West Virginia of Family Physicians
59th Annual Scientific Assembly
March 31, 2011
Presented by: David W. Avery, MD
David W. Avery, M.D.
Private Practice Family Physician
Grand Central Family Medicine a part
of Marietta Health Care Physicians, Inc.
418 Grand Park Dr.
Vienna, WV 26105
(304) 422-3400
Specialty: Family Practice
Residency: United Hospital Center,
Clarksburg, WV
School & Degree: LeMoyne College,
Syracuse,
SUNY Upstate Medical, Syracuse
Certification: American Board of Family
Practice
The West Virginia Academy of Family Physicians has a Conflict of
Interest Policy that requires course faculty to disclose whether or
not they have financial interest or affiliations with organizations
with a direct or substantial interest in subject matter of their
presentations. The following information was received from the
course speakers for the West Virginia Academy of Family Physicians
59th Annual Scientific Assembly at the Embassy Suites Hotel, in
Charleston, WV . It is not the assumption that any listed financial
interests or affiliations will have an adverse impact on the
speaker’s presentation; they are noted here to fully inform course
participants.
Dr. Avery has disclosed that neither he, nor any immediate family
member, have a significant financial interest in or affiliation with a
commercial supporter of the educational activity and/or with the
manufacturer(s) of commercial products and/or providers of any
commercial services in this educational activity:
The ABFM certifies the ongoing ability of
family physicians by:
 Evidence of professional standing
 Evidence of commitment to life-long learning,
to include self assessment
 Evidence of cognitive expertise based on
performance on an examination
 Evidence of evaluation of performance in
practice



At the present time, you may recertify
every 7 or 10 years.
To maintain your certification, you must
maintain your professional license and
pass an examination at the end of 7 or
10 years.
This examination is computer based
and usually done locally.

To qualify for a ten-year term of board
certification, for each 3-three year cycle
you must demonstrate self assessment
and practice evaluation by:
 2 SAMs (or equivalent)
 1 Performance in Practice Module (PPM) in
which you perform a 3-6 month quality
assessment

To fulfill Stage One (1st 3 year cycle)
requirements, all participants who
begin MC-FP during the period from
2004-2011 will have the choice of
completing
 Two Part II modules (SAMs) and one part IV
module (PPM)
OR
◦ Three Part II modules (SAMs)


The ABFM used to require that a SAM or
PPM be done each year, but now you
can do them all at any time during the
3 year cycle.
If you do not complete all three
requirements in each of the three, 3year cycles, you go from the 10-year
recertification cycle to the 7-year cycle.






Diabetes
Hypertension
Asthma
Congestive Heart
Failure
Coronary Artery
Disease
Depression






Pain Management
Well Child Care
Maternity Care
Health Behavior
Childhood illness
Care of the
vulnerable elderly

AAFP METRIC

Colorado Permanente Medical Group Department
modules in Diabetes, Asthma, Coronary
Artery Disease, and Chronic Obstructive Pulmonary Disease
of Education Performance Improvement CME

ABIM PIMs
Completed in a Group Setting within a Mixed
Practice

NCQA Physicians Recognition Programs in
Diabetes and Heart/Stroke

Geriatrics Education Network of Indiana
(GENI) Geriatrics Quality Improvement Initiative
Part IV: Depending on whether you see
patients in continuity and your practice
setting, the requirements for the
component differ
◦ Traditional practice setting/Patients seen in
continuity-options include PPM Methods in
Medicine Module (MIMMs), Patient Safety
Improvement Program, a METRIC from the
AAFP or other approved external provider
module
◦ Non-traditional practice setting/Patients not
seen in continuity or not seen at all-options
include MIMMs or the Patient Safety
Improvement Program.


The SAMs consist
of 60 multiplechoice questions
and a clinical
Simulation


The 60 questions
are divided into 68 content
categories.

You must correctly
complete 80% of each
of the 6-8
competencies to
complete this portion
of the self
assessment to be
able to take the
Clinical Assessment
portion of the selfassessment.
References are given
for each question.
Complete Clinical
Simulation (less than
two hours)



You must register for a Self Assessment Module
(SAM) you must go to the ABFM website, which is
www.theabfm.org You will need a login and
password and you can get these at
www.help@theabfm.org
You must pay the Board in order to
access/complete the SAM
The SAM course fee that you paid to take part in
this session is for facilitation of this educational
activity provided by KAFP




Attendees need to register for the MC-FP
process with ABFM and pay the fee in order
to obtain MC-FP credit from the ABFM
Attendees must provide their ABFM ID#
and or their AAFP ID# to KAFP to receive
credit for this portion of the SAMs
The ABFM has given us permission to have
this group session.
As a group, we will answer each of the 60
questions in turn with a show of hands.




The answers will be recorded on the
ABFM website.
At the end of the presentation, the
ABFM will process the answers and
report percentage of correct answers.
As a group, we will go back and answer
those we missed until the group
receives a 100%.
The ABFM has given us permission to
have the group’s correct answers for
the 60 questions logged into your
personal account (barring any glitches)
when you have registered for this
course and paid the ABFM fee for this
SAM.

After this workshop, you will need to
◦ Login to your personal account with the
ABFM
◦ Complete payment
◦ Finish the Clinical Simulation (less than 2
hours)

After successfully completing both
portions of the self assessment module
(60 questions & clinical simulation) you
will receive 15 category 1 CME credits
from the AAFP

This is not a test it is considered a selfassessment.

We did not participate in writing these
questions.

We may disagree with the construction of a
question &/or answer.

Reproduction of questions & answers are
strictly prohibited.

1. Mark all options below that are true regarding nonpharmacologic
therapy to reduce insulin resistance.

○ A decrease I caloric intake will increase insulin sensitivity with
or without weight loss.

