CM0504
CM0586
A stressful event caused by either a mechanical or chemical injury from serious burns to the gradual, cumulative trauma, and any accidents, but not traffic accident.
OtherAccident
Trauma from Other Accidents
CM0615
(CSP) Branch of medicine that deals with the treatment of injury, deformity, and disease by manual and instrumental means.
(NCI) A diagnostic or treatment procedure performed by manual and/or instrumental means, often involving an incision and the removal or replacement of a diseased organ or tissue; of or relating to or involving or used in surgery or requiring or amenable to treatment by surgery.
Surgery
Operation
Operative Surgical Procedures
Operative procedure
CM1764
A type of dialysis that uses the peritoneum in an abdomen of person as the membrane through which fluid and dissolved substances are exchanged with the blood.
PeritoneaDialysis
Dialyses, Peritoneal
PD - Peritoneal dialysis
CM0553
CM0529
(CSP) Result of measurement and interpretation of the electrical manifestations of muscle activity.
(NCI) Finding from an assessment of skeletal muscle function and nerve control, obtained by recording and studying the intrinsic electrical properties of the muscles.
Electromyogram
Finding from EMG - Electromyography
Result of electromyography
Payor
CM1756
An ability of individual to perform normal daily activities required to meet basic needs, fulfill usual roles, and maintain health and well-being
FunctionalState
History disease
CM0557
History of the medicines taken by patients, Medication history for euthanasia.
MedicationforEuthanasia
History of Medication for Euthanasia
CM0603
(NCI) Finding from a test that used to measure how well the lungs work. It measures how much air the lungs can hold and how quickly air is moved into and out of the lungs. It also measures how much oxygen is used and how much carbon dioxide is given off during breathing. A PFT can be used to diagnose a lung disease and to see how well treatment for the disease is working.
PulmonaryFunctionTest
Finding from Function Tests, Lung
Finding from PFT - Pulmonary Function Testing
Result of Lung Function Tests
CM0142
(MSH) The signs of life that may be monitored or measured, namely pulse rate, respiratory rate, body temperature, and blood pressure.
VitalSigns
Vital Signs, Function (observable entity)
CM1651
A record of a patient's medical background regarding rectal diseases.
Rectal
Rectal Disease History
History of the medicines taken by patients, Medication history for contraception.
MedicationforContraception
Advanced directive
CM0563
History of the medicines taken by patients, Medication history for neoplastic disorders.
MedicationforNeoplasticDisorders
History of Medication for Neoplastic Disorders
CM0594
Finding from the physical examination, which is an exam of the body to check for general signs of disease.
PhsycialExamination
Physical Exam Result
Result of Physical Examination
CM0619
Trauma from accidents on streets, roads, and highways involving drivers, passengers, pedestrians, or vehicles. Traffic accidents refer to AUTOMOBILES (passenger cars, buses, and trucks), BICYCLING, and MOTORCYCLES but not OFF-ROAD MOTOR VEHICLES; RAILROADS nor snowmobiles.
TrafficAccident
Trauma from Traffic Accident
CM1650
A record of a patient's medical background regarding diseases in pediatrics.
Pediatrics
Pediatric Disease History
Directive, advance
CM0604
(CSP) Finding from examination of a specimen or any part of the body, usually for diagnostic purposes, by means of roentgen rays, recording the image on a sensitized surface such as photographic film.
(MSH) Finding from examination of any part of the body for diagnostic purposes by means of X-RAYS or GAMMA RAYS, recording the image on a sensitized surface (such as photographic film).
Radiology
Radiologic Result Finding
CM1753
Health problems that are caused by pregnancy
AbnormalHistoryOfPregnancy
Abnormal History of Mother Pregnancy
Pregnancy Complications
CM0617
Finding from a kind of medical procedure performed to detect, diagnose, or monitor diseases, disease processes, susceptibility, and determine a course of treatment.
Test
Clinical Test Result
CM0590
Social and personal circumstances
CM0524
A record of a patient's medical background regarding certain disease.
DiseaseHistory
CM0560
CM0601
CMO ID
Finding from the examination of any recent color changes (to include the use of dyes or other chemicals), texture, abnormal loss or growth distribution, lesions of scalp, and baldness.
Hair
CM0631
(NCI) Any record of a medical imaging event whether physical or electronic.
FindingByImage
CM1675
(NCI) An indication that a person has a condition or disease. Some examples of symptoms are headache, fever, fatigue, nausea, vomiting, and pain.
(NCI) Subjective evidence of disease perceived by the patient.
Symptom
Symptoms
CM1669
Finding from the physical examination on lymph nodes.
LymphNode
Result of Physical Examination of Lymph node
CM0506
(WebMD) Finding from allergy testing that involves having a skin or blood test to find out what substance, or allergen, may trigger an allergic response in a person. Skin tests are usually done because they are rapid, reliable, and generally less expensive than blood tests, but either type of test may be used.
AllergyTest
Finding from allergy testing
Result from test for allergy
CM1654
Any visit made during the person's reference period to a hospital emergency room.
EmergencyVisit
Emergency Visits
CM0530
(NCI) A sudden unforeseen crisis that requires immediate action.
(NCI) Emergency procedures must be performed as soon as possible because of substantial concerns that delay could lead to death. Clinical situation demands that procedure should be performed immediately or in next available room, even if it means another case must be rescheduled.
