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ID
16506
Beschreibung
Medical history form, Study hospital, Medical Faculty Münster derived from Medical history form by Dr. Schusdziarra
Stichworte
Versionen (3)
- 20.07.16 20.07.16 -
- 20.07.16 20.07.16 -
- 21.07.16 21.07.16 -
Hochgeladen am
21. Juli 2016
DOI
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Creative Commons BY-NC 3.0
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Study hospital, Medical Faculty Münster- Clinical Examination findings
Clinical Examination findings
- StudyEvent: ODM
Ähnliche Modelle
Clinical Examination findings
- StudyEvent: ODM
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Patient Name
Item
Patient Name
text
C1299487 (UMLS CUI [1])
Birth date
Item
Patient date of birth
date
C0421451 (UMLS CUI [1])
Occupation
Item
Patient Occupation
text
C0421456 (UMLS CUI [1])
Physical Examination Date
Item
Physical Examination Date
date
C0031809 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,2])
Treating physician
Item
Treating physician
text
C1710470 (UMLS CUI [1])
CL Item
Normal (1)
CL Item
Feeble (2)
CL Item
Critically ill (3)
CL Item
Normal (1)
CL Item
Slurred speech (2)
CL Item
Hoarse (3)
CL Item
Stutter (4)
CL Item
Normal (1)
CL Item
Reduced (2)
CL Item
Trained (3)
CL Item
ectomorph (1)
CL Item
endomorph (2)
CL Item
mesomorph (3)
CL Item
cross type (4)
CL Item
Normal (1)
CL Item
Erect (2)
CL Item
Piked (3)
CL Item
Disability (specify) (4)
Gait
Item
Gait:Please specify the nature of disability
text
C0016928 (UMLS CUI [1])
CL Item
Normal (1)
CL Item
Impaired (2)
CL Item
Restless (3)
CL Item
Tremor (4)
CL Item
Normal (1)
CL Item
Skinny (2)
CL Item
Cachexia (3)
CL Item
Adipose (4)
Weight
Item
Body weight
float
C0005910 (UMLS CUI [1])
Height
Item
Body height
float
C0005890 (UMLS CUI [1])
CL Item
Average (1)
CL Item
Strong (2)
CL Item
Atrophic (3)
CL Item
Normal (1)
CL Item
Face rigidity (2)
Body Temperature
Item
Body Temperature
float
C0005903 (UMLS CUI [1])
CL Item
Normal (1)
CL Item
Pale (2)
CL Item
Reddened (3)
CL Item
Cyanotic (4)
CL Item
Jaundice (5)
CL Item
Pigmented (6)
CL Item
Urticaria (1)
CL Item
Papules (2)
CL Item
Abcesses (3)
CL Item
Skin lesions (4)
CL Item
Ulcers (5)
CL Item
Fissures (6)
CL Item
Petechiae (1)
CL Item
Ecchymosis (2)
CL Item
Suggillation (3)
CL Item
Suffusions (4)
CL Item
Telangiectasia (1)
CL Item
Spider naevus (2)
CL Item
Angioma (3)
Skull
Item
Skull:Shape
text
C0037303 (UMLS CUI [1])
Skull
Item
Skull: percussion pain
text
C0037303 (UMLS CUI [1])
Skull
Item
Skull: Hair growth
text
C0037303 (UMLS CUI [1])
Facial bones
Item
Facial bones: Asymmetry, scars
text
C0015455 (UMLS CUI [1])
CL Item
Normal (1)
CL Item
Pressure tenderness (2)
CL Item
submandibular (1)
CL Item
cervical (2)
CL Item
preauricular (3)
CL Item
retroauricular (4)
CL Item
suboccipital (5)
CL Item
supraclavicular (6)
CL Item
axillary (7)
CL Item
inguinal (8)
CL Item
submandibular (1)
CL Item
cervical (2)
CL Item
preauricular (3)
CL Item
retroauricular (4)
CL Item
suboccipital (5)
CL Item
supraclavicular (6)
CL Item
axillary (7)
CL Item
inguinal (8)
CL Item
submandibular (1)
CL Item
cervical (2)
CL Item
preauricular (3)
CL Item
retroauricular (4)
CL Item
suboccipital (5)
CL Item
supraclavicular (6)
CL Item
axillary (7)
CL Item
inguinal (8)
CL Item
submandibular (1)
CL Item
cervical (2)
CL Item
preauricular (3)
CL Item
retroauricular (4)
CL Item
suboccipital (5)
CL Item
supraclavicular (6)
CL Item
axillary (7)
CL Item
inguinal (8)
CL Item
Ptosis (1)
CL Item
Edema (2)
Sclera
Item
Sclera:Color
text
C0036410 (UMLS CUI [1])
CL Item
round (1)
CL Item
miosis (2)
CL Item
mydriasis (3)
