ID

15513

Beschrijving

Discharge Letter Items for Patient diagnosed with Multiple Sclerosis from Neurology Department of University Clinic Muenster

Trefwoorden

Versies (2)
  1. 27-05-16 27-05-16 -
  2. 02-06-16 02-06-16 -
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2 juni 2016

DOI

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Creative Commons BY-NC 3.0
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Discharge Letter Items 1215271678 Multiple Sclerosis

Engels

Discharge Letter Items 1215271678 Multiple Sclerosis

1 Formulieren  
Administrative Data
Beschrijving

Administrative Data

Alias
UMLS CUI-1
C1320722
Document ID of Discharge Letter
Beschrijving

Document ID

Datatype

integer

Alias
UMLS CUI [1]
C1300638
Patient`s Name
Beschrijving

Name of Patient

Datatype

text

Alias
UMLS CUI [1]
C0421448
Patients date of birth
Beschrijving

Date of birth

Datatype

date

Alias
UMLS CUI [1]
C0421451
Date of Appointment/Stay
Beschrijving

Date of Appointment

Datatype

date

Alias
UMLS CUI [1]
C0585085
Inpatient or Outpatient
Beschrijving

Care

Datatype

text

Alias
UMLS CUI [1]
C0017313
Principal Diagnosis
Beschrijving

Principal Diagnosis

Alias
UMLS CUI-1
C0332137
Principal Diagnosis Multiple Sclerosis
Beschrijving

Type of MS

Datatype

text

Alias
UMLS CUI [1,1]
C0332137
UMLS CUI [1,2]
C0026769
Onset
Beschrijving

Date of Onset

Datatype

date

Alias
UMLS CUI [1]
C0574845
Earliest date of diagnosis
Beschrijving

Earliest date of diagnosis

Datatype

date

Alias
UMLS CUI [1]
C4019001
EDSS
Beschrijving

EDSS

Datatype

integer

Alias
UMLS CUI [1]
C0451246
History of Retrobulbar Neuritis
Beschrijving

Retrobulbar Neuritis

Datatype

boolean

Alias
UMLS CUI [1,1]
C0085582
UMLS CUI [1,2]
C0455483
Reason for Admission
Beschrijving

Reason for Admission

Alias
UMLS CUI-1
C0392360
UMLS CUI-2
C0809949
Reason for admission
Beschrijving

Reason for admission

Datatype

text

Alias
UMLS CUI [1,1]
C0392360
UMLS CUI [1,2]
C0809949
Summary and Assessment
Beschrijving

Summary and Assessment

Alias
UMLS CUI-1
C0743221
Introduction: Reason for current Admission
Beschrijving

Introduction: Reason for current Admission

Datatype

text

Alias
UMLS CUI [1,1]
C0392360
UMLS CUI [1,2]
C0809949
Introduction: Department
Beschrijving

Introduction: Department

Datatype

text

Alias
UMLS CUI [1]
C1704729
Past medical history
Beschrijving

PMH

Datatype

text

Alias
UMLS CUI [1]
C0455458
Previous MRI findings
Beschrijving

Previous

Datatype

text

Alias
UMLS CUI [1,1]
C0024485
UMLS CUI [1,2]
C0205156
Visual evoked potential findings
Beschrijving

both sides compare results please

Datatype

text

Alias
UMLS CUI [1,1]
C0546834
UMLS CUI [1,2]
C1274040
Central motor evoked potential results
Beschrijving

CMEP

Datatype

text

Alias
UMLS CUI [1]
C2210335
Cerebrospinal fluid
Beschrijving

Cerebrospinal fluid

Datatype

text

Alias
UMLS CUI [1]
C0007807
Oligoclonal Bands
Beschrijving

Oligoclonal Bands

Datatype

text

Alias
UMLS CUI [1]
C0069426
Immunoglobulin G synthesis in Cerebrospinal fluid
Beschrijving

IgG in CSF

Datatype

text

Alias
UMLS CUI [1]
C1629580
Cerebrospinal fluid viral antibody test (measles, rubella, varicella)
Beschrijving

CSF Viral Antibodies

Datatype

text

Alias
UMLS CUI [1]
C2368116
Previous Therapy Medication
Beschrijving

Previous Therapy Medication

Datatype

text

Alias
UMLS CUI [1]
C2114510
Previous Therapie Benefit
Beschrijving

Previous Therapie Benefit

Datatype

text

Alias
UMLS CUI [1,1]
C0087113
UMLS CUI [1,2]
C2114510
Did a loss of bladder function control occur?
Beschrijving

