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skills/clinical-reports/references/medical_terminology.md

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+# Medical Terminology and Coding Standards
+
+## Standard Nomenclature Systems
+
+### SNOMED CT (Systematized Nomenclature of Medicine - Clinical Terms)
+
+**Purpose:** Comprehensive clinical terminology for electronic health records
+
+**Coverage:**
+- Clinical findings
+- Symptoms
+- Diagnoses
+- Procedures
+- Body structures
+- Organisms
+- Substances
+- Pharmaceutical products
+- Specimens
+
+**Structure:**
+- Concepts with unique identifiers
+- Descriptions (preferred and synonyms)
+- Relationships between concepts
+- Hierarchical organization
+
+**Example:**
+- Concept: Myocardial infarction
+- SNOMED CT code: 22298006
+- Parent: Heart disease
+- Children: Acute myocardial infarction, Old myocardial infarction
+
+**Benefits:**
+- Enables semantic interoperability
+- Supports clinical decision support
+- Facilitates data analytics
+- International standard
+
+### LOINC (Logical Observation Identifiers Names and Codes)
+
+**Purpose:** Universal code system for laboratory and clinical observations
+
+**Components of LOINC code:**
+1. **Component** (analyte or measurement): What is measured
+2. **Property**: What characteristic (mass, volume, etc.)
+3. **Timing**: When measured (point in time, 24-hour)
+4. **System**: Specimen or system (serum, urine, arterial blood)
+5. **Scale**: Type of result (quantitative, ordinal, nominal)
+6. **Method**: How measured (when relevant to interpretation)
+
+**Examples:**
+- **Glucose [Mass/volume] in Serum or Plasma**: 2345-7
+  - Component: Glucose
+  - Property: Mass concentration
+  - Timing: Point in time
+  - System: Serum/Plasma
+  - Scale: Quantitative
+
+- **Hemoglobin A1c/Hemoglobin.total in Blood**: 4548-4
+  - Component: Hemoglobin A1c/Hemoglobin.total
+  - Property: Mass fraction
+  - Timing: Point in time
+  - System: Blood
+  - Scale: Quantitative
+
+**LOINC Parts:**
+- Document types
+- Survey instruments
+- Clinical attachments
+- Radiology codes
+- Pathology codes
+
+### ICD-10-CM (International Classification of Diseases, 10th Revision, Clinical Modification)
+
+**Purpose:** Diagnosis and procedure coding for billing, epidemiology, and health statistics
+
+**Structure:**
+- Alphanumeric codes (3-7 characters)
+- First character: letter (except U)
+- Characters 2-3: numbers
+- Characters 4-7: alphanumeric (decimal after 3rd character)
+- Laterality, severity, encounter type specified
+
+**Code structure example:**
+- **S72.001A**: Fracture of unspecified part of neck of right femur, initial encounter
+  - S: Injury category
+  - 72: Femur
+  - 001: Unspecified part of neck
+  - A: Initial encounter for closed fracture
+  - Right side indicated by 1 in 5th position
+
+**Common categories:**
+- A00-B99: Infectious diseases
+- C00-D49: Neoplasms
+- E00-E89: Endocrine, nutritional, metabolic
+- F01-F99: Mental and behavioral
+- G00-G99: Nervous system
+- I00-I99: Circulatory system
+- J00-J99: Respiratory system
+- K00-K95: Digestive system
+- M00-M99: Musculoskeletal
+- N00-N99: Genitourinary
+- S00-T88: Injury, poisoning
+
+**Seventh character extensions:**
