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7/26/2019 Post PETwith Answers

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ost ET

1. Mr. Shields is a 42-year-old man with recently diagnosed type 2 diabetes. His initial bloodpressure was 150/5 mm Hg. !espite urging "rom his physician the patient re"usespharmacologic therapy "or hypertension# instead insisting on a trial o" li"estyle modi"ication. $"ter% wee&s his repeat blood pressure was 140/%5 mm Hg.

'hich o" the "ollowing statements is true(

a) *he obser+ed blood pressure reduction i" maintained o+er the long-term is associated withsigni"icant reduction in morbidity and mortality "rom cardio+ascular conditions.

b) *he patient re,uires immediate pharmacologic therapy to lower blood pressure to targets in order to appreciate signi"icant change in deaths related to diabetes.

c) *he obser+ed blood pressure reduction i" maintained o+er the long-term is associated with areduction in macro-+ascular complications but not micro-+ascular complications.

d) *he patient is at target "or blood pressure control in diabetics without e+idence o" endorgan damage and should be "ollowed closely to ensure he maintains this le+el o" control.

Pharmacological blood pressure lowering in persons with diabetes mellitus

results in reductions in micro- and macro-vascular complications as well as in

deaths related to diabetes mellitus and overall mortality.

Correct answer: a

2. $ 45 year old man presents with "or "ollow-up e+aluation o" ele+ated blood pressures noted ontwo pre+ious eaminations). n eam his blood pressure is again ele+ated at 150/0.3aboratory e+aluation re+eals a "asting glucose o" 122.

'hich o" the "ollowing is true in regards to antihypertensi+e drug therapy "or this patient(

a) *hiaide diuretics are contraindicated because they ha+e been associated with an increased

ris& o" de+eloping diabetes mellitus.b) -bloc&ers are contraindicated because they ha+e been associated with an increased ris& o"

de+eloping diabetes mellitus.c) $6 inhibitors and angiogenesis receptor bloc&ers may decrease this patient7s ris& o"

de+eloping diabetes mellitus.d) alcium channel bloc&ers are contraindicated in metabolic syndrome.

Both thiazides and beta-blockers have been linked to an increased risk o

developing diabetes in persons initially ree o diabetes who are treated with

these agents over the long-term. !CE inhibitors and !"Bs have been shown in

several studies to reduce the risk o new diabetes cases by # $%&. !CE

inhibitors improve insulin sensitivity and' in some studies' have been associatedwith increased risk o hypoglycemia' but typically do not aect asting glucose

levels. "elative to beta-blockers' angiotensin receptor blockers have a reduced

risk o diabetes development in patients treated or hypertension ()*+E ,tudy.

!CE inhibitors provide their greatest protection relative to calcium antagonists

and other agents in the setting o heavy proteinuria. !CE inhibitors do not

appear to preserve kidney unction better than calcium antagonists in diabetics

without heavy proteinuria (!BC study. !ngiotensin receptor blockers protect

the kidney better (proteinuria' E," incidence' doubling o serum creatinine

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than calcium antagonist-based regimens (*/T study. There is no evidence that

calcium channel blocker adversely aect patients with the metabolic syndrome.

Correct answer: c

8. ' is a 59-year-old woman with diabetes mellitus "or the last 10 years. Her glycemic control hasbeen ecellent since her diagnosis. Her body mass inde M:) is 84 &g/m2. *hough she "ollows

a diabetic diet# her sodium inta&e remains relati+ely unrestricted. lood pressure control hasbeen poor ranging "rom 15% ; 19 mm Hg systolic and between


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The !! Clinical Practice 6uidelines recommend ophthalmologic evaluation or

all Type diabetes who have had diabetes or at least $ years and in all patients

with Type 4 diabetes. ! ma;or dierence between type and type 4 diabetes

mellitus is that many persons with type 4 diabetes have had the disease or many

years prior to diagnosis

Correct answer: a

5. Mrs. @ is a 85-year-old $"rican $merican woman who presents to the o""ice with complaints o"polyuria# polydipsia and intermittent blurred +ision. She is o+erweight and states she was ne+erable to lose the weight she gained with her pregnancy. Her son# now age 8# weighed pounds 4ounces at birth.

'hich o" the "ollowing tests could be used to diagnose diabetes in Mrs. @(

a) Aasting glucose o" 140b) 1-hour post-prandial glucose o" 10 mg/dlc) $ random glucose o" 195d) Hgb $1 o" 10.0B

The revised criteria or diabetes mellitus include either a casual glucose o

< 4%% mg=dl repeated on a subse1uent day or 4 a casual glucose o < 4%% mg=dl in a

patient with symptoms o diabetes (polyuria' polydipsia' and une>plained weight

loss or $ a asting (no caloric intake or ? hours glucose o < 4@ mg=dl conirmed

on a subse1uent day. /ormal asting glucose is A % mg=dl. +asting glucose o %

5 4 mm g are considered impaired asting glucose. *n its early stages' diabetes

is a post-prandial rather than a asting disease. That is' asting glucose levels will

oten be normal despite post-prandial elevations in glucose levels. !lthough

hemoglobin !C is elevated in many patients with diabetes and is used to document

metabolic control' there are no diagnostic criteria available or diabetes using this

measure. Thus' until the diagnosis o diabetes is made' there is no clear rationaleor ordering hemoglobin !C levels. This test provides an integrated look at glucose

levels over the previous 4 5 $ months. /evertheless' it is very likely that a

hemoglobin !C o ?.%& does actually represent poor glycemic control and clinical

diabetes. ! -hour postprandial glucose is not diagnostic o diabetes mellitus.

