Rafael was seen by the nurse practitioner with complaints of abdominal burning and cramping, abdominal pain and inability to eat for a few weeks, but incidentally resolved as of the appointment. The nurse practitioner prescribed Zantac and set up a complete physician exam for the next month.
During this visit the patient gave a history of chewing tobacco and heavy coffee intake, occasional abdominal pain and increased in stool frequency. Rafael also indicated a family history that his mother was diagnosed with colon cancer at the age of 54. The nurse practitioner changed the medication regimen from Zantac to Protonix and ordered an upper GI series with contrast to rule out gastritis or an ulcer. The negative test results were provided to the primary care physician, who never saw the patient or reviewed the patients chart.
The patient was seen by the nurse practitioner a month later, when he reported that his symptoms were improved on Protonix, but he continued to have problems with eating. The nurse practitioner continued with a diagnosis of gastritis and gave instructions to call with any concerns and scheduled a follow-up visit in six months.
Rafael returned and reported worsening stomach cramps and burning to the nurse practitioner. The nurse practitioner then changed the medication to Prevacid, continued with a diagnosis of gastritis and arranged for an appointment with a gastroenterologist for a possible esophagogastroduodenscopy in July.
Rafael returned for an appointment with the MD, complaining of increasing pain and loose stools. The appointment for a GI consult was moved up after a discussion with the physician, but Rafael went to an emergency room before the scheduled visit. A work-up at the hospital, which included an abdominal CT scan and colonoscopy, resulted in a diagnosis of near obstruction of the right side of the colon by a Stage IV tumor and metastasis to the peritoneum and lymph nodes.
