The admission ticket

Why does the ‘chief complaint’ make me think about  pancakes and fig newtons? The chief complaint may just be an admission ticket.


Every parent and grandparent knows the phenomenon well.  On a recent vacation, my 16 month high-speed toddler granddaughter rocketed from the dining room to the deck with a partly eaten (and very sticky) pancake in her hand. Her shoe caught the lintel and she did a most impressive digger. The pancake went flying and she came up crying. Inconsolably, in fact.  Parents and grandparents (including me, the doctor) did a thorough inventory looking for injuries to explain the continued wailing. We found nothing. Offers of hugs, a band aid, a lap, a story and a swim did nothing. Finally, in response to my somewhat exasperated ‘You have to tell me what you want’ she pointed at the pancake on the floor. After it was retrieved, dusted off and delivered, she was fine.

I experienced this as a child, in a story my family has heard too often to count. As I rushed to visit Freddy in the apartment below us, carrying a box of my absolute favorite cookie, fig newtons, I tripped at the top of the steps. My mother heard her four year old somersaulting down a full flight of uncarpeted wooden stairs and then wailing at the bottom. As with my granddaughter, careful inspection showed no obvious cause for my distress until I explained: “I squished the fig newtons.”

This is important to remember when we see patients in our offices. Like the toddler with the non-injury, they come to us in real distress, but the cause may be no more obvious than the pancake or the fig newton. The chief complaint listed on the schedule should be considered the ticket for admission, not the reason for the visit. Like the toddler’s wailing, it serves to attract attention and emphasize the importance of the interaction. The ‘History of Presenting Illness’ (HPI) should be renamed the history of the primary issue, as the ‘presenting’ illness may be a fig newton of someone’s imagination.

Some examples from a recent week in my office:

  • ‘Back pain, ? kidney stone’ turned out to be fear that a rare childhood sarcoma had recurred. (It hadn’t.)
  • ‘Red spots’ turned about to be benign cherry angiomata that she had had (unchanged) for years, but had recently read that they could be a sign of liver disease. (Her liver was fine.)
  • ‘Can’t sleep’ turned out to be nocturnal urinary frequency and urgency related to prostatitis. (He did well with treatment.)
  • ‘Cough for 2 weeks’ was the presenting complaint of a woman whose husband was forgetting things and having episodes of confusion, with a strong family history of Alzheimer’s disease. (Testing was arranged.)

It is important not to prejudge the reason for the visit, or to assume that what the patient (standing in front of a spouse or sitting in the middle of their break room at work surrounded by co-workers) said on the phone is really what they want you to help them with. Ask them yourself.



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