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Revised on Friday, August 4, 2006 by Stacy Rhee
Diagnosis
A Fib (Atrial Fibrillation or
Flutter) AFB (Acid-Fast Bacilli/
Bacillus) AFP (Alpha Fetoprotein) ABD Pain/ Weight Loss Abdominal Liver Function Study Abdominal Pain/ Bloating/ Food Related
Sys Abnormal Blood Chemistry Abnormal Bone Scan/ BP Abnormal Incompatibility Abnormal Pap smear Abortion Abscess Absent, Scant, Rare
Menstruation Accelerated Ace Inhibitor Therapy Acid. Peptic Disease, Stomach Acidosis Acne Rosacea Actinic Keratosis Acute Radial
Artery Occlusion A D D ADDM ADH (Antidiuretic Hormone) Adenitis/ Lymphadenitis Adnexal Mass Adverse Effects AHI (Apnea/ Hypopnea Index) AICD (Automatic Implantable Cardioverter
Defibrillator) Alcoholic Ketoacidosis Allergic Reaction/ Rhinitis Allied Condition Alopecia Alveolar Ventilation Alzheimer AMI (Acute Myocardial
Infarction) Amenorrhea Anal Fissure/ CA Anasarca Anatomy & Dates Anemia F-2 Aneurysm Angina Pectoris Angiosarcoma Scal Ankle Pain/ Injury Anosmia Anticoagulation Therapy Antidiuretic Hormone ANVD (Anorexia, Nausea, Vomiting,
Diarrhea) Anxiety Disorder/ Panic Aortic Aneurysm/ Stenosis APH (Anterior Pituitary
Hormone) ARD (Acute Respiratory
Disease) Arm Pain to
Hand
Arrhythmia,
Maternal age Arterial Arteritis Arthritis Rheumatoid Artherosoler, Excl Hear &
Brain Arthropathy a.s. (Aortic Stenosis) Ascites ASHD (Arteriosclerotic Heart
Disease) Aspiration Asthma Asymmetric Hearing Atherosclerosis/ Coronary Graft/ Native
Vessel Atrial Fibrillation Axillary B&C (Bleeding &
Clotting) Back Pain/ Radiates To/ Spasms Bacteremia Baker’s Cyst, Knee Bartholin’s Gland Cyst Basal Cell Baseline Mapping for Beckwith-Wiedemon Bell’s Palsy Benign Hypertention Benign Neoplasm of Colon/
Meninges Benign Prostatic Hypertrophy Bilateral Feet Stress
Fxs (Fracture)
Bilateral Lower
Extremity Pain Bilateral
Nodules Bipolar
Dis Bladder
CA BLE (Bilateral
Lower Extremities) Bleeding During
Pregnancy Blepharitis/ Sty/
Chalazion Blockage in
Tubes BP (Blood
Pressure) BPH (Benign
Prostatic Hypertrophy Brachial
Arthery Bradycardia Brain Paresthesia/ Tumor Breast CA2 Positive / Lump Bronchiolitis Bronchities, Acute/ Chronic Bronchus Bruise, Contusion Crush Bruit – Arterial BSO (Bilateral
Salpingo-Oophorectomy) BUE (Bilateral Upper
Extremities) Bulging BUN (Blood Urea Nitrogen) Burns & Scalds, All
Degrees Bursitis BUS (Barthollin’s, Urethral, and Skene’s
(glands) Bx (Biopsy) Ca (Calcium) CA (Carcinoma) CAD (Coronary Artery Disease) Calculus of Kidney Calf Edema
Carbohydrate Carbon
Dioxide Carbuncle Carotid endarterectomy Carpal Tunnel
Syndrome CAPD (Continuous
Ambulatory Peritoneal Dialysis) Carotid
Stenosis Cataract CBC (Complete
Blood Count) CBI (Continuous
Bladder Irrigation Cellulitis Cerebral CVA
(Cerebrovascular Accident) Cerebral
Edema Cervical Spine
Syndromes/ Pain/ Myopathy Cervicitis Circulatory CHD (Coronary
Heart Disease) Chest Nodules/ Wall Pains &
Ribs CHF (Congestive Heart Failure) Chickenpox Cholecystitis Chondromalacia Chronic HEP C W/O Coma Chronic (chr) Renal
Insufficiency Chronic Serous Otitis Media Circulating Anticoag Dis CIRC (Circumcision) Cirrhosis CIRC (Circumcision) CK (Creatinine Kinase) Claudication Clavicular Sclerotic CML (Chronic Myelogenous
Leukemia) CMS (Circulation, Motion and
Sensation) CNS (Central Nervous System) CO2 (Carbon Dioxide) Coagulation Cognitive Impairment Colon Cancer/ Polyp Colovaginal Fistula Compression FX (Fracture) Concave Concussion Confirm Cyst Confusion Difficulty Congestive Heart Failure Conjunctivitis &
Ophthalmia Consistency Constipation Abd Pain
GI Contusion Convalescent Convulsive Epilepsy COPD (Chronic
Obstructive Pulmonary Disease) Coronary Heart
