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2.2 Insulin Therapy, Hyperglycemic Emergencies & Chronic Complications

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ABIM Internal Medicine Exam

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1 Chapter 0: The ABIM Exam, Blueprint & Study Strategy

0.1 Exam Format, Question Types & the 2026 Blueprint 0.2 Eligibility, Registration, Fees & Exam-Day Logistics 0.3 Scoring, the Passing Standard & Score Reports 0.4 Building a Blueprint-Weighted Study Plan

2 Chapter 1: Cardiovascular Disease (14% of Exam)

1.1 Ischemic Heart Disease & Acute Coronary Syndromes 1.2 Antithrombotic Therapy, Secondary Prevention & Mechanical Complications of MI 1.3 Atrial Fibrillation, Atrial Flutter & Stroke Prevention 1.4 Supraventricular Tachycardias, Ventricular Arrhythmias & Bradycardias 1.5 Heart Failure: Classification, Staging & Guideline-Directed Medical Therapy 1.6 Device Therapy, HFpEF & the Cardiomyopathies 1.7 Valvular Heart Disease & Endocarditis Prophylaxis 1.8 Pericardial Disease & Acute Aortic Syndromes 1.9 Hypertension: Classification, Diagnosis & Secondary Causes 1.10 Hypertensive Crises & Dyslipidemia 1.11 Adult Congenital Heart Disease & Coarctation of the Aorta 1.12 Syncope: Reflex, Orthostatic & Cardiac Causes 1.13 Cardiac Physical Examination, Murmurs & Antithrombotic Selection

3 Chapter 2: Endocrinology, Diabetes & Metabolism (9% of Exam)

2.1 Diabetes Mellitus: Diagnosis, Glycemic Targets & Pharmacotherapy 2.2 Insulin Therapy, Hyperglycemic Emergencies & Chronic Complications 2.3 Thyroid Function Testing & Hypothyroidism 2.4 Thyrotoxicosis, Thyroid Storm & Thyroid Nodules 2.5 Adrenal & Pituitary Disorders 2.6 Hypercalcemia, Hypocalcemia & Disorders of Mineral Metabolism 2.7 Osteoporosis & Paget Disease of Bone 2.8 Ovarian, Testicular & Reproductive Endocrine Disorders 2.9 Hypoglycemia, Endocrine Tumors, Polyglandular Syndromes & Severe Hypertriglyceridemia

4 Chapter 3: Gastroenterology & Hepatology (9% of Exam)

3.1 Esophageal Disease 3.2 Stomach & Duodenal Disease and Gastrointestinal Hemorrhage 3.3 Inflammatory Bowel Disease 3.4 Celiac Disease & Irritable Bowel Syndrome 3.5 Diverticular Disease & Colorectal Cancer Screening 3.6 Viral Hepatitis, Steatotic & Alcohol-Associated Liver Disease 3.7 Cirrhosis & the Complications of Portal Hypertension 3.8 Acute Pancreatitis 3.9 Chronic Pancreatitis & Biliary Tract Disease 3.10 Inherited, Autoimmune & Drug-Induced Liver Disease 3.11 Small Intestinal Disease, Ischemia & Gastrointestinal Complications of HIV

5 Chapter 4: Infectious Disease (9% of Exam)

4.1 Lower Respiratory Tract Infections & Sepsis Syndromes 4.2 Viral Respiratory Pathogens & Tuberculosis 4.3 Central Nervous System Infections 4.4 Skin, Soft Tissue, Bone & Joint Infections 4.5 Infective Endocarditis & Cardiovascular Infection 4.6 Clostridioides difficile & Catheter-Related Bloodstream Infection 4.7 HIV Diagnosis, Antiretroviral Therapy & Prevention 4.8 Opportunistic Infections & Sexually Transmitted Infections 4.9 Fever of Unknown Origin, Neutropenic Fever & Toxic Shock 4.10 Travel-Related Illness, Vector-Borne Disease & Outbreaks 4.11 Infection Prevention, Nosocomial Infection & Postexposure Prophylaxis 4.12 Rheumatic Fever, Poststreptococcal Disease, Enteric & Hepatic Infections