+- A: Initial encounter
+- D: Subsequent encounter
+- S: Sequela
+
+**Placeholder X:**
+- Used when code requires 7th character but fewer than 6 characters
+- Example: T36.0X5A (Adverse effect of penicillins, initial encounter)
+
+**Combination codes:**
+- Single code describing two diagnoses or diagnosis with manifestation
+- Example: E11.21 (Type 2 diabetes with diabetic nephropathy)
+
+### CPT (Current Procedural Terminology)
+
+**Purpose:** Procedure and service coding for billing
+
+**Maintained by:** American Medical Association (AMA)
+
+**Categories:**
+- **Category I**: Procedures and services (5-digit numeric codes)
+- **Category II**: Performance measurement (4 digits + F)
+- **Category III**: Emerging technology (4 digits + T)
+
+**Category I Sections:**
+- 00100-01999: Anesthesia
+- 10000-69990: Surgery
+- 70000-79999: Radiology
+- 80000-89999: Pathology and Laboratory
+- 90000-99999: Medicine
+- 99000-99607: Evaluation and Management (E/M)
+
+**E/M Codes (commonly used):**
+- **99201-99215**: Office visits (new and established)
+- **99221-99239**: Hospital inpatient services
+- **99281-99285**: Emergency department visits
+- **99291-99292**: Critical care
+- **99304-99318**: Nursing facility services
+
+**Modifiers:**
+- Two-digit codes appended to CPT codes
+- Indicate service was altered but not changed
+- Examples:
+  - -25: Significant, separately identifiable E/M service
+  - -50: Bilateral procedure
+  - -59: Distinct procedural service
+  - -76: Repeat procedure by same physician
+  - -RT/LT: Right/Left side
+
+### RxNorm
+
+**Purpose:** Normalized names for clinical drugs and drug delivery devices
+
+**Structure:**
+- Includes brand and generic names
+- Dose forms
+- Strengths
+- Links to other drug vocabularies (NDC, SNOMED CT)
+
+**Example:**
+- Concept: Amoxicillin 500 MG Oral Capsule
+- RxNorm CUI: 308191
+- Ingredients: Amoxicillin
+- Strength: 500 MG
+- Dose Form: Oral Capsule
+
+## Medical Abbreviations
+
+### Acceptable Standard Abbreviations
+
+**Time:**
+- q: every (q4h = every 4 hours)
+- qd: daily (avoid - use "daily")
+- bid: twice daily
+- tid: three times daily
+- qid: four times daily
+- qhs: at bedtime
+- prn: as needed
+- ac: before meals
+- pc: after meals
+- hs: at bedtime
+
+**Routes:**
+- PO: by mouth (per os)
+- IV: intravenous
+- IM: intramuscular
+- SC/SQ/subcut: subcutaneous
+- SL: sublingual
+- PR: per rectum
+- NG: nasogastric
+- GT: gastrostomy tube
+- TD: transdermal
+- inh: inhaled
+
+**Frequency:**
+- stat: immediately
+- now: immediately
+- continuous: without interruption
+- PRN: as needed
+
+**Laboratory:**
+- CBC: complete blood count
+- BMP: basic metabolic panel
+- CMP: comprehensive metabolic panel
+- LFTs: liver function tests
+- PT/INR: prothrombin time/international normalized ratio
+- PTT/aPTT: partial thromboplastin time/activated PTT
+- ESR: erythrocyte sedimentation rate
+- CRP: C-reactive protein
+- ABG: arterial blood gas
+- UA: urinalysis
+- HbA1c: hemoglobin A1c
+
+**Diagnoses:**
+- HTN: hypertension
+- DM: diabetes mellitus
+- CHF: congestive heart failure
+- CAD: coronary artery disease
+- COPD: chronic obstructive pulmonary disease
+- CVA: cerebrovascular accident
+- MI: myocardial infarction
+- PE: pulmonary embolism
