ID

19010

Description

Hospital Routine Documentation Subform at the University Hospital Muenster. Original Form name: AN MS MEDD Anamnese KU NTX.

Keywords

Versions (2)
  1. 11/15/16 11/15/16 -
  2. 11/30/16 11/30/16 -
Uploaded on

November 30, 2016

DOI

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License

Creative Commons BY-NC 3.0
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AN MS MEDD Anamnese KU NTX University Hospital Muenster (UKM) Subform

German English

AN MS MEDD Anamnese KU NTX University Hospital Muenster (UKM) Subform

1 forms  
Allgemeine Angaben
Description

Allgemeine Angaben

Alias
UMLS CUI-1
C1508263
UMLS CUI-2
C1955348
UMLS CUI-3
C0587474
UMLS CUI-4
C0022671
Untersucher
Description

Examiner

Data type

text

Alias
UMLS CUI [1,1]
C0025082
UMLS CUI [1,2]
C0025084
UMLS CUI [1,3]
C0031809
Vorstellung vom
Description

Date of medical history taking

Data type

date

Alias
UMLS CUI [1,1]
C0034927
UMLS CUI [1,2]
C0025084
UMLS CUI [1,3]
C0011008
Erhebungsmodus
Description

Mode of medical history taking

Data type

text

Alias
UMLS CUI [1,1]
C0025084
UMLS CUI [1,2]
C0332307
Jetzige Anamnese
Description

Current medical history

Data type

text

Alias
UMLS CUI [1]
C0262926
Vegetative Anamnese und Risikofaktorenmanagement
Description

Vegetative Anamnese und Risikofaktorenmanagement

Alias
UMLS CUI-1
C0262926
UMLS CUI-2
C0037088
UMLS CUI-3
C0035648
UMLS CUI-4
C0376636
Größe
Description

Height

Data type

float

Measurement units
  • cm
Alias
UMLS CUI [1]
C0005890
cm
Gewicht
Description

Weight

Data type

float

Measurement units
  • kg
Alias
UMLS CUI [1]
C0005910
kg
BMI
Description

BMI

Data type

text

Alias
UMLS CUI [1]
C1305855
Gewichtsveränderung
Description

Change in weight

Data type

boolean

Alias
UMLS CUI [1]
C0005911
Gewichtsveränderung (wenn ja, bitte beschreiben)
Description

Change in weight (specification)

Data type

text

Alias
UMLS CUI [1,1]
C0005911
UMLS CUI [1,2]
C2348235
Trinkmenge (pro Tag)
Description

Amount of liquid consumed (per day)

Data type

float

Measurement units
  • l
Alias
UMLS CUI [1]
C0429791
l
Trinkmenge (Beschreibung)
Description

Amount of liquid consumed (specification)

Data type

text

Alias
UMLS CUI [1]
C0429791
Eigendiurese (pro Tag)
Description

Diuresis (per day)

Data type

float

Measurement units
  • l
Alias
UMLS CUI [1]
C0012797
l
Eigendiurese
Description

Diuresis

Data type

text

Alias
UMLS CUI [1]
C0012797
Hypertonus: Mittlerer sys. RR
Description

Hypertension: Mean systolic blood pressure

Data type

integer

Alias
UMLS CUI [1]
C0020538
UMLS CUI [2,1]
C0428886
UMLS CUI [2,2]
C0871470
Hypertonus: systolisch
Description

Hypertension: systolic

Data type

text

Hypertonus: Mittlerer diast. RR
Description

Hypertension: Mean diastolic blood pressure

Data type

integer

Alias
UMLS CUI [1]
C0020538
UMLS CUI [2,1]
C0428886
UMLS CUI [2,2]
C0428883
Hypertonus: diastolisch
Description

Hypertension: diastolic

Data type

text

Alias
UMLS CUI [1]
C0428883
UMLS CUI [2]
C0020538
Hypertonus: 24 h RR (syst/diast)
Description

Hypertension: 24 h RR (syst/diast)

Data type

text

Alias
UMLS CUI [1]
C0451604
UMLS CUI [2]
C0020538
Hypertonus: Datum 24 h RR
Description

Hypertension: Date of 24 h RR measurement

Data type

date

Alias
UMLS CUI [1,1]
C0451604
UMLS CUI [1,2]
C0011008
UMLS CUI [2]
C0020538
Hypertonus: Bemerkungen 24 H RR
Description

Hypertension: Comments 24 h RR

Data type

text

Alias
UMLS CUI [1,1]
C0451604
UMLS CUI [1,2]
C0947611
UMLS CUI [2]
C0020538
Fieber
Description

Fever

Data type

boolean

Alias
UMLS CUI [1]
C0015967
Fieber (wenn ja, bitte beschreiben)
Description

Fever (specification)

Data type

text

Alias
UMLS CUI [1]
C0015967
Stuhlverhalten
Description

Stool

Data type

boolean

Alias
UMLS CUI [1,1]
C1290944
UMLS CUI [1,2]
C0015733
Stuhlverhalten (wenn ja, bitte beschreiben)
Description

Stool (specification)

Data type

text

Alias
UMLS CUI [1,1]
C1290944
UMLS CUI [1,2]
C0015733
Miktion
Description

Micturition

Data type

boolean

Alias
UMLS CUI [1,1]
C0042034
UMLS CUI [1,2]
C0542565
Miktion (wenn ja, bitte beschreiben)
Description

Micturition (specification)

Data type

text

Alias
UMLS CUI [1,1]
C0042034
UMLS CUI [1,2]
C0542565
Nykturie
Description

Nocturia

Data type

boolean

Alias
UMLS CUI [1]
C0028734
Nykturie (wenn ja, bitte beschreiben)
Description

Nocturia (specification)