Correct answer: a

9. Mrs. @ returns to the o""ice to discuss the results o" her blood wor&. *he "asting glucose done last+isit was 140 mg/dl. Her "asting glucose today is 190 mg/dl. !uring your discussion o" herlaboratory results Mrs. @. relates trying to diet and says that she lost "i+e pounds since her last

+isit. She still# howe+er# complains o" polyuria and polydipsia. $"ter a lengthy discussion thepatient elects to begin medical therapy.

'hich o" the "ollowing hypoglycemic drugs has been associated with weight gain(

a) Clargine :nsulinb) Sul"onylureasc) *hiaolidinedionesd) $ll o" the abo+e

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9etormin has been associated with weight loss. Both sulonylureas and insulin

have been associated with weight gain. TDs have also been associated with

weight gain and edema however' redistribution o at has been noted away rom

the visceral depots to the subcutaneous region and peripheral depots. Though

she has lost pounds' one concern is that this may not solely relect her dietary

eorts but rather may be related to her persistently catabolic state attributable

to unabated hyperglycemia.

Correct answer: d


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d) $D

!CE inhibitors' angiotensin receptor blockers' and aldosterone antagonists all

can increase serum potassium. There is some evidence that angiotensin

receptor blockers increase potassium less than !CE inhibitors do. Both thiazide

diuretic and loop diuretics may cause hypokalemia and are not known to cause

hyperkalemia under normal circumstances. Calcium channel blockers are

unlikely to aect potassium homeostasis.

Correct answer: a

. Mrs. Miller returns to the o""ice to discuss her lipid pro"ile. Her "asting 3!3 cholesterol is 110# H!3is 20# and triglycerides are 250.

'hich o" the "ollowing is true(

a) *riglycerides are ele+ated# H!3 is normal# and her 3!3 is at goal le+els.b) *riglycerides are normal# H!3 is low# and her 3!3 is abo+e goal le+els.c) *riglycerides are ele+ated# H!3 is low# and her 3!3 is abo+e goal le+els.

d) *riglycerides are normal# H!3 is normal# and her 3!3 is below goal le+els.

!TP *** recommended aggressive lipid lowering therapy or patients with an

absolute % year risk o clinical coronary disease o < 4%&. Patients with

diabetes are considered to have a Hcoronary heart disease e1uivalent.I The

/CEP=!TP *** recommends a target )) cholesterol o less than %% or all

patients with diabetes whether or not clinical coronary disease is present. This

is the same ))-C goal or persons with known coronary heart disease.

Triglyceride levels should be less than % mg=dl. !verage ) level or a middle-

aged woman is # mg=dl' so her ) is low. *n addition' and an ) level A% is

considered to be an independent risk actor or coronary artery disease.

Correct !nswer: c

10. 'hich o" the "ollowing medications should not be prescribed during pregnancy(

a) $6 inhibitorsb) Met"orminc) $carbosed) :nsulin

Pregnancy in diabetic patients should be planned. iscussions with patients

should include planning or pregnancy and ad;ustment o medication to minimize

risks to the etus while maintaining the health o the mother. !CE inhibitors are

category C in the irst trimester (maternal beneit may outweigh etal risk in

certain situations' but category in later pregnancy' and should be discontinued

prior to pregnancy. ,tatins are pregnancy category 3 and should be discontinued

prior to conception or as soon as the woman is ound to be pregnant.

Correct answer: a

11. Mrs. @7s Hgb$1 at the time her pregnancy is diagnosed is 4.%B

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'hich o" the "ollowing statements are true(

a) Mrs. @ is no longer a diabeticb) Mrs. @ has an increased ris& "or deli+ering a diabetic in"ant.c) Mrs. @7 baby has increased ris& li&elihood or ha+ing congenital mal"ormations.d) Mrs. @7s baby has a no increased li&elihood o" ha+ing congenital mal"ormations.

The ma;ority o pregnancies in women with diabetes are unplanned. This is very

unortunate because maternal hyperglycemia is associated with an increased

rate o etal malormations.

!ll women with diabetes and childbearing potential should be educated about the

need or good glucose control beore pregnancy and instructed in eective

contraception at all times unless the patient is in good metabolic control and

actively trying to conceive. emoglobin !C should be normal or as close to

normal as possible in an individual beore conception is attempted.

9etormin and acarbose are pregnancy category B

CATEGORY INTERPRETATION

A CONTROLLED STUDIES SHOW NO RISK.$de,uate# well-controlled studies inpregnant women ha+e "ailed to demonstrate a ris& to the "etus in any trimester o"pregnancy.

B NO EVIDENCE OF RISK IN HUMANS. $de,uate# well-controlled studies inpregnant women ha+e not shown increased ris& o" "etal abnormalities despitead+erse "indings in animals# or# in the absence o" ade,uate human studies#animal studies show no "etal ris&. *he chance o" "etal harm is remote# but remainsa possibility.

C RISK CANNOT BE RULED OUT.$de,uate# well-controlled human studies arelac&ing# and animal studies ha+e shown a ris& to the "etus or are lac&ing as well.*here is a chance o" "etal harm i" the drug is administered during pregnancy? butthe potential bene"its may outweigh the potential ris&s.

D POSITIVE EVIDENCE OF RISK. Studies in humans# or in+estigational or post-mar&eting data# ha+e demonstrated "etal ris&. e+ertheless# potential bene"its"rom the use o" the drug may outweigh the potential ris&. Aor eample# the drugmay be acceptable i" needed in a li"e-threatening situation or serious disease "orwhich sa"er drugs cannot be used or are ine""ecti+e.

X CONTRAINDICATED IN PREGNANCY. Studies in animals or humans# orin+estigational or post-mar&eting reports# ha+e demonstrated positi+e e+idence o""etal abnormalities or ris&s which clearly outweighs any possible bene"it to the

patient.