+- DVT: deep vein thrombosis
+- UTI: urinary tract infection
+- CKD: chronic kidney disease
+- ESRD: end-stage renal disease
+
+**Physical Examination:**
+- HEENT: head, eyes, ears, nose, throat
+- PERRLA: pupils equal, round, reactive to light and accommodation
+- EOMI: extraocular movements intact
+- JVP: jugular venous pressure
+- RRR: regular rate and rhythm
+- CTAB: clear to auscultation bilaterally
+- BS: bowel sounds or breath sounds (context dependent)
+- NT/ND: non-tender, non-distended
+- FROM: full range of motion
+
+**Vital Signs:**
+- BP: blood pressure
+- HR: heart rate
+- RR: respiratory rate
+- T or Temp: temperature
+- SpO2: oxygen saturation
+- Wt: weight
+- Ht: height
+- BMI: body mass index
+
+### Do Not Use Abbreviations (Joint Commission)
+
+**Prohibited abbreviations:**
+
+| Abbreviation | Intended Meaning | Problem | Use Instead |
+|--------------|------------------|---------|-------------|
+| U | Unit | Mistaken for 0, 4, or cc | Write "unit" |
+| IU | International Unit | Mistaken for IV or 10 | Write "international unit" |
+| Q.D., QD, q.d., qd | Daily | Mistaken for each other | Write "daily" |
+| Q.O.D., QOD, q.o.d., qod | Every other day | Mistaken for QD or QID | Write "every other day" |
+| Trailing zero (X.0 mg) | X mg | Decimal point missed | Never write zero after decimal (write X mg) |
+| Lack of leading zero (.X mg) | 0.X mg | Decimal point missed | Always write zero before decimal (write 0.X mg) |
+| MS, MSO4, MgSO4 | Morphine sulfate or magnesium sulfate | Confused for each other | Write "morphine sulfate" or "magnesium sulfate" |
+
+**Additional problematic abbreviations:**
+- µg: micrograms (mistaken for mg) → write "mcg"
+- cc: cubic centimeters → write "mL"
+- hs: half-strength or hour of sleep → write "half-strength" or "bedtime"
+- TIW: three times a week → write "three times weekly"
+- SC, SQ: subcutaneous → write "subcut" or "subcutaneous"
+- D/C: discharge or discontinue → write full word
+- AS, AD, AU: left ear, right ear, both ears → write "left ear," "right ear," "both ears"
+- OS, OD, OU: left eye, right eye, both eyes → write "left eye," "right eye," "both eyes"
+
+## Medication Nomenclature
+
+### Generic vs. Brand Names
+
+**Best practice:** Use generic names in medical documentation
+
+**Examples:**
+- Acetaminophen (generic) vs. Tylenol (brand)
+- Ibuprofen (generic) vs. Advil, Motrin (brand)
+- Atorvastatin (generic) vs. Lipitor (brand)
+- Metformin (generic) vs. Glucophage (brand)
+- Lisinopril (generic) vs. Zestril, Prinivil (brand)
+
+**When to include brand:**
+- Patient education (recognition)
+- Novel drugs without generic
+- Narrow therapeutic index drugs with bioequivalence issues
+- Biologic products
+
+### Dosage Forms
+
+**Solid oral:**
+- Tablet
+- Capsule
+- Caplet
+- Chewable tablet
+- Orally disintegrating tablet (ODT)
+- Extended-release (ER, XR, SR)
+- Delayed-release (DR)
+
+**Liquid oral:**
+- Solution
+- Suspension
+- Syrup
+- Elixir
+- Drops
+
+**Parenteral:**
+- Solution for injection
+- Powder for injection (reconstituted)
+- Intravenous infusion
+- Intramuscular injection
+- Subcutaneous injection
+
+**Topical:**
+- Cream
+- Ointment
+- Gel
+- Lotion
+- Paste
+- Patch (transdermal)
+- Foam
+- Spray
+
+**Other:**
