Dealing with information from the medical and dental history
Remember: in these modules we are building a framework you can use to deal with patient cases.
In the last module you learned how to elicit the chief complaint and the history of the present illness from the patient using the 5 interrogatories, WHO, WHAT, WHERE, WHEN AND HOW. The present illnessequals "chief complaint" or the patient's problem.
You must take a medical history on every patient. In the context of this course, the term MEDICAL HISTORYwill include present and past illnesses or diseases, medications, surgeries, allergies and other medical problems.
- Obtain a medical history from every new patient
- Update your medical history on every patient, every time you see them.
Every time means even if you see them 24 hours' later, you have to update the medical history. It is possible the patient became ill during that time, went to a physician and was prescribed a new medication. All kinds of things can happen in 24 hours. It can be as simple as asking: "Has anything changed in your medical history in the last 24 hours? New medicines? New illnesses? Have you thought of anything you didn't tell me before?" Of course if you haven't seen your patient in months or years, you are obligated to update your medical history in detail. The amount of detail and the forms vary, but the responsibility is yours.
DENTAL HISTORY is more flexible and may or may not be related to the specific problem.
- Obtain an initial dental history on your patient the first time you see them, especially if their presenting problem is dental.
- Update this history according to your needs and your specific type of practice. In the clinics at VCU School of Dentistry, specific forms for updating the medical and dental history are available.
You use the data from the medical and dental histories to find and make connections, if they exist, between that data and elements of the patient's "chief complaint" and "history of the present illness."
EXAMPLE: A patient, Mary Roberts, comes to you with a 6 month history of dry mouth and oral irritation..
Physical examination confirms the patient's complaint.
Medical history: She was diagnosed with bipolar disorder 9 months previously and is taking the medication Zoloft for this condition.
Making the connections:
From the History:
- Mary Roberts has a 6 month history of dry mouth.
- Nine months ago she was diagnosed as bipolar.
- She has been taking Zoloft for about 9 months.
- Medication reference says: Zoloft has the side effect of producing dry mouth in some patients.
Put the information together:
- The history of the problem coincides with the length of time taking the medication (giving a little extra time for the medication to cause the dry mouth).
- Your pathology book says: medications are one of the most common factors in cases of dry mouth.
BINGO! you have synthesized your diagnosis: medication-induced xerostomia.
This example illustrates quite simply what you do with data from medical and dental histories. You make connections.
Sometimes these connections are within the history itself:
- Your patient lists an antibiotic among the medications they are taking.
- You note they listed no illnesses for which they were being treated.
- You must ask the patient what they are taking the antibiotic for.
- Courteously refer to the inconsistency in the history in your review of history.
Your patient may be taking tetracycline for acne, and they may not have thought of acne as an illness. The patient may be taking penicillin for a sexually transmitted disease (STD) and may be initially embarrassed to mention the illness. Or, they may simply have forgotten to list the illness or may not have known where to list it. There are many scenarios, but the point is that you have to look carefully for inconsistencies in the history. Sometimes the inconsistencies are between the history and some information in the chief complaint or the history of the present illness, as in the above example.
There are hundreds of examples of connections you can to make while asking questions of your patient. You will not make them all perfectly the first time. This doesn't change your obligation. It serves to point out the need to be on guard, constantly looking for connections and relationships. Nothing reaches out of the page and makes the connection for you. The absolute minimum you start with is a thorough working knowledge of anatomy, physiology, pathology, microbiology, pharmacology and other basic sciences. Understand why you are asking the questions in histories. Know why diseases you ask about are important to the care of your patient. If you can't figure out why medical history elements are important, look them up in books or ask someone. Keep the patient's chief complaint in mind and keep on looking for connections between it and the histories and examinations you are conducting.
Take the quiz
You are now finished with Module 4. Go take the Quiz for Module 4 so you can go on to