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Clinical examination and history taking

M. Greenwood

Components of a medical history

There are various ways of taking a medical history. Most methods follow a scheme similar to the one described below. The history aims to:

• Enable the formulation of a differential diagnosis or diagnosis

• Put the patient’s disease process into the correct medical and social context

• Establish a rapport with the patient.

Any clinician obtaining a medical history should introduce themselves and give their designation. The taking of a history may then commence and should follow a scheme similar to that shown in Table 1.1.

Presenting complaint

The presenting complaint can be expressed in medical terms, but often is better expressed in the patient’s own words. When recording the history in writing, quotation marks should be placed around the patient’s words. In a verbal case presentation, it should be stated that the patient’s own words are being used. It is important to avoid a presumptive diagnosis in the presenting complaint. For example, patients do not present with iron deficiency anaemia, they may present with symptoms which arise from it. It should be remembered that symptoms are the features of the illness that the patient describes; signs are physical findings obtained by the clinician.

History of the presenting complaint

The history of the presenting complaint should be a chronological but succinct account of the patient’s problem. It is important to start at the onset of the problem and describe its progression. Symptoms should be similarly described.

Points to include when asking patients about pain are as follows:

• Site

• Character, e.g. tight/band-like (in the chest suggestive of cardiac origin)

• Does the pain radiate anywhere?

• Onset – sudden or gradual

• Severity (ask the patient to rate on a scale of 1–10, with 10 being the most severe)

• Duration

• Exacerbating/relieving factors (including the use and efficacy of medication)

• Preceding events or associated features

• Has the pain occurred before/is it getting better or worse?

Past medical history

It is worth asking a generic set of opening questions. For example, ‘Do you have any heart or chest problems?’ Questioning should then focus on specific disorders, e.g. asthma, diabetes, epilepsy, hypertension, hepatitis, jaundice or tuberculosis. It is also worth specifically asking about any previous problems with the arrest of haemorrhage. Past problems with intravenous sedation or general anaesthesia should be noted. It is still worth bearing in mind a previous history of rheumatic fever which may have led to cardiac valve damage. Since the NICE (National Institute for Health and Clinical Excellence) guidelines of 2008, the use of antibiotic prophylaxis in patients with valvular lesions has been discontinued. Severe damage, however, could rarely lead to valvular damage, producing clinically relevant cardiac dysfunction.

Table 1.1 Areas to be covered in a medical history

It is clearly important that positive findings are recorded. Some important negative findings are worth recording.

Allergies

Any known allergies should be recorded. This is one aspect of the medical history that should be recorded even if there are no known allergies. Any allergies that are identified should be highlighted in the clinical record.

Past dental history

In a general history, the dental history should be relatively brief. It can include details of the regularity or otherwise of dental attendance and the use of local anaesthesia or sedation. Any adverse events, including post-extraction haemorrhage, could also be included here.

Drugs

Any medication taken by the patient should be recorded. The use of recreational drugs can be included in this section or in the social history.

Social history

This should be a succinct but comprehensive assessment of the patient’s social circumstances. It should include the following details:

• Smoking behaviour

• Alcohol consumption – type and quantity

• Occupation (or previous occupation if retired)

• Home circumstances – a brief description of the residence, e.g. a house, flat or sheltered accommodation. Who else lives in the household?

Family history

Any disorders with a genetic origin should be recorded.

Psychiatric history

This will only need to be included in specific cases. More detail is given in Chapter 18.

In hospital practice, after the history comes the systems review. Specific questions are asked to refine the patient’s overall medical condition further. Many schemes are described. The following scheme has been adapted for the dental clinician.

General questions

As with the history, a series of general questions can help to encompass wide-ranging possibilities in terms of the underlying medical problem. Questions cover the following topics:

• Appetite

• Weight loss

• Fevers

• The presence of lumps or bumps

• Any rashes or itchy rashes

• Lethargy or fatigue.

Cardiovascular system

• Chest pain (a differential diagnosis is given in Chapter 19)

• Dyspnoea – difficult or disordered breathing (beware of co-existing/alternative respiratory causes)

• If dyspnoea on exertion, try and quantify in terms of metres walked or stairs climbed before dyspnoea occurs

• Paroxysmal nocturnal dyspnoea (waking up in the night feeling breathless – Chapter 5)

• Orthopnoea (breathlessness on lying flat – Chapter 5)

• Ankle oedema – beware of other possible causes of lower limb swelling

• Palpitations (an awareness of the beating of the heart)

• Calf claudication (distance walked until pain occurs in the ‘calf’ muscles of the leg is referred to as the claudication distance).

Respiratory system

• The presence of a cough and its duration

• Whether the cough is productive of sputum or not

• Haemoptysis (coughing up blood)

• Wheeze.

Gastrointestinal system

• Indigestion

• Nausea or vomiting

• Dysphagia (difficulty swallowing)

• Odynophagia (pain on swallowing)

• Haematemesis (vomiting of blood) described as looking like ‘coffee grounds’

• Change in bowel habit

• Change in bowel motion, e.g. pale stool and dark urine is pathognomonic of obstructive jaundice (Chapter 7)

• Melaena is a black stool containing blood altered by gastric acid. Fresh blood indicates bleeding from further down the gastrointestinal tract.

Neurological system

A brief overview is required, in particular:

• Any history of fits or faints

• Disturbance in sensation – particularly in the orofacial region

• Headache or facial pain.

Musculoskeletal system

• Gait (overlaps with neurological system)

• Pain/swelling/stiffness of joints

• Impairment of function.

Genitourinary system

This is usually of little relevance to the dental practitioner. Repeated urinary tract infections may be relevant in so far as the patient may be undergoing antibiotic treatment of which the dental practitioner should be aware. For the dental patient in a general hospital setting, enquiry is useful regarding symptoms of prostatism. Some patients who require significant surgical procedures may require catheterisation, and an enlarged prostate gland can lead to difficulties with catheter insertion. Hesitancy is the term which is used to describe difficulty in initiating the urine stream, and terminal dribbling is difficulty in stopping. Frequency of passing water and nocturia (passing urine at night) should all be included.

Clinical observations in the clothed patient

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