1: Routine History-Taking and Physical Examination

1

Routine History-Taking and Physical Examination

GENERAL OVERVIEW

Patient Interview Introduction

The primary job of the dental student starting clinical work is to learn to conduct a patient workup thoroughly and efficiently. The heart of every patient workup is a set pattern done in a sequential order of data collection and analysis.

Patient Workup Sequential Pattern

The sequential pattern of patient workup consists of the following:

1. History and physical examination.
2. Laboratory data collection and analysis.
3. Diagnostic and therapeutic plan formulation.

The first step, the patient interview, or the history, is probably the single most important task in the diagnostic patient workup because of its importance in diagnosis and in the development of a good doctor-patient relationship. The provider should demonstrate a professional manner that will put the patient at ease. During the interview, always listen carefully to the patient. Use interrogation sparingly, or use it later to aid a communicating patient, or to restrict the rare patient who has a tendency to ramble!

Patient Interview Practical Points

Keep your appearance neat and clean. This will help gain your patient’s trust. Always introduce yourself when meeting a patient and refer to the patient as “Mr. John Doe” or “Miss Jane Doe.” Do not use first names during the initial encounter. Exchange a few brief pleasantries because moving forward, this will help both you and the patient feel comfortable and at ease with one another.

Always have a friendly and sincere interest in your patient’s problem(s). Always be courteous, respectful, and confidential and show a continued interest while you are with the patient.

Physical Examination Practical Points

Prior to the start of the physical examination let the patient know that you are going to take the pulse and blood pressure and examine the head and neck area. This heads-up will enable the patient to understand that you will be touching him or her. Your attentive and respectful ways will enhance a good doctor-patient relationship.

The physical examination is an art that is learned by constant repetition. There are many styles and methods for conducting the general examination, and every clinician will ultimately choose one examination sequence to go by. Most clinicians, however, prefer the head-to-foot order. When examining any area of the body, it is usually best to follow an orderly sequence of inspection, palpation, percussion, and auscultation. This sequential routine ensures thoroughness.

The physical examination should always be conducted and assessed in the context of the patient’s dental and medical history. The range of “normal” varies from patient to patient.

The student needs to become familiar with the use of the stethoscope and the blood pressure cuff. Fumbling with your equipment or the technique during patient examination will cause you embarrassment. The student also needs to practice the head-and-neck exam techniques often on friends or family members to get a good sense of the normal.

History-Taking and Physical Examination: Broad Conclusions

After the history and physical examination is completed, you should, in most cases, be able to answer the following questions:

  • The disease states that exist in the patient and whether the patient’s problems are acute or chronic.
  • The organ systems that may be involved.
  • The differential diagnosis of the patient’s problems.
  • The laboratory tests that will be needed for the evaluation of the disease states.
  • Confirmation or exclusion of a diagnosis and/or whether to follow the course of a disease state.

HISTORY-TAKING DETAILS

The purpose of medical history and physical examination is to collect information from the patient, to examine the patient, and to understand the patient’s problems. Traditional history-taking has several parts, each with a specific purpose. In order to achieve maximum success, the medical history must be accurate, concise, and systematic.

The following is a standard outline in sequential order of the different components of history-taking. The introductory materials in the health history consist of collecting several types of information from the patient.

Data Collection

The following information is obtained in all patients to gain a basic understanding of the patient:

Date of the visit: Record number:
Name:
(last) (first) (middle)
Home address: Home phone:
Business address: Business phone: Cell phone:
Occupation: Date of birth:
Sex: M/F/Transgender/Other
Marital status: S/M/D/W/Partnership
Height:
Weight:
Referred by:

Chief Complaint

The chief complaint states in the patient’s own words the reason for the visit, for example, “I have a toothache” or “I need a root canal.”

Present History

Present history lists, in clear, chronological order, the details of the problem or problems for which the patient is seeking care. You will determine by interrogation a timeline of the following:

1. When did the patient’s problem(s) begin?
2. Where did the problem(s) begin?
3. What kinds of symptoms did the patient experience?
4. Has the patient had any treatment for the problem(s)?
5. Has the treatment had any positive or negative effect on the patient’s condition?
6. Has the patient’s lifestyle been affected by the problem(s)?

Past History

The past history gives you an insight about the health status of the patient until now. Check with the patient for the presence or absence of diseases by eliciting the symptoms and signs associated with the disease states. It is best to access the disease states with the patient in alphabetical order to ensure you address each disease state and do not miss anything. Use interrogation to check for the following disease states:

Anemia

Determine the presence or absence of the nutritional, congenital, and acquired or chronic disease-associated anemias.