○ Moderate alcohol intake increases insulin resistance

○ Exercise has been shown to enhance insulin action in skeletal muscle





○ A decrease of as little as 5% in body weight can result
in substantial reduction in insulin resistance
○ All patients with insulin-resistance syndrome should be
advised to engage in 30 minutes of modest aerobic
exercise at least 4-5 times/week
AACE: AACE Position Statement on the Insulin Resistance
Syndrome, 2002.
The American Association of Clinical Endocrinologists Medical
Guidelines for the Management of Diabetes Mellitus: The AACE
System of Intensive Diabetes Sekf-Management-2002 Update.
Endocrine Practice 2002;8 (suppl 1): 40-65
Howard AA, Arnsten JH, Gourevitch MN: Effect of alcohol
consumption on diabetes mellitus: A systematic review. Ann
Intern Med 2004; 140 (3): 211-219.
Last modified 02/05
2.Which of the following neurologic test is most useful for
predicting the future occurrence of a diabetic foot ulcer?
A. Pressure sensation with Semmes-Weinstein
monofilament (10 g)
B. Deep tendon reflexes of the ankle
C. Proprioception
D. Vibratory sensation with a 128-mHz tuning fork
E. Light touch with a wisp of cotton
Rith-Najarian SJ, Stolusky T, Gohdes DM: Identifying
diabeticv patients at high risk for lower extremity
amputation in the primary health care setting. Diabetes
Care 1992;15:1386.
Vinik AI: Management of neuropathy and foot problems in
diabetic patients. Clinical Cornerstone 2003;5920:217218
Last modified 02/05
3. Which of the following lipid-lowering agents can worsen
glycemic control? (Mark all that are true.)
•Colestipol (Colestid)
•Ezetimibe (Zetia)
•Gemfibrozil (Lopid)
•Nicotinic acid (Niacin)
•Atorvastatin (Liptor)
American Diabetes Association: Standards of medical care in diabetes—
2008. Diabetes Care
2008:31(suppl 1):S12-S54.
AACE Diabetes Mellitus Clinical Practice Guidelines Task Force: American
Association of Clinical
Endocrinologists medical guidelines for clinical practice for the
management of diabetes
mellitus. Endocr Pract 2007;13(suppl 1):1-68.
Executive Summary of the Third Report of the National Cholesterol
Education Program (NCEP)
on Detection, Evaluation, and Treatment of High Blood Cholesterol in
Adults (Adult Treatment
Panel III). National Heart, Lung, and Blood Institute (NHLBI), 2001.
Last modified 05/06
A 58-year –old type 2 diabetic patient comes in during the early afternoon
for his annual physical examination. His current medication regimen is
insulin glargin (Lantus), 18 units in the evening; glipizide (Glucotrol), 20
mg/day; metformin (Glucophage), 1000 mg twice a day; and acarbose
(Precose), 100 mg three times a day. He suddenly becomes shaky,
diaphoretic, and pale, and tells you he thinks it is because his skipped lunch
before his appointment.
Which of the following would be effective options for managing this episode
(Mark all that are true.)
○ Glucose tablets
○ A sugar cube
○ A banana
○ A Cracker
○ Orange juice
○ Rasins
○ Glucagon
Inzucchi SE: Oral antihyperglycemic therapy for
type 2 diabetes—Scientific Review. JAMA
2002;287:360.
Last modified 02/05

5 . Which of the following medications can cause
hyperglycemia? (Mark all that are true.)

○•Nicotinic acid

○ Clozapine (Clozaril)
•

○ Prednisone
•

○•Spironolactone

○ Ramipril (Altace)
•

American Diabetes Association: Diagnosis and
classification of diabetes mellitus. Diabetes Care
2008;31(suppl 1):S55-S60.
Yusuf S, Sleight P, Pogue J, et al: Effects of an angiotensinconverting inhibitor, ramipril, on
cardiovascular events in high-risk patients. The Heart
Outcomes Prevention Evaluation Study
Investigators. N Engl J Med 2000;342:145.
American Diabetes Association, American Psychiatric
Association, American Association of
Clinical Endocrinologists, North American Association for the
Study of Obesity: Consensus
development conference on antipsychotic agents and obesity
and diabetes. Diabetes Care
2004;27(2):596-601.

Last modified 02/05









6. A 55-year-old- African-American male sees you for a routine visit. His past medical
history is notable for an 8-year history of diabetes mellitus and a past history of
hypercholesterolemia. His current medications are atorvastatin (Lipitor), 20mg/day, and
extended-release metformin (Glucophage XR), 1000 mg/day. He also reports a history of
severe peanut allergy manifested by dip and tongue angioedema, and carries an
epinephrine auto-injector (EpiPen).
On examination he has a blood pressure of 120/74 mm Hg. Laboratory evaluation reveals a
hemoglobin A1c of 6.7%. A spot urine sample reveals 40 ug albumin/mg creatinine.
You see the patient return in 6 months for a repeat urine test for albumin and creatinine.
Which of the following would be most appropriate initially?
A) Have the patient return in 6 months for a repeat urine test for for albumin and creatinine
B) Order a 24-hour urine collection for creatinine
C) Recommend that the patient reduce his daily protein intake to 1.5 g/kg/day
D) Begin an ACE inhibitor
E) Begin an angiotensin receptor blocker













Chobanian AV, Bakris GL, Black HR, et al: The Seventh Report of the Joint
National Committee
on Prevention, Detection, Evaluation, and Treatment of High Blood
Pressure—The JNC 7 Report.
National Heart Lung and Blood Institute (NHLBI), 2003.
American Diabetes Association: Standards of medical care in diabetes—
2007. Diabetes Care
2007:30(suppl 1):S4-S41.
Gross JL, de Azevado MJ, Silveiro SP, et al: Diabetic nephropathy:
Diagnosis, prevention, and
treatment. Diabetes Care 2005;28(1):164-176.
Hunt SA, Abraham WT, Chin MH, et al: ACC/AHA 2005 guideline update
for the diagnosis and
management of chronic heart failure in the adult: A report of the
American College of
Cardiology/American Heart Association Task Force on Practice
Guidelines (Writing Committee
to Update the 2001 Guidelines for the Evaluation and Management of
Heart Failure). J Am Coll
Cardiol 2005;46(6):e1-e82.
Last modified 04/08
7. Mark all options below that are true regarding the dietary
intake of carbohydrates in diabetic patients.
○ Use of the glycemic index is not felt to be of value in the
management of diabetes
○ Patients should be advised to avoid sucrose since it increases
glycemia more than a comparable amount of starch
○ Low-carbohydrates diets (130 g/day) are more effective than
low-fat, calorie-restricted diets for achieving short-term
weight loss
○ The total amount of carbohydrate ingested is a strong
predictor of glycemic response.
○ The caloric value of carbohydrates is less than that of alcohol






American Diabetes Association: Nutrition
recommendations and interventions for diabetics.
Diabetes Care 2008;31(suppl 1):S61-78.
American Diabetes Association: Standards of medical care in
diabetes—2008. Diabetes Care
2008:31(suppl 1):S12-S54.
Lieber CS: Medical disorders of alcoholism. N Engl J Med
1995;1058-1065.
Last modified 04/08
8. A 51-year-old male with type 2 diabetes controlled with
diet is found to have a serum triglyceride level of 350 mg/dL
and LDL-cholesterol level of 101 mg/dL, and HDLcholesterol level of 45 mg/dL.
Which one of the following would be most likely to help
reduce his serum triglyceride levels?
A) Vitamin E
B) Vitamin C
C) Omega-3 fatty acids
D) Folate
E) Chromium


Kris-Etherton PM, Harris WS, Appel LJ, for the Nutrition
Committee: Fish consumption, fish oil, omega-3 fatty acids,
and cardiovascular disease. Circulation 2002;106:2747-2757.
Last modified 02/05


9. Which one of the following is ineffective for treating pain
syndromes arising from diabetic neuropathy?
A) Tricyclic antidepressants


B) SSRIs

C) Duloxetine (Cymbalta)
D) Pregabalin (Lyrica)