NA = None ass!ne"

Correct answer: d

12. $ 40 year old woman with diet controlled *ype 2 diabetes is seen "or e+aluation. $"ter completingyour history and physical eamination and re+iewing pre+ious records you "eel con"idant thepatient has no e+idence o" end-organ damage. 3aboratory studies re+eal a Hgb $1c o" 9.5B and3!3 cholesterol to be 120.

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'hich o" the "ollowing would you recommend(

a) egin clopidogrel to pre+ent cardio+ascular e+ents.b) egin 825 milligrams $S$ daily to decrease cardio+ascular e+ents.c) egin aspirin and lo+astatind) egin lo+astatin and clopidogrel to pre+ent cardio+ascular e+ents.

!spirin (J-$4 mg=d is recommended in all adult patients with diabetes and

macrovascular disease. *t should be considered in patients older than orty with

diabetes and possibly as young as thirty with additional cardiovascular risk

actors. !spirin is contraindicated in patients less than 4 years o age

secondary to concerns about "eyes ,yndrome. Clopidogrel should be considered

in patients who are aspirin intolerant.

Correct answer: c

18. Mrs. @7s brother# age 50# presents to your o""ice "or an initial e+aluation. She is asymptomatic.She is a large woman. Her weight is 1% and her calculated M: is 80. 'aist circum"erence is

8% inches. lood pressure is 185/%% mm Hg. Aasting glucose is 112 mg/dl# triglycerides are 1cellentcandidate or oral glucose tolerance testing. +urthermore' diagnosing diabetes

would modiy targets or blood pressure and lipids.

Correct answer: b

14. $ 40 year old man with *ype 2 diabetes wants to begin eercising. He has ne+er been athleticand is interested in something easy and not too +igorous. $"ter a thorough history and physicaleamination you "ind Mr. @ to be mildly o+erweight M: 2%) but otherwise healthy. His bloodpressure is 12%/%0. Hgb$1 is 9..

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$t this time you would ad+ise Mr. @ to

a) Start slow and gradually ad+ance to a modest eercise program.b) rder a 12 lead 6EC# stress test and echocardiogram.c) rder an eercise stress test.d) rder a cardiac calcium scan.

There are no speciic recommendations advocating the use o screening 4 lead

EK6s in asymptomatic diabetics. The !! Clinical Practice 6uidelines states

candidates or screening e>ercise stress testing include patients with either

atypical cardiac symptoms' 4 an abnormal resting EC6' $ a history or peripheral

or carotid occlusive disease' 7 sedentary liestyle age ercise program or those with two or more risk actors noted above.

There is' however' no current evidence that e>ercise testing in asymptomatic

patients with risk actors improves prognosis.

*t is advisable or sedentary patients to begin their e>ercise program slowly

beore advancing to a vigorous program. * 9r. 3 wanted to proceed with a

vigorous program' a resting EK6 and an e>ercise stress test are indicated.

Correct answer: a

15. Mr. @ started wal&ing e+ery night a"ter dinner. Decently he noticed some chest hea+iness a"terwal&ing "or 2-8 minutes. He denies "ran& pain but states now unable to "inish his wal&.

$t this point you would

a) Schedule a eercise stress testb) btain a lipid pro"ile.c) :nitiate aspirin F 825 mg per dayd) :nitiate aspirin F 825 mg per day# order a lipid pro"ile and schedule a pharmacologic stress

test.

9r. 3 has a classic history o angina pectoris. *t would be appropriate to begin

aspirin i this was not already done. *n addition' assessment o lipids is

appropriate in all diabetics and in particular in patients with vascular disease.

!n e>ercise stress test is may not achieve a high enough degree o sensitivity i

the patient cannot e>ercise. ! pharmacological stress test would be an

acceptable alternative.

Correct answer: d

19. Mr. =hillips is a 95-year-old white man with a three-year history o" *ype 2 diabetes. He returns tothe o""ice "or re-e+aluation o" his blood pressure. *hree months ago his blood pressure was"ound to be 15%/%0. *oday he is asymptomatic. He is currently "ollowing an 1%00-calorie $!$diet. He has "inally achie+ed ideal body weight. His last Hgb$1 was


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b) :t is li&ely that this patient will re,uire at least two drugs o" di""erent classes to ade,uatelycontrol his blood pressure.

c) *his patient is doing well and should be encouraged to continue his present dietary program.Aollow-up should be arranged in 8 months.

d) *his patient should be started on an $6 inhibitor to achie+e a blood pressure o" less than180/%0.

Patients with diabetes are at increased risk or coronary events. Part o this risk

is related to associated cardiovascular risk actors such as hypertension.

iabetics with hypertension have twice the risk o cardiovascular disease when

compared with non-diabetic with hypertension. (Clinical Practice

"ecommendations 4%%

)iestyle modiication should be recommended or all patients with diabetes and

elevated blood pressure. This should include a low-sodium (A 4g=d' low-saturated

at (A %& to total daily at intake' low-cholesterol diet. *n addition' patients

should be strongly counseled to 1uit smoking restrict alcohol consumptions'

achieve ideal body weight and participate in regular aerobic e>ercise.

9ulti-drug therapy is the rule to attain a goal blood pressure when the blood

pressure is above =% mmg above the target goal blood pressure. The target

blood pressure or diabetic patients is less than $%=?%(F/C G**. 2ne should not

settle or suboptimal control. !CE inhibitors or angiotensin receptor blockers are

the antihypertensive drugs o choice in persons with diabetes.

Correct answer: d

1cretion is

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< L %% mg=day. !nother alternative would be to measure the albumin:creatinine

ratio on a spot urine. +irst morning void urines are the best' however' random

urines are acceptable or spot albumin or protein measurements.

9ost patients with diabetes and hypertension re1uire multiple medications to

control blood pressure. iuretics are essential to the multi-drug HcocktailI when

< 4 antihypertensive medications are prescribed.