+- Suppository (rectal, vaginal)
+- Inhaler (MDI, DPI)
+- Nebulizer solution
+- Ophthalmic (drops, ointment)
+- Otic (drops)
+- Nasal spray
+
+### Prescription Writing Elements
+
+**Complete prescription includes:**
+1. Patient name and DOB
+2. Date
+3. Medication name (generic preferred)
+4. Strength/concentration
+5. Dosage form
+6. Quantity to dispense
+7. Directions (Sig)
+8. Number of refills
+9. Prescriber signature and credentials
+10. DEA number (for controlled substances)
+
+**Sig (Directions for use):**
+- Clear, specific instructions
+- Route of administration
+- Frequency
+- Duration (if applicable)
+- Special instructions
+
+**Example:**
+- "Take one tablet by mouth twice daily with food for 10 days"
+- "Apply thin layer to affected area three times daily"
+- "Instill 1 drop in each eye every 4 hours while awake"
+
+## Anatomical Terminology
+
+### Directional Terms
+
+**Superior/Inferior:**
+- Superior: toward the head
+- Inferior: toward the feet
+- Cranial: toward the head
+- Caudal: toward the tail/feet
+
+**Anterior/Posterior:**
+- Anterior: toward the front
+- Posterior: toward the back
+- Ventral: toward the belly
+- Dorsal: toward the back
+
+**Medial/Lateral:**
+- Medial: toward the midline
+- Lateral: away from the midline
+
+**Proximal/Distal:**
+- Proximal: closer to the trunk or point of origin
+- Distal: farther from the trunk or point of origin
+
+**Superficial/Deep:**
+- Superficial: toward the surface
+- Deep: away from the surface
+
+### Body Planes
+
+**Sagittal plane:** Divides body into right and left
+- Midsagittal: exactly through midline
+- Parasagittal: parallel to midline
+
+**Coronal (frontal) plane:** Divides body into anterior and posterior
+
+**Transverse (axial) plane:** Divides body into superior and inferior
+
+### Anatomical Position
+
+- Standing upright
+- Feet parallel
+- Arms at sides
+- Palms facing forward
+- Head facing forward
+
+### Regional Terms
+
+**Head and Neck:**
+- Cephalic: head
+- Frontal: forehead
+- Orbital: eye
+- Nasal: nose
+- Oral: mouth
+- Cervical: neck
+- Occipital: back of head
+
+**Trunk:**
+- Thoracic: chest
+- Abdominal: abdomen
+- Pelvic: pelvis
+- Lumbar: lower back
+- Sacral: sacrum
+
+**Extremities:**
+- Brachial: arm
+- Antebrachial: forearm
+- Carpal: wrist
+- Manual: hand
+- Digital: fingers/toes
+- Femoral: thigh
+- Crural: leg
+- Tarsal: ankle
+- Pedal: foot
+
+## Laboratory Units and Conversions
+
+### Common Laboratory Units
+
+**Hematology:**
+- RBC: × 10⁶/μL or × 10¹²/L
+- WBC: × 10³/μL or × 10⁹/L
+- Hemoglobin: g/dL or g/L
+- Hematocrit: % or fraction
+- Platelets: × 10³/μL or × 10⁹/L
+- MCV: fL
+- MCHC: g/dL or g/L
+
+**Chemistry:**
+- Glucose: mg/dL or mmol/L
+- BUN: mg/dL or mmol/L
+- Creatinine: mg/dL or μmol/L
+- Sodium, potassium, chloride: mEq/L or mmol/L
+- Calcium: mg/dL or mmol/L
+- Albumin: g/dL or g/L
+- Bilirubin: mg/dL or μmol/L
+- Cholesterol: mg/dL or mmol/L
+
+**Therapeutic Drug Levels:**
+- Usually: mcg/mL, ng/mL, or μmol/L
+
+### Unit Conversions (Selected)
+
+**Glucose:**
+- mg/dL ÷ 18 = mmol/L
+- mmol/L × 18 = mg/dL
+
+**Creatinine:**
+- mg/dL × 88.4 = μmol/L
+- μmol/L ÷ 88.4 = mg/dL
+
+**Bilirubin:**
+- mg/dL × 17.1 = μmol/L
+- μmol/L ÷ 17.1 = mg/dL
+
+**Cholesterol:**
