Mr N, aged 42 years, was a nurse practitioner who worked in a small primary care practice with two physicians and a physician assistant. When he started with the practice, five years earlier, he only saw existing patients of the physicians. However, over the last two years, and with the support of his supervising physician, he had been seeing his own patients and patients new to the practice.

One such patient was Mr P, aged 34 years. The patient had recently moved to town and had picked Mr N’s practice to provide his primary care. His first appointment was in January, when he saw Mr N for his first regular checkup.

The patient had not been seen for a regular physical examination in several years. “You know how it is,” he said to Mr N. “I’ve been so busy with work, and then they relocated me here. My wife and I had to get our new place set up, and we have a toddler, so everything takes longer than you expect… Anyway… we’re hoping to try for another baby soon and my wife said I really needed to find a local healthcare provider… so here I am.”

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Mr P was fit and athletic. He told Mr N that he stayed in shape by playing tennis and running. His blood pressure was normal. He denied smoking cigarettes or using recreational drugs, and he said he only drank socially on weekends. The patient was in good health, and both his parents were alive.

At the end of the exam, Mr N asked the patient if he had any questions. “Well, yes,” the patient said. “I’ve got this little mole on the back of my calf that I’ve had for as long as I can remember, but I noticed that it seems to be changing. I’ve read that it’s important to tell your healthcare provider if you see something like that.”

“You’re absolutely right,” said Mr. N, as he bent to examine the small mole. “But I don’t think you have to worry about this one. I’m not concerned about it. But if the appearance bothers you, I recommend you return in 6 months and we can remove it for cosmetic reasons.” Mr N noted in the patient’s file that the mole was about 1 cm x 1 cm in size, and that it appeared to be a hemangioma or dermatofibroma, which are both benign.

The patient thanked him and left the office.

Over the next 5 months, the mole on the patient’s calf continued to change, and he came into the practice to have it looked at again. Mr N was off that day, and the patient saw one of the physicians instead. The physician, upon seeing the mole, immediately sent the patient to a surgeon for a consultation and biopsy. The surgeon removed the mole and sent it for analysis, which revealed ulcerating melanoma with downward growth, Clark Level IV. The following month, wide excision and lymph node dissection were performed revealing clear margins and no involvement of lymph nodes.

The patient came in for follow-up visits every 4 months, however 18 months after removal of the mole, a mass was found in his liver. The mass was biopsied and diagnosed to be metastatic spread of the melanoma. The patient died 2 months later, at the age of 36. He left behind a pregnant wife and 3-year-old daughter. Mr P’s son was born 2 months after his death.