Data type

text

Alias
UMLS CUI [1]
C0028734
Husten
Description

Coughing

Data type

boolean

Alias
UMLS CUI [1]
C0010200
Husten (wenn ja, bitte beschreiben)
Description

Coughing (specification)

Data type

text

Alias
UMLS CUI [1]
C0010200
Auswurf
Description

Sputum

Data type

boolean

Alias
UMLS CUI [1]
C0038056
Auswurf (wenn ja, bitte beschreiben)
Description

Sputum (specification)

Data type

text

Alias
UMLS CUI [1]
C0038056
Luftnot
Description

Shortness of breath

Data type

boolean

Alias
UMLS CUI [1]
C0013404
Luftnot (wenn ja, bitte beschreiben)
Description

Shortness of breath (specification)

Data type

text

Alias
UMLS CUI [1]
C0013404
Ödeme
Description

Edema

Data type

boolean

Alias
UMLS CUI [1]
C0013604
Ödeme (wenn ja, bitte beschreiben)
Description

Edema (specification)

Data type

text

Alias
UMLS CUI [1]
C0013604
Nachtschweiß
Description

Night sweats

Data type

boolean

Alias
UMLS CUI [1]
C0028081
Nachtschweiß (wenn ja, bitte beschreiben)
Description

Night sweats (specification)

Data type

text

Alias
UMLS CUI [1]
C0028081
Gelenkbeschwerden
Description

Joint trouble

Data type

boolean

Alias
UMLS CUI [1]
C0022408
Gelenkbeschwerden (wenn ja, bitte beschreiben)
Description

Joint trouble (specification)

Data type

text

Alias
UMLS CUI [1]
C0022408
Vasculitiszeichen
Description

Signs of vasculitis

Data type

boolean

Alias
UMLS CUI [1,1]
C0042384
UMLS CUI [1,2]
C0037088
Vasculitiszeichen (wenn ja, bitte beschreiben)
Description

Signs of vasculitis (specification)

Data type

text

Alias
UMLS CUI [1,1]
C0042384
UMLS CUI [1,2]
C0037088
Appetit
Description

Appetite

Data type

boolean

Alias
UMLS CUI [1]
C0003618
Appetit (wenn ja, bitte beschreiben)
Description

Appetite (specification)

Data type

text

Alias
UMLS CUI [1]
C0003618
Schlaf
Description

Sleep

Data type

boolean

Alias
UMLS CUI [1]
C0037313
Schlaf (wenn ja, bitte beschreiben)
Description

Sleep (specification)

Data type

text

Alias
UMLS CUI [1]
C0037313
Nikotin
Description

Nicotine

Data type

boolean

Alias
UMLS CUI [1]
C0543414
Nikotin: Schachteln/Tag
Description

Nicotine: packets per day

Data type

float

Alias
UMLS CUI [1,1]
C0543414
UMLS CUI [1,2]
C2348070
UMLS CUI [2]
C0560663
Nikotin: Konsum seit (Jahre)
Description

Nicotine: duration of consumption (years)

Data type

float

Measurement units
  • years
Alias
UMLS CUI [1,1]
C0543414
UMLS CUI [1,2]
C0449238
years
Nikotin: Ex-Raucher
Description

Nicotine: Ex-smoker

Data type

boolean

Alias
UMLS CUI [1]
C0543414
UMLS CUI [2]
C0337671
Nikotin: Ex-Raucher seit (Jahre)
Description

Nicotine: Ex-smoker since (years)

Data type

float

Measurement units
  • years
Alias
UMLS CUI [1]
C0543414
UMLS CUI [2,1]
C0337671
UMLS CUI [2,2]
C0449238
years
Nikotin (sonstiges)
Description

Nicotine (specification)

Data type

text

Alias
UMLS CUI [1,1]
C0543414
UMLS CUI [1,2]
C0205394
Alkohol
Description

Alcohol

Data type

boolean

Alias
UMLS CUI [1]
C0038586
UMLS CUI [2]
C0085762
Alkohol (wenn ja, bitte beschreiben)
Description

Alcohol (specification)

Data type

text

Alias
UMLS CUI [1]
C0038586
UMLS CUI [2]
C0085762
Hypercholesterinämie
Description

Hypercholesterolemia

Data type

boolean

Alias
UMLS CUI [1]
C0020443
Hypercholesterinämie (wenn ja, bitte beschreiben)
Description

Hypercholesterolemia (specification)

Data type

text

Alias
UMLS CUI [1]
C0020443
Diabetes
Description

Diabetes

Data type

boolean

Alias
UMLS CUI [1]
C0011849
Diabetes (wenn ja, bitte beschreiben)
Description

Diabetes (specification)

Data type

text

Alias
UMLS CUI [1]
C0011849
Calcium/Phosphat-Haushalt
Description

Calcium/phosphate balance

Data type

boolean

Alias
UMLS CUI [1,1]
C0013831
UMLS CUI [1,2]
C0201925
UMLS CUI [1,3]
C0523826
Calcium/Phosphat-Haushalt (wenn ja, bitte beschreiben)
Description

Calcium/phosphate balance (specification)

Data type

text

Alias
UMLS CUI [1,1]
C0013831
UMLS CUI [1,2]
C0201925
UMLS CUI [1,3]
C0523826
Sonstige Risikofaktoren
Description

Other risk factors

Data type

boolean

Alias
UMLS CUI [1,1]
C0035648
UMLS CUI [1,2]
C0205394
Sonstige Risikofaktoren (wenn ja, bitte beschreiben)
Description

Other risk factors (specification)

