Chief complaint

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The chief complaint, formally known as CC in the medical field, or termed presenting complaint (PC) in Europe and Canada, forms the second step of medical history taking. It is sometimes also referred to as reason for encounter (RFE), presenting problem, problem on admission or reason for presenting.[ citation needed ] [1] The chief complaint is a concise statement describing the symptom, problem, condition, diagnosis, physician-recommended return, or other reason for a medical encounter. [2] In some instances, the nature of a patient's chief complaint may determine if services are covered by health insurance. [3]

Contents

When obtaining the chief complaint, medical students are advised to use open-ended questions. [4] [5] Once the presenting problem is elucidated, a history of present illness can be done using acronyms such as SOCRATES or OPQRST to further analyze the severity, onset and nature of the presenting problem. The patient's initial comments to a physician, nurse, or other health care professionals are important for formulating differential diagnoses.[ citation needed ]

Prevalence

The collection of chief complaint data may be useful in addressing public health issues. [6] Certain complaints are more common in certain settings and among certain populations. Fatigue has been reported as one of the ten most common reasons for seeing a physician. [7] In acute care settings, such as emergency rooms, reports of chest pain are among the most common chief complaints. [8] The most common complaint in ERs has been reported to be abdominal pain. [9] Among nursing home residents seeking treatment at ERs, respiratory symptoms, altered mental status, gastrointestinal symptoms, and falls are the most commonly reported. [10]

CMS required history elements [11]
Type of history CC HPI ROS Past, family, and/or social
Problem focusedRequiredBriefN/AN/A
Expanded problem focusedRequiredBriefProblem pertinentN/A
DetailedRequiredExtendedExtendedPertinent
ComprehensiveRequiredExtendedCompleteComplete

See also

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<span class="mw-page-title-main">Back pain</span> Area of body discomfort

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<span class="mw-page-title-main">Constipation</span> Bowel dysfunction

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<span class="mw-page-title-main">Emergency department</span> Medical treatment facility specializing in emergency medicine

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<span class="mw-page-title-main">Chest pain</span> Discomfort or pain in the chest as a medical symptom

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<span class="mw-page-title-main">Abdominal pain</span> Stomach aches

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<span class="mw-page-title-main">Physical examination</span> Process by which a medical professional investigates the body of a patient for signs of disease

In a physical examination, medical examination, clinical examination, or medical checkup, a medical practitioner examines a patient for any possible medical signs or symptoms of a medical condition. It generally consists of a series of questions about the patient's medical history followed by an examination based on the reported symptoms. Together, the medical history and the physical examination help to determine a diagnosis and devise the treatment plan. These data then become part of the medical record.

The medical history, case history, or anamnesis of a patient is a set of information the physicians collect over medical interviews. It involves the patient, and eventually people close to them, so to collect reliable/objective information for managing the medical diagnosis and proposing efficient medical treatments. The medically relevant complaints reported by the patient or others familiar with the patient are referred to as symptoms, in contrast with clinical signs, which are ascertained by direct examination on the part of medical personnel. Most health encounters will result in some form of history being taken. Medical histories vary in their depth and focus. For example, an ambulance paramedic would typically limit their history to important details, such as name, history of presenting complaint, allergies, etc. In contrast, a psychiatric history is frequently lengthy and in depth, as many details about the patient's life are relevant to formulating a management plan for a psychiatric illness.

The SOAP note is a method of documentation employed by healthcare providers to write out notes in a patient's chart, along with other common formats, such as the admission note. Documenting patient encounters in the medical record is an integral part of practice workflow starting with appointment scheduling, patient check-in and exam, documentation of notes, check-out, rescheduling, and medical billing. Additionally, it serves as a general cognitive framework for physicians to follow as they assess their patients.

Medically unexplained physical symptoms are symptoms for which a treating physician or other healthcare providers have found no medical cause, or whose cause remains contested. In its strictest sense, the term simply means that the cause for the symptoms is unknown or disputed—there is no scientific consensus. Not all medically unexplained symptoms are influenced by identifiable psychological factors. However, in practice, most physicians and authors who use the term consider that the symptoms most likely arise from psychological causes. Typically, the possibility that MUPS are caused by prescription drugs or other drugs is ignored. It is estimated that between 15% and 30% of all primary care consultations are for medically unexplained symptoms. A large Canadian community survey revealed that the most common medically unexplained symptoms are musculoskeletal pain, ear, nose, and throat symptoms, abdominal pain and gastrointestinal symptoms, fatigue, and dizziness. The term MUPS can also be used to refer to syndromes whose etiology remains contested, including chronic fatigue syndrome, fibromyalgia, multiple chemical sensitivity and Gulf War illness.

<span class="mw-page-title-main">Emergency nursing</span>

Emergency nursing is a specialty within the field of professional nursing focusing on the care of patients who require prompt medical attention to avoid long-term disability or death. In addition to addressing "true emergencies," emergency nurses increasingly care for people who are unwilling or unable to get primary medical care elsewhere and come to emergency departments for help. In fact, only a small percentage of emergency department (ED) patients have emergency conditions such as a stroke, heart attack or major trauma. Emergency nurses also tend to patients with acute alcohol and/or drug intoxication, psychiatric and behavioral problems and those who have been raped.

Emergency ultrasound employing point-of-care ultrasound (POCUS) is the application of ultrasound at the point of care to make immediate patient-care decisions. It is performed by the health care professional caring for the injured or ill persons. This point-of-care use of ultrasound is often to evaluate an emergency medical condition, in settings such as an emergency department, critical care unit, ambulance, or combat zone.

SOCRATES is a mnemonic acronym used by emergency medical services, physicians, nurses, and other health professionals to evaluate the nature of pain that a patient is experiencing.

<span class="mw-page-title-main">Medical diagnosis</span> Process to identify a disease or disorder

Medical diagnosis is the process of determining which disease or condition explains a person's symptoms and signs. It is most often referred to as a diagnosis with the medical context being implicit. The information required for a diagnosis is typically collected from a history and physical examination of the person seeking medical care. Often, one or more diagnostic procedures, such as medical tests, are also done during the process. Sometimes the posthumous diagnosis is considered a kind of medical diagnosis.

<span class="mw-page-title-main">Gender bias in medical diagnosis</span>

Gender-biased diagnosing is the idea that medical and psychological diagnosis are influenced by the gender of the patient. Several studies have found evidence of differential diagnosis for patients with similar ailments but of different sexes. Female patients face discrimination through the denial of treatment or miss-classification of diagnosis as a result of not being taken seriously due to stereotypes and gender bias. According to traditional medical studies, most of these medical studies were done on men thus overlooking many issues that were related to women's health. This topic alone sparked controversy and brought about question to the medical standard of our time. Popular media has illuminated the issue of gender bias in recent years. Research that was done on diseases that affected women more were less funded than those diseases that affected men and women equally.

Undertreatment of pain is the absence of pain management therapy for a person in pain when treatment is indicated.

<span class="mw-page-title-main">Spleen pain</span> Human pain from the area of the spleen

Spleen pain is a pain felt from the left upper quadrant of the abdomen or epigastrium where the human spleen is located or neighboring.

References

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