CL Item
asymmetric (4)
CL Item
reaction to light (1)
CL Item
direct (2)
CL Item
indirect (3)
CL Item
Accommodation (4)
CL Item
Movements (1)
CL Item
Strabism (2)
CL Item
Nystagmus (3)
CL Item
Exophthalmus (4)
CL Item
Enophthalmus (5)
CL Item
Normal (1)
CL Item
Reduced (2)
CL Item
Corrected (Glasses) (3)
CL Item
Pale (1)
CL Item
Reddened (2)
Auricle
Item
Auricle
text
C0928075 (UMLS CUI [1])
External auditory canal
Item
External auditory canal
text
C0013444 (UMLS CUI [1])
Hearing
Item
Hearing
text
C0018767 (UMLS CUI [1])
Nasal airway patency
Item
Nasal airway patency
text
C0429212 (UMLS CUI [1])
Mucous Membrane
Item
Mucous Membrane: Color, secretion
text
C0026724 (UMLS CUI [1])
Tongue
Item
Tongue: Moisture, plaque, movement
text
C0040408 (UMLS CUI [1])
Tonsils
Item
Tonsils: Size, plaques
text
C0836921 (UMLS CUI [1])
Tonsils
Item
Tonsils: normal
boolean
C0836921 (UMLS CUI [1])
CL Item
Restored (1)
CL Item
Caries (2)
CL Item
False teeth (3)
CL Item
Normal (1)
CL Item
Reddened (2)
CL Item
Mucus (3)
CL Item
Purulence (4)
Lips
Item
Lips:Color, Moisture, skin lesions
text
C0023759 (UMLS CUI [1])
CL Item
Normal (1)
CL Item
Enlarged (2)
CL Item
Thyroid nodules (3)
CL Item
Whizz (4)
Neck circumference
Item
Neck circumference
integer
C1630403 (UMLS CUI [1])
CL Item
Venous Engorgement (1)
CL Item
Bruit (2)
Larynx
Item
Larynx
text
C0023078 (UMLS CUI [1])
CL Item
Normal (1)
CL Item
Barrel chest (2)
CL Item
Normal (1)
CL Item
Symmetric (2)
Respiratory rate
Item
Respiratory rate
integer
C0231832 (UMLS CUI [1])
Respiratory rhythm
Item
Respiratory rhythm
text
C0231842 (UMLS CUI [1])
Inspiratory circumference
Item
Inspiratory chest circumference
integer
C0424683 (UMLS CUI [1,1])
C0004048 (UMLS CUI [1,2])
C0004048 (UMLS CUI [1,2])
Exspiratory circumference
Item
Exspiratory chest circumference
integer
C0424683 (UMLS CUI [1,1])
C0231800 (UMLS CUI [1,2])
C0231800 (UMLS CUI [1,2])
CL Item
Normal (1)
CL Item
Enhanced chest kyphosis and lumbar lordosis (2)
CL Item
Scoliosis (3)
Mammae
Item
Mammae: Size,Symmetry, distance of mamillae, knots, retractions
text
CL Item
sonoric (1)
CL Item
dull (2)
CL Item
hypersonoric (3)
CL Item
tympanitic (4)
Inferior margin of lower lobe of lung
Item
Inferior margin of lower lobe of lung, right side
text
C0507801 (UMLS CUI [1])
Inferior margin of lower lobe of lung
Item
Inferior margin of lower lobe of lung, left side
text
C0507801 (UMLS CUI [1])
Mobility of lung margin
Item
Mobility of right lung margin
text
C2371451 (UMLS CUI [1,1])
C0225690 (UMLS CUI [1,2])
C0225690 (UMLS CUI [1,2])
Mobility of lung margin
Item
Mobility of left lung margin
text
C2371451 (UMLS CUI [1,1])
C0225690 (UMLS CUI [1,2])
C0225690 (UMLS CUI [1,2])
CL Item
vesicular (1)
CL Item
reduced (2)
CL Item
bronchial breathing (3)
CL Item
Wheezing (1)
CL Item
Whistling sound (2)
CL Item
Humming sound (3)
CL Item
Fine rales (4)
CL Item
Medium rales (5)
CL Item
Coarse rales (6)
CL Item
Sounding rales (7)
CL Item
Non-sounding rales (8)
CL Item
Pleural Rub (9)
CL Item
normal (1)
CL Item
enlarged (2)
CL Item
normal (1)
CL Item
enlarged (2)
CL Item
not palpable (1)
CL Item
widened (2)
CL Item
raising (3)
Position of apex beat
Item
Apex beat localization
text
C1287711 (UMLS CUI [1])
CL Item
Normal (1)
CL Item
Light (2)
CL Item
Pronounced (3)
CL Item
Split (4)
CL Item
Extra sounds (5)
CL Item
Heart murmur (6)
CL Item
Regular rhythm (1)
CL Item
Arrhythmia absoluta (2)
CL Item
Extrasystoles (3)
Heart rate
Item
Heart rate
text
C0018810 (UMLS CUI [1])
Blood pressure
Item
Blood pressure
text
C0005823 (UMLS CUI [1])
CL Item
peripheral (1)
CL Item
central (2)
Abdominal shape
Item
Abdominal shape symmetrical?
