HPI, Case Study Example

This is 19 year old college student in HM without significant PMH, who is now present to this outpatient clinic complaining of upper abdominal pain and nausea for the last two weeks. The patient admits that his current symptoms were presiding by an epigastric gnawing burning sensation that lasted approximately two weeks, and it was replaced a week ago by his current symptoms. The patient describes the pain as constant, gnawing, burning, and as 4/10max. The patient states that the pain is localized in the epigastic region and it radiates to his entire upper abdomen; he denies radiation to the esophagus or dysphagia.   The patient also admits feeling nauseous and blotted and experiencing mild (2/10 max), diffuse, and episodic headaches that seems to correlate with increases in the abdominal pain. The patient also admits that there is the worsening of the pain when he lie down flat on his belly (5/10 max) or on his back (4/10 max)”. The patient admits that sometimes eating is responsible for the alleviation of pain, but he also admits worsening of pain (5/10 max) after ingesting spicy food, coffee, or carbonated drinks. The patient also admits about a situation of difficulty in finishing most of the meals, loss of appetite, and losing about 4 lb of weight during the last month. There is also a denial by the patient concerning ever experiencing something like this in the past, and he admits taking one Omeprazole OTC tablet and two Tums tablets daily for the last 13 days without getting relief of his symptoms.  The patient denies recent travels, changes in diet but he admits eating out every day, mostly fast food. The patient also admits having a normal bowel movement this morning, but he states that he experienced a mild constipated and passing “hard – light yellow – looking stools” a couple of times this week. The patient also admits being more anxious during the last two months due to the high level of stress that his first year of college is putting in his life. The patient admits being sexually active with three partners, and he admits not always using condoms.

The patient also admits smocking 1/4 packet of cigarettes a day for the last ten months. The patient denies having fever, vomiting, hematemesis, hemoptisis, dysphagia,  cough, SOB, CP, diarrhea,   hematochizia, melena,  Jaundice, dysnuria, LOC, dizziness, seizures, changes in vision, trauma to the area,  use of alcohol or recreational drugs, and  food or drugs allergy.   The patient also denies history GERD, Chronic Gastritis, PUD, Zollinger syndrome, Cholelithiasis,  Liver disease, IBS, Cronh’s, Ulcerative colitis,  Diverticulosis, STDs , HIV, history  of cancer, or any other illness. The patient finally admits family history of coronary disease (MI x 2, father); Breast cancer (mother), and he denies any other history of significant illnesses.

Clinical Synthesis

The patient is a 19 year old college student HM without significant PMH, who presents himself to the PCP office complaining of burning epigastric pain and nausea for two weeks.   According to the patient his current symptoms were presided by a two week long epigastric gnawing and burning discomfort that was replaced by a constant burning epigastric pain (3/10max) and nausea a week ago.  The patient admits the pain is localized in the epigastric region and it radiates to the rest of his upper abdomen.  The patient admits worsening of the pain after ingesting spicy food, coffee, or carbonated drinks (6/10 max) and lying on the decubito position (5/10max) or supine (4/10max).   The patient admits feeling constantly nauseous and blotted and experiencing mild episodic headaches that seems to correlate with increases in the abdominal pain.    He also admits early satiety, post-prandial fullness, decrease in appetite, weight loss (6 lb in the last month), and increased levels of stress and anxiety for a period of the last 2 months.    The patient admits taking OTC medication (Omeprazole and Tums) without improving his condition, being mild constipated and passing “hard – light yellow – looking stools” twice this week.     The patient denies changes in diet, and he admits eating out daily (mostly fast food).   Patient denies previous history of gastrointestinal problems, ever experiencing something like this before, or any other illness or physical problem.

The history provided by the patient was not specific to clearly identify the etiology of the   patient’s condition, but it indicates that his symptoms had intra-abdominal roots.  The characteristics of the patient’s symptoms favor a gastrointestinal rather than a vascular or a genitourinary pathology.   Furthermore, the patient’s account of epigastric pain, early satiety, and post prandial fullness is an indication of dyspepsia.  However, the available information did not provide specific information to clearly identify what was causing this condition.

Physical Examination

There were no red flags in his physical examination, and it revealed a well nourished and well developed young male, who was not in acute distress.The patient’s facial expression was relaxed, and he was not pale, jaundice, diaphoretic or agitated.   His respiration and heart rate were within the normal limits as well as his blood pressure. His sclera and low palate were non- icteric, and his pharynx did not show signs of irritation. However, the patient’s upper abdomen was tender to slight palpation, and he expressed mild pain epigastric  with deep palpation. Nevertheless, his abdomen was not distended, without skin lesions, discolorations, pulsation or bruits, and he had normative bowel sounds in all quadrants.  His liver and spleen did not revealed enlargement through percussion, and they were not palpable.   He had negative rebound tenderness, referred rebound tenderness, Murphy’s sing, and cutaneous hyperesthesia signs.   The lungs of the patient sounded clear and there was no swelling in his extremities or CVA tenderness.