6 Chapter 5: Pulmonary Disease (9% of Exam)

5.1 COPD: Diagnosis, GOLD Classification & Initial Pharmacotherapy 5.2 Interventions That Reduce COPD Mortality & Exacerbation Management 5.3 Asthma: Diagnosis, Stepwise Therapy & Status Asthmaticus 5.4 Interstitial Lung Disease & Idiopathic Pulmonary Fibrosis 5.5 Sarcoidosis, Hypersensitivity Pneumonitis & Occupational Lung Disease 5.6 Pulmonary Embolism: Diagnosis, Risk Stratification & Anticoagulation 5.7 Pulmonary Hypertension & Sleep-Disordered Breathing 5.8 Acute Respiratory Distress Syndrome & Mechanical Ventilation 5.9 Pleural Disease, Empyema & Pneumothorax 5.10 Bronchiectasis, Cystic Fibrosis & Restrictive Lung Disease 5.11 Evaluation of Cough, Dyspnea, Hemoptysis & the Solitary Pulmonary Nodule

7 Chapter 6: Rheumatology & Orthopedics (9% of Exam)

6.1 Rheumatoid Arthritis: Diagnosis & Systemic Manifestations 6.2 Antirheumatic Pharmacotherapy & the Spondyloarthropathies 6.3 Gout: Pathophysiology & Acute Management 6.4 Urate-Lowering Therapy & Calcium Pyrophosphate Deposition Disease 6.5 Osteoarthritis 6.6 Systemic Lupus Erythematosus 6.7 Systemic Sclerosis, Sjogren Syndrome & Inflammatory Myopathies 6.8 The Vasculitides 6.9 Regional Musculoskeletal Syndromes, Back Pain & Sports Injuries 6.10 Other Primary Rheumatic Disorders & Mixed Connective Tissue Disease 6.11 Osteonecrosis & Metabolic Bone Disease

8 Chapter 7: Hematology (6% of Exam)

7.1 Approach to Anemia & the Microcytic Anemias 7.2 Macrocytic, Normocytic & Hemolytic Anemias 7.3 Hemoglobinopathies, Thalassemias & Paroxysmal Nocturnal Hemoglobinuria 7.4 Platelet Disorders, Thrombocytopenia & the Bleeding Patient 7.5 Coagulation Factor Disorders, Thrombophilia & Anticoagulant Reversal 7.6 Acute Leukemias, Chronic Leukemias & Myeloproliferative Neoplasms 7.7 Lymphomas & Plasma Cell Disorders 7.8 Myelodysplastic Syndrome, Myeloproliferative Neoplasms & Porphyria 7.9 Transfusion Medicine & Late Complications of Transplantation

9 Chapter 8: Medical Oncology (6% of Exam)

8.1 Breast, Lung, Colorectal & Prostate Cancer 8.2 Oncologic Emergencies 8.3 Genitourinary & Gynecologic Malignancies 8.4 Head and Neck, Bone & Soft Tissue Cancer and Cancer of Unknown Primary 8.5 Complications of Cancer & Its Treatment 8.6 Cancer Prevention, Survivorship & Psychosocial Care

10 Chapter 9: Nephrology & Urology (6% of Exam)

9.1 Acute Kidney Injury: Staging, Etiology & Urine Microscopy 9.2 Glomerular Disorders & Nephrotic Syndrome 9.3 Nephritic Syndromes, RPGN & Indications for Renal Replacement Therapy 9.4 Chronic Kidney Disease: Staging & Progression Retardation 9.5 Complications of Chronic Kidney Disease: Anemia, CKD-MBD & Acidosis 9.6 Hyponatremia, Hypernatremia & Water Balance 9.7 Potassium Disorders & Systematic Acid-Base Analysis 9.8 Renal Tubular Acidosis & Nephrolithiasis 9.9 Prostate Disorders, Urinary Incontinence & Other Urologic Conditions 9.10 Cystic Kidney Disease, Obstructive Uropathy, Tubulointerstitial Disease & Hematuria

