Description CMO ID UMLS CUI ClinicalMetadata C0022885 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 Lab Findings Laboratory Test Finding Laboratory Test Result C0518766 CM0142 (MSH) The signs of life that may be monitored or measured, namely pulse rate, respiratory rate, body temperature, and blood pressure. VitalSigns Signs, Vital Vital Signs, Function (observable entity) C1879316 CM0158 (SNOMEDCT_US) An infusion of blood or blood product Transfusion Blood Transfusion Transfusions C0007203 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 CPR Cardio Pulmonary Resuscitation Heart resuscitation Resuscitation, Cardio-Pulmonary Resuscitation, Cardiopulmonary CM0501 Gait is evaluated by having the patient walk across the room under observation. Gross gait abnormalities should be noted in neurologic examination. CoordinationAndGait Finding by coordination and gait exam C0000726 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 C0184666 CM0503 (SNOMEDCT_US) Performance of the steps necessary to admit a patient to a hospital. Admission Admission to hospital Hospital admission C0559546 CM0504 (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) C0489531 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 C0199747 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 allergies tests C0002903 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 Administration of anesthesia Anaesthesia Anesthesia procedure Anesthesias Generic anaesthesia procedure Procedure anesthesia C2346834 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 C0004398 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 Necropsy Post-Mortem Examinations 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 C0040405 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. CT Computerized Axial Tomography, Finding Computerized Tomography Finding, CT scan as Radiology Test Result of CAT scan test Tomography, X-Ray Computer Assisted X-Ray CT Scans C0018803 CM0513 (Wiki) Result of the test for identifying heart conditions associated with healthy vs. unhealthy, pathologic, heart function. HeartFuncgtionTest Cardiac function testing Finding from Cardiac Function Tests Result of Heart Function Tests Tests, Cardiac Function Tests, Heart Function C1880008 CM0514 (NCI) A record of a patient's medical background regarding cardiovasular diseases. Cardiovascular Cardiovascular Disease History C0277786 CM0515 Description of the primary symptom that a patient states as the reason for seeking medical care, or termed Presenting Complaint (PC) ChiefComplaint CC Complaints present Presenting complaint C0558819 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 Finding by cranial nerve examination cranial nerve examination C0010819 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 Biology, Cellular Cell Biologies Cellular Biology Finding from Cytology field C1306577 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 C0011298 CM0520 (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 C0678257 CM0521 A detailed account of the certain characteristics, or symptoms of a patient provided by themselves or their family Description DESCR Descriptive Descriptor C0011900 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 Dx C0030685 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 C0683519 CM0524 A record of a patient's medical background regarding certain disease. DiseaseHistory Diseases history History disease C0278350 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 C0455216 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 C0013798 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 C0013819 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 electroencephalogram C0013839 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 EM-Electromyography EMG - Electromyography Finding from EMG - Electromyography Result of electromyography C0013956 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 C0455484 CM0531 A record of a patient's medical background regarding endocrine related diseases. Endocrine Endocrine Disease History Hx of Endocrine Disorders C0014245 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 Inspection using endoscope C0441471 CM0533 (NCI) Something that happens at a given place and time in medicine. Event Events C0015392 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 C0015450 CM0535 Finding from a physical exam for symmetrical facial features. Face Result of Physical Examination of Face C0241889 CM0536 (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 FH - Family history Family Medical History Family health history Family history with explicit context C0243095 CM0537 (Wiki) The collective physical and psychological occurrences of patients surveyed or proceeded by a medical doctor. Finding Investigation Finding C0562233 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 C0521316 CM0539 (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 Gallium Scanning Result of Gallium Scan Test C0455553 CM0540 A record of a patient's medical background regarding gastrointestinal diseases. Gastrointestinal H/O: GIT Disease H/O: Gastrointestinal Disease History of Gastrointestinal Disease C0455554 CM0541 A record of a patient's medical background regarding genitourinary diseases. Genitourinary History of Genitourinary Systems Disorders History of Symptoms & Diseases of Genitourinary Systems Hx of GU Disorders C0018670 CM0542 Finding from an physical examination for head Head Finding, Head examination C0018786 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 Audiometric Test Audiometry Auditory acuity evaluation Finding from Audiometric Test Finding from Clinical test of hearing Result of HT - Hearing test C0279025 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 Therapy, hormone C0023017 CM0545 (MSH) Rehabilitation of persons with language disorders or training of children with language development disorders. LanguageTherapy Language Therapies Language Therapy