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ABIM Endocrinology practice questions

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Question 1Diabetes Mellitus and Glucose Metabolism

An asymptomatic 48-year-old man has a screening hemoglobin A1c of 6.7%, confirmed at 6.6% two weeks later. Which hemoglobin A1c value is the accepted threshold for diagnosing diabetes mellitus?

  1. 6.5% Correct answer.
  2. 5.7%
  3. 7.0%
  4. 6.0%

Explanation

A hemoglobin A1c of 6.5% or higher, confirmed on a second sample in an asymptomatic patient, establishes the diagnosis of diabetes. Values from 5.7% to 6.4% define prediabetes, and 7.0% is a glycemic target rather than a diagnostic cutoff.

Question 2Diabetes Mellitus and Glucose Metabolism

A fasting plasma glucose at or above which value meets the diagnostic criterion for diabetes mellitus?

  1. 200 mg/dL
  2. 126 mg/dL Correct answer.
  3. 140 mg/dL
  4. 100 mg/dL

Explanation

A fasting plasma glucose of 126 mg/dL or greater, a 2-hour oral glucose tolerance value of 200 mg/dL or greater, or an A1c of 6.5% or greater each diagnose diabetes. A random glucose of 200 mg/dL or higher with classic symptoms is also diagnostic without a repeat test.

Question 3Diabetes Mellitus and Glucose Metabolism

Which mechanism best describes the glucose-lowering action of metformin?

  1. Activation of PPAR gamma
  2. Inhibition of sodium-glucose cotransporter 2
  3. Reduced hepatic gluconeogenesis Correct answer.
  4. Closure of beta-cell ATP-sensitive potassium channels

Explanation

Metformin lowers glucose chiefly by suppressing hepatic gluconeogenesis and improving hepatic insulin sensitivity, with AMP-activated protein kinase activation contributing. It does not stimulate insulin secretion, so it rarely causes hypoglycemia when used alone.

Question 4Diabetes Mellitus and Glucose Metabolism

A patient with type 2 diabetes and heart failure is started on empagliflozin. Which action accounts for its glucose-lowering effect?

  1. Inhibition of dipeptidyl peptidase-4
  2. Insulin sensitization in skeletal muscle
  3. Delayed gastric emptying and appetite suppression
  4. Blocking proximal tubular glucose reabsorption Correct answer.

Explanation

SGLT2 inhibitors block glucose reabsorption in the proximal tubule, producing glycosuria and lowering glucose independently of insulin. The same mechanism explains their benefits in heart failure and chronic kidney disease.

Question 5Diabetes Mellitus and Glucose Metabolism

A pregnant woman with no prior history of diabetes is receiving routine prenatal care. When should screening for gestational diabetes be performed?

  1. At 6 to 8 weeks of gestation
  2. Only after delivery
  3. 24 to 28 weeks of gestation Correct answer.
  4. At 32 to 34 weeks of gestation

Explanation

Routine screening for gestational diabetes is performed at 24 to 28 weeks, when placental insulin resistance rises sharply. Earlier testing is reserved for women with risk factors such as prior gestational diabetes or marked obesity.

Question 6Diabetes Mellitus and Glucose Metabolism

A 55-year-old woman is newly diagnosed with type 2 diabetes and has no visual symptoms. When should her first dilated retinal examination be scheduled?

  1. Every 2 years beginning at age 65
  2. At the time of diagnosis Correct answer.
  3. Only if her A1c exceeds 9%
  4. After 5 years of diabetes

Explanation

In type 2 diabetes, retinopathy may already be present at diagnosis, so a dilated examination is obtained promptly after diagnosis and repeated annually. In type 1 diabetes, screening begins 3 to 5 years after onset.

Question 7Diabetes Mellitus and Glucose Metabolism

An obese adolescent is noted to have velvety, hyperpigmented thickening of the skin at the nape of the neck and in the axillae. Which underlying process does this finding most likely indicate?