11 Chapter 10: Neurology (4% of Exam)

10.1 Acute Ischemic Stroke: Syndromes & Reperfusion 10.2 Transient Ischemic Attack, Secondary Prevention & Hemorrhagic Stroke 10.3 Headache & Facial Pain 10.4 Seizures, Epilepsy & Movement Disorders 10.5 Multiple Sclerosis & Neuromuscular Junction Disorders 10.6 Motor Neuron Disease & Acute Peripheral Neuropathy 10.7 Cranial Neuropathies & Neuro-Ophthalmology 10.8 Peripheral Neuropathies, CNS Tumors & Other Neurologic Disorders

12 Chapter 11: Psychiatry & Behavioral Health (4% of Exam)

11.1 Major Depressive Disorder & Medical Mimics 11.2 Antidepressant Pharmacotherapy & Treatment-Resistant Depression 11.3 Bipolar Disorder, Mood Stabilizers & Lithium Toxicity 11.4 Anxiety, Stress-Related & Obsessive-Compulsive Disorders 11.5 Alcohol Use Disorder & Withdrawal 11.6 Pharmacotherapy for Alcohol & Opioid Use Disorder 11.7 Toxidromes, Psychiatric Emergencies & Suicide Risk Assessment 11.8 Psychotic, Somatic Symptom, Factitious & Personality Disorders 11.9 Eating Disorders, Sleep Disorders & Sexual Health

13 Chapter 12: Dermatology (3% of Exam)

12.1 Dermatitis, Papulosquamous & Inflammatory Dermatoses 12.2 Acne, Rosacea & Cutaneous Infections 12.3 Herpes Zoster & Autoimmune Blistering Diseases 12.4 Nodules, Tumors & Cutaneous Oncology 12.5 Dermatologic Emergencies & Severe Cutaneous Adverse Reactions 12.6 Pigment Disorders, Alopecia, Nail Disease & Photosensitivity 12.7 Vascular Dermatoses, Environmental Injury & Cutaneous Signs of Systemic Disease

14 Chapter 13: Obstetrics & Gynecology / Women's Health (3% of Exam)

13.1 Contraception, Preconception Care & Teratogenicity 13.2 Hypertensive Disorders of Pregnancy & Gestational Diabetes 13.3 Thyroid Disease & Venous Thromboembolism in Pregnancy 13.4 Menopause & Menopausal Hormone Therapy 13.5 Abnormal Uterine Bleeding, Endometrial Disease & Gynecologic Cancer Screening 13.6 Breast Disorders & Diseases of the Vulva and Vagina 13.7 Menstrual Disorders, Fibroids, Endometriosis & Early Pregnancy Complications

15 Chapter 14: Geriatric Syndromes (3% of Exam)

14.1 Comprehensive Geriatric Assessment & Frailty 14.2 Falls, Gait Assessment & Polypharmacy 14.3 Urinary Incontinence & Pressure Injuries in Older Adults 14.4 Mild Cognitive Impairment, Dementia & Its Subtypes 14.5 Delirium & the Pharmacotherapy of Cognitive Disorders 14.6 Palliative Care, Hospice & Advance Care Planning 14.7 Chronic Wounds, Nutrition, Swallowing, Constipation & Hip Fracture 14.8 Sensory Impairment, Dizziness, Elder Mistreatment & Care Settings

16 Chapter 15: Allergy & Immunology (2% of Exam)

15.1 Anaphylaxis: Recognition & Emergency Management 15.2 Urticaria & Angioedema 15.3 Drug Allergy, Desensitization & Adult Immunodeficiency 15.4 Food Allergy, Insect Venom Hypersensitivity, Serum Sickness & Contrast Reactions 15.5 Rhinitis, Conjunctivitis, Eosinophilic & Mast Cell Disorders

17 Chapter 16: Preventive Medicine, Immunization & Clinical Epidemiology

16.1 The USPSTF Framework & Evidence-Based Cancer Screening 16.2 Cardiovascular & Metabolic Screening and Primary Prevention 16.3 Adult Immunization & Vaccines in Special Populations 16.4 Clinical Epidemiology, Biostatistics & Study Design

18 Chapter 17: Miscellaneous - Ethics, Patient Safety & Quality Improvement (2% of Exam)

17.1 Principles of Bioethics & Decisional Capacity 17.2 Informed Consent, Treatment Refusal & Special Scenarios 17.3 Surrogate Decision-Making, Advance Directives & Confidentiality 17.4 Patient Safety Science, Medical Error & Diagnostic Reasoning 17.5 Quality Improvement Methods, Health Disparities & Health Equity