Emergency
Emergencies
Emergency Situation
History immunizations
CM0534
Finding from an eye examination, which is a series of tests performed by an ophthalmologist (medical doctor), optometrist, or orthoptist assessing vision and ability to focus on and discern objects, as well as other tests and examinations pertaining to the eyes.
Eyes
Finding, Ophthalmic examination
Result of Ophthalmic examination and evaluation
CM0589
(NCI) An imaging technique that utilizes positron emission tomography and computed tomography in a single machine.
PET/CTScan
Finding from PET/CT SCAN
Finding from Positron Emission Tomography and Computed Tomography Scan
PET-CT Scan
Positron Emission Tomography/Computed Tomography
CM0537
CM1668
Finding from the respiratory examination that aims to pick up on any respiratory (breathing) pathology that may be causing a patient’s symptoms e.g. shortness of breath, cough, wheeze etc.
Lung
(MSH) Statistical interpretation and description of a population with reference to distribution, composition, or structure.
(NCI) The statistical characterization of human populations or segments of human populations (e.g., characterization by age, sex, race, or income).
Demographics
Demography
CM0547
(NCI) A synthetic, aralkylguanidine analogue of the adrenergic neurotransmitter norepinephrine (NE) and adrenergic neuron blocking agent with potential diagnostic imaging or antineoplastic activity when radiolabeled. Iobenguane, also known as metaiodobenzylguanidine (MIBG), is taken up and accumulates in the granules of adrenal medullary chromaffin cells and in the pre-synaptic granules of adrenergic neurons in a manner almost identical with that of NE. In radiolabeled forms, iobenguane may be used to image or eradicate neuroendocrine tissues and tumor cells.
MIBG
Finding from MIBG scan
metaiodobenzylguanidine (MIBG) scan
A record of a patient's medical background regarding genitourinary diseases.
Genitourinary
History of Genitourinary Systems Disorders
History of Symptoms & Diseases of Genitourinary Systems
CM0517
Finding from the part of the neurological examination that it is used to identify problems with the cranial nerves by physical examination and to examine the functionality of the cranial nerves.
CranialNerves
Examination of cranial nerve
cranial nerve examination
CM0629
(WebMD) A lack of physical or muscle strength and the feeling that extra effort is needed to perform daily activities that require you to move your arms, legs, or other muscles.
Alerts
Alert
Arousal
CM0627
Finding from an exam of the breast performed by a health care provider to check for lumps or other changes.
Breast
Examination of breast
Result of Physical Examination of Breast
FH - Family history
CM1748
Finding from an echocardiogram or 'echo' is a noninvasive ultrasound cardiac screening test that records specific geographical areas of the beating heart, which reveals blood flow patterns and allows us to measure size and wall thickness of the heart‘s chambers. We can get a good sense of where valves may be too loose and leaky, or too tight and restrictive. In addition, an echo can detect possible enlargement of the heart as well as potential presence of fluid around the heart.
Echocardiogram
Finding from Echocardiography
Result of Ultrasound Heart Scan
Events
CM1767
(Wiki) Medical histroy of the state of carrying a developing embryo or fetus within the female body
PregnancyHistory
H/O: pregnancy
History of pregnancies
CM1649
Developmental history is an account of how and when a person met developmental milestones, such as walking and talking. For adults, information on social-emotional development may be included. Used primarily in the diagnosis of developmental disorders.
DevelopmentalHistory
CM1752
Planned education program designed for a particular patient for their current issue of health
EducationPlan
planning education
CM0620
(CSP) damage inflicted on the body as the direct or indirect result of an external force, with or without disruption of structural continuity; for emotional trauma use PSYCHOLOGICAL SHOCK.
(MSH) Damage inflicted on the body as the direct or indirect result of an external force, with or without disruption of structural continuity.
Trauma
injuries wound
traumatic disorder
traumatic injury
CM0536
CM0565
History of the medicines taken by patients, Medication history for obstetrics and gynecology.
MedicationforOBGY
History of Medication for OBGY
History of Medication for obstetrics and gynecology
CM1660
(CSP) transfer and growth of a neoplasm from one organ or part of the body to another remote from the primary site; the capacity to metastasize is a characteristic of all malignant cancers.
(MSH) The transfer of a neoplasm from one organ or part of the body to another remote from the primary site.
Metastatis
Metastatic disease
CM0606
Finding from reflex neurological exam. Generally, decreased reflexes indicate a peripheral problem, and lively or exaggerated reflexes a central one.
Reflex
Finding by reflex neurological exam
Reflex action
CM0542
Finding from an physical examination for head
Head
Finding, Head examination
ClinicalMetadata
CM1661
Physical findings of general status in the process by which a medical professional investigates the body of a patient for signs of disease.
GneralFindings
CM0549
Finding from the physical examination on mandible.
Mandible
Result of Physical Examination of Mandible
CM0574
Finding from examination for the motor system, that is the part of the central nervous system that is involved with movement including muscle strength, muscle tone and signs of rigidity, and examination of posture. Normal motor function depends on intact upper and lower motor neurons, sensory pathways and input from a number of other neurological systems.
Motor
motor movement
CM0521
A detailed account of the certain characteristics, or symptoms of a patient provided by themselves or their family
Description
Descriptor
(NCI) A record of a patient's background regarding health and disease events of blood relatives. A patient's family medical history may be important in diagnosing existing conditions.
(NCI) A record of the relationships among family members along with their medical histories. This includes current and past illnesses. A family history may show a pattern of certain diseases in a family.