+- mg/dL × 0.0259 = mmol/L
+- mmol/L × 38.67 = mg/dL
+
+**Hemoglobin:**
+- g/dL × 10 = g/L
+- g/L ÷ 10 = g/dL
+
+## Grading and Staging Systems
+
+### Cancer Staging (TNM)
+
+**T (Primary Tumor):**
+- TX: Cannot be assessed
+- T0: No evidence of primary tumor
+- Tis: Carcinoma in situ
+- T1-T4: Size and/or extent of primary tumor
+
+**N (Regional Lymph Nodes):**
+- NX: Cannot be assessed
+- N0: No regional lymph node metastasis
+- N1-N3: Involvement of regional lymph nodes
+
+**M (Distant Metastasis):**
+- M0: No distant metastasis
+- M1: Distant metastasis present
+
+**Stage Grouping:**
+- Stage 0: Tis N0 M0
+- Stage I-III: Various T and N combinations, M0
+- Stage IV: Any T, any N, M1
+
+### NYHA Heart Failure Classification
+
+- **Class I**: No limitation. Ordinary physical activity does not cause symptoms
+- **Class II**: Slight limitation. Comfortable at rest, ordinary activity causes symptoms
+- **Class III**: Marked limitation. Comfortable at rest, less than ordinary activity causes symptoms
+- **Class IV**: Unable to carry out any physical activity without symptoms. Symptoms at rest
+
+### Child-Pugh Score (Liver Disease)
+
+**Parameters:** Bilirubin, albumin, INR, ascites, encephalopathy
+
+**Classes:**
+- **Class A (5-6 points)**: Well-compensated
+- **Class B (7-9 points)**: Significant functional compromise
+- **Class C (10-15 points)**: Decompensated
+
+### Glasgow Coma Scale
+
+**Eye Opening (1-4):**
+- 4: Spontaneous
+- 3: To speech
+- 2: To pain
+- 1: None
+
+**Verbal Response (1-5):**
+- 5: Oriented
+- 4: Confused
+- 3: Inappropriate words
+- 2: Incomprehensible sounds
+- 1: None
+
+**Motor Response (1-6):**
+- 6: Obeys commands
+- 5: Localizes pain
+- 4: Withdraws from pain
+- 3: Abnormal flexion
+- 2: Extension
+- 1: None
+
+**Total Score:** 3-15 (3 = worst, 15 = best)
+- Severe: ≤8
+- Moderate: 9-12
+- Mild: 13-15
+
+## Medical Prefixes and Suffixes
+
+### Common Prefixes
+
+- **a-/an-**: without, absence (anemia, aphasia)
+- **brady-**: slow (bradycardia)
+- **dys-**: abnormal, difficult (dyspnea, dysuria)
+- **hyper-**: excessive, above (hypertension, hyperglycemia)
+- **hypo-**: below, deficient (hypotension, hypoglycemia)
+- **poly-**: many (polyuria, polydipsia)
+- **tachy-**: fast (tachycardia, tachypnea)
+- **macro-**: large (macrocephaly)
+- **micro-**: small (microcephaly)
+- **hemi-**: half (hemiplegia)
+- **bi-/di-**: two (bilateral, diplopia)
+
+### Common Suffixes
+
+- **-algia**: pain (arthralgia, neuralgia)
+- **-ectomy**: surgical removal (appendectomy, cholecystectomy)
+- **-emia**: blood condition (anemia, leukemia)
+- **-itis**: inflammation (appendicitis, arthritis)
+- **-oma**: tumor (carcinoma, melanoma)
+- **-osis**: abnormal condition (cirrhosis, osteoporosis)
+- **-pathy**: disease (neuropathy, nephropathy)
+- **-penia**: deficiency (thrombocytopenia, neutropenia)
+- **-plasty**: surgical repair (rhinoplasty, angioplasty)
+- **-scopy**: visual examination (colonoscopy, bronchoscopy)
+- **-stomy**: surgical opening (colostomy, tracheostomy)
+
+---
+
+This reference provides comprehensive medical terminology, coding systems, abbreviations, and nomenclature standards. Use these guidelines to ensure accurate, standardized clinical documentation.
+