Chief Complaint

When evaluating patients in the emergency department, we start with what is called “The Chief Compliant.” This is what the patient says is wrong, usually a symptom. Sometimes, that is very straightforward: “I fell and twisted my ankle” or “I have chest pain.”

Based on the chief complaint, we ask more questions, do a physical exam and maybe some testing.

Sometimes, the chief compliant is so bizarre it is hard to even get passed it. Once, a lady came in and said, “Every time I have sex, I bark like a dog.”

When I hear a complaint like that, it is hard to even think of a question to ask in clarification and there is certainly nothing you can image would be helpful in a physical examination or any lab tests. It all just kind of stops with the chief complaint.

Another case like that happened recently when a man in his twenties came in and said, “I’ve been tasting saltiness in my throat, like seawater for the last two days.” He had Googled it and been unable to find a cause so he came in because he was sure it was something serious. I asked some more questions to make sure I was not missing something then did a thoughtful examination before sending the patient home with reassurance. My usual line for this sort of complaint goes something like this: “I have never experienced this symptom in my life nor have I ever heard of anyone else having this symptom.” I then explain why I think there is no reason to be concerned and send the patient home.

Another way the chief complaint can tell the whole story is when it is so long, bizarre and covers too many different symptoms. This is especially true if the symptoms have been going on for a long time. Basically, the more complaints, the stranger they are, the more they involve different body parts and the longer they have been going on, the less likely it is to be an issue in the emergency department.

Sometimes, people have so many different complaints that they actually have them written out, in list form. These are often amazingly long, detailed and even bizarre.

Here is a list I was given by a 38-year-old Vietnamese patient who had been having trouble for many years. She had come from Vietnam two months previously and came to my emergency department so I could figure out what was wrong with her.

Since childish:

-easy having fatigue

-tired when working

-excited easily

-often passed out when I was in VN (not use any medication)

-insomnia

-forgettable hard study

-starting

-grinding of the teeth

In this case, some follow-up questions, a good examination and some basic lab tests showed nothing to worry about. She was referred to find a primary care doctor.