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Vol. 66, No. 4 2015
Northeast Florida Medicine
DCMS online
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CME
CME Questions & Answers
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The Role of a Primary Care Physician in the management of Inflammatory Bowel Disease
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1. A 26-year-old Caucasian female presents to you
with symptoms of abdominal pain, diarrhea,
rectal bleeding and low back pain for 8-12
months. She has no known medical problems.
She denies overseas travel, antibiotic use or
NSAID use. Physical examination shows mild
tenderness in the right lower quadrant. Lab
work shows anemia and elevated CRP. What
should be the next step:
a. Order an IBD panel by Prometheus lab.
b. Order a CT scan of the abdomen and pelvis
with oral and IV contrast.
c. Refer to a gastroenterologist.
d. Treat with Levaquin and Flagyl for 10 days
and assess response.
e. Prescribe a fiber supplement, probiotics
and hyoscyamine for four weeks and then
reassess the patient.
2. Which of the following tests is
diagnostic of Crohn’s disease:
a. Very high CRP (C Reactive Protein).
b. Positive IBD panel for Crohn’s disease.
c. A small bowel follow-through showing
narrowing of the terminal ileum.
d. Colonoscopy showing multiple ulcers in the
cecum and terminal ileum.
e. None of the above.
3. In patients with IBD, the main risk
factor for osteoporosis is:
a. Physical inactivity.
b. BMI (Body Mass Index) above 30.
c. Smoking.
d. Corticosteroid use.
e. Alcoholism.
4. A 30-year-old Caucasian male with a 10 year
history of ulcerative colitis (UC), presents
with “low energy” and intermittent cramping
and bloating. He reports interpersonal problems
at work. His gastroenterologist has told him that
his disease is under control with mesalamine
and azathioprine. Examination is unremarkable.
Lab work shows mild anemia and normal CRP.
You should:
a. Reassure him that he is doing well.
b. Refer him back to his gastroenterologist to
try infliximab (Remicade).
c. Refer him to a psychiatrist.
d. Screen for depression and, if positive,
treat with medications.
e. Refer him to a different gastroenterologist for
a second opinion.
5. A 50-year-old African American male with
a history of Crohn’s disease presents for the
evaluation of malaise and occasional tingling
and numbness in both feet. He has a remote
history of “bowel resection.” He is on no med-
ications for his Crohn’s disease. Examination is
unremarkable. Lab work shows a normal CBC,
Chem12 and CRP. Your next step should be:
a. Reassurance
b. Referral to a neurologist
c. Check a serum B12 and folate level
d. Prescribe a therapeutic multivitamin twice a
day for 3 months
e. Check serum ferritin, iron saturation and TIBC.
6. A 45-year-old Caucasian female presents to
you for evaluation of intermittent knee and
ankle pains, after playing tennis. Symptoms are
intermittent and stable over six months. She has
a history of severe Crohn’s disease for 10 years;
in remission on infliximab (Remicade) for four
years. Examination is unremarkable. Her BMI
is 32 kg/m2. Lab work shows a normal CBC,
Chem12 and CRP. Your recommendations are:
a. Acetaminophen 500-1000mg four times a
day, as needed. Patient continues playing
tennis and adds bicycling or swimming.
b. Ibuprofen 400-800mg four times a day, as
needed. Patient stops playing tennis.
c. Celecoxib (Celebrex) 200mg daily. Patient
stops playing tennis and considers bicycling
or swimming.
d. Refer patient back to her gastroenterologist to
increase the infliximab (Remicade) dose.
e. A short course of oral steroids.
7. Regarding smoking and IBD, all of the follow-
ing statements are true except:
a. Smoking increases the risk of flares in
Crohn’s disease.
b. Quitting smoking may exacerbate ulcerative colitis
c. Smoking increases the risk of surgery in
Crohn’s disease.
d. The risks of smoking are highest in women
with ileal disease.
e. Patient with ulcerative colitis should be
encouraged to continue smoking, but
in moderation.
8. A 25-year-old Caucasian female with ulcerative
colitis presents with abdominal pain, diarrhea
and rectal bleeding for two weeks. Her colitis
has been in remission on adalimumab (Humira)
40mg SQ every two weeks. She denies overseas
travel. She was given oral amoxicillin for a
dental procedure six weeks ago. Examination
reveals evidence of mild dehydration and mild
abdominal tenderness. Your next step is:
a. Start Prednisone 40mg daily and refer her to
her gastroenterologist.
b. Start Ciprofloxacin and Metronidazole for
10 days.
c. Check stools for bacterial culture and
Clostridium difficile and hold adalimumab
(Humira) until the results come back.
d. Consider a flexible sigmoidoscopy in the office.
e. Start metronidazole 250mg four times a day for
10 days. Continue adalimumab (Humira).
1. What will you do differently as a result of this information? _ ___________________________________________________________________________
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2. How will you apply what you learned to your practice? ________________________________________________________________________________
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