Bleeding Disorders

Determine the presence or absence of the congenital and acquired types of bleeding disorders.

Cardiorespiratory Disorders

Determine whether the patient has a history of angina, myocardial infarction, transient ischemic attacks (TIAs), cerebrovascular attacks (CVAs/strokes), hypertension, rheumatic heart disease, asthma, tuberculosis, bronchitis, sinusitis, and chronic obstructive pulmonary disease (COPD).

Drugs/Medications

Determine the patient’s current medications. Check for prescribed, herbal, and over-the-counter (OTC) medications. Determine whether the patient is currently on corticosteroids or has been on them, by mouth or by injection, for two weeks or longer within the past two years. Check if the patient has known allergies to any drugs, such as NSAIDS, aspirin, codeine, morphine, penicillin, sulpha antimicrobials, bisulfites, metabisulfites, or local anesthetics.

Endocrine Disorders

Check for diabetes, hyperthyroidism, hypothyroidism, parathyroid disorders, and pituitary and adrenal disorders (Addison’s disease or Cushing’s syndrome).

Fits or Faints

Check for the presence of different kinds of seizures: grand mal epilepsy, petit mal epilepsy, temporal lobe or psychomotor epilepsy, or localized motor seizures.

Gastrointestinal Disorders

Check for oral ulcerations, esophagitis, gastritis, peptic ulcerations, Crohn’s disease, celiac disease, ulcerative colitis, diverticulitis, polyps, and hemorrhoids.

Hospital Admissions

Determine the cause or causes for admission and also check if the patient had any history of accidents or injuries. Determine whether the patient was given any anesthesia, either local or general, during the hospital admission. Furthermore, determine whether there were any complications during the hospital admission due to the anesthesia or due to the medical/surgical condition for which the patient was admitted. Determine whether the patient was given a blood transfusion during hospitalization.

Immunological Diseases

Check for lupus, Sjögrens syndrome, rheumatoid arthritis, and polyarthritis nodosa.

Infectious Diseases

Check for infectious diseases of childhood: measles, mumps, chicken pox, streptococcus pharyngitis, rheumatic fever, or scarlet fever. Also check for infectious diseases of adulthood: sexually transmitted diseases (STDs), hepatitis, HIV infection, Methicillin-Resistant Staphylococcus Aureus (MRSA) infection, and infectious mononucleosis.

Jaundice or Liver Disease

If the patient is jaundiced or has had jaundice, determine the cause. Is it due to viral hepatitis, alcoholic hepatitis, or gallstones? Determine whether there is any history of gallbladder dysfunction. Check whether there is any indication of improper liver function.

Kidney Disorders

Determine whether there is any indication of kidney dysfunction, renal stones, urinary tract infections, renal disease, renal failure, or renal transplant.

Likelihood of Pregnancy

Determine the date of the patient’s last menstrual period (LMP) and whether the patient is pregnant. Always let the patient know that prior to dental radiographs, you need to know if the patient is pregnant. You need to also know the pregnancy status, as there are certain anesthetics, analgesics, and antibiotics that are contraindicated during pregnancy.

Musculoskeletal Disorders

Check for osteoporosis and other causes of impaired bone metabolism, Paget’s disease, osteoarthritis, rheumatoid arthritis, psoriatic arthritis, gout, muscular dystrophy, polymyositis, and myasthenia gravis.

Neurological Disorders

Check for cranial nerve disorders, headaches, facial pains, migraine, multiple sclerosis, motor neuron disease, transient ischemic attacks (TIAs), or cerebrovascular accidents (CVAs) associated neurological deficits, Parkinson’s disease, and peripheral neuropathies.

Obstetric and Gynecological Disorders

Check for conditions or diseases that can lead to spontaneous abortions, miscarriages, bleeding, or anemia. Also check for any tumors needing chemotherapy or radiotherapy.

Psychiatric Disease

Check for personality disorders, neuroses, anxiety, phobias, hysteria, psychoses, schizo- phrenia, dementia, Alzheimer’s disease, and posttraumatic stress disorder (PTSD).

Radiation Therapy

Check for any radiation to the head and neck region and the RADS or Gy of radiation received.