19 Chapter 18: Perioperative Medicine & Medical Consultation

18.1 Preoperative Cardiovascular Risk Assessment 18.2 Preoperative Pulmonary Risk & Perioperative Medication Management 18.3 Perioperative Anticoagulation, Bridging & Postoperative Complications

20 Chapter 19: Ophthalmology (1% of Exam)

19.1 The Acute Red Eye & Ophthalmic Emergencies 19.2 Painless Vision Loss & Chronic Ophthalmic Disease 19.3 Uveitis, Scleritis & Orbital Disease

21 Chapter 20: Otolaryngology & Dental Medicine (1% of Exam)

20.1 Dizziness, Vertigo & Epistaxis 20.2 Ear Disorders, Hearing Loss & Upper Respiratory Infections 20.3 Oral Cavity, Salivary Gland, Laryngeal & Taste and Smell Disorders

2.2 Insulin Therapy, Hyperglycemic Emergencies & Chronic Complications

Key Takeaways Explain This Topic AI

Complications of diabetes mellitus are explicitly enumerated in the blueprint alongside the diabetes subtypes.

Intravenous fluid resuscitation precedes insulin in diabetic ketoacidosis, and insulin must be withheld until serum potassium exceeds the threshold at which insulin-driven shifts would cause dangerous hypokalemia.

Hyperosmolar hyperglycemic state features profound hyperglycemia and hyperosmolality with minimal ketosis and a far larger fluid deficit than ketoacidosis.

Basal insulin plus correction is preferred to sliding-scale-only regimens for inpatient glycemic management.

Sensory symptoms of diabetic polyneuropathy are treated first with an agent proven for neuropathic pain rather than with a conventional analgesic.

Last updated: October 2026

  • 1. Insulin Initiation, Intensification & Inpatient Management
  • Outpatient Insulin Regimens in Type 2 Diabetes

Basal Insulin Initiation: Indicated when HbA1c remains elevated despite 2–3 non-insulin agents or when baseline HbA1c >=10% (86 mmol/mol) or blood glucose >=300 mg/dL with catabolic features (ketosis, weight loss).

Starting dose: 10 units daily or 0.1–0.2 units/kg/day of long-acting basal insulin (Glargine U-100/U-300, Degludec U-100/U-200, Detemir).

Titration: Increase by 2 units every 3 days until fasting plasma glucose reaches 80–130 mg/dL without hypoglycemia.

Prandial Insulin Intensification (Basal-Plus to Basal-Bolus): If fasting glucose is at target but HbA1c remains elevated, or basal dose exceeds >0.5 units/kg/day:

Add 4 units or 10% of basal dose of rapid-acting insulin (Lispro, Aspart, Glulisine) before the largest meal of the day.

Titrate prandial dose by 1–2 units or 10–15% twice weekly based on 2-hour postprandial glucose (<180 mg/dL).

Expand to full basal-bolus (prandial before all 3 meals) or transition to GLP-1 RA/basal fixed-ratio combinations.

Inpatient Glycemic Management

Target Blood Glucose: 140–180 mg/dL (7.8–10.0 mmol/L) for both critically ill ICU patients (managed with continuous IV regular insulin infusion) and non-critically ill general medical-surgical floor patients.

Regimen Design: For non-critically ill patients with poor oral intake, administer scheduled basal insulin + correctional (sliding scale) insulin. For patients with adequate nutritional intake, administer scheduled Basal-Bolus-Correction (40–50% basal, 50–60% divided among 3 nutritional meals, plus prandial correction).

Sliding Scale Insulin (SSI) Alone: Strongly discouraged as monotherapy; SSI monotherapy leads to glycemic volatility ("rollercoaster effect") and increased hospital complications.

2. Hyperglycemic Emergencies: DKA vs. HHS

Diabetic Ketoacidosis (DKA) and Hyperosmolar Hyperglycemic State (HHS) are life-threatening acute metabolic decompensations requiring structured ICU resuscitation.