Loss of Bladder Function Control

Datatype

boolean

Alias
UMLS CUI [1]
C0542565
Did a loss of bowl function control occur?
Beschrijving

Loss of Bowl Function Control

Datatype

boolean

Alias
UMLS CUI [1]
C1290944
Does an impairment of everyday life occur due to fatigue?
Beschrijving

Fatigue

Datatype

boolean

Alias
UMLS CUI [1]
C0015672
Follow-up MRI
Beschrijving

Follow-up MRI

Datatype

text

Alias
UMLS CUI [1,1]
C0412674
UMLS CUI [1,2]
C0260832
Number of T2-hyperintense Lesions in cMRT
Beschrijving

Number of Lesions

Datatype

integer

Alias
UMLS CUI [1,1]
C2238926
UMLS CUI [1,2]
C0449788
Localisation of Lesions
Beschrijving

Localisation of Lesions

Datatype

text

Alias
UMLS CUI [1,1]
C2238926
UMLS CUI [1,2]
C0475264
Criteria Dissemination in Time
Beschrijving

Dissemination Time

Datatype

boolean

Alias
UMLS CUI [1,1]
C0026769
UMLS CUI [1,2]
C0205221
UMLS CUI [1,3]
C0040223
Criteria Dissemination in Space
Beschrijving

Dissemination Space

Datatype

boolean

Alias
UMLS CUI [1,1]
C0026769
UMLS CUI [1,2]
C0205221
UMLS CUI [1,3]
C1515974
Neurological Examination
Beschrijving

Neurological Examination

Datatype

text

Alias
UMLS CUI [1]
C0437208
Therapeutic Options
Beschrijving

Therapeutic Options

Datatype

text

Alias
UMLS CUI [1]
C0683525
Study Participation
Beschrijving

Patient participates in TOLERATE/DIMAT Study

Datatype

boolean

Alias
UMLS CUI [1]
C1997894
Procedures
Beschrijving

Procedures

Alias
UMLS CUI-1
C2700391
Anti-aquaporin-4 antibody Blood Test
Beschrijving

Anti-aquaporin-4 antibody

Datatype

text

Alias
UMLS CUI [1]
C3203589
Borrelia test
Beschrijving

Borrelia test

Datatype

text

Alias
UMLS CUI [1]
C2748236
Vasculitis Laboratory Tests
Beschrijving

Vasculitis Blood tests

Datatype

text

Alias
UMLS CUI [1,1]
C0042384
UMLS CUI [1,2]
C0022885
Therapy Recommendation
Beschrijving

Recommendation Therapy

Datatype

text

Neurological Exam
Beschrijving

every 6 months

Datatype

text

Alias
UMLS CUI [1,1]
C0027853
UMLS CUI [1,2]
C0585339
MRI Follow-Up
Beschrijving

Recommendation MRI Follow-Up

Datatype

text

Alias
UMLS CUI [1,1]
C0260832
UMLS CUI [1,2]
C0412674
Medication
Beschrijving

Medication

Alias
UMLS CUI-1
C0013227
Neurological Examination: Cranial Nerves
Beschrijving

Neurological Examination: Cranial Nerves

Alias
UMLS CUI-1
C0027853
Orientation
Beschrijving

Orientation

Datatype

text

Alias
UMLS CUI [1]
C0029266
Meningism
Beschrijving

Meningism

Datatype

text

Alias
UMLS CUI [1]
C0025287
Nerve stretch tests
Beschrijving

Laségue

Datatype

text

Alias
UMLS CUI [1,1]
C1287971
UMLS CUI [1,2]
C1287969
Lhermitte's sign
Beschrijving

Lhermittes sign

Datatype

text

Alias
UMLS CUI [1]
C0576702
Visual Field Fingerperimetric
Beschrijving

Cranial Nerves: Visual Field

Datatype

text

Alias
UMLS CUI [1]
C0858409
Pupils Size
Beschrijving

Cranial Nerves: Pupils Size

Datatype

text

Alias
UMLS CUI [1]
C0437590
Pupils regularity
Beschrijving

Cranial Nerves: Pupils regularity

Datatype

text

Alias
UMLS CUI [1]
C0437592
Pupils reaction
Beschrijving

Cranial Nerves: Pupils reaction

Datatype

text

Alias
UMLS CUI [1]
C0437599
Direct pupil reaction to light
Beschrijving

Cranial Nerves: Direct pupil reaction to light

Datatype

text

Alias
UMLS CUI [1,1]
C0700372
UMLS CUI [1,2]
C1947931
Consensual pupil reaction to light
Beschrijving