Skin Disorders

Lichen planus, phemphigus, herpes simplex, herpes zoster, eczema, unhealed skin lesions, and urticaria (itching of the skin) are conditions that should be checked for.

Tetanus

Determine the patient’s immunization status for tetanus, hepatitis, influenza, and pneumonia.

Violence

Check for domestic violence, intimate partner violence (IPV), and elder or child abuse.

Wounds

Determine the patient’s wound-healing capacity.

Personal History

In this part of the history, we try to get an insight into the patient’s lifestyle, occupation, and habits. In the lifestyle component, an attempt is made to understand what constitutes a typical day for the patient. What does the patient do for recreation, relaxation, and so on? What is the patient’s job like? Are there any job-related toxic exposures? Is there any history of alcohol, coffee, or tea intake? How much of these does the patient consume? Is there any history of diarrhea or vomiting?

Is there any history of smoking cigarettes or using “recreational” drugs such as marijuana, cocaine, or amphetamines? Has the patient ever used intravenous (IV) drugs or swapped needles? Has the patient been exposed to any infectious diseases or sexually transmitted diseases (STDs)? Does the patient use any herbal medications or over-the-counter medications?

Does the patient use diet pills, birth control pills, laxatives, analgesics (aspirin, acetaminophen, NSAIDS, and other pain medications), or cough/cold medications?

Family History

Once the patient’s medical history has been completed, it is important to assess the health status of the immediate family members. Determine whether certain common diseases run in the family or if a familial disease pattern exists. Determine the age and health of the patient’s parents, siblings, and children. If any member is deceased, the cause of death and age at death should always be established.

Presence of diseases with a strong hereditary component or tendency for familial clustering should be determined. These diseases are coronary artery disease (CAD), heart disease, diabetes mellitus (DM), hypertension (Htn), stroke (CVA), asthma, allergies, arthritis, anemia, cancer, kidney disease, or psychiatric illness.

Review of Systems: Overview and Components

Review of systems (ROS) is a final methodical inquiry prior to physical examination. All organ systems not discussed during the interview are systematically reviewed here. It provides a thorough search for further, as yet unestablished, disease processes in the patient. If the patient has failed to mention certain symptoms, the process of ROS helps remind the patient. Also, if you have unknowingly omitted questioning the patient about certain aspects of his or her health, now is the time to include these aspects.

Review of Systems: Assessment Components

Constitutional

Determine whether there is any history of recent weight change, anorexia (loss of appetite), weakness, fatigue, fever, chills, insomnia, irritability, or night sweats.

Skin

Is there any history of allergic skin rashes, itching of the skin, unhealed lesions (probably due to diabetes, poor diet, steroids, HIV/AIDS, an so on)? Is the rash acute or chronic? Is the rash unilateral or bilateral? Does the patient have any history of bruising or bleeding?

Head

Is there any history of headaches or loss of consciousness (LOC)? LOC may be due to cardiovascular, neurologic, or metabolic causes; or it may be due to anxiety.

Is there any history of seizures? Are the seizures generalized (with or without loss of consciousness) or focal? Are there any motor movements? Is there any history of head injury?

Eyes

Check for acuity of vision, history of glaucoma (can cause eye pain), redness, irritation, halos (seeing a white ring around a light source), or blurred vision. Is there any irritation of the eyes or excessive tearing? These symptoms could also be allergy-associated.

Ears

Check for recent changes in hearing, ear pain, discharge, vertigo (dizziness), or ringing in the ears (tinnitus).

Lymph Glands

Check for lymph glandular enlargement in the neck or elsewhere. Are the nodes tender or painless, or are they hot or cold to touch? When did the patient first notice any changes in the nodes? Are the nodes freely mobile, or are they anchored to the underlying tissues?

Respiratory System

Ask if there is any history of frequent sinus infection, postnasal drip, nosebleed, sore throat, or shortness of breath (SOB) on exertion, or at rest. SOB can be due to respiratory, cardiac, or metabolic diseases.

Check for wheezing (may be due to asthma, allergies, and so on) and hemoptysis or blood in the sputum (may be due to dental causes or due to lung causes such as bronchitis or tuberculosis). Check if the cough with expectoration is blood-tinged or is there frank blood in the sputum. Is there any history of bronchitis, asthma, pneumonia, or emphysema?

Cardiovascular System

Is there any history of chest pain or />

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Jan 4, 2015 | Posted by in General Dentistry | Comments Off on 1: Routine History-Taking and Physical Examination
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