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West Virginia of Family Physicians 59 th Annual Scientific Assembly March 31, 2011 Presented by: David W. Avery, MD.

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Presentation on theme: "West Virginia of Family Physicians 59 th Annual Scientific Assembly March 31, 2011 Presented by: David W. Avery, MD."— Presentation transcript:

1 West Virginia of Family Physicians 59 th Annual Scientific Assembly March 31, 2011 Presented by: David W. Avery, MD

2 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 (304) Specialty: Family Practice Residency: United Hospital Center, Clarksburg, WV School & Degree: LeMoyne College, Syracuse, SUNY Upstate Medical, Syracuse Certification: American Board of Family Practice

3 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 59 th 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:

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6 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

7  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.

8  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

9  To fulfill Stage One (1 st 3 year cycle) requirements, all participants who begin MC-FP during the period from will have the choice of completing  Two Part II modules (SAMs) and one part IV module (PPM) OR ◦ Three Part II modules (SAMs)

10  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, 3- year cycles, you go from the 10-year recertification cycle to the 7-year cycle.

11  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

12  AAFP METRIC modules in Diabetes, Asthma, Coronary Artery Disease, and Chronic Obstructive Pulmonary Disease  Colorado Permanente Medical Group Department 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

13 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.

14  The SAMs consist of 60 multiple- choice questions and a clinical Simulation  The 60 questions are divided into 6- 8 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 self- assessment.  References are given for each question.  Complete Clinical Simulation (less than two hours)

15  You must register for a Self Assessment Module (SAM) you must go to the ABFM website, which is You will need a login and password and you can get these at  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

16  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.

17  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.

18  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

19  This is not a test it is considered a self- assessment.  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.

20  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

21 AACE: AACE Position Statement on the Insulin Resistance Syndrome, 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): Howard AA, Arnsten JH, Gourevitch MN: Effect of alcohol consumption on diabetes mellitus: A systematic review. Ann Intern Med 2004; 140 (3): Last modified 02/05

22 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

23 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: Last modified 02/05

24 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)

25 American Diabetes Association: Standards of medical care in diabetes— 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), Last modified 05/06

26 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

27 Inzucchi SE: Oral antihyperglycemic therapy for type 2 diabetes—Scientific Review. JAMA 2002;287:360. Last modified 02/05

28  5. Which of the following medications can cause hyperglycemia? (Mark all that are true.)  ○ Nicotinic acid  ○ Clozapine (Clozaril)  ○ Prednisone  ○ Spironolactone  ○ Ramipril (Altace)

29  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 angiotensin- converting 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):  Last modified 02/05

30  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

31  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),  American Diabetes Association: Standards of medical care in diabetes— 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):  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

32 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

33  American Diabetes Association: Nutrition recommendations and interventions for diabetics.  Diabetes Care 2008;31(suppl 1):S  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;  Last modified 04/08

34 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 HDL- cholesterol 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

35  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:  Last modified 02/05

36  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)

37  Newton WP, Collins L: What is the best treatment for diabetic neuropathy? J Fam Pract 2004;53(5):  McCarberg B: Pharmacotherapy for neuropathic pain: the old and the new. Adv Stud Med 2006;6(9):  Wiffen PJ, McQuay HJ, Edwards JE, Moore RA. Gabapentin for acute and chronic pain. Cochrane Database Syst Rev 2005.(3):CD  American Diabetes Association: Standards of medical care in diabetes Diabetes Care 2008:31(suppl 1):S12-S54.  Last modified 02/05

38 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 

39  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 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):  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):  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

40  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

41  Remuzzi G, Scheppati A, Ruggenenti P: Nephropathy in patients with type 2 diabetes. N Engl J Med 2002;346:1145.  Last modified 02/05

42 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)

43  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):  Singh S, Loke YK, Furberg CD: Long-term risk of cardiovascular events with rosiglitazone: A meta-analysis. JAMA 2007;298(10):  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):  DeFronzo RA: Pharmacologic therapy for type 2 diabetes mellitus. Ann Intern Med 1999;131(4):  Last modified 04/08

