Mr N was a 38-year-old nurse practitioner working for a small practice that included his supervising physician, Dr S, and a physician assistant. Mr N had been working at the practice for close to a decade. He and his supervisor, Dr S, had a good working relationship. When Mr N started at the practice, Dr S had been very careful to go over his patients’ charts with him, to make suggestions when necessary, and to follow up on more intricate cases. As the years passed, however, her involvement with his day-to-day work gradually decreased, until she rarely looked at his patients’ charts and they only discussed things if there was a particular question. Mr N worked mostly independently. Most of his patients made appointments directly to see him.

One of his patients was Mr P, a 45-year-old man with a history of gout. Mr P was what Mr N thought of as an anxious patient. Every new pain caused him great worry and concern, and he frequently feared the worst. One afternoon Mr P came into the office complaining of a flare-up of his gout. The patient described his pain with great animation and concern. After a brief exam, Mr P prescribed prednisone and gave the patient a steroid injection in his left leg.

The patient left but returned 3 weeks later. “My left calf is all swollen,” he told the clinician. “It hurts behind my knee. I can barely limp around! Do you think this is serious? Do I need an X-ray or something?” Mr P’s anxiety was palpable. 

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Mr N measured the patient’s left calf, which was 42 cm. The patient’s right calf measured 40.5 cm. Mr N considered the situation. He knew that deep vein thrombosis (DVT) was a possible cause of swelling and pain, but he doubted this was the case and he noted this in the patient’s file. Instead, he stated in the file that he believed the pain was due to the patient’s gout, Baker’s cyst, or radiculopathy. “I don’t think this is anything to be worried about,” he told the patient in what he hoped was a calming voice. “I’m going to give you another prednisone injection in your left ankle. If your calf continues to swell, then I will order an ultrasound so we can get a better idea of what is going on.” He did not mention to the patient that the purpose of the ultrasound was to rule out DVT, nor did he explain to the patient what a DVT was to not alarm him more than necessary. 

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The patient went home but called the office later that day complaining of increased swelling and pain in his left calf and knee area. Mr N ordered an ultrasound to be performed the next day. The following day, after the ultrasound was performed, the results were called into Mr N’s office, and they revealed that the patient did have a DVT. The patient was called and told to come to Mr N’s office for an evaluation. When he arrived, Mr N measured his left calf and it was larger than it had been the previous day, so Mr N advised him to go right to the emergency department immediately.