A 22-year-old lean woman is found to have fasting glucose of 182 mg/dL and HbA1c of 8.6% at a pre-employment check. She has no ketonuria. Her mother was diagnosed with diabetes at 24 and her maternal grandfather at 28; both have been on tablets for years without insulin. Glycosuria was noted even at a plasma glucose of 150 mg/dL. Anti-GAD65 is negative and fasting C-peptide is normal. Which drug is the best initial treatment for her?

Low-dose sulfonylurea such as gliclazide

Metformin with a GLP-1 receptor agonist

No drug, diet and follow-up only

A 70-year-old woman with type 2 diabetes takes metformin 1 g twice daily and has an HbA1c of 7.2%. On her latest review her eGFR has fallen from 42 to 26 mL/min/1.73 m², with no acute illness. What should be done about her metformin?

Halve the dose and recheck in 3 months

A 30-year-old man with type 1 diabetes collapses at home after a late-night shift; his wife finds him unrousable and his glucometer reads 34 mg/dL. He cannot swallow, and there is no one at home who can start an IV line. What should she give first?

Glucagon by intramuscular injection

An extra dose of his rapid-acting insulin

Glucose gel squeezed into his mouth

Sugar dissolved in water by mouth

A 24-year-old man with type 1 diabetes takes NPH and regular insulin before breakfast and before dinner. His fasting glucose has been 240-280 mg/dL for two weeks, and his doctor increased the evening NPH dose, after which morning values rose further. He wakes with night sweats and headache. A 3 a.m. glucose is 52 mg/dL. What is the best change?

Increase the evening NPH dose further

Increase the morning regular insulin

Diabetes and its emergencies

35 NEET-PG practice questions on Diabetes and its emergencies, part of General Medicine. The first 25 are below; the first 5 with answers and explanations (tap Show answer after you have chosen), the rest in Learn with a free account.

