Chief complaint refers to the most serious symptoms and signs and their duration felt by the patients when they come to the doctor. Chief complaint is the main reason why the patient comes to the doctor and the chief symptom of the illness.
Accurate chief complaint is key to further understanding of the pathological conditions of the patient. So, chief complaint is helpful for primary classification and diagnosis of the disease. And it is also an important evidence for investigation, cognition, analysis and treatment of diseases.
Careful recording must be made of the symptoms included in the chief complaint or the location, nature, degree and time of signs. The recording to the chief complaint must be concise and avoid any ambiguity.
Inquiry of the history of present illness:
The history of present illness refers to the whole course of the onset, development and changes of illness from its occurrence to the time that the patient comes to the doctor. The inquiry of the history of present illness includes three aspects, occurrence, pathological changes and course of diagnosis and treatment.
Occurrence:
Occurrence includes the time of onset, whether the onset is sudden or gradual, cause of onset, initial symptoms and their nature and location as well as primary treatment. The understanding of such aspects is important for differentiating the cause and location and nature of disease.
Development of disease:
Inquiry of the development of disease includes the pathological changes from the onset of disease to the time that the patient comes to the doctor. Specifically speaking, it includes the nature, degree and changes of the main symptoms, the time of alleviation or aggravation, when there are new pathological changes, and whether there are any rules in the pathological changes. Such an inquiry is important for the understanding of the struggle between healthy qi and pathogenic factors as well as the tendency of the development of pathological changes.
Procedure of diagnosis and treatment:
Inquiry of the procedure of diagnosis and treatment includes whether the patient consults the doctor after onset, what test has been made, what the result is, what the diagnosis is made, what treatment has been taken and what the curative effect is, etc. Such data above the diagnosis and treatment made in the past can be taken as a reference for the present diagnosis and treatment.