Disease/ Graft/ Atherosclerosis Costal
Pain Costochondritis Cough Coumadin Use/
Therapy CPR
(CardioPulmonary Resuscitation) Crackles Cradle
Cap Creatinine
Crohn’s Disease Croup CTS (Carpal Tunnel
Syndroms) CVA
(CerebroVascular Accident) CVD
(CerebroVascular Disease) Cyst Ovary Ovarian Cystitis & Urinary Tract
Dis. Cystocele Deafness Decreased Mentation Deep Laceration Deep Vein Thrombosis Degenerative Joint Disease Dehydration Delirium Density Depo Provera Depression Diabetes Uncompleted Type II Diabetes Renal Manif Type II Diaper Rash Diarrhea/ Enteritis Digestive Dilopia Claustro Disc DZ Radiculopathy Discrepancy Dislocation, Finger, Radius, Proximal End,
Shoulder Diuretic Diverticular Disease of Intestine/
Diverticulitis Dizziness & Giddiness/
Vertigo DJD (Degenerative Joint
Disease) DM (Diabetes Mellitus) Type II, Non Insulin/ Insulin
Dep DNR (Do Not Resuscitate) DOE (Dyspnea On Exertion) Dorsum Sella Chordoma Drug Reaction Dub. Enlarged Uterus Duodenal Ulcer w/wo Comp DVT (Deep Vein Thrombosis) Dysfunc. Uterine Bleeding Dysmenorrhea Dyspepsia Dysphagia Dysplasia of Cervix/ Hip Dyspnea/ Hypoxia Dysuria Ear Pain/ Numbness Early Menarche Ectopic Beats All Types Eczema & Contact Dermatitis
Nec. Edema Elbow Pain Electrolyte and Fluid Disorders
Nos Elevated Blood Glucose Elevated Creatine Elevated Liver Enzymes Elevated Prostate
Spec Antigen Embolism &
Thrombosis Nos Emesis Emphysema &
COPD Encephalopathy Endocrine Endometriosis/
Endometrial CA Enema Enteritis Enterocolitis Enuresis Eosinophil
Epididymitis Epidural
PAC Epigastric Ruq
Pain Epilepsy Epistaxis Erythropoietin Esophageal
Obstruciton Esophagitis /Reflux/ Vomiting Etiology
undetermined Evaluate for
Abnornal Excessive
Menstruation Exacerbation of
Asthma Exophasia Family Hx –
Ischemic Heart Disease Fatigue, Malaise Febrile Seizure Fell on Outstretched hands Fetal/ Neonatal Jaund Nos Fetal Anomaly Screen/ Survey Fetal Well Being Fever
FHR (Fetal Heart Rate) Fibrocystic Breast Disease Fibromyalgia Fibroid Muscular Dysplasia Fibroids/ Pelvic Pain Fistula btwn
Bladder/Bowel prv ct Flank
Pain Folliculitis Foreign body in
Tissue Fracture/ Scaphoid F/U Single Umbilical Arthery Fx (Fracture) Gait Disturbance Gallbladder Disease, Acute Ganglion Gas Edema Gastritis General contraceptive guidance Genitourinary GERD (Gastroesophageal Reflux
Disease) Gestational Diabetes GI (Gastrointestinal) Bleed Giddiness & Dizziness Gingivitis Goiter Gout Gouty Nephropathy Graft Groin GYN (Gynecology) HA’S Hallux Pain Head & Neck CA Headaches Heart Failure, R/L Sided Heartburn Heel Pain Helicobacter Pylori Hemangioma Hematemesis Hematuria Hemoptysis/ Hemoptysia Hemorrhoids Hemothorax Hepatitis, Acute Hepatoma Hernia Hiatal/ Inguinal Herpes Simplex/ Zoster High Grade Right Carotid High Platelets HTN (Hypertension) Involved Target
Oran Hx (History) Hydrocele Hydronephrosis/
Fatty Hyper Prost W/ Urine Obst Hyperbilirubinemia/ Icterus/
Jaundice Hypercholesterolemia Hypercoagulable GI Bleed Hyperemesis Hyperlipidemia Nec Hyperglycemia Hyperkalemia hyperlipidemia Hyperparathyroidism Hypertension On Diuretic Hyperthyroidism Hypoglycemia Unspec Hypomotility Hyponatremia Hypothyroidism Hypoxia Icterus/ Jaundice/
Hyperbilirubinemia IDDM (Insulin Dependent Diabetes
Mellitus) Ileitis Impetigo Impingement
C4-5-6 Impotence Incontinence Increased Brain
Tumor Infective &
Parasitic Infertility Female 628.9 Male 606.9/ Infantile
Colic Influenza Ingrowing Nail Injuries & Adverse Effects Increased Liver Enzymes Indigestion Insect Bite and Sting Insertion, Intrauterine Devices
Insomnia & Other Sleep
Dis. Intermenstruation Bleeding Intermittent Exophasia Intrauterine Devices,
Insertion Iron Deficiency Irrit Bowel Syn/ Intest Dis.