Question 1 · Medium
A 54-year-old man has had type 2 diabetes for 8 years and takes metformin 1 g twice daily; HbA1c is 8.1%. Last month he was admitted with heart failure, and echocardiography shows an ejection fraction of 32%. eGFR is 58 mL/min/1.73 m². Which drug is the best to add?
1. ASaxagliptin
2. BPioglitazone
3. CGlibenclamide
4. DDapagliflozin
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Answer: D · Dapagliflozin
SGLT2 inhibitors lower glucose by blocking proximal tubular glucose reabsorption, and in large trials they reduced heart-failure hospitalisation and cardiovascular death and slowed CKD, even in people without diabetes. Current diabetes guidance therefore recommends an SGLT2 inhibitor for anyone with heart failure or CKD, whatever the HbA1c. His eGFR is high enough to start one. Counsel him about genital mycotic infection and euglycaemic ketoacidosis, and to stop the drug during acute illness or before surgery.
- A: Saxagliptin increased heart-failure admissions in its outcome trial.
- B: Pioglitazone causes fluid retention and is contraindicated in heart failure.
- C: Sulfonylureas cause hypoglycaemia and weight gain and give no heart-failure benefit.
Question 2 · Hard
A 22-year-old lean woman is found to have fasting glucose of 182 mg/dL and HbA1c of 8.6% at a pre-employment check. She has no ketonuria. Her mother was diagnosed with diabetes at 24 and her maternal grandfather at 28; both have been on tablets for years without insulin. Glycosuria was noted even at a plasma glucose of 150 mg/dL. Anti-GAD65 is negative and fasting C-peptide is normal. Which drug is the best initial treatment for her?
1. AMetformin with a GLP-1 receptor agonist
2. BBasal-bolus insulin regimen
3. CNo drug, diet and follow-up only
4. DLow-dose sulfonylurea such as gliclazide
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Answer: D · Low-dose sulfonylurea such as gliclazide
Diabetes in three generations, onset before 25, no autoimmunity and preserved C-peptide point to maturity-onset diabetes of the young. Glycosuria at low glucose levels (a low renal threshold) and progressive hyperglycaemia fit HNF1A-MODY, the commonest type, rather than glucokinase MODY, which causes mild, stable fasting hyperglycaemia needing no drug. HNF1A-MODY is very sensitive to sulfonylureas, which act downstream of the defect, so low-dose gliclazide often controls it for years. Genetic testing confirms the type and allows family screening.
- A: This is the obese type 2 approach; HNF1A-MODY responds best to sulfonylureas.
- B: Insulin is not needed: antibodies are negative and C-peptide is preserved.
- C: Diet alone suits glucokinase MODY, whose hyperglycaemia is mild and stable, unlike her HbA1c of 8.6%.
Question 3 · Medium
A 70-year-old woman with type 2 diabetes takes metformin 1 g twice daily and has an HbA1c of 7.2%. On her latest review her eGFR has fallen from 42 to 26 mL/min/1.73 m², with no acute illness. What should be done about her metformin?
1. AReplace it with glibenclamide
2. BStop metformin
3. CContinue the same dose
4. DHalve the dose and recheck in 3 months
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Answer: B · Stop metformin
Metformin is excreted unchanged by the kidney, and its accumulation in renal failure raises the risk of lactic acidosis. It is contraindicated when eGFR is below 30 mL/min/1.73 m², should not be started at 30-45, and the dose is reviewed and usually reduced when eGFR falls into the 30-45 range. With an eGFR of 26 it must be stopped. A DPP-4 inhibitor such as linagliptin, an SGLT2 inhibitor for kidney protection (it can be started down to an eGFR of about 20), or insulin are the alternatives.
- A: Glibenclamide accumulates in CKD and causes prolonged hypoglycaemia, especially in the elderly.
- C: Full-dose metformin at eGFR below 30 risks lactic acidosis.
- D: Dose reduction applies to eGFR 30-45, not below 30.
Question 4 · Easy
A 30-year-old man with type 1 diabetes collapses at home after a late-night shift; his wife finds him unrousable and his glucometer reads 34 mg/dL. He cannot swallow, and there is no one at home who can start an IV line. What should she give first?
1. AGlucagon by intramuscular injection
2. BAn extra dose of his rapid-acting insulin
3. CGlucose gel squeezed into his mouth
4. DSugar dissolved in water by mouth
Show answerHide answer
Answer: A · Glucagon by intramuscular injection
Severe hypoglycaemia is a level of hypoglycaemia in which the patient needs help from another person. If he cannot swallow safely, nothing is given by mouth because of the risk of aspiration; glucagon, by intramuscular or subcutaneous injection or as nasal powder, raises glucose by stimulating hepatic glycogenolysis within about 10-15 minutes. Once awake he should eat carbohydrate, because the effect is short. Family members of insulin users should be taught to use glucagon.
- B: Insulin would lower his glucose further.
- C: Oral gel in an unrousable patient risks aspiration.
- D: Fluids by mouth can be aspirated when he cannot swallow.
Question 5 · Medium
A 24-year-old man with type 1 diabetes takes NPH and regular insulin before breakfast and before dinner. His fasting glucose has been 240-280 mg/dL for two weeks, and his doctor increased the evening NPH dose, after which morning values rose further. He wakes with night sweats and headache. A 3 a.m. glucose is 52 mg/dL. What is the best change?
1. AAdd regular insulin at bedtime
2. BIncrease the evening NPH dose further
3. CIncrease the morning regular insulin
4. DReduce the evening NPH dose
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Answer: D · Reduce the evening NPH dose