FamilyHistory
Epidemiology, Family Medical History
Family Medical History
Family health history
Family history with explicit context
CM1667
Finding from a physical examination that principally concerns the head, eyes, ears, nose, and throat.
HEENT
Head, Ears, Eyes, Nose and Throat Examination
Result of Physical Examination of HEENT
CM1653
(NCI) A Latin abbreviation for "nothing by mouth".
(Wiki) medical instruction meaning to withhold oral food and fluids from a patient for various reasons.
NPO
Fasting patients
NPO - Nothing by mouth
Patients starving
Starving the patient
CM0568
History of the medicines taken by patients, Medication history for respiratory system.
MedicationforRespiratorySystem
History of Medication for Respiratory System
CM0545
(MSH) Rehabilitation of persons with language disorders or training of children with language development disorders.
LanguageTherapy
Language Therapies
Therapy, Language
CM1647
(NCI) Each individual, unique interaction between two subjects of interest.
Encounter
CM0591
Finding an essential nature of disease.
PathologicFindings
Pathologic Finding
CM0613
CM0632
(MSH) Deliberate stimulation of the host's immune response. ACTIVE IMMUNIZATION involves administration of ANTIGENS or IMMUNOLOGIC ADJUVANTS. PASSIVE IMMUNIZATION involves administration of IMMUNE SERA or LYMPHOCYTES or their extracts (e.g., transfer factor, immune RNA) or transplantation of immunocompetent cell producing tissue (thymus or bone marrow).
(NCI) A technique used to cause an immune response that results in resistance to a specific disease, especially an infectious disease.
(NCI) Inoculating an individual with either killed or live agents to prevent contraction of a disease.
Immunization
CM0544
(CSP) Hormones used in the treatment of any disease; in addition also index the specific disorder chemotherapy term and hormone used.
(NCI) Treatment that adds, blocks, or removes hormones. For certain conditions (such as diabetes or menopause), hormones are given to adjust low hormone levels. To slow or stop the growth of certain cancers (such as prostate and breast cancer), synthetic hormones or other drugs may be given to block the body's natural hormones. Sometimes surgery is needed to remove the gland that makes a certain hormone.
(NCI) Various treatment modalities that produce the desired therapeutic effect by means of change of hormone/hormones level. The treatment may include administration of hormones or hormone analogs to the patient, or decreasing the level of hormones in the body by using hormone antagonists, or hormone ablation therapy.
HormoneTherapy
Endocrine therapy
HT - Hormone therapy
Hormone treatment
CM1755
(CSP) state of being aware, or perceiving physical facts or mental concepts; a state of general wakefulness and responsiveness to environment; a functioning sensorium.
(MSH)Sense of awareness of self and of the environment.
(NCI) A level of awareness that can be described as being alert.
ConsciousState
Consciousness
State of awareness
CM0538
Finding from a test in which the activity of a particular organ or gland is measured based on the activity evoked by the hormone, factor, or other product.
FunctionTest
Finding from Function Test
Finding from the neck examination that includes neck inspection, neck palpation and cervical movement.
Neck
CM0509
(NCI) Finding from a postmortem examination of the body that includes an examination of the internal organs and structures after dissection to determine the cause of death and the nature of pathological changes.
Autopsy
Finding from Autopsy examination
Finding, Postmortem Examination
(NCI) The act of conveying or transporting from one place to another.
Transfer
CM0562
History of the medicines taken by patients, Medication history for musculoskeletal disorders.
MedicationforMusculoskeletalDisorders
History of Medication for Musculoskeletal Disorders
CM0535
Finding from a physical exam for symmetrical facial features.
Face
CM1677
(Wiki) A meeting between a patient with a physician to get health advice or treatment for a symptom or condition.
MedicalConsult
Consultation
Medical Consulting Procedure
CM0173
(CSP) the artificial substitution of heart and lung action as indicated for heart arrest resulting from electric shock, drowning, respiratory arrest, or other causes; the two major components of cardiopulmonary resuscitation are artificial ventilation and closed-chest cardiac massage.
(MSH) The artificial substitution of heart and lung action as indicated for HEART ARREST resulting from electric shock, DROWNING, respiratory arrest, or other causes. The two major components of cardiopulmonary resuscitation are artificial ventilation (RESPIRATION, ARTIFICIAL) and closed-chest CARDIAC MASSAGE.
CardiopulmonaryResuscitation
Resuscitation, Cardio-Pulmonary
Resuscitation, Cardiopulmonary
CM0602
(NCI) In medicine, a treatment or action taken to prevent or treat disease, or improve health in other ways.
Procedure
Medical and Surgical (procedure)
CM0552
History of the medicines taken by patients, Medication history for central nervous system.
MedicationforCNS
History of Medication for CNS
History of Medication for central nervous system
Personal Medical History
CM0550
CM0515
CM0508
Antineoplastic therapy a regimen that includes chemotherapy, aimed at destruction of malignant cells using a variety of agents that directly affect cellular growth and development.
AntineoplaticDrugAgentTherapy
Antineoplatic Drug Agent Therapy
CM1672
(CSP) prediction as to the probable outcome of a disease or disorder as indicated by the nature and symptoms of the case.
(MSH) A prediction of the probable outcome of a disease based on a individual's condition and the usual course of the disease as seen in similar situations.
(NCI) The likely outcome or course of a disease; the chance of recovery or recurrence.
