1. A 60-year-old female with type 2 diabetes mellitus for over 20 years, treated with multiple daily insulin injections, came in for a routine follow-up. Her recent medical history is significant for menorrhagia secondary to uterine fibroids. Her typical A1c value is 9.0 %, however, her most recent A1c value was 10.6 %. The patient is quite surprised as she has focused on managing her diabetes over the past 3 months, and checks her blood glucose before and after meals. Her blood glucose meter download report reveals an average glucose level of 191 mg/dL, which is consistent with an A1c value of 8.3 %. The A1c value does not seem to accurately reflect mean glycemic control in this patient. What could explain the inaccuracy of her A1c value? What other tests could be used?

• Iron deficiency anemia
• Anemia from acute or chronic blood loss
• Hemolytic anemia
• Vitamin E ingestion

2. A 8-year-old girl with new-onset diabetes is admitted to the hospital with diabetic ketoacidosis (DKA). She has been treated appropriately; the DKA is resolved, and she is discharged home on long-acting insulin once a day and short-acting insulin with each meal. After 2 weeks on this regimen, she has a hypoglycemic seizure. Which of the following represents a possible explanation for this event?

• Incorrect diagnosis of insulin-dependent diabetes mellitus (DM)
• Dawn phenomenon
• Honeymoon phenomenon
• Sepsis

3. Which of the following drug has been approved by the FDA, for the treatment of type 2 diabetes mellitus?

• Bromocriptine
• Reboxetin
• Quinagolide
• Bosentan

4. A 55-year-old male with h/o type 2 diabetes mellitus presented with h/o below skin lesions for the last 4months. It initially started as a group of firm well-demarcated rounded erythematous papules which then expanded and aggregated into plaques characterised by circumferential red-brown borders and a firm yellow-brown waxen atrophic centre containing telangiectasias. There was no history of any trauma prior to the appearance of these lesions. Which of the following statements is false regarding the lesion?

• More common in women than in men
• Exhibits Koebnerization
• The age of onset is earlier in type 1 than type 2 diabetes
• Surgical excision of the lesion is the treatment of choice

5. A 60-year-old lady who is a known case of diabetes mellitus for the last 10 yrs and hypertension for 8 years presents with a diminution of vision in her left eye. She is on Vildagliptin and metformin for diabetes and Telmisartan for hypertension with the last measured HbA1c of 8.6% six months back. Her best-corrected vision was 20/30 in the right eye and 20/40 in the left eye. The crystalline lens was clear in each eye with normal intraocular pressure. She underwent a fundus examination of the right eye which is shown below. What is the most likely location of the abnormality near the fovea?

• Outer nuclear layer
• Outer plexiform layer
• Retinal pigment epithelium
• Internal limiting membrane

6. A 50-year-old male with a history of hypertension and paroxysmal atrial fibrillation had been treated with digoxin and quinidine. During his routine health care visit, he was noted to have raised blood sugar levels and hence the practitioner started an oral medication to help control postprandial sugar levels. The patient began to experience severe flatulence and diarrhoea. Three months after starting the medication, he was admitted to the emergency because of rapid atrial fibrillation, and was found to have sub-therapeutic levels of digoxin (0.23ng/ml). When probed regarding compliance, the patient insisted that he was taking the medication regularly. What is the likely mechanism of action of the drug prescribed by the practitioner?

• Increases insulin release from pancreatic beta-cells
• Decreases glucose production by the liver
• Increases insulin sensitivity in peripheral tissues
• Slows the digestion of ingested carbohydrates

7.  A 65-year-old male with a past medical history of chronic kidney disease, congestive heart failure, and type 2 diabetes mellitus presents to the clinic to establish care. The patient currently manages his diabetes mellitus with only metformin but his hemoglobin A1C is 9.2% today. The patient requires adding a second oral agent to manage his diabetes but the patient is unsure about which stage of chronic kidney disease he is currently at. Which of the following is a contraindication for starting this patient on a sodium-glucose cotransporter-2 inhibitor?

• Glomerular filtration rate less than 60 L/min
• Glomerular filtration rate less than 45 L/min
• Glomerular filtration rate less than 30 L/min
• Hemoglobin A1C above 9.0%

8. A 60 yr old female, diabetic since 12yrs presented with a history of numbness in B/L feet ascending till knee with painless traumatic ulcers for 4yrs, numbness in B/L hands till wrist for 2yrs, difficulty in holding slippers and slippage without knowledge since 1 year. No bowel/bladder involvement was noted. On examination, weakness was noted in EHL, with absent ankle reflex and decreased touch, pain and vibration sense with loss of joint position sense. 

Which of the following statements is false regarding the above condition?

• Most common form of diabetic neuropathy
• Pain can occur even at rest and typically worsens at night
• Intensively treating patients with T1DM to achieve near normo-glycaemia reduces its incidence and progression
• The pathogenesis involved is demyelination of the distal portions of longest myelinated sensory fibres with relative sparing of motor fibres

9.  A 65-year-old woman, with a history of type 2 diabetes mellitus for the last 10yrs, with poorly controlled blood sugar levels comes to the clinic with difficulty walking and moderate-intensity left-sided foot pain for the past eight months. She also complains of associated pins and needle sensations on all four extremities and fatigue for the past six months. These symptoms are not associated with fever or chills. She has not seen a provider for the past 2 years. Her recent medical history is unknown. She does not have a smoking or drinking history.  Vital signs are stable. Her mucous membranes are moist and pale. Her left foot appears significantly deformed. Radiographs reveal effusions in many tarsometatarsal joints, osteophytes, and extra-articular bone fragments are also seen. Which of the following leads to this presentation?

• Osteomyelitis
• Nerve impairment
• Hyperuricemia
• Osteoporosis

10. In a recent 13-week, multicenter, randomised trial funded by the National Institute of Diabetes and Digestive and Kidney Diseases and others, adults and children older than 6 years of age with type 1 diabetes were randomised either to receive bionic pancreas treatment with insulin aspart or insulin lispro or to receive standard care (defined as any insulin-delivery method with unblinded, real-time continuous glucose monitoring), to determine the HbA1C level at the end of 13weeks. Which of the following result was obtained in the study?

• Rate of severe hypoglycemia was lower in the bionic-pancreas group than in the standard-care group.
• Bionic pancreas group patients had risk of euglycemic diabetic ketoacidosis.
• Bionic pancreas was associated with a greater reduction than standard care in the glycated hemoglobin level.
• The treatment effect of the bionic pancreas on the glycated hemoglobin level was lesser among participants with a higher baseline glycated hemoglobin level.