Common medical history questions

physical medicine it is common, after initial open questions about the patients general
health, to
ask questions in relation to each body system in turn:cardiovascular, respiratory, CNS,
gastrointestinal tract(including the liver), genitourinary tract (including the kidneys), etc. It is
essential also to ask specific
questions about drug therapy, allergies and abnormal bleeding.
Another possible scheme is:
Anaemia
Bleeding disorders
Cardiorespiratory disorders
Drug treatment and allergies
Endocrine disease
Fits and faints
Gastrointestinal disorders
Hospital admissions and attendance
Features of pain worth noting in the history
Character
Severity
Site
Radiation

(spread)

Onset
Duration
Periodicity
Aggravating

factors
factors
Associated phenomena
Relieving

Extraoral examination
The general appearance of the patient should be considered. Do they look ill or well; are
they anxious?
Look for obvious upper respiratory tract infection. Note the skin complexion and mucosal
colour for
signs of anaemia or jaundice. Assess the body in general and the head and neck for signs of
deformity
or asymmetry. In trauma cases look carefully for lacerations and abrasions.
Look systematically at, or for:
lymph nodes: these should be palpated for
enlargement or change in texture
trismus: defined as limitation of mouth
opening of musculoskeletal origin, trismus
can be partial or complete. Normal mouth
opening is at least 40 mm
rima oris (oral entrance): a small mouth
opening can make surgery difficult.
Limitation could be due to scarring or the
patient may naturally have a small mouth
swellings or deformity.

Intraoral examination

The size of the oral cavity and the distensibility of the soft tissues should be noted. The soft
tissues should then be examined in sequence, and this sequence should always be used by
that clinician, so no area is omitted
buccal sulci (upper and lower)
fl oor of the mouth
tongue (dorsal and ventral surfaces)
palate (hard and soft)
oropharynx
gingivae.
Next, the teeth may be examined and charted using a conventional system to identify the
number present
and their distribution; noting dentures, crowns, bridges, implants, partial eruption of teeth
and coronal disease.The periodontal condition should be noted. The surgical or problem area
should now be examined.Redness or swelling or infl ammation should be
noted, as should any discharge of pus. Look specifically for ulceration, erosion or keratosis of
mucosal
surfaces and for any lumps or deformity.Consider which teeth may be involved in the
disease
process and whether any are in abnormal position

Features worth noting during history and examination

of a lump or swelling
Duration
Change in size
Any possible cause
Exact anatomical site
Associated lymph nodes
Single or multiple
Shape
Size
Colour
Definition of periphery
Consistency
Warmth
Tenderness
Attachment to skin
Attachment to deeper structures
Fluctuance
Infl ammation
Pulsation
General

well-being of the patient

Features worth noting on examination of an ulcer

Anatomical location
Single or multiple
Size
Shape
Base
Edge
Adjacent tissues
Discharge
Is it painful?

General condition of the patient

FURTHER INVESTIGATION

radiography and other imaging

vitality tests
haematological investigations
microbial culture
temperature, pulse, respiratory rate, blood
pressure, weight
urinalysis
biopsyincisional or excisional.
For a patient to give consent to a procedure, they must
know:
The implication of not having treatment
What treatments are available
All possible serious adverse effects of each treatment
The more likely but less serious effects
To give informed consent, a patient must be:
Over 16 years of age
Mentally competent to understand and judge the
implications of the decision
Allowed to make the decision, without pressure
of time and away from the environment in which
treatment will be performed
Surgical sieve
A surgical sieve is an aide-mmoire which crossreferences
disease processes and tissues involved.
Disease processes may be listed as:
traumatic (physical, chemical, thermal,
irradiation)
infl ammatory
infective (bacterial, viral, fungal and possibly
protozoal)
immunological
neoplastic
benign
malignant
congenital and developmental
degenerative
nutritional
metabolic
idiopathic (of unknown cause).
Some lists will also include vascular (e.g. stroke),

haematological (e.g. anaemias) or cystic (particularly

in relation to the jaws), all of which tend to cut across
the other categories. However, as this is only an aid
to memory, you may include whatever categories
you find helpful.
The anatomical classification might include:
surface or glandular epithelium
connective tissue
muscle
nerves
vessels
lymphatics
joints
bone
tooth (enamel, dentine, pulp, cementum,
periodontal ligament, structures from tooth
development).