Therapy, Language C0455550 CM0546 A record of a patient's medical background regarding liver diseases. Liver History of Hepatic Organ System Liver Disease History C0047506 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 Result of MIBG Scan Test metaiodobenzylguanidine (MIBG) scan C0024485 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 Magnetic Resonance Imaging Magnetic Resonance Imaging Scan Result of MRI Scan Test C0024687 CM0549 Finding from the physical examination on mandible. Mandible Result of Physical Examination of Mandible CM0550 History of the medicines taken by patients, Medication history for allergic disorders. MedicationforAllergicDisorders History of Medication for Allergic Disorders CM0551 History of the medicines taken by patients, Medication history for cardiovascular system. MedicationforCardiovascular History of Medication for Cardiovascular System 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 CM0553 History of the medicines taken by patients, Medication history for contraception. MedicationforContraception History of Medication for Contraception CM0554 History of the medicines taken by patients, Medication history for diagnostics. MedicationforDiagnostics History of Medication for Diagnostics 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 CM0557 History of the medicines taken by patients, Medication history for euthanasia. MedicationforEuthanasia History of Medication for Euthanasia CM0558 History of the medicines taken by patients, Medication history for eye conditions and eye diseases. MedicationforEye History of Medication for Eye CM0559 History of the medicines taken by patients, Medication history for gastrointestinal and astroenterology. MedicationforGI History of Medication for gastrointestinal CM0560 History of the medicines taken by patients, Medication history for immune system. MedicationforImmuneSystem History of medication for Immune System CM0561 History of the medicines taken by patients, Medication history for infection and infestation. MedicationforInfectionAndInfestation History of Medication for Infection and Infestation CM0562 History of the medicines taken by patients, Medication history for musculoskeletal disorders. MedicationforMusculoskeletalDisorders History of Medication for Musculoskeletal Disorders CM0563 History of the medicines taken by patients, Medication history for neoplastic disorders. MedicationforNeoplasticDisorders History of Medication for Neoplastic Disorders CM0564 History of the medicines taken by patients, Medication history for nutrition. MedicationforNutrition History of Medication for Nutrition 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 CM0566 History of the medicines taken by patients, Medication history for pain and consciousness. MedicationforPainAndConsciousness History of Medication for Pain and Consciousness 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 CM0569 History of the medicines taken by patients, Medication history for skin. MedicationforSkin History of Medication for Skin C1273865 CM0570 History of the medicines taken by patients. MedicationHistory Past medication history C0278060 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 (observable entity) Mental state finding C0596962 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 Pathology, Molecular C1513492 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 Finding by motor system exam motor movement C0230028 CM0575 Finding from the physical examination on mouth. Mouth Examination of mouth Oral Examination Result of Physical Examination of Mouth C0559112 CM0576 A record of a patient's medical background regarding musculoskeletal diseases. Musculoskeletal H/O: Musculoskeletal Disease History of - Musculo-skeletal Disorder History of - Musculoskeletal Disease C0027530 CM0577 Finding from the neck examination that includes neck inspection, neck palpation and cervical movement. Neck Result of Physical Examination of Neck neck maneuvers (examination of neck) C3262422 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 C0027853 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 Finding from Neurologic Examination Neurological exam C0426407 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 C0203634 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 C1541629 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 OB-GYN History Obstetrics and Gynecology Disease History C1318464 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 C0744961 CM0584 A record of an individual's background in regard to surgical operation. OperationHistory History surgical C3844570 CM0585 History of unspecified diseases. Other Other Relevant Medical History C0029484 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 C0002424 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 C1699633 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 Result of PET-CT Scan Test C0455458 CM0590 (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 Medical History PMH Personal Medical History C1317598 CM0591 Finding an essential nature of disease. PathologicFindings Pathologic Finding C0030797 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 C0205487 CM0593 A record of a patient's medical background regarding psychiatric diseases. Psychiatric History of Psychiatric Symptoms & Diseases C0031809 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 C0949766 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 Physical Therapy Procedure C0033968 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 C0599880 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 C0162701 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 Full sleep study Result of Sleep recording C0033080 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 C0262512 CM0601 (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 HO History of present illness PI - Present illness C1948041 CM0602 (NCI) In medicine, a treatment or action taken to prevent or