Common

Diagnoses in Family Practice

1. URI
Acute vs. Subacute
Bacterial vs. Viral

2. Constipation
Acute vs. Chronic
Known cause?
Slow Transit
Opioid Induced
Neurogenic
Pelvic Floor Outlet Obstruction
Psychogenic
Colonic spasm
Spastic

3. Otitis Media
Left, Right, or Bilateral
Suppurative vs. Non-suppurative (purulent exudate)
Acute vs. Chronic
Effusion?
Allergic vs. Infectious
Indicate if the patient has PE tubes in place

4. Streptococcal pharyngitis (strep throat)
Indicate etiology if known (m/c is Group A Strep)
Indicate if secondary scarlet fever
If septic, indicate that (not common in FP)

5. Diabetes
Type I or Type II
Gestational
If due to KNOWN underlying condition, indicate
Drug or alcohol induced
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6. Hypertension
Specify type
Essential (primary)
Indicate if it involves vessels of brain and/or eye
Secondary
Hypertensive Chronic Kidney Disease (renovascular)
Due to kidney disease
Indicate stage of the kidney disease
HTN secondary to other renal disorders
Secondary to endocrine disorders
Other
Unspecified
Hypertensive Heart Disease
Indicate if it is with/without heart failure
Pulmonary
Complications
Controlled vs. Uncontrolled
Indicate if with pharmacologic therapy or lifestyle modifications

7. Depression
Acute vs. Chronic
If chronic, indicate which episode this is (1st, 2nd, etc.)
Severity (mild, moderate, severe)
Where in the process they are (acute, partial remission, full remission)

8. Anxiety
Acute vs. Chronic
Generalized vs. Panic vs. Mixed vs. Phobic
If phobic, need to list the phobia (i.e. agoraphobia, arachnophobia, etc)
Cause (if known)
Acute stress reaction
Transient adjustment reaction
Separation

9. ADHD
Subtype
Predominantly inattentive type, Predominantly hyperactive type, Combined
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Type

10. Arthritis
Infectious vs. Inflammatory vs. Osteoarthritis
Laterality (right or left)
Which joint (i.e. knee, shoulder, PIP, etc)

11. Health Maintenance Examination
Any abnormal findings (i.e. general exam with no abnormal findings)

12. Headache
Subtype
Tension headache
Migraine headache
Severity

13. Dyslipidemia
Specify if possible
Hyperlipidemia
Hypercholesterolemia
Low HDL
Etc.
Comorbid with any other current diagnoses?
Type 1 diabetes
Type 2 diabetes
Heart disease
Steroid use?
Chronic
Acutely steroid induced
Meeting goal range? (i.e. hyperlipidemia meeting goal on Lipitor)

14. Sinusitis
Acute vs. Chronic
Acute recurrent is a subtype
Which sinuses?
Maxillary/frontal/ethmoidal/sphenoidal/pansinusitis
15. Asthma
Severity
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Uncomplicated
Mild
Moderate
Severe
Intermittent vs. Persistent
Type
Allergic
Atopic
Exercise induced
Idiosyncratic
Intrinsic non-allergic
In acute exacerbation or status asthmaticus?
Include ACT score if completed

16. COPD
Subtype
Chronic bronchitis
Emphysema
Cause if there is one (COPD due to ***)
Interstitial vs. Mediastinal if known
If applicable, identify the following (they all have ICD10 codes)
Exposure to environmental tobacco smoke
History of tobacco use
Occupational exposure to environmental tobacco smoke
Tobacco dependence
Tobacco use
If in acute exacerbation, state that as well

17. Cystitis
Acute vs. Chronic
With or without hematuria

18. Vaginitis
Acute vs. Chronic
Circumscribed vs. Diffuse
Subtypes
Venereal
Gonococcal
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Chlamydial
Herpetic
Syphilitic
Early or Late
Trichomonal
Emphysematous
Non-venereal
Ulcerative
Other
With ectopic or molar pregnancy
Amebic
Atrophic, postmenopausal
Bacterial
Candidal
Pinworm infection
Postpartum
Tuberculosis

19. Cellulitis
Acute vs. Chronic
Diffuse vs. Circumscribed
Laterality
Where specifically (i.e. right knee and right anterior lower extremity, etc)
With exudate or without exudate
Complications if applicable
i.e. sepsis, etc.

20. Supervision of Pregnancy
Age of woman (i.e. young or elderly)
Risk (High vs. low)-- If high risk, then need to specify why (i.e. due to social vs. medical
problems)
Past pregnancies (primigravida, multigravida, grand multiparity)
Trimester (1st, 2nd, 3rd, unspecified)
History of complications w/past pregnancies (i.e. ectopic or preterm labor)
Specify any pre-pregnancy conditions affecting current care (chronic kidney disease,
alcohol use, strep B positive)
Pre-existing conditions (gestational diabetes, pregnancy induced hypertension)
If there is diabetes specify as being diet or insulin controlled
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