Prognosis
Forecast of outcome
Prediction of Outcome
CM0512
(CSP) radiography in which a three dimensional image of a body structure is constructed by computer from a series of plane cross sectional images made along an axis.
(NCI) A method of examining structures within the body by scanning them with X rays and using a computer to construct a series of cross-sectional scans along a single axis.
Computerized Tomography
Finding, CT scan as Radiology Test
CM0573
(CSP) Study of pathological phenomena in terms of the chemical and physical interactions of molecules.
(NCI) Description of disease and disease processes based upon the underlying protein and genetic defects rather than by a description of morphology.
MolecularPathology
Finding, Molecular Pathologies
History of the medicines taken by patients, Medication history for immune system.
MedicationforImmuneSystem
History of medication for Immune System
CM1758
(NCI) Occurring during the course of a surgical procedure.
Intraoperative
Intra-operative progress
CM0503
CM0624
Finding from an examination in the vascular system.
Vscular
Result of Physical Examination of vascular system.
Signs, Vital
CM0609
(NCI) A comprehensive assessment of a patient, which includes a subjective history taking component as well as an objective based structured interview and physical examination of all the body systems.
ReviewOfSystems
ROS
CM1761
a symptom that is evident to the observer
ObjectiveSymptom
CM0566
CM0623
Finding from the physical examination for urinary; of or relating to urine, of or relating to the urinary system.
Urinary
Examination of urinary system
Result of Physical Examination of Urinary system
Urinary system examination
CM1680
(MSH) The teaching or training of patients concerning their own health needs.
Education
Education of Patients
Patient Education
PI - Present illness
(NCI) Past events that occurred between individuals and/or their communities.
SocialHistory
CM1749
Finding from Holter Monitoring, that is usually worn for 24 hours and records every heartbeat for that time period. Electrodes are placed on the chest, and a recorder is worn on a shoulder strap or belt. I order this test to identify cardiac arrhythmias, and to monitor how well medication is working to minimize them. Sometimes we see signs of ischemia on Holter, and most Holter monitor computer analysis programs also measure heart rate variability (HRV).
HolterMonitoring
Finding from Holter Electrocardiography
Alcohol use Hx Reported
CM1765
(MSH) Planned care program designed for a particular patient usually reflecting patient and family goals as well those institution and healthcare providers.
CareGoal
Goals of Care
CM0569
History of the medicines taken by patients, Medication history for skin.
MedicationforSkin
History of Medication for Skin
CM1683
CM0519
(Wiki) The medical definition of death is a major medical and legal issue, and an important issue in declaring a person legally dead.
Death
On examination - dead
Patient died
CM1679
Part of job as a nursing assistant is to help patients with activities of dressing.
DressingPatiet
Assisting with dressing
Nursing care - dressing
CM1747
(NCI) A record of an individual's background in regard to smoking tobacco. This would include such factors as start date, end date (if applicable), number of cigarette smoked, attempts to quit, and others.
SmokingHistory
A record of an individual's background in regard to surgical operation.
OperationHistory
CM0579
Finding from a series of questions and tests to check brain, spinal cord, and nerve function. The exam checks a person's mental status, coordination, ability to walk, and how well the muscles, sensory systems, and deep tendon reflexes work.
Finding from the assessment of the functionality of the brain, spinal column, and nerves.
NeurologicalExamination
Neurological exam
(Wiki) The collective physical and psychological occurrences of patients surveyed or proceeded by a medical doctor.
Finding
Investigation Finding
CM0502
Finding from the abdominal exam, which is performed as part of a physical examination, or when a patient presents with abdominal pain or a history that suggests an abdominal pathology.
Abdomen
Result of Physical Examination of Abdomen
abdominal cavity exam
CM1681
(NCI) A combination of multiple drugs used in standard or clinical trial treatments. The order, dosage or dosing interval of the individual ingredients may not be specified.
(NCI) The use of synthetic or naturally-occurring chemicals for the treatment of diseases. Although this term is used to describe any therapy involving the use of chemical-based agents, it is particularly used to refer to the use of chemical-based agents to treat cancer. Antineoplastic chemotherapy works by arresting or killing the growth and spread of cancer cells. Chemotherapy may also include agents that enhance immune function or alter hormonal activity.
Chemotherapy
Administration chemotherapy
Cancer chemotherapy regimen
Chemotherapy Regimen or Agent Combination
Chemotherapy, Cancer, General
(MSH) The unsuccessful attempt to kill oneself.
(NCI) A disorder characterized by self-inflicted harm in an attempt to end one's own life.
(NCI) Self-inflicted harm in an attempt to end one's own life.
SuicideAttempt
Attempted Suicide
Suicide, Attempted
CM1652
Past medication
CM0532
(CSP) Use of instruments for visual examination of interior structures of the body; there are rigid endoscopes and flexible fiberoptic endoscopes for various types of viewing for disease diagnosis and treatment; involves passing an optical instrument along either natural body pathways such as the digestive tract, or through keyhole incisions to examine the interior parts of the body; with advances in imaging, endoscopes, and miniaturization of endosurgical equipment, surgery can be performed during endoscopy.
(NCI) A procedure that uses an endoscope to examine the inside of the body. An endoscope is a thin, tube-like instrument with a light and a lens for viewing. It may also have a tool to remove tissue to be checked under a microscope for signs of disease.
(NCI) An examination of the body using an endoscope.
Endoscopy
Endoscopic Examination
Finding from Endoscopic Examination
Admission to hospital
CM0561
CM1746
A record of someone's behaviors associated with the ingesting of alcoholic beverages, including social drinking.