Newton WP, Collins L: What is the best treatment for diabetic
neuropathy? J Fam Pract 2004;53(5):403-406.
McCarberg B: Pharmacotherapy for neuropathic pain: the old
and the new. Adv Stud Med 2006;6(9):399-408.
Wiffen PJ, McQuay HJ, Edwards JE, Moore RA. Gabapentin for
acute and chronic pain. Cochrane Database Syst Rev
2005.(3):CD005452.
American Diabetes Association: Standards of medical care in
diabetes--2008. Diabetes Care 2008:31(suppl 1):S12-S54.
Last modified 02/05
10. At a routine health maintenance visit, a 42-year-old
obese male is found to have a fasting plasma glucose level of
118 mg/dL. Which one of the following is the most
appropriate initial intervention for preventing or delaying the
development of diabetes in this patient?
A) Lifestyle modification

B) Metformin (Glucophage)

C) A thiazolidinedione

D) An oral sulfonylurea agent E) An ACE inhibitor

E) An ACE inhibitor








American Diabetes Association: Diagnosis and classification
of diabetes mellitus. Diabetes Care 2008;31(suppl 1):S55-S60.
American Diabetes Association: Standards of medical care in
diabetes--2008. Diabetes Care 2008:31(suppl 1):S12-S54.
AACE Diabetes Mellitus Clinical Practice Guidelines Task Force:
American Association of Clinical Endocrinologists medical
guidelines for clinical practice for the management of diabetes
mellitus. Endocr Pract 2007;13(suppl 1):1-68.
Tuomilehto J, Lindstrom J, Eriksson JG, et al: Prevention of type 2
diabetes mellitus by changes in lifestyle among subjects with
impaired glucose tolerance. N Engl J Med 2001;344(18):13431350.
Diabetes Prevention Program Research Group: Reduction in the
incidence of type 2 diabetes with life-style intervention or
metformin. N Engl J Med 2002;346(6):393-403.
American Diabetes Association, National Institute of Diabetes
and Digestive and Kidney Diseases: Prevention or delay of type 2
diabetes. Diabetes Care 2004;27(suppl 1):S47-S54.
Last modified 05/06

11. Antihypertensive medications that can worsen
proteinuria and accelerate the progression of disease in
patients with diabetic nephropathy include which of the
following? (Mark all that are true.)

o ACE inhibitors

o Beta-blockers

o Dihydropyridine calcium channel blockers

o Thiazide diuretics

o Alpha-blockers


Remuzzi G, Scheppati A, Ruggenenti P: Nephropathy in
patients with type 2 diabetes. N Engl J Med 2002;346:1145.
Last modified 02/05
12. Which one of the following antidiabetic agents has been
associated with an increased risk of myocardial infarction?
A) Rosiglitazone (Avandia)
B) Sitagliptin (Januvia)


C) Pioglitazone (Actos)
D) Metformin (Glucophage)

E) Exenatide (Byetta)





Nissen SE, Wolski K: Effect of rosiglitazone on the risk of
myocardial infarction and death from cardiovascular causes.
N Engl J Med 2007;356(24):2457-2471.
Singh S, Loke YK, Furberg CD: Long-term risk of
cardiovascular events with rosiglitazone: A meta-analysis.
JAMA 2007;298(10):1189-1195.
Lincoff AM, Wolski K, Nicholls SJ, et al: Pioglitazone and the
risk of cardiovascular events in patients with type 2 diabetes
mellitus: A meta-analysis of randomized trials. JAMA
2007;298(10):1180-1188.
DeFronzo RA: Pharmacologic therapy for type 2 diabetes
mellitus. Ann Intern Med 1999;131(4):281-303.
Last modified 04/08
13. Microalbuminuria is linked strongly to which of the
following diabetic complications? (Mark all that are true.)

o Progressive nephropathy


o Progressive retinopathy


o Autonomic neuropathy

o Increased cardiovascular risk

o Chronic interstitial nephritis


American Diabetes Association: Standards of medical care
in diabetes--2008. Diabetes Care 2008:31(suppl 1):S12-S54.
Last modified 02/05

14. A 66-year-old postmenopausal female smoker is
diagnosed with metabolic syndrome. Interventions
recommended to reduce her cardiovascular risk include which
of the following? (Mark all that are true.)

o Smoking cessation

o Aerobic exercise

o Postmenopausal hormone therapy

o Vitamin E, 400-800 IU/day

o Aspirin, 81 mg/day



Miller EF III, Pastor-Barriuso R, Dalal D, et al: Meta-analysis:
High-dosage vitamin E supplementation may increase all
cause mortality. Ann Intern Med 2005;142(1):37-46.
Mosca L, Appel LJ, Benjamin EJ, et al: Evidence-based
guidelines for cardiovascular disease prevention in women.
Circulation 2004;109(5):672-693.
Last modified 04/08

15. Hypoglycemia is a possible side effect of which of the
following diabetes agents? (Mark all that are true.)

o Insulin

o Pioglitazone (Actos)

o Metformin (Glucophage)

o Sulfonylureas

o Repaglinide (Prandin)

o Acarbose (Precose)





Nathan DM, Buse JB, Davidson MB, et al: Management of
hyperglycemia in type 2 diabetes: A consensus algorithm for
the initiation and adjustment of therapy: A consensus
statement from the American Diabetes Association and the
European Association for the Study of Diabetes. Diabetes Care
2006;29(8):1963-1972.
AACE Diabetes Mellitus Clinical Practice Guidelines Task
Force: American Association of Clinical Endocrinologists
medical guidelines for clinical practice for the management of
diabetes mellitus. Endocr Pract 13(suppl 1):1-68.
Inzucchi SE: Oral antihyperglycemic therapy for type 2
diabetes--Scientific Review. JAMA 2002;287:360.
Nathan DM: Initial management of glycemia in type 2
diabetes mellitus. N Engl J Med 2002; 347:1342.
Last modified 02/05

16. Mark all options below that are true regarding dietary
intake of fat in the diabetic patient.

o Dietary intake of cholesterol should generally not exceed
200 mg/day

o Trans-fatty acids have been shown to lower LDL
cholesterol and raise HDL cholesterol


o Less than 10% of caloric intake should be derived from
saturated fats

o Intake of omega-3 (or n-3) fatty acids is associated with a
cardioprotective effect

o A gram of fat contains 50% more calories than a gram of
carbohydrate




American Diabetes Association: Nutrition recommendations
and interventions for diabetics. Diabetes Care 2008;31(suppl
1):S61-78.
AACE: The AACE System of Intensive Diabetes SelfManagement--2002 Update.
Mozaffarian D, Katan MB, Ascherio A, et al: Trans fatty acids
and cardiovascular disease. N Engl J Med 2006;354(15):16011613.
Last modified 04/08








