Mr. R, age 54, was a diabetic, moderately overweight construction worker. One day he tripped at a job site, falling heavily on his right hip. Despite the pain, he finished his shift, then he went home, took an ibuprofen tablet, and went to bed.

When he awoke in agony at 6 am, his wife called an ambulance to speed him to the emergency department (ED). X-rays showed nothing unusual, so the ED doctor prescribed hydrocodone (Vicodin) for the pain and sent Mr. R home.

Over the next three days, Mr. R’s pain worsened, and he developed sweats, shortness of breath, pallor, and a loss of appetite. His wife and his 25-year-old daughter grew increasingly concerned. They decided to take Mr. R to the local walk-in clinic for another opinion.

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Ms. K, aged 47 and an NP for more than 20 years, was nearing the end of her shift when Mr. R and his family arrived. She had been looking forward to going home and sighed as she watched the family arrive. She covered her impatience with a warm smile as she greeted them.

Mrs. R described her husband’s accident and the trip to the ED. The patient himself complained that he didn’t seem to be getting better; in fact, his pain was getting worse. But whether the family mentioned any symptoms besides pain became an issue in the subsequent lawsuit.

After a brief examination, Ms. K diagnosed a muscle strain. She advised Mr. R to rest. Mrs. R and her daughter were not satisfied. “Aren’t you going to do an MRI?” they asked. “Shouldn’t the doctor see him as well?”

“I’ll discuss the case with Dr. W,” Ms. K replied, “and he can decide what to do.”

Ms. K caught her supervising physician in the hallway as he was about to enter another exam room. She outlined Mr. R’s symptoms, her examination, and her diagnosis. Based on that report, Dr. W said there was no need for him to see Mr. R and turned to greet his waiting patient.

Ms. K returned to Mr. R and his family. She remembered the wise words a mentor had taught her long ago: “Treat patients with kindness and compassion, but remember that you’re the health-care professional. Don’t let them bully you into prescriptions, tests, or treatments that you don’t think are warranted.” Ms. K had tried to live by that advice for her entire career, and she intended to do so now.

“The doctor agrees with my diagnosis,” she told Mr. R and his family. “Please go home and rest. I’m sure you’ll find that your pain will improve over the next few days.”

“What about the MRI?” demanded Mrs. R. “I’d like my husband to have one. And what about a better painkiller? Aren’t you going to give him a prescription?”

“An MRI is not necessary,” replied Ms. K, kindly but firmly. “Nor is a prescription. Your husband has a muscle strain and just needs to rest. Feel free to call me if he doesn’t improve.”

But Mr. R did not improve. On the contrary, he continued to decline. Two days after his clinic visit, he was admitted to the hospital with septic shock and multi-organ failure that was ultimately blamed on an infection of the psoas muscle. Within two weeks, Mr. R was dead.

His family, furious at what seemed an unnecessary and preventable death, consulted a plaintiff’s lawyer. He hired an expert primary-care physician to review the case.

“If Mr. R had had a CT scan or MRI, the infection would have shown up,” the expert opined. “Treatment would have involved a broad-spectrum antibiotic and draining the abscess. Increasing pain would not be consistent with muscle strain. The NP and physician should have realized this.”

That conclusion was just what the attorney needed to begin the lawsuit against Ms. K, Dr. W, and the clinic.

At trial, Mr. R’s wife gave a heart-wrenching description of her happy 30-year marriage and Mr. R’s close relationship with his daughter. Mother and daughter both testified that they had given Ms. K a complete rundown of Mr. R’s symptoms and had repeatedly asked for an MRI or CT scan. Ms. K had insisted the scans weren’t necessary, they told the jury.

Testifying in her own defense, Ms. K maintained that neither the patient nor his family mentioned any symptoms other than pain. They didn’t tell her about shortness of breath or loss of appetite, she swore, and she did not observe pallor or sweating during the examination. Recounting her conversation with Dr. W, Ms. K said she specifically told him that Mr. R’s pain had been increasing over the past few days.

But Dr. W contradicted that version of events. He insisted that Ms. K never told him that the patient’s pain was getting worse. Had she done so, the doctor declared, he would have examined Mr. R himself, noticed signs of infection, and ordered an MRI or CT scan.

During their closing statements, the defense attorneys stressed that a psoas infection was so rare that most clinicians never encounter one. The argument failed to impress the jurors, who awarded the plaintiffs $7 million.

Legal theory
It is not unusual for codefendants to offer conflicting testi-mony, as Ms. K and Dr. W did in this case. Sometimes it works in the defendants’ favor by introducing doubt or confusing jurors so they are not sure whom to believe. For this reason, codefendants often have separate attorneys; part of the defense strategy might be for defendants to blame each other.

However, that strategy did not work in this case. The jury chose to believe that the family gave Ms. K the facts, that Ms. K told Dr. W about the increasing pain, and that both Ms. K and Dr. W had misdiagnosed Mr. R’s symptoms.

Protecting yourself
While it’s true that psoas infections are rare, they are not unheard of. Besides, both Ms. K and Dr. W testified that they were familiar with the condition.

Ms. K’s mistake was to arrive at a diagnosis that wasn’t supported by the symptoms. Muscle strain was an easy first guess, but Ms. K should have noticed Mr. R’s symptoms indicated something else was going on. The fact that the pain was increasing should have been her first clue. Had Ms. K questioned Mr. R or his family about his breathing, his appetite, his pallor, or his sweating she should have come to a conclusion other than simple muscle strain.

While it can be annoying when a patient or his relatives demand a particular diagnostic tool or medication, try to find out why they’re so insistent. You may discover the family has good reason to believe something serious may be involved.

Symptoms are like pieces of a jigsaw puzzle. They need to be examined  to be put together correctly. If a piece doesn’t fit, ignoring it won’t do. In this case, Ms. K should have worked to solve the puzzle, rather than settling for a hasty diagnosis.

Ms. Latner, a former criminal defense attorney, is a freelance medical writer in Port Washington, N.Y.