Nec. Ischemic Heart Disease Iscities Jaundice/ Icterus/ HyPerbilirubinemia,
Newborn Keratoacanthoma Kidney Stone Knee Pain Labial Labral Tear L Shoulder/ L Hip Labyrinthitis Laceration/ Open Wound Lactation Education Langerhans of Pancreas Laryngitis & Tracheitis Late Care Gestational LBP (Low Back Pain) Lesion on R Kidney Letter Forms Presc. w/o Exam LFT (Liver Function Tests) Limb Pain/ Osteo Lipid Liver Cyst/ Mass Lobe Nodule/ Poss Pneumonia Long-Term Lost IUD (Intrauterine Device) Low Back Pain (LBP)/ Stenosis Lumbar Radiculopathy Lump On Right Wrist Lung/ Kidney Lesion Lymph
Nodes Lymphadenitis/
Lymphadenoma Lymphoma, Nos Extranodal Malabsorption Malaise/
Fatigue Malignant Neoplasm
of Breast/ Bronchus/ Colon/ Lung/ Prostate Malleolar
Fracture Mass in RLQ/ on Rt
Mastoid Mastitis Medical Exam
(Camp, DMV, School) Melana (LGI Bleed.) Melanoma Staging on Back Memory Loss Menarche Menopausal Symptoms Menorrhagia Mental Disorders Metabolic Acidosis Metastatic
Carcinoma/ Rectal CA MI (Myocardial Infarction) Microhematuria Migraine Mitral Valve
Disorder/ Stenosis Mixed
Hyperlipidemia Monoclon
Paraproteinemia Mononucleosis MS (Mitral
Stenosis) Multiple Myeloma
w/o Mention of Remission Musculoskeletal
Connective Tissue Mylanoma Myeloma Myocardial Infarction Myofascial Pain Myoma Nasal Congestion/ Polyp/
Sinusitis Nausea Persistent/ Vomiting Neck Pain w/
Radiculopathy Neoplasm Breast/ Spine Neoplasm of Unc Behavior
Lymphatic Nerve system, Sense Organ Dis. Neuropathy Nevus New Onset of HA’s Nipple Dimpling/ Discharge Abn Nodular Goiter Nontox Multinodul Goiter Normal Delivery NOS (Not Otherwise Specified) Numbness/ Pain Nursery NVD (Nausea, Vomiting,
Diarrhea) OA (Osteoarthritis) OB (Obstetrics) Obesity OBS (Organic Brain Syndrome) Occlusion Rle Octreo Scan Onychomycosis Ophthalmia &
Conjunctivitis OPIS (OutPatient Immunology
Services) Oral Contraceptives Methods Orbital CA Organomegaly Osteoarthritis & Allied
Condition Osteoporosis Osteopenia Other Injuries & Trauma Other Malaise and Fatigue Other Viral Exanthems Otitis Externa/ Media Ovarian Cyst Noted On PAD (Pulmonary Artery
Diastolic) Pancreatic Mass Pancreatitis Panic/ Anxiety Disorder Paraproteinemia Parasite Disease/ Infect Nos Parasitism Parasitosis paresthesia Parkinsonism Parotid
Mass Partial Right
Thyroidism Persistant Pain W/Snapping Pelvic Abscess/ Inflammatory
disease Pelvictasis Pericardial Disease Peripheral Neuropathy/ Vessel
Dis Pesudomonas Pneumonia PET (Positron Emission
Tomography) Pharyngitis Phenylketonuria Pilonidal Cyst Pityriasis rosea Plagiocephaly Pleuropneumonia Plueral Effusion Plueral Thickening Pos Pet Plum Abscess Pneumonia/ Pneumothorax Polycythemia Polyps/ Sinusitis Polyhydroaminos Positive AFP (alpha
fetoprotein) Positive PPD (Purified Protein Derivative) Hx
(History) PostPartum Care Post Pyelopathy Post Term Pregnancy Postmeno bleed PPD (Purified Protein
Derivative) Pre-Eclampsia Pre-Op Physical Prediabetes Pregnancy Prenatal Care Preterm Labor Preumbilical/ Pelvic Projectile Vomiting Prostate CA (Testosterone test)/