  1. Necrobiosis lipoidica
  2. Insulin resistance Correct answer.
  3. Adrenal androgen excess
  4. Dermatophyte infection

Explanation

Acanthosis nigricans reflects chronic hyperinsulinemia acting on keratinocytes and is a cutaneous marker of insulin resistance. It improves when insulin sensitivity is restored through weight loss or pharmacologic therapy.

Question 8Diabetes Mellitus and Glucose Metabolism

Glipizide lowers blood glucose through which action on pancreatic beta cells?

  1. Closing beta-cell potassium channels Correct answer.
  2. Inhibiting intestinal alpha-glucosidase
  3. Activating beta-cell GLP-1 receptors
  4. Suppressing hepatic glucose production

Explanation

Sulfonylureas close ATP-sensitive potassium channels on beta cells, depolarizing the membrane and triggering insulin release independent of the ambient glucose level. Because secretion is stimulated regardless of glycemia, hypoglycemia is the principal adverse effect.

Question 9Diabetes Mellitus and Glucose Metabolism

A 22-year-old with type 1 diabetes presents with glucose 480 mg/dL, arterial pH 7.15, bicarbonate 8 mEq/L, and large serum ketones. What is the most appropriate first step in management?

  1. Subcutaneous insulin glargine
  2. Intravenous sodium bicarbonate
  3. Intravenous isotonic saline Correct answer.
  4. Intravenous potassium chloride

Explanation

Volume repletion with isotonic crystalloid is the first step in diabetic ketoacidosis and is begun before or alongside the insulin infusion. Bicarbonate is not indicated at a pH of 7.15, and potassium is added only after the serum level is known and is below roughly 5.3 mEq/L.

Question 10Diabetes Mellitus and Glucose Metabolism

Which feature best distinguishes hyperosmolar hyperglycemic state from diabetic ketoacidosis?

  1. Marked hyperosmolality with minimal ketosis Correct answer.
  2. Arterial pH below 7.30
  3. Strongly positive serum ketones
  4. Serum bicarbonate below 10 mEq/L

Explanation

Hyperosmolar hyperglycemic state is characterized by severe hyperglycemia and hyperosmolality with sufficient residual insulin to suppress ketogenesis, so acidosis is absent or mild. Ketoacidosis instead shows a low pH, low bicarbonate, and high ketone burden.

Question 11Diabetes Mellitus and Glucose Metabolism

During treatment of diabetic ketoacidosis, a patient's serum potassium is 5.8 mEq/L and urine output is adequate. How should potassium be managed when the insulin infusion is started?

  1. Give intravenous calcium gluconate first
  2. Hold potassium and recheck hourly Correct answer.
  3. Give 40 mEq/L of potassium in the first liter of fluid
  4. Give sodium bicarbonate to shift potassium intracellularly

Explanation

Insulin and volume repletion shift potassium into cells and will lower the serum level, so potassium is withheld when it exceeds roughly 5.3 mEq/L and is added once it falls below that threshold. Hourly monitoring prevents both hyperkalemia and precipitous hypokalemia.

Question 12Diabetes Mellitus and Glucose Metabolism

A woman taking empagliflozin presents with nausea and vomiting. Glucose is 190 mg/dL, venous pH is 7.20, bicarbonate is 10 mEq/L, and beta-hydroxybutyrate is positive. Which diagnosis best fits?

  1. Starvation ketosis
  2. Metformin-associated lactic acidosis
  3. Euglycemic ketoacidosis Correct answer.
  4. Hyperosmolar hyperglycemic state

Explanation

SGLT2 inhibitors promote glucosuria and lipolysis, so ketoacidosis can develop with glucose well below the usual ketoacidosis threshold. Management is the same as for classic ketoacidosis: fluids, insulin, and glucose infusion until ketones clear.

Question 13Diabetes Mellitus and Glucose Metabolism

In the Diabetes Prevention Program, intensive lifestyle intervention reduced progression from impaired glucose tolerance to diabetes by approximately what proportion?

