ID

15513

Description

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

Keywords

Versions (2)
  1. 5/27/16 5/27/16 -
  2. 6/2/16 6/2/16 -
Uploaded on

June 2, 2016

DOI

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License

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

English

Discharge Letter Items 1215271678 Multiple Sclerosis

1 forms  
Administrative Data
Description

Administrative Data

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

Document ID

Data type

integer

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

Name of Patient

Data type

text

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

Date of birth

Data type

date

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

Date of Appointment

Data type

date

Alias
UMLS CUI [1]
C0585085
Inpatient or Outpatient
Description

Care

Data type

text

Alias
UMLS CUI [1]
C0017313
Principal Diagnosis
Description

Principal Diagnosis

Alias
UMLS CUI-1
C0332137
Principal Diagnosis Multiple Sclerosis
Description

Type of MS

Data type

text

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

Date of Onset

Data type

date

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

Earliest date of diagnosis

Data type

date

Alias
UMLS CUI [1]
C4019001
EDSS
Description

EDSS

Data type

integer

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

Retrobulbar Neuritis

Data type

boolean

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

Reason for Admission

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

Reason for admission

Data type

text

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

Summary and Assessment

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

Introduction: Reason for current Admission

Data type

text

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

Introduction: Department

Data type

text

Alias
UMLS CUI [1]
C1704729
Past medical history
Description

PMH

Data type

text

Alias
UMLS CUI [1]
C0455458
Previous MRI findings
Description

Previous

Data type

text

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

both sides compare results please

Data type

text

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

CMEP

Data type

text

Alias
UMLS CUI [1]
C2210335
Cerebrospinal fluid
Description

Cerebrospinal fluid

Data type

text

Alias
UMLS CUI [1]
C0007807
Oligoclonal Bands
Description

Oligoclonal Bands

Data type

text

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

IgG in CSF

Data type

text

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

CSF Viral Antibodies

Data type

text

Alias
UMLS CUI [1]
C2368116
Previous Therapy Medication
Description

Previous Therapy Medication

Data type

text

Alias
UMLS CUI [1]
C2114510
Previous Therapie Benefit
Description

Previous Therapie Benefit

Data type

text

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

Loss of Bladder Function Control

Data type

boolean

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

Loss of Bowl Function Control

Data type

boolean

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

Fatigue

Data type

boolean

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

Follow-up MRI

Data type

text

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

Number of Lesions

Data type

integer

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

Localisation of Lesions

Data type

text

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

Dissemination Time

Data type

boolean

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

Dissemination Space

Data type

boolean

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

Neurological Examination

Data type

text

Alias
UMLS CUI [1]
C0437208
Therapeutic Options
Description

Therapeutic Options

Data type

text

Alias
UMLS CUI [1]
C0683525
Study Participation
Description

Patient participates in TOLERATE/DIMAT Study

Data type

boolean

Alias
UMLS CUI [1]
C1997894
Procedures
Description

Procedures

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

Anti-aquaporin-4 antibody

Data type

text

Alias
UMLS CUI [1]
C3203589
Borrelia test
Description

Borrelia test

Data type

text

Alias
UMLS CUI [1]
C2748236
Vasculitis Laboratory Tests
Description

Vasculitis Blood tests

Data type

text

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

Recommendation Therapy

Data type

text

Neurological Exam
Description

every 6 months

Data type

text

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

Recommendation MRI Follow-Up

Data type

text

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

Medication

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

Neurological Examination: Cranial Nerves

Alias
UMLS CUI-1
C0027853
Orientation
Description

Orientation

Data type

text

Alias
UMLS CUI [1]
C0029266
Meningism
Description

Meningism

Data type

text

Alias
UMLS CUI [1]
C0025287
Nerve stretch tests
Description

Laségue

Data type

text

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

Lhermittes sign

Data type

text

Alias
UMLS CUI [1]
C0576702
Visual Field Fingerperimetric
Description

Cranial Nerves: Visual Field

Data type

text

Alias
UMLS CUI [1]
C0858409
Pupils Size
Description

Cranial Nerves: Pupils Size

Data type

text

Alias
UMLS CUI [1]
C0437590
Pupils regularity
Description

Cranial Nerves: Pupils regularity

Data type

text

Alias
UMLS CUI [1]
C0437592
Pupils reaction
Description

Cranial Nerves: Pupils reaction

Data type

text

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

Cranial Nerves: Direct pupil reaction to light

Data type

text

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

Cranial Nerves: Consensual pupil reaction to light

Data type

text

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

Cranial Nerves: Eye Movement

Data type

text

Alias
UMLS CUI [1]
C0015413
Nystagmus Test
Description

Cranial Nerves: Nystagmus

Data type

text

Alias
UMLS CUI [1]
C0200205
Gaze Palsy
Description

Cranial Nerves: Gaze Palsy

Data type

text

Alias
UMLS CUI [1]
C1112261
Diplopia
Description

Cranial Nerves: Diplopia

Data type

text

Alias
UMLS CUI [1]
C0012569
Facial Paralysis
Description

Cranial Nerves: Facial Paralysis

Data type

text

Alias
UMLS CUI [1]
C0015469
Trigeminal Sensory Function
Description

Cranial Nerves: Trigeminal Sensory Function

Data type

text

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

Cranial Nerves: Trigeminal Motor Function

Data type

boolean

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

Cranial Nerves: Caudal cranial nerves

Data type

text

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

Neurological Examination: Motor

Alias
UMLS CUI-1
C2237216
Pareses
Description

latent manifest

Data type

text

Alias
UMLS CUI [1]
C0030552
Pronator Drift Test
Description

Pronator Drift Test

Data type

text

Alias
UMLS CUI [1]
C1504476
Leg drift test
Description

Leg drift test

Data type

text

Muscle Tonus
Description

Motor tone

Data type

text

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

Fine motor skills

Data type

text

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

Gait

Data type

text

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

Standing

Data type

text

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

Muscular reflex

Data type

text

Alias
UMLS CUI [1]
C0034943
Pyramidal signs
Description

Pyramidal

Data type

text

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

Sensibility

Data type

boolean

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

Motor Coordination Tests

Data type

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 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
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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