Data type

text

Alias
UMLS CUI [1,1]
C0035648
UMLS CUI [1,2]
C0205394
Klinische Untersuchung
Description

Klinische Untersuchung

Alias
UMLS CUI-1
C0031809
Allgemeinbefund/Haut
Description

General findings/skin

Data type

boolean

Alias
UMLS CUI [1]
C0455205
Allgemeinbefund/Haut (wenn ja, bitte beschreiben)
Description

General findings/skin (specification)

Data type

text

Alias
UMLS CUI [1]
C0455205
Kopf
Description

Head

Data type

boolean

Alias
UMLS CUI [1,1]
C0018670
UMLS CUI [1,2]
C0243095
UMLS CUI [1,3]
C0031809
Kopf (wenn ja, bitte beschreiben)
Description

Head (specification)

Data type

text

Alias
UMLS CUI [1,1]
C0018670
UMLS CUI [1,2]
C0243095
UMLS CUI [1,3]
C0031809
Hals
Description

Neck

Data type

boolean

Alias
UMLS CUI [1,1]
C0027530
UMLS CUI [1,2]
C0243095
UMLS CUI [1,3]
C0031809
Hals (wenn ja, bitte beschreiben)
Description

Neck (specification)

Data type

text

Alias
UMLS CUI [1,1]
C0027530
UMLS CUI [1,2]
C0243095
UMLS CUI [1,3]
C0031809
Thorax
Description

Thorax

Data type

boolean

Alias
UMLS CUI [1,1]
C0817096
UMLS CUI [1,2]
C0243095
UMLS CUI [1,3]
C0031809
Thorax (wenn ja, bitte beschreiben)
Description

Thorax (specification)

Data type

text

Alias
UMLS CUI [1,1]
C0817096
UMLS CUI [1,2]
C0243095
UMLS CUI [1,3]
C0031809
Lunge
Description

Lungs

Data type

boolean

Alias
UMLS CUI [1,1]
C2228454
UMLS CUI [1,2]
C0243095
Lunge (wenn ja, bitte beschreiben)
Description

Lungs (specification)

Data type

text

Alias
UMLS CUI [1,1]
C2228454
UMLS CUI [1,2]
C0243095
Herz- und Gefäßsystem
Description

Cardiovascular system

Data type

boolean

Alias
UMLS CUI [1,1]
C0007226
UMLS CUI [1,2]
C0243095
UMLS CUI [1,3]
C0031809
Herz- und Gefäßsystem (wenn ja, bitte beschreiben)
Description

Cardiovascular system (specification)

Data type

text

Alias
UMLS CUI [1,1]
C0007226
UMLS CUI [1,2]
C0243095
UMLS CUI [1,3]
C0031809
Cor
Description

Heart

Data type

boolean

Alias
UMLS CUI [1,1]
C0018787
UMLS CUI [1,2]
C0243095
UMLS CUI [1,3]
C0031809
Cor (wenn ja, bitte beschreiben)
Description

Heart (specification)

Data type

text

Alias
UMLS CUI [1,1]
C0018787
UMLS CUI [1,2]
C0243095
UMLS CUI [1,3]
C0031809
Pulsstatus
Description

Pulse status

Data type

boolean

Alias
UMLS CUI [1]
C0558829
Pulsstatus (wenn ja, bitte beschreiben)
Description

Pulse status (specification)

Data type

text

Alias
UMLS CUI [1]
C0558829
Pulsstatus: Obere Extremität o.p.B.
Description

Pulse status: Upper limb N.A.D.

Data type

boolean

Alias
UMLS CUI [1,1]
C0558829
UMLS CUI [1,2]
C1140618
Pulsstatus: Carotis rechts
Description

Pulse status: Right carotid artery

Data type

text

Alias
UMLS CUI [1,1]
C1096529
UMLS CUI [1,2]
C0226086
Pulsstatus: Carotis links
Description

Pulse status: Left carotid artery

Data type

text

Alias
UMLS CUI [1,1]
C1096529
UMLS CUI [1,2]
C0226087
Pulsstatus: Radialis rechts
Description

Pulse status: Right radial artery

Data type

text

Alias
UMLS CUI [1,1]
C2363059
UMLS CUI [1,2]
C0226438
Pulsstatus: Radialis links
Description

Pulse status: Left radial artery

Data type

text

Alias
UMLS CUI [1,1]
C2363059
UMLS CUI [1,2]
C0226439
Pulsstatus: Untere Extremität o.p.B.
Description

Pulse status: Lower limb N.A.D.

Data type

boolean

Alias
UMLS CUI [1]
C0558829
Pulsstatus: Femoralis rechts
Description

Pulse status: Right femoral artery

Data type

text

Alias
UMLS CUI [1,1]
C2228442
UMLS CUI [1,2]
C0226447
Pulsstatus: Femoralis links
Description

Pulse status: Left femoral artery

Data type

text

Alias
UMLS CUI [1,1]
C2228442
UMLS CUI [1,2]
C0226448
Pulsstatus: Poplitea rechts
Description

Pulse status: Right popliteal artery

Data type

text

Alias
UMLS CUI [1,1]
C0232151
UMLS CUI [1,2]
C0226462
Pulsstatus: Poplitea links
Description

Pulse status: Left popliteal artery

Data type

text

Alias
UMLS CUI [1,1]
C0232151
UMLS CUI [1,2]
C0226463
Pulsstatus: Tibialis posterior rechts
Description

Pulse status: Right posterior tibial artery

Data type

text

Alias
UMLS CUI [1,1]
C1720310
UMLS CUI [1,2]
C0226474
Pulsstatus: Tibialis posterior links
Description