  1. 25%
  2. 8%
  3. 58% Correct answer.
  4. 85%

Explanation

The Diabetes Prevention Program showed that a 7% weight loss plus 150 minutes of activity weekly reduced incident diabetes by about 58% over roughly three years. Metformin in the same trial reduced incidence by about 31%.

Question 14Diabetes Mellitus and Glucose Metabolism

Which antibody is most frequently detected at diagnosis in adult-onset autoimmune type 1 diabetes?

  1. Anti-tissue transglutaminase antibody
  2. GAD65 antibody Correct answer.
  3. Anti-thyroid peroxidase antibody
  4. Anti-insulin receptor antibody

Explanation

Glutamic acid decarboxylase (GAD65) antibodies are the most commonly found autoantibody in adult-onset type 1 diabetes and tend to persist longer than islet cell antibodies. Their presence supports autoimmune, insulin-requiring diabetes rather than type 2 diabetes.

Question 15Diabetes Mellitus and Glucose Metabolism

A man with type 2 diabetes on metformin begins high-dose prednisone for a chronic lung disease. Which pattern of hyperglycemia is most expected?

  1. Postprandial and afternoon hyperglycemia Correct answer.
  2. Fasting hyperglycemia with normal afternoon values
  3. Nocturnal hypoglycemia requiring lower insulin doses
  4. Persistent hyperglycemia unresponsive to insulin

Explanation

Glucocorticoids increase hepatic gluconeogenesis and induce insulin resistance, predominantly raising postprandial and late-afternoon glucose after a morning dose. Fasting glucose may remain near normal early in therapy, so treatment is often directed at the postprandial period.

Question 16Diabetes Mellitus and Glucose Metabolism

A 60-year-old with type 2 diabetes has an A1c of 9.2% on metformin despite adherence and a stable weight. Which is a standard way to initiate basal insulin?

  1. Start 50 units of NPH daily
  2. Start 10 units subcutaneously once daily Correct answer.
  3. Start basal-bolus with four daily injections
  4. Start 0.5 units/kg of glargine at bedtime

Explanation

Basal insulin is typically started at 10 units daily or 0.1 to 0.2 units/kg once daily and titrated every few days according to fasting glucose. Escalating to a full basal-bolus regimen is reserved for patients who remain above target on optimized basal insulin.

Question 17Diabetes Mellitus and Glucose Metabolism

A patient with type 2 diabetes and hypertension has an albumin-to-creatinine ratio of 120 mg/g and an eGFR of 70 mL/min/1.73 m². Which intervention slows progression of kidney disease?

  1. An ACE inhibitor Correct answer.
  2. Dietary protein of 2 g/kg daily
  3. Intermittent high-dose furosemide
  4. A dihydropyridine calcium channel blocker

Explanation

An ACE inhibitor or ARB titrated to the maximum tolerated dose reduces albuminuria and slows progression of diabetic kidney disease, particularly in hypertensive patients. Potassium and creatinine are checked shortly after initiation and after dose changes.

Question 18Diabetes Mellitus and Glucose Metabolism

Metformin should be discontinued when the estimated glomerular filtration rate falls below which value?

  1. 60 mL/min/1.73 m²
  2. 75 mL/min/1.73 m²
  3. 30 mL/min/1.73 m² Correct answer.
  4. 45 mL/min/1.73 m²

Explanation

Metformin is contraindicated at an eGFR below 30 mL/min/1.73 m² because drug accumulation increases the risk of lactic acidosis. Between 30 and 45 mL/min/1.73 m², the dose is capped and initiation is generally avoided.

Question 19Diabetes Mellitus and Glucose Metabolism

Which adverse effect is most characteristic of pioglitazone?