The correct answer is d .

1%. Mrs. ones is a 50-year-old $"rican $merican woman who presents "or assistance with weightloss. She has always been o+erweight but gained 20 pounds a"ter her husband died 8 monthsago. She states she sits at home drin&ing lemonade and loo&ing at the "amily album. =astmedical history is unremar&able. n re+iew o" systems the patient is able to wal& a "light o" stairswithout chest pain# pressure or shortness o" breath. Howe+er# she does complain o" ha+ing to goto the bathroom o"ten and also o" urinary incontinence which she attributes to ha+ing children.Her largest baby was pounds. She does not smo&e. Aamily history is positi+e "or diabetes inher two sisters and mother# hypertension and coronary artery disease. Mrs. ones weighs 1%0lbs. She is 574G. lood pressure is 140/0 and pulse is %0. *he remainder o" the physical

eamination is within normal limits ecept "or trace pedal edema. 3aboratory analysis re+eals arandom glucose o" 145 mg/dl# total cholesterol 210 mg/dl# 3!3 125 mg/dl# H!3 50# mg/dl and *C1


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appropriate or both hypertension and dyslipidemia. owever' according to the

/CEP=!TP *** guidelines' liestyle modiication or @ weeks is appropriate. This

should be ollowed by reevaluation o ))-C and either' intensiication o

therapeutic liestyle changes (T)C' or initiation o medical therapy. *n addition'

i this patient is in act diagnosed with diabetes (conirmation o elevated asting

glucose on a subse1uent visit' then the patient should be treated with both T)C

and pharmacologic therapy to achieve a blood pressure o A $%=?% mm g.

)iestyle modiication alone is only recommended or diabetics with bloodpressure o $%-$=?%-? and only or a ma>imum o three months. The target

goals outlined in /CEP=!TP *** and F/C G* or patients with diabetics are

recommended to modiy the elevated risk or cardiovascular disease associated

with diabetes.

Correct answer: d

1. Mr. Deynolds has longstanding type 2 diabetes. rine "or microalbuminuria demonstrated 8%0micrograms per milligram o" creatinine. *oday his blood pressure is 199/2 and his creatinine is1.9 mg/dl.

'hich o" the "ollowing statements are true(

a) !iuretic therapy is indicated to reduce albuminuria.b) Deduction o" blood pressure is important to capture the re+ersible component o"

microalbuminuria.c) :nitiation o" an $D will delay the progression o" nephropathyd) *reatment with an $6 will delay the progression to microalbuminuria

!CE inhibitors slow progression o diabetic nephropathy in both Type and Type

4 diabetes. !CE inhibitors decrease glomerular capillary pressure by decreasing

arterial pressure and selectively dilating the eerent glomerular more so than

the aerent arteriole. !"B, have recently been shown to decrease progressiono diabetic nephropathy in persons with type 4 diabetes mellitus. !"BMs do have

a stronger database that !CE inhibitors supporting their use in diabetic

nephropathy' especially heavy (more than microalbuminuria proteinuria patients.

There are no long-term studies o the eect o alpha-blockers' loop diuretics or

centrally acting agents on the long-term complications o diabetics.

/evertheless' the overwhelming evidence is in avor o obtaining blood pressure

control as an eective means or preventing micro- and macro-vascular

complications. These drugs should be used as ad;unctive therapy to better

studied drugs in persons with diabetes such angiotensin receptor blockers' !CE

inhibitors' calcium antagonists' and thiazide diuretics. iuretics are alsoimportant drugs when attempting to control blood pressure in comple> (pansion o e>tracellular luid volume that antagonizes

blood pressure lowering with many antihypertensive agents.

ihydropyridine calcium blockers selectively dilate aerent arterioles and can

result in increase in intraglomerular pressures. +or this reason they are not

avored in the management o hypertension in diabetics with severe reductions in

kidney unction or with proteinuria 5 unless there is simultaneous use o an !"B

or an !CE. The "E/!!) study demonstrated the saety o adding a

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dihydropyridine calcium antagonist to losartan' an !"B' in person with diabetic

nephropathy and heavy proteinuria. There was no diminution o the eect o the

!"B on preservation o kidney unction when this combination was used. Though

rate-lowering calcium antagonists such as verapamil and diltiazem theoretically

cause less preerential dilation o the aerent arteriole' there are no long-term

clinical studies showing their impact on clinical outcomes such as doubling o

serum creatinine or development o E," .

This patient already has microalbuminuria. Thereore the correct answer is

Correct answer: c

20. Mr. Deynolds is a 40 year old man. He was started on hydrochlorothiaide and an $6 inhibitorthree wee&s ago. He returns to clinic "our wee&s later. $t this +isit his blood pressure is 150/0mm Hg down "rom 190/0). He is howe+er# complaining o" some diiness# especially early inthe morning that comes and goes throughout the remainder o" the day.

$t this point you would you wouldI

a) !iscontinue his antihypertensi+e medication and ree+aluate his blood pressure in one month.b) Deassure him.c) !iscontinue the diuretic but continue the $6 inhibitor.d) 6+aluate him "or pheochromocytoma.

2verall' it is oten very diicult to control blood pressure in diabetics with

nephropathy. *t also takes 7 - @ or sometimes ? weeks to see the ma>imal blood

pressure lowering eect when a drug is prescribed. e has only been on his dual

therapy or a ew weeks. 6iven the height o his BP elevation above his goal BP

(A$%=?% mm g you can up-titrate his medication' add another drug' or watch his

BP on his current dose or a ew more weeks. *t is very likely that he will need

another second drugN yet gradually lowering blood pressure will minimize sideeects as blood pressure is reduced. 2n the other hand' at eight weeks it is

unlikely that his BP will have allen to goal with either watching him or a ew more

weeks or up titrating his medication dose. This is a ;udgment call 5however' there

is no immediate payo in lowering BP too rapidly. * it takes you three or our

months to get his BP to goal' you shouldnMt worry. Thus' reassuring him is ine.