boolean
C2230330 (UMLS CUI [1])
CL Item
Soft (1)
CL Item
Sunken (2)
CL Item
adipose (3)
CL Item
scar(s) (4)
CL Item
abdominal rigidity (5)
CL Item
Inguinal hernia (1)
CL Item
Umbilical hernia (2)
CL Item
Incisional hernia (3)
CL Item
Closed hernia (4)
Palpation tenderness
Item
Palpation tenderness:localization
text
C0232498 (UMLS CUI [1])
CL Item
Circumscript (1)
CL Item
Diffuse (2)
Intraabdominal resistance
Item
Intraabdominal resistance:localization
text
C1562335 (UMLS CUI [1])
Intraabdominal resistance
Item
Intraabdominal resistance: expanse
text
C1562335 (UMLS CUI [1])
Intraabdominal resistance
Item
Intraabdominal resistance:Consistency
text
C1562335 (UMLS CUI [1])
Intraabdominal resistance
Item
Intraabdominal resistance:pressure pain
text
C1562335 (UMLS CUI [1])
Intraabdominal resistance
Item
Intraabdominal resistance:pulsation
text
C1562335 (UMLS CUI [1])
Intraabdominal resistance
Item
Intraabdominal resistance:None
boolean
C1562335 (UMLS CUI [1])
Ascites
Item
Ascites
boolean
C0003962 (UMLS CUI [1])
Ascites
Item
Ascites: abdominal circumference
integer
C0003962 (UMLS CUI [1])
CL Item
Normal (1)
CL Item
Reduced (2)
CL Item
Dead silent (3)
CL Item
Increased (4)
Liver size
Item
Liver size
integer
C0426688 (UMLS CUI [1])
CL Item
Elasic (1)
CL Item
Soft (2)
CL Item
Coarse (3)
CL Item
Hard (4)
CL Item
Smooth (1)
CL Item
Nodular liver (2)
CL Item
Blunt (1)
CL Item
Pointed (2)
CL Item
Indolent (1)
CL Item
Painful (2)
Spleen palpation: consistency
Item
Spleen palpation: consistency
text
C0030250 (UMLS CUI [1])
CL Item
palpable (1)
CL Item
not palpable (2)
CL Item
Normal (1)
CL Item
Painful on percussion (2)
CL Item
Pressure pain (3)
CL Item
Fissures (1)
CL Item
Fistula (2)
CL Item
Hemorrhoides (3)
CL Item
Prolapse (4)
CL Item
Ampulla recti normal (1)
CL Item
Palpable resistencies (2)
Prostate
Item
Prostate: Size
text
C0033572 (UMLS CUI [1])
Prostate
Item
Prostate: Consistency
text
C0033572 (UMLS CUI [1])
Prostate
Item
Prostate: Nodules
text
C0033572 (UMLS CUI [1])
Prostate
Item
Prostate: Pressure pain
text
C0033572 (UMLS CUI [1])
Genitalia
Item
Genitalia normal
boolean
C0017420 (UMLS CUI [1])
Pubic hair
Item
Pubic hair
text
C1305636 (UMLS CUI [1])
Genitalia shape
Item
Genitalia shape
text
C1820234 (UMLS CUI [1])
Testicle size
Item
Testicle size
text
C0426327 (UMLS CUI [1])
Axis of limb
Item
Axis of limb
text
C1183516 (UMLS CUI [1])
Active Range of Motion
Item
Active Range of Motion
text
C1879548 (UMLS CUI [1])
Passive Range of Motion
Item
Passive Range of Motion
text
C0079991 (UMLS CUI [1])
Skeletal muscle structure
Item
Skeletal muscle structure
text
C0242692 (UMLS CUI [1])
Joint swelling
Item
Joint swelling
text
C0152031 (UMLS CUI [1])
Joint pain
Item
Joint pain
text
C0003862 (UMLS CUI [1])
CL Item
normal (1)
CL Item
reduced (2)
CL Item
normal (1)
CL Item
reduced (2)
Joint
Item
Joint:specify location
text
C0022417 (UMLS CUI [1])
Item
Pulse taking: Palpation of A.carotis communis
integer
C0034107 (UMLS CUI [1,1])
C0162859 (UMLS CUI [1,2])