  1. Hypoglycemia when used as monotherapy
  2. Fluid retention with peripheral edema Correct answer.
  3. Diarrhea and flatulence
  4. Genital mycotic infections

Explanation

Thiazolidinediones cause dose-related fluid retention and peripheral edema, which can precipitate or worsen heart failure, along with weight gain and an increased risk of fractures. Because they require endogenous insulin secretion to act, hypoglycemia is uncommon in monotherapy.

Question 20Diabetes Mellitus and Glucose Metabolism

A patient with type 2 diabetes reports a personal history of medullary thyroid carcinoma. Which drug class should be avoided?

  1. Sulfonylureas such as glipizide
  2. GLP-1 receptor agonists Correct answer.
  3. Biguanides such as metformin
  4. Dipeptidyl peptidase-4 inhibitors

Explanation

GLP-1 receptor agonists carry a boxed warning for medullary thyroid carcinoma derived from rodent studies and are avoided in patients with a personal or family history of medullary thyroid cancer or MEN2. A history of pancreatitis also warrants caution with this class.

Question 21Diabetes Mellitus and Glucose Metabolism

A patient using insulin glargine and lispro has a fasting glucose of 210 mg/dL and a 3 AM glucose of 60 mg/dL. Which is the most likely cause of the fasting hyperglycemia?

  1. Dawn phenomenon
  2. Basal insulin underdosing
  3. Somogyi effect Correct answer.
  4. Gastroparesis

Explanation

Nocturnal hypoglycemia followed by a counterregulatory hormone surge produces rebound morning hyperglycemia, so the basal insulin dose should be reduced. The dawn phenomenon instead shows a rising early-morning glucose without preceding hypoglycemia and is managed by increasing basal insulin.

Question 22Diabetes Mellitus and Glucose Metabolism

A 58-year-old with a 15-year history of diabetes and peripheral neuropathy presents with a warm, swollen, erythematous foot with intact skin. He is afebrile, and radiographs show osseous fragmentation at the midfoot. Which diagnosis is most likely?

  1. Deep venous thrombosis
  2. Osteomyelitis
  3. Charcot arthropathy Correct answer.
  4. Cellulitis

Explanation

Charcot neuroarthropathy presents as a warm, swollen, erythematous foot with intact skin and radiographic fragmentation or collapse, typically at the midfoot, and is treated with offloading and immobilization. Osteomyelitis is suggested by an overlying ulcer, a positive probe-to-bone test, or systemic signs of infection.

Question 23Diabetes Mellitus and Glucose Metabolism

A woman with type 2 diabetes and hereditary spherocytosis has an A1c of 5.4%, while her fasting glucose is 165 mg/dL and log values range from 200 to 250 mg/dL. What best explains the discordance?

  1. Unrecognized nocturnal hypoglycemia
  2. Shortened red cell survival Correct answer.
  3. A hemoglobin variant interfering with the assay
  4. Elevated hemoglobin F fraction

Explanation

A1c reflects glycation over the lifespan of circulating erythrocytes, so chronic hemolysis shortens exposure and falsely lowers the value. Fructosamine, self-monitoring, or continuous glucose monitoring should be used to assess glycemia in such patients.

Question 24Diabetes Mellitus and Glucose Metabolism

A lean 22-year-old woman has a three-generation family history of diabetes, an A1c of 6.8%, negative islet autoantibodies, and a high-normal C-peptide. If HNF1A-MODY is confirmed, which therapy is most appropriate?

  1. Metformin plus a DPP-4 inhibitor
  2. Low-dose sulfonylurea Correct answer.
  3. Begin basal-bolus insulin
  4. Pioglitazone monotherapy

Explanation

HNF1A-MODY causes autosomal dominant, young-onset, non-autoimmune diabetes with preserved C-peptide and marked sensitivity to sulfonylureas. Many patients achieve excellent control on low-dose sulfonylurea and can avoid or discontinue insulin.

Question 25Diabetes Mellitus and Glucose Metabolism

A 78-year-old with type 2 diabetes and an eGFR of 25 mL/min/1.73 m² has recurrent hypoglycemia while taking glyburide. Which best explains this?