Cranial Nerves: Consensual pupil reaction to light

Datatype

text

Alias
UMLS CUI [1]
C0700372
Examination of Eye Movement
Beschrijving

Cranial Nerves: Eye Movement

Datatype

text

Alias
UMLS CUI [1]
C0015413
Nystagmus Test
Beschrijving

Cranial Nerves: Nystagmus

Datatype

text

Alias
UMLS CUI [1]
C0200205
Gaze Palsy
Beschrijving

Cranial Nerves: Gaze Palsy

Datatype

text

Alias
UMLS CUI [1]
C1112261
Diplopia
Beschrijving

Cranial Nerves: Diplopia

Datatype

text

Alias
UMLS CUI [1]
C0012569
Facial Paralysis
Beschrijving

Cranial Nerves: Facial Paralysis

Datatype

text

Alias
UMLS CUI [1]
C0015469
Trigeminal Sensory Function
Beschrijving

Cranial Nerves: Trigeminal Sensory Function

Datatype

text

Alias
UMLS CUI [1]
C0234284
Trigeminal Motor Function abnormal?
Beschrijving

Cranial Nerves: Trigeminal Motor Function

Datatype

boolean

Alias
UMLS CUI [1]
C0234282
Function of caudal cranial nerves
Beschrijving

Cranial Nerves: Caudal cranial nerves

Datatype

text

Alias
UMLS CUI [1,1]
C0010268
UMLS CUI [1,2]
C0205097
Neurological Examination: Motor
Beschrijving

Neurological Examination: Motor

Alias
UMLS CUI-1
C2237216
Pareses
Beschrijving

latent manifest

Datatype

text

Alias
UMLS CUI [1]
C0030552
Pronator Drift Test
Beschrijving

Pronator Drift Test

Datatype

text

Alias
UMLS CUI [1]
C1504476
Leg drift test
Beschrijving

Leg drift test

Datatype

text

Muscle Tonus
Beschrijving

Motor tone

Datatype

text

Alias
UMLS CUI [1]
C0026841
Fine motor skills abnormal?
Beschrijving

Fine motor skills

Datatype

text

Alias
UMLS CUI [1]
C0678857
Gait, Manner of walking
Beschrijving

Gait

Datatype

text

Alias
UMLS CUI [1]
C0016928
Standing, Manner of Standing
Beschrijving

Standing

Datatype

text

Alias
UMLS CUI [1]
C0231472
Function of Muscular reflex
Beschrijving

Muscular reflex

Datatype

text

Alias
UMLS CUI [1]
C0034943
Pyramidal signs
Beschrijving

Pyramidal

Datatype

text

Alias
UMLS CUI [1]
C0234132
Sensibility on neurological exam abnormal?
Beschrijving

Sensibility

Datatype

boolean

Alias
UMLS CUI [1]
C0439823
Abnormal motor coordination tests?
Beschrijving

Motor Coordination Tests

Datatype

text

Alias
UMLS CUI [1,1]
C0237543
UMLS CUI [1,2]
C0039593
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Similar models

