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Test Your Knowledge

Take a quiz and test your knowledge on diabetes and related health concerns.

CLINICAL CASE VIGNETTE: Treating Weight Concerns

After four years of good glycemic control with metformin 1500 mg a day, Mrs. Hunter returns for her 6-month follow-up visit. At this time, her office A1C is 8.2% and she has gained seven pounds. She is very concerned about her weight gain. If weight is a concern, what would be the best antiglycemic drug to add to her regimen? A. A sulfonylurea B. A DPP-4 inhibitor C. A thiazolidinedione D. A GLP-1 receptor agonist Follow the link for the answer.

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BMI for Bariatric Surgery

Mr. Carlson is 52-year old Caucasian grocery store manager you saw last week for a new patient visit. His labs from that visit were significant for elevated random plasma glucose 166 mg/dL, A1C 7.4% and elevated lipids (TG equals 175 mg/dL, LDL 148 mg/dL, HDL 38 mg/dL, total cholesterol 221 mg/dL). He has returned to your clinic for a follow-up appointment. His physical exam is notable for central abdominal obesity (waist circumference 42”),left eyelid xanthelasma, BP 147/91, HR 72, RR 18, BMI 36 kg/m2, but otherwise normal. A repeat A1C test shows A1C 7.6% Mr. Carlson smokes between 1 and 1.5 packs of cigarettes daily. After discussing the labs and your findings with Mr. Carlson, you begin collaborating on a management plan. You write prescriptions for metformin, a statin and ACE inhibitor. Mr. Carlson doesn’t think “taking medication will be too tough” but expresses skepticism about your recommendations for a change in his diet, exercise and smoking programs because he has tried them, without success in the past. What is considered the starting BMI for consideration of bariatric surgery? 1. BMI greater than 28 kg/m2 2. BMI greater than 30 kg/m2 3. BMI greater than 35 kg/m2 4. BMI greater than 37 kg/m2 Follow the link for the answer.

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Clinical Case Vignette Follow-up: Two Steps Back

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.

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Clinical Case Vignette: Treatment Next Steps

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.
Follow the link for the answer.

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A1C Inaccuracy

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.

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Clinical Case Study: Metformin Side Effects

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.

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Clinical Parameters

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.

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Comprehensive Diabetes Tests

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.

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