Correctly diagnosing a patient, often in a very short period of time and sometimes with little background information on the patient, is one of a clinician’s most challenging jobs. Symptoms can often be attributed to numerous medical conditions, making diagnosis difficult. 

Ms. R was a 32-year-old nurse practitioner (NP) who worked in an on-campus health clinic at a college. The clinic was staffed with 2 rotating NPs who were employed by a medical practice that provided healthcare services to students at several college clinics. A physician in the practice was responsible for reviewing the NPs’ notes, and for answering any questions and acting as a consultant or backup for the NPs should they encounter anything complicated. Ms. R had previously worked for a family practitioner for a year, and before that she worked in an OB/GYN office.

In most cases, the students would come in with colds, influenza, sore throats, rash, or other minor ailments. Occasionally, they would have a small accident that resulted in cuts, bruises, or a burn. Periodically, Ms. R received questions from embarrassed students about sexually transmitted diseases and birth control. She was often asked about antidepressants and ways to minimize anxiety. Some students seemed to appear in the clinic every other day, often just to talk, whereas many students completed their 4 years without ever visiting the health center.

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Ms. R had been working on campus for 6 months when Mr. J, an 18-year-old male freshman student came in to see her. Ms. R had never seen Mr. J before and had no medical records for him. The student told Ms. R that he had had severe headaches for the past 4 days and that he felt lethargic. A brief examination revealed that the patient’s temperature and blood pressure were normal. 

Ms. R asked the student whether he was experiencing any unusual stress.

“Well, we’re in the finals period, and this was my first time with college finals,” said the young man. He commented that he was on a scholarship and had to maintain passing grades to continue receiving the money to go to school. Ms. R nodded, sympathetically.

“The first year can be especially tough,” she told the student. “Stress can cause physical problems, including headaches.” She gave the young man some tips for reducing stress, recommended an over-the-counter pain reliever for his headache, and told him to come back if he did not improve. “Oh, and good luck on the rest of your finals!” she added. 

She noted “stress-related headache” in his chart and filed it away where it was looked at but not remarked on by the supervising physician. 

A week later, on a Friday, the young man returned to the health center. Again, Ms. R was on duty. 

“What are you doing back here again?” she joked to the student. “Anything to avoid those finals, right?”