  1. Reduced protein binding in aging
  2. Shortened half-life with age
  3. Renal accumulation of active metabolites Correct answer.
  4. Hepatic conversion to inactive metabolites

Explanation

Glyburide is metabolized to active metabolites that are renally excreted, so they accumulate in chronic kidney disease and in older adults and cause prolonged hypoglycemia. Glipizide, which is hepatically converted to inactive metabolites, is the preferred sulfonylurea in this setting.

Question 26Diabetes Mellitus and Glucose Metabolism

A 48-year-old asymptomatic man has a fasting plasma glucose of 132 mg/dL confirmed on a repeat sample. What is the most likely diagnosis?

  1. Need for a 2-hour oral glucose tolerance test before diagnosis
  2. Impaired fasting glucose
  3. Diabetes mellitus Correct answer.
  4. Normal glucose tolerance

Explanation

A fasting plasma glucose of 126 mg/dL or higher on two occasions establishes diabetes in an asymptomatic adult. A single value in the 100-125 mg/dL range defines impaired fasting glucose, and values below 100 mg/dL are normal. Confirmatory testing with an OGTT is not required once two fasting values meet the diabetes threshold.

Question 27Diabetes Mellitus and Glucose Metabolism

A conscious 34-year-old woman with type 1 diabetes has a glucose of 54 mg/dL and is able to swallow. Which is the most appropriate initial treatment?

  1. A snack containing 60 g of complex carbohydrate
  2. Intravenous 50% dextrose bolus
  3. Subcutaneous insulin lispro
  4. 15 g of fast-acting oral carbohydrate Correct answer.

Explanation

Conscious patients who can swallow should receive about 15 g of fast-acting carbohydrate, with glucose rechecked in 15 minutes and the dose repeated if hypoglycemia persists. Intravenous dextrose is reserved for patients who cannot take oral therapy or have severe hypoglycemia. A complex-carbohydrate snack alone does not raise glucose quickly enough.

Question 28Diabetes Mellitus and Glucose Metabolism

A 30-year-old woman at 12 weeks gestation has no history of diabetes. When should routine screening for gestational diabetes be performed?

  1. At 32 to 34 weeks gestation
  2. At 24 to 28 weeks gestation Correct answer.
  3. At the first prenatal visit
  4. At 16 to 18 weeks gestation

Explanation

Routine screening for gestational diabetes is recommended at 24 to 28 weeks gestation in pregnant women without known diabetes. Women with risk factors may be screened earlier, but this patient has no such history. Screening before 24 weeks is not routinely indicated in average-risk pregnancies.

Question 29Diabetes Mellitus and Glucose Metabolism

A 56-year-old woman with newly diagnosed type 2 diabetes and an A1c of 7.4% has no contraindications. Which medication is the preferred initial therapy?

  1. Insulin glargine
  2. Pioglitazone
  3. Metformin Correct answer.
  4. Glipizide

Explanation

Metformin is the preferred initial glucose-lowering medication for most patients with type 2 diabetes because it is effective, well tolerated, and inexpensive. It is started at diagnosis unless there is a contraindication such as advanced kidney disease. Insulin and sulfonylureas are generally reserved for specific clinical situations or later intensification.

Question 30Diabetes Mellitus and Glucose Metabolism

A 60-year-old man with type 2 diabetes on metformin and glipizide has an A1c of 9.8%. He agrees to start basal insulin. Which starting dose of insulin glargine is most appropriate?

  1. 0.5 units/kg three times daily
  2. 0.1 to 0.2 units/kg daily Correct answer.
  3. 4 units before each meal
  4. 1 unit/kg with each meal

Explanation

Basal insulin is typically started at 0.1 to 0.2 units/kg once daily and titrated every few days according to fasting glucose. Starting higher doses increases the risk of hypoglycemia. Mealtime insulin is added later if basal insulin alone does not achieve the A1c goal.

