How to Approach and Acquire a Comprehensive Patient Medical History
Dentistry is a profession established on a foundation of scientific knowledge through research with influences from individual doctors’ artistic abilities. Each of us has acquired our own unique style and methods to obtain information necessary to evaluate and treat patients. Perfecting this process is an art and, in many ways, modified as we practice and see our patients year after year. The premise of a question can affects the patients answer. It seems that at this time during a pandemic, the information we need before proceeding with routine questions is now directed toward the risk of transmission and infection by a potential patient visit.
The patient interview begins when they call for an appointment. Staff ask a short list of common medical conditions and medications they may take and that’s documented in the schedule appointment notes which are carried over to their chart upon conversion.
Interviewing a patient is a skill, necessitating behaving as a detective to gather information. A particular skill when perfected, draws on all senses. With this in mind there are instances when the presence of the next patient is evident without seeing them. Smells can permeate an area, particularly when foul or pungent, and are indicative of a severe odontogenic infection, very poor oral hygiene, a metabolic condition or alcohol consumption. Certainly, a characteristic that is noted in one’s chart and used in consideration for the cause of their problem.
Once the patient goes from the reception to the treatment area, it allows a view of their face, body habitus, their ability to ambulate or not, their mood when interacting with staff on their way to the panorex and then the operatory. The process of obtaining information doesn’t end with just the doctor, staff first review the patients completed medical history, record their vital signs and have the patient prep with an antibacterial rinse. At the same time build an atmosphere of comfort and trust to elicit the nature of their visit, and make them feel welcome. Dedicated staff are good at warming up patients and engaging in idle chit-chat to get their mind off of their current situation. After this, the dental assistant reports their findings to the doctor.
It’s not uncommon for patients to present with an elevated blood pressure, and if it remains too high, it necessitates medical consult to control the blood pressure before care is initiated. Patient’s anxiety can affect their mental status creating a negative physiologic response, elevating the blood pressure and or heart rate. It’s recommended to retake the blood pressure when it’s high, and then on the other extremity if it continues to remain elevated. Patients with a history of mastectomy or axillary lymph node removal are contraindicated for extremity blood pressure taking, and in these situations as a last resort use a thigh cuff on the leg. We know odontogenic pain can have a similar effect on one’s corporal response, causing a higher reading. Therefore, it’s necessary to have the ability to evaluate all the findings the patient presents with (i.e. mental status, chronic disease states, medications, social habits, blood pressure values, dental diagnosis) before deciding to proceed with treatment. In specific situations when it’s not contraindicated, nitrous oxide and oxygen analgesia and oxygen is used to relax the patient and to obtain a lower reading particularly in severely anxious patients or those in pain. It’s necessary to say that this is not a standard approach to obtain a lower blood pressure.
THE INTERVIEW
After introductions, the doctor can best view and speak with the patient face-to-face, visualizing their head and neck area. Simultaneously the dental assistant, intently listening ready to transcribe and chart the verbal findings the doctor dictates to the assistant:
SIGNS & SYMPTOMS
Skin color, symmetry of the face and, proportions of the head and neck, monitor facial expression and function of the facial and neck musculature, check color and movement of eyes and sclera, any signs of inflammation.
Of course, the information in a patient’s medical history is very private and personal, so reviewing this should be undertaken in a private setting, away from the ear shot of others.
HISTORY OF PRESENT ILLNESS
When asking about the patient’s history-of-present-illness, evoke:
1. Noting symptom factors:
2. Location
3. Severity of their symptoms
4. Duration
5. Exacerbating factors
6. Ameliorating factors that alleviate symptoms. A medication or remedy
7. Concomitant symptoms
A comprehensive Medical history is mandatory for all evaluations and treatment. Obtaining accurate information is of paramount importance because misinformation or missing information can have a deleterious effect on the process and the outcome. The primary tenet of the Hippocratic oath is “At first do no harm”. Our position as a dental surgeon is a powerful one, respecting our responsibilities to care for the sick and infirm is important.
Use a form that asks direct questions about organ system disease states followed with “yes” or “no” answers. Asking open ended questions on a form or using fill in the blank questions is inadequate as it allows that question to be skipped over. The electronic record is verified by noting appropriate positives and negatives that are documented on the daily progress note that’s created and has the patient’s current diagnoses, medications, etc. If the patient is a prior patient, the notes will carry all prior diagnoses and information.
Regardless of what is recorded the doctor begins the query of their history with a litany of questions. This gives the patient the opportunity to recall what’s in the past. It’s not uncommon for people to mark “no” to an answer in haste or because their memory or recollection is fuzzy. By asking them “Have you ever had or do you have” “heart, lung, liver, kidney diseases, diabetes, high blood pressure?”? “Do you take…..” asking specific situational questions pertaining to medications associated with their history. Additionally, when inquiring about allergies, note the type of allergic response. The type of reaction, hives vs difficulty breathing, is an indication to the potential degree of allergenicity and important information.
TEMPOROMANDIBULAR FUNCTION EXAM
An extraoral head and neck exam should include evaluating the temporomandibular joint. Noting its function, any sounds or noises from the area, preauricular symptoms, factitious habits of teeth grinding, jaw clenching or chewing gum. Evaluate their maximal incisal opening (MIO) and jaw excursions. We understand the importance of knowing that before initiating care because it can have an impact on our ability to treat them without modifications to treatment.
PALPATORY EXAM
Recognizing masses or pathology of the skin and mucosa over the head and neck region and the underlying tissues are an important part of our exam. Taking the same approach each time Noting:
Size
Consistency
Location
Shape
Tender/Painful with palpation
If the mass is fixed to the local tissues or movable
Thyroid size, symmetry
Evaluate head and neck range of motion
SOCIAL HISTORY
An individual’s current or past use of tobacco, alcohol, vaporizers, illicit drug use and sexual history are important to note. These questions are approached toward the end of your interview and due to the delicate nature of their topic, it’s best to wait until you have developed a trust between you and the patient. In many instances’ patients are reluctant to note it on a form but willing to disclose it to the dental assistant and sometimes the doctor.
EXAMINATION TECHNIQUES
CRANIAL NERVE EXAM
INTAORAL EXAM
Have available, gauze, dental mirror, Sheppard’s-hook explorer, periodontal probe and light for transillumination. The metal handle of a dental mirror is used to perform tactile fremitus. Transillumination is another means to determine the density and varying composition of tissues and to detect demineralization of enamel.
Further examination of the rest of the body is necessary particularly in patients that require parenteral anesthesia to complete their treatment. Inspect extremity mobility, their peripheral pulses and potential venous access. Determine adequate placement of pulse oximetry, blood pressure and temperature monitors.
DIFFERENTIAL DIAGNOSIS & TREATMENT PLAN
Once all the data is gathered, we wrap up the diagnostic process and create a plan of care.
The Girldoc 😉
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