17. Mark all options below that are true with regard to coronary heart
disease in patients with diabetes.
o Diabetic patients with no previous history of myocardial infarction have
the same risk for an acute coronary event as nondiabetic patients who have
had a previous myocardial infarction
o Beta-blockers should be avoided in diabetic patients with coronary artery
disease, due to the risk of masking hypoglycemia and reducing insulin
secretion
o Long-term outcomes following percutaneous transluminal coronary
angioplasty are as good in diabetic patients as in nondiabetic patients
o The survival of diabetic patients with multivessel disease is better after
coronary revascularization with coronary artery bypass graft surgery than
with percutaneous transluminal coronary angioplasty
o Optimal glycemic control has been shown to reduce the risk of coronary
heart disease in patients with type 1 diabetes






American Diabetes Association: Standards of medical care
in diabetes--2008. Diabetes Care 2008:31(suppl 1):S12S54.
ACC/AHA Guidelines for CABG Surgery--2004 Update.
American College of Cardiology/American Heart
Association, 2004.
Nathan DM, Cleary PA, Barklund JY, et al: Diabetes Control
and Complications Trial/Epidemiology of Diabetes
Interventions and Complications (DCCT/EDIC) Study
Research Group: Intensive diabetes treatment and
cardiovascular disease in patients with type 1 diabetes. N
Engl J Med 2005;353(25):2643-2653.
American Diabetes Association: Implications of the United
Kingdom Prospective Diabetes Study. Diabetes Care
2003;26(supp 1):S28.
Hurst RT, Lee RW: Increased incidence of coronary
atherosclerosis in type 2 diabetes mellitus: Mechanisms
and management. Ann Intern Med 2003;139(10):824-834.
Last modified 02/05


18. The threshold fasting plasma glucose level
recommended for confirming the diagnosis of diabetes
mellitus is
____ mg/dL


American Diabetes Association: Diagnosis and classification
of diabetes mellitus. Diabetes Care 2008;31(suppl 1):S55S60.
Last modified 02/05


19. A type 2 diabetic is found to have an LDL-cholesterol level of
140 mg/dL, an HDL level of 45 mg/dL, and a triglyceride level of
425 mg/dL.
Which one of the following lipid-lowering agents should be avoided
in this patient because of its effect on serum triglycerides?

A) Cholestyramine (Questran)

B) Atorvastatin (Lipitor)

C) Fenofibrate (Tricor, Lofibra)

D) Nicotinic acid

E) Ezetimibe (Zetia)


Executive Summary of the Third Report of the National
Cholesterol Education Program (NCEP) on Detection,
Evaluation, and Treatment of High Blood Cholesterol in Adults
(Adult Treatment Panel III). JAMA 2001;285:2486.
Last modified 02/05

20. Endocrinopathies associated with diabetes mellitus
include which of the following? (Mark all that are true.)

o Cushing's syndrome


o Acromegaly

o Pheochromocytoma

o Hyperparathyroidism

o Glucagonoma


American Diabetes Association: Diagnosis and
classification of diabetes mellitus. Diabetes Care
2008;31(suppl 1):S55-S60.
Last modified 02/05

21. According to National Cholesterol Education Program
guidelines, criteria for the diagnosis of metabolic syndrome
include which of the following? (Mark all that are true.)

o A waist circumference >40 inches in a male

o An HDL-cholesterol level � 50 mg/dL in women


o An LDL-cholesterol level � 160 mg/dL

o Serum triglycerides � 150 mg/dL

o Diastolic blood pressure � 85 mm Hg



Sowers JR: Update on the cardiometabolic syndrome.
Clinical Cornerstone 2001;4(2):17.
Expert Panel on Detection, Evaluation, and Treatment of High
Cholesterol in Adults. Executive Summary of the Third Report
of the National Cholesterol Education Program (NCEP) Expert
Panel on Detection, Evaluation, and Treatment of High Blood
Cholesterol in Adults (Adult Treatment Panel III). National
Heart, Lung, and Blood Institute (NHLBI), 2001.
Last modified 5/06

22. A 62-year-old female is diagnosed with type 2 diabetes on the
basis of consecutive fasting plasma glucose levels of 138 mg/dL and
143 mg/dL. Current American Diabetes Association guidelines
recommend which of the following in initial management? (Mark all
that are true.)





o Lifestyle intervention
o Metformin (Glucophage)

o An oral sulfonyurea

o A thiazolidinedione

o Pramlintide (Symlin)


Nathan DM, Buse JB, Davidson MB, et al: Management of
hyperglycemia in type 2 diabetes: A consensus algorithm for
the initiation and adjustment of therapy: A consensus
statement from the American Diabetes Association and the
European Association for the Study of Diabetes. Diabetes Care
2006;29(8):1963-1972.
Last modified 04/08

23. Antidiabetic agents found to be effective in reducing the
progression of impaired glucose tolerance to overt diabetes
include which of the following? (Mark all that are true.)
o Acarbose (Precose)

o Metformin (Glucophage)



o Non-sulfonylurea secretagogues

o Pioglitazone (Actos)

o Orlistat (Alli, Xenical)




American Diabetes Association: The prevention or delay of type 2
diabetes. Diabetes Care 2004;27(suppl 1):S47.
American Diabetes Association: Standards of medical care in diabetes-2008. Diabetes Care 2008:31(suppl 1):S12-S54.
AACE Diabetes Mellitus Clinical Practice Guidelines Task Force: American
Association of Clinical Endocrinologists medical guidelines for clinical
practice for the management of diabetes mellitus. Endocr Pract
2007;13(suppl 1):1-68.
Rao SS, Disraeli P, McGregor T: Impaired glucose tolerance and impaired
fasting glucose. Am Fam Physician 2004;69:1961-8,1971-1972.



DREAM (Diabetes REduction Assessment with ramipril and
rosiglitazone Medication) Trial Investigators: Effect of rosiglitazone on
the frequency of diabetes in patients with impaired glucose tolerance or
impaired fasting glucose: A randomised controlled trial. Lancet
2006;368(9541):1096-1105.
Last modified 04/08


24. A 29-year-old female with polycystic ovary syndrome asks if
you can correct her oligomenorrhea and infertility. Her fasting
glucose level is 100 mg/dL and she has a normal glycosylated
hemoglobin level.
Which of the following diabetes medications have been found to
address these problems? (Mark all that are true.)

o Glyburide (Micronase, DiaBeta)

o Metformin (Glucophage)

o Pioglitazone (Actos)

o Miglitol (Glyset)

o Repaglinide (Prandin)




Nestler JE: Metformin for the treatment of the polycystic
ovary syndrome. N Engl J Med. 2008;358(1):47-54.
Nestler JE, Jakubowicz DJ, Evans WS, Pasquali R: Effects of
metformin on spontaneous and clomiphene-induced
ovulation in the polycystic ovary syndrome. N Engl J Med
1998; 338:1876.
Ehrmann DA, Schneider DJ, Sobel BE, et al: Troglitazone
improves defects in insulin action, insulin secretion, ovarian
steroidogenesis, and fibrinolysis in women with polycystic
ovary syndrome. J Clin Endocrinol Metab 1997;82:2108.
Last modified 02/07