44 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

45  American Diabetes Association: Standards of medical care in diabetes Diabetes Care 2008:31(suppl 1):S12-S54.  Last modified 02/05

46  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, IU/day  o Aspirin, 81 mg/day

47  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):  Mosca L, Appel LJ, Benjamin EJ, et al: Evidence-based guidelines for cardiovascular disease prevention in women. Circulation 2004;109(5):  Last modified 04/08

48  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)

49  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):  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

50  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

51  American Diabetes Association: Nutrition recommendations and interventions for diabetics. Diabetes Care 2008;31(suppl 1):S  AACE: The AACE System of Intensive Diabetes Self- Management Update.  Mozaffarian D, Katan MB, Ascherio A, et al: Trans fatty acids and cardiovascular disease. N Engl J Med 2006;354(15):  Last modified 04/08

52  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 

53  American Diabetes Association: Standards of medical care in diabetes Diabetes Care 2008:31(suppl 1):S12- S54.  ACC/AHA Guidelines for CABG Surgery Update. American College of Cardiology/American Heart Association,  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):  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):  Last modified 02/05

54  18. The threshold fasting plasma glucose level recommended for confirming the diagnosis of diabetes mellitus is  ____ mg/dL

55  American Diabetes Association: Diagnosis and classification of diabetes mellitus. Diabetes Care 2008;31(suppl 1):S55- S60.  Last modified 02/05

56  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)

57  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

58  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

59  American Diabetes Association: Diagnosis and classification of diabetes mellitus. Diabetes Care 2008;31(suppl 1):S55-S60.  Last modified 02/05

60  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

61  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),  Last modified 5/06

62  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)

63  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):  Last modified 04/08

64  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)

65  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 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,   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):  Last modified 04/08

66  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)

67  Nestler JE: Metformin for the treatment of the polycystic ovary syndrome. N Engl J Med. 2008;358(1):  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

68  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 A 1c 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

69  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): American Diabetes Association: Standards of medical care in diabetes Diabetes Care 2008:31(suppl 1):S12- S54. Last modified 04/08

70  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 cost- effective o Measurement of hemoglobin A1c has no role in screening for diabetes 2

71 American Diabetes Association: Screening for type 2 diabetes. Diabetes Care 2003;26(suppl 1):S21. American Diabetes Association: Standards of medical care in diabetes Diabetes Care 2008:31(suppl 1):S12-S54. Last modified 04/08

72  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 A 1c 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)

73 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): 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

74  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

75  American Diabetes Association: Screening for type 2 diabetes. Diabetes Care 2003;26(suppl 1):S21.  Last modified 02/05

76  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

77  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 Update. Endocrine Practice 2002;8(suppl 1):40.  Last modified 02/05

78  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

79  The American Association of Clinical Endocrinologists Medical Guidelines for the Management of Diabetes Mellitus: The AACE System of Intensive Diabetes Self-Management Update. Endocrine Practice 2002;8(suppl 1):40.  Last modified 02/05

80  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

81  American Diabetes Association: Standards of medical care in diabetes Diabetes Care 2008:31(suppl 1):S12-S54.  Last modified 02/05

82  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

83  Mohammed Q, Gillies MC, Wong TY: Management of diabetic retinopathy: a systematic review. JAMA 2007;298(8):  Last modified 02/05

84 33. List three conditions included in the differential diagnosis of a high anion gap metabolic acidosis: __________________

85  Fall PJ: A stepwise approach to acid-base disorders. Practical patient evaluation for metabolic acidosis and other conditions. Postgrad Med 2000;107:  Last modified 02/05

86  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

87  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

88  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 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

89  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):   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),  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):  Last modified 02/05

90 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

91  American Diabetes Association: Physical activity/exercise and diabetes mellitus. Diabetes Care 2003;26(suppl 1):S73.  Last modified 02/05

92  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 mg/dL AST U/L (N 10-40) ALT U/L (N 10-55) FSH U/mL (N ) LH U/mL (N ) Testosterone ng/mL (N )  What is the most likely diagnosis?

