Chief complaint

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.^[1][2][3] The chief complaint is a concise statement describing the symptom, problem, condition, diagnosis, physician-recommended return, or other reason for a medical encounter.^[4] In some instances, the nature of a patient's chief complaint may determine if services are covered by health insurance.^[5]

When obtaining the chief complaint, medical students are advised to use open-ended questions.^[6][7] Once the presenting problem is elucidated, a history of present illness can be done using acronyms such as SOCRATES^[8] or OPQRST^[9] 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.^[10]

主訴データの収集は、公衆衛生上の問題に対処する上で役立つ可能性がある。^{[ 11 ]}特定の訴えは、特定の環境や特定の集団でより一般的である。疲労は、医師の診察を受ける最も一般的な理由の 10 位の 1 つとして報告されている。^{[ 12 ]}救急外来などの急性期医療環境では、胸痛の報告が最も一般的な主訴の 1 つである。^{[ 13 ]}救急外来で最も多い訴えは腹痛であると報告されている。^{[ 14 ]}救急外来で治療を求める介護施設の入居者の間では、呼吸器症状、意識状態の変化、胃腸症状、転倒が最もよく報告されている。^{[ 15 ]}

• 患者を特定
• 病歴

• ロヨラ大学の医学教育プログラムipm/comphx1/sld003.htm