Question 31Diabetes Mellitus and Glucose Metabolism

A 24-year-old woman with type 1 diabetes presents in diabetic ketoacidosis with blood pressure 100/60 mm Hg and heart rate 120/min. Which intravenous fluid is most appropriate initially?

  1. Sodium bicarbonate
  2. 0.45% sodium chloride
  3. 5% dextrose in water
  4. 0.9% sodium chloride Correct answer.

Explanation

Initial management of diabetic ketoacidosis includes isotonic 0.9% sodium chloride to restore intravascular volume. Hypotonic saline and dextrose-containing fluids are used later, depending on sodium and glucose levels. Bicarbonate is not routine therapy and is reserved for severe acidosis.

Question 32Diabetes Mellitus and Glucose Metabolism

In which situation is intravenous sodium bicarbonate most clearly indicated during diabetic ketoacidosis?

  1. Arterial pH 6.85 Correct answer.
  2. Arterial pH 7.15
  3. Arterial pH 7.25
  4. Serum bicarbonate 15 mEq/L

Explanation

Sodium bicarbonate is generally reserved for severe DKA with arterial pH below 6.9, because routine use at higher pH has not improved outcomes and may cause harm. Lesser degrees of acidosis are treated with fluids and insulin. Bicarbonate therapy does not replace volume resuscitation or insulin.

Question 33Diabetes Mellitus and Glucose Metabolism

A 62-year-old woman taking empagliflozin for type 2 diabetes is scheduled for elective abdominal surgery. How long before surgery should the drug be withheld?

  1. No hold is needed
  2. 24 hours
  3. 3 days Correct answer.
  4. 7 days

Explanation

SGLT2 inhibitors should be discontinued at least 3 days before elective surgery to reduce the risk of euglycemic ketoacidosis. They are restarted after the patient resumes normal oral intake and is clinically stable. A 24-hour hold is too short for the longer-acting agents.

Question 34Diabetes Mellitus and Glucose Metabolism

A 52-year-old man with type 2 diabetes and no history of cardiovascular disease has an LDL cholesterol of 95 mg/dL. Which lipid-lowering therapy is recommended?

  1. High-intensity statin therapy plus ezetimibe
  2. Moderate-intensity statin therapy Correct answer.
  3. No lipid-lowering therapy because LDL is below 100 mg/dL
  4. Fenofibrate monotherapy

Explanation

Adults aged 40 to 75 years with diabetes and no clinical atherosclerotic cardiovascular disease should receive at least moderate-intensity statin therapy. An LDL of 95 mg/dL does not remove the indication because diabetes itself is a risk-enhancing condition. High-intensity statin plus ezetimibe is reserved for higher-risk patients.

Question 35Diabetes Mellitus and Glucose Metabolism

A 34-year-old woman with long-standing type 1 diabetes has recurrent nausea, early satiety, and vomiting of undigested food. A gastric emptying study is delayed. Which medication is most appropriate to improve symptoms?

  1. Omeprazole
  2. Ondansetron for nausea and vomiting
  3. Loperamide
  4. Metoclopramide Correct answer.

Explanation

Diabetic gastroparesis is managed with prokinetic agents such as metoclopramide in addition to glycemic control and dietary modification. Metoclopramide should be used at the lowest effective dose for the shortest time because of tardive dyskinesia risk. Antiemetics may help vomiting but do not improve gastric emptying.

Question 36Diabetes Mellitus and Glucose Metabolism

Which finding is most consistent with diabetic autonomic neuropathy in a patient with long-standing diabetes?

  1. Unilateral foot pain relieved by walking
  2. Orthostatic hypotension without a compensatory rise in heart rate Correct answer.
  3. Burning pain in both feet that worsens at night
  4. Orthostatic hypotension accompanied by a 25-beat/min rise in heart rate

Explanation

Autonomic neuropathy impairs the baroreflex, so standing may cause a fall in blood pressure without the normal compensatory tachycardia. Burning distal foot pain and unilateral pain relieved by walking reflect peripheral neuropathy and musculoskeletal claudication, respectively. Orthostatic hypotension with an adequate heart-rate rise is more consistent with volume depletion.

