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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.

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.

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.

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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Do you smoke?

  • ¿Usted fuma?

  • How many cigarettes a day?

¿Cuántos cigarrillos al día?

Did you have asthma as a child?

¿Usted tuvo asma en su niñez?

Have you ever been intubated for your asthma/emphysema?

¿Ha sido usted alguna vez entubado/a por su asma o enfisema?

  • How many times?

  • ¿Cuántas veces?

  • How long ago was the last time (months, years)?

  • ¿Cuándo fue la última vez (meses, años)?

Have you taken steroids for your asthma/emphysema?

¿Ha usted tomado esteroides debido a su asma o enfisema?

Have you been to the ER for your asthma/emphysema recently?

¿Ha usted estado en la sala de emergencia debido a su asma o enfisema recientemente?

  • How long ago (days, weeks, months)?

  • ¿Cuánto tiempo hace (días, semanas, meses)?

  • How many times have you gone in the past year?

  • ¿Cuántas veces usted estuvo en la sala de emergencia el pasado año?

Have you been hospitalized for your asthma/emphysema recently?

¿Ha sido usted hospitalizado(a) por su asma o enfisema recientemente?

  • How long ago (days, weeks, months)?

  • ¿Cuánto tiempo hace (días, semanas, meses)?

What medicines do you take for your asthma/emphysema?

¿Qué medicinas usted toma para su asma o enfisema?

  • Show me your inhalers.

  • Enséñeme sus inhaladores.

  • Muéstreme sus inhaladores.

  • How many times a day do you use this inhaler?

  • ¿Cuántas veces al día usted utiliza este inhalador?

  • ¿Cuántas veces al día usted usa este inhalador?

  • Show me how ...

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