IBD in special populations — MCQs

A 33-year-old woman with Crohn’s disease colitis presents to her physician after 2 days of photophobia and blurred vision. She has had no similar episodes in the past. She has no abdominal pain or diarrhea and takes mesalazine, azathioprine, and prednisone as maintenance therapy. Her vital signs are within normal range. Examination of the eyes shows conjunctival injection. The physical examination is otherwise normal. Slit-lamp examination by an ophthalmologist shows evidence of inflammation in the anterior chamber. Which of the following is the most appropriate modification to this patient’s medication at this time?

A 62-year-old man comes to the physician in May for a routine health maintenance examination. He feels well. He underwent a right inguinal hernia repair 6 months ago. He has hypertension and type 2 diabetes mellitus. There is no family history of serious illness. Current medications include metformin, sitagliptin, enalapril, and metoprolol. He received the zoster vaccine 1 year ago. He received the PPSV23 vaccine 4 years ago. His last colonoscopy was 7 years ago and was normal. He smoked a pack of cigarettes a day for 20 years but quit 17 years ago. He drinks two to three alcoholic beverages on weekends. He is allergic to amoxicillin. He is scheduled to visit Australia and New Zealand in 2 weeks to celebrate his 25th wedding anniversary. He appears healthy. Vital signs are within normal limits. An S4 is heard at the apex. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate recommendation at this time?

A 38-year-old man presents to his primary care provider for abdominal pain. He reports that he has had a dull, burning pain for several months that has progressively gotten worse. He also notes a weight loss of about five pounds over that time frame. The patient endorses nausea and feels that the pain is worse after meals, but he denies any vomiting or diarrhea. He has a past medical history of hypertension, and he reports that he has been under an unusual amount of stress since losing his job as a construction worker. His home medications include enalapril and daily ibuprofen, which he takes for lower back pain he developed at his job. The patient drinks 1-2 beers with dinner and has a 25-pack-year smoking history. His family history is significant for colorectal cancer in his father and leukemia in his grandmother. On physical exam, the patient is moderately tender to palpation in the epigastrium. A fecal occult test is positive for blood in the stool. Which of the following in the patient’s history is most likely causing this condition?

An 11-month-old boy is brought to a pediatrician by his parents for evaluation of vomiting and watery diarrhea over the last day. The mother informs the pediatrician that the boy had consumed an apple bought from a fruit vendor on the previous day, but that otherwise there has been no recent change in his diet. There is no history of blood in the stool, flatulence, irritability, or poor appetite. There is no history of recurrent or chronic diarrhea or any other gastrointestinal symptoms. On physical examination, his temperature is 37.6°C (99.6°F), pulse is 120/min, respirations are 24/min, and blood pressure is 92/60 mm Hg. General examination reveals a playful infant with normal skin turgor and no sunken eyes. The pediatrician explains to the parents that he most likely has acute gastroenteritis and that no specific medication is indicated at present. He also instructs the parents about his diet during the illness and reviews the danger signs of dehydration. He suggests a follow-up evaluation after 48 hours or earlier if any complications arise. Which of the following dietary recommendations did the pediatrician make?

A 31-year-old man presents to an urgent care clinic with symptoms of lower abdominal pain, bloating, bloody diarrhea, and fullness, all of which have become more frequent over the last 3 months. His vital signs are as follows: blood pressure is 121/81 mm Hg, heart rate is 87/min, and respiratory rate is 15/min. Rectal examination reveals a small amount of bright red blood. Lower endoscopy is performed, showing extensive mucosal erythema, induration, and pseudopolyps extending from the rectum to the splenic flexure. Given the following options, what is the most appropriate initial treatment for this patient's underlying disease?

Three days after admission to the hospital with a clinical diagnosis of ischemic colitis, a 65-year-old man has recovered from his initial symptoms of bloody diarrhea and abdominal pain with tenderness. He feels well at this point and wishes to go home. He has a 15-year history of diabetes mellitus. Currently, he receives nothing by mouth, and he is on IV fluids, antibiotics, and insulin. His temperature is 36.7°C (98.1°F), pulse is 68/min, respiratory rate is 13/min, and blood pressure is 115/70 mm Hg. Physical examination of the abdomen shows no abnormalities. His most recent laboratory studies are all within normal limits, including glucose. Which of the following is the most appropriate next step in management?