treat disease, or improve health in other ways. Procedure Intervention or Procedure Medical and Surgical (procedure) C0024119 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 Function Tests, Lung Function Tests, Pulmonary PFT - Pulmonary Function Test Result of Lung Function Tests C1962945 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 Radiology, General Finding Result of Radiology Test C1522449 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 Cancer Radiotherapy Irradiation RT Radiation Therapy Radiotherapeutics Therapy, Radiation C0034929 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 C0034991 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 Care rehabilitation Rehabilitation care Rehabilitation program Rehabilitation treatments Rehabilitation treatments and procedures Therapy rehabilitation Treatment rehabilitation C0455540 CM0608 A record of a patient's medical background regarding respiratory diseases. Respiratory History of - Respiratory Disease Respiratory Disease History C0489633 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 Finding by Review Systems ROS Review of Systems (finding) C0445254 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 Finding by sensory system exam C0455569 CM0612 A record of a patient's medical background regarding skin diseases. Skin H/O: Skin Disorder History of - Skin Disease History of - Skin Disorder Skin Disease History C0424945 CM0613 (NCI) Past events that occurred between individuals and/or their communities. SocialHistory Social and personal circumstances C0038663 CM0614 (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 C0543467 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 Surgical Procedure, Operative C0030669 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 pathology surgical C0392366 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 Diagnostic Test Result C0426483 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 C0000932 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 C0043251 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 C0087111 CM0621 Medical/surgical/therapeutic management of the patient, the presenting problem and its cause/s. Treatment Procedure - therapeutic Therapeutic Interventions Therapeutic Technique Therapeutic method Therapeutic procedure Therapy C0041618 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 US - Ultrasound USS - Ultrasound scan ultrasound imaging/scanning ultrasound scanning C1524119 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 CM0624 Finding from an examination in the vascular system. Vscular Result of Physical Examination of vascular system. C0043539 CM0626 Finding from the physical examination on zygoma. Zygoma Result of Physical Examination of zygoma C0199850 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 C0001683 CM0628 (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 Advanced directive Directive, advance C0239110 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 C1515974 CM0630 Named locations of or within the body from medical finding. FindingByAnatomicSite Finding by Anatomic Site C1704254 CM0631 (NCI) Any record of a medical imaging event whether physical or electronic. FindingByImage Finding by Image C0020971 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 History immunizations Immunization history C1547635 CM0634 Someone as a payer if they pay a particular kind of hospital or medical bill or fee. Payer Payor C0040291 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 C0012155 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 Dietary Procedure C0220825 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 C1947978 CM1647 (NCI) Each individual, unique interaction between two subjects of interest. Encounter C3262595 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 C3261183 CM1650 A record of a patient's medical background regarding diseases in pediatrics. Pediatrics Pediatric Disease History CM1651 A record of a patient's medical background regarding rectal diseases. Rectal Rectal Disease History C0425963 CM1652 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 History obstetric C0419179 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 NBM - Nil by mouth NPO - Nothing by mouth Patients starving Starving the patient C0553618 CM1654 Any visit made during the person's reference period to a hospital emergency room. EmergencyVisit Emergency Visits C0589120 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 C0034866 CM1657 (NCI) Advice telling someone what the best thing to do is. Recommendation Recommended C1705822 CM1658 (NCI) The act of conveying or transporting from one place to another. Transfer C0009566 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 C0027627 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 Metastasis tumor Metastatic disease Metastatic neoplasm Secondary malignancies C0488609 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 Gneral Findings CM1664 Finding from a physical examination, or when a patient presents with a respiratory problem (shortness of breath, cough, chest pain). Chest Chest Examination Result of Physical Examination of Chest CM1665 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 Result of Physical Examination of Hair C0562319 CM1666 Finding from the cardiac examination for dealing with chest pain suggestive of a cardiovascular pathology. Heart Result of Physical Examination of Heart C0438125 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 C0024109 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 Result of Physical Examination of Lung C0024204 CM1669 Finding from the physical examination on lymph nodes. LymphNode Result of Physical Examination of Lymph node C0037949 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 C0033213 CM1671 (NCI) A difficulty, disorder, or condition needing resolution. Problem Issue C0033325 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 C1280477 CM1673 (NCI) The