25. A 53-year-old obese male with a history of type 2 diabetes sees you for the first
time. He tells you that his previous physician had him see a dietician and started him on
metformin (Glucophage), 500 mg twice daily. He brings in a copy of his most recent
laboratory tests and you note that his hemoglobin A 1c is 7.7%. He admits he has always
been sedentary, and wonders if it would be worthwhile for him to join an exercise
facility and begin an exercise program.
Which of the following would be appropriate advice? (Mark all that are true.)

o Aerobic exercise can be expected to lower hemoglobin A1c by 1%
o Resistance training has been shown to improve glycemic control

o Combined aerobic and resistance training results in
greater glycemic control

o Aerobic exercise alone may not lower hemoglobin A1c in a diabetic patient who has
already achieved good glycemic control

o Improved glycemic control is seen only in those who exercise and achieve a reduction


in BMI

Sigal RJ, Kenny GP, Boule NG, et al: Effects of aerobic
training, resistance training, or both on glycemic control in
type 2 diabetes: A randomized trial. Ann Intern Med
2007;147(6):357-369.
American Diabetes Association: Standards of medical care
in diabetes--2008. Diabetes Care 2008:31(suppl 1):S12S54.
Last modified 04/08




26. Mark all options below that are true regarding screening for type 2
diabetes, according to current American Diabetes Association guidelines.
o A 2-hour glucose challenge test is the preferred initial screening test for
nonpregnant adults
o Screening at 3-year intervals is recommended in individuals with a BMI
25.0 kg/m, beginning at age 45
o Screening should be considered in all women who have delivered a baby
weighing over 9 lb
o Community screening for diabetes is felt to be valuable and costeffective

o Measurement of hemoglobin A1c has no role in screening for
diabetes 2
American Diabetes Association: Screening for type 2 diabetes. Diabetes
Care 2003;26(suppl 1):S21.
American Diabetes Association: Standards of medical care in diabetes-2008. Diabetes Care 2008:31(suppl 1):S12-S54.
Last modified 04/08







27. A 72-year-old African-American female with a history of hypertension,
stage 3 chronic kidney disease, chronic heart failure, and recurrent urinary
tract infections is found to have type 2 diabetes. A trial of dietary therapy is
unsuccessful. Her laboratory evaluation is notable for a random glucose of
240 mg/dL, a hemoglobin A1c of 8.2%, macroalbuminuria, and a serum
creatinine level of 2.4 mg/dL.
Which one of the following diabetes agents would be most appropriate?
A) Metformin (Glucophage)
B) Glyburide (Micronase, DiaBeta)
C) Pioglitazone (Actos)
D) Sitagliptin (Januva)
E) Repaglinide (Prandin)
Amori RE, Lau J, Pittas AG: Efficacy and safety of incretin therapy in
type 2 diabetes: Systematic review and meta-analysis. JAMA
2007;298(2):194-206.
AACE Diabetes Mellitus Clinical Practice Guidelines Task Force:
American Association of Clinical Endocrinologists medical guidelines
for clinical practice for the management of diabetes mellitus. Endocr
Pract 2007;13(suppl 1):1-68.
Last modified 04/08

28. A significantly higher risk for pre-diabetes and
diabetes has been noted in persons with a body mass index
(BMI) over 25 who are members of which of the following
racial/ethnic populations? (Mark all that are true.)

o African American

o Latino/Hispanic

o Slavic

o Australian

o Pacific Islander


American Diabetes Association: Screening for type 2
diabetes. Diabetes Care 2003;26(suppl 1):S21.
Last modified 02/05

29. Which of the following oral agents should be used with
caution in patients with advanced heart failure? (Mark all that are
true.)

o Thiazolidinediones

o Metformin (Glucophage)

o Sulfonylureas

o Meglitinides

o Alpha-glucosidase inhibitors




Holmboe ES: Oral antihyperglycemic therapy for type 2
diabetes--Clinical applications. JAMA 2002;287:373.
Inzucchi SE: Oral antihyperglycemic therapy for type 2
diabetes--Scientific Review. JAMA 2002;287:360.
The American Association of Clinical Endocrinologists Medical
Guidelines for the Management of Diabetes Mellitus: The
AACE System of Intensive Diabetes Self-Management--2002
Update. Endocrine Practice 2002;8(suppl 1):40.
Last modified 02/05


30. Clinical conditions associated with the insulin
resistance syndrome include which of the following? (Mark all
that are true.)
o Atherosclerotic cardiovascular disease


o Polycystic ovary syndrome

o Acanthosis nigricans

o Nonalcoholic steatohepatitis

o Polycythemia


The American Association of Clinical Endocrinologists Medical
Guidelines for the Management of Diabetes Mellitus: The
AACE System of Intensive Diabetes Self-Management--2002
Update. Endocrine Practice 2002;8(suppl 1):40.
Last modified 02/05






31. True statements regarding aspirin therapy in
patients with diabetes include which of the following?
o The recommended dosage is 325 mg twice daily
o It is recommended for diabetic patients over 40 years of
age
o It is recommended for teenage diabetic patients with
dyslipidemia
o Its use in patients under age 21 years is associated with an
increased risk of Reye's syndrome
o The development of microalbuminuria is a potential
indication for its use


American Diabetes Association: Standards of medical care in
diabetes--2008. Diabetes Care 2008:31(suppl 1):S12-S54.
Last modified 02/05






32. True statements regarding diabetic retinopathy include
which of the following?
o Laser photocoagulation therapy has not been shown to be
of benefit in patients with macular edema
o Aspirin therapy (650 mg/d) has been shown to retard
progression of retinopathy
o Glycemic control has been shown to prevent and delay
progression of retinopathy
o There is no evidence that blood pressure control has a
favorable impact on the progression of diabetic retinopathy
o Panretinal photocoagulation has been shown to reduce
severe visual loss in patients with proliferative retinopathy


Mohammed Q, Gillies MC, Wong TY: Management of
diabetic retinopathy: a systematic review. JAMA
2007;298(8):902-916.
Last modified 02/05
33. List three conditions included in the differential diagnosis
of a high anion gap metabolic acidosis:
__________________
__________________
__________________


Fall PJ: A stepwise approach to acid-base disorders. Practical
patient evaluation for metabolic acidosis and other
conditions. Postgrad Med 2000;107: 249-258.
Last modified 02/05

34. Select the three most effective oral agents for lowering
hemoglobin A1c in diabetic patients.


o Thiazolidinediones

o Metformin (Glucophage)

o Sulfonylureas

o Dipeptidyl-peptidase 4 inhibitors

o Alpha-glucosidase inhibitors


AACE Diabetes Mellitus Clinical Practice Guidelines Task
Force: American Association of Clinical Endocrinologists
medical guidelines for clinical practice for the management of
diabetes mellitus. Endocr Pract 2007;13(suppl 1):1-68.
Last modified 04/08






35. A 67-year-old male with type 2 diabetes is evaluated for
intermittent claudication and is found to have a right ankle-brachial
index of 0.65. He has no history of hypertension and his urine is
negative for microalbuminuria. Mark all options below that are true
in this situation.
o Cilostazol (Pletal) has been shown to improve walking distance
o Supervised exercise therapy has been shown to improve
walking distance

o Evidence supports starting him on an ACE inhibitor

o Peripheral artery disease is an indication for starting aspirin
therapy

o Percutaneous revascularization with iliac artery stenting is as
successful in diabetic patients as in non-diabetic patients


Beckman JA, Creager MA, Libby P: Diabetes and atherosclerosis:
epidemiology, pathophysiology, and management. JAMA
2002;287:2570.
American Diabetes Association: Peripheral arterial disease in
people with diabetes. Diabetes Care 2003;26(12):3333-3341.




