Mr N, aged 38 years, was a nurse practitioner working in a small primary care medical practice with a physician, Dr F. Mr N had been working with Dr F, aged 60 years, for the past year and enjoyed the challenges of working in a busy office. Dr F took her supervisory role seriously and would take a half hour at the end of every day to go over Mr N’s charts with him and discuss any issues that had occurred during the day.

One morning, one of the practice’s patients, Mrs G, aged 47 years, came in to see Mr N.

“I’ve been getting heartburn a lot lately,” the patient said. “I get a burning feeling in my chest after I eat. It happened yesterday after lunch as well. And it’s just been more than usual over the last few weeks.”

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The patient was obese and admitted to smoking and drinking alcohol socially. Mr N suspected that poor food choices might be part of her problem but did not say so.

A review of Mrs G’s medical record showed elevated blood pressure over the past six months and an elevated cholesterol level of 237 mg/dL. A heart examination revealed a normal rate and rhythm. Mr N noted in the patient’s chart that the patient was sweating heavily but was not in acute distress and that she was pain-free during the examination. An electrocardiogram (ECG) revealed a left bundle branch block, but prior ECGs were not available for comparison.

Mr N questioned the patient about whether there was any history of coronary artery disease in her family, and she answered that she was unaware of any. He also asked Mrs G what she had eaten that day, before the burning sensation began. She replied that she had eaten a hamburger and fries from a fast food restaurant.

Suspecting acid reflux, Mr N advised the patient to take an antacid and try to make better food choices. He told her to return to the office if the symptoms continued.

At the end of the day, Mr N and Dr F went over Mrs G’s file together. The physician was familiar with the patient, and, like Mr N, also suspected that poor food choices, obesity, and alcohol use could be contributing to her discomfort. Dr F suggested to Mr N that next time he saw the patient he should counsel her on not eating large meals late at night, not lying down immediately after eating, and other techniques to help manage her heartburn. The doctor also suggested doing a follow-up ECG at the next check-up.

Two days later, Mrs G called the doctor’s office after lunch, complaining that the burning sensation in her chest was continuing. Both Dr F and Mr N were completely booked that afternoon, but Mr N called the patient on the phone, advised her to continue taking the antacid, and scheduled an office appointment for the next day. He advised the patient to go to the emergency department of the hospital if she developed chest pain.