Ms. F, aged 34 years, was a nurse practitioner employed in the office of Dr. G, a family practice physician. Ms. F had been working at the busy practice for nearly five years. To make better use of their time, the two clinicians each saw their own patients, and Dr. G would look over and sign off on Ms. F’s patient files at the end of each day. Ms. F appreciated the autonomy and the confidence that the physician had in her. 

Some days at the practice, however, were busier than others, and the pressure of the packed waiting room would weigh heavily on Ms. F. On one such busy day, a regular patient of the practice, Mrs. T, aged 63 years, came in with complaints of pain. However, Mrs. T came in frequently with various complaints, but none of her complaints had ever been related to anything serious. Mrs. T also always took a very long time to explain her complaints and would relay them in a dramatic manner.

On that day, Mrs. T described pain of the left side of her chest, shoulder, and back. She said the pain had originated in her lower left side suddenly the day before. She added that she had not gotten much sleep the night before because every time she rolled over, she would wake up from the pain. 

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Ms. F performed a physical examination and asked Mrs. T if she was experiencing shortness of breath. Mrs. T said that breathing deeply caused her pain. “Every time I breathe deeply, it hurts!” she exclaimed. 

Ms. F noted that the patient was hypertensive with a blood pressure of 150/90 and tachycardic with a pulse of 120. She also noted that Mrs. T’s lower and middle back were mildly tender. An electrocardiogram was performed and confirmed sinus tachycardia. No other tests were performed or ordered. 

While the patient continued complaining about her discomfort, the office manager had knocked on the door twice to ask Ms. F to take phone calls from other patients. At the same time, Ms. F was also aware that every seat in the waiting room was taken and only standing room was available as more patients came into the clinic. Her patience was beginning to fray.