CHIEF COMPLAINT AND HISTORY OF THE PRESENT ILLNESS


The chief complaint is established by asking the patient to describe the problem for which he or she is seeking help or treatment. The chief complaint is recorded in the patient’sown words as much as possible and should not be documented in technical (ie, formal diagnostic) language unless reported in that fashion by the patient; this may give the dentist some insight into the patient’s “dental intelligence quotient.” Patients may or may not volunteer a detailed history of the problem for which they are seeking treatment, and additional information usually needs to be elicited by the examiner. The patient’s responses to these questions constitute the history of the present illness (HPI). A typical description of the chief complaint of a patient presenting for emergency dental care might be the following: This 32-year-old white male presents for emergency dental care, complaining that “I have been having pain in my lower left back tooth for the last 2 weeks, and it needs to be taken out.” Questioning during the HPI will center around the offending tooth in the mandibular left posterior sextant. The astute clinician will note that this patient may not realize that this particular tooth can be retained and can then inform the patient of appropriate treatment options once more historical and diagnostic data have been collected.

The HPI is the course of the patient’s chief complaint: when and how it began; what exacerbates and what ameliorates the complaint (when applicable); if and how the complaint has been treated, and what was the result of any such treatment; and what diagnostic tests have been performed. Direct and specific questions are used to elicit this information and should be recorded in the patient record in narrative form, as follows:
1. When did this problem start?
2. What did you notice first?
3. Did you have any problems or symptoms related to
this?
4. What makes the problem worse or better?
5. Have the symptoms gotten better or worse at any time?
6. Have any tests been performed to diagnose this com-
plaint?
7. Have you consulted other dentists, physicians, or any-
one else related to this problem? 8. What have you done to treat these symptoms?
In the example of the 32-year-old patient with pain in the mandibular left sextant described above, the HPI may be documented as follows:
The discomfort began acutely 2 weeks ago while the patient was chewing ice. This discomfort was first noted as a sharp pain and a cracking sound. The patient claims that a piece of his tooth came out. The patient complains of subsequent extreme sensitivity to hot and cold stimuli that does not linger once the stimulus is removed. The patient avoids this area of his mouth and does not have any pain unless the tooth is exposed to thermal stimuli. He is a patient of record in this practice and has been out of town, so he has not sought care elsewhere. When asked, he claims that he desires to have his tooth extracted because of the discomfort. When he was advised that it may be possible to completely relieve his discomfort and retain his tooth, he commented, “let me know what this will involve.”