93 Brandhagen DJ, Fairbanks VF, Baldus W: Recognition and management of hereditary hemochromatosis. Am Fam Physician 2002;65(5): Last modified 02/05

94  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

95  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),  Last modified 02/05

96  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 mmol/L (N )  Serum potassium mmol/L (N )  Serum chloride mmol/L (N )  CO mmol/L (N 24-30) Serum glucose mg/dL Serum creatinine mg/dL (N ) BUN 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 

97  American Diabetes Association: Hyperglycemic crises in diabetes. Dibetes Care 2004;27(1):S94

98  A 71-year-old male with history of type 2 diabetes and long- standing 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; extended- release 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

99  Singh S, Loke YK, Furberg CD: Long-term risk of cardiovascular events with rosiglitazone: A meta-analysis. JAMA 2007;298(10):  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):  U.S. Food and Drug Administration: Manufacturers of some diabetes drugs to strengthen warning on heart failure risk. August 14,  Last modified 04/08

100  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

101  American Diabetes Association: Insulin administration. Diabetes Care 2003;26(suppl 1):S121. Last modified 02/05

102  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

103  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

104  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

105  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:  Last modified 02/05

106  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 ).   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

107 American Diabetes Association. Diabetic nephropathy. Diabetes Care 2003;26(suppl 1):S94. Last modified 02/05

108  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 A 1c 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 

109  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):  Last modified 02/05

110  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 LDL- cholesterol 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)

111  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 Diabetes Care 2008:31(suppl 1):S12-S54.  Last modified 04/08

112  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

113 American Diabetes Association: Insulin administration. Diabetes Care 2003;26(suppl 1):S121. Last modified 02/05

114  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

115  American Diabetes Association: Implications of the United Kingdom Prospective Diabetes Study. Diabetes Care 2003;26(supp 1):S28  Last modified 02/05

116  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

117  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

118  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

119  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

120  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

121 Lightman S, Towler HMA: Diabetic retinopathy. Clinical Cornerstone 2003;5(2):12. Last modified 02/05

122  52. A 58-year-old male with type 2 diabetes is started on a twice- daily 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 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

123  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): Last modified 02/05

124  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 ).  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

125  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

126  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

127  Palmer BF: Renal dysfunction complicating the treatment of hypertension. N Engl J Med 2002;347:1256.  Last modified 02/05

128  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

129  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):  Last modified 02/05

130  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 ), 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 Increasing the dosage of metformin  o Increasing the dosage of lisinopril  o Beginning aspirin, 81 mg/day  o Beginning a statin  o Beginning a fibric acid derivative

131  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):  American Diabetes Association: Standards of medical care in diabetes Diabetes Care 2008:31(suppl 1):S12-S54.  Last modified 02/05

132  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

133  American Diabetes Association: Diagnosis and classification of diabetes mellitus. Diabetes Care 2008;31(suppl 1):S55-S60.  Last modified 02/05

134  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 mmol/L (N ) Serum potassium mmol/L (N ) Serum chloride mmol/L (N ) CO mmol/L (N 24-30)  Serum glucose mg/dL Serum creatinine mg/dL (N ) BUN 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

135 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

136  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, volume- depleted 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 mg/dL  Serum sodium mEq/L (N )  Serum potassium mmol/L (N ) Chloride mmol/L (N )  CO mmol/L (N 24-30)  Arterial blood gases  pH (N ) pCO mm Hg (N 35-45)  pO mm Hg (N )  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

137 American Diabetes Association: Hyperglycemic crises in diabetes. Diabetes Care (2004;27 (1):S94 Last modified 05/06

138  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 LDL- cholesterol level as the target level for this patient?  _____ mg/dL

139  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 Diabetes Care 2008:31(suppl 1):S12-S54.  Last modified 05/06   Copyright © 2008 American Board of Family Medicine, Inc. Version Last modified: 04/08


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