Prostatitis Proximal Muscle Weakness PSA Elevated Psoriasis PTH Level 478 Pubic Ramus Pulmonary Edema/ Tuberculosis Pulsating Pure Hypercholesterolemia Purulent Pyelonephritis Pyeloplasty/
Pyelopathy Pylori Quinsy &
Tonsillitis R 10th
Rib Lesion Radial Artery
Occlusion Radiculapathy Radio
Ablation Rare Menstr. Recurrent UTI Rectal CA Reflex
Esophogitis Reflux/ Vomiting / Esophagitis Renal Calculus/ Failure/ Insufficiency/
Lesions Renal Mass US (UltraSound) Done/ Ureter
Disorder Respiration Distress/ Tract
Infection Restaging Colon CA RHD (Rheumatic Heart Disease) Rheumatoid Arthritis & Allied
Condition Rhinitis/ Prulurent RLQ Abd
Pain Routine Medical
Exam (V700)/ Gyn Exam Rotator Cuff
Tear Rupture
Membranes RUQ Pain/ Hx
(History) Salpingo-oophorectomy Salpinx Sarcoidosis T-12. Hx Scalds & Burns, All
Degrees Scant, Rare Menstr. Sciatica Disabling Pain Rt Sclerosis Density Screen – Phenylketonuria Screening Exam for Venereal
Disease Sebaceous Cyst Seborrhea Dermatitis/
Keratosis Seizure/ Convulsion/ Paroxysm Serous Otitis Med Severe Hip Pain Severe HA’S Severe HA’s
Blurred Vision Severe Sciatica Severe Scoliosis Sexual Dysfunction Shin Splints Shoulder Pain Sided
Ha’s Sinus Pressure/
Sinusitis Situation
Reaction Size Smaller/ Larger Than Dates
Discrepancy Skin Tags/ Disorder Nos Slight Elevated Creatinine Small Bone for Age SOB (Shortness of
Breath) Soft Tissue Mass
on T-Spine Probable Spasm Spec Screen
Malignant Neop Ovry/ Prostate Spinal
Stenosis Spontaneous Sprain/ Strain
Ankle, Foot, Toes, Knee, Low Leg, Shoulder, Arm
Vertebra Exc. Neck, Wrist Hand Finger, All Other Sites
Nec. Sputum Aerobic
Fungal Afb Cx St Jude
Avr Staging Breast
CA Stat Status Post
Diverticulitis Steatohepatitis Stenosis Sterilization Sternum Injury Stomatitis/ Stomach pain/ GERD Strep Throat Stress Fracture in Bilateral Stroke Superficial Phlebitis SVT (SupraVentricular
Tachycardia) Swelling Lf Foot Syncope/ Faint/ Blackout Syst Lupus Erythematosis Tachypnea/ Tachycardia Temporal Lobe Seizures Tenderness Tendonitis Tension Headache Terminal Ilio Inflammation Thorasic
AVM Throat Thrombophlebitis Thyroid CA/ Toxicosis Nos Thyroid Nodule TIA (Transient Ischemic
Attack) Tia Loss of Vision Tibia Plateau Fracture Tinea Corporis Tinnitus Titer Toe Pain Tonsillitis & Quinsy/ Tonsil
CA Toxicosis Tracheitis & Laryngitis Transient L Hand/ Foot w/
Ataxia Transitory Tachypnea Newborn Trapezius/ Strain
Trauma to L Shoulder Tremor Trigeminal Neuralgia Triglycerides Tubercular/ Tuberculosis UC (Uterine Contraction) Ulceration Ulcerative Colitis Ulnar Impaction Syndrome Umbilical Arthery Unsure Dates Upper Respir. Tract Inf. Urethritis Urticaria (Rash) UTI (Urinary Tract Infection) Uterine Bleeding/ CA/
Contraction Vaginal Discharge/ Pregnancy Vaginal/ Vaginitis NOD
Vulvitis Varicocele Varicose Veins of Legs Valve Disease VDH (Valvular Disease of the
Heart) Venereal Disease Venous Thrombosis Nos Ventral Hernia Abd Pain Ventricular Fibrillation Vertigo Vomiting/ Nausea Warfarin Rx And Bleeding Warts, Genital & Plantar/ All
Sites Wax in Ear Weight Loss Unexpected Well Child Care Well Woman Exam, Medicare Low/ Medium/
High Wheeze Worsening Low Back Pain Wrist Pain
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