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ID
15341
Beschreibung
Discharge Letter for Patient diagnosed with Multiple Sclerosis from Neurology Department of University Clinic Muenster Publication granted by PD Dr. Klotz
Stichworte
Versionen (2)
- 27.05.16 27.05.16 -
- 27.09.21 27.09.21 -
Hochgeladen am
27. Mai 2016
DOI
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Creative Commons BY-NC 3.0
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Discharge Letter Items -18546 Multiple Sclerosis
Discharge Letter Items -18546 Multiple Sclerosis
- StudyEvent: ODM
Ähnliche Modelle
Discharge Letter Items -18546 Multiple Sclerosis
- StudyEvent: ODM
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Document ID
Item
Document ID
integer
C1300638 (UMLS CUI [1])
Name
Item
Patient`s Name
text
C0421448 (UMLS CUI [1])
Date of birth
Item
Date of birth:
date
C0421451 (UMLS CUI [1])
CL Item
Inpatient (Inpatient)
C0021562 (UMLS CUI-1)
CL Item
Outpatient (Outpatient)
C0029921 (UMLS CUI-1)
Date of Appointment
Item
Date of Appointment/Stay
date
C0585085 (UMLS CUI [1])
Principal Diagnosis Multiple Sclerosis
Item
Principal Diagnosis Multiple Sclerosis
text
C0026769 (UMLS CUI [1,1])
C0332137 (UMLS CUI [1,2])
C0332137 (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])
Previous Therapy Medication
Item
Previous Therapy Medication
text
C2114510 (UMLS CUI [1])
Previous Therapy Time Range
Item
Time Range of Previous Therapy
text
C2114510 (UMLS CUI [1,1])
C1554109 (UMLS CUI [1,2])
C1554109 (UMLS CUI [1,2])
Previous Therapie Benefit
Item
Previous Therapie Benefit
text
C0087113 (UMLS CUI [1,1])
C2114510 (UMLS CUI [1,2])
C2114510 (UMLS CUI [1,2])
Previous MS Flares
Item
Indicate the dates of previous flares of MS.
text
C0856120 (UMLS CUI [1,1])
C0205156 (UMLS CUI [1,2])
C0205156 (UMLS CUI [1,2])
Neutralizing Antibodies
Item
Neutralizing Antibodies (Nab) against Interferone Beta
boolean
C1997641 (UMLS CUI [1])
Neutralizing Antibodies Date
Item
Neutralizing Antibodies Test Date
date
C1997641 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,2])
Item Group
Risk Stratification of Therapy with Natalizumab
Previous Immunosuppressive Therapy
Item
Previous Immunosuppressive Therapy
boolean
C0021079 (UMLS CUI [1,1])
C2114510 (UMLS CUI [1,2])
C2114510 (UMLS CUI [1,2])
Use of Natalizumab
Item
Use of Natalizumab
text
C1172734 (UMLS CUI [1,1])
C0439231 (UMLS CUI [1,2])
C0240320 (UMLS CUI [1,3])
C0439231 (UMLS CUI [1,2])
C0240320 (UMLS CUI [1,3])
JCV Antibodies
Item
JCV Antibodies
text
C3511565 (UMLS CUI [1])
Date JCV-Antibody
Item
Date of JCV-Antibody Measurement
date
C3511565 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,2])
Therapy Alemtuzumab
Item
Therapy with Alemtuzumab
boolean
C0383429 (UMLS CUI [1,1])
C0418981 (UMLS CUI [1,2])
C0418981 (UMLS CUI [1,2])
Therapy Alemtuzumab Date
Item
Therapy Alemtuzumab Date of Treatment
date
C0383429 (UMLS CUI [1,1])
C0418981 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,3])
C0418981 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,3])
Secondary Diagnosis
Item
Secondary Diagnosis
text
C0332138 (UMLS CUI [1])
Reason for admission
Item
Reason for admission
text
C0392360 (UMLS CUI [1,1])
C0809949 (UMLS CUI [1,2])
C0809949 (UMLS CUI [1,2])
Rituximab Induction
Item
Rituximab Induction to treat Multiple Sclerosis
text
C4047978 (UMLS CUI [1])
Introduction: Reason for current Admission
Item
Introduction: Reason for current Admission
text
C0809949 (UMLS CUI [1,1])
C0392360 (UMLS CUI [1,2])
C0392360 (UMLS CUI [1,2])
PMH
Item
Past medical history
text
C0455458 (UMLS CUI [1])
Progression Natalizumab
Item
Continuous progression of MS under Therapie with Natalizumab
boolean
C0242656 (UMLS CUI [1,1])
C1172734 (UMLS CUI [1,2])
C1172734 (UMLS CUI [1,2])
Therapy Alemtuzumab
Item
Therapy with Alemtuzumab
text
C0383429 (UMLS CUI [1,1])
C0418981 (UMLS CUI [1,2])
C0418981 (UMLS CUI [1,2])
Symptoms
Item
Symptoms
text
C1457887 (UMLS CUI [1])
Therapy Corticosteroid
Item
Therapy with Corticosteroid
text
C0149783 (UMLS CUI [1])
Urge Incontinence
Item
Urge Incontinence
boolean
C0150045 (UMLS CUI [1])
Loss of Bowl Function Control
Item
Did a loss of bowl function control occur?