Diagnostic Comparison

Diagnostic Parameter Mild DKA Moderate DKA Severe DKA Hyperosmolar Hyperglycemic State (HHS)

Plasma Glucose ≥ 200 mg/dL or known diabetes ≥ 200 mg/dL or known diabetes ≥ 200 mg/dL or known diabetes (euDKA <200) > 600 mg/dL (often >1000 mg/dL)

  • Arterial pH 7.25–7.30 7.00–7.24 < 7.00 > 7.30
  • Serum Bicarbonate 15–18 mEq/L 10–14 mEq/L < 10 mEq/L > 18 mEq/L
  • Urine / Serum Ketones Positive (acetoacetate/beta-OHB) Positive Strongly Positive Small / Minimal
  • Serum Osmolality Variable Variable Variable > 320 mOsm/kg
  • Anion Gap (Na - [Cl + HCO3]) > 10–12 mEq/L > 12 mEq/L > 12 mEq/L Variable (usually normal or mild)
  • Mental Status Alert Alert / Drowsy Stupor / Coma Stupor / Coma
  • Step-by-Step DKA & HHS Resuscitation Protocol

Fluid Resuscitation (Restoring Intravascular Volume):

First 2–4 hours: isotonic saline or a balanced crystalloid at 500–1,000 mL/hr in adults without renal or cardiac compromise; smaller 250 mL boluses in older adults, heart failure, or dialysis (2024 adult consensus).

Subsequent Hours: Assess corrected sodium: Corrected Na = Measured Na + 1.6 × ( Glucose − 100 100 ) \text{Corrected Na} = \text{Measured Na} + 1.6 \times \left(\frac{\text{Glucose} - 100}{100}\right) Corrected Na = Measured Na + 1.6 × ( 100 Glucose − 100 ​ ) .

If corrected Na is normal or elevated: Switch to 0.45% NaCl (Half-Normal Saline) at 250–500 mL/hr.

If corrected Na is low: Continue 0.9% NaCl at 250–500 mL/hr.

When plasma glucose falls below 250 mg/dL in DKA (or < 300 mg/dL in HHS): add 5–10% dextrose to the IV fluids. This prevents hypoglycemia while allowing continued insulin infusion to close the anion gap.

Potassium Management (The Mandatory Gatekeeper):

Serum K+ is falsely elevated due to extracellular shifts from acidosis and insulin deficiency, despite total body potassium depletion (3–5 mEq/kg deficit).

If K+ < 3.5 mEq/L: HOLD INSULIN . Administer IV KCl about 10 mEq/hr until K+ >3.5 mEq/L (giving insulin when K+ is low risks fatal ventricular arrhythmias and respiratory muscle weakness from acute hypokalemia) (2024 adult consensus).

If K+ 3.5–5.0 mEq/L: Add 20–30 mEq KCl per liter of IV fluid to maintain serum K+ between 4.0–5.0 mEq/L; start insulin simultaneously.

If K+ > 5.0 mEq/L: Do not give K+ yet; start insulin, recheck K+ 2 hours after insulin starts and then every 4 hours, and add K+ once it falls below 5.0.

Insulin Administration:

Continuous IV Regular Insulin: 0.1 units/kg bolus IV followed by 0.1 units/kg/hr infusion (or 0.14 units/kg/hr continuous infusion without bolus).

Target glucose fall rate: 50–75 mg/dL/hr . If glucose does not decrease by 50 mg/dL in the first hour, double the insulin infusion rate.

Criteria for Resolution of DKA & Subcutaneous Bridging:

Resolution: DKA is resolved when plasma ketone (β-hydroxybutyrate) is <0.6 mmol/L and venous pH is ≥7.3 or bicarbonate is ≥18 mEq/L (ideally glucose <200 mg/dL); the anion gap and urine ketones are not used as resolution criteria. Transition to subcutaneous insulin once DKA has resolved and the patient tolerates oral intake.

The 2-Hour Overlap Rule: Administer subcutaneous basal insulin (e.g., Glargine) 2 hours BEFORE discontinuing the IV insulin infusion . Discontinuing IV insulin without an active SQ basal depot causes rapid recurrence of ketoacidosis due to the ultra-short half-life of IV insulin (minutes).

