Presenting problem

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 medical or vision insurance.[3]

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.

## Contents

* 1 Prevalence
* 2 See also
* 3 References
* 4 External links

## 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 focused  | Required  | Brief  | N/A  | N/A
Expanded problem focused  | Required  | Brief  | Problem pertinent  | N/A
Detailed  | Required  | Extended  | Extended  | Pertinent
Comprehensive  | Required  | Extended  | Complete  | Complete

## See also

* Identified patient
* Medical history

## References

1. ↑ "Structured classification for ED presenting complaints - from free text field-based approach to ICPC-2 ED application". Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 20 (1): 76. November 2012. doi:10.1186/1757-7241-20-76. PMID 23176447.
2. ↑ "VI. Evaluation and Management (E/M) Services". Compliance Training Manual. www.usc.edu. http://www.usc.edu/health/uscp/compliance/tm6.html#6.
3. ↑ "coding q & a - Medical Vs. Vision Insurance". Optometric Management. July 1, 2004. http://www.optometricmanagement.com/issues/2004/july-2004/coding-q-a-medical-vs-vision-insurance.
4. ↑ Shah, Nayankumar (2005). "Taking a history: Introduction and the presenting complaint". Student BMJ 13: 309–52. doi:10.1136/sbmj.0509314. http://student.bmj.com/student/view-article.html?id=sbmj0509314.
5. ↑ Bickley, Lynn (2017). Bates' Guide to Physical Examination and History Taking (12th ed.). Philadelphia: Wolters Kluwer. ISBN 9781469893419.
6. ↑ "Implementation Guide for Transmission of Patient Chief Complaint as Public Health Information using Version 2.3.1 of the Health Level Seven (HL7) Standard Protocol". Centers for Disease Control and Prevention. May 27, 2003. https://www.cdc.gov/PHIN/architecture/implementation_guides/Healthcare Related/PHIN_Healthcare_Encounter_Chief_Complaint_v231.pdf.
7. ↑ "Chief complaint fatigue: a longitudinal study from the patient's perspective". Family Practice Research Journal 6 (4): 175–88. 1987. PMID 3455125.
8. ↑ Hussain, Nasir; Karnath, Bernard. "Differentiating Chest Pain". Emergency Medicine. http://www.emedmag.com/html/pre/cov/covers/021504.asp.
9. ↑ "Abdominal pain and emergency department evaluation". Emergency Medicine Clinics of North America 19 (1): 123–36. February 2001. doi:10.1016/S0733-8627(05)70171-1. PMID 11214394.
10. ↑ "Emergency department use by nursing home residents". Annals of Emergency Medicine 31 (6): 749–57. June 1998. doi:10.1016/S0196-0644(98)70235-5. PMID 9624316.
11. ↑ "Evaluation and Management Services Guide" (PDF). www.cms.gov. December 2010. Archived from the original on 2012-04-11. https://web.archive.org/web/20120411172702/https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval_mgmt_serv_guide-ICN006764.pdf. Retrieved 2011-02-27.

## External links

* MedEd at Loyola ipm/comphx1/sld003.htm

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Medical examination and history taking

Medical history|

* Chief complaint
* History of the present illness
* Systems review
* Nursing assessment
* Allergies
* Medications
* Past medical history
* Family history
* Social history
* Psychiatric history
* Progress notes
* Mnemonics
* SAMPLE
* OPQRST
* SOAP
* COASTMAP

Physical examination|

| General/IPPA|

* Inspection
* Auscultation
* Palpation
* Percussion

|

Vital signs|

* Temperature
* Heart rate
* Blood pressure
* Respiratory rate

HEENT|

* Oral mucosa
* TM
* Eyes (Ophthalmoscopy, Swinging-flashlight test)
* Hearing (Weber, Rinne)

Respiratory|

* Respiratory sounds
* Cyanosis
* Clubbing

Cardiovascular|

* Precordial examination
* Peripheral vascular examination
* Heart sounds

* Other
* Jugular venous pressure
* Abdominojugular test
* Carotid bruit
* Ankle-brachial pressure index

Abdominal|

| Digestive|

* Liver span
* Rectal
* Murphy's sign
* Bowel sounds

|

Urinary|

* Murphy's punch sign

Extremities/Joint|

* Back (Straight leg raise)
* Knee (McMurray test)
* Hip
* Wrist (Tinel sign, Phalen maneuver)
* Shoulder (Adson's sign)
* GALS screen

Neurological|

* Mental state
* Mini–mental state examination
* Cranial nerve examination
* Upper limb neurological examination

Neonatal|

* Apgar score
* Ballard Maturational Assessment

Gynecological|

* Well-woman examination
* Vaginal examination
* Breast examination
* Cervical motion tenderness

Assessment and plan|

* Medical diagnosis
* Differential diagnosis

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