C0162859 (UMLS CUI [1,2])
CL Item
palpable (1)
CL Item
not palpable (2)
CL Item
palpable but reduced (3)
Item
Pulse taking: Palpation of A.brachialis
integer
C0034107 (UMLS CUI [1,1])
C1096531 (UMLS CUI [1,2])
C1096531 (UMLS CUI [1,2])
CL Item
palpable (1)
CL Item
not palpable (2)
CL Item
palpable but reduced (3)
Item
Pulse taking: Palpation of A.radialis
integer
C0034107 (UMLS CUI [1,1])
C0204685 (UMLS CUI [1,2])
C0204685 (UMLS CUI [1,2])
CL Item
palpable (1)
CL Item
not palpable (2)
CL Item
palpable but reduced (3)
Item
Pulse taking: Palpation of A.femoralis
integer
C0034107 (UMLS CUI [1,1])
C0232148 (UMLS CUI [1,2])
C0232148 (UMLS CUI [1,2])
CL Item
palpable (1)
CL Item
not palpable (2)
CL Item
palpable but reduced (3)
Item
Pulse taking: Palpation of A.poplitea
integer
C0034107 (UMLS CUI [1,1])
C0232151 (UMLS CUI [1,2])
C0232151 (UMLS CUI [1,2])
CL Item
palpable (1)
CL Item
not palpable (2)
CL Item
palpable but reduced (3)
Item
Pulse taking: Palpation of A.dorsalis pedis
integer
C0034107 (UMLS CUI [1,1])
C1706488 (UMLS CUI [1,2])
C1706488 (UMLS CUI [1,2])
CL Item
palpable (1)
CL Item
not palpable (2)
CL Item
palpable but reduced (3)
Item
Pulse taking: Palpation of A.tibialis posterior
integer
C0034107 (UMLS CUI [1,1])
C2366939 (UMLS CUI [1,2])
C2366972 (UMLS CUI [1,3])
C2366939 (UMLS CUI [1,2])
C2366972 (UMLS CUI [1,3])
CL Item
palpable (1)
CL Item
not palpable (2)
CL Item
palpable but reduced (3)
Auscultation of Aortic murmur and heart murmur
Item
Auscultation of Aortic murmur and heart murmur
text
C0586288 (UMLS CUI [1,1])
C0004339 (UMLS CUI [1,2])
C0586288 (UMLS CUI [2,1])
C0232222 (UMLS CUI [2,2])
C0004339 (UMLS CUI [1,2])
C0586288 (UMLS CUI [2,1])
C0232222 (UMLS CUI [2,2])
Assessment of neurologic status
Item
Assessment of neurologic status
text
C0746866 (UMLS CUI [1])
CL Item
Normal (1)
CL Item
Stuporous (2)
CL Item
Somnolent (3)
CL Item
Semicoma (4)
CL Item
Comatose (5)
Orientation
Item
Orientation as to time, place and personal
text
C0029266 (UMLS CUI [1])
CL Item
Euphorical (1)
CL Item
Irritable (2)
CL Item
Anxious (3)
CL Item
Depressed (4)
CL Item
Disinhibited (1)
CL Item
Impulsive (2)
CL Item
Retarded (3)
CL Item
Passive (4)
Item
Active innervation and function of head and extremities
integer
C0026828 (UMLS CUI [1])
Code List
Active innervation and function of head and extremities
CL Item
Hemiplegia (1)
CL Item
Hemiparesis (2)
CL Item
Tetraparesis (3)
CL Item
Muscle Spasticity (4)
CL Item
Muscle Rigidity (5)
CL Item
Tremor (6)
CL Item
Normal (1)
CL Item
Symmetrical (2)
CL Item
Brisk (3)
CL Item
Reduced (4)
CL Item
Clonus exhaustible (1)
CL Item
Clonus inexhaustible (2)
Coordination
Item
Coordination
text
C0242414 (UMLS CUI [1])
Sensitivity
Item
Sensitivity
text
C1522640 (UMLS CUI [1])
Combined Functions
Item
Combined Functions:Romberg, Unterberger
text
C1260928 (UMLS CUI [1])
C0456756 (UMLS CUI [2])
C0456756 (UMLS CUI [2])
Diagnosis or tentative diagnosis
Item
Diagnosis or tentative diagnosis
text
C0011900 (UMLS CUI [1])