Empirically Incorrect

A CLINICAL PROBLEM-SOLVING article by Amy Schmitt from Legacy Emanuel and Legacy Good Samaritan Hospitals in Portland, Oregon.
A 46-year-old Mexican immigrant presented with epigastric pain and vomiting of coffee-grounds material. He reported fatigue, malaise, jaundice, and a weight loss of 20 lb during the previous two months. He had also had dark stools, light-headedness, and mild shortness of breath, but no fever, chills, or night sweats.
Analysis of a peripheral-blood smear showed nucleated red cells. Endoscopy revealed a duodenal ulcer; a urease enzyme test of a biopsy specimen was positive for H. pylori. A liver biopsy was performed.
On the basis of the insidious nature of this patient's illness, the fever and lymphadenopathy, and the history of exposure to livestock, he was treated empirically for brucellosis and he was treated for H. pylori.
When his condition ??? improve, he was treated with empirical prednisone for presumed granulomatous hepatitis.
In this case, the delay in diagnosis, compounded by the subtlety of the finding on the initial liver-biopsy specimen, resulted in a substantial delay in identifying the cause of the patient's jaundice.
When a patient's condition worsens despite the use of empirical therapy, clinicians must decide whether to continue the empirical therapy, change the empirical therapy, or repeat diagnostic testing.