A 34-year-old woman comes to the emergency department because of decreased appetite, nausea, vomiting, and episodic abdominal pain for the past two months. The pain is sharp, colicky, and lasts about an hour after meals. Her stools are light in appearance and difficult to flush. Physical examination shows tenderness in the right upper quadrant. Without treatment, this patient is at greatest risk for developing which of the following?

A 33-year-old primigravid visits the clinic at the 22 weeks’ gestation with concerns about several episodes of loose watery stool over the past 4 months, which are sometimes mixed with blood. Use of over-the-counter antidiarrheal medications has not been helpful. She also reports having painful ulcers in her mouth for the last 2 months. Pregnancy has been otherwise uncomplicated so far. On physical examination, the blood pressure is 110/60 mm Hg, the pulse rate is 90/min, the respiratory rate is 19/min, and the temperature is 36.6°C (97.8°F). There is bilateral conjunctival redness. Abdominal examination shows minimal tenderness but no guarding or rebound tenderness. Fundal height is proportionate to 22 weeks of gestation, and fetal heart sounds are audible. Colonoscopy shows focal areas of inflammation in the ileum, separated by normal mucosa, with rectal sparing. Based on the colonoscopy results, which of the following complications is the patient at risk for?

Five days after undergoing an open abdominal aortic aneurysm repair, a 68-year-old woman has crampy abdominal pain. During this period, she has also had two episodes of loose, bloody stools. Her surgery was complicated by severe blood loss requiring the administration of vasopressors and multiple transfusions. Cefazolin was administered as a perioperative antibiotic. The patient has hypertension, hypercholesterolemia, and coronary artery disease. The patient has smoked 2 packs of cigarettes daily for 50 years and drinks 3–4 glasses of wine every week. Her current medications include hydrochlorothiazide, atorvastatin, amlodipine, aspirin, and metoprolol. She appears ill. Her temperature is 38.0°C (100.4°F), pulse is 110/min, and blood pressure is 96/58 mm Hg. Physical examination shows a distended abdomen with absent bowel sounds. The abdomen is exquisitely tender to palpation in all quadrants. The lungs are clear to auscultation. Cardiac examination shows an S4 gallop. An x-ray of the abdomen shows air-filled distended bowel. Which of the following is the most likely diagnosis?

Background and Methods: Aldosterone is important in the pathophysiology of heart failure. In a double-blind study, we enrolled 1,663 patients who had severe heart failure, a left ventricular ejection fraction of no more than 35 percent, and were being treated with an angiotensin-converting-enzyme inhibitor, a loop diuretic, and in most cases digoxin. A total of 822 patients were randomly assigned to receive 25 mg of spironolactone daily and 841 to receive placebo. The primary endpoint was death from all causes. Results: The trial was discontinued early, after a mean follow-up period of 24 months, because an interim analysis determined that spironolactone was efficacious. There were 386 deaths in the placebo group (46%) and 284 in the spironolactone group (35%; relative risk of death, 0.70; 95% confidence interval, 0.60 to 0.82; p<0.001). This 30 percent reduction in the risk of death among patients in the spironolactone group was attributed to a lower risk of both death from progressive heart failure and sudden death from cardiac causes. The frequency of hospitalization for worsening heart failure was 35% lower in the spironolactone group than in the placebo group (relative risk of hospitalization, 0.65; 95% confidence interval, 0.54 to 0.77; p<0.001). In addition, patients who received spironolactone had a significant improvement in the symptoms of heart failure, as assessed on the basis of the New York Heart Association functional class (p<0.001). Gynecomastia was reported in 10% of men who were treated with spironolactone, as compared with 1% of men in the placebo group (p<0.001). The incidence of serious hyperkalemia was minimal in both groups of patients. Which of the following statements represents the most accurate interpretation of the results from the aforementioned clinical trial?