Diabetes, Obesity and Lipid metabolism Questions

A 36-year-old African Amerian man with no significant past medical history presents with a 3-week history of polyuria, polydipsia and 20-pound weight loss. His BMI is 22. He has a family history of Graves disease in his mother and celiac disease in a younger sister. He had no evidence of ketoacidosis at presentation and there were no skin tags or acanthosis nigricans.

The patient’s A1C was 9 during his brief period of hospitalization. He was discharged home on metformin and glipizide. In addition, the patient started therapeutic lifestyle interventions. Metformin and glipizide were both uptitrated to their maximal doses. His A1C improved to 8.5% during his three-month clinic visit. He reports feeling much better. What diagnosis should his primary care provider consider?

A 22-year-old woman with a history of PCOS is diagnosed with Gestational diabetes mellitus at 25weeks gestation. Which of these statements regarding the management of GDM is inaccurate?

Which of these is not a clinical marker of insulin resistance?

Which of these medications does not have a direct drug-to-drug interaction with orlistat, a weight loss medication?

A patient with insulin resistance requiring U-500 insulin is admitted to the medicine service. You are consulted for management of hyperglycemia due to the patient’s history of significant insulin resistance. What will be your recommendation?

A couple with T1DM is concerned about the risk of T1DM in their unborn child. What will you tell these expectant parents?

What is the first deficit in the evolution of Type 2 diabetes mellitus?

A patient is started on an antipsychotic agent and develops significant weight gain and newly diagnosed dysglycemia. Which of these medications is a preferred antipsychotic agent with an acceptable metabolic profile?

34-year-old Hispanic woman with class III obesity was admitted to the medicine service due to diabetic ketoacidosis in a newly diagnosed diabetic. Her insulin requirements declined significantly, necessitating discontinuation of insulin a few weeks after discharge from the hospital. She is currently well controlled on metformin 500mg BID with an A1C of 6.4%. Her family history is strong for T2DM (mother, two maternal aunts, and a younger sister). Patient has acanthosis nigricans and multiple skin tags. What is the next step in management

Which of these medications should be avoided in a patient with type 2 diabetes mellitus and an estimated GFR < 60?

A 45-year-old woman with a 3-decade history of T1DM. She has noticed a progressively enlarging tumor in her preferred insulin injection site. She has been admitted on two occasions within the past month for diabetic ketoacidosis. You notice a hard nodular mass in the subcutaneous tissue of the anterolateral abdomen. You inform the patient of the rarity of this clinical finding even in patients with a long-standing history of T1DM. What is the most likely diagnosis?

A primary care provider refers a 36-year-old African American man with a hemoglobinopathy (SC genotype) and poorly controlled T1DM to your practice for optimization of glycemic control. He has obstructive hepatopathy as a consequence of long-standing diabetes. His serum albumin is 1.8. Patient has stage IV chronic kidney disease and is being scheduled for placement of an arterio-venous fistula in the near future. Which of these options is the best way to assess glycemic control in this patient?

Which of these is not a goal of optimal glycemic management of cystic fibrosis-related diabetes (CFRD).

A 54-year-old female with T2DM complicated CKD stage IIIA is referred to a nephrologist. Which of these is an indication for renal biopsy in the setting of presumed diabetic nephropathy?

Which of these drugs or combination of drugs has both antiproteinuric effects and a demonstrable preservation of glomerular filtration rate?

A 42-year-old man with morbid obesity, status post Roux-en-Y gastric bypass, who presented to the emergency room after an unresponsive hypoglycemic event. He had a positive Whipple’s triad. What is the most likely diagnosis based on the results of his biochemical tests obtained after a 72hour fast?

A 54-year-old woman with uncontrolled T2DM complicated by nephropathy. She has a consistent blood pressure > 160/90mmHg and is currently on a maximally tolerated dose of lisinopril. What would you recommend next to control her blood pressure?

36-year-old female with PCOS is diagnosed with non-alcoholic fatty liver disease (NAFLD). What is the most important cause of death in NAFLD?