boolean
C1290944 (UMLS CUI [1])
Item Group
Medication on Admission
C0013227 (UMLS CUI-1)
C0457453 (UMLS CUI-2)
C0457453 (UMLS CUI-2)
Medication name
Item
Medication name:
text
C2360065 (UMLS CUI [1])
Medication dosage
Item
Medication dosage (6:00-12:00-18:00-22:00)
float
C3174092 (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])
CL Item
positive (positive)
CL Item
negative (negative)
Cranial Nerves: Visus
Item
Cranial Nerves: Visus
text
C0042812 (UMLS CUI [1])
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 reaction
Item
Pupils reaction
text
C0437599 (UMLS CUI [1])
Cranial Nerves: Pupils regularity
Item
Pupils regularity
text
C0437592 (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: Trigeminal Sensory Function
Item
Trigeminal Sensory Function
text
C0234284 (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])
C0205097 (UMLS CUI [1,2])
Cranial Nerves: Sensory Function
Item
Facial Sensory Function
text
C0234292 (UMLS CUI [1])
Pronator Drift Test
Item
Pronator Drift Test
text
C1504476 (UMLS CUI [1])
Leg drift test
Item
Leg drift test
text
Fine motor skills
Item
Fine motor skills abnormal?
text
C0678857 (UMLS CUI [1])
Item Group
Neurological Examination: Reflexes
C0437364 (UMLS CUI-1)
Muscular reflex
Item
Function of Muscular reflex
text
C0034943 (UMLS CUI [1])
Pyramidal
Item
Pyramidal signs
text
C0234132 (UMLS CUI [1])
Item Group
Neurological Examination: Sensibility
C0439823 (UMLS CUI-1)
Hypesthesia Upper Extremity
Item
Hypesthesia Upper Extremity
text
C1140618 (UMLS CUI [1,1])
C0020580 (UMLS CUI [1,2])
C0020580 (UMLS CUI [1,2])
Hypesthesia Lower Extremity
Item
Hypesthesia Lower Extremity
text
C0023216 (UMLS CUI [1,1])
C0020580 (UMLS CUI [1,2])
C0020580 (UMLS CUI [1,2])
Item Group
Neurological Examination: Coordination and Gait
Diadochokinesis
Item
Diadochokinesis
text
C0278157 (UMLS CUI [1])
Finger-to-nose test
Item
Finger-to-nose test abnormal?
text
C0278158 (UMLS CUI [1])
Heel-to-knee test
Item
Heel-to-knee test abnormal?
text
C0278160 (UMLS CUI [1])
Rhomberg Test
Item
Rhomberg Test abnormal?
text
C1656968 (UMLS CUI [1])
Aphasia
Item
Aphasia?
boolean
C0003537 (UMLS CUI [1])
Neglect
Item
Neglect
boolean
C0422887 (UMLS CUI [1])
Apraxia
Item
Apraxia?