Discharge Letter Items 1215271678 Multiple Sclerosis

1 Formulieren
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Item Group
Administrative Data
C1320722 (UMLS CUI-1)
Document ID
Item
Document ID of Discharge Letter
integer
C1300638 (UMLS CUI [1])
Name of Patient
Item
Patient`s Name
text
C0421448 (UMLS CUI [1])
Date of birth
Item
Patients date of birth
date
C0421451 (UMLS CUI [1])
Date of Appointment
Item
Date of Appointment/Stay
date
C0585085 (UMLS CUI [1])
Item
Inpatient or Outpatient
text
C0017313 (UMLS CUI [1])
undefined item
Code List
Inpatient or Outpatient
CL Item
Inpatient (Inpatient)
C0021562 (UMLS CUI-1)
CL Item
Outpatient (Outpatient)
C0029921 (UMLS CUI-1)
Item Group
Principal Diagnosis
C0332137 (UMLS CUI-1)
Principal Diagnosis Multiple Sclerosis
Item
Principal Diagnosis Multiple Sclerosis
text
C0332137 (UMLS CUI [1,1])
C0026769 (UMLS CUI [1,2])
Date of Onset
Item
Onset
date
C0574845 (UMLS CUI [1])
Earliest date of diagnosis
Item
Earliest date of diagnosis
date
C4019001 (UMLS CUI [1])
EDSS
Item
EDSS
integer
C0451246 (UMLS CUI [1])
Retrobulbar Neuritis
Item
History of Retrobulbar Neuritis
boolean
C0085582 (UMLS CUI [1,1])
C0455483 (UMLS CUI [1,2])
Item Group
Reason for Admission
C0392360 (UMLS CUI-1)
C0809949 (UMLS CUI-2)
Reason for admission
Item
Reason for admission
text
C0392360 (UMLS CUI [1,1])
C0809949 (UMLS CUI [1,2])
Item Group
Summary and Assessment
C0743221 (UMLS CUI-1)
Introduction: Reason for current Admission
Item
Introduction: Reason for current Admission
text
C0392360 (UMLS CUI [1,1])
C0809949 (UMLS CUI [1,2])
Introduction: Department
Item
Introduction: Department
text
C1704729 (UMLS CUI [1])
PMH
Item
Past medical history
text
C0455458 (UMLS CUI [1])
Previous
Item
Previous MRI findings
text
C0024485 (UMLS CUI [1,1])
C0205156 (UMLS CUI [1,2])
VEP
Item
Visual evoked potential findings
text
C0546834 (UMLS CUI [1,1])
C1274040 (UMLS CUI [1,2])
CMEP
Item
Central motor evoked potential results
text
C2210335 (UMLS CUI [1])
Cerebrospinal fluid
Item
Cerebrospinal fluid
text
C0007807 (UMLS CUI [1])
Oligoclonal Bands
Item
Oligoclonal Bands
text
C0069426 (UMLS CUI [1])
IgG in CSF
Item
Immunoglobulin G synthesis in Cerebrospinal fluid
text
C1629580 (UMLS CUI [1])
CSF Viral Antibodies
Item
Cerebrospinal fluid viral antibody test (measles, rubella, varicella)
text
C2368116 (UMLS CUI [1])
Previous Therapy Medication
Item
Previous Therapy Medication
text
C2114510 (UMLS CUI [1])
Previous Therapie Benefit
Item
Previous Therapie Benefit
text
C0087113 (UMLS CUI [1,1])
C2114510 (UMLS CUI [1,2])
Loss of Bladder Function Control
Item
Did a loss of bladder function control occur?
boolean
C0542565 (UMLS CUI [1])
Loss of Bowl Function Control
Item
Did a loss of bowl function control occur?
boolean
C1290944 (UMLS CUI [1])
Fatigue
Item
Does an impairment of everyday life occur due to fatigue?
boolean
C0015672 (UMLS CUI [1])
Follow-up MRI
Item
Follow-up MRI
text
C0412674 (UMLS CUI [1,1])
C0260832 (UMLS CUI [1,2])
Number of Lesions
Item
Number of T2-hyperintense Lesions in cMRT
integer
C2238926 (UMLS CUI [1,1])
C0449788 (UMLS CUI [1,2])
Localisation of Lesions
Item
Localisation of Lesions
text
C2238926 (UMLS CUI [1,1])
C0475264 (UMLS CUI [1,2])
Dissemination Time
Item
Criteria Dissemination in Time
boolean
C0026769 (UMLS CUI [1,1])
C0205221 (UMLS CUI [1,2])
C0040223 (UMLS CUI [1,3])
Dissemination Space
Item
Criteria Dissemination in Space
boolean
C0026769 (UMLS CUI [1,1])
C0205221 (UMLS CUI [1,2])
C1515974 (UMLS CUI [1,3])
Neurological Examination
Item
Neurological Examination
text
C0437208 (UMLS CUI [1])