Patients re1uently re1uire multiple medications to achieve blood pressure targets.

6enerally a diuretic should be added to an !CE or !"B prior to adding a calcium

blocker' e>cept where contraindicated. iabetic patients should always have

orthostatic blood pressure changes measured given their propensity to autonomic

neuropathy. There is no reason to stop his current medication or to evaluate him

or pheochromocytoma. is dizziness might be related to his blood pressureelevation' to the all in his blood pressure' or his medication.

Correct answer: b

21. Mr. Santiago is a 40-year old man with a ten-year history o" diabetes mellitus# hypertension andhypercholesterolemia and recently diagnosed coronary heart disease. His medications includemet"ormin# a statin# metoprolol# chlorthalidone# and $6 inhibitor. He saw the ophthalmologistyou re"erred him to last wee& and has the consultati+e report "or you to see. $ccording to theophthalmologist he has Jnon-proli"erati+e retinopathyG with e+idence o" dot and blot hemorrhages.

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'hich o" the "ollowing medications are contraindicated in Mr. Santiago(

a) $spirinb) lopidorgrelc) Sildena"ild) one o" the abo+e

The Early Treatment o iabetic "etinopathy ,tudy (ET", investigated whether

aspirin (@% mg=day could retard the progression o retinopathy. !ter e>amining

progression o retinopathy' development o vitreous hemorrhage' or duration o

vitreous hemorrhage' aspirin was shown to have no eect on retinopathy. There

are no ocular contraindications to the use o aspirin when re1uired or

cardiovascular disease or other medical indications.

Correct answer: d

22. $ 94 year old patient has *ype 2 !iabetes and microalbuminuria. 'hich o" the "ollowinginter+entions will reduce urinary albumin ecretion(

a) :ncreased sodium inta&eb) se o" an $6 inhibitorc) Deduction in potassium inta&ed) 6nhanced "luid inta&ee) $ll o" the abo+e

!CE inhibitors and !"BMs reduce urinary protein e>cretion. owever' they cannot

ma>imally reduce urinary albumin e>cretion in the setting o unrestricted sodium

intake. ecreased sodium intake will act with !CE and !"B, to reduce

proteinuria. *ncreased adiposity elevates urinary protein e>cretion. ecreasing

adiposity will decrease urinary albumin e>cretion. Thereore' 6lycemic control is

well established as an eective strategy to reduce urinary protein e>cretion.

2ther eective strategies to reduce proteinuria include smoking cessation andlowering o blood pressure.

Correct answer: b

28. $ patient presents "or "ollow-up e+aluation. She is 45 years old and has long standing *ype 2diabetes# hypertension and hyperlipidemia. Her blood pressure today is 190/2 mm Hg a le+elthat is similar to pre+iously documented clinical +isits. Her calculated M: is 80 &g/m2. Aastingglucose is 2%0 mg/dl. Her hemoglobin $1 is 11.%B. Her lipid pro"ile isK 3!3 cholesterol is 145mg/dl# H!3 cholesterol is 44 mg/dl and triglycerides are 800.


a) egin li"estyle modi"ication# and initiate treatment "or diabetes with met"ormin.b) egin li"estyle modi"ication# pharmacologic treatment "or hypertension# met"ormin# a

thiaolidinedione# a statin and aspirin.c) egin li"estyle modi"ication# pharmacologic treatment "or hypertension# sul"onyluria and a

statin.d) Airst control her diabetes and then discuss treatment "or her hypertension and hyperlipidemia.

!ccording to F/C G**' all patients with diabetes and ,tage 4 hypertension should

be started on pharmacologic therapy. +urthermore' although the !! practice

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6uidelines recommends repeat blood pressure measurement in one month to

conirm hypertension' they recommend immediate pharmacologic treatment or

all patient with blood pressures


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25. :n patients with *ype 2 diabetes recei+ing statins "or lipid lowering# which o" the "ollowing is to beepected(

a) Deduction in proteinuriab) Deduction in stro&e ris&c) 6nhanced erectile "unctiond) :mpro+ed glycemic control

,tatins reduce both coronary and stroke risk. 0nortunately they have not been

shown to reduce the likelihood o erectile dysunction in patients with

established E or to enhance erectile unction. !lthough theoretically they might

since they improve endothelial unction. !lso' statins might reduce urinary

albumin e>cretion also because o their ability to improve endothelial unction.

2ne study suggested that statins lowered the risk o uture diabetes but no

studies have shown improved glycemic control with statins.

Correct answer: b

29. 'hich o" the "ollowing blood pressure phenotypes is most common in patients with diabetes

mellitus(

a) Systolic N140 and diastolic N0 with normal pulse pressureb) Systolic pressure 180-140# !iastolic O%0# pulse pressure N40c) Systolic N 140# diastolic blood pressure


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loss' and calorie restriction should be encouraged to promote weight loss to a

healthier body weight.