History of someone's consumption of liquids containing ethanol; includes the behavior of drinking the alcohol.
DrinkingHistory
History of Alcohol Use Narrative
History of the medicines taken by patients, Medication history for infection and infestation.
MedicationforInfectionAndInfestation
History of Medication for Infection and Infestation
CM1646
(NCI) Systematic, objective appraisal of the significance, effectiveness, and impact of activities or condition according to specified objectives and criteria.
Assessment
Evaluation
Evaluation Procedure
CM1678
(CSP) Dialysis fluid being introduced into and removed from the peritoneal cavity or kidneys as either a continuous or an intermittent procedure.
(NCI) A procedure to remove toxic substances from the blood that is used in patients with end-stage chronic kidney disease or acute kidney failure. This includes hemodialysis and peritoneal dialysis.
DialysisProcedure
Dialysis
Dialysis Therapy
(NCI) An unexpected medical problem that happens during treatment with a drug or other therapy. Adverse effects do not have to be caused by the drug or therapy, and they may be mild, moderate, or severe.
AdverseEvent
ADR - Adverse Reactions
Adverse Effect
Adverse Reactions (disorder)
CM0605
(CSP) Therapeutic use of ionizing and nonionizing radiation; for radioisotope therapy refer to RADIONUCLIDE THERAPY and narrower terms; for therapeutic radiation with visible, laser, or ultraviolet light, respectively refer to PHOTOTHERAPY, LASER THERAPY, or ULTRAVIOLET THERAPY and narrower terms.
(NCI) Treatment of a disease by means of exposure of the target or the whole body to radiation. Radiation therapy is often used as part of curative therapy and occasionally as a component of palliative treatment for cancer. Other uses include total body irradiation prior to transplantation.
Raiotherapy
Radiation Therapy
Radiotherapeutics
CM1656
An act of renewing contact with sources of information and reviewing data needed to reinforce or evaluate a previous action or report such as reexamination of an earlier diagnosis or prognosis.
Followup
F/U
Follow-up
Gait is evaluated by having the patient walk across the room under observation. Gross gait abnormalities should be noted in neurologic examination.
CoordinationAndGait
History of the medicines taken by patients, Medication history for pain and consciousness.
MedicationforPainAndConsciousness
History of Medication for Pain and Consciousness
(Wiki) Present Illness is presenting symptoms with following questions; onset, location/radiation, duration, character, aggrevating factors, reliving factors, timing and severity as referencing practical guide.
PresentIllness
History of present illness
CM0571
Finding from the mental status examination in neurological exam is a series of detailed but simple questions designed to test cognitive ability, including the patient's state of consciousness (awareness and responsiveness to the environment and the senses) or appearance and general behavior, and so on and assess consciousness.
MentalStatus
Mental state finding
CM0598
(NCI) A document outlining the essential treatment issues which will be addressed. This may include the problem to be addressed, the proposed treatment, the treatment goal, the time frame to meet goals, and an estimate of the costs.
Plan
Planning Procedure
CM0567
History of the medicines taken by patients, Medication history for reproduction system or urinary system.
MedicationforReproductionSystemOrUrinarySystem
History of Medication for Reproduction System or Urinary System
CM0592
Finding from the physical examination for pelvic fracture that includes checking the functional activity of the various body organs present in the pelvic region.
Pelvic
Pelvic Examination
Result of Physical Examination of Pelvic
Personal and social circumstances
CM1745
(CSP) Transferring cells, tissues or organs within an individual, between individuals of the same species, or between individuals of different species.
(MSH) Transference of a tissue or organ, alive or dead, within an individual, between individuals of the same species, or between individuals of different species.
Transplantation
Transplant procedure
Tx - Transplant
CM1766
Direction on the type of clinical care
CarePlan
Plan of care
TP - Treatment plan
care planning
CM0635
(MSH) Preparations made from animal tissues or organs (ANIMAL STRUCTURES). They usually contain many components, any one of which may be pharmacologically or physiologically active. Tissue extracts may contain specific, but uncharacterized factors or proteins with specific actions.
TissueExtracts
Extracts, Tissue
CM1759
(NCI) Relating to or occurring during the period immediately before a surgical operation.
Preoperative
Pre-operative progress
UMLS CUI
CM0578
A record of a patient's medical background regarding neurologic diseases.
Neurologic
History of Nervous system disorders Narrative
History of Symptoms & Diseases of Neurologic system
Hx of Neurologic disorders
Neurologic system Disease History
History of the medicines taken by patients, Medication history for allergic disorders.
MedicationforAllergicDisorders
History of Medication for Allergic Disorders
CM0599
(CSP) Finding from simultaneous and continuous monitoring of relevant normal and abnormal physiological activity during sleep.
(NCI) Finding from the measurement of physiologic parameters during sleep.
Finding from Sleep Monitoring
Polysomnography
Finding from PSG - Polysomnographies
Finding from sleep test
CM0607
(CSP) research directed towards restoration or improvement of functional capability lost as a consequence of injury, disease, congenital disorder, or natural aging process; for through searching, see RTs.
(MSH) Restoration of human functions to the maximum degree possible in a person or persons suffering from disease or injury.
(NCI) In medicine, a process to restore mental and/or physical abilities lost to injury or disease, in order to function in a normal or near-normal way.