text
C0234520 (UMLS CUI [1])
Item Group
Neurological Examination: On Discharge
C0027853 (UMLS CUI-1)
C1548175 (UMLS CUI-2)
C1548175 (UMLS CUI-2)
Changes Neurological Exam
Item
Changes Neurological Exam
text
C0542115 (UMLS CUI [1])
Urine Specific Gravity
Item
Urine Specific Gravity
float
C0202517 (UMLS CUI [1])
Urine pH
Item
Urine pH
float
C0042044 (UMLS CUI [1])
CL Item
neg (neg )
CL Item
pos (pos)
CL Item
neg (neg)
CL Item
pos (pos)
CL Item
neg (neg)
CL Item
pos (pos)
Urine Glucose
Item
Urine Glucose
text
C0004076 (UMLS CUI [1])
Urine Ketone Bodies
Item
Urine Ketone Bodies
integer
C0860805 (UMLS CUI [1])
Urine Urobilinogen
Item
Urine Urobilinogen
text
C0427736 (UMLS CUI [1])
Urine Bilirubin
Item
Urine Bilirubin
text
C0042040 (UMLS CUI [1])
Urine Erythrocytes
Item
Urine Erythrocytes
integer
C1254564 (UMLS CUI [1])
Item Group
Laboratory Results Urine Analysis FACS
C0042014 (UMLS CUI-1)
Urine Erythrocytes (FACS)
Item
Urine Erythrocytes (FACS)
integer
C1114250 (UMLS CUI [1,1])
C0016263 (UMLS CUI [1,2])
C0016263 (UMLS CUI [1,2])
Item
Urine leukocytes (FACS)
text
C1256582 (UMLS CUI [1,1])
C0016263 (UMLS CUI [1,2])
C0016263 (UMLS CUI [1,2])
CL Item
neg (neg )
CL Item
pos (pos)
Urine Epithelial Cells (FACS)
Item
Urine Epithelial Cells (FACS)
integer
C1273342 (UMLS CUI [1,1])
C0016263 (UMLS CUI [1,2])
C0016263 (UMLS CUI [1,2])
Urine Cylinder Cells (FACS)
Item
Urine Cylinder Cells (FACS)
integer
C0946010 (UMLS CUI [1,1])
C1114250 (UMLS CUI [1,2])
C0016263 (UMLS CUI [1,3])
C1114250 (UMLS CUI [1,2])
C0016263 (UMLS CUI [1,3])
Urine Bacteria (FACS)
Item
Urine Bacteria (FACS)
integer
C0430380 (UMLS CUI [1,1])
C0016263 (UMLS CUI [1,2])
C0016263 (UMLS CUI [1,2])
Urine Crystals (FACS)
Item
Urine Crystals (FACS)
integer
C0427897 (UMLS CUI [1,1])
C0016263 (UMLS CUI [1,2])
C0016263 (UMLS CUI [1,2])
Urine Yeast (FACS)
Item
Urine Yeast (FACS)
integer
C2188427 (UMLS CUI [1,1])
C0016263 (UMLS CUI [1,2])
C0016263 (UMLS CUI [1,2])
Urine Pathological Cylinder (FACS)
Item
Urine Pathological Cylinder (FACS)
integer
C0946010 (UMLS CUI [1,1])
C0007634 (UMLS CUI [1,2])
C0016263 (UMLS CUI [1,3])
C0007634 (UMLS CUI [1,2])
C0016263 (UMLS CUI [1,3])
Urine Round Epithelial Cell Count (FACS)
Item
Urine Round Epithelial Cell Count (FACS)
integer
C2699115 (UMLS CUI [1,1])
C0016263 (UMLS CUI [1,2])
C0016263 (UMLS CUI [1,2])
CL Item
positive (positive)
CL Item
negative (negative)
Sodium
Item
Sodium Measurement
integer
C0337443 (UMLS CUI [1])
Potassium
Item
Potassium
float
C0202194 (UMLS CUI [1])
Calcium
Item
Calcium
float
C0201925 (UMLS CUI [1])
Chloride
Item
Chloride
integer
C0201952 (UMLS CUI [1])
Glucose
Item
Glucose
integer
C0202042 (UMLS CUI [1])
Blood Urea Nitrogen
Item
Blood Urea Nitrogen
float
C0005845 (UMLS CUI [1])
Creatinin
Item
Creatinin
float
C0201976 (UMLS CUI [1])
Bilirubin Total
Item
Bilirubin Total
float
C1278039 (UMLS CUI [1])
AST
Item
AST (SGOT)
float
C0201899 (UMLS CUI [1])
ALT
Item
ALT (SGPT)
float
C0201836 (UMLS CUI [1])
gamma-GT
Item
gamma-GT
float
C0202035 (UMLS CUI [1])
Alkaline Phosphatase
Item
Alkaline Phosphatase
text
C0201850 (UMLS CUI [1])
Albumin
Item
Albumin
float
C0201838 (UMLS CUI [1])
Uric acid
Item
Uric acid
float
C0041980 (UMLS CUI [1])
Urea
Item
Urea
float
C0523961 (UMLS CUI [1])
LDH
Item
Lactate Dehydrogenase (LDH)
float
C0202113 (UMLS CUI [1])
Creatinine kinase
Item
CPK
float
C0201973 (UMLS CUI [1])
CK MB
Item
CK MB
integer
C0523584 (UMLS CUI [1])
CRP
Item
CRP
float
C0201657 (UMLS CUI [1])
Leucocytes
Item
Leucocytes
float
C0023508 (UMLS CUI [1])
Erythrocytes
Item
Erythrocytes