Expert Panel on Detection, Evaluation, and Treatment of High
Cholesterol in Adults. Executive Summary of the Third Report of
the National Cholesterol Education Program (NCEP) Expert Panel
on Detection, Evaluation, and Treatment of High Blood
Cholesterol in Adults (Adult Treatment Panel III). National Heart,
Lung and Blood Institute (NHLBI), 2001.
Smith SC Jr, Allen J, Blair SN, et al: AHA/ACC guidelines for
secondary prevention for patients with coronary and other
atherosclerotic vascular disease: 2006 update: Endorsed by the
National Heart, Lung, and Blood Institute. Circulation
2006;113(19):2363-2372.
Last modified 02/05
36. A 28-year-old patient with a 10-year history of type 1
diabetes is found to have reduced vibratory sensation in both feet,
as well as reduced sensation to 10-g monofilament.
Which of the following exercise activities should be recommended?
(Mark all that are true.)
o Swimming
o Jogging
o Bicycling
o Prolonged walking
o Rowing


American Diabetes Association: Physical activity/exercise
and diabetes mellitus. Diabetes Care 2003;26(suppl 1):S73.
Last modified 02/05



37. A 55-year-old male with type 2 diabetes mellitus has a
chronic history of reduced libido and erectile dysfunction. On
examination you note hepatomegaly and mild testicular
atrophy. You perform a nonfasting laboratory workup, with
the following serum levels reported:
Glucose. .......................................................... 250 mg/dL
AST...................................................... 260 U/L (N 10-40)
ALT...................................................... 210 U/L (N 10-55)
FSH. .............................................. 5.0 U/mL (N 1.0-12.0)
LH. ................................................ 8.1 U/mL (N 2.0-12.0)
Testosterone................................ 180 ng/mL (N 280-1250)
What is the most likely diagnosis?
-----------------------------
Brandhagen DJ, Fairbanks VF, Baldus W: Recognition and
management of hereditary hemochromatosis. Am Fam
Physician 2002;65(5):853-860. Last modified 02/05

38. Which one of the following is most effective for raising
HDL levels?

A) Bile acid sequestrants

B) Statins

C) Fibric acid derivatives

D) Nicotinic acid
E) Ezetimibe


Expert Panel on Detection, Evaluation, and Treatment of
High Cholesterol in Adults. Executive Summary of the Third
Report of the National Cholesterol Education Program (NCEP)
Expert Panel on Detection, Evaluation, and Treatment of High
Blood Cholesterol in Adults (Adult Treatment Panel III).
National Heart, Lung and Blood Institute (NHLBI), 2001.
Last modified 02/05










39. A 60-year-old grounds keeper is brought to the emergency department
unconscious. His temperature is 38.1°C (100.6°F) rectally, blood pressure 96/70 mm Hg,
pulse 128 beats/min, and respirations 15/min. The examination is otherwise
unremarkable except for very dry skin and mucous membranes.
Laboratory Findings
Serum sodium.............................. 150 mmol/L (N 135-145)
Serum potassium ........................... 3.1 mmol/L (N 3.5-5.0)
Serum chloride.............................. 112 mmol/L (N100-108)
CO2 .................................................. 26 mmol/L (N 24-30)
Serum glucose. ............................................... 1080 mg/dL
Serum creatinine. ............................. 4.0 mg/dL (N 0.6-1.5)
BUN.................................................... 70 mg/dL (N 8-25) Serum
ketones.................................. small amount present
Which one of the following does he have?
A) Diabetic ketoacidosis
B) Diabetes mellitus with lactic acidosis
C) Diabetes mellitus with sepsis
D) Hyperosmolar, hyperglycemic state
E) Paraldehyde toxicity

American Diabetes Association: Hyperglycemic crises in
diabetes. Dibetes Care 2004;27(1):S94






A 71-year-old male with history of type 2 diabetes and longstanding hypertension sees you because of worsening ankle
edema, weight gain and “getting more winded” when climbing
stairs. His current medications are glipizide (Glucotrol),
10mg/day; pioglitazone (Actos), 30mg/day; extendedrelease metformin (Glucophage XR), 1000 mg/day; acarbose
(Precos), 25 mg three times a day; lisinopril (Prinivil, Zestril),
40 mg/day; and hydrochlorothiazide, 12.5 mg/day.
Which one of his medications is most likely responsible for
his symptoms?
A) Metformin
B) Glipizide
C) Pioglitazone
D) Acarbose




Singh S, Loke YK, Furberg CD: Long-term risk of
cardiovascular events with rosiglitazone: A meta-analysis.
JAMA 2007;298(10):1189-1195.
Lincoff AM, Wolski K, Nicholls SJ, et al: Pioglitazone and the
risk of cardiovascular events in patients with type 2 diabetes
mellitus: A meta-analysis of randomized trials. JAMA
2007;298(10):1180-1188.
U.S. Food and Drug Administration: Manufacturers of some
diabetes drugs to strengthen warning on heart failure
risk. August 14, 2007.
Last modified 04/08
41. Which one of the following types of insulin should never
be mixed with any other form of insulin?
A) Lente

B) Ultralente
C) Insulin glargine
D) NPH
E) Insulin lispro

American Diabetes Association: Insulin administration.
Diabetes Care 2003;26(suppl 1):S121. Last modified 02/05

42. Which one of the following oral agents is most likely to
produce weight loss in the diabetic patient?

A) Thiazolidinediones

B) Metformin (Glucophage
C) Sulfonylureas

D) Meglitinides

E) Alpha-glucosidase inhibitors



Inzucchi SE: Oral antihyperglycemic therapy for type 2
diabetes--Scientific Review. JAMA 2002;287:360.
Nathan DM: Initial management of glycemia in type 2
diabetes mellitus. N Engl J Med 2002;347:1342.
Last modified 02/05

43. What is the minimum degree of weight loss
recommended to reduce the risk of diabetes in a patient with
impaired glucose tolerance?