act of moving forward toward a goal. Progress C0311392 CM1674 (NCI) Objective evidence of disease perceptible to the examining healthcare provider. Sign Physical finding Physical sign Signs - physical C1457887 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 Symptom (finding) Symptoms C0009818 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 C0011946 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 C0152053 CM1679 Part of job as a nursing assistant is to help patients with activities of dressing. DressingPatiet Assisting with dressing Dressing - nursing care Nursing care - dressing C0030688 CM1680 (MSH) The teaching or training of patients concerning their own health needs. Education Education of Patients Education, Patient Patient Education C0392920 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 Administration of antineoplastic agent Cancer chemotherapy Cancer chemotherapy regimen Chemo Chemotherapy Regimen Chemotherapy Regimen or Agent Combination Chemotherapy, Cancer, General Combination Chemotherapy Regimen C0746467 CM1682 Medication list at the present time from prescription. CurrentMedication Current Medication prescribed medication current C0262926 CM1683 (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 Hx C0040732 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 Transplantation procedure Transplanting Tx - Transplant C0556303 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 Alcohol use Hx Reported History of Alcohol Use Narrative C1519384 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 Smoking History C2243117 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 Cardiac Echo Finding from Echocardiography Heart Sonography Result of Ultrasound Heart Scan C0013801 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 Result of Holter Monitoring C0684322 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 Emotional State Observations C0026516 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 Finding by patient mood Finding of level of mood C0920485 CM1752 Planned education program designed for a particular patient for their current issue of health EducationPlan planning education CM1753 Health problems that are caused by pregnancy AbnormalHistoryOfPregnancy Abnormal History of Mother Pregnancy Pregnancy Complications discomforts of pregnancy C3166194 CM1754 (Wiki) Current health as a state dependent on the presence or absence of diseases CurrentState Health Status C0234421 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 C0598463 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 C0000768 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 Congenital deformity Fetal developmental abnormality C0456904 CM1758 (NCI) Occurring during the course of a surgical procedure. Intraoperative Intra-operative progress C0445204 CM1759 (NCI) Relating to or occurring during the period immediately before a surgical operation. Preoperative Pre-operative progress C0032790 CM1760 (NCI) Relating to or occurring during the period immediately following a surgical operation. Postoperative Post-operative progress CM1761 a symptom that is evident to the observer ObjectiveSymptom Finding by Objective Symptoms C2266644 CM1762 Found symptom by personal perspective and discovery of the clinician SubjectiveSymptom Finding by Subjective Symptoms subjective (symptom) C0019004 CM0510 CM1763 (CSP) Therapy for the insufficient cleansing of the blood by the kidneys based on dialysis. Hemodialysis Extracorporeal hemodialysis HD - Hemodialysis C0031139 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 C2930505 CM1765 (MSH) Planned care program designed for a particular patient usually reflecting patient and family goals as well those institution and healthcare providers. CareGoal Care Goals Goals of Care C0178916 CM1766 Direction on the type of clinical care CarePlan Care Plans Plan of care TP - Treatment plan care planning C0032967 CM1767 (Wiki) Medical histroy of the state of carrying a developing embryo or fetus within the female body PregnancyHistory H/O: pregnancy Histories, Pregnancy History of - pregnancy History of pregnancies CM0504 C0034866 C0744961 CM0553 C0518766 Payor History disease C0262512 Advanced directive C0020971 Directive, advance C0556303 CM0590 Social and personal circumstances C0683519 CM0560 CM0601 C0033325 History immunizations C0424945 CM0537 CM0563 FH - Family history C0013956 Events Vital Signs, Function (observable entity) C0000768 CM0536 C0243095 C1947978 CM0557 C0029484 Arousal C0277786 CM0613 C0011900 Family health history C1524119 C0038663 Alert CM0629 C1515974 C1519384 CM0568 C0152053 C1513492 CM0552 C0043539 Personal Medical History CM0550 CM0515 C0001683 C0030797 C0455458 C3262595 CM0503 Signs, Vital C0000932 CM0566 C0234421 PI - Present illness Alcohol use Hx Reported CM1683 C0027530 C0031809 CM0569 Epidemiology, Family Medical History C0009566 CM1652 Past medication Admission to hospital CM0561 C0030685 C1705822 Medical and Surgical (procedure) CM1747 C0011298 C0024109 C0024204 C0012155 C1547635 Personal and social circumstances Demography CM0521 CM0533 H&P.HX CM1746 C0220825 C0425963 CM0570 Intervention or Procedure C0489531 CM0551 Presenting complaint CM0632 CM0564 C0558819 C0559546 CM0559 CM0562 C0598463 CM1646 CM1647 CM0554 Evaluation Procedure C0392366 Complaints present CM0567 CM1649 C0553618 C0678257 C0445204 CM0520 History obstetric Hospital admission C0241889 C1273865 History of present illness C0262926 C3166194 Descriptor Descriptive C0024687 CM0628 CM0634 C0441471 Investigation Finding C0230028 Evaluation C0239110 CM0524 CM0565 C0043251 Family Medical History C0002424 History of Alcohol Use Narrative C0589120 CM0628 CM0555 CM0558 CM0142 CM0584 C0007203 C0184666 C0455484 CM0556 C0456904 C2266644 C1948041 C0684322 Immunization history CM0568 History of the medicines taken by patients, Medication history for respiratory system. MedicationforRespiratorySystem History of Medication for Respiratory System