Module 3 Part 1

Chief Complaint - The patient's statement of the problem.

and

History of the Present Illness - The History of that Problem

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Chief Complaint:

"Chief Complaint." is a poor name for what we want the patient to tell us. To some patients it's a "complaint," but to most, what they come to you with is a "problem." Let's try to flesh out the definition of the "Chief Complaint."

Defining the Patient's Problem - the "chief complaint"

Everything we do as dentists stems from defining our patient's problem. Sometimes it's easy and other times complicated. Everything hinges on communicating with your patient, and eliciting the information you need to make sense of their problem.

Every patient tries to give you the information you need to define their problem. they want to get on with therapy. Some patients are adept at this, and others are unable to articulate their problem successfully. Thus, your task is to seek out and understand the patient's problem so you can help relieve the symptoms, cure the disease, etc. To do this you must

• listen
• interpret
• find additional or supplemental information
• analyze the problem
• plan therapy

The term "chief complaint" really means the Patient's Statement of the Problem. Let us resolve that although the term "chief complaint" is used in books and on forms, we will use this term only among ourselves, not with our patients. With patients use a phrase more easily understood, for example: "Can you tell me why you came to the clinic?" or "Please tell me about your problem."

To be able to interpret the patient's problem, you need to organize your investigation. Listen carefully to what the patient says. Look for information that tells you: WHO, WHAT, WHERE, WHEN and HOW. These are 5 of the 6 major interrogatories in the English language. The obvious missing one is WHY. WHY is answered by synthesizing the information you gather through the other 5 questions and making a diagnosis. You will always need this information, but will develop your own way of assessing and gathering it. This is not an exact process and there are numerous methods of information gathering.

WHO: Establish that the patient is seeking your help for themselves. This may seem strange, but if they are asking you to help their brother, or sister, father or girlfriend, then that person must be present and allowed to speak for him or herself. You can't evaluate a patient through the eyes and perceptions of a third party. If your patient indicates the problem to be in their own mouth, you can assume it is their problem.

The other reason to establish the patient's identity, is you want to be sure you have the correct record. In a busy practice, dealing with multiple records, it is easy to pick up or be handed the wrong record. One way to be sure of the patient's identity is to say the entire name of the patient whose record you hold. You could use their name in a greeting: "Good morning Sandra Jones. What can we help you with today?"

Once you have established that the patient wants your help for themselves, your next WHO task is to characterize your patient demographically: age, sex, race and occupation. This information is important in determining the differential diagnosis and ultimately the final diagnosis. You have to think of your patient demographically, as part of an age, sex, racial and occupational group, while you consider their problem. Many diseases and conditions are found in specific age, sex, race and occupational clusters. This may help you rule in or out one or another disease or condition.

Example:

Mr. Jones comes to you for help with a lump on his lip. It is important you know Mr. Jones is a 45 year old Caucasian male during your evaluation of his problem. Lumps on the lip are more frequent in males. He might tell you he is a prize fighter. This is also part of WHO. What a patient does may or may not be important in regard to the problem, but in this case, lumps in the lip are more frequent in people who have had trauma to their lip. You can read about lumps in the lip in your book and find out this information.

There are many other parts of WHO your patient is besides age, sex, race and occupation that may or may not prove to be important as well: marital status, sexual preference, leisure activities, interests, hobbies and tastes in food are only a few. You start with basic demographic information (age, sex, race and occupation), then see how the case develops and revisit WHO as the need arises.

WHAT: Identify the problem. What is it that is bothering the patient. It is preferable that this question be answered in the patient's own words. Be careful not to put words in the patient's mouth, so to speak.

In determining "WHAT," you are describing the problem as clearly and completely as possible. Emphasis is placed on the word describe. (Webster defines describe as: to represent or give an account of in words. To represent by a figure, model or picture. To delineate.) Thus the patient first tells you as accurately as possible in their own words what their problem is, and you listen carefully. The patient may point out what they are describing, if visible. You, in turn, will use your powers of observation, diagnostic tools and vocabulary to describe the patient's problem from your objective viewpoint. Your tools of description are:

• physical examination
• medical and dental history
• radiographs and other imaging studies
• tests conducted on tissues or body fluids

REMEMBER, description of the problem is a necessary step in obtaining a diagnosis, but description is not the diagnosis.