Correct answer: e

PD is a 32-year-old woman who is in her 20 thweek of prenan!y with her first !hild" #he has not had any

prenatal $isits" %er fastin l&!ose le$els' howe$er' ha$e (een at the &pper limits of normal )* 95 m+dl," 75

ram oral l&!ose toleran!e test is o(tained after a 12 ho&r fast" %er fastin plasma l&!ose was 128 m+dl andher 1-ho&r post-l&!ose load plasma l&!ose was 188 m+dl and her 2- ho&r post-load l&!ose was 160 m+dl"Prior to this prenan!y her fastin l&!ose $al&es were all normal at her ann&al physi!als"

2%. How would you classi"y her C**(

,a #he has normal l&!ose toleran!e

,( #he has estational dia(etes

,! #he has de$eloped type 2 dia(etes mellit&s,d .one of the a(o$e

Correct answer: !ccording to the !! 4%% guideline' Hgestational diabetes

mellitus (69 is deined as any degree o glucose intolerance with onset or irstrecognition during pregnancy. The deinition applies regardless o whether

insulin or only diet modiication is used or treatment or whether the condition

persists ater pregnancy. *t does not e>clude the possible that unrecognized

glucose intolerance may have antedated or begun concomitantly with the

pregnancy.I /ormal astingplasma glucose is A mg=dl' -hour post-load

glucose should be A ?% mg=dl' and 4-hour post-load glucose should be A

mg=dl. Ohen two or more o these values are either met or e>ceeded in a woman

where the irst evidence o impaired glucose tolerance is occurring during this

pregnancy' then the diagnosis o gestational diabetes mellitus is made. 6lucose

tolerance typically deteriorates during the third trimester o pregnancy. Oomen'

who are not at low-risk or 69' should be screened at the irst prenatal visit and

retested at 47 - 4? weeks o gestation. Oomen at low risk o 69 including

women who are A 4 years' are o normal body weight' have no irst degree

relative with 9' no history o abnormal glucose tolerance or poor obstetrical

outcome and women who are not members o a racial or ethnic group with high

diabetes prevalence do not re1uire testing or gestational diabetes. 6iven that

this patient is ispanic' she should have been screened at her irst prenatal visit.

Correct answer: b

2. 'hich o" the "ollowing is not true regarding gestational diabetes mellitus(

a) C!M is a ris& "actor "or perinatal morbidity and mortalityb) C!M is a ris& "actor "or de+elopment o" diabetes mellitus later in li"ec) C!M is a ris& "actor "or prolonged gestationd) C!M is a ris& "actor "or cesarean section

69 is a risk actor or all o the above. 69 accounts or # %& o the diabetes

encountered during pregnancy. @-weeks post delivery the mother should be

reclassiied according to standard criteria - normal' impaired asting glucose'

impaired glucose tolerance' or diabetes mellitus.

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Correct answer: c

80. 'hich o" the "ollowing patients should be screened "or diabetes(

a) $ 85 year old ati+e $merican with M: o" 22 &g/m2b) $ 80 year white woman who is physically inacti+e with a M: o" 84 &g/m2c) $ 40 year old $"rican $merican woman with M: o" 24

d) $ 2% year old $"rican $merican man who is physically acti+e and has a M: o" 2%

Testing or diabetes should be considered in all individuals at age 7 years and

above' particularly in those with a B9*


18/26

instead o the normal sigmoidal relationship between systemic blood pressure and

6+"' there is a more linear relationship. Thus' renal perusion pressure is more

closely linked to 6+" than in normal kidneys. ,tated another way' the normal auto-

regulation o renal blood low and 6+" are disrupted. Ohen 6+" and renal blood low

auto-regulation are abnormal' abrupt and=or sizeable drops in BP can cause reductions

in 6+" and thereore elevations in serum creatinine. *n chronic kidney disease the

remaining nephrons also over-e>press C23-4. The over-e>pression o this enzyme

leads to the production o vasodilatory prostaglandins (dilates glomerular aerentarteriole and also augments angiotensin ** synthesis (constricts glomerular eerent

arterioleN this leads to increased glomerular pressure that' i maintained over the

long-term' causes renal in;ury and loss o kidney unction. *n the setting o bilateral 5

not typically unilateral 5 critical renal artery stenosis' drops in BP as well as initiation

o !CE inhibitor therapy can lead to global reductions in 6+" and elevations in serum

creat. There is' however' no evidence that this man has e>perienced a signiicant

drop in BP. /,!*8s including C23-4 inhibitors can lead to reductions in global 6+"' so

ibuproen is a viable suspect. "anitidine is unlikely to have caused the deterioration

in kidney unction. The most likely e>planation or his acute deterioration in kidney

unction is that the bilaterally critically stenosed renal arteries were highly dependent

on vasodilatory prostaglandins and ang ** to maintain 6+" in the underperusednephrons. The !CE inhibitor' maybe in con;unction with the /,!*' interrupted this

compensatory set o mechanisms leading to global reductions in 6+". 2verdiuresis is

the most common cause o deteriorations in kidney unction in persons with chronic

kidney disease ater initiating !CE inhibitor therapy. owever' with a 6+" below the

mid-7%8s' the low-dose thiazide he had been prescribed is not likely to have caused

much' i any' diuresis. Thiazides are typically ineective when the 6+" drops much

below the mid 7%8s.

Best answer: b

82. D$ is a 4%-year-old person with long-standing diabetes mellitus "or the last 10 years. +er thelast 8 years eight hemoglobin $17s ha+e ranged between % ; .B. His blood pressure hasranged 159;10 /


19/26

there is no physiological reason or these agents not to orestall progressive

nephropathy in type 4 diabetes. *n persons with type diabetes mellitus' the data

on orestalling progressive nephropathy belongs to the !CE inhibitorsN however'

there is little reason to believe that angiotensin receptor blockers wouldn8t be

eective in this setting 5 despite the act that the database or their use in type

diabetes mellitus is ar less robust than or !CE inhibitors. ietary sodium

restriction will lower blood pressure. owever' the ma;or problem is getting the

patient to restrict sodium. Thus o the choices available' choice aI is the leastlikely to lead to improvement his blood pressure control.

