Test Your Knowledge

Mrs. Hunter is 36-year-old African-American who comes to your office for her annual wellness exam. She has excessive weight (BMI 27 kg/m2), but is otherwise healthy. She jokes that she, “just can’t seem to lose that extra baby weight” after giving birth 3 years ago. However, her daughter recently started preschool so she has been able to go to her new gym several times per week. In fact, one of the added bonuses of her membership is that she has been participating in their free, weekly nutrition and exercise support groups. In addition to her routine labs, you order an A1C, which comes back elevated at 7.1%. You and Mrs. Hunter set a goal for A1C<6.5%. She returns 3 months later for a follow-up visit and her office labs show an A1C 6.8%. You congratulate her on her progress and ask her to return in another 3–4 months. When she does, she is above her goal with an A1C 8.1%. She explains that she has gone back to full-time work and just doesn’t have the time to get to the gym anymore. At this time, what would your next step be and what would her individualized glycemic targets be?

A. Encourage lifestyle modifications and start metformin with a target A1C less than 6.5%
B. Encourage lifestyle modifications and start metformin with a target A1C less than 7.5%
C. Encourage lifestyle modifications and start a 2-drug combination target A1C target less than 7%
D. Encourage lifestyle modifications and do not initiate drug therapy at this time

Follow the link for the answer.

Mrs. Hunter is a 36-year-old African-American who comes to your office for her annual wellness exam. She has excess weight (BMI 27 kg/m2), but is otherwise healthy. She jokes that she, “just can’t seem to lose that extra baby weight” after giving birth 3 years ago. However, her daughter recently started preschool so she has been able to go to her new gym several times per week. In fact, one of the added bonuses of her membership is that she has been participating in their free, weekly nutrition and exercise support groups. In addition to her routine labs, you order an A1C, which comes back elevated at 7.1%. This measurement is confirmed several days later. Based on Mrs. Hunter’s profile, what would a reasonable next step be? A. Encourage lifestyle modifications and start metformin with an A1C target of < 7.0%.
B. Encourage lifestyle modifications and start metformin with an A1C target of < 6.0%.
C. Encourage lifestyle modifications and do not initiate drug therapy at this time.
D. Encourage lifestyle modifications and start metformin and a sulfonylurea.
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How many new “first-in-class” treatments for diabetes are in the diabetes pipeline as of May 2018? A. 7 B. 28 C. 56 D. 107 E. 152 Follow the link for the answer.

How much higher is the rate of cardiovascular (CV) death among unmarried vs married patients who are at high CV risk, according to a recent study? A. 19% B. 28% C. 34% D. 45% E. 56% Follow the link for the answer.

In which of the examples can HbA1c be inaccurate? (When presented to 200 medical professionals, 20% got it wrong.) A. Recent blood transfusion B. Renal failure C. G6PD deficiency D. Medication Uwe (e.g. aspirin) E. All of the above Follow the link for the answer.

Mr. Hernandez' lab results are A1C 7.5%, FPG 137 mg/dL, LDL 190 mg/dL, HDL 38 mg/DL and triglycerides 232 mg/dL. He is started on metformin, lifestyle modifications, an ACE inhibitor, and a statin. He was asked to return in 3 months' time to evaluate how everything is going. However, he fails to keep his appointment. He returns 1 year after his initial diagnosis for a recurrent yeast infection. His A1C is currently 7.7%. Upon questioning, he admits that while he has been good about taking his “heart meds,” he has not taken the “sugar pill” because he didn’t like it. What side effect did the patient most likely find intolerable? A. Diarrhea and abdominal cramping B. Paresthesias C. Increased appetite D. Insomnia Follow the link for the answer.

