Medical History

Obtaining an appropriate and accurate medical history is a critical first step for all patient care. It begins with a systematic review of the patient’s chief or primary complaint, a detailed history related to this complaint, information about past and present medical conditions, pertinent social and family histories, and a review of symptoms by organ system. A medical history also includes biographic and demographic data used to identify the patient.

There is no universally agreed method for obtaining a medical history, but a systematic approach will help the practitioner to gather all necessary information without overlooking important facts. The nature of the patient’s oral health visit (i.e., initial dental visit, complex diagnostic problem, emergency, elective continuous care, or recall) often dictates how the history is obtained. The two most common means of obtaining initial patient information are a patient self‐administered preprinted health questionnaire, or recording information during a systematic health interview without the benefit of having the patient fill out a questionnaire. The use of self‐administered screening questionnaires is the most common method in dental settings. This technique can be useful in gathering background medical information, but the accurate diagnosis of a specific oral complaint requires a history of the present illness and other verbal information. While the basic information for a past medical history may be obtained by a questionnaire, a vital part of the evaluation of a patient with a complex diagnostic problem is the history of the present illness, which is a combination of science and art and should be taken directly by the clinician.

The challenge in any healthcare setting is to use a questionnaire that has enough items to obtain the essential medical information, but is not too long to deter a patient’s willingness and ability to fill it out. These questionnaires should be constructed in a manner that allows the clinician to query the patient about the most essential and relevant required information, yet provides a starting point for a dialogue with the patient about other pertinent information not included on the health form. Preprinted self‐administered or online health questionnaires are readily available, standardized, and easy to administer and do not require significant “chair time.” They give the clinician a starting point for a dialogue to conduct more in‐depth medical queries, but are restricted to the questions chosen on the form and are therefore limited in scope. The questions on the form can be misunderstood by the patient, resulting in inaccurate information, and they require a specific level of reading comprehension. Preprinted forms cover broad areas without necessarily focusing on particular problems pertinent to an individual patient’s specific medical condition. Therefore, the use of these forms requires that the provider has sufficient background knowledge to understand the reasons for the questions on the forms. Furthermore, the provider needs to realize that a given standard history form necessitates timely and appropriate follow‐up questions, especially when positive responses have been elicited. An established routine for performing and recording the history and examination should be followed conscientiously.

The oral healthcare professional has a responsibility to obtain relevant medical and dental health information, yet the patient cannot always be relied upon to know this information or to provide an accurate and comprehensive assessment of their medical or dental status.

All medical information obtained and recorded in an oral healthcare setting is considered confidential and may in many jurisdictions constitute a legal document. Although it is appropriate for the patient to fill out a history form in the waiting room, any discussion of the patient’s responses must take place in a private setting. Furthermore, access to the written or electronic (if applicable) record must be limited to personnel who are directly responsible for the patient’s care. Any other release of private information should be approved, in writing, by the patient and that approval retained by the dentist as part of the patient’s medical record.

Given that medical status and medication regimens often change, a patient’s health status or medication regimen should be reviewed at each office visit prior to initiating dental care. The monitoring of patients’ compliance with suggested medical treatment guidelines and prescribed medications is part of the oral healthcare professional’s responsibilities. The following strategies are common to nearly all methods of history‐taking:

• Review available patient information prior to meeting the patient.
• Greet the patient; use the patient’s name; ensure privacy; sit rather than stand, preferably at eye level; maintain eye contact as often as possible; listen carefully to the patient’s concerns; do not rush the interview process.
• Do not concentrate chiefly on entering the information into an electronic health record, as this may distract you from listening to pertinent information.
• Use the patient’s own words (in quotation marks) to describe the primary reason(s) to seek care/consultation; i.e., be absolutely clear about the patient’s chief complaint(s).
• Use open‐ended questions to encourage open dialogue with the patient. Although all information should be collected in a systematic fashion, the order is not as important as is initiating a dialogue with the patient about their health.
• Create a timeline of the reported patient‐related events. An accurate chronology is an extremely important element to establish or deny a causative relationship.

The medical history traditionally consists of the following subcategories:

• Identification—name, date and time of the visit, date of birth, gender, ethnicity, occupation, contact information of a primary care provider (physician and, if applicable, dentist), referral source.
• Chief complaint (CC)—the main reason for the patient seeking care or consultation and the length of time these symptoms have been present, recorded in the patient’s own words.
• History of present illness (HPI)—taking an effective HPI takes experience and is often the key to making an accurate differential diagnosis. It includes a chronologic account of events; state of health before the presentation of the present problem; description of the first signs and symptoms and how they may have changed; description of occurrences of amelioration or exacerbation; previous clinicians consulted, prior treatment, and degree of the response to previous treatment. For those who favor mnemonics, the nine dimensions of a medical problem can be easily recalled using OLD CHARTS (Onset, Location/radiation, Duration, Character, Habits, Aggravating factors, Reliving factors, Timing, and Severity).⁷
• Review of systems (ROS)—identifies symptoms in different body systems (Table 1‐1). The ROS is a comprehensive and systematic review of subjective symptoms affecting different bodily systems. It is an essential component for identifying patients with a disease that may affect dental treatment or associated symptoms that will help determine the primary diagnosis. For example, a patient with skin, genital, or conjunctival lesions who also has oral mucosal disease, or a patient with anesthesia, paresthesia, or weakness who also presents with orofacial pain. The clinician records both negative and positive responses. Direct questioning of the patient should be aimed at collecting additional data to assess the severity of a patient’s medical conditions, monitor changes in medical conditions, and assist in confirming or ruling out those disease processes that may be associated with patient’s symptoms.
  

  General: Weight changes, malaise fatigue, night sweats

  Head: Headaches, tenderness, sinus problems

  Eyes: Changes in vision, photophobia, blurring, diplopia, spots, discharge

  Ears: Hearing changes, tinnitus, pain, discharge, vertigo

  Nose: Epistaxis, obstructions

  Throat: Hoarseness, soreness

  Respiratory: Chest pain, wheezing, dyspnea, cough, hemoptysis

  Cardiovascular: Chest pain, dyspnea, orthopnea (number of pillows needed to sleep comfortably), edema, claudication

  Dermatologic: Rashes, pruritus, lesions, skin cancer (epidermoid carcinoma, melanoma)

  Gastrointestinal: Changes in appetite, dysphagia, nausea, vomiting, hematemesis, indigestion, pain, diarrhea, constipation, melena, hematochezia, bloating, hemorrhoids, jaundice

  Genitourinary: Changes in urinary frequency or urgency, dysuria, hematuria, nocturia, incontinence, discharge, impotence

  Gynecologic: Menstrual changes (frequency, duration, flow, last menstrual period), dysmenorrhea, menopause

  Endocrine: Polyuria, polydipsia, polyphagia, temperature intolerance, pigmentations

  Musculoskeletal: Muscle and joint pain, deformities, joint swellings, spasms, changes in range of motion

  Hematologic: Easy bruising, epistaxis, spontaneous gingival bleeding, increased bleeding after trauma

  Lymphatic: Swollen or enlarged lymph nodes

  Neuropsychiatric: Syncope, seizures, weakness (unilateral and bilateral), changes in coordination, sensations, memory, mood, or sleep pattern, emotional disturbances, history of psychiatric therapy

• Past medical history (PMH) (may not have been revealed in systems review)—general health; immunizations; major adult illnesses; any surgical operations (date, reason, and outcome); medications (prescribed medications, over‐the‐counter medications, supplements) and home remedies; allergies.
• Personal and social history (SH)—birthplace; marital status; children; habits (tobacco use, alcohol use, recreational drug use); occupation; religion (if it may have an impact on therapy); sexual history if relevant to complaint.
• Family history (FH)—health or cause of death of parents, siblings, and children. The FH should also include diseases important to the patient’s chief compliant, including genetic disorders; and common diseases, such as cardiovascular diseases or diabetes mellitus.

Patient Examination

The examination of the patient represents the second stage of the evaluation and assessment process. An established routine for examination decreases the possibility of missing important findings (signs).

A routine head and neck examination should be carried out at least annually or at each recall visit. This includes a thorough inspection (and when appropriate palpation, auscultation, or percussion) of the exposed surface structures of the head, neck, and face and a detailed examination of the oral cavity, dentition, oropharynx, and adnexal structures. Laboratory studies and additional special examination of other organ systems may be required for the evaluation of patients with orofacial pain, oral mucosal disease, or signs and symptoms suggestive of otorhinologic or salivary gland disorders, or signs or symptoms suggestive of a systemic etiology. A less comprehensive but equally thorough inspection of the face and oral and oropharyngeal mucosa< ?span Start cssStyle="text-decoration:line-through"?>e should be carried out at each visit and the tendency to focus on only the tooth or jaw quadrant in question should be strongly resisted.

Each visit should be initiated by a deliberate inspection of the entire face and oral cavity prior to intraoral examination. The importance of this approach in the early detection of head and neck cancer cannot be overstated (see Chapter 7, Oral and Oropharyngeal Cancer).

Examination carried out in the dental office (surgery) is traditionally restricted to that of the superficial tissues of the oral cavity, head, and neck and the exposed parts of the extremities. On occasion, evaluation of an oral lesion logically leads to an inquiry about similar lesions on other skin or mucosal surfaces or about the enlargement of other regional groups of lymph nodes. Although these inquiries can usually be satisfied directly by questioning the patient, the oral health professional may also quite appropriately request permission from the patient to examine axillary nodes or other skin surfaces, provided that the examination is carried out competently and there is adequate privacy for the patient. A male oral health professional should have a female assistant present in the case of a female patient; a female oral health professional should have a male assistant present in the case of a male patient. Similar precautions should be followed when it is necessary for a patient to remove tight clothing for accurate measurement of blood pressure. A complete physical examination should not be attempted when facilities are lacking or when religious or other customs prohibit it, or when no chaperone is present.

