Chapter 2

History Taking and Clinical Examination of Patients on a Dental Emergency Clinic

I.P. Corbett, C.B. Hayward and M. Greenwood

Introduction

This chapter outlines a system of history taking and examination of patients attending the dental emergency clinic (DEC) and issues related to consent.

History taking

This should include the following:

• Demographic data
• Presenting complaint (the presenting problem, ideally recorded in the patient’s own words)
• History of presenting complaint (a detailed history of the complaint and the symptoms associated with it recorded in a logical and chronological manner)
• Dental history
• Medical history (current and past)
• Social and family history

Obtaining information

The initial step in any patient contact is to confirm their identity. It is not unknown in a busy clinic to have two patients with the same surname, or indeed the same forename and surname. In addition, the clinician should introduce themselves and give their designation or grade, in order that the patient knows to whom they are talking. It is also good practice to introduce other people who may be present, which may help to lessen the patient’s anxiety.

It is important to establish that the advice being sought is for the patient and not for another person, friend or family member. It is also important to ensure that the person with the presenting problem is allowed to speak for themselves. In a multi-cultural society, this may require the use of interpreting services. Such services can be provided by an independent interpreter, a family member in the surgery, or by telephone, for example using ‘language lines’. There are possible problems with using a family member for this purpose; the interpretation may be inaccurate, or the family member may not interpret faithfully, in order to manipulate the treatment for reasons that may not be in the patient’s best interests. Where an interpreter has been used, this should be carefully documented.

Demographic data

Demographic data are necessary to identify the correct patient and corresponding clinical record. The minimum data required include the following:

• Title (Mr, Mrs, Ms, Miss, etc.)
• Name (both forename and surname)
• Marital status
• Date of birth
• Sex
• Occupation
• Current address and contact telephone numbers
• Name and contact details of the patient’s general medical/dental practitioner (GMP/GDP)

Many organisations may require further data such as ethnicity, religion, NHS number or insurance details. Most DECs will also generate a unique patient identification number in order to reference or cross-reference the patient’s attendances.

Data obtained must be recorded accurately and consistently to avoid the inadvertent duplication of records: an example might be ‘Mc’ used instead of ‘Mac’ in the case of McDonald or Macdonald.

Some conditions are correlated with age, sex, ethnicity or occupation, and demographic data may help to diagnose a presenting condition more easily, for example a heavy metal worker with dark blue staining at the gingival margins.

Factors to consider in history taking

History taking is a skill that requires practice. Patients respond in different ways to similar lines of questioning, and it may be necessary to modify questioning style or to ask the same question several times but in different ways in order to optimise the information obtained.

The medical and dental professions are often poor listeners and interject at the earliest opportunity. Although practitioners are all familiar with patients who present their ‘life story’ following the practitioner’s opening question, much important information may be lost by frequent interruptions or curtailing the patient’s answers. Other reasons for poor history giving by the patient may include fear or apprehension about treatment, anxiety around hospital-type situations, the so-called `white coat syndrome’. A perceived lack of confidentiality or an unwillingness to disclose information in front of a parent or other family member may prevent a patient from talking freely. Some patients may have a fear or embarrassment about their condition or what the clinician might say. The patient may misguidedly think that the requested information does not matter or is no business of the clinician. In such cases, the practitioner needs to be persistent in obtaining the information and reassure and explain to the patient why the information is being requested. The clinician may need to take the case history in a more private situation with only a member of staff present to chaperone.

Components of the history

Presenting complaint and history of presenting complaint

Patients attending a DEC often present complaining of pain. In order to reach a reliable differential diagnosis or diagnosis, it is important to obtain as far as possible a clear description of the pain. Where possible, use open questions and avoid prompting the patient; for example, ‘What does the pain feel like?’ is preferable to ‘Is the pain sharp or dull?’, which restricts and influences the patient response. Once a description of the pain has been obtained, more specific questions can then be used to develop the history further. Basic questions that should be asked are summarised in Box 2.1.

It is particularly worth asking the patient about the efficacy of analgesics or other treatments that they may have tried as this can sometimes give an indication about the severity of the problem, as highlighted in Box 2.1.

If patients have been subjected to an alleged assault or are injured in any other way, it is particularly important to record comprehensive details of the incident as these may become subject to a legal enquiry at a later stage. Important questions to ask in such situations are summarised in Box 2.2.

Past and current medical history

The past and current medical history is a description of previous and current medical issues. A systematic approach to data collection is required. The use of a medical history pro forma, often completed by the patient prior to the consultation, may assist in collecting information. However, it is important to go through the collected information carefully with the patient in order to identify any areas of confusion or omission. The medical history should be carefully recorded. Although it is generally only necessary to record positive findings, some practitioners record both negative and positive findings as an aide-memoire to history taking.

Relating the history to the systems of the body is a useful systematic method of questioning the patient on their health and for recording information (see Table 2.1).

Table 2.1 Example of a systemic approach to medical history taking.

It is important to place the patient’s medical issues into both medical and social contexts. Many patients and their families live with chronic medical and social conditions and are used to dealing with related problems. The degree of severity of a medical problem can be judged by asking further questions. For example, in patients with epilepsy, the frequency and severity of the problem should be ascertained using key questions such as: What medications do you take? What symptoms do you get prior to a seizure? When was your last seizure? Have you been treated in an accident and emergency unit or admitted to a hospital following a seizure? Are you looked after by your GMP or by a specialist? If the clinician has this information, a simple risk assessment can be made, and in the event of a seizure, emergency care is facilitated and a specialist’s help more easily obtained if required.

A thorough medical history may uncover conditions that are relevant to diagnosis of the presenting complaint, for example oral ulceration in a patient taking the potassium channel activator nicorandil, or to the subsequent management of the patient, such as alcoholic cirrhosis in a patient requiring extractions. Clearly, patients taking the anticoagulant warfarin require special consideration. This is highlighted in Appendix 3. It is important to remember that warfarin interacts with many of the drugs that dentists can prescribe, and if in doubt, the British National Formulary should be consulted.

Patients who have a high alcohol intake may also have problems with coagulation. In such cases, if surgical treatment is contemplated, blood should be taken for a full blood count (principally to check the platelet count) and a clotting screen.

Patient examination

The examination should start from the moment the patient walks into the surgery. Observation of any overt physical or possible psychological disease should be noted. This may manifest in the way a patient moves or walks, their demeanour or relationship with an accompanying family member or person.

The clinician should remember to examine both the normal and affected sides, and record findings, both positive and negative. Examination should be systematic; it is easy to be distracted by an obvious problem and miss a more subtle but possibly more important sign. A full primary examination should be completed before returning to the presenting complaint.

The examination is best divided into an extra-oral examination, followed by intra-oral examination.

Extra-oral examination

The extra-oral examination starts with a visual examination of the head and neck with particular note made of swellings or deformity, asymmetry of the face, abnormal colour or scars on the skin or lips. In cases of trauma or assault, all soft tissue lacerations, bruising and other related findings must be recorded in detail. A clinical photograph is a useful way of recording information; a diagram can also be made on either a pro forma or freehand sketch, paying particular attention to the abnormal area(s).

Where appropriate, a gross examination of the cranial nerves should be performed, particularly in cases of trauma and infection or if there are other manifest indications, for example in the case of a suspected malignancy.

Examination of cranial nerves