A 32-year-old Female Gravida 2 para 1, with a history of PCOS, presents at 16weeks gestation. She had diet controlled gestational diabetes during her first pregnancy, which resolved post delivery. What should be done next?

67-year-old female with a history of T2DM complicated by retinopathy and neuropathy, was brought to the ED by EMS after a hypoglycemic event. Her chronic anti-hyperglycemic regimen includes metformin, glipizide, and linagliptin. She has an estimated GFR of 50 to 55 (Serum creatinine 1.6 to 1.7) over the preceding two years. The patient was recently started on trimethoprim-sulfamethoxazole for a skin infection. She was found unresponsive in her living room. Her blood glucose was 30mg/dl. The patient recovered after two ampoules of 50% Dextrose and an intramuscular injection of glucagon. What is the most likely explanation for this patient’s hypoglycemic event?

A 30-year-old with class III obesity and PCOS is referred to the endocrine clinic for further management of severe insulin resistance. She is currently on 70 units of Levemir insulin twice a day, Novolog insulin 60units with each meal 3 times a day and SQ liraglutide 1.8mg daily. Her current glycated hemoglobin is 8.4%. You plan on switching her from U-100 insulin to Humulin R U-500 insulin. What is the best approach in this clinical setting?

A 54-year-old man with type 2 diabetes mellitus, hypertension, dyslipidemia, and heart failure. His estimated GFR is 50, normal liver function tests and glycated hemoglobin of 11. His fasting blood glucose readings range from 80mg/dl to 100mg/dl with average daily glucose of 185 mg/dl. He has a remote history of splenectomy due to a blunt abdominal injury and recurrent acute pancreatitis. He is currently on a maximally tolerated dose of metformin. His primary care provider is considering an additional agent to metformin due to his uncontrolled glycohemoglobin. Which of these management options is the next best step?

A 28-year-old woman with class I obesity is motivated to lose weight. She has started an exercise and diet program. Despite adherence to these therapeutic lifestyle interventions, she has been unable to lose 5% of her weight. Her current medications include an oral contraceptive and a daily “health supplement”.  The patient is diagnosed with subclinical hypothyroidism due to a TSH of 7 and a normal free T4. Her TPO antibody status is negative. What is the most likely reason for her difficulty in losing weight?

A 48-year-old woman with a 6-year history of type 2 diabetes
mellitus is referred for a second opinion regarding her
unexplained high hemoglobin A1c level. She has been treated
with basal plus mealtime insulin for 3 years. She performs selfmonitoring
of blood glucose 6 to 8 times daily, with values
ranging between 75 and 120 mg/dL (4.2-6.7 mmol/L) before
meals and between 110 and 130 mg/dL (6.1-7.2 mmol/L) 2
hours after meals. She reports rare hypoglycemic episodes.

Her review of systems is notable for recent fatigue and
lightheadedness. Her medications include aspirin and ramipril.
For years, her hemoglobin A1c level has been in the range of
6.5% to 6.9% (48-52 mmol/mol), but 4 months ago it was 7.8%
(62 mmol/mol) and a recent value was 8.5% (69 mmol/mol).

Laboratory test results:
• Hemoglobin = 8.9 g/dL (12.1-15.1 g/dL)
(SI: 89 g/L [121-151 g/L])
• Serum creatinine = 0.8 mg/dL (0.6-1.1 mg/dL)
(SI: 70.7 μmol/L [53.0-97.2 μmol/L])
• Liver function, normal
• TSH, normal
• Urine albumin-to-creatinine ratio = 205 mg/g creat (<30 mg/g creat)

Which of the following is the most likely
cause of her high hemoglobin A1c?

A 31-year-old man with a 16-year history of type 1 diabetes
mellitus complicated by nephropathy and retinopathy is referred
for help achieving better glycemic control. His regimen consists
of insulin degludec, 18 units at bedtime, and insulin lispro with
meals using an insulin-to-carbohydrate ratio of 1:12. He
performs self-monitoring of blood glucose 4 times daily, with
values ranging between 200 and 300 mg/dL (11.1-16.7 mmol/L).
His hemoglobin A1c level has been between 8.5% and 10.0%
(69-86 mmol/mol). His medications include lisinopril,
rosuvastatin, and biotin.