A) Weight reduction of 2%-4%

B) Weight reduction of 5%-10%

C) Weight reduction of 10%-20%


D) Weight reduction of 20%-30%

E) Achievement of ideal body weight

Tuomilehto J, Lindstrom J, Eriksson JG, et al: Prevention of
type 2 diabetes mellitus by changes in lifestyle among
subjects with impaired glucose tolerance. N Engl J Med 2001;
344:1343.



Diabetes Prevention Program Research Group: Reduction in
the incidence of type 2 diabetes with lifestyle intervention or
metformin. N Engl J Med 2002;346:393-403.
Last modified 02/05

44. A 39-year-old female with type 2 diabetes develops
microalbuminuria and is started on enalapril (Vasotec). At a
follow-up visit 2 months later, an electrolyte panel reveals a
normal serum creatinine level of 1.1 mg/dL, but her potassium
level has risen from a baseline of 4.0 mmol/L to its present level
of 5.4 mmol/L (N 3.5-5.0).







Which one of the following is the most likely cause of her
potassium elevation?
A) Diabetic glomerulosclerosis
B) Hyporeninemic hypoaldosteronism
C) Hyperaldosteronism
D) Hemolytic anemia
E) Bilateral renal artery stenosis
American Diabetes Association. Diabetic nephropathy.
Diabetes Care 2003;26(suppl 1):S94. Last modified 02/05








45. A 42-year-old female with a body mass index (BMI) of 31
kg/m2 has a 3week history of polyuria and polydipsia,
accompanied by a 10-lb weight loss. Her fasting plasma
glucose level is 320 mg/dL, and her hemoglobin A1c level is
11.1%.
Initial treatment with which one of the following will reverse
glucose toxicity and improve glycemic response?
A) Metformin (Glucophage)
B) Pioglitazone (Actos)
C) Glipizide (Glucotrol)
D) Acarbose (Precose)
E) Insulin



Holmboe ES: Oral antihyperglycemic therapy for type 2
diabetes--Clinical applications. JAMA 2002;287:373.
Nathan DM, Buse JB, Davidson MB, et al: Management of
hyperglycemia in type 2 diabetes: A consensus algorithm for
the initiation and adjustment of therapy: A consensus
statement from the American Diabetes Association and the
European Association for the Study of Diabetes. Diabetes Care
2006;29(8):1963-1972.
Last modified 02/05





46. A 66-year-old white male has a 10-year history of type
2 diabetes and a history of coronary heart disease, and
underwent percutaneous transluminal angioplasty 2 years
ago. At a routine visit, his lipid profile reveals an LDLcholesterol level of 103 mg/dL, an HDL-C level of 32 mg/dL,
and a serum triglyceride level of 160 mg/dL.
Which one of the following lipid-lowering agents has been
shown to reduce the risk of a major cardiovascular event in
patients such as this?
A) Nicotinic acid (Niacin)
B) Gemfibrozil (Lopid)
C) Colestipol (Colestid)
D) Ezetimibe (Zetia)



Rubins HB, Robins SJ, Collins D, et al: Gemfibrozil for the
secondary prevention of coronary heart disease in men with
low levels of high-density lipoprotein cholesterol: Veterans
Affairs High-Density Lipoprotein Cholesterol Intervention
Trial Study Group. N Engl J Med 1999;341:410.
American Diabetes Association: Standards of medical care in
diabetes--2008. Diabetes Care 2008:31(suppl 1):S12-S54.
Last modified 04/08

47. Patients must eat within 15 minutes of administration of
which one of the following types of insulin?
A) Lente

B) Ultralente

C) Insulin glargine

D) NPH
E) Insulin lispro
American Diabetes Association: Insulin administration.
Diabetes Care 2003;26(suppl 1):S121. Last modified 02/05





48. The United Kingdom Prospective Diabetes Study found
which one of the following interventions to be most effective
in reducing the risk of stroke and heart failure in diabetics?
A) Good glycemic control
B) Aggressive treatment of mild-to-moderate hypertension
C) Aggressive treatment to lower triglyceride levels and raise
HDL levels

D) Aspirin therapy

E) Use of an ACE inhibitor


American Diabetes Association: Implications of the United
Kingdom Prospective Diabetes Study. Diabetes Care
2003;26(supp 1):S28
Last modified 02/05

49. You are evaluating a patient with diabetes and
hypertension with 24 hour ambulatory blood pressure
monitoring. You note a rise in systolic blood pressure during
sleep. This has been shown to be an early indicator of which
one of the following?

A) Microalbuminuria

B) Orthostatic hypotension
C) Gustatory sweating
D) Proliferative diabetic retinopathy

E) Systolic hypertension


Lurbe E, Redin J, Kesani A, et al: Increase in nocturnal blood
pressure and progression to microalbuminuria in type 1
diabetes. N Engl J Med 2002:347:797.
Last modified 02/05






50. The strongest predictor for the development and
progression of diabetic retinopathy is
A) Glycemic control
B) Blood pressure
C) Lipid levels
D) Duration of disease
E) Smoking history


American Diabetic Association: Diabetic Retinopathy.
Diabetes Care 2003;26(suppl 1):S99.
Lightman S, Towler HMA: Diabetic retinopathy. Clinical
Cornerstone 2003;5(2):12. Last modified 02/05

51. The most common cause of sudden monocular loss of
vision in a patient with diabetic retinopathy is

A) Acute glaucoma

B) Vertebrobasilar stroke

C) Central retinal vein occlusion


D) Ischemic optic neuropathy

E) Vitreous hemorrhage
Lightman S, Towler HMA: Diabetic retinopathy. Clinical
Cornerstone 2003;5(2):12. Last modified 02/05






52. A 58-year-old male with type 2 diabetes is started on a twicedaily insulin regimen consisting of 20 units of NPH/10 units of regular
insulin in the morning and 10 units of NPH/4 units of regular insulin in
the evening before dinner. His fasting glucose levels have generally been
in the 140180 mg/dL range, as have his glucose levels just before lunch
and dinner. He complains of frequent midmorning hypoglycemic
episodes requiring midmorning snacks, as well as hypoglycemic
episodes just before bedtime, also requiring snacks.
Which one of the following adjustments is most likely to be effective?
A) Reduce the regular insulin dosage
B) Reduce the NPH dosage
C) Have the patient eat later in the morning and evening
D) Have the patient increase meal sizes at breakfast and dinner
E) Change the patient's regimen to insulin glargine in the evening and
insulin lispro for each meal


DeWitt DE, Hirsch IB: Outpatient insulin therapy in type 1
and type 2 diabetes mellitus: scientific review. JAMA
2003:289:2254.
Hirsch IB: Insulin analogues. N Engl J Med 2005;352(2):174183. Last modified 02/05





53. A 16-year-old male has a 1-week history of
polyuria, polydipsia, and polyphagia. On laboratory evaluation
he is found to have a serum glucose level of 270 mg/dL, a
serum bicarbonate level of 9 mEq/L (N 22-26), a serum pH of
7.0, and a serum potassium level of 4.0 mmol/L (N 3.5-5.0).
Which one of the following most accurately describes this
patient's total body potassium?
A) Mild total body potassium excess
B) Normal total body potassium stores
C) Mild total body potassium deficiency
D) Severe total body potassium deficiency

Kitabchi A, Umpierrez GE, Murphy MB, et al: Management
of hyperglycemic crises in patients with diabetes. Diabetes
Care 2001;24(1):131.
Rastergar A, Soleimani M: Hypokalemia and hyperkalemia.
Postgrad Med J 2001;77(914):759
764.

