Welcome to your 🩸 Diabetes Mellitus Across the Lifespan & Its Complications with Type 2 Diabetes Clinical Long Case Arena — 40 MCQs
1.
A 54-year-old man with symptomatic type 2 diabetes has HbA1c of 9.2%, estimated GFR of 85 mL/min/1.73 m² and no clinical evidence of acute metabolic decompensation. His clinician is considering initial oral glucose-lowering treatment. Which management approach is most appropriate?
2.
A 58-year-old woman with a 16-year history of type 2 diabetes mellitus has persistent albuminuria and an estimated glomerular filtration rate of 48 mL/min/1.73 m². She is receiving appropriate renin–angiotensin system blockade and has satisfactory blood pressure control. Which additional treatment class may slow progression of diabetic kidney disease through renal haemodynamic and metabolic effects?
3.
A 54-year-old man with newly diagnosed type 2 diabetes has an LDL cholesterol of 145 mg/dL, hypertension and obesity. He has no known previous myocardial infarction or stroke. Which approach is most appropriate for reducing long-term cardiovascular complications?
4.
A 61-year-old man with poorly controlled diabetes mellitus presents with a plantar ulcer beneath the second metatarsal head. The wound extends through the skin into a tendon, but there is no evidence of abscess, osteomyelitis or gangrene. Using the Wagner classification of diabetic foot ulcers, which grade best describes this lesion?
5.
A 55-year-old man presents with excessive thirst and frequent urination. He is concerned about diabetes insipidus because a relative had a similar presentation. His investigations reveal raised plasma glucose, HbA1c of 9.0% and glucose-positive urine. Which finding most strongly distinguishes diabetes mellitus from diabetes insipidus in this patient?
6.
A 54-year-old man with an eight-year history of type 2 diabetes mellitus is found to have proteinuria and increasing serum creatinine. Further assessment reveals rapid deterioration of renal function over three weeks, visible haematuria and red blood cell casts in the urine. Which interpretation is most appropriate?
7.
A 24-year-old man with type 1 diabetes mellitus presents with vomiting, abdominal pain and increasing weakness. Blood glucose is 490 mg/dL, arterial pH is 7.12, bicarbonate is 10 mmol/L and blood ketones are markedly elevated. His serum potassium is 3.0 mmol/L. Intravenous fluids have been started. Which is the most appropriate next management decision?
8.
A 54-year-old man with recently diagnosed type 2 diabetes returns with increasing thirst, repeated vomiting, abdominal discomfort and marked weakness. Examination reveals dehydration and deep, rapid breathing. Which is the most appropriate immediate management decision?
9.
A 57-year-old man with type 2 diabetes mellitus is reviewed after a recent hospital admission for unstable angina. He has an HbA1c of 7.2%, blood pressure of 146/88 mmHg and elevated LDL cholesterol. He asks whether controlling blood glucose alone will prevent future cardiovascular complications. Which approach is most appropriate?
10.
A 54-year-old man presents with four months of classic hyperglycaemic symptoms. His random plasma glucose is 268 mg/dL and HbA1c is 9.2%. He asks whether additional fasting glucose testing is necessary before a diagnosis can be made. What is the most appropriate interpretation?
11.
A newly diagnosed patient with type 2 diabetes has a serum creatinine of 1.0 mg/dL, estimated GFR of 85 mL/min/1.73 m² and urine albumin-to-creatinine ratio of 65 mg/g. His blood pressure is 148/90 mmHg. What is the most appropriate interpretation of his renal findings?
12.
A 54-year-old man with newly diagnosed type 2 diabetes reports burning pain and reduced sensation in both feet. Examination shows symmetrical sensory impairment and reduced ankle reflexes without muscle weakness or active foot lesions. Which diagnosis best accounts for his neurological symptoms?
13.
A 54-year-old man presents with gradually progressive thirst, nocturia and unintentional weight loss. He is obese, has hypertension and reports that his father developed diabetes in middle age. Which additional historical feature would most strongly suggest significant insulin deficiency requiring early reassessment of the diabetes type?