Question 37Diabetes Mellitus and Glucose Metabolism

A 28-year-old man with type 1 diabetes uses a continuous glucose monitor. What is the recommended target time in range (70-180 mg/dL) for most adults with type 1 diabetes?

  1. Greater than 70% Correct answer.
  2. Greater than 60%
  3. Greater than 50%
  4. Greater than 90%

Explanation

The recommended target for time in range (70-180 mg/dL) is greater than 70% for most adults with type 1 diabetes. Time below 70 mg/dL should be less than 4%, and time below 54 mg/dL should be less than 1%. Achieving greater than 90% is not a routine target because it may increase hypoglycemia risk.

Question 38Diabetes Mellitus and Glucose Metabolism

A 35-year-old woman with type 1 diabetes has high-risk proliferative diabetic retinopathy and a vitreous hemorrhage. Which treatment is most appropriate to reduce the risk of severe vision loss?

  1. Intravitreal anti-VEGF therapy alone for macular edema
  2. Aspirin therapy
  3. Observation until the hemorrhage clears
  4. Panretinal photocoagulation Correct answer.

Explanation

High-risk proliferative diabetic retinopathy is treated with panretinal photocoagulation to reduce the risk of severe visual loss. Anti-VEGF therapy is used for center-involved macular edema and is an alternative in some cases, but PRP remains the standard for high-risk proliferative disease. Aspirin does not treat retinopathy.

Question 39Diabetes Mellitus and Glucose Metabolism

A 31-year-old woman with type 2 diabetes takes metformin and lisinopril. She reports a positive home pregnancy test. Which medication should be stopped immediately?

  1. Metformin
  2. Lisinopril Correct answer.
  3. Both metformin and lisinopril
  4. Neither medication

Explanation

Angiotensin-converting enzyme inhibitors are contraindicated in pregnancy because of fetal renal toxicity and should be stopped as soon as pregnancy is recognized. Metformin is sometimes continued in pregnancy, although insulin is preferred when medication is needed. Stopping both drugs is unnecessary.

Question 40Diabetes Mellitus and Glucose Metabolism

A 58-year-old man with diabetes has a painless plantar foot ulcer with a callus. Which intervention is most important for healing?

  1. Oral antibiotics
  2. Offloading the ulcer Correct answer.
  3. Daily wet-to-dry dressing changes
  4. Hyperbaric oxygen therapy

Explanation

The cornerstone of healing for a neuropathic plantar ulcer is offloading pressure, often with a total contact cast or removable cast walker. Antibiotics are reserved for clinical infection, and hyperbaric oxygen is not routine initial therapy. Reducing pressure allows the ulcer to heal.

Question 41Obesity, Lipids, and Nutrition

According to the World Health Organization classification, which BMI range defines class I obesity in adults?

  1. 30.0 to 34.9 kg/m2 Correct answer.
  2. 40.0 kg/m2 or higher
  3. 35.0 to 39.9 kg/m2
  4. 25.0 to 29.9 kg/m2

Explanation

Obesity begins at a BMI of 30 kg/m2. Class I obesity spans 30.0 to 34.9 kg/m2, class II spans 35.0 to 39.9 kg/m2, and class III is 40 kg/m2 or higher.

Question 42Obesity, Lipids, and Nutrition

In the NCEP ATP III definition of metabolic syndrome, which waist circumference threshold identifies elevated risk in men?

  1. 94 cm or more
  2. 102 cm or more Correct answer.
  3. 80 cm or more
  4. 88 cm or more

Explanation

ATP III uses a sex-specific waist threshold of greater than 102 cm in men and greater than 88 cm in women. These cutoffs identify abdominal obesity as one of the five metabolic syndrome criteria.