Pulse status: Left posterior tibial artery

Data type

text

Alias
UMLS CUI [1,1]
C1720310
UMLS CUI [1,2]
C0226475
Pulsstatus: Dorsalis pedis rechts
Description

Pulse status: Right dorsalis pedis artery

Data type

text

Alias
UMLS CUI [1,1]
C1706488
UMLS CUI [1,2]
C0834665
Pulsstatus: Dorsalis pedis links
Description

Pulse status: Left dorsalis pedis artery

Data type

text

Alias
UMLS CUI [1,1]
C1706488
UMLS CUI [1,2]
C0834666
Blutdruck rechts
Description

Blood pressure right

Data type

text

Measurement units
  • mmHg
Alias
UMLS CUI [1,1]
C0005823
UMLS CUI [1,2]
C0205090
mmHg
Blutdruck links
Description

Blood pressure left

Data type

text

Measurement units
  • mmHg
Alias
UMLS CUI [1,1]
C0005823
UMLS CUI [1,2]
C0205091
mmHg
Transplantat
Description

Transplant

Data type

boolean

Alias
UMLS CUI [1,1]
C0478647
UMLS CUI [1,2]
C0243095
UMLS CUI [1,3]
C0031809
Transplantat (wenn ja, bitte beschreiben)
Description

Transplant (specification)

Data type

text

Alias
UMLS CUI [1,1]
C0478647
UMLS CUI [1,2]
C0243095
UMLS CUI [1,3]
C0031809
Abdomen
Description

Abdomen

Data type

boolean

Alias
UMLS CUI [1,1]
C0000726
UMLS CUI [1,2]
C0243095
UMLS CUI [1,3]
C0031809
Abdomen (wenn ja, bitte beschreiben)
Description

Abdomen (specification)

Data type

text

Alias
UMLS CUI [1,1]
C0000726
UMLS CUI [1,2]
C0243095
UMLS CUI [1,3]
C0031809
Urogenitalsystem / Rektum
Description

Genitourinary system / rectum

Data type

boolean

Alias
UMLS CUI [1,1]
C0042066
UMLS CUI [1,2]
C0243095
UMLS CUI [1,3]
C0031809
UMLS CUI [2,1]
C0034896
UMLS CUI [2,2]
C0243095
UMLS CUI [2,3]
C0031809
Urogenitalsystem / Rektum (wenn ja, bitte beschreiben)
Description

Genitourinary system / rectum (specification)

Data type

text

Alias
UMLS CUI [1,1]
C0042066
UMLS CUI [1,2]
C0243095
UMLS CUI [1,3]
C0031809
UMLS CUI [2,1]
C0034896
UMLS CUI [2,2]
C0243095
UMLS CUI [2,3]
C0031809
Extremitäten/Ödem
Description

Limbs/edema

Data type

boolean

Alias
UMLS CUI [1,1]
C0015385
UMLS CUI [1,2]
C0243095
UMLS CUI [1,3]
C0031809
UMLS CUI [2,1]
C0013604
UMLS CUI [2,2]
C0243095
UMLS CUI [2,3]
C0031809
Extremitäten/Ödem (wenn ja, bitte beschreiben)
Description

Limbs/edema (specification)

Data type

text

Alias
UMLS CUI [1,1]
C0015385
UMLS CUI [1,2]
C0243095
UMLS CUI [1,3]
C0031809
UMLS CUI [2,1]
C0013604
UMLS CUI [2,2]
C0243095
UMLS CUI [2,3]
C0031809
Wirbelsäule
Description

Spine

Data type

boolean

Alias
UMLS CUI [1,1]
C0037949
UMLS CUI [1,2]
C0243095
UMLS CUI [1,3]
C0031809
Wirbelsäule (wenn ja, bitte beschreiben)
Description

Spine (specification)

Data type

text

Alias
UMLS CUI [1,1]
C0037949
UMLS CUI [1,2]
C0243095
UMLS CUI [1,3]
C0031809
Nervensystem und Psyche
Description

Nervous system and psyche

Data type

boolean

Alias
UMLS CUI [1,1]
C0027763
UMLS CUI [1,2]
C0243095
UMLS CUI [1,3]
C0031809
UMLS CUI [2,1]
C0846574
UMLS CUI [2,2]
C0243095
Nervensystem und Psyche (wenn ja, bitte beschreiben)
Description

Nervous system and psyche (specification)

Data type

text

Alias
UMLS CUI [1,1]
C0027763
UMLS CUI [1,2]
C0243095
UMLS CUI [1,3]
C0031809
UMLS CUI [2,1]
C0846574
UMLS CUI [2,2]
C0243095
Lymphknoten
Description

Lymph nodes

Data type

boolean

Alias
UMLS CUI [1,1]
C0024204
UMLS CUI [1,2]
C0243095
UMLS CUI [1,3]
C0031809
Lymphknoten (wenn ja, bitte beschreiben)
Description

Lymph nodes (specification)

Data type

text

Alias
UMLS CUI [1,1]
C0024204
UMLS CUI [1,2]
C0243095
UMLS CUI [1,3]
C0031809
Sonstiges
Description

Other

Data type

boolean

Alias
UMLS CUI [1,1]
C0205394
UMLS CUI [1,2]
C0243095
UMLS CUI [1,3]
C0031809
Sonstiges (wenn ja, bitte beschreiben)
Description

Other (specification)

Data type

text

Alias
UMLS CUI [1,1]
C0205394
UMLS CUI [1,2]
C0243095
UMLS CUI [1,3]
C0031809
Wunde
Description

Wound

Data type

boolean

Alias
UMLS CUI [1,1]
C0043250
UMLS CUI [1,2]
C0243095
UMLS CUI [1,3]
C0031809
Wunde (wenn ja, bitte beschreiben)
Description

