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This chapter includes many of the chronic medical conditions most commonly encountered in clinical practice. Frequently, patients will present with no specific “chief complaint,” but rather as a routine follow-up for a chronic medical condition, say hypertension or diabetes. In this case the “OLD CARTS” method of history taking (see Chapter 5, “History of Present Illness for Common Symptoms”) no longer applies. Instead, the clinician needs a “snapshot” idea of where a patient is in their disease process.
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You will likely encounter these scenarios in a variety of settings. Certainly in outpatient office visits, but also in emergency room or inpatient encounters where you need to assess the status of existing comorbidities and determine how they may impact the patient’s current medical problem.
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In this chapter, you will find a sequence of questions for each disorder. It may not be necessary to ask all the questions for each condition. Ask the relevant questions that you feel are necessary to gauge the status of each disorder. If a patient has an essentially negative response for many of the questions, you may want to move on to the next problem. However, when a patient gives several positive responses, you may need to delve further with more questions. How detailed you get will depend on the patient’s responses.
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This chapter is especially handy as a quick reference for the office-based clinician seeing patients for “routine” follow-up visits.
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