Ms N, aged 36 years, was a nurse practitioner who had worked out of a general practitioner’s office. She saw her own patients, and she sometimes covered patient appointments for the physician, Dr M, as well. She had been working at the practice for almost a decade, and she and Dr M had a close relationship. He had been something of a mentor to her, and she respected his advice.

One piece of advice that he had given her early on was that “if you don’t think you can diagnose a specific problem, you should refer the patient to someone who can” — meaning a specialist.

She understood this to be good advice, and regularly referred patients to cardiologists, gastroenterologists, endocrinologists, and other specialists. She knew that she could not be the expert at everything, and she wanted to make sure that her patients had the best outcomes possible. 

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One of Ms N’s patients was Mrs V, aged 60 years. Mrs V came in regularly for annual check-ups, and she occasionally made appointments for minor illnesses. The patient, a postmenopausal woman, was in good overall health, did not smoke, and was the appropriate weight for her height.

Her blood pressure was borderline high, but no medication had been prescribed yet as the patient was trying to control it with dietary changes. Her only other issue was hypothyroidism, which was being successfully treated with replacement levothyroxine. 

One afternoon, Mrs V came in for an appointment after complaining about abdominal pain. “I’m quite uncomfortable most of the time these days,” she told Ms N. “I thought maybe it was something I ate, but it hasn’t gone away and it doesn’t really feel like my stomach.…”

After further discussion, Mrs V confided that she had also been experiencing rectal bleeding. Ms N questioned her about this, but the patient’s description was not consistent with what Ms N had found was the most common cause of rectal bleeding in her patients — hemorrhoids. A physical examination did not reveal anything out of the ordinary. 

Ms N decided the best option was to refer the patient to a gynecologist. She explained this to the patient, and Mrs V agreed to see the specialist. 

A few weeks later, Ms N was notified that the gynecologist had diagnosed a likely uterine fibroid after an ultrasound but that an endometrial biopsy was benign. The gynecologist diagnosed benign pelvic disease. 

However, Mrs V began  calling the nurse practitioner, complaining of continued symptoms. The patient even came into the office on two occasions to tell Ms N that she was still experiencing discomfort. 

Ms N initially reassured the patient that her issues were benign, as per the gynecologist. But, after several months of Mrs V’s continued complaints, Ms N ordered an abdominal computed tomography (CT) scan. The scan revealed a malignant rectal mass displacing the uterus.