Inside Look into New Patient Questioning (Full Dialogue)

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In a previous post, I discussed the basic overview of patient questioning in the family medicine scene. We looked at its purpose, types of questioning, and reasoning. Click on the button to the left to read that article!

Quick Note

In this post, you will get the full dialogue of a new patient questioning procedure including the doctor's questions and patient responses. I've removed any details that could give away the doctor or patient for privacy reasons. Read through below and you can read my final thoughts underneath!

Patient Questioning Dialogue

D: "How long have you been with another doctor? "

"About 3 years"

D: "Have you had vaccine, moderna?"

"Yes, Moderna about 3 months ago."

D: "What brings you in today?"

"Left arm went weak and numb for 3 minutes, I thought I pinched a nerve?"

D: "When did your arm go numb?"

"One month ago, I went to a doctor/cardiologist. I had an aortic valve replacement before that and the results were successful, he didn't concern himself over it"

D: "I see that you tried to see a neurologist but insurance caused a problem?

" I cannot see a neurologist since September. Then went to an alternative neurologist. MRI shows degenerative disc disease in the neck. I have potential problems with my brain and MRI so that's a concern as well. I switched to primary care because friends suggested it to me. "

D: "How long did the pain last?"

"Only 3 mins"

D: "How was the hand?"

"Weakness and tingliness almost as if it fell – Felt strange. After 5 minutes I got strength and coordination"

D: "After MRI and everything, do you seem to be fine?"

"Yes!"

D: "Medical history I should know?"

"In 2017, aortic valve replacement, 4 years ago: Aortic calcification. I had a digestion slight issue: Gallbladder flair ups – aches in the area in which my back would ache – and have been taking supplements starting last week for 6 days"

D: "How often?"

"6 months"

D: "What do you do to relieve pain?"

"Supplements and changed diet, stretch, exercise."

D: "Exercise?"

"Swim, yoga, water sports"

D: "Any Other problems?"

"hyperthyroid based on antibody test (1990) and been on hypoglycemia, eating dried fruits and nuts."

D: "Do you smoke?"

"Smoked between 17-34, a pack or a pack and a half a day (1988) stopped"

D: "Alcohol?"

"No"

D: "Recreational meds or drugs ?"

Just supplements

D: "Occupation?"

"Research and professor in FIU for 40 years."

D: "Family:"

"Father – has a hip replacement, alive and well, he is 96. Lives in Ohio."

D: "Occupation of dad"

"Psychology professor - liberal arts college"

D: "Mother? "

"Passed away at 89 from a heart attack."

D: "Did she smoke?"

"Yes, even while pregnant with me."

D: "Siblings? "

"Younger brothers, I am the oldest. Both are in good health. They live in Miami."

D: "Kids?"

"Both are in good health, Daughter – works in the financial market, Son in software. I divorced my husband, but he has prostate cancer, kids are from him.

D: "New husband?"

" Has no kids and he works in a psychology professor at FIU"

D: "Allergy?"

"Many, listed."

D: "Anything else?"

"Having cataract surgery soon, hydration issue where water does ingest easily. Some headache and low electrolytes."

D: "Anything bothering you now?"

"No, nothing specific"

D: " Bone density exam?"

"Did an osteoporosis testing and nothing came out irregularly."

D: "Colonoscopy?

"I am allergic to specific meds used in colonoscopy so maybe not suitable."

Thoughts and Additional Information

If you got the chance to see the general structure from the previous post, you will begin to quickly see the similarities and differences from this instance. Many times, the doctor deviates from his general questions to gain more content about a specific word or event the patient brings up. Most questions are very broad such as the family questions, which simply asked to describe the people.

The doctor explained to me afterward that he usually classifies patients into two categories:

1) Regular Patients- Mostly healthy, annual check-ups

2) Complex Patients- Multitude of symptoms that usually implies some emotional conflict

In this case, the patient would be classified under type 2 and would require more careful examination of conditions with more check-ups at a later date. The doctor also explained that there are three aspects of happiness that he hopes to address with his patients.

1) Family

2) Professional

3) Personal

We can see that this questioning was just the starting point of the doctor-patient relationship but such a vast amount of information came out of this one moment. The doctor will record and plan based on his medical notes of this patient for their future visits.