14.
A 54-year-old overweight man presents with polyuria, polydipsia, fatigue and fluctuating blurred vision. Random plasma glucose is 268 mg/dL and HbA1c is 9.2%. He is alert, haemodynamically stable and has no vomiting or abnormal breathing. What is the most likely diagnosis?
15.
A man newly diagnosed with type 2 diabetes has HbA1c of 9.2%. He is clinically stable but has hypertension, obesity and an elevated urine albumin-to-creatinine ratio. His physician is selecting long-term glucose-lowering therapy. Which factor should most strongly guide treatment individualization?
16.
A 51-year-old woman with type 2 diabetes has an HbA1c of 7.8% despite regular medication. She has obesity, limited physical activity and a diet containing frequent refined carbohydrates. She expresses frustration because earlier attempts at weight reduction were unsuccessful. Which management strategy is most appropriate?
17.
A 65-year-old man with long-standing type 2 diabetes mellitus presents with a non-healing plantar ulcer of six weeks' duration. The ulcer is deep, with surrounding erythema and purulent discharge. A sterile metal probe gently introduced into the wound contacts a hard underlying structure. Plain radiography shows cortical destruction involving the adjacent metatarsal bone. Which complication is most likely?
18.
A 56-year-old woman with type 2 diabetes mellitus has an HbA1c of 8.4% despite taking metformin and following dietary advice. She also has established atherosclerotic cardiovascular disease following a previous myocardial infarction. Her estimated glomerular filtration rate is 72 mL/min/1.73 m². Which additional glucose-lowering treatment would offer cardiovascular benefit beyond its effect on blood glucose?
19.
A 14-year-old boy with type 1 diabetes develops fever and a respiratory infection. He is eating less than usual and has mild nausea. His capillary glucose is 260 mg/dL, and blood ketones are mildly elevated. He is alert, well perfused and able to drink. His parents suggest stopping insulin until he can eat normally. Which advice is most appropriate?
20.
A 68-year-old man with type 2 diabetes mellitus is admitted with confusion, severe dehydration and a plasma glucose concentration of 920 mg/dL. Serum osmolality is markedly elevated, while ketonaemia and acidosis are absent. Blood pressure is 92/58 mmHg, and the pulse is 118/min. Which intervention should receive the highest initial priority?
21.
A 54-year-old man with newly diagnosed diabetes has intermittent blurred vision. His visual acuity is satisfactory during the clinic visit, and bedside examination reveals no obvious fundal abnormality. Which is the most appropriate next step for evaluating diabetic eye complications?
22.
A newly diagnosed 54-year-old diabetic patient reports burning sensations in both feet, particularly at night. Examination reveals symmetrical reduction in distal vibration sensation and diminished ankle reflexes. Which clinical interpretation best explains these findings?
23.
A 64-year-old man with poorly controlled type 2 diabetes mellitus attends a primary care clinic with a three-day history of increasing pain and swelling in his right foot. Examination reveals fever, tachycardia, spreading erythema, a deep plantar ulcer and foul-smelling discharge. His blood pressure is 94/60 mmHg, and capillary glucose is 340 mg/dL. Which is the most appropriate next step?
24.
A 54-year-old man with suspected diabetes has a blood pressure of 148/90 mmHg, BMI of 30 kg/m² and increased waist circumference. He has no peripheral oedema or signs of heart failure. Which interpretation best reflects the significance of these examination findings?
25.
A 63-year-old man with a 20-year history of type 2 diabetes presents with a painful ulcer on the tip of his great toe. Examination reveals cool feet, shiny skin, absent dorsalis pedis pulses and delayed capillary refill. The ulcer has a punched-out appearance with surrounding tissue necrosis. Which underlying mechanism is most likely responsible for the poor healing?
26.
A newly diagnosed diabetic patient has reduced plantar protective sensation but no active foot ulcer. He works long hours in a shop and frequently walks barefoot at home. Which advice is most effective for preventing future diabetic foot complications?