WHERE: Locate the problem. Let the patient tell you where they see (or feel) their problem. You will have the opportunity to confirm it. The exact location is important. The patient may point to the location of the problem initially. If they don't, it is useful to have them point to what is bothering them. This way you get the patient's point of view up front. You should confirm the patient's location to your satisfaction, either by sight, palpation or other means of physical examination.

Some lesions occur in certain locations but don't occur in others. For example: the Peripheral Ossifying Fibroma is seen only on the gingiva in the oral cavity because it is of periodontal ligament origin. Thus, a lesion located on the lip could not be a Peripheral Ossifying Fibroma, because they don't grow there. Another reason location is important is that certain lesions occur more frequently in some areas than others. Some places in the mouth are high risk areas for oral cancer. For example: a leukoplakia (white lesion) located on the floor of the mouth would carry a higher risk of being a dysplasia or cancer than the same leukoplakia located on the alveolar ridge or buccal mucosa. Thus when gathering information about a "chief complaint," the exact location is extremely important and can influence the ranking of diagnoses in your differential diagnosis list. Get the exact location - the patient points and you confirm

Information you would want to ask about location include:

• is the location always the same or does it change?
• if lesion comes and goes, does it always occur in the same place?
• any potential areas of trauma located near lesion?
• what are risk factors in the location?

Other questions might arise. The skill involved is to know why you want the information so you can selectively ask some questions and not others. This knowledge presumes a basic understanding of how symptoms and signs translate into biologic behavior.

WHEN: You need to know all the time frame elements relevant to the problem. Duration is an important element of any problem. Some problems can be treated easily if the patient seeks care early, but the same problem might be difficult to treat or untreatable if the patient delays.

The length of time a problem persists can sometimes tell you how urgent the problem is to the patient. If pain or esthetics is involved, the patient may seek care sooner rather than later. When pain and esthetics are not part of the problem, delay is often a factor. You also will find patients who delay seeking help with problems involving both pain and esthetics. You need to look carefully at the motivation and priorities of these patients. Duration may reflect the nature of the growth and development of the problem from a pathophysiological standpoint. Time factors may enlighten you about the patient's tolerance for pain. Many questions about time and the patient's problem should be in your mind, for example:

• when does it start?
• how long does it last?
• is this the first time this problem has come up?
• has the problem occurred before?
• what were you doing when you first noticed it?

This list is not exhaustive. Learn which of many questions you need to ask about a problem? Superfluous questions are confusing both to you and the patient. On the other hand, you may miss important information if you don't ask. So concentrate on learning the right questions to ask in each circumstance. The best way to go about this is to learn how symptoms translate into biologic behavior.

HOW: Know how the problem has affected the patient. Sometimes they will volunteer the information: "I can't chew my food." Other patients will not mention how a problem affects them until you ask. Some problems apparently don't affect patients at all. A patient may not be aware of how a certain problem affects them. You may have to ask questions that draw out HOW the problem affects them. For example, until the effects of malocclusion or missing teeth are explained, patients may be unaware of their consequences. Malocclusion often doesn't hurt or malfunction until it's too late.

Function is important for patients, and when function is interrupted, your patient will tell you. For example, the problem is preventing the patient from eating. Does this problem become more important than an incipient carious lesion?

• can the patient continue to function with the problem?
• does the problem cause loss of function?

Pain is important and often affects function. Pain is an incredibly complex variable that involves the disease itself, how it causes the pain, the patient's past history and experience with pain, their current perception of pain and their pain threshold. In your role as the objective gatherer of information, you should seek to characterize pain as accurately as possible.

• is the pain sharp or dull?
• constant or episodic?
• stimulated or unstimulated?
• related to any activity, food, substance, position etc.?
• duration of pain
• has the pain been there before?
• what makes it hurt?
• what stops the pain?
• what medicine do you take for the pain?
• does the pain keep you awake?

Characterizing the pain is only the first step. What makes it possible for you to help the patient is if you can relate the character of the pain to the picture of what is going on pathologically. This can happen only when you have a good working knowlege of basic science.

Does the patient worry about the problem? What do they worry about? Is the patient fearing cancer, infection etc? Worry about a problem is sometimes half of the problem. If you can reassure the patient, you may find out more about the problem than they were willing to tell you prior to the reassurance. Worry is a common cause of loss of function.

This is not a complete discussion of the issue of HOW the problem affects the patient, but it should suffice to get you on the right track with gathering information.