RehabilitationTherapy
Rehabilitation care
Rehabilitation treatments
Rehabilitation treatments and procedures
Therapy rehabilitation
Treatment rehabilitation
CM0533
H&P.HX
CM0608
A record of a patient's medical background regarding respiratory diseases.
Respiratory
History of - Respiratory Disease
Respiratory Disease History
CM0564
History of the medicines taken by patients, Medication history for nutrition.
MedicationforNutrition
History of Medication for Nutrition
CM0531
A record of a patient's medical background regarding endocrine related diseases.
Endocrine
Hx of Endocrine Disorders
CM0630
Named locations of or within the body from medical finding.
FindingByAnatomicSite
Finding by Anatomic Site
History of the medicines taken by patients, Medication history for eye conditions and eye diseases.
MedicationforEye
CM1670
Finding from the examination of any localised spinal disorder requires inspection of the entire spine.
Spine
Examination of spine
Result of Physical Examination of Spine
CM1750
A person's state of feeling in the sense of an affect from pleasure to dejection. Emotion is often intertwined with mood, temperament, personality, disposition, and motivation.
EmotionalState
Emotional State Finding
CM0570
Intervention or Procedure
CM0600
(MSH) Directions written for the obtaining and use of PHARMACEUTICAL PREPARATIONS; MEDICAL DEVICES; corrective LENSES; and a variety of other medical remedies.
(SNOMEDCT_US) A legal order to dispense and possibly prepare a substance or physical object
PrescriptionProcedure
Prescriptions
CM0551
(NCI) A collection of information about a person's health. It may include information about allergies, illnesses and surgeries, and dates and results of physical exams, tests, screenings, and immunizations. It may also include information about medicines taken and about diet and exercise.
(NCI) A record of a patient's background regarding health and the occurrence of disease events of the individual. In addition, personal medical history may be a variable in epidemiologic studies.
MedicalHistory
Presenting complaint
(SNOMEDCT_US) Performance of the steps necessary to admit a patient to a hospital.
Admission
Hospital admission
CM1657
(NCI) Advice telling someone what the best thing to do is.
Recommendation
Recommended
CM0575
Finding from the physical examination on mouth.
Mouth
Examination of mouth
Oral Examination
CM1674
(NCI) Objective evidence of disease perceptible to the examining healthcare provider.
Sign
CM0518
(MSH) The study of the structure, behavior, growth, reproduction, and pathology of cells; and the function and chemistry of cellular components.
(NCI) The study of the internal workings of cells at the microscopic and molecular level. (On-line Medical Dictionary)
Cytoology
Finding from Cytology field
CM0527
Eldctrocardiogram
(WebMD) Finding from an electrocardiogram (EKG or ECG) test that checks for problems with the electrical activity of your heart. An EKG shows the heart's electrical activity as line tracings on paper. The spikes and dips in the tracings are called waves.
EKG finding
Electrocardiogram finding
Electrocardiographic Finding
CM0559
CM0523
(MSH) The administrative process of discharging the patient, live or dead, from hospitals or other health facilities.
(NCI) The release of a patient from a course of care.
(SNOMEDCT_US) Performance of the steps necessary to discharge a patient from a location of care delivery
Discharge
Discharge from Healthcare Facility
Discharge, Patient
Patient Discharge
CM1682
Medication list at the present time from prescription.
CurrentMedication
Current Medication
prescribed medication current
Someone as a payer if they pay a particular kind of hospital or medical bill or fee.
Payer
CM1751
(NCI) A relatively temporary state of feeling.
(Wiki) Moods differ from emotions, feelings or affects in that they are less specific, less intense, and less likely to be triggered by a particular stimulus or event. Moods generally have either a positive or negative valence. In other words, people typically speak of being in a good mood or a bad mood.
Mood
CM0528
(MSH) Recording of electric currents developed in the brain by means of electrodes applied to the scalp, to the surface of the brain, or placed within the substance of the brain.
(NCI) The neurophysiologic exploration of the electrical activity of the brain by the application of electrodes to the scalp. The resulting traces are known as an electroencephalogram (EEG). This test is used to assess brain damage, epilepsy and other problems.
Electroencephalography
Finding from Electroencephalogram (EEG)
Result of EEG
CM0621
Medical/surgical/therapeutic management of the patient, the presenting problem and its cause/s.
Treatment
Therapeutic Interventions
Therapeutic Technique
Therapeutic procedure
CM0554
(NCI) Finding from the test to detect areas of the body where cells are dividing rapidly. It is used to locate cancer cells or areas of inflammation. A very small amount of radioactive gallium is injected into a vein and travels through the bloodstream. The gallium is taken up by rapidly dividing cells in the bones, tissues, and organs and is detected by a scanner.
GalliumScan
CM1645
(CSP) usual food and drink consumed by an individual; for indexing what is medically prescribed to treat a condition use DIET THERAPY.
(Wiki) Ask about everything the patient has eaten the day before and for the past week. Note the type of food consumed and do a nutritional status assessment.
Diet
Dietary Procedure
Complaints present
CM0546
A record of a patient's medical background regarding liver diseases.
Liver
History of Hepatic Organ System
Liver Disease History
CM0587
Outpatient care, sometimes called ambulatory care, is defined as medical care or treatment that does not require an overnight stay in a hospital or medical facility.
OutpatientCare
CM0540
A record of a patient's medical background regarding gastrointestinal diseases.
