An 18-year-old white female presents to your clinic today with a 2-week history of intermittent

abdominal pain. She also is positive for periodic cramping and diarrhea as well as low grade fever.

She also notes reduced appetite. She notes that She admits smoking ½ PPD for the last 2 years.

Denies any illegal drug or alcohol use. Does note a positive history of Crohn’s Disease. Based on the

information provided answer the following questions:

1. What are the top 3 differentials you would consider with the presumptive final diagnosis

listed first?

According to (2020), the top three differential diagnoses would be Crohn’s disease

which Regueiro & Hashash (2019) describe as an inflammatory disease of the entire gastrointestinal

tract that can affect the walls of the digestive tract transmurally (which means throughout the wall of

the intestinal tract). Symptoms would include weight loss, anorexia, fatigue, right sided abdominal

pain that could mimic appendicitis, fever, hematochezia and perianal ulcers (, 2020).

They further stated that the patient’s symptoms would dictate the severity of the flare. This patient

is positive for pain, cramping, diarrhea and low-grade fever which places her in the moderate flare


Another differential would be ulcerative colitis, which is an inflammation of the mucosal wall section

of the colon usually manifesting on the left side of the abdomen and presenting with bloody diarrhea

(, 2020). The patient did c/o abdominal pain but did not state where the pain was

located. The patient denied bloody diarrhea.

The last differential would be infectious colitis which is characterized by three or more loose stools

for less than 14 days and is usually associated with travel abroad or travel to areas that have endemic

cases of rotavirus, norovirus, astrovirus, or bacterial causes such as shigella, salmonella, E. coli or

other bacterial causes. The diagnosis of infectious colitis is usually done by stool testing and

treatment of the infection is by fluid and electrolyte replacement and/or treatment of the infectious

agent if the agent is bacterial or parasitic (, 2020).

2. What focused physical exam findings would be beneficial to know?

According to Peppercorn & Kane (2019), when assessing the patient for crohns, the practitioner

should assess the mouth for ulcers, the abdomen for distention, masses (especially in the lower

quadrants) which could be appreciated as loops of full bowel and fistulas, sinus tracts or skin tags to

the anus which could be indicative of ulcerative processes in the rectum. Auscultation of the

abdomen would reveal hyperactive bowel sounds. History of intermittent weight loss, abdominal

pain and hematochezia are usually the diagnostic findings when diagnosing crohns disease (Buttaro

et al., 2017).

3. What diagnostic testing needs completed if any to confirm diagnosis?

Buttaro et al. (2017) states that a CBC can determine if anemia is present and also if the patient’s

platelets are elevated which could determine if active inflammation is present. CRP and ESR are

helpful in determining inflammatory bowel disease but are not specific to either colitis or crohns

disease. Buttaro et al. (2017) further stated that anemia and iron deficiency was usually indicative of

extraintestinal inflammation (such as crohns disease) and that ferritin and reticulocyte in addition to

liver labs should be monitored during flares. Genetic biomarkers such as ANCAs, perinuclear

antineutrophil cytoplasmic antibodies (pANCAs) and ASCA immunoglobulin A (IgA) and IgG; outer

membrane protein C (anti-OmpC) are helpful in diagnosing more aggressive forms of crohns disease

in patients over 18 and can be used to determine the patient’s prognosis in the future. Stool samples

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are evaluated for other forms of inflammatory processes including infection and parasitism.

Radiographic studies such as enterographic CT scans and MRI are used to determine if strictures,

inflammation, perforation or obstructions are present, especially in the small intestines. Colonoscopy

and endoscopy can be diagnostic in distinguishing UC versus crohns in that UC will have

inflammation in the bowel that is continuous with the rectal inflammation. Crohns will have more

scattered areas of transmural inflammation that has what is known as “skip lesions” or areas that are

not inflamed.

4. Using evidence-based treatment guidelines note a treatment plan.

For this patient who has moderately active crohns flares, the number one therapy would be smoking

cessation as it is not well-known what causes crohns disease in the first place (Buttaro et al., 2017)

but according to (2020) new diagnosis of crohns disease patients revealed that about

half of these patients used tobacco products. Further, (2020) stated that smoking

changed the bowel’s immune properties and thus set up the patient for inflammatory flares.

Regueiro & Hashash (2019) stated that the goal of treatment for crohns flares is the endoscopic,

colonoscopic and clinical remission of the disease with mucosal healing and recommended that

enteric coated budesonide (a glucocoticoid) be the first line treatment in the treatment of crohns

flares. Further, a 5-Aminosalicylates (5-ASA) such as mesalamine, pentasa or asacol achieved

remission 93% vs placebo. To prevent remission budesonide is not recommended as long-term use of

glucocorticoids can affect the patient’s immune system and complicate metabolic systems in the

patient, rather a maintenance dose of the 5-ASA that helped with remission should be continued and

the patient is to receive an ileocolonoscopy in 6-12 months to assure that remission has been

maintained. For patients that cannot maintain remission without a glucocorticoid an

immunomodulator drug such as methotrexate or azathioprine are used to maintain remission.

Further, the patient needs to modify their diet as it has been shown that crohns patients can develop

lactose intolerance which can cause inflammation and health maintenance must be maintained to

help keep the patient’s immune system functioning properly.




Buttaro, Terry M., amp, JoAnn Trybulski, amp, Patricia Polgar-Bailey, amp, Joanne Sandberg-Cook.

(2017). Primary Care: A Collaborative Practice.. [South University]., (2020). Crohn-Disease. Epocrates. Retrieved

from, (2020) Smoking and Crohns Disease. How Does Smoking Affect Crohns Disease?

University of Alberta. Retrieved from



Peppercorn, M. & Kane, S. (2019). Clinical Manifestations, Diagnosis and Prognosis of Crohns Disease

in Adults. UpToDate. Retrieved from

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Regueiro, M. & Hashash, J.A., (2019). Overview of the Medical Management of Mild (low risk) Crohn

Disease in Adults. UpToDate. Retrieved from




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