Last modified 05/06








54. A 58-year-old male with type 2 diabetes mellitus has a
blood pressure of 147/92 mm Hg. You start him on benazepril
(Lotensin) and order a baseline serum creatinine level, which is
1.7 mg/dL. Two weeks later his blood pressure is 128/80 mm
Hg, and his serum creatinine level is 2.1 mg/dL. His creatinine
level is unchanged 1 week later.
Which one of the following is the most appropriate course of
action?
A) Continue benazepril at the same dosage
B) Reduce the benazepril dosage
C) Discontinue benazepril
D) Evaluate the patient for bilateral renal artery stenosis
E) Have the patient increase his sodium intake


Palmer BF: Renal dysfunction complicating the treatment of
hypertension. N Engl J Med 2002;347:1256.
Last modified 02/05

55. Mechanisms of action of exenatide (Byetta) include
which of the following? (Mark all that are true.)

o Enhanced insulin secretion

o Suppression of glucagon secretion

o Enhanced insulin sensitivity of muscle

o Slowing of gastric motility

o Reduction of the rate of polysaccharide digestion in the
small intestine


Nathan DM, Buse JB, Davidson MB, et al: Management of
hyperglycemia in type 2 diabetes: A consensus algorithm for
the initiation and adjustment of therapy: A consensus
statement from the American Diabetes Association and the
European Association for the Study of Diabetes. Diabetes Care
2006;29(8):1963-1972.
Last modified 02/05

56. A 49-year-old female homemaker sees you for her annual examination. Her past
medical history is notable only for a 2-year history of type 2 diabetes and hypertension.
Her current medications are metformin (Glucophage), 500 mg twice daily before
breakfast and dinner, and lisinopril (Prinivil, Zestril), 10 mg once daily. She is a
nonsmoker. Her physical examination is unremarkable, and her blood pressure is
134/82 mm Hg. Laboratory evaluation reveals a serum creatinine level of 0.8 mg/dL (N
0.6-1.5), a hemoglobin A1c of 6.7%, and no microalbuminuria. Her lipid profile includes
an LDL-cholesterol level of 90 mg/dL, an HDL-cholesterol level of 45 mg/dL, and a
serum triglyceride level of 160 mg/dL.







According to current ADA guidelines, which of the following interventions would be
appropriate? (Mark all that are true.)
o
o
o
o
o
Increasing the dosage of metformin
Increasing the dosage of lisinopril
Beginning aspirin, 81 mg/day
Beginning a statin
Beginning a fibric acid derivative



Nathan DM, Buse JB, Davidson MB, et al: Management of
hyperglycemia in type 2 diabetes: A consensus algorithm for
the initiation and adjustment of therapy: A consensus
statement from the American Diabetes Association and the
European Association for the Study of Diabetes. Diabetes Care
2006;29(8):1963-1972.
American Diabetes Association: Standards of medical care in
diabetes--2008. Diabetes Care 2008:31(suppl 1):S12-S54.
Last modified 02/05

57. A 58-year-old obese male comes to your office with
a 2-week history of fatigue associated with polyuria,
polydipsia, and weight loss. You suspect he has type 2
diabetes. This diagnosis would be corroborated by a random
glucose level greater than or equal to


________ mg/dL


American Diabetes Association: Diagnosis and
classification of diabetes mellitus. Diabetes Care
2008;31(suppl 1):S55-S60.
Last modified 02/05








58. A 63-year-old handyman is brought to the emergency
department unconscious. His temperature is 38.1° C (100.6°F) rectally,
blood pressure 90/70 mm Hg, pulse 128 beats/min, and respirations
13/min. The examination is otherwise unremarkable except for very dry
skin and mucous membranes.
Laboratory Findings:
Serum sodium.............................. 150 mmol/L (N 135-145)
Serum potassium............................ 3.2 mmol/L (N 3.5-5.0)
Serum chloride ............................. 107 mmol/L (N100-108)
CO2 .................................................. 22 mmol/L (N 24-30)
Serum glucose. ............................................... 1080 mg/dL Serum
creatinine. ............................. 4.0 mg/dL (N 0.6-1.5)
BUN..................................................... 70 mg/dL (N 8-25)
Serum ketones.................................. small amount present
Adjusting for the hyperglycemia, what is the patient's corrected serum
sodium level?
____________ mmol/L
Kitabchi A, Umpierrez GE, Murphy MB, et al: Management of
hyperglycemic crises in patients with diabetes. Diabetes Care
2001;24(1):131. Last modified 05/06















59. A 16-year-old female is admitted to the hospital with a 1-week history of
polyuria, polydipsia, and polyphagia. Examination reveals a lethargic, volumedepleted female with the smell of acetone on her breath. Her blood pressure is
96/70 mm Hg, her pulse rate is 120 beats/min, and she has Kussmaul
respirations at a rate of 32/min.
Laboratory Findings
Serum glucose. ................................................ 525 mg/dL
Serum sodium............................... 122 mEq/L (N 135-145)
Serum potassium............................ 3.1 mmol/L (N 3.5-5.0)
Chloride........................................ 95 mmol/L (N 100-108)
CO2 .................................................... 7 mmol/L (N 24-30)
Arterial blood gases
pH. ................................................... 7.10 (N 7.35-7.45)
pCO2 . ............................................. 15 mm Hg (N 35-45)
pO2 . .............................................. 98 mm Hg (N 80-100)
After initiation of intravenous fluid therapy, which one of the following should be
done next?
A) Initiation of insulin therapy
B) Potassium replacement
C) Bicarbonate therapy
D) Phosphate therapy
E) Dexamethasone therapy
American Diabetes Association: Hyperglycemic crises in
diabetes. Diabetes Care (2004;27 (1):S94
Last modified 05/06


60. A 64-year-old male stockbroker has a 5-year history
of type 2 diabetes. He underwent percutaneous transluminal
coronary angioplasty (PTCA) 3 years ago for a right coronary
artery lesion. NCEP guidelines now recommend what LDLcholesterol level as the target level for this patient?
_____ mg/dL




Grundy SM, Cleeman JI, Merz CNB, et al: Implications of the recent
clinical trials for the National Cholesterol Education Program Adult Treatment
Panel III Guidelines. Circulation 2004;110:227
239.
American Diabetes Association: Standards of medical care in diabetes-2008. Diabetes Care 2008:31(suppl 1):S12-S54.
Last modified 05/06


Copyright © 2008 American Board of Family Medicine, Inc. Version 01.02.06
Last modified: 04/08