ID

24072

Description

Examination form converted to ODM format. Routine documentation of University Hospital of Münster. Publication granted by Univ.-Prof. Dr. med. Sven Martens.

Keywords

Versions (3)
  1. 7/23/17 7/23/17 -
  2. 7/24/17 7/24/17 -
  3. 7/25/17 7/25/17 -
Uploaded on

July 24, 2017

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License

Creative Commons BY-NC 3.0
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Examination cardiac surgery UKM

German English

Examination

1 forms  
  1. StudyEvent: ODM
    1. Examination
Patient demographics
Description

Patient demographics

Patient name
Description

Patient name

Data type

text

Alias
UMLS CUI [1]
C1299487
Date of birth
Description

Date of birth

Data type

date

Alias
UMLS CUI [1]
C0421451
Date
Description

Date

Data type

date

Alias
UMLS CUI [1]
C0011008
Operation
Description

Operation

Data type

integer

Alias
UMLS CUI [1]
C0543467
Diagnosis
Description

Diagnosis

Data type

integer

Alias
UMLS CUI [1]
C0011900
Comment
Description

Comment

Data type

text

Alias
UMLS CUI [1]
C0947611
Heart disease
Description

Heart disease

Data type

integer

Alias
UMLS CUI [1]
C0018799
Examination
Description

Examination

Family history
Description

Family history

Data type

integer

Alias
UMLS CUI [1]
C0241889
Symptoms
Description

Symptoms

Data type

text

Alias
UMLS CUI [1]
C1457887
Desire for food
Description

Desire for food

Data type

integer

Alias
UMLS CUI [1]
C0003618
Thirst
Description

Thirst

Data type

integer

Alias
UMLS CUI [1]
C0039971
Stool
Description

Stool

Data type

integer

Alias
UMLS CUI [1]
C0015733
Frequency of urination
Description

Frequency of urination

Data type

integer

Alias
UMLS CUI [1]
C2584336
Coughing
Description

Coughing

Data type

integer

Alias
UMLS CUI [1]
C0010200
Sleeping
Description

Sleeping

Data type

integer

Alias
UMLS CUI [1]
C0237086
Blood Vessel Examination finding
Description

Blood Vessel Examination finding

Common carotid artery
Description

Common carotid artery

Data type

integer

Alias
UMLS CUI [1]
C0751635
Brachial artery
Description

Brachial artery

Data type

text

Alias
UMLS CUI [1]
C0006087
Radial artery
Description

Radial artery

Data type

text

Alias
UMLS CUI [1]
C0162857
Ulnar artery
Description

Ulnar artery

Data type

integer

Alias
UMLS CUI [1]
C0162858
Femoral artery
Description

Femoral artery

Data type

integer

Alias
UMLS CUI [1]
C0015801
Popliteal artery
Description

Popliteal artery

Data type

text

Alias
UMLS CUI [1]
C0032649
Dorsalis pedis artery
Description

Dorsalis pedis artery

Data type

integer

Alias
UMLS CUI [1]
C0226492
Posterior tibial artery
Description

Posterior tibial artery

Data type

integer

Alias
UMLS CUI [1]
C0086835
General assessment
Description

General assessment

Neurological status: consciousness
Description

Neurological status: consciousness

Data type

integer

Alias
UMLS CUI [1]
C0517960
Mental disorder
Description

Mental disorder

Data type

integer

Alias
UMLS CUI [1]
C0004936
General Appearance
Description

General Appearance

Data type

integer

Alias
UMLS CUI [1]
C1148438
Nutritional status
Description

Nutritional status

Data type

integer

Alias
UMLS CUI [1]
C0392209
Somatotype
Description

Somatotype

Data type

integer

Alias
UMLS CUI [1]
C0037669
Skin
Description

Skin

Data type

integer

Alias
UMLS CUI [1]
C1123023
Dyspnea
Description

Dyspnea

Data type

boolean

Alias
UMLS CUI [1]
C0013404
Bad breath
Description

Bad breath

Data type

integer

Alias
UMLS CUI [1]
C0018520
Edema
Description

Edema

Data type

integer

Alias
UMLS CUI [1]
C0013604
Lymph nodes
Description

Lymph nodes

Data type

text

Alias
UMLS CUI [1]
C0024204
Head
Description

Head

Eyes
Description

Eyes

Data type

text

Alias
UMLS CUI [1,1]
C0015392
UMLS CUI [1,2]
C0031809
Ears
Description

Ears

Data type

integer

Alias
UMLS CUI [1]
C0455216
Nose
Description

Nose

Data type

integer

Alias
UMLS CUI [1]
C0028429
Lips
Description

Lips

Data type

integer

Alias
UMLS CUI [1]
C0023759
Tongue
Description

Tongue

Data type

integer

Alias
UMLS CUI [1,1]
C0031809
UMLS CUI [1,2]
C1274040
Pharyngeal structure
Description