Wound (specification)

Data type

text

Alias
UMLS CUI [1,1]
C0043250
UMLS CUI [1,2]
C0243095
UMLS CUI [1,3]
C0031809
Transplantatsonographie
Description

Transplantatsonographie

Alias
UMLS CUI-1
C2456887
UMLS CUI-3
C0022671
Morphologie (qualitativ)
Description

Morphology (qualitative)

Data type

text

Alias
UMLS CUI [1,1]
C0332437
UMLS CUI [1,2]
C0022646
UMLS CUI [2]
C2456887
Längsdurchmesser
Description

Longitudinal diameter

Data type

integer

Measurement units
  • mm
Alias
UMLS CUI [1,1]
C1301886
UMLS CUI [1,2]
C0022646
UMLS CUI [2]
C2456887
mm
Querdurchmesser
Description

Lateral diameter

Data type

integer

Measurement units
  • mm
Alias
UMLS CUI [1,1]
C1301886
UMLS CUI [1,2]
C0022646
UMLS CUI [2]
C2456887
mm
Parenchymbreite
Description

Width of parenchyma

Data type

integer

Measurement units
  • mm
Alias
UMLS CUI [1,1]
C0227628
UMLS CUI [1,2]
C0487742
UMLS CUI [2]
C2456887
mm
Doppler/Duplexsonographie
Description

Doppler/Duplex sonography

Data type

text

Alias
UMLS CUI [1,1]
C0162481
UMLS CUI [1,2]
C0022646
UMLS CUI [2]
C2456887
Resistenzindex
Description

Resistive index

Data type

text

Alias
UMLS CUI [1,1]
C0807745
UMLS CUI [1,2]
C0022646
UMLS CUI [2]
C2456887
Nierenarterien Vmax
Description

Renal arteries Vmax

Data type

integer

Measurement units
  • cm/s
Alias
UMLS CUI [1,1]
C0035065
UMLS CUI [1,2]
C1710637
UMLS CUI [1,3]
C0022646
UMLS CUI [2]
C2456887
cm/s
Flowqualität in der Nierenarterie
Description

Quality of flow in renal artery

Data type

text

Alias
UMLS CUI [1,1]
C0035065
UMLS CUI [1,2]
C0232338
UMLS CUI [1,3]
C0022646
UMLS CUI [2]
C2456887
Sonstiges
Description

Other

Data type

text

Alias
UMLS CUI [1,1]
C0205394
UMLS CUI [1,2]
C2456887
UMLS CUI [1,3]
C0022671
Zusammenfassung/Procedere
Description

Zusammenfassung/Procedere

Alias
UMLS CUI-1
C0087111
UMLS CUI-2
C0242482
Procedere
Description

Procedure

Data type

text

Alias
UMLS CUI [1]
C0087111
Zusammenfassung Anamnese
Description

Summary of medical history

Data type

text

Alias
UMLS CUI [1,1]
C0242482
UMLS CUI [1,2]
C0262926
Zusammenfassung klinische Untersuchung
Description

Summary of clinical examination

Data type

text

Alias
UMLS CUI [1,1]
C0242482
UMLS CUI [1,2]
C0031809
Zusammenfassung Sonographie
Description

Summary of sonography

Data type

text

Alias
UMLS CUI [1,1]
C0242482
UMLS CUI [1,2]
C2456887
UMLS CUI [1,3]
C0022671
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Similar models