Best answer: a

88. ** is a 52 year old woman with long-standing diabetes mellitus. Her glycemic control has been,uite good o+er the years. +er the past 8 years# a re+iew o" her chart documents nohemoglobin $17s abo+e


20/26

Best answer: e

85. @ is a 4%-year-old $"rican $merican woman with a 14 year history o" diabetes mellitus. She hasne+er eperienced !E$ nor hyperosmolar coma. Her most recent serum creatinine was 1.4mg/dl 6CAD R 50 ml/min/1.pression o anemia at reduced' though higher 6+"8s' than persons

with reduced 6+" but no diabetes. The anemia o reduced kidney unction'

particularly in persons with diabetes' begins to be maniest at 6+"8s o #@%

ml=min=.J$ m4. /onetheless is prudent to e>clude intermittent 6* bleeding. * these

are positive the patient deserves a diagnostic colonoscopy.

Best answer: c

89. :n a patient with a strong "amily history o" diabetes which approach "or establishing the diagnosiso" diabetes mellitus is most li&ely to con"irm the diagnosis o" diabetes mellitus in its earliest

stages(

a) Measuring hemoglobin $1b) Aasting plasma glucosec) ral glucose tolerance testingd) Measuring glycated hemoglobin

Though hemoglobin !C is used to ollow the course o therapeutic response to

diabetes therapy' no diagnostic criteria are available or using this test to

diagnose diabetes mellitus. iagnostic criteria deinitely e>ist or asting plasma

glucose' however' in its earliest stages' diabetes mellitus is more readily

detected in the post-prandial than in the asting state. ,ome labs measure and

report glycated hemoglobin levels (always higher than hemoglobin !C levels'however' diagnostic criteria or diabetes mellitus do not e>ist or this lab test.

2ral glucose tolerance testing is most likely to detect diabetes mellitus in its

earliest stages.

Correct answer: c

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control o" her "asting and post-prandial glucose le+els. *here has been no e+idence o"retinopathy# although she de+eloped microalbuminuria R 8 years ago. Her medical records nowindicate a progressi+e rise in her "asting and post-prandial blood sugars. Her hemoglobin $1le+els ha+e risen "rom 9.1B to %.%B o+er the last 1% months with no change in diet# stablemedications# and no e+idence o" intercurrent in"ections or other identi"iable stressors. Her weight#diet# and physical acti+ity le+els ha+e remained relati+e constant o+er the last 2 years. urrentmedications include met"ormin 2550 mg/d ta&en in di+ided doses)# pioglitaone 45 mg/d#enalapril 20 mg bid# amlodipine 5 mg/d# $S$ 825 mg/d# and lamisil 250 mg once daily. She saysthat she ta&es her medications e+ery day and rarely misses any doses.

*he most li&ely eplanation "or her deterioration in glucose tolerance is(

a) :ncreasing insulin resistanceb) =rogressi+e insulinopeniac) *he patient is not being entirely truth"uld) Her antihypertensi+e medication

The natural history o persons with Type 4 iabetes 9ellitus is progressive loss

o pancreatic beta-cell insulin secretion. ,ome patients will clearly become

insulinopenic and may even develop symptoms such o polyuria' polydipsia'

polyphagia' weight loss' and visual symptoms i their hyperglycemia becomes

severe enough. *nsulin resistance' per se' is not a suicient cause or diabetesmellitus 5 unless pancreatic insulin secretion is also abnormal. +urthermore' in

this lady there is no evidence that some o the main causes o insulin resistance

such as physical inactivity' high-at diet' and weight gain have changed much

over the last several years. er antihypertensive medications have no eect

(amlodipine' dihydropyridine calcium antagonist on glucose tolerance or actually

improve glucose tolerance (enalparil' an !CE inhibitor. !CE inhibitors typically

do not change asting glucose levels' however' they do improve glucose tolerance

and have been implicated as contributing to the risk o hypoglycemia.

Correct answer: b

8%. 'hich o" the "ollowing drugs) is/are contraindicated in diabetics(

a) thiaide diureticsb) dilantinc) nicotinic acidd) doaosine) one o" the abo+e

Thiazide and other potassium-wasting diuretics may precipitate diabetes or

worsen glycemic control and=or glucose tolerance. /evertheless' they are

important agents in the management o hypertension in patients with diabetes.

Beta-blockers can also worsen glucose tolerance and have been linked to an

increased risk o developing diabetes mellitus. !CE inhibitors appear to reduce

the long-term risk o developing diabetes mellitus by #$%& and improve insulin

sensitivity though not asting glucose in persons with diabetes. Girtually every

authoritative body recommends an !CE inhibitor (or an !"Bin persons with

diabetes. /icotinic acid or niacin also can worsen glucose tolerance' and or

these reason are cautiously used in the management o lipid abnormalities in

persons with diabetes. !lpha-intereron also can cause worsening glucose

tolerance. 2ther drugs that may worsen glucose tolerance or cause diabetes

include pentamidine' glucocorticoids' and thyroid hormone. o>azosin' an alpha

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adrenergic blocker' improves insulin sensitivity and glucose tolerance' and

thereore has an opposite eect on glucose tolerance and levels compared to the

other drugs discussed. owever' none o the above drugs are HcontraindicatedI in

diabetics. !s always thgough the therapeutic beneit must out weigh the risk.

Correct answer: e

8. E3 is a 44-year-old woman with diabetes mellitus "or the past 5 years. She once eperienceddiabetic &etoacidosis during a bout o" pyelonephritis complicated by sepsis. E3 also smo&ed "or50-pac& years and has se+ere hypercholesterolemia 3!3- 200 mg/dl)# low H!3 cholesterol 84mg/dl) and ele+ated "asting triglycerides 2%0 ; 440 mg/dl). *hree years ago she eperienced ananterior wall myocardial in"arction. ardiac catheteriation showed se+ere 3$! stenosis that wasamenable to angioplasty with stent placement and 40 ; ugular +enous pressure F45 degrees# bilateral "emoral bruits# and 8 lower etremity edema etending to the le+el o" the&nees.