Gastrointestinal
H/O: Gastrointestinal Disease
History of Gastrointestinal Disease
CM1664
Finding from a physical examination, or when a patient presents with a respiratory problem (shortness of breath, cough, chest pain).
Chest
Chest Examination
CM0514
(NCI) A record of a patient's medical background regarding cardiovasular diseases.
Cardiovascular
Cardiovascular Disease History
CM0610
Finding from the sensory system testing. Fine touch can be evaluated with a monofilament test, touching various dermatomes with a nylon monofilament to detect any subjective absence of touch perception.
Sensory
History of the medicines taken by patients, Medication history for gastrointestinal and astroenterology.
MedicationforGI
History of Medication for gastrointestinal
CM0622
(CSP) high frequency sound waves used to identify and examine internal organs and structures without the invasive hazards of X xays, dyes, or fluoroscopy.
(NCI) A computer picture of areas inside the body created by bouncing high-energy sound waves (ultrasound) off internal tissues or organs.
Ultrasonography
Finding of USS - Ultrasound scan
Finding, Ultrasound scan
Finding, ultrasound imaging/scanning
CM0580
Finding from the nasal examination, that can provide valuable information on the patient's general health status, including identifying specific systemic diseases.
Nose
Finding from an physical examination for nose
Finding, Nose examination
CM1762
Found symptom by personal perspective and discovery of the clinician
SubjectiveSymptom
subjective (symptom)
CM0543
(NCI) Finding from hearing test that a graphic record of the softest sounds that a person can hear at various frequencies, used to measure hearing loss.
HearingTest
Finding from Audiometric Test
Finding from Clinical test of hearing
Result of HT - Hearing test
CM0520
History obstetric
CM0596
(CSP) Therapies to prevent, correct, or alleviate dysfunction of anatomic or physiologic origin, employing physical phenomena such as temperature, light, water, and sound, as well as exercise and massage.
(NCI) The use of exercises and physical activities to help condition muscles and restore strength and movement. For example, physical therapy can be used to restore arm and shoulder movement and build back strength after breast cancer surgery.
Physiotherapy
Physical Medicine Procedure
Physical Therapy
CM0522
(CSP) general term for detecting and classifying diseases.
(MSH) The determination of the nature of a disease or condition, or the distinguishing of one disease or condition from another. Assessment may be made through physical examination, laboratory tests, or the likes. Computerized programs may be used to enhance the decision-making process.
Diagnosis
CM0583
(CSP) Therapeutic use of self-care, work and play activities to increase function, enhance development, and prevent disability; may include modification of tasks or environment to increase independence and enhance quality of life.
(MSH) Skilled treatment that helps individuals achieve independence in all facets of their lives. It assists in the development of skills needed for independent living.
OccupationalTherapy
Occupational Therapy Regime
Occupational Therapy Treatment
Therapy, Occupational
CM0582
(Wiki) Obstetric/Gynecologic history includes total number of pregnancies, whether they are full term, preterm, miscarriages, abortions, living, as well as any complications. Include menopause and date. Include sexual history and any history of sexually transmitted diseases.
OBG
History of OBG/GYN
History of Obstetrics and Gynecology
Obstetrics and Gynecology Disease History
CM1671
(NCI) A difficulty, disorder, or condition needing resolution.
Problem
Issue
Descriptive
CM0628
CM0634
History of the medicines taken by patients.
MedicationHistory
Past medication history
CM0576
A record of a patient's medical background regarding musculoskeletal diseases.
Musculoskeletal
H/O: Musculoskeletal Disease
History of - Musculoskeletal Disease
CM0025
(NCI) Finding from a medical procedure that involves testing a sample of blood, urine, or other substance from the body. Tests can help determine a diagnosis, plan treatment, check to see if treatment is working, or monitor the disease over time.
(NCI) Finding from the procedure that involves testing or manipulating a sample of blood, urine, or other body substance in a laboratory setting.
LaboratoryTest
Finding from Laboratory Test Result
Laboratory Test Result
CM0581
(Wiki) Finding from nuclear medicine. and it is a medical specialty involving the application of radioactive substances in the diagnosis and treatment of disease, and is 'radiology done inside out' or 'endoradiology' because it records radiation emitting from within the body rather than radiation that is generated by external sources like X-rays.
NuclearMedicine
Finding from Result of Radiology-Nuclear Medicine
Radiology / Radiation Biology / Nuclear Medicine
CM0626
Finding from the physical examination on zygoma.
Zygoma
Result of Physical Examination of zygoma
(MSH) Declarations by patients, made in advance of a situation in which they may be incompetent to decide about their own care, stating their treatment preferences or authorizing a third party to make decisions for them. (Bioethics Thesaurus)
(NCI) A legal document that states the treatment or care a person wishes to receive or not receive if he or she becomes unable to make medical decisions (for example, due to being unconscious or in a coma). Some types of advance directives are living wills and do-not-resuscitate (DNR) orders.
AdvanceDirectives
CM0616
(MSH) A field of anatomical pathology in which living tissue is surgically removed for the purpose of diagnosis and treatment.
(NCI) A field of anatomical pathology in which tissue or cells removed from a living organism are macroscopically and microscopically reviewed for the purpose of disease diagnosis.
SugicalPathology
Finding, pathologies surgical
CM0513
(Wiki) Result of the test for identifying heart conditions associated with healthy vs. unhealthy, pathologic, heart function.
HeartFuncgtionTest
Finding from Cardiac Function Tests
Result of Heart Function Tests
CM0597
(CSP) Treatment of emotional, behavioral, personality, and psychiatric disorders based primarily upon verbal or nonverbal communication and interventions with the patient.