Question 43Obesity, Lipids, and Nutrition

A 34-year-old woman with class I obesity and no obesity-related complications asks about initial weight management. What is the most appropriate first step?

  1. Orlistat three times daily
  2. Bariatric surgery
  3. Intensive lifestyle intervention Correct answer.
  4. Liraglutide daily

Explanation

Guidelines recommend comprehensive lifestyle intervention as first-line therapy for most adults with obesity. Pharmacotherapy and bariatric surgery are added for selected patients who meet specific criteria.

Question 44Obesity, Lipids, and Nutrition

Which medication class is first-line for lowering LDL cholesterol in most adults with hypercholesterolemia?

  1. Bile acid sequestrants
  2. Fibrates
  3. Niacin
  4. Statins Correct answer.

Explanation

Statins inhibit HMG-CoA reductase and produce the largest reliable LDL reduction among oral lipid-lowering drugs. They also reduce atherosclerotic cardiovascular events and are first-line for most patients who need LDL lowering.

Question 45Obesity, Lipids, and Nutrition

Orlistat promotes weight loss through which mechanism?

  1. GLP-1 receptor agonism
  2. Sympathomimetic appetite suppression
  3. Amylin receptor agonism
  4. Pancreatic lipase inhibition Correct answer.

Explanation

Orlistat inhibits gastric and pancreatic lipases, reducing intestinal absorption of dietary fat. This produces steatorrhea and can impair absorption of fat-soluble vitamins.

Question 46Obesity, Lipids, and Nutrition

How many of the five NCEP ATP III criteria must be present to diagnose metabolic syndrome?

  1. One
  2. Four
  3. Two
  4. Three Correct answer.

Explanation

Metabolic syndrome is diagnosed when at least three of five criteria are present: abdominal obesity, elevated triglycerides, low HDL cholesterol, elevated blood pressure, and elevated fasting glucose.

Question 47Obesity, Lipids, and Nutrition

One year after Roux-en-Y gastric bypass, a patient has microcytic anemia and a low ferritin level. Which nutrient deficiency is most likely?

  1. Thiamine
  2. Vitamin B12
  3. Iron Correct answer.
  4. Vitamin D

Explanation

Roux-en-Y bypass excludes the duodenum and proximal jejunum, where dietary iron is absorbed. Low ferritin with microcytic anemia supports iron deficiency.

Question 48Obesity, Lipids, and Nutrition

Untreated heterozygous familial hypercholesterolemia typically produces which lipid profile?

  1. Markedly elevated LDL cholesterol Correct answer.
  2. Chylomicronemia with milky serum
  3. Elevated triglycerides with low HDL cholesterol
  4. Low LDL cholesterol

Explanation

Heterozygous familial hypercholesterolemia is caused by defective LDL receptor clearance and causes lifelong markedly elevated LDL cholesterol. Triglycerides are usually normal or only mildly elevated.

Question 49Obesity, Lipids, and Nutrition

Which personal history is an absolute contraindication to starting a GLP-1 receptor agonist for weight loss?

  1. Hypertension
  2. Medullary thyroid carcinoma Correct answer.
  3. Type 2 diabetes
  4. Major depressive disorder

Explanation

GLP-1 receptor agonists are contraindicated in patients with a personal or family history of medullary thyroid carcinoma or MEN2. Rodent studies showed thyroid C-cell tumors, and this risk is treated as a class caution.

Question 50Obesity, Lipids, and Nutrition

Which patient meets standard criteria for bariatric surgery?

  1. A patient with BMI 33 and hypertension
  2. A patient with BMI 28 and sleep apnea
  3. A patient with BMI 31 and no comorbidities
  4. A patient with BMI 36 and type 2 diabetes Correct answer.

Explanation

Bariatric surgery is generally indicated for BMI 40 or higher, or BMI 35 or higher with an obesity-related comorbidity such as type 2 diabetes. Lower BMI thresholds may apply in some ethnicities but are not the standard US criteria.