid of choice
B. Close monitoring of fluid balance is
unnecessary
C. Intravenous insulin is not required initially in
the absence of significant ketonaemia
D. Serum osmolality should normalise within 4
hours of treatment
E. Thromboprophylaxis is contraindicated

20.27. A 28 year old female has recently been

found to have hepatocyte nuclear factor 1 ex
(HNF1cx) MODY. It is decided to treat
her diabetes with gliclazide. Gliclazide, a
sulphonyulrea drug, exerts its hypoglycaemic
effect by enhancing endogenous insulin
secretion. By which mechanism is this achieved?
A. Activation of PPARy
B. Activation of the GLP-1 receptor
C. Closure of the transmembrane J3-cell KATP
channel
D. Inhibition of DPP-4
E. Inhibition of SGL T2

20.28. A 21 year old female with type 1

diabetes since childhood attends the diabetes
clinic for review. She has been symptomatic of
hypoglycaemia several times since her last
appointment 6 months ago. Which of the
following is classed as a neuroglycopenic
symptom of hypoglycaemia?
A. Anxiety
B. Confusion
C. Headache
D. Hunger
E. Sweating

20.29. A 24 year old male with type 1 diabetes

of 12 years' duration presents with frequent
episodes of hypoglycaemia. He goes running
for up to 60 minutes 4 times per week and the
hypoglycaemic episodes occur after exercise.
He has good awareness of hypoglycaemia and
is able to take corrective action on each
occasion. He is on a basal-bolus insulin
regimen and his latest HbA1c is 62 mmol/mol
(7.8%). Which of the following interventions is
the most appropriate management?
A. Advise him to avoid exercise
B. Always omit the short-acting insulin dose
after exercise
C. Reduce his total daily insulin dose to relax
his glycaemic control
D. Refer for structured diabetes education
programme
E. Refer to a tertiary centre for consideration of
pancreatic islet transplantation

20.30. A 58 year old man with type 2 diabetes

of 10 years' duration and a BMI of 33 kg/m2
attends clinic for review of his diabetes
management. He has a suboptimal HbA1c
of 69 mmol/mol (8.5%) on metformin
monotherapy 1 g twice daily and would like to
discuss the addition of a second-line agent.
Which of the following options are the most
appropriate if he wishes a strategy that
promotes weight loss?
A. DPP-4 inhibitor (e.g. sitagliptin)
B. GLP-1 agonist (e.g. liraglutide)
C. Insulin
D. PPARy agonistlthiazolidinedione (e.g.
pioglitazone)
E. Sulphonylurea (e.g. glipizide)

20.31. A 50 year old woman with type 2

diabetes presents to her family physician
complaining of genital thrush, which has ~ot
settled with topical antifungal treatment. She
had been started on a new oral hypoglydaemic
drug 4 months earlier. Which of the following
drugs is most likely to be responsible for her
presentation?
A. DPP-4 inhibitor (e.g. sitagliptin)
B. Glucosidase inhibitor (e.g. acarbose)
C. PPARy agonistlthiazolidinedione (e.g.
pioglitazone)
D. SGL T2 inhibitor (e.g. empagliflozin)
E. Sulphonylurea (e.g. glimepiride)
20.32. A 35 year old .woman with type 1
diabetes of 20 years: duration presents with
chronic nausea, early satiety and intermittent
vomiting after meals.l She has a history of poor
glycaemic control, retinopathy and peripheral
neuropathy. Which of the following
investigations will b~,most helpful in
establishing a diagnosis?
A. Abdominal ultrasonography
B. Anti-tissue transgl!Jtaminase (anti-tTG) antibody
C. Barium swallow
D. Gastric emptying study
E. Plain chest radiograph

20.33. A 21 year old women with type 1

diabetes of 8 years' duration with good
glycaemic control - HbA1c 48 mmol/mol (6.5%)
- on basal-bolus insulin presents to her young
adult specialist clinic for routine review. She has
been experiencing intermittent abdominal
bloating, diarrhoea and weight loss over the last
3 months. Recent urea and electrolytes, liver
function tests and thyroid function tests were all
within normal limits. Which of the following is
the best next investigation to perform?
A. Abdominal ultrasonography
B. Anti-tTG antibody
c. Flexible sigmoidoscopy
D. Gastric emptying study
E. Upper Gl endoscopy