Mr. Hernandez's labs are notable for A1C 7.5, FPG 137 mg/dL, LDL-cholesterol 190 mg/dL, HDL-cholesterol 38 mg/dL, and triglycerides 232 mg/dL. You discuss his lab results, his diagnosis, and how to manage diabetes, then you make referrals to the appropriate diabetes team clinicians. You start Mr. Hernandez on metformin, lifestyle modifications, an ACE inhibitor, and a statin. What clinical parameters are you looking to achieve? A. A1C less than 7%, BP less than 130/80 mmHg, LDL less than 100 mg/dL B. A1C less than 7%, BP less than 130/90 mmHg, LDL less than 100 mg/dL C. A1C less than 7%, BP less than 140/80 mmHg, LDL less than 100 mg/dL D. A1C less than 7%, BP less than 140/90 mmHg, LDL less than 150 mg/dL Follow the link for the answer.

Mr. Hernandez is a 45-year-old plumber of Hispanic heritage who has excessive weight (BMI 30 kg/m2). He arrives at your office for a first-time visit. He has not been to a physician during the last 7 years because he hasn’t always had health insurance and “doesn’t like going to the doctor.” However, he has been noticing lately that his vision seems a little blurry and he’s developed a red, itchy rash in his groin. He is a non-smoker and recalls being told a long time ago that he should eat a low salt diet, but he can’t remember why. On examination, his BP is 154/96 mm/Hg, and his pulse is 72, RR 22. His physical exam is notable for signs of a yeast infection in his groin. You order a CBC and A1C to be drawn that day before he leaves. You advise him how to treat his skin infection. When you receive the results of the blood test, it shows a random plasma glucose of 162 mg/dL and A1C 7.3%. You call Mr. Hernandez and ask him to return the next morning, before he has eaten, for additional labs. In this individual, you might order all the following labs EXCEPT: A. A1C B. chem 12 panel C. fasting lipid profile D. urine ketones Follow the link for the answer.

Mrs. O’Doole is a 34 year-old of Irish descent. She works as a florist and is married with three children. She arrives at your clinic for her annual wellness exam. Her blood pressure is 130/84 mmHg, pulse 65, BMI 24 kg/m2 and her physical exam is notable for acne and mild hirsutism. Her only current medication is oral birth control pills. She recalls starting OCP, 15 years prior, due to irregular menses. Based upon her medical history and physical, you believe it would be prudent to screen Mrs. O’Doole for type 2 diabetes. The lab returns a fasting plasma glucose (FPG) of 112 mg/dL. You share these results with your patient and inform her that while only mildly elevated, she has impaired fasting glucose. You recommend that she see a diabetes educator to help her modify her diet and exercise to lose some weight. At a follow-up appointment 6 months later, Mrs. O’Doole tells you despite good intentions, she has not been able to adhere to any meaningful lifestyle changes. In fact, she has gained 5 pounds. At this time, her repeat fasting plasma glucose shows FPG 138 mg/dL. After discussing management options with her, you decide the best management would be: A. lifestyle modifications only B. metformin only C. metformin + continue with lifestyle modifications D. repaglinide only Follow the link for the answer.

Mrs. O’Doole is a 34 year-old of Irish descent. She works as a florist who and is married with three children. She arrives at your clinic for her annual wellness exam. Her blood pressure is 130/84 mmHg, pulse 65, BMI 24 kg/m2 and her physical exam is notable for acne and mild hirsutism. Her only current medication is oral birth control pills. She recalls starting OCP, 15 years prior, due to irregular menses. Based upon her medical history and physical, you believe it would be prudent to screen Mrs. O’Doole for type 2 diabetes. You discuss your recommendations with her and she agrees to be tested. The lab returns a fasting plasma glucose (FBG) of 112 mg/dL. You share these results with your patient and inform her, that while only mildly elevated, she has impaired fasting glucose. What is the best choice for initial management of Mrs. O’Doole’s prediabetes? A. Metformin B. Metformin+ Pioglitazone C. Lifestyle modifications + Pioglitazone D. Lifestyle modifications (dietary modifications, weight loss and exercise) Follow the link for the answer.