High blood pressure layman's - ✔✔ Hypertension
Hypertension (abbv) - ✔✔ HTN
High cholesterol layman's - ✔✔
... [Show More] Hyperlipidemia
Hyperlipidemia (abbv) - ✔✔ HLD
Diabetes layman's - ✔✔ Diabetes mellitus
Diabetes mellitus (abbv) - ✔✔ DM
"I only take pills for my diabetes" - ✔✔ NIDDM (Type 2)
"I take insulin for my diabetes" - ✔✔ IDDM (Type 1)
Heart disease layman's - ✔✔ Usually coronary artery disease
Coronary artery disease (abbv) - ✔✔ CAD
Heart failure layman's - ✔✔ Congestive heart failure
Congestive heart failure (abbv) - ✔✔ CHF
Irregular heartbeat layman's - ✔✔ Atrial fibrillation (A-fib)
Murmur layman's - ✔✔ Heart murmur
Episodes of abnormally fast/racing heartbeat - ✔✔ Supraventricular tachycardia
Supraventricular tachycardia (abbv) - ✔✔ SVT
Emphysema or chronic bronchitis layman's - ✔✔ Chronic obstructive pulmonary disease (COPD)
Blood clot in lung layman's - ✔✔ Pulmonary embolism (PE)
Pneumonia (abbv) - ✔✔ PNA
Reflux layman's - ✔✔ Gastroesophageal reflux disease (GERD)
Gastroesophageal reflux disease (abbv) - ✔✔ GERD
Ulcer layman's - ✔✔ Gastric ulcer or Peptic ulcer disease
Crohn's or UC layman's - ✔✔ Crohn's disease or Ulcerative colitis
Irritable bowel layman's - ✔✔ Irritable bowel syndrome (IBS)
Irritable bowel syndrome (abbv) - ✔✔ IBS
Bladder infection layman's - ✔✔ Urinary tract infection (UTI)
Kidney infection layman's - ✔✔ Pyelonephritis (Pyelo)
Kidney stones layman's - ✔✔ Renal calculi
"I'm on dialysis" - ✔✔ Chronic renal failure (CRF) or End stage renal disease (ESRD) on dialysis
Enlarged prostate layman's - ✔✔ Benign prostate hypertrophy (BPH)
Document GPA for a pt who is currently pregnant, has been pregnant 3 times in the past, and has 2 kids at home. - ✔✔ G: 4 P:2 A:1
Stroke layman's - ✔✔ Ischemic cerebrovascular accident (CVA)
"Mini-stroke" layman's - ✔✔ Transient ischemic attack (TIA)
Seizures layman's - ✔✔ Seizure disorder / Epilepsy
Brain bleed layman's - ✔✔ Hemorrhagic CVA
Bipolar layman's - ✔✔ Bipolar disorder
Schizophrenia layman's - ✔✔ Schizophrenia
"I drink a lot" - ✔✔ EtOH abuse or Alcoholism
"I do drugs" - ✔✔ Substance abuse
"Blood clot in my leg" - ✔✔ Lower extremity deep vein thrombosis (DVT)
"Bulge in my aorta" or "Triple A" - ✔✔ Abdominal aortic aneurysm (AAA)
"Bad blood flow to my legs" - ✔✔ Peripheral vascular disease (PVD)
"Numbness in my legs" - ✔✔ Peripheral neuropathy (caused by DM)
"Low back pain" - ✔✔ Chronic lower back pain
"Bulging/herniated disc" - ✔✔ Degenerative disc disease (DDD)
Osteoarthritis (abbv) - ✔✔ (OA)
Rheumatoid arthritis (abbv) - ✔✔ RA
"Chronic joint pain" - ✔✔ Degenerative joint disease (DJD)
"Weak/fragile bones" - ✔✔ Osteoporosis (usually)
"Cancer" - ✔✔ Cancer or carcinoma (CA) and specify which (brain, breast, lung, colon, skin...)
"Spread to my..." - ✔✔ With metastases to the...
"Chemo" - ✔✔ Chemotherapy
"Radiation" - ✔✔ Radiation therapy
"They cut it out" - ✔✔ Status-post (s/p) surgical resection
"The cancer is gone" - ✔✔ In remission
Tonsils removed - ✔✔ Tonsillectomy
Adenoids removed - ✔✔ Adenoidectomy
"Ear tubes" - ✔✔ Pressure equalizer (PE) tubes
"Heart bypass" - ✔✔ Coronary artery bypass graft (CABG) (also PMHx CAD)
"Stents" - ✔✔ Coronary stents (also PMHx CAD) [Show Less]