20.34. A 1 9 year old male with type 1 diabetes

is admitted to hospital complaining of
generalised abdominal pain and vomiting. He is
apyrexial, tachycardic and clinically dehydrated.
There is no peritonism in the abdomen. He has
the following blood results: blood glucose
22 mmoi/L (396 mg/dl), ketones 4.3 mmoi/L,
bicarbonate 11 mmoi/L, alkaline phosphatase
250 U/L, white cell count 19 x 1 09/L and
haemoglobin 182 g/L. Which of the following
statements regarding interpretation of these
results is correct?
A. He can safely be discharged home
B. Measurement of venous pH will be normal
C. The elevated alkaline phosphatase
enzyme invariably indicates vitamin D
deficiency
D. The elevated haemoglobin concentration will
likely normalise after intravenous fluid
administration
E. The elevated white cell count invariably
indicates underlying infection

20.35. A 48 year old man with type 1 diabetes

of 30 years' duration attends clinic for routine
review. He is on a basal-bolus insulin regimen
and has an HbA1c of 70 mmol/mol (8.6%). He
is on no other medication. Blood pressure is
155/92 mmHg (repeated 3• times with similar
results) and he has microalbuminuria with an
ACR of 7.3 mg/mmol. Estimated glomerular
filtration (eGFR) rate is 54 mUmin/1.73 m2
Which of the following drugs would be most
beneficial? 1
A. ACE inhibitor (e.g. lisinopril)
B. ~-blocker (e.g. atenolol) '
C. Calcium channel blocker (e.g. amlodipine)
D. Centrally acting antihypertensive (e.g.
moxonidine)
E. Thiazide diuretic (e.g. bendroflumethiazide)

20.36. A 65 year old man with type 2 diabetes

of 20 years' duration is referred to the specialist
diabetes foot clinic by his family physician with
an ulcer of the plantar surface of the right foot.
The ulcer has been present for approximately
6 weeks and there is a history of peripheral
diabetic neuropathy. On examination, there is a
2-cm diameter ulcer in proximity to the first
metatarsal head. It has an offensive odour and
discharge. The area around the ulcer is hot and
erythematous. Which of the following features,
if present, would most strongly indicate the
presence of osteomyelitis (bone infection)?
A. A normal plain foot radiograph
B. Elevated blood white cell count
C. Increased skin temperature compared to the
contralateral foot
D. Peripheral oedema
E. The ulcer probing to the depth of bone
20.37. A 72 year old man is admitted to hospital
by his family physician for urgent investigation
of weight loss. He has a progressive 3-month
history of back pain, jaundice, dark urine and
anorexia. He has lost approximately 15 kg in
weight. In the last 4 weeks he has developed
increased thirst and is drinking excessively.
A random venous glucose is 16.0 mmoi/L
(288 mg/dl). Which investigation is most likely
to reveal the cause of his diabetes?
A. Anti-GAD and anti-IA-2 antibodies
B. CT scan of the pancreas
C. Dexamethasone suppression test
D. Faecal elastase
E. Serum C-peptide

20.38. A 29 year old woman with type 1

diabetes for 18 years attends clinic for routine
review. She has poor glycaemic control with an
HbA1c of 90 mmol/mol (1 0.4%). She is keen to
embark on stricter glycaemic management in
advance of planning pregnancy. Which of the
following complications of diabetes would be
the most likely to deteriora!e· significantly should
her glycaemic control impfove suddenly?
A. Foot ulceration
B. Gastroparesis
C. Microalbuminuria
D. Peripheral vascular disease
E. Retinopathy

20.39. An 18 year old woman with type 1

diabetes attends her diabetes clinic to discuss
the possibility of continuous subcutaneous
insulin therapy (insulin pump therapy). She has
a suboptimal HbA1c of 68 mmol/mol (8.4%) and
takes multiple daily injections of insulin. Which
of the following statements is correct with
regard to insulin pump therapy?
A. A continuous glucose monitoring system
(CGMS) is mandatory for all patients
B. DKA does not occur as insulin administration
is constant
G. Patients have to inject long-acting insulin in
addition to the pump-delivered insulin
D. The rate of insulin delivery can be adjusted
depending on the time of day
E. There is an increased risk of microvascular
disease compared to multiple daily
injections

nswer
20.40. A 45 year old man with diabetes
presents with a 4-week history of weight loss,
polyuria and polydipsia. His blood results
include: random plasma glucose 20 mmoi/L
(360 mg/dl), ketones 2 mmoi/L and HbA1c
110 mmol/mol (12.2%). He was diagnosed with
diabetes 6 months ago at which point his BMI
was 23 kg/m2 and HbA1c 65 mmol/mol (8.1 %).
There is no family history of diabetes. Since
diagnosis he has been treated with metformin
and a sulphonylurea. p-cell antibodies are
checked and he is found to have a very high
titre of anti-GAD antibodies. Which of the
following diagnoses best fits with this scenario?
A.LADA
B. Mitochondrial diabetes
G. MODY
D. Pancreatic disease
E. Type 2 diabetes