Timing
Timing is so important. Orthopedic residents must be time efficient when seeing consults because procedures can take so long and it is easy for your list to grow quickly.
Aim for keeping your patient interview around <4 minutes and your whole interaction <8-10 minutes. Of course this will vary depending on this situation, but these are good numbers to shoot for.
Agenda setting can help you keep your whole visit short. Let people know, “I have about ~8 minutes to get the story, do an exam, and discuss the next steps.”
Questions to ask the patient:
Mechanism (story, aka. HPI)
Pain locations
Only do PPQRST if it is actually helpful to you for a diagnosis (often it isn’t necessary)
Numbness or tingling?
Add on pertinent ROS to injuries if you can think of them
Each type of pathology will require more specific questions, a good example is spine: “Any bowel or bladder problem? Difficulty urinating? Bowel bladder incontinence? Numbness or tingling in your groin? Difficulty walking? Difficulty writing or clumsiness in your hands?
We will discuss more specifics depending on the pathology in future posts
I like to always ask the same ROS for billing purposes and picking up on the more dangerous things like chest pain, shortness of breath, nausea, vomiting, fevers, chills.
You need a documented 10 point ROS for billing in an H&P (possibly for consult notes as well)
instead of taking the time to ask the whole ROS you can infer some of the ROS from discussion with the patient)
I like to use smartphrases or “dotphrases” in EPIC that are already in my note template
Medical history:
Heart problems, diabetes, bleeding, clotting problems, blood thinners, or problems with anesthesia in the past, allergies,
baseline mental status (if they are unable to communicate)
For billing you need medical, family, surgical, social histories
If you already wrote each of these out in the HPI I like to write, “medical, family, surgical, social histories reviewed”.
Meds:
You can ask about medications, but the lists can be very long. I would focus on the most important ones like blood thinners.
Sometimes you have to list out the names to help people recognize them, “Any aspirin, coumadin, eliquis, heparin?…etc.”
Surgical history:
Previous to limb of interest
Ortho surgeries in the past?
Always ask when it was done and who performed those ortho surgeriesGood time to ask about problems with anesthesia or bleeding.
Social history:
Smoking, alcohol, drugs; all are very important factors for you to be able to identify healing problems
Uses a walking assist device? (Walker, cane, wheelchair?)
Living situation? (Nursing home vs. live alone?)
Attendings often want to know for planning purposes
Occupation:
Helps you to know their activity level and functional status
Commenting on how reasonable the patient is mentally/socially can be helpful. Attendings may change their construct based on when it seems like patients will not be able to follow instructions.
Depending on the surgery patients may need to protect their weight bearing. Meaning placing no weight on a leg, or only partially. Unreasonable people can ruin their surgeries if they can’t follow directions.
Dominant hand? (If pertinent to the problem)
If you know that surgery is needed:
DNR status, time of last food intake (so you know if they can go to surgery right away, anesthesia usually likes no food or drink within at least 6 hours of surgery)
These questions are based on what attendings and other residents commonly ask. There is some other more detailed information to ask based on specific case presentations. A good example is for spine pathology. You should always get in the habit of asking about bowel and bladder symptoms such as difficulty urinating or bowel/bladder incontinence, and numbness or tingling in the groin. These types of things will be covered in future posts. This post is meant to give you the basis of what most interview questions should include.
As always if you have any questions, please post them below!