An Example

A patient named David Tate comes into your office and says: "Can you help me?" Which of the above interrogatories does this information begin to satisfy?

If you said WHO, you are correct. The patient is asking you to help "me" (David Tate). WHO is not completely satisfied, however. You can observe that David Tate is a male and he is Caucasian. You have to ask or read from his chart that David Tate is 38 years old. Thus, WHO is: David Tate, 38 year old Caucasian, for now. Other demographic WHO information may be necessary and you can revisit that question if necessary.

This patient could have said: "Can you help me with this ulcer?" In this case you have answered WHO and WHAT. David Tate (WHO) needs help with and ulcer (WHAT).

Suppose the patient said: "Can you help me with this ulcer that started yesterday?" They have answered yet another of your interrogatories, WHEN. They told you that the ulcer "started yesterday."

Another piece of information the patient might add would be: "Can you help me with this ulcer that started yesterday here on the inside of my cheek?" You know that the location is "on the inside of my cheek." The patient told you WHERE.

Your patient could say: "Can you help me with this ulcer that started yesterday here on the inside of my cheek? I can't chew my food now." Your patient just told you HOW the problem they've just described influences them, "I can't chew my food."

Your patient could have added a final piece of information: "Can you help me with this ulcer that started yesterday here on the inside of my cheek? I can't chew my food now, and I can't have it hurt while I'm driving my rig to Miami tomorrow." He just added another piece of WHO information. He's a truck driver. So you put this back with the WHO data. You might have to ask him what his occupation is if he doesn't volunteer the information.

If you're really sharp, you noticed he also added another bit of information to HOW: "I can't have it hurt while I'm driving." He doesn't want to have the painful ulcer distracting him from his driving. You will soon learn you can use all the information you can get, and your ear will become a sponge for information

Now look at the whole statement with the interrogatories highlighted:

"Can you help me with this ulcer that started yesterday here on the inside of my cheek? I can't chew my food now, and I can't have it hurt while I'm driving my rig to Miami tomorrow."

The basic information is:

• WHO: David Tate, 38 year old truck driver
• WHAT: ulcer
• WHEN: started yesterday
• WHERE: inside of my cheek
• HOW: can't chew my food; can't have it hurt while I'm driving

If you don't get all of this basic information, then formulate questions that will get you what you need to know.

Thus you harvest the information you need from what the patient says. The statement, "Can you help me with this ulcer that started yesterday here on the inside of my cheek? I can't chew my food now, and I can't have it hurt while I'm driving' my rig to Miami tomorrow." is called the "chief complaint," or the patient's statement of the problem. This is usually the first statement you get from your patient when they present to you for treatment. You want it in their own words with all the baggage. Don't interrupt them while they are telling you their "problem." Ask your initial question in the most open ended manner possible. For example, "Please tell me about your problem."

The "chief complaint' 'is a subjective statement influenced by much baggage. Emotional overtones, inaccuracies, frustrations, pain and vague qualities that come from the patient's inability to communicate in clinical and anatomic terms are only examples.

An important part of your role is to verify the patient's claims. Visualize the problem for yourself, if possible. Conduct your own examination, testing and questioning. In this way, you will build an objective observer's viewpoint and translate information from the patient's statement into your own familiar clinical terminology. Thus your first step is to listen carefully to the patient's statement of their problem and then go through the information supplied by the patient and verify it from an objective point of view.

Now go to the Course Index Page and try Module 3 Quiz 1 to see if you can apply what you have just learned.

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Module 3, Part 2

History of the Present Illness:

FILLING IN MISSING INFORMATION/fleshing out incomplete information

In the examples above, there is missing and incomplete information. This means that when information is "not stated," you need to obtain it. When some information is given by the patient and you need more, you need to expand on what you have (supplement).

How do you know what is missing and what needs to be augmented? The real answer is you're probably never absolutely sure. As you gain experience through practicing, it gets easier and you'll get surer. If every time you communicate with your patient you think "who, what, where, when and how," you at least have a place to start.

How do you obtain missing or supplemental information? Ask questions. No patient (perhaps with the exception of a dentist or other health professional) will ever supply you with all and just the right kind of information about their problem. Thus you will ask questions of nearly every patient.

How do you know what questions to ask? There's no simple answer to this question because asking questions to draw information from a patient is dependent on such variables as your sense of curiosity, scientific background, depth of knowledge, self confidence, ability to articulate what you know etc. From the patient's point of view, previous experience with dentists, fear of disclosing personal information, fear of things happening in the mouth, anticipation of pain all influence what information you get.