AN MS MEDD Anamnese KU NTX University Hospital Muenster (UKM) Subform

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Allgemeine Angaben
C1508263 (UMLS CUI-1)
C1955348 (UMLS CUI-2)
C0587474 (UMLS CUI-3)
C0022671 (UMLS CUI-4)
Examiner
Item
Untersucher
text
C0025082 (UMLS CUI [1,1])
C0025084 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,3])
Date of medical history taking
Item
Vorstellung vom
date
C0034927 (UMLS CUI [1,1])
C0025084 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,3])
Mode of medical history taking
Item
Erhebungsmodus
text
C0025084 (UMLS CUI [1,1])
C0332307 (UMLS CUI [1,2])
Current medical history
Item
Jetzige Anamnese
text
C0262926 (UMLS CUI [1])
Item Group
Vegetative Anamnese und Risikofaktorenmanagement
C0262926 (UMLS CUI-1)
C0037088 (UMLS CUI-2)
C0035648 (UMLS CUI-3)
C0376636 (UMLS CUI-4)
Height
Item
Größe
float
C0005890 (UMLS CUI [1])
Weight
Item
Gewicht
float
C0005910 (UMLS CUI [1])
BMI
Item
BMI
text
C1305855 (UMLS CUI [1])
Change in weight
Item
Gewichtsveränderung
boolean
C0005911 (UMLS CUI [1])
Change in weight (specification)
Item
Gewichtsveränderung (wenn ja, bitte beschreiben)
text
C0005911 (UMLS CUI [1,1])
C2348235 (UMLS CUI [1,2])
Amount of liquid consumed (per day)
Item
Trinkmenge (pro Tag)
float
C0429791 (UMLS CUI [1])
Amount of liquid consumed (specification)
Item
Trinkmenge (Beschreibung)
text
C0429791 (UMLS CUI [1])
Diuresis (per day)
Item
Eigendiurese (pro Tag)
float
C0012797 (UMLS CUI [1])
Diuresis
Item
Eigendiurese
text
C0012797 (UMLS CUI [1])
Hypertension: Mean systolic blood pressure
Item
Hypertonus: Mittlerer sys. RR
integer
C0020538 (UMLS CUI [1])
C0428886 (UMLS CUI [2,1])
C0871470 (UMLS CUI [2,2])
Hypertension: systolic
Item
Hypertonus: systolisch
text
Hypertension: Mean diastolic blood pressure
Item
Hypertonus: Mittlerer diast. RR
integer
C0020538 (UMLS CUI [1])
C0428886 (UMLS CUI [2,1])
C0428883 (UMLS CUI [2,2])
Hypertension: diastolic
Item
Hypertonus: diastolisch
text
C0428883 (UMLS CUI [1])
C0020538 (UMLS CUI [2])
Hypertension: 24 h RR (syst/diast)
Item
Hypertonus: 24 h RR (syst/diast)
text
C0451604 (UMLS CUI [1])
C0020538 (UMLS CUI [2])
Hypertension: Date of 24 h RR measurement
Item
Hypertonus: Datum 24 h RR
date
C0451604 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
C0020538 (UMLS CUI [2])
Hypertension: Comments 24 h RR
Item
Hypertonus: Bemerkungen 24 H RR
text
C0451604 (UMLS CUI [1,1])
C0947611 (UMLS CUI [1,2])
C0020538 (UMLS CUI [2])
Fever
Item
Fieber
boolean
C0015967 (UMLS CUI [1])
Fever (specification)
Item
Fieber (wenn ja, bitte beschreiben)
text
C0015967 (UMLS CUI [1])
Stool
Item
Stuhlverhalten
boolean
C1290944 (UMLS CUI [1,1])
C0015733 (UMLS CUI [1,2])
Stool (specification)
Item
Stuhlverhalten (wenn ja, bitte beschreiben)
text
C1290944 (UMLS CUI [1,1])
C0015733 (UMLS CUI [1,2])
Micturition
Item
Miktion
boolean
C0042034 (UMLS CUI [1,1])
C0542565 (UMLS CUI [1,2])
Micturition (specification)
Item
Miktion (wenn ja, bitte beschreiben)
text
C0042034 (UMLS CUI [1,1])
C0542565 (UMLS CUI [1,2])
Nocturia
Item
Nykturie
boolean
C0028734 (UMLS CUI [1])
Nocturia (specification)
Item
Nykturie (wenn ja, bitte beschreiben)
text
C0028734 (UMLS CUI [1])
Coughing
Item
Husten
boolean
C0010200 (UMLS CUI [1])
Coughing (specification)
Item
Husten (wenn ja, bitte beschreiben)
text
C0010200 (UMLS CUI [1])
Sputum
Item
Auswurf
boolean
C0038056 (UMLS CUI [1])
Sputum (specification)
Item
Auswurf (wenn ja, bitte beschreiben)
text
C0038056 (UMLS CUI [1])
Shortness of breath
Item
Luftnot
boolean
C0013404 (UMLS CUI [1])
Shortness of breath (specification)
Item
Luftnot (wenn ja, bitte beschreiben)
text
C0013404 (UMLS CUI [1])
Edema
Item
Ödeme
boolean
C0013604 (UMLS CUI [1])
Edema (specification)
Item
Ödeme (wenn ja, bitte beschreiben)
text
C0013604 (UMLS CUI [1])
Night sweats
Item
Nachtschweiß
boolean
C0028081 (UMLS CUI [1])
Night sweats (specification)
Item
Nachtschweiß (wenn ja, bitte beschreiben)
text
C0028081 (UMLS CUI [1])
Joint trouble
Item
Gelenkbeschwerden
boolean
C0022408 (UMLS CUI [1])
Joint trouble (specification)
Item
Gelenkbeschwerden (wenn ja, bitte beschreiben)
text
C0022408 (UMLS CUI [1])
Signs of vasculitis
Item
Vasculitiszeichen
boolean
C0042384 (UMLS CUI [1,1])
C0037088 (UMLS CUI [1,2])
Signs of vasculitis (specification)
Item
Vasculitiszeichen (wenn ja, bitte beschreiben)
text
C0042384 (UMLS CUI [1,1])
C0037088 (UMLS CUI [1,2])
Appetite
Item
Appetit
boolean
C0003618 (UMLS CUI [1])
Appetite (specification)
Item
Appetit (wenn ja, bitte beschreiben)
text
C0003618 (UMLS CUI [1])
Sleep
Item
Schlaf
boolean
C0037313 (UMLS CUI [1])
Sleep (specification)
Item
Schlaf (wenn ja, bitte beschreiben)
text
C0037313 (UMLS CUI [1])
Nicotine
Item
Nikotin
boolean
C0543414 (UMLS CUI [1])
Nicotine: packets per day
Item
Nikotin: Schachteln/Tag
float
C0543414 (UMLS CUI [1,1])
C2348070 (UMLS CUI [1,2])
C0560663 (UMLS CUI [2])
Nicotine: duration of consumption (years)
Item
Nikotin: Konsum seit (Jahre)
float
C0543414 (UMLS CUI [1,1])