float
C0014772 (UMLS CUI [1])
Haemoglobin
Item
Haemoglobin
integer
C0518015 (UMLS CUI [1])
Haematocrit Blood
Item
Haematocrit
float
C0018935 (UMLS CUI [1])
MCV
Item
Mean Corpuscular Volume
float
C1948043 (UMLS CUI [1])
MCH
Item
MCH
float
C0369183 (UMLS CUI [1])
MCHC
Item
Mean corpuscular hemoglobin concentration
float
C0474535 (UMLS CUI [1])
Thrombocytes
Item
Thrombocytes
float
C0032181 (UMLS CUI [1])
Item Group
Laboratory Results Differential EDTA
C1820731 (UMLS CUI-1)
Neutrophils (rel)
Item
Neutrophils relative
integer
C4028217 (UMLS CUI [1])
Neutrophils (abs)
Item
Neutrophils absolute
float
C0948762 (UMLS CUI [1])
Lymphocytes (rel)
Item
Lymphocytes relative
integer
C2349983 (UMLS CUI [1])
Lymphocytes (abs)
Item
Lymphocytes absolute
float
C0200635 (UMLS CUI [1])
Monocytes (rel)
Item
Monocytes relative
integer
C0587345 (UMLS CUI [1])
Monocytes (abs)
Item
Monocytes absolute
float
C0200637 (UMLS CUI [1])
Eosinophils (rel)
Item
Eosinophils relative
integer
C1171399 (UMLS CUI [1])
Eosinophils (abs)
Item
Eosinophils absolute
float
C0200638 (UMLS CUI [1])
Basophils (rel)
Item
Basophils relative
integer
C1318432 (UMLS CUI [1])
Basophils (abs)
Item
Basophils absolute
float
C1883362 (UMLS CUI [1])
MPV
Item
Mean Platelet Volume
float
C0200665 (UMLS CUI [1])
Granulocytes immature
Item
Immature Granulocytes
float
C3272953 (UMLS CUI [1])
Item Group
Laboratory Results Blood coagulation tests
C0005790 (UMLS CUI-1)
TPZ
Item
TPZ
integer
C0491338 (UMLS CUI [1])
INR
Item
INR
float
C0525032 (UMLS CUI [1])
PTT
Item
PTT
float
C0030605 (UMLS CUI [1])
Item Group
Laboratory Results Thyroid Function Tests
C0040130 (UMLS CUI-1)
TSH
Item
TSH
float
C0202230 (UMLS CUI [1])
eGFR
Item
eGFR
integer
C3811844 (UMLS CUI [1])
Lymphocytes (Beads)
Item
Lymphocytes (Beads)
integer
CD3+
Item
CD3+
integer
C3542405 (UMLS CUI [1])
CD4+
Item
CD4+
integer
C1277776 (UMLS CUI [1])
CD4+
Item
CD4+
integer
C1277791 (UMLS CUI [1])
CD8+
Item
CD8+
integer
C1277777 (UMLS CUI [1])
CD8+
Item
CD8+
integer
C1277792 (UMLS CUI [1])
CD4/CD8 Ratio
Item
CD4/CD8 Ratio
float
C0085115 (UMLS CUI [1])
CD19+
Item
CD19+
integer
C3540683 (UMLS CUI [1])
Natural Killer Cells
Item
Natural Killer Cells
integer
C2363836 (UMLS CUI [1])
Item Group
Summary and Procedures
C0743221 (UMLS CUI-1)
C2700391 (UMLS CUI-3)
C2700391 (UMLS CUI-3)
Introduction: Reason for current Admission
Item
Introduction: Reason for current Admission
text
C0809949 (UMLS CUI [1,1])
C0392360 (UMLS CUI [1,2])
C0392360 (UMLS CUI [1,2])
Current Immunosuppressive Therapy
Item
Current Immunosuppressive Therapy
text
C2827774 (UMLS CUI [1,1])
C0021079 (UMLS CUI [1,2])
C0021079 (UMLS CUI [1,2])
Last MRI Head
Item
Results of latest MRI of Head and Brain
text
C0412674 (UMLS CUI [1,1])
C1517741 (UMLS CUI [1,2])
C1517741 (UMLS CUI [1,2])
Findings of neurological Examination
Item
Pathological findings of neurological examination
text
C0437208 (UMLS CUI [1])
Summary Progression of Disease
Item
Summary of the current progression and stage of disease
text
C0242656 (UMLS CUI [1,1])
C0743221 (UMLS CUI [1,2])
C0743221 (UMLS CUI [1,2])
Summary Paraclinical Findings
Item
Summary of paraclinical findings
text
C0497120 (UMLS CUI [1,1])
C0743221 (UMLS CUI [1,2])
C0743221 (UMLS CUI [1,2])
Summary of Hospital Stay
Item
Summary of Procedures during hospitalisation
text
C0019993 (UMLS CUI [1,1])
C0743221 (UMLS CUI [1,2])
C0743221 (UMLS CUI [1,2])
Recommendation Blood Sample
Item
Recommendation Blood Sample
text
C0178913 (UMLS CUI [1])
MEDICATION NAME
Item
Medication name:
text
C2360065 (UMLS CUI [1])