Question | Answer |
Sx | Symptons Subjective evidence of disease or physical disturbance |
Hx | History |
Px | An acronym for Physical Exam |
Dx | Abbreviation for Diagnosis |
MEDCIN | A medical, nomenclature and knowledge base developed by medicomp systems inc. It is incorporated in many commerical EHR systems |
DM | Diabetes Mellitus |
RX | Abbreviation for Therapy( including prescriptions) |
HEENT | An acronym for head, eyes, ears, nose, throat |
HIT | Acronym for health information technology also healthcare information technology |
GI/GU | Acronym for gastrointestinal/genitourinary |
ROS | Acronym for review of systems |
Sig | Instructions for labeling prescriptions |
URI | acronym for upper respiratory infection |
CC | Cheif complaint |
HPI | acronym for history of present illness |
E/M | evaluation and management codes |
PFSH | past history, family history, social history |
CBC | Complete blood count |
EMR | electronic medical record |
MDM | Medical decision making |
NEC | not elsewhere classified |
NOS | not otherwise spcified |
OIG | office of inspector general |
Primary diagnosis | main reason patient came to office |
ENT | ears, nose and throat |
Dis | apart |
-blast | immature cells, germ cells |
-dynia | pain |
-ar | pertaining to |
bradykinesia | slowness of motion or movement |
neuromyopathic | Pertaining to a disease, condition involving both nerves and muscles |
myofibroma | tumor that contains muscle and fiber |
myoplasty | surigcal repair of a muscle |
tenodesis | surgical binding of a tendon |
massage | kneading that applies pressure and friction to external body tissue |
con- | with, together |
quadri- | four |
dacty/o | finger and toes |
-oid | resemble |
-ceps | head |
=ure | process |
combination codes | a code from radiology section as well as a code from one of the other sections. must be used to fully describe the procedure |
multiple coding | also known as dual coding. use of more than one icd-9-cm code to identify both etiology and manifestopn of a disease |
morphology code | the science of the form and structure of organisms |
neoplasm | new tumor growth that can be benign or malignant |
in situ | malignancy that is within the orignal site of development and has not invaded neighboring tissue |
benign | not progressive |
malignant | used to describe cancerous tumor |
malignant hypertension | Accelerated severe form of hypertension, Manifested by headaches, blurred vision, dyspena and uremia usally cause permanment + organ damage |