Nocturnal hypoglycaemia (52 mg/dL at 3 a.m., night sweats, morning headache) followed by high fasting glucose fits the Somogyi effect: counter-regulatory hormones cause rebound hyperglycaemia. Raising the evening dose made it worse. The evening NPH dose should be reduced, or moved to bedtime, so that it peaks later; a long-acting analogue such as glargine reduces nocturnal hypoglycaemia. In the dawn phenomenon, by contrast, the 3 a.m. glucose is normal or high.
- A: Bedtime regular insulin would worsen the night-time hypoglycaemia.
- B: More evening NPH deepens the nocturnal hypoglycaemia that drives the rebound.
- C: Morning regular insulin acts on post-breakfast glucose, not the fasting value.
Question 6 · Medium
A 74-year-old woman with type 2 diabetes and CKD (eGFR 35 mL/min/1.73 m²) takes glibenclamide 5 mg twice daily. Over a month she has had three early-morning episodes of sweating and confusion, with capillary glucose of 48-55 mg/dL. HbA1c is 6.4%. What is the best change to her treatment?
1. AReplace glibenclamide with linagliptin
2. BReduce glibenclamide to 5 mg daily
3. CReplace glibenclamide with insulin glargine
4. DAdd acarbose and continue glibenclamide
Answer and explanation in LearnFree account
Question 7 · Easy
A 50-year-old woman with type 2 diabetes was started on a new tablet 6 weeks ago. Her glucose is better, but she now has vulval itching with a thick white curdy discharge, the first such episode in her life. Which drug did she most likely start?
1. ASitagliptin
2. BPioglitazone
3. CGlimepiride
4. DDapagliflozin
Answer and explanation in LearnFree account
Question 8 · Medium
A 62-year-old man has taken metformin for 10 years. He complains of tingling and numbness in both feet. Haemoglobin is 10.2 g/dL with an MCV of 108 fL; ankle jerks are absent and vibration sense is reduced up to the knees. Which test should be done next?
1. ASerum vitamin B12 level
2. BSerum folate level
3. CRepeat HbA1c
4. DNerve conduction studies
Answer and explanation in LearnFree account
Question 9 · Medium
A 30-year-old woman is being treated for DKA with IV fluids and an insulin infusion. After 6 hours her glucose has fallen to 190 mg/dL, but pH is 7.22, bicarbonate 12 mmol/L and the anion gap 20 mmol/L. Potassium is 4.2 mmol/L. What is the next best step?
1. AGive IV sodium bicarbonate
2. BAdd IV dextrose and continue the insulin infusion
3. CStop insulin until glucose rises above 250 mg/dL
4. DStop the insulin infusion and give SC insulin
Answer and explanation in LearnFree account
Question 10 · Medium
A 55-year-old man with type 2 diabetes on insulin was started on propranolol for essential tremor. He now has episodes in which he feels confused and sweaty; his glucose at these times is 50-55 mg/dL. He says he no longer gets the palpitations and shakiness that used to warn him. Through which receptors is the warning symptom that he still gets produced?
1. AAlpha-1 receptors in skin arterioles
2. BBeta-1 receptors in the heart
3. CMuscarinic receptors on sweat glands
4. DBeta-2 receptors in skeletal muscle
Answer and explanation in LearnFree account
Question 11 · Medium
A 9-year-old girl with newly diagnosed type 1 diabetes is being treated for severe DKA in the paediatric ward. Five hours into treatment she complains of headache, becomes irritable and then drowsy. Her heart rate has fallen from 120 to 62/min and BP has risen to 132/86 mmHg. Capillary glucose is 210 mg/dL. What is the next best step?
1. AIncrease the IV fluid rate
2. BIV mannitol or hypertonic saline now
3. CUrgent CT head before any treatment
4. DGive IV 10% dextrose bolus
Answer and explanation in LearnFree account
Question 12 · Hard
A 30-year-old woman is brought to casualty 2 hours after swallowing about 20 of her mother's glimepiride tablets after a family quarrel. Glucose is 34 mg/dL. She wakes after an IV dextrose bolus and is put on a 10% dextrose infusion, but over the next 6 hours glucose falls below 60 mg/dL three times. What is the best next step to control her glucose?
1. AIV hydrocortisone
2. BLarger IV 25% dextrose boluses only
3. COctreotide by subcutaneous injection
4. DRepeated IV glucagon boluses
Answer and explanation in LearnFree account
Question 13 · Medium
A 38-year-old man from a slum in Mumbai presents with 2 months of thirst, polyuria and 7 kg weight loss. Random plasma glucose is 386 mg/dL, HbA1c 12.4%, urine ketones trace, venous pH 7.38 and bicarbonate 24 mmol/L. Anti-GAD65 is negative. What is the best initial treatment?
1. AMetformin alone, review in 3 months
2. BMetformin with a DPP-4 inhibitor
3. CAdmission for IV insulin infusion
4. DBasal insulin with metformin
Answer and explanation in LearnFree account
Question 14 · Easy
An 11-year-old girl is admitted with diabetic ketoacidosis after 3 weeks of thirst, bedwetting and weight loss. She has no family history of diabetes and is not obese. Which antibody test best supports an autoimmune cause of her diabetes?
1. AAnti-tissue transglutaminase IgA
2. BAntinuclear antibody
3. CAnti-GAD65 antibody
4. DAnti-TPO antibody
Answer and explanation in LearnFree account
Question 15 · Hard
A 45-year-old man with poorly controlled diabetes is admitted to a Bengaluru hospital in DKA. On day 2 he develops right facial pain and swelling, drooping of the right eyelid and reduced vision. There is a black necrotic patch on the hard palate. KOH mount of nasal tissue shows broad, ribbon-like, sparsely septate hyphae branching at right angles. What is the most appropriate management?
1. AIV fluconazole with nasal decongestants
2. BLiposomal amphotericin B with urgent surgical debridement