Sodium Bicarbonate Utility:

Routine bicarbonate therapy is NOT recommended; consider it only if pH < 7.0 (administer 100 mmol sodium bicarbonate in 400 mL sterile water with 20 mEq KCl over 2 hours). Bicarbonate carries risks of paradoxical CSF acidosis, hypocalcemia, delayed ketone clearance, and severe hypokalemia.

3. Chronic Microvascular & Macrovascular Complications +-------------------------------------------------------------------------------------------------------------+

| COMPLICATION | SCREENING / DIAGNOSTIC PROTOCOL | EVIDENCE-BASED MANAGEMENT STRATEGY |

+--------------------+---------------------------------------------+------------------------------------------+

  • | Diabetic Kidney | Annual spot urine albumin-to-creatinine | 1. ACEi (Lisinopril) or ARB (Losartan) |
  • | Disease (DKD) | ratio (UACR) + serum creatinine/eGFR; | if UACR >= 30 mg/g (titrate to max) |
  • | | Microalbuminuria: UACR 30-299 mg/g; | 2. SGLT2i (Empagliflozin/Dapagliflozin) |
  • | | Macroalbuminuria / Overt DKD: >=300 mg/g | down to eGFR 20 mL/min |
  • | | | 3. Non-steroidal MRA (Finerenone) for |
  • | | | persistent UACR >=30 mg/g with normal K|
  • | | | 4. GLP-1 RA (Semaglutide) for eGFR decline|

+--------------------+---------------------------------------------+------------------------------------------+

  • | Diabetic | Annual dilated funduscopic eye exam by | Non-proliferative (microaneurysms, |
  • | Retinopathy | ophthalmologist/optometrist (Type 2: at | cotton-wool spots, hard exudates): |
  • | | diagnosis; Type 1: 5 years after onset); | Strict glycemic and blood pressure control
  • | | Pregnant women: 1st trimester & postpartum | Proliferative (neovascularization) or |
  • | | | Macular Edema: Intravitreal anti-VEGF |
  • | | | (Aflibercept, Ranibizumab) or panretinal |
  • | | | photocoagulation (PRP) |

+--------------------+---------------------------------------------+------------------------------------------+

  • | Diabetic | Annual screening using 10g Semmes-Weinstein | First-Line Pharmacotherapy for Pain: |
  • | Peripheral | monofilament (loss of protective sensation) | 1. SNRIs: Duloxetine (60-120 mg/day) |

| Neuropathy (DSPN) | plus 128-Hz tuning fork vibration or pinprick| 2. Gabapentinoids: Pregabalin, Gabapentin|

  • | | at dorsal hallux | (Avoid opioids; Tricyclic antidepressants|
  • | | | like Amitriptyline effective but antichol|
  • | | | inergic risks in elderly) |

+--------------------+---------------------------------------------+------------------------------------------+

  • | Autonomic | - Gastroparesis (early satiety, postprandial| - Gastroparesis: Small frequent meals, |
  • | Neuropathy | nausea; diagnose via 4-hr solid gastric | low fat/fiber; Metoclopramide (short- |
  • | | emptying scintigraphy) | term, monitor tardive dyskinesia), oral|
  • | | - Orthostatic hypotension (drop SBP >=20 | Erythromycin |
  • | | or DBP >=10 within 3 min standing) | - Orthostasis: Compression stockings, |
  • | | - Neurogenic bladder (urinary retention) | Midodrine, Droxidopa, Fludrocortisone |

+--------------------+---------------------------------------------+------------------------------------------+

  • | Diabetic Foot | Comprehensive annual visual inspection; | Offloading pressure; aggressive surgical |
  • | Ulcers (DFU) & | Palpate dorsalis pedis / posterior tibial | debridement of necrotic tissue; |
  • | Osteomyelitis | pulses; Ankle-Brachial Index (ABI) if PAD | Probe-to-bone test (if positive, >90% PPV|
  • | | suspected; Wagner ulcer staging | for osteomyelitis -> perform plain X-ray |
  • | | | and Foot MRI; bone biopsy gold standard) |

+--------------------+---------------------------------------------+------------------------------------------+