Pharyngeal structure

Data type

integer

Alias
UMLS CUI [1]
C0031354
Dentures
Description

Dentures

Data type

integer

Alias
UMLS CUI [1]
C0011394
Neck
Description

Neck

Data type

integer

Alias
UMLS CUI [1]
C2228463
Chest
Description

Chest

Chest
Description

Chest

Data type

integer

Alias
UMLS CUI [1]
C0850563
Mamma
Description

Mamma

Data type

integer

Alias
UMLS CUI [1]
C1268990
Lungs
Description

Lungs

lung borders
Description

lung borders

Data type

integer

Alias
UMLS CUI [1]
C3671937
percussion sound
Description

percussion sound

Data type

integer

Alias
UMLS CUI [1]
C1291006
Respiratory Sounds
Description

Respiratory Sounds

Data type

text

Alias
UMLS CUI [1]
C0035234
Heart
Description

Heart

Heart
Description

Heart

Data type

integer

Alias
UMLS CUI [1,1]
C0562319
UMLS CUI [1,2]
C0457109
Apex beat
Description

Apex beat

Data type

integer

Heart sounds
Description

Heart sounds

Data type

integer

Pulse
Description

Pulse

Data type

integer

Alias
UMLS CUI [1]
C0232117
Artery
Description

Artery

Data type

integer

Alias
UMLS CUI [1]
C0003842
Vein
Description

Vein

Data type

integer

Alias
UMLS CUI [1]
C0042449
Abdomen
Description

Abdomen

Abdominal wall
Description

Abdominal wall

Data type

integer

Alias
UMLS CUI [1]
C1269041
Rupture
Description

Rupture

Data type

text

Alias
UMLS CUI [1]
C0948106
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Similar models