C0449238 (UMLS CUI [1,2])
Nicotine: Ex-smoker
Item
Nikotin: Ex-Raucher
boolean
C0543414 (UMLS CUI [1])
C0337671 (UMLS CUI [2])
Nicotine: Ex-smoker since (years)
Item
Nikotin: Ex-Raucher seit (Jahre)
float
C0543414 (UMLS CUI [1])
C0337671 (UMLS CUI [2,1])
C0449238 (UMLS CUI [2,2])
Nicotine (specification)
Item
Nikotin (sonstiges)
text
C0543414 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
Alcohol
Item
Alkohol
boolean
C0038586 (UMLS CUI [1])
C0085762 (UMLS CUI [2])
Alcohol (specification)
Item
Alkohol (wenn ja, bitte beschreiben)
text
C0038586 (UMLS CUI [1])
C0085762 (UMLS CUI [2])
Hypercholesterolemia
Item
Hypercholesterinämie
boolean
C0020443 (UMLS CUI [1])
Hypercholesterolemia (specification)
Item
Hypercholesterinämie (wenn ja, bitte beschreiben)
text
C0020443 (UMLS CUI [1])
Diabetes
Item
Diabetes
boolean
C0011849 (UMLS CUI [1])
Diabetes (specification)
Item
Diabetes (wenn ja, bitte beschreiben)
text
C0011849 (UMLS CUI [1])
Calcium/phosphate balance
Item
Calcium/Phosphat-Haushalt
boolean
C0013831 (UMLS CUI [1,1])
C0201925 (UMLS CUI [1,2])
C0523826 (UMLS CUI [1,3])
Calcium/phosphate balance (specification)
Item
Calcium/Phosphat-Haushalt (wenn ja, bitte beschreiben)
text
C0013831 (UMLS CUI [1,1])
C0201925 (UMLS CUI [1,2])
C0523826 (UMLS CUI [1,3])
Other risk factors
Item
Sonstige Risikofaktoren
boolean
C0035648 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
Other risk factors (specification)
Item
Sonstige Risikofaktoren (wenn ja, bitte beschreiben)
text
C0035648 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
Item Group
Klinische Untersuchung
C0031809 (UMLS CUI-1)
General findings/skin
Item
Allgemeinbefund/Haut
boolean
C0455205 (UMLS CUI [1])
General findings/skin (specification)
Item
Allgemeinbefund/Haut (wenn ja, bitte beschreiben)
text
C0455205 (UMLS CUI [1])
Head
Item
Kopf
boolean
C0018670 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,3])
Head (specification)
Item
Kopf (wenn ja, bitte beschreiben)
text
C0018670 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,3])
Neck
Item
Hals
boolean
C0027530 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,3])
Neck (specification)
Item
Hals (wenn ja, bitte beschreiben)
text
C0027530 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,3])
Thorax
Item
Thorax
boolean
C0817096 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,3])
Thorax (specification)
Item
Thorax (wenn ja, bitte beschreiben)
text
C0817096 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,3])
Lungs
Item
Lunge
boolean
C2228454 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
Lungs (specification)
Item
Lunge (wenn ja, bitte beschreiben)
text
C2228454 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
Cardiovascular system
Item
Herz- und Gefäßsystem
boolean
C0007226 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,3])
Cardiovascular system (specification)
Item
Herz- und Gefäßsystem (wenn ja, bitte beschreiben)
text
C0007226 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,3])
Heart
Item
Cor
boolean
C0018787 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,3])
Heart (specification)
Item
Cor (wenn ja, bitte beschreiben)
text
C0018787 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,3])
Pulse status
Item
Pulsstatus
boolean
C0558829 (UMLS CUI [1])
Pulse status (specification)
Item
Pulsstatus (wenn ja, bitte beschreiben)
text
C0558829 (UMLS CUI [1])
Pulse status: Upper limb N.A.D.
Item
Pulsstatus: Obere Extremität o.p.B.
boolean
C0558829 (UMLS CUI [1,1])
C1140618 (UMLS CUI [1,2])
Pulse status: Right carotid artery
Item
Pulsstatus: Carotis rechts
text
C1096529 (UMLS CUI [1,1])
C0226086 (UMLS CUI [1,2])
Pulse status: Left carotid artery
Item
Pulsstatus: Carotis links
text
C1096529 (UMLS CUI [1,1])
C0226087 (UMLS CUI [1,2])
Pulse status: Right radial artery
Item
Pulsstatus: Radialis rechts
text
C2363059 (UMLS CUI [1,1])
C0226438 (UMLS CUI [1,2])
Pulse status: Left radial artery
Item
Pulsstatus: Radialis links
text
C2363059 (UMLS CUI [1,1])
C0226439 (UMLS CUI [1,2])
Pulse status: Lower limb N.A.D.
Item
Pulsstatus: Untere Extremität o.p.B.
boolean
C0558829 (UMLS CUI [1])
Pulse status: Right femoral artery
Item
Pulsstatus: Femoralis rechts
text
C2228442 (UMLS CUI [1,1])
C0226447 (UMLS CUI [1,2])
Pulse status: Left femoral artery
Item
Pulsstatus: Femoralis links
text
C2228442 (UMLS CUI [1,1])
C0226448 (UMLS CUI [1,2])
Pulse status: Right popliteal artery
Item
Pulsstatus: Poplitea rechts
text
C0232151 (UMLS CUI [1,1])
C0226462 (UMLS CUI [1,2])
Pulse status: Left popliteal artery
Item
Pulsstatus: Poplitea links
text
C0232151 (UMLS CUI [1,1])
C0226463 (UMLS CUI [1,2])
Pulse status: Right posterior tibial artery
Item
Pulsstatus: Tibialis posterior rechts
text
C1720310 (UMLS CUI [1,1])
C0226474 (UMLS CUI [1,2])
Pulse status: Left posterior tibial artery
Item
Pulsstatus: Tibialis posterior links
text
C1720310 (UMLS CUI [1,1])
C0226475 (UMLS CUI [1,2])
Pulse status: Right dorsalis pedis artery
Item
Pulsstatus: Dorsalis pedis rechts