An easy way to start is to use the five interrogatories, "who, what, where, when and how." List what you know from the information your patient initially gives you then decide what you need to know.

• fill in missing information
• augment incomplete information

Be satisfied that you have explored each interrogatory to its fullest. Be thoughtful about which questions you ask. Don't ask random questions. Random questions confuse, promote incomplete answers and cause you to repeat questions. If you do forget whether or not you've asked a question, take the responsibility on yourself and say: "I may have asked you this before, but..." Questions can be grouped to cover a subject completely before moving on. You will become better the more you practice.

Example, Mr. Brown

"I've been a smoker for 25 years and never had a problem until I noticed this little dark spot here on the inside of my lip where I hold my cigarette."

WHO: seems satisfactory. We know Mr. Brown is talking about himself.

WHAT: "this little dark spot" is the information Mr. Brown gives you.

What is missing?

• Is the description Mr. Brown gives you adequate?
• Does it tell you all you need to know?
• What is "little" to you? To Mr. Brown? What is dark?
• Does Mr. Brown's description answer all the interogatories? If not, you have an array of tools to help you find out more information.

TOOLS

1. Physical examination - Look at the lesion and describe it in your record. Note all the details. Palpate it, probe it, measure it, compare it to other areas of the mouth. Look for similar or different lesions. Do a complete physical examination of the oral cavity.

2. History - You can take a history of the " dark spot." What has been the course of this disease has been for the patient.

3. Radiographs - When appropriate, radiographs can be helpful and in some cases indispensable. Radiographs are usually most effective with lesions in bone.

4. Tests - Laboratory tests on blood, saliva, aspirated fluid etc, biopsies of soft or hard tissue and cytological smears are useful.

WHERE: Mr. Brown states the "dark spot" is located on the inside of his lip.

• Is this location exact enough?
• Do you know which lip, upper, lower, right or left? Does the location change?
• Has he had lesions like this before? Do they appear in the same area?
• Do you know what he means when he says "never had a problem."

Why do you have to know these things? Risk factor data. that shows some lesions occur in one location more frequently than another. A lesion that comes back repeatedly is often different from one that does not, and one that comes back in different locations may be different still. This is information that tells you about the way lesions behave. The way a lesion behaves often reveals its nature. Benign, malignant, inflammatory, traumatic all describe the "nature" of a lesion.

WHEN: Mr. Brown doesn't tell you much about WHEN. He says he has been a smoker for 25 years, and he "never had a problem," otherwise there is no real time frame information. You have a lot of missing data here.

Length of time gives you insight into the growth pattern of the lesion. If a lesion grows slowly at first then speeds up its growth, you could say it changed its behavior and perhaps its nature. Always be aware of behavior that may indicate a change.

Another important piece of information is the circumstances of discovery. This is a WHEN question. What was the patient doing when he discovered it? Here you are looking for patterns of patient behavior. Is the patient a frequent observer of his mouth? Was the patient eating at the time of discovery? Was the circumstances of discovery related to the cause or appearance of the lesion?

You are a detective in this activity, investigating and questioning.

• Correlate and spot inconsistencies between pieces of information.
• Connect pieces of information together.
• Organize your information.
• Maintain a healthy level of skepticism.

HOW: Mr. Brown also failed to give us information on HOW his problem affected him.

You are concerned about two major areas, pain and loss of function. A simple "Is there any pain associated with this spot?" will get you started. For function questions you can ask about whether the spot interferes with eating or chewing food. Is the patient constantly probing the lesion with their tongue or teeth? Does the lesion cause loss of sleep or interfere with work? Ask directly if anything about the lesion worries the patient. Fear can either make a patient hold back or make them talkative.

WHO,WHAT, WHERE, WHEN and HOW are simple ways to find out what you know about the case (the facts) and what you don't know (missing information). Once you name what you know and what is missing, you can then decide if you need all the information you don't know. Once you decide what you must know, go and find it out.

You have reached the end of this module on analyzing the patient's problem. Using the standard terminology for investigating a patient problem, after you have found out all you need to know about WHO, WHAT, WHERE, WHEN and HOW, you have essentially covered the Chief Complaint and the History of the Present Illness.

Go to the course index page now and take Module 3 Quiz 2, so you can get on with Module 4.

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