Therapeutic Options
Item
Therapeutic Options
text
C0683525 (UMLS CUI [1])
Study Participation
Item
Study Participation
boolean
C1997894 (UMLS CUI [1])
Item Group
Procedures
C2700391 (UMLS CUI-1)
Anti-aquaporin-4 antibody
Item
Anti-aquaporin-4 antibody Blood Test
text
C3203589 (UMLS CUI [1])
Borrelia test
Item
Borrelia test
text
C2748236 (UMLS CUI [1])
Vasculitis Blood tests
Item
Vasculitis Laboratory Tests
text
C0042384 (UMLS CUI [1,1])
C0022885 (UMLS CUI [1,2])
Recommendation Therapy
Item
Therapy Recommendation
text
Recommendation Neurological Exam
Item
Neurological Exam
text
C0027853 (UMLS CUI [1,1])
C0585339 (UMLS CUI [1,2])
Recommendation MRI Follow-Up
Item
MRI Follow-Up
text
C0260832 (UMLS CUI [1,1])
C0412674 (UMLS CUI [1,2])
Item Group
Medication
C0013227 (UMLS CUI-1)
Item Group
Neurological Examination: Cranial Nerves
C0027853 (UMLS CUI-1)
Orientation
Item
Orientation
text
C0029266 (UMLS CUI [1])
Meningism
Item
Meningism
text
C0025287 (UMLS CUI [1])
Nerve stretch tests
Item
Nerve stretch tests
text
C1287971 (UMLS CUI [1,1])
C1287969 (UMLS CUI [1,2])
Item
Lhermitte's sign
text
C0576702 (UMLS CUI [1])
Lhermittes sign
Code List
Lhermitte's sign
CL Item
positive (positive)
CL Item
negative (negative)
Cranial Nerves: Visual Field
Item
Visual Field Fingerperimetric
text
C0858409 (UMLS CUI [1])
Cranial Nerves: Pupils Size
Item
Pupils Size
text
C0437590 (UMLS CUI [1])
Cranial Nerves: Pupils regularity
Item
Pupils regularity
text
C0437592 (UMLS CUI [1])
Cranial Nerves: Pupils reaction
Item
Pupils reaction
text
C0437599 (UMLS CUI [1])
Cranial Nerves: Direct pupil reaction to light
Item
Direct pupil reaction to light
text
C0700372 (UMLS CUI [1,1])
C1947931 (UMLS CUI [1,2])
Cranial Nerves: Consensual pupil reaction to light
Item
Consensual pupil reaction to light
text
C0700372 (UMLS CUI [1])
Cranial Nerves: Eye Movement
Item
Examination of Eye Movement
text
C0015413 (UMLS CUI [1])
Cranial Nerves: Nystagmus
Item
Nystagmus Test
text
C0200205 (UMLS CUI [1])
Cranial Nerves: Gaze Palsy
Item
Gaze Palsy
text
C1112261 (UMLS CUI [1])
Cranial Nerves: Diplopia
Item
Diplopia
text
C0012569 (UMLS CUI [1])
Cranial Nerves: Facial Paralysis
Item
Facial Paralysis
text
C0015469 (UMLS CUI [1])
Cranial Nerves: Trigeminal Sensory Function
Item
Trigeminal Sensory Function
text
C0234284 (UMLS CUI [1])
Cranial Nerves: Trigeminal Motor Function
Item
Trigeminal Motor Function abnormal?
boolean
C0234282 (UMLS CUI [1])
Cranial Nerves: Caudal cranial nerves
Item
Function of caudal cranial nerves
text
C0010268 (UMLS CUI [1,1])
C0205097 (UMLS CUI [1,2])
Item Group
Neurological Examination: Motor
C2237216 (UMLS CUI-1)
Item
Pareses
text
C0030552 (UMLS CUI [1])
Paresis
Code List
Pareses
CL Item
present (1)
CL Item
not present (2)
CL Item
not examined (3)
Pronator Drift Test
Item
Pronator Drift Test
text
C1504476 (UMLS CUI [1])
Leg drift test
Item
Leg drift test
text
Motor tone
Item
Muscle Tonus
text
C0026841 (UMLS CUI [1])
Fine motor skills
Item
Fine motor skills abnormal?
text
C0678857 (UMLS CUI [1])
Gait
Item
Gait, Manner of walking
text
C0016928 (UMLS CUI [1])
Standing
Item
Standing, Manner of Standing
text
C0231472 (UMLS CUI [1])
Muscular reflex
Item
Function of Muscular reflex
text
C0034943 (UMLS CUI [1])
Pyramidal
Item
Pyramidal signs
text
C0234132 (UMLS CUI [1])
Sensibility
Item
Sensibility on neurological exam abnormal?
boolean
C0439823 (UMLS CUI [1])
Motor Coordination Tests
Item
Abnormal motor coordination tests?
text
C0237543 (UMLS CUI [1,1])
C0039593 (UMLS CUI [1,2])
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