27.
A 49-year-old man with central obesity and hypertension undergoes diabetes screening during a routine medical examination. He has no polyuria, polydipsia or weight loss. His HbA1c is 6.8%, while fasting plasma glucose measured on the same day is 118 mg/dL. He has no known disorder affecting HbA1c reliability. Which is the most appropriate next step to establish the diagnosis?
28.
A 13-year-old girl with newly diagnosed type 1 diabetes mellitus is admitted with diabetic ketoacidosis. She receives intravenous fluids and insulin under close monitoring. Six hours later, she develops worsening headache, irritability, bradycardia and declining consciousness. Which complication should be suspected immediately?
29.
A 20-year-old woman with type 1 diabetes mellitus is treated for diabetic ketoacidosis. After several hours of intravenous fluids and insulin, plasma glucose decreases to 190 mg/dL. However, serum bicarbonate remains 13 mmol/L, the anion gap is elevated and ketonaemia persists. Which is the most appropriate next management principle?
30.
A 54-year-old shopkeeper with newly diagnosed type 2 diabetes expresses concern about medication costs, long working hours and the possibility of future complications. He has hypertension, obesity, peripheral neuropathy and increased urinary albumin. Which counselling approach is most appropriate?
31.
A 54-year-old man with type 2 diabetes has persistent hypertension and repeatedly elevated urine albumin-to-creatinine ratios. Renal filtration remains preserved. Which antihypertensive treatment principle is most appropriate for reducing renal and cardiovascular risk?
32.
During the examination of a patient with newly diagnosed type 2 diabetes, a 10-g monofilament is not perceived at several plantar sites. Both dorsalis pedis pulses are palpable, and there are no current ulcers or skin infections. What is the most important implication of this finding?
33.
A 54-year-old man begins treatment for type 2 diabetes and returns for review after several weeks. His thirst and urinary frequency have improved, and he is tolerating treatment. Which investigation is most useful for assessing his longer-term glycaemic response approximately three months after treatment initiation?
34.
A patient with diabetes and established peripheral neuropathy presents with a new plantar wound. The surrounding foot is red, warm and swollen, and he has developed fever. Pedal pulses remain palpable. What is the most appropriate interpretation?
35.
A 37-year-old man presents with progressive polyuria, polydipsia, blurred vision and recurrent skin infections. His fasting plasma glucose is 172 mg/dL on two separate occasions. Urine glucose is positive, but urine ketones are negative. Which physiological mechanism most directly explains his excessive urinary output?
36.
A 43-year-old woman with type 2 diabetes mellitus is found unconscious at home. Her husband reports that she received her usual insulin dose but had persistent vomiting and could not eat. Capillary blood glucose is 32 mg/dL. She has no intravenous access, and an emergency team is arranging transfer to hospital. Which immediate treatment is most appropriate?
37.
A 16-year-old girl with type 1 diabetes mellitus has experienced repeated episodes of hyperglycaemia over the previous three months. Her mother reports that she occasionally omits insulin injections while attending school because she is embarrassed about her condition. She has no current symptoms of ketoacidosis. Which management approach is most appropriate?
38.
A 60-year-old man with type 2 diabetes mellitus attends routine follow-up. He has no foot pain or visible ulceration. Examination with a 10-g monofilament demonstrates an inability to perceive pressure at several plantar sites. His pedal pulses are palpable, and there is no active infection. What is the most important clinical implication of this finding?
39.
A 45-year-old woman with type 2 diabetes mellitus is prescribed metformin. At a follow-up visit, she develops persistent vomiting and dehydration due to acute gastroenteritis. Investigations reveal acute kidney injury with a marked reduction in renal function. Which medication-related concern is most important?
40.
A 54-year-old overweight shopkeeper presents with four months of excessive thirst, frequent urination, fatigue and intermittent blurring of vision. He has hypertension and a family history of type 2 diabetes. Which mechanism best explains his polyuria?