3. CBroad-spectrum antibiotics and repeat KOH mount
4. DIV voriconazole and await fungal culture
Answer and explanation in LearnFree account
Question 16 · Medium
A 19-year-old thin boy from a poor family in rural Odisha has had recurrent upper abdominal pain since childhood and passes bulky, greasy stools. He now has polyuria; plasma glucose is 340 mg/dL, and urine ketones are negative. A plain X-ray of the abdomen shows multiple calcific densities along the pancreas. What is the most likely diagnosis?
1. AFibrocalculous pancreatic diabetes
2. BMaturity-onset diabetes of the young
3. CType 1 diabetes mellitus
4. DLatent autoimmune diabetes in adults
Answer and explanation in LearnFree account
Question 17 · Medium
A 30-year-old man with type 1 diabetes is recovering from DKA on an insulin infusion. He is alert and eating breakfast. Glucose 168 mg/dL, pH 7.36, bicarbonate 19 mmol/L, anion gap 10 mmol/L. He took basal-bolus insulin before admission. What is the best next step?
1. AStop insulin and restart it if glucose rises
2. BContinue the infusion for another 24 hours
3. CStop the infusion now and give SC insulin at lunch
4. DGive SC insulin, then stop the infusion after an overlap
Answer and explanation in LearnFree account
Question 18 · Medium
A 70-year-old man is admitted with hyperglycaemic hyperosmolar state. Consider these statements on his care: 1. IV fluid replacement is the first and main treatment. 2. A high-dose insulin infusion should be started before any fluid. 3. He should receive prophylactic low-molecular-weight heparin unless contraindicated. 4. HHS carries a lower mortality than DKA. Which statements are correct?
1. A1, 3 and 4 only
2. B2 and 4 only
3. C1, 2 and 3 only
4. D1 and 3 only
Answer and explanation in LearnFree account
Question 19 · Hard
A 26-year-old man with type 1 diabetes is admitted with DKA: glucose 480 mg/dL, pH 7.08, bicarbonate 7 mmol/L, sodium 132 mmol/L and potassium 3.0 mmol/L. ECG shows prominent U waves. He has received 1 litre of 0.9% saline. What is the next step?
1. AGive an IV insulin bolus and recheck K in 4 hours
2. BGive IV sodium bicarbonate, then start insulin
3. CStart the insulin infusion at 0.1 units/kg/h now
4. DGive IV potassium; delay insulin until K is at least 3.3
Answer and explanation in LearnFree account
Question 20 · Medium
A 60-year-old man with type 2 diabetes for 12 years is on metformin and the maximum dose of ramipril. BP is 132/80 mmHg and HbA1c 7.6%. eGFR is 48 mL/min/1.73 m², and the urine albumin-creatinine ratio is 420 mg/g on two samples. He has no heart failure. Which drug, added now, best slows his kidney disease?
1. ATelmisartan
2. BPioglitazone
3. CEmpagliflozin
4. DGlimepiride
Answer and explanation in LearnFree account
Question 21 · Medium
A 36-year-old lean IT professional (BMI 21 kg/m²) was diagnosed with type 2 diabetes a year ago and responded at first to metformin and glimepiride. He has now lost 5 kg and his HbA1c has risen to 10.2%. He has no ketoacidosis. Anti-GAD65 antibodies are strongly positive and fasting C-peptide is low. What is the most likely diagnosis?
1. AMaturity-onset diabetes of the young
2. BLatent autoimmune diabetes in adults
3. CFibrocalculous pancreatic diabetes
4. DType 2 diabetes with secondary drug failure
Answer and explanation in LearnFree account
Question 22 · Hard
A 29-year-old staff nurse has had three episodes of confusion and sweating at work. During an episode in hospital: plasma glucose 38 mg/dL, insulin 62 µU/mL (expected below 3 when glucose is this low), C-peptide 0.1 ng/mL (expected 0.6 or more if insulin is from the pancreas), proinsulin low, and a sulfonylurea screen negative. Symptoms resolve with IV dextrose. What is the most likely cause?
1. ASelf-injection of exogenous insulin
2. BIGF-2 from a non-islet cell tumour
3. CUndeclared sulfonylurea ingestion
4. DInsulin-secreting pancreatic tumour
Answer and explanation in LearnFree account
Question 23 · Easy
A 46-year-old schoolteacher with no symptoms is screened under NP-NCD at a primary health centre. Her random capillary glucose is 168 mg/dL. Next morning her fasting plasma glucose is 134 mg/dL and HbA1c is 6.9%. How should her glycaemic status be classified?
1. AType 2 diabetes mellitus
2. BNormal glucose tolerance
3. CPrediabetes with impaired fasting glucose
4. DUnclassified until an OGTT is done
Answer and explanation in LearnFree account
Question 24 · Hard
A 58-year-old man with type 2 diabetes on empagliflozin and metformin underwent laparoscopic cholecystectomy two days ago and has eaten little since. He now has nausea and rapid deep breathing. Glucose 186 mg/dL, pH 7.12, bicarbonate 9 mmol/L, anion gap 24 mmol/L, serum beta-hydroxybutyrate 5.8 mmol/L (normal below 0.6), lactate 1.4 mmol/L (normal below 2), creatinine 1.0 mg/dL. Besides stopping empagliflozin, what is the next best step?
1. AHaemodialysis for metformin-associated lactic acidosis
2. BIV fluids and insulin infusion with dextrose
3. CWithhold insulin as glucose is below 250 mg/dL
4. DIV sodium bicarbonate and observation
Answer and explanation in LearnFree account
Question 25 · Medium
A 44-year-old woman with type 2 diabetes and obesity is to start once-weekly semaglutide. Consider these points for her counselling: 1. It usually causes weight loss. 2. It slows gastric emptying, so early nausea is common. 3. Used alone, it often causes hypoglycaemia. 4. It should be avoided if she or a family member has had medullary thyroid carcinoma. Which statements are correct?
1. A2, 3 and 4 only
2. B1, 2, 3 and 4
3. C1 and 2 only
4. D1, 2 and 4 only
Answer and explanation in LearnFree account