The degree of responsibility accorded to the oral health professional in carrying out a complete physical examination varies among institutions, hospitals, states, and countries.

The examination procedure in a dental office setting may include any or all of the following six areas:

• Registration of vital signs (respiratory rate, temperature, pain level, pulse, and blood pressure).
• Examination of the head, neck, and oral cavity, including salivary glands, temporomandibular joints, and head and neck lymph nodes.
• Lesions of the oral mucosa should have a detailed description including location, size, color, ulceration and induration, and an assessment of the severity made. Detailed descriptions of specific diseases presenting as ulcers, blisters, or white or red lesions can be found in Chapters 3–7.
• Assessment of cranial nerves, particularly when the patient presents with nondental orofacial pain, weakness, anesthesia, or paresthesia.
• Examination of other organ systems, when appropriate.
• Ordering indicated laboratory studies.

Consultations

Responding to Consult Requests from Other Clinicians

There are three major categories of oral medicine consultations:

• Diagnosis and nonsurgical treatment of orofacial disorders, including oral mucosal disease, temporomandibular and myofascial dysfunction, chronic lesions involving the maxilla and the mandible, orofacial pain, dental anomalies, maxillary and mandibular bone lesions, salivary gland disorders, and disorders of oral sensation, such as dysgeusia, dysesthesia, and glossodynia.
• Dental treatment of patients with medical problems that affect the oral cavity or for whom modification of standard dental treatment is required to avoid adverse events.
• Opinion on the management of dental disease that does not respond to standard treatment, such as rampant dental caries or periodontal disease in which there is a likelihood of a systemic etiologic cofactor.

In response to a consultation request, the diagnostic procedures outlined in this chapter may be followed, with the referral problem listed as the chief complaint and with supplementary questioning (i.e., history of the present illness) directed to the exact nature, mode of development, prior diagnostic evaluation/treatment, and associated symptomatology of the primary complaint. An examination of the head, neck, and oral cavity is important and should be fully documented, and the ROS should include an exploration of any associated symptoms and including pertinent negatives. When pertinent, existing laboratory, radiographic, and medical records should be reviewed and documented in the consultation record, and any additional testing or specialized examinations should be ordered.

A comprehensive consultation always includes a written report of the consultant’s examination, usually preceded by a history of the problem under investigation and any items from the medical or dental history that may be relevant to the problem. A formal diagnostic summary follows, together with the consultant’s opinion on appropriate treatment and management of the issue. Other previously unrecognized abnormalities or significant health disorders should also be communicated to the referring clinician. When a biopsy or initial treatment is required before a definitive diagnosis is possible, and when the terms of the consultation request are not clear, a discussion of the initial findings with the referring clinician is appropriate before proceeding. Likewise, the consultant usually discusses the details of their report with the patient, unless the referring dentist specifies otherwise. In community practice, patients are sometimes referred for consultation by telephone or are simply directed to arrange an appointment with a consultant and acquaint them with the details of the problem at that time; a written report is still necessary to clearly identify the consultant’s recommendations, which otherwise may not be transmitted accurately by the patient. The details of an oral consultation must be documented on the patient’s chart.

An important responsibility for hospital‐based dentists is responding to consults from medical and surgical services. It is not at all uncommon for hospitalized patients to have routine maxillofacial problems (e.g., toothache) that have nothing to do with their reason for hospitalization. More commonly, patients may have a wide variety of problems that are directly related to their medical condition or its treatment (e.g., mucositis secondary to cancer chemotherapy) or require a dental exam to eliminate a possible source of infection during cancer chemotherapy.⁹

In hospital practice, the dental consultant is always advisory to the patient’s attending physician; the recommendations listed at the end of the consultation report are suggestions and not orders, and are not implemented unless authorized by the attending physician. For some oral lesions and mucosal abnormalities, a brief history and examination of the lesion will readily identify the problem, and only a short report is required; this accelerated procedure is referred to as a limited consultation (Box 1‐2).

Both custom and health insurance reimbursement systems recognize the need of individual practitioners to request the assistance of a colleague who may have more experience with the treatment of a particular clinical problem or who has received advanced training in a medical or dental specialty pertinent to the patient’s problem. However, this practice of specialist consultation is usually limited to defined problems, with the expectation that the patient will return to the referring primary care clinician once the nature of the problem has been identified (diagnostic consultation) and appropriate treatment has been prescribed or performed (consultation for diagnosis and treatment).