History Taking and Clinical Examination

• Diagnosis entails acquisition of data about the patient and their complaint using the senses:

  • Hearing - history taking
  • Observing - appearance, behaviour
  • Touching - induration, temperature
  • Smelling - malodour

  The purpose of making a diagnosis is to be able to offer the most effective and safe treatment and accurate prognostication.
• Chief complaint and history of presenting illness - procurement of this info is approached in one of two ways:

  1. A patient-generated history may be completed prior to the visit. Then, during the appointment the clinician reviews the history and enters additional notions that are gleaned during the patient interview
  2. The doctor generates the history by direct interview, making appropriate notions throughout the one-on-one discourse
• Symptoms = subjective musings on the part of the patient. Pain, discomfort, burning, numbness, roughness, and swelling are all examples of symptoms. These are usually the first aspects of the history to be recorded.
• Signs = objective findings discovered by the examining clinician. The pulse, blood pressure, a mass, ulcer, erosion, white lesion, blister, pigmentation, and red lesion are all examples of signs. Signs are usually observed in the physical examination segment of the database. Signs of disease are detected by observation, listening (auscultation), smell and palpation of tissues.
• Medical history:

  • Usual childhood infections (such as mumps, measles, rubella, varicella, etc, are noted with verification of vaccinations, both in childhood and later, in adult years)
  • A record of hospitalisations is recorded, obtaining info on the nature of the stay & any surgical procedures the pt has undergone
  • Pt's drug history both current & past, noting adverse/allergic reactions. Each drug should be listed along with dosage and daily intake.
  • Dental history
  • Habits (tobacco products; alcohol; tooth grinding/ clenching)
• Extra-oral examination - the face:

  • Pallor (mainly in the conjunctivae) indicating haematologic disorders
  • Rash (ie malar rash in SLE [systemic lupus erythematosus])
  • Erythema
• Extra-oral examination - the eyes:

  • Exophthalmos (prominent eyes) seen in hyperthyroidism
  • Jaundice (yellow sclerae), seen in liver disease
  • Redness, seen in trauma or Sjogren syndrome or other inflammatory disorders
  • Scarring, seen in trauma, infection and pemphigoid
• Extra-oral examination - the neck:

  • Inspection of the neck, looking for swellings or sinuses, is best made by observing the patient from the front, noting any obvious asymmetry or swelling
  • Afterwards, palpate carefully all cervical lymph nodes and salivary glands and thyroid glands searching for swelling or tenderness
  • Stand behind or to the side of the patient for all nodes except for supraclavicular nodes
  • The neck should be flexed for examination of all the lymph nodes
  • Parotid, mastoid and occipital lymph nodes can be palpated simultaneously using both hands
• Extra-oral examination - the lymph nodes:

  • Submental lymph nodes are examined by tipping the pt's head forwards & rolling the nodes against inner aspect of the mandible
  • Submandibular lymph nodes are examined with pt's head tipped to the side which is being examined
  • Superficial cervical lymph nodes are examined with light fingers; they can only be compressed against the softer sternocleidomastoid muscle
  • To palpate the deep cervical lymph nodes have the pt tilt their head forward & towards the side you're examining
  • The supraclavicular nodes are palpated at the same time with the neck flexed
• Extra-oral examination - salivary glands:

  • The major salivary glands (parotids & submandibulars) should be inspected & palpated for symmetry, evidence of enlargement & salivary flow from the salivary ducts
  • Milking the glands will give a crude estimation of salivary flow & can be determined whether an obstruction is present
  • Parotid glands are palpated by fingers placed over the glands in front of the ears
  • The parotid duct (Stensen's duct) open at the papilla on the buccal mucosa opposite the upper molars
• Extra-oral examination - salivary glands:

  • Submandibular glands are palpated bimanually between fingers inside the mouth and extra-orally. The finger of one hand is placed in the floor of the mouth lingual to the lower molar teeth and one finger of the other hand is placed over the submandibular triangle.
  • The submandibular duct (Wharton's duct) opens in the floor of the mouth at the side of the lingual frenum
• Extra-oral examination - TMJ:

  • Facial symmetry (masseteric hypertrophy)
  • Mandibular opening and closing paths (noises and/or deviations)
  • Mandibular opening extent (measuring the inter-incisal distance at maximum mouth opening)
  • Lateral excursions
  • Joint noises (using a stethoscope)
  • Palpation of the condyles (to detect pain, abnormal movement or clicking)
  • Palpation of the masticatory muscles (noting tenderness or hypertrophy)
  • Dentition and occlusion
  • Mucosal examination (occlusal lines and/or scalloping of the tongue margins)
• Extra-oral examination - cranial nerves (V and VII):

  • Facial movement should be tested and facial sensation determined
  • The facial cranial nerve function is evaluated by having the patient generate various facial expressions
  • Wrinkling the forehead
  • Raising the eyebrows
  • Smiling
  • Pursing the lips (whistle)
  • Closing the eyes
• Extra-oral examination - cranial nerves (V and VII):

  • The trigeminal motor branches innervate the masticatory muscles, thus any weakness on opening the jaw or muscle wasting or reduction in motor power should be considered
  • Corneal reflex: gently touching the cornea with cotton wool should cause a blink but if not there is a facial palsy or ophthalmic division lesion
  • Taste sensation
• Oral examination:

  • Examination of the oral cavity involves visual inspection & palpation. It's prudent to develop a specific sequence and to follow it consistently so as not to overlook any areas.
  • Complete visualisation with a good source of light is essential.
  • The lips should first be inspected. The labial mucosa, the buccal mucosa, floor of the mouth, and ventral surface of the tongue, dorsal surface of the tongue, borders of the tongue, hard palate, soft palate, gingivae, and teeth, should be examined in sequence.