(MSH) A generic term for the treatment of mental illness or emotional disturbances primarily by verbal or nonverbal communication.
(NCI) Treatment of mental, emotional, personality, and behavioral disorders using methods such as discussion, listening, and counseling.
PsyChotherapy
Psychotherapies
Talk therapy
CM0507
(MSH) A state characterized by loss of feeling or sensation. This depression of nerve function is usually the result of pharmacologic action and is induced to allow performance of surgery or other painful procedures.
(NCI) A loss of feeling or awareness caused by drugs or other substances. Anesthesia keeps patients from feeling pain during surgery or other procedures. Local anesthesia is a loss of feeling in one small area of the body. Regional anesthesia is a loss of feeling in a part of the body, such as an arm or leg. General anesthesia is a loss of feeling and a complete loss of awareness that feels like a very deep sleep.
AnethesiaProcedure
Anesthesia procedure
Generic anaesthesia procedure
CM1666
Finding from the cardiac examination for dealing with chest pain suggestive of a cardiovascular pathology.
Heart
Result of Physical Examination of Heart
CM1757
(MSH) Malformations of organs or body parts during development in utero.
(NCI) Any abnormality-anatomical or biochemical-evident at birth or during the neonatal period.
CogenitalAnomaly
Abnormal development
Fetal developmental abnormality
CM0505
(Wiki) Allergy notes any environmental, food, or drug allergies, as well as the specific type of reaction, e.g. anaphylaxis, rash, itching.
Allergy
Allergy History
History of previous and current pregnancy with activity of fetus, vaginal bleeding, contractions and other important information such as blood type, rubella immunity, serology (HepB, HIV, VDRL), GBS status
ObstetricHistory
CM0525
A record of a patient's medical background regarding ear, nose and throat (ENT) condition related diseases.
ENT
Ear, Nose and Throat Disease History
Ear, nose and throat examination history
History of ENT examination
CM1659
Medical finding of any disease or disorder or an unfavorable evolution that occurs during the course of (or because of) another disease.
Complication
Complications
CM1763
(CSP) Therapy for the insufficient cleansing of the blood by the kidneys based on dialysis.
Hemodialysis
HD - Hemodialysis
CM0510
Finding from the physical examination in upper extremity exam (anatomy of the shoulder, elbow, wrist and hand) and lower extremity exam (including the foot, thigh and even the hip).
BackAndExtremity
Result of Physical Examination of Back and Extremity
CM0555
History of the medicines taken by patients, Medication history for endocrine problems.
MedicationforEndocrineProblems
History of Medication for Endocrine Problems
CM0556
History of the medicines taken by patients, Medication history for ear, nose and throat (ENT) conditions and otolaryngology.
MedicationforENT
History of Medication for ENT
History of Medication for ear, nose and throat
CM1673
(NCI) The act of moving forward toward a goal.
Progress
CM0593
A record of a patient's medical background regarding psychiatric diseases.
Psychiatric
History of Psychiatric Symptoms & Diseases
CM0618
Finding from the examination for any painful sensation localized to the pharynx or surrounding anatomy.
Throat
Finding from an physical examination for throat
Finding, Throat examination
CM1760
(NCI) Relating to or occurring during the period immediately following a surgical operation.
Postoperative
Post-operative progress
(Wiki) Current health as a state dependent on the presence or absence of diseases
CurrentState
CM0558
History of the medicines taken by patients, Medication history for diagnostics.
MedicationforDiagnostics
CM0612
A record of a patient's medical background regarding skin diseases.
Skin
H/O: Skin Disorder
History of - Skin Disorder
Skin Disease History
CM0584
CM0158
(SNOMEDCT_US) An infusion of blood or blood product
Transfusion
Blood Transfusion
(NCI) Something that happens at a given place and time in medicine.
Event
CM0548
(CSP) non-invasive method of demonstrating internal anatomy based on the principle that atomic nuclei in a strong magnetic field absorb pulses of radiofrequency energy and emit them as radiowaves which can be reconstructed into computerized images; concept includes proton spin tomographic techniques.
(NCI) A procedure in which radio waves and a powerful magnet linked to a computer are used to create detailed pictures of areas inside the body. These pictures can show the difference between normal and diseased tissue. NMRI makes better images of organs and soft tissue than other scanning techniques, such as computed tomography (CT) or x-ray. NMRI is especially useful for imaging the brain, the spine, the soft tissue of joints, and the inside of bones.
MRI
Finding from Medical Imaging, Magnetic Resonance / Nuclear Magnetic Resonance
Finding, Magnetic Resonance Imaging Scan
CM0526
Finding from an ear examination, which is a thorough evaluation of the ears that is done to screen for ear problems, such as hearing loss, ear pain, discharge, lumps, or objects in the ear.
Ears
Finding from Clinical examination of ear
Finding, Examination of ear
History of the medicines taken by patients, Medication history for cardiovascular system.
MedicationforCardiovascular
History of Medication for Cardiovascular System
(Wiki) Total sum of a patient's health status prior to the presenting problem as including previous presence of the signs/symptom, allergies, family history, medicines.
PastHistory
Description of the primary symptom that a patient states as the reason for seeking medical care, or termed Presenting Complaint (PC)
ChiefComplaint
CM0585
History of unspecified diseases.
Other
Other Relevant Medical History
Immunization history