text
C1706488 (UMLS CUI [1,1])
C0834665 (UMLS CUI [1,2])
Pulse status: Left dorsalis pedis artery
Item
Pulsstatus: Dorsalis pedis links
text
C1706488 (UMLS CUI [1,1])
C0834666 (UMLS CUI [1,2])
Blood pressure right
Item
Blutdruck rechts
text
C0005823 (UMLS CUI [1,1])
C0205090 (UMLS CUI [1,2])
Blood pressure left
Item
Blutdruck links
text
C0005823 (UMLS CUI [1,1])
C0205091 (UMLS CUI [1,2])
Transplant
Item
Transplantat
boolean
C0478647 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,3])
Transplant (specification)
Item
Transplantat (wenn ja, bitte beschreiben)
text
C0478647 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,3])
Abdomen
Item
Abdomen
boolean
C0000726 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,3])
Abdomen (specification)
Item
Abdomen (wenn ja, bitte beschreiben)
text
C0000726 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,3])
Genitourinary system / rectum
Item
Urogenitalsystem / Rektum
boolean
C0042066 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,3])
C0034896 (UMLS CUI [2,1])
C0243095 (UMLS CUI [2,2])
C0031809 (UMLS CUI [2,3])
Genitourinary system / rectum (specification)
Item
Urogenitalsystem / Rektum (wenn ja, bitte beschreiben)
text
C0042066 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,3])
C0034896 (UMLS CUI [2,1])
C0243095 (UMLS CUI [2,2])
C0031809 (UMLS CUI [2,3])
Limbs/edema
Item
Extremitäten/Ödem
boolean
C0015385 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,3])
C0013604 (UMLS CUI [2,1])
C0243095 (UMLS CUI [2,2])
C0031809 (UMLS CUI [2,3])
Limbs/edema (specification)
Item
Extremitäten/Ödem (wenn ja, bitte beschreiben)
text
C0015385 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,3])
C0013604 (UMLS CUI [2,1])
C0243095 (UMLS CUI [2,2])
C0031809 (UMLS CUI [2,3])
Spine
Item
Wirbelsäule
boolean
C0037949 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,3])
Spine (specification)
Item
Wirbelsäule (wenn ja, bitte beschreiben)
text
C0037949 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,3])
Nervous system and psyche
Item
Nervensystem und Psyche
boolean
C0027763 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,3])
C0846574 (UMLS CUI [2,1])
C0243095 (UMLS CUI [2,2])
Nervous system and psyche (specification)
Item
Nervensystem und Psyche (wenn ja, bitte beschreiben)
text
C0027763 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,3])
C0846574 (UMLS CUI [2,1])
C0243095 (UMLS CUI [2,2])
Lymph nodes
Item
Lymphknoten
boolean
C0024204 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,3])
Lymph nodes (specification)
Item
Lymphknoten (wenn ja, bitte beschreiben)
text
C0024204 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,3])
Other
Item
Sonstiges
boolean
C0205394 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,3])
Other (specification)
Item
Sonstiges (wenn ja, bitte beschreiben)
text
C0205394 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,3])
Wound
Item
Wunde
boolean
C0043250 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,3])
Wound (specification)
Item
Wunde (wenn ja, bitte beschreiben)
text
C0043250 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,3])
Item Group
Transplantatsonographie
C2456887 (UMLS CUI-1)
C0022671 (UMLS CUI-3)
Morphology (qualitative)
Item
Morphologie (qualitativ)
text
C0332437 (UMLS CUI [1,1])
C0022646 (UMLS CUI [1,2])
C2456887 (UMLS CUI [2])
Longitudinal diameter
Item
Längsdurchmesser
integer
C1301886 (UMLS CUI [1,1])
C0022646 (UMLS CUI [1,2])
C2456887 (UMLS CUI [2])
Lateral diameter
Item
Querdurchmesser
integer
C1301886 (UMLS CUI [1,1])
C0022646 (UMLS CUI [1,2])
C2456887 (UMLS CUI [2])
Width of parenchyma
Item
Parenchymbreite
integer
C0227628 (UMLS CUI [1,1])
C0487742 (UMLS CUI [1,2])
C2456887 (UMLS CUI [2])
Doppler/Duplex sonography
Item
Doppler/Duplexsonographie
text
C0162481 (UMLS CUI [1,1])
C0022646 (UMLS CUI [1,2])
C2456887 (UMLS CUI [2])
Resistive index
Item
Resistenzindex
text
C0807745 (UMLS CUI [1,1])
C0022646 (UMLS CUI [1,2])
C2456887 (UMLS CUI [2])
Renal arteries Vmax
Item
Nierenarterien Vmax
integer
C0035065 (UMLS CUI [1,1])
C1710637 (UMLS CUI [1,2])
C0022646 (UMLS CUI [1,3])
C2456887 (UMLS CUI [2])
Quality of flow in renal artery
Item
Flowqualität in der Nierenarterie
text
C0035065 (UMLS CUI [1,1])
C0232338 (UMLS CUI [1,2])
C0022646 (UMLS CUI [1,3])
C2456887 (UMLS CUI [2])
Other
Item
Sonstiges
text
C0205394 (UMLS CUI [1,1])
C2456887 (UMLS CUI [1,2])
C0022671 (UMLS CUI [1,3])
Item Group
Zusammenfassung/Procedere
C0087111 (UMLS CUI-1)
C0242482 (UMLS CUI-2)
Procedure
Item
Procedere
text
C0087111 (UMLS CUI [1])
Summary of medical history
Item
Zusammenfassung Anamnese
text
C0242482 (UMLS CUI [1,1])
C0262926 (UMLS CUI [1,2])
Summary of clinical examination
Item
Zusammenfassung klinische Untersuchung
text
C0242482 (UMLS CUI [1,1])
C0031809 (UMLS CUI [1,2])
Summary of sonography
Item
Zusammenfassung Sonographie
text
C0242482 (UMLS CUI [1,1])
C2456887 (UMLS CUI [1,2])
C0022671 (UMLS CUI [1,3])
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