Examination

1 forms
  1. StudyEvent: ODM
    1. Examination
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Patient demographics
Patient name
Item
Patient name
text
C1299487 (UMLS CUI [1])
Date of birth
Item
Date of birth
date
C0421451 (UMLS CUI [1])
Date
Item
Date
date
C0011008 (UMLS CUI [1])
Operation
Item
Operation
integer
C0543467 (UMLS CUI [1])
Diagnosis
Item
Diagnosis
integer
C0011900 (UMLS CUI [1])
Comment
Item
Comment
text
C0947611 (UMLS CUI [1])
Heart disease
Item
Heart disease
integer
C0018799 (UMLS CUI [1])
Item Group
Examination
Family history
Item
Family history
integer
C0241889 (UMLS CUI [1])
Symptoms
Item
Symptoms
text
C1457887 (UMLS CUI [1])
Item
Desire for food
integer
C0003618 (UMLS CUI [1])
Desire for food
Code List
Desire for food
CL Item
normal (1)
C0205307 (UMLS CUI-1)
(Comment:en)
CL Item
less (2)
C0439092 (UMLS CUI-1)
(Comment:en)
Item
Thirst
integer
C0039971 (UMLS CUI [1])
Thirst
Code List
Thirst
CL Item
normal (1)
C0205307 (UMLS CUI-1)
(Comment:en)
Stool
Item
Stool
integer
C0015733 (UMLS CUI [1])
Frequency of urination
Item
Frequency of urination
integer
C2584336 (UMLS CUI [1])
Coughing
Item
Coughing
integer
C0010200 (UMLS CUI [1])
Sleeping
Item
Sleeping
integer
C0237086 (UMLS CUI [1])
Item Group
Blood Vessel Examination finding
Item
Common carotid artery
integer
C0751635 (UMLS CUI [1])
Common carotid artery
Code List
Common carotid artery
CL Item
pulse (1)
C0232117 (UMLS CUI-1)
(Comment:en)
CL Item
noise (2)
C3257923 (UMLS CUI-1)
(Comment:en)
Item
Brachial artery
text
C0006087 (UMLS CUI [1])
Brachial artery
Code List
Brachial artery
CL Item
pulse (pulse)
C0232117 (UMLS CUI-1)
(Comment:en)
Item
Radial artery
text
C0162857 (UMLS CUI [1])
Brachial artery
Code List
Radial artery
CL Item
pulse (pulse)
C0232117 (UMLS CUI-1)
(Comment:en)
Item
Ulnar artery
integer
C0162858 (UMLS CUI [1])
Ulnar artery
Code List
Ulnar artery
CL Item
pulse (1)
C0232117 (UMLS CUI-1)
(Comment:en)
Item
Femoral artery
integer
C0015801 (UMLS CUI [1])
Ulnar artery
Code List
Femoral artery
CL Item
pulse (1)
C0232117 (UMLS CUI-1)
(Comment:en)
CL Item
noise (2)
C3257923 (UMLS CUI-1)
(Comment:en)
Item
Popliteal artery
text
C0032649 (UMLS CUI [1])
Popliteal artery
Code List
Popliteal artery
CL Item
pulse (pulse)
C0232117 (UMLS CUI-1)
(Comment:en)
Item
Dorsalis pedis artery
integer
C0226492 (UMLS CUI [1])
Dorsalis pedis artery
Code List
Dorsalis pedis artery
CL Item
pulse (1)
C0232117 (UMLS CUI-1)
(Comment:en)
Item
Posterior tibial artery
integer
C0086835 (UMLS CUI [1])
Posterior tibial artery
Code List
Posterior tibial artery
CL Item
pulse (1)
C0232117 (UMLS CUI-1)
(Comment:en)
Item Group
General assessment
Item
Neurological status: consciousness
integer
C0517960 (UMLS CUI [1])
Neurological status: consciousness
Code List
Neurological status: consciousness
CL Item
NAD (1)
C0559229 (UMLS CUI-1)
(Comment:en)
CL Item
unconscious (2)
C0041657 (UMLS CUI-1)
(Comment:en)
CL Item
agitation (3)
C0085631 (UMLS CUI-1)
(Comment:en)
CL Item
stupor (4)
C0009421 (UMLS CUI-1)
C0085628 (UMLS CUI-2)
(Comment:en)
CL Item
coma (5)
C0009421 (UMLS CUI-1)
(Comment:en)
Item
Mental disorder
integer
C0004936 (UMLS CUI [1])
Mental disorder
Code List
Mental disorder
CL Item
NAD (1)
C0559229 (UMLS CUI-1)
(Comment:en)
Item
General Appearance
integer
C1148438 (UMLS CUI [1])
General Appearance
Code List
General Appearance
CL Item
Normal (1)
C0205307 (UMLS CUI-1)
(Comment:en)
CL Item
Abnormal (2)
C0205161 (UMLS CUI-1)
(Comment:en)
CL Item
Not Examined (3)
C0332128 (UMLS CUI-1)
C1518422 (UMLS CUI-2)
(Comment:en)
Nutritional status
Item
Nutritional status
integer
C0392209 (UMLS CUI [1])
Item
Somatotype
integer
C0037669 (UMLS CUI [1])
Somatotype
Code List
Somatotype
CL Item
athletic (1)
C1510656 (UMLS CUI-1)
(Comment:en)
CL Item
asthenisch (2)
(Comment:en)
CL Item
pyknic (3)
(Comment:en)
Item
Skin
integer
C1123023 (UMLS CUI [1])
Skin
Code List
Skin
CL Item
NAD (1)
C0559229 (UMLS CUI-1)
(Comment:en)
CL Item
paleness (2)
C0030232 (UMLS CUI-1)
(Comment:en)
CL Item
Cyanosis (3)
C0010520 (UMLS CUI-1)
(Comment:en)
CL Item
Jaundice (4)
C0022346 (UMLS CUI-1)
(Comment:en)
CL Item
Redness (5)
C0332575 (UMLS CUI-1)
(Comment:en)
CL Item
Bleeding (6)
C0019080 (UMLS CUI-1)
(Comment:en)
CL Item
Turgor pressure (7)
(Comment:en)
CL Item
Exanthem (8)
C0015230 (UMLS CUI-1)
(Comment:en)
Dyspnea
Item
Dyspnea
boolean
C0013404 (UMLS CUI [1])
Item
Bad breath
integer
C0018520 (UMLS CUI [1])
Bad breath
Code List
Bad breath
CL Item
no (1)
CL Item
ex ore (2)
Item
Edema
integer
C0013604 (UMLS CUI [1])
Edema
Code List
Edema
CL Item
none (1)
C0549184 (UMLS CUI-1)
(Comment:en)
CL Item
face (2)
C0015450 (UMLS CUI-1)
(Comment:en)
CL Item
arm (3)
C1140618 (UMLS CUI-1)
(Comment:en)
CL Item
back (4)
C0460009 (UMLS CUI-1)
(Comment:en)
CL Item
legs (5)
C1140621 (UMLS CUI-1)
(Comment:en)
Item
Lymph nodes
text
C0024204 (UMLS CUI [1])
Lymph nodes
Code List
Lymph nodes
CL Item
nad (nad)
C0559229 (UMLS CUI-1)
(Comment:en)
CL Item
neck (neck)
C0588054 (UMLS CUI-1)
(Comment:en)
CL Item
axilla (axle)
C0842723 (UMLS CUI-1)
(Comment:en)
CL Item
Inguinal region (Inguinal region)
C1518054 (UMLS CUI-1)
(Comment:en)
Item Group
Head
Item
Eyes
text
C0015392 (UMLS CUI [1,1])
C0031809 (UMLS CUI [1,2])
Eyes
Code List
Eyes
CL Item
nad (nad)
C0559229 (UMLS CUI-1)
(Comment:en)
CL Item
Strabismus (Strabismus)
C0038379 (UMLS CUI-1)
(Comment:en)
CL Item
Nystagmus (Nystagmus)
C0028738 (UMLS CUI-1)
(Comment:en)
CL Item
blind (blind)
C0456909 (UMLS CUI-1)
(Comment:en)
CL Item
injury (injury)
C3263723 (UMLS CUI-1)
(Comment:en)
Item