'hich o" the "ollowing is true(

a) She has class ::: heart "ailure symptoms.b) *he most logical drug to add to her diabetes treatment regimen# a"ter rein"orcing dietary

counseling# is met"ormin"c) *he drug in her current regimen that should de"initely be discontinued is glucotrol.d) Her lower etremity edema is predominantly "rom her heart "ailure.e) H*L/triamterene should be prescribed.

,he does not have heart ailure symptoms at rest (class *G' however' given the

appearance o he heart ailure symptoms with minimal e>ertion' this is

consistent with class *** heart ailure. er glycemic control has been poor and

her kidney unction is signiicantly depressed. Both class *** heart ailure and

reduced kidney unction are contraindications to metormin 5 there is an

increased risk in these settings o lactic acidosis. There is no compelling reason

to discontinue glucotrol at this time. er physical e>am suggests that she

indeed has both right and let sided heart ailure. Thus' the right-sided heart

ailure has likely contributed to her lower e>tremity edema. owever' assigning

right sided heart ailure the predominant role in her edema cannot be done with

conidence. Both elodpine (a dihyrdopyridine calcium antagonist and

pioglitazone can cause edema' though the underlying mechanisms are dierent.

+urthermore' pioglitazone is a known cause o luid retention=volume e>pansion

and is therore contraindicated in class *** 5 *G heart ailure. 9ultiple causes o

lower e>tremity edema can be identiied. 6iven that her estimated 6+" is below

the mid 7%8s' a thiazide diuretic' especially at low dose' is unlikely to be eective

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in initiating a diuresis or in controlling blood pressure. ! higher dose diuretic (bid

urosemide or metolazone' or e>ample would eectively diurese her and help

her attain better BP control. *mproved BP control might improve her cardiac

perormance as well.

Correct answer: a

40. Mr. Ehan is a 5% year man with *ype 2 !iabetes and coronary heart disease. He has a strong"amily history o" early coronary heart and sudden death. His sugars are currently well controlledon diet and an alpha glucosidase inhibitor and met"ormin. His 3!3 cholesterol is on a statin.*riglycerides are 200 and his H!3 cholesterol is 28. He ta&es $S$ 825 milligrams daily.

'hich o" the "ollowing approaches would optimie his lipid pro"ile(

a) $d+ise the patient to drin& 4 "our alcoholic be+erages daily.b) egin iacin 250 milligrams bid and gradually titrate to 1000 milligrams per day.c) egin a +igorous eercise programd) Start Aolic acid 1 milligram daily

This patient has a low ) level. There are various ways to increase ).

!lthough alcohol has been shown to increase ) levels recommending our

alcoholic beverages a day would not be advised. /iacin increases )

cholesterol' lowers )) cholesterol and triglycerides. !dding niacin to statins

has been shown to slow the progression o atherosclerosis (!rterial Biology or the

*nvestigation o the Treatment Eects o "educing Cholesterol (!"B*TE" 4 Trial. /iacin

can be used saely in diabetic patients. E>ercise can increase ) levels but

recommending a HvigorousI e>ercise program in a patient with C! would not be

advisable. /iacin

Correct answer: b

41. Mr. is a 45 man who was diagnosed to ha+e diabetes more than 12 years ago. His CAD is 40.Aour months ago he underwent stent placement "or occlusion o" his 3$!. He also hasproli"erati+e retinopathy which was treated by laser 2 years ago. He is doing well today althoughhe mentions he is ha+ing some burning discom"ort o" his "eet "or the last two months. Hisglycemic control has been ecellent? "asting glucoses range between 110 and 125 and postprandial glucoses are ne+er higher than 190.

$t this +isit you wouldK

a) rder an an&le brachial inde testb) *est sensation with a 10 g mono"ilamentc) rder ner+e conduction testsd) *est sensation to pain and temperature# +ibration# and light touch with a cotton wisp

This patient8s symptoms are suggestive o peripheral neuropathy. The best initial

way to evaluate this patient is to assess sensation using a % g monoilament.

Testing or sensation to pain' temperature' vibration and light touch are

appropriate but will not be as sensitive or reproducible as testing sensation with

the monoilament. /erve conduction tests will diagnoses peripheral neuropathy

but are not recommended as part o a standard oice evaluation. The ankle

23


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brachial inde> is recommended to evaluate or arterial insuiciency not

neuropathy. would deine might be helpul

Correct answer: b

42. Mr. 7s sensation is "ound to be intact to all modalities. 'hich o" the "ollowing statements is true(

a) Mr. should be instructed in use o" the mono"ilament so that he can asses his sensation and

participate in reducing his ris& o" ulceration and amputationb) Mr. has had diabetes "or more than 10 years and is at increased ris& "or amputationc) Mr. has a normal sensory eamination and is there"ore not at increased ris& "or diabetic

"ood ulcerd) Mr. has a normal sensory eamination and is there"ore not at increased ris& "or ris& o"

amputation

Correct answer: b

48. Mr. presents "or a "ollow +isit "or diabetes. He ta&es met"ormin 1000 milligrams twice daily andsel"-monitors his blood glucose. Aasting and pre-prandial glucose are all less than 180. Hgb$1cis %B.


a) ontinue the met"ormin and ha+e the patient come bac&ing in si months "or anotherHg$1c.

b) $dd a *L!.c) Depeat the Hg$1c as it is +ery unli&ely that to ha+e such a high +alue with the "asting and

pre-prandial +alues describedd) !iscontinue met"ormin and begin a sul"onylurea to achie+e a Hg$1c o" O


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Correct answer: a

49. 'hich o" the "ollowing should be per"ormed at e+ery routine diabetes +isit(

a) omprehensi+e "oot eaminationb) Measurement o" capillary glucosec) Measurement o" blood pressured) Measurement o" Hgb$1c

Correct answer: c

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