Laboratory test results:
• Hemoglobin A1c = 9.0% (4.0%-5.6%)
(75 mmol/mol [20-38 mmol/mol])
• Serum creatinine = 2.2 mg/dL (0.7-1.3 mg/dL)
(SI: 194.5 μmol/L [61.9-114.9 μmol/L])
• Urine albumin-to-creatinine ratio = 3886 mg/g creat (<30 mg/g creat)
• Liver function, normal
• TSH = 7.5 mIU/L (0.5-5.0 mIU/L)
• Serum fructosamine = 210 μmol/L (200-285 μmol/L)

The discrepancy between this patient’s
hemoglobin A1c and fructosamine levels
is most likely caused by which of the
following?

A 42-year-old man with a 22-year history of type 1 diabetes
mellitus is seeing you for a follow-up visit. He has had poor
glycemic control over the past few years while on insulin pump
therapy. He is reluctant to increase his pump settings because of
the potential for weight gain. He has tried metformin and
pramlintide in the past, but he could not tolerate the
gastrointestinal adverse effects. His hemoglobin A1c value is
now 7.8% (62 mmol/mol), and his BMI is 27 kg/m2.

His basic metabolic panel, liver function, and TSH level are
normal. You suggest off-label use of empagliflozin to lower his
hemoglobin A1c and reduce his weight. He asks about potential
adverse effects.

You tell him that empagliflozin could increase his risk of which of the following?

A 32-year-old woman with type 1 diabetes mellitus is 6 weeks’
pregnant. Her most recent hemoglobin A1c value is 6.9% (52
mmol/mol). She is taking insulin detemir, 8 units in the morning
and 12 units in the evening, in addition to prandial doses of insulin
aspart based on an insulin-to-carbohydrate ratio of 1:10 and a
sensitivity (or correction) factor of 1:40. Her overnight (3 AM) and
fasting blood glucose levels range between 110 and 122 mg/dL
(6.1-6.8 mmol/L), and her peak (1-hour) postprandial glucose
levels range between 112 and 129 mg/dL (6.2-7.2 mmol/L).

Which of the following should you
recommend during this pregnancy?

A 35-year-old man has a 15-year history of type 1 diabetes
mellitus complicated by nonproliferative diabetic retinopathy. He is
concerned about renal complications of diabetes. His most recent
hemoglobin A1c level is 7.8% (62 mmol/mol) on insulin glargine
and mealtime insulin aspart.
Two separate measurements of his urine albumin-to-creatinine
ratio are 20 and 12 mg/g creat. His estimated glomerular filtration
rate is 82 mL/min per 1.73 m2 (>60 mL/min per 1.73 m2).
On physical examination, his blood pressure is 128/72 mm Hg
and BMI is 24 kg/m2.

Which of the following is the most effective
approach to reduce future risk of clinically
significant diabetic nephropathy in this
patient?

A 19-year-old man presents for continued management of
diabetes mellitus, having “aged-out” of pediatric endocrine care.
Diabetes was diagnosed at age 16 years when glycosuria and
moderate hyperglycemia were documented on a yearly checkup.
Insulin therapy was started immediately. His current insulin dose
is approximately 0.3 units/kg per day, administered as multiple
daily injections, and his current hemoglobin A1c level is 6.4% (46
mmol/mol) with occasional hypoglycemia. His family history is
positive for diabetes in his mother, maternal grandfather, and an
older sibling, all diagnosed at age 19 years or younger. His BMI
is 23 kg/m2.

Tests for glutamic acid decarboxylase antibodies, islet-cell
antibodies, insulinoma-associated protein 2 antibodies, and
ZnT8 antibodies are negative; he did not have antibody testing
at the time of diagnosis. His serum C-peptide concentration is
1.1 ng/mL (0.4 nmol/L).

Which of the following is the optimal
management of this patient’s diabetes