10 more Diabetes and its emergencies questions

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Diabetes and its emergencies

A 54-year-old man has had type 2 diabetes for 8 years and takes metformin 1 g twice daily; HbA1c is 8.1%. Last month he was admitted with heart failure, and echocardiography shows an ejection fraction of 32%. eGFR is 58 mL/min/1.73 m². Which drug is the best to add?

A 70-year-old woman with type 2 diabetes takes metformin 1 g twice daily and has an HbA1c of 7.2%. On her latest review her eGFR has fallen from 42 to 26 mL/min/1.73 m², with no acute illness. What should be done about her metformin?

A 30-year-old man with type 1 diabetes collapses at home after a late-night shift; his wife finds him unrousable and his glucometer reads 34 mg/dL. He cannot swallow, and there is no one at home who can start an IV line. What should she give first?

A 74-year-old woman with type 2 diabetes and CKD (eGFR 35 mL/min/1.73 m²) takes glibenclamide 5 mg twice daily. Over a month she has had three early-morning episodes of sweating and confusion, with capillary glucose of 48-55 mg/dL. HbA1c is 6.4%. What is the best change to her treatment?

A 50-year-old woman with type 2 diabetes was started on a new tablet 6 weeks ago. Her glucose is better, but she now has vulval itching with a thick white curdy discharge, the first such episode in her life. Which drug did she most likely start?

A 62-year-old man has taken metformin for 10 years. He complains of tingling and numbness in both feet. Haemoglobin is 10.2 g/dL with an MCV of 108 fL; ankle jerks are absent and vibration sense is reduced up to the knees. Which test should be done next?

A 30-year-old woman is being treated for DKA with IV fluids and an insulin infusion. After 6 hours her glucose has fallen to 190 mg/dL, but pH is 7.22, bicarbonate 12 mmol/L and the anion gap 20 mmol/L. Potassium is 4.2 mmol/L. What is the next best step?

A 38-year-old man from a slum in Mumbai presents with 2 months of thirst, polyuria and 7 kg weight loss. Random plasma glucose is 386 mg/dL, HbA1c 12.4%, urine ketones trace, venous pH 7.38 and bicarbonate 24 mmol/L. Anti-GAD65 is negative. What is the best initial treatment?

An 11-year-old girl is admitted with diabetic ketoacidosis after 3 weeks of thirst, bedwetting and weight loss. She has no family history of diabetes and is not obese. Which antibody test best supports an autoimmune cause of her diabetes?

A 30-year-old man with type 1 diabetes is recovering from DKA on an insulin infusion. He is alert and eating breakfast. Glucose 168 mg/dL, pH 7.36, bicarbonate 19 mmol/L, anion gap 10 mmol/L. He took basal-bolus insulin before admission. What is the best next step?

A 26-year-old man with type 1 diabetes is admitted with DKA: glucose 480 mg/dL, pH 7.08, bicarbonate 7 mmol/L, sodium 132 mmol/L and potassium 3.0 mmol/L. ECG shows prominent U waves. He has received 1 litre of 0.9% saline. What is the next step?

A 46-year-old schoolteacher with no symptoms is screened under NP-NCD at a primary health centre. Her random capillary glucose is 168 mg/dL. Next morning her fasting plasma glucose is 134 mg/dL and HbA1c is 6.9%. How should her glycaemic status be classified?