Relevant pages in other chapters It could, of course, be said that all pages are relevant to this section, because history and examination are the first steps in the care of any patient. However, as that is hardly helpful, the reader is referred specifically to the following: dental charting, p. 734; medical conditions, Chapter 11; the child with toothache, p. 60; pre-operative management of the dental patient, p. 538; the cranial nerves, p. 508; orthodontic assessment, p. 126; pulpal pain, p. 220.
Principal sources Experience.
Much of what you need to know about any individual patient can be obtained by watching them enter the surgery and sit in the chair, their body language during the interview, and a few well-chosen questions (Chapter 16). One of the great secrets of health care is to develop the ability to actually listen to what your patients tell you and to use that information. Doctors and dentists are often concerned that if they allow patients to speak rather than answer questions, history-taking will prove inefficient and prolonged. In fact, most patients will give the information necessary to make a provisional diagnosis, and further useful personal information, if allowed to speak uninterrupted. Most will lapse into silence after 2–3min of monologue. History-taking should be conducted with the patient sitting comfortably; this rarely equates with supine! In order to produce an all-round history it is, however, customary and frequently necessary to resort to directed questioning, here are a few hints:
Specifics of a medical or dental history are described on pp. 6 and 4. The object is to elicit sufficient information to make a provisional diagnosis for the patient whilst establishing a mutual rapport, thus facilitating further investigations and/or treatment.
The aim of this part of the history is to have a provisional differential diagnosis even before examining the patient. The following is a suggested outline, which would require modifying according to the circumstances:
C/O (complaining of) in the patient’s own words. Use a general introductory question, e.g. ‘Why did you come to see us today? What is the problem?’
‘What brought you here today?’ unless you want to give them the chance to make a joke about transport or car parking.
If symptoms are present:
Onset and pattern
When did the problem start? Is it getting better, worse or staying the same?
How often, how long does it last? Does it occur at any particular time of day or night.
Exacerbating and relieving factors
What makes it better, what makes it worse? What started it?
If pain is the main symptom:
Origin and radiation
Where is the pain and does it spread?
Character and intensity
How would you describe the pain: sharp, shooting, dull, aching, etc. This can be difficult, but patients with specific ‘organic’ pain will often understand exactly what you mean whereas patients with symptoms with a high behavioural overlay will be vague and prevaricate.
Is there anything, in your own mind, which you associate with the problem?
The majority of dental problems can quickly be narrowed down using a simple series of questions such as these to create a provisional diagnosis and judge the urgency of the problem.
It is important to assess the patient’s dental awareness and the likelihood of raising it. A dental history may also provide invaluable clues as to the nature of the presenting complaint and should not be ignored. This can be achieved by some simple general questions:
There is much to be said for asking patients to complete a medical history questionnaire, as this encourages more accurate responses to sensitive questions. However, it is important to use this as a starting point, and clarify the answers with the patient.
Example of a medical questionnaire
Are you fit and well?
Have you ever been admitted to hospital?
If yes, please give brief details:
Have you ever had an operation?
If so, were there any problems?
Have you ever had any heart trouble or high blood pressure?
Have you ever had any chest trouble?
Have you ever had any problems with bleeding?
Have you ever had asthma, eczema, hayfever?
Are you allergic to penicillin?
Are you allergic to any other drug or substance?
Have you ever had:
Are you pregnant?
Are you taking any drugs, medications, or pills?
If yes, please give details: (see Chapter 12)
Who is your General Medical Practitioner (GMP)?
Check the medical history at each recall.
If in any doubt contact the patient’s GMP, or the specialist they areattending, before proceeding.
NB A complete medical history (as required when clerking in-patients) would include details of the patient’s family history (for familial disease) and social history (for factors associated with disease, e.g. smoking, drinking, and for home support on discharge). It would be completed by a systematic enquiry:
chest pain, palpitations, breathlessness.
breathlessness, wheeze, cough—productive or not.
appetite and eating, pain, distension, and bowel habit.
pain, frequency (day and night), incontinence, straining, or dribbling.
Central nervous system
fits, faints, and headaches.
Screening for medical problems in dental practice
Certain conditions are so commonplace and of such significance that screening (specifically looking for asymptomatic markers of disease) is justifiable. Whether or not it is appropriate to use the dental practice environment to screen for hypertension, smoking or drug and alcohol abuse is very much a cultural, personal and pragmatic decision for the dentist.
What is crucial is that if you choose to initiate say a screening policy for hypertension in practice (i.e. you measure every adult’s blood pressure) you must ensure you are adequately trained in the technique, are aware of and avoid the risk of inducing disease (people get anxious at the dentist and may have ‘white coat hypertension’ which is of no significance) and act on significant results in a meaningful way. Generating a cohort of ‘worried well’ who then overload their GMP is hardly helpful whereas detecting significant hypertension in an unsuspecting middle age man who then has this corrected, could be.
For the vast majority of dental patients attending as out-patients to a practice, community centre, or hospital, simply recording a medical history should suffice to screen for any potential problems. The exceptions are patients who are to undergo general anaesthesia and anyone with a positive medical history undergoing extensive treatment under LA or sedation. The aim in these cases is to detect any gross abnormality so that it can be dealt with (by investigation, by getting a more experienced or specialist opinion, or by simple treatment if you are completely familiar with the problem). This is a summary, for more detail see ‘In-patients’ Chapter 11.
Look at sclera in good light for jaundice & anaemia. Cyanosis, peripheral: blue extremities, central: blue tongue. Dehydration, lift skin between thumb and forefinger.
Feel and time the pulse. Measure blood pressure. Listen to the heart sounds along the left sternal edge and the apex (normally 5th intercostal space midclavicular line on the left), murmurs are whooshing sounds between the ‘lup dub’ of the normal heart sounds. Palpate peripheral pulses and look at the neck for a prominent jugular venous pulse (this is difficult and takes much practice).
Look at the respiratory rate (12–18/min), is expansion equal on both sides? Listen to the chest, is air entry equal on both sides, are there any crackles or wheezes indicating infection, fluid, or asthma? Percuss the back, comparing resonance.
With the patient lying supine and relaxed with hands by their sides, palpate with the edge of the hand for liver (upper right quadrant) and spleen (upper left quadrant). These should be just palpable on inspiration. Also palpate bimanually for both kidneys in the right and left flanks (healthy kidneys are not palpable) and note any masses, scars, or hernia. Listen for bowel sounds and palpate for a full bladder.
Mostly covered by abdominal examination above. Patients with genitourinary symptoms are more likely to go into post-operative urinary retention. Pelvic and rectal examinations are neither appropriate nor indicated and should not be conducted by the non-medically qualified.
Central nervous system
Is the patient alert and orientated in time, place, and person? Examination of the cranial nerves, p. 508. Ask the patient to move their limbs through a range of movements, then repeat passively and against resistance to assess tone, power, and mobility. Reflexes: brachioradialis, biceps, triceps, knee, ankle, and plantar are commonly elicited (stimulation of the sole normally causes plantar flexion of the great toe).
Note limitations in movement and arthritis, especially affecting the cervical spine, which may need to be hyperextended in order to intubate for anaesthesia.