Real clinical cases from practice, told the way the reasoning actually unfolded, not the textbook version. ← Back to the main site
Some identifying details have been omitted or approximated to protect confidentiality.
A 26-year-old female presented to urgent care with an acute rash that started that day. She had been taking Augmentin, a penicillin-class antibiotic, for six days for suspected mumps, and was on no other medications. No significant PMH. Known penicillin allergy, confirmed on Laura's own review. Vitals stable. On physical exam: severe, diffuse urticaria on her chest and back, with no obvious signs of systemic involvement.
Laura treated it as evolving anaphylaxis before progression: epinephrine IM and diphenhydramine, followed by close monitoring until vital signs and symptoms stabilized. Treatment was straightforward. The underlying cause took longer to reconstruct. The diagnosis had been correct: mumps, appropriately identified. The treatment plan was not. Mumps is a viral illness; an antibiotic was never indicated, independent of the allergy. Augmentin combines amoxicillin, a penicillin, with clavulanic acid, a beta-lactamase inhibitor with no antibiotic activity of its own. Given her known penicillin allergy, the amoxicillin component was the clinically relevant one here. Laura hadn't been present for the original visit and couldn't speak to exactly what had been communicated there at that time. What she did know: the allergy wasn't documented until hours after the Augmentin prescription was written, and the pharmacy dispensed it regardless. Establishing care there as a new patient was also a natural point for the pharmacy to ask directly, and her supervising physician later confirmed with the pharmacist that the question hadn't been asked. This wasn't a single point of failure. It was a wrong treatment for a correctly diagnosed illness, compounded by a missed allergy and a documentation gap.
She was monitored for several hours and demonstrated clinical improvement. She was discharged with instructions to discontinue Augmentin, a prescription for an EpiPen, and continued antihistamines as needed for residual hives. She was counseled on anaphylaxis as a life-threatening condition with risk of recurrence, given an anaphylaxis emergency action plan, and educated on allergen avoidance. Having recently relocated to the U.S. with no established primary care, that gap wasn't left for her to sort out on her own. Rather than a generic referral list to a provider she'd never met, with no idea how they actually practice, Laura connected her directly with her own supervising physician, someone she personally knew and trusted to give her a genuinely positive, evidence-based experience. It was her choice to make that specific connection, the physician's choice to take real care of a new patient, and, ultimately, still the patient's choice whether to go.
Multiple factors contributed here: a prescription that was not indicated, a documentation delay, and a new-patient pharmacy intake where the allergy question wasn't asked. It would be easy to attribute this to any one contributing error. The more useful standard is full accountability for your own role in it, regardless of how many other factors were also present. No amount of clinical training, years of experience, or a prestigious employer changes that. You decide the care a patient gets, not your title. Physicians, PAs, and pharmacists, at every level of seniority, are all capable of the same kind of error, and assuming otherwise is its own kind of risk. The goal isn't never making a mistake. It's building a practice, a system, and a version of yourself that's self-aware, confident, and honest enough to catch it when you do.
A 21-year-old male patient came into urgent care with chest pain that had been present for five weeks, already seen once elsewhere and diagnosed at that time with costochondritis. He'd been prescribed symptomatic treatment for it with no response, and otherwise denied trying anything else to relieve the symptoms. He denied ever being diagnosed with or treated for TB before.
He arrived with a chest X-ray and labs already done, but no one had gone over the results with him.
Laura reviewed them herself, then went over the findings directly with him: the radiology report described old, calcified tissue in his lungs as "chronic," with no prior imaging to actually confirm that. Rather than take that read at face value, she ordered a follow-up work-up, including a Quantiferon Gold blood test.
The Quantiferon Gold came back positive. With no signs of active disease and no prior history of treatment, it was diagnosed as latent tuberculosis, and he started treatment.
Not every finding gets caught on initial clinical presentation, and that's ok. What matters is not letting go of a case until the clinical picture is actually clear.
A 30-year-old male came in for an abdominal wall abscess (L02.211) that needed to be incised and drained, with no systemic symptoms.
Rather than treat it as a quick procedure to get through, Laura let his partner stay in the room to hold his hand, had her MA bring him a pillow and water, didn't rush the visit, and made sure his questions were actually answered before moving on.
Local anesthesia was achieved, and the incision and drainage was successful and uncomplicated. He returned for a wound check with normal wound healing and no active infection.
Continuity isn't only about the diagnosis. It's the small things, not rushing, giving someone room to ask questions, that make a visit feel like it actually mattered.
A 69-year-old female came in asking for a note to justify using a cane. She'd fallen a few months earlier while visiting her daughter out of state, and the pharmacy had told her she needed sign-off from an actual medical provider first.
She was asymptomatic at the time of presentation, with no midline bony tenderness, no paraspinal muscle tenderness, and no other abnormal findings on exam. Laura assessed her gait, balance, and mobility, then asked why she felt she needed the cane, and the patient couldn't really say why. The exam and history didn't support a need for one, so she didn't prescribe it that day. She also screened for a pattern: had this happened before, or come close to, since. The patient consistently denied any falls or near-falls back home in New York, pointing to an isolated incident in an unfamiliar environment rather than an ongoing mobility problem, and she had no plans to travel again in the near future. She also noted the patient had never had a bone density scan. That led to ordering a lumbar spine X-ray and a DEXA, both scheduled with an outpatient radiology center.
The patient completed both tests, but Laura left the practice before the results came back, so she never learned what they showed. Based on her age, the unclear mechanism of her fall, and never having had prior imaging, Laura suspected the results would come back showing something significant, a risk that would have gone unaddressed if the visit had stopped at the paperwork.
The chief complaint isn't always the real complaint. Figuring out the difference is the job.
This case is a composite, built from a pattern Laura has seen repeatedly rather than one specific visit.
A 32-year-old male came in for a routine PrEP refill. As part of standard care, the visit included PHQ-9 and GAD-7 screening alongside the usual labs.
The screen came back positive for both anxiety and depression. He had a known history of both, but a positive screen alone doesn't say if it's currently controlled. Further questions followed: had he taken anything for this before, was it effective, would he consider it again. Immediate safety was assessed before anything else. He didn't meet criteria for emergent referral, and there was no active plan or intent.
He was open to restarting a medication that had worked for him previously. Treatment was restarted with outpatient follow-up planned in one month.
Mental health doesn't wait for a psychiatry visit to show up. It shows up in a PrEP refill, a physical, a sore throat check. PA education gives it a fraction of the time its prevalence deserves, and part of getting comfortable with it is simply seeing these situations often enough to trust your clinical judgment.