Differentials Diagnosis

The physical examination did not show any red flag, and confirmed that the patient condition did not require emergency attention.   The only remarkable finding was upper abdominal tenderness and mild epigastric pain. The differential diagnosis for a patient presenting with the above-listed symptoms and physical exam findings included GERD,  Bacterial or chemical gastritis, viral gastroenteritis,  peptic ulcer,  Cholecystitis, cholelithiais, crohn’s disease,  Gastric cancer or B-cell lymphoma,

The facts that the patient was otherwise a healthy young  male (he was 19) with a negative g test, and  without  history of melena, co-morbidities, family history of gastrointestinal  diseases or malignancies, as well as that this  was the first time that he experience similar symptoms make the diagnosis of gastric cancer, lymphoma, and cronh’s  disease  less feasible.

The  facts of absent of fever or jaundice, and  that his physical examination showed a negative murphy’s sign, as well as a  mild epigastic, localized, burning  pain  with deep palpation  instead of sharp,  intense,  and radiating to the shoulder or back  made the diagnosis of cholecystitis  and cholelithiasis less provable.

The lack of history of dysphagia, food or sour like liquid regurgitations, chest pain, hoarseness, or lump like sensation in the throat did not favor the diagnosis of GERD. The relative short duration of the patient problem, the lack of history of NSAID or alcohol use, added to the patient’s absence of emesis, hematemesis and melena made the diagnosis of peptic ulcer disease, and chemical gastritis less likely.    At this point the leading diagnosis was bacterial gastritis; because the patient was taking Omeprazole. However,  a rapid urea breath was not performed during the office visit.

We inform the patient that he was diagnosed with acute gastritis, which could be caused by H-pylori infection.  We order H-pylori serology test,   and we started him on Prevacid 30 mg po once a day. He was also instructed to change his diet;we recommend him to stay away from caffeine, pizza, spicy food, carbonated drinks and other foods that might irritate his gastric mucosa. Patient was asked to get the blood work done as soon as possible, and we scheduled him for a follow up visits in five days to discuss his laboratory results. The patient was advice that if he experience worsening of symptoms, he should call us or go to the ER right  away.

When he showed up for the follow appointment, he was still complaining of the same symptom. We informed that the serology test confirmed H-pylori infection and other labs were normal. We prescribed the following H-pylori eradicator regiment: Lansoprazole 30 mg, amoxicillin 1g, Carithrocycin 500 mg all twice a day for 7 days. The patient was advised to schedule a follow up appointment 4 weeks after he finished the treatment regiment.  However, three weeks after finishing the treatment, he called the office complaining that even though he finished all his medication as prescribed; his abdominal symptoms were still affecting him.

When we saw him the following week, he was still complaining of dyspepsia and mild epigastric tenderness. We received an urea bread test to determine if H-pylori was still present; it confirmed the presence of the bacterium and the failure of the eradication regimen. We prescribed a second eradication treatment that included Lansoprazole 30 mg, Amoxicillin 1 gm, metronidazole 500 mg, all twice daily for 14 days. Six weeks later, the patient came back for his follow up appointment, and he happily admitted that all his symptoms were gone.  The success of the second eradication regiment was confirmed by a Urea breath test.

The question is if the failure of the first h-pylori eradication treatment was due to the length of the therapy or the antibiotic, then the regiment selected needed to be addressed. Even though the treatment prescribed is the first line treatment regimen of choice for most clinician, the literature shows it has a failure rate of 20%, and H-pylori strength  resistance  to this antibiotic are becoming more frequent.

The USA guidelines favor the “test and treat” approach in dyspeptic patients suspected of H-pylori infections and propose several treatment regimes to eradicate the bacterium.  These regimens differ in the medication combination as well as the length of the treatment (7, 10, 14 days).    Most of them recommend the use of a PPI or bismuth salt and 2 different antibiotics. However, it is left to the clinician to choose what regiment to use and the length of the therapy. Some clinicians prefer to use 7 days regimes because it seems to offer a higher rate of compliance and similar eradication rate than the longer one. It is my opinion, after I reviewed the current literature, that the effects of short term eradication regiments have on the H-pylori antibiotics resistance and re-infestation rates are still unknown.    In my view the selection of an H-pylori eradication regiment and its length should be base overall on the age of patient and the antibiotic resistance present in the local population.  Short term therapies should not be used on younger patients where the lifetime risk of re-infection and developing of new pathologens is higher, until the existence of concrete data that finally establish that short regimens do not increase antibiotic resistance and re-infestations rates.    Therefore, I would not have used as first line treatment, a regiment that included claritromycin, and I would not have used a 7 days treatment.  In my opinion the first line treatment that should have been used in this patient was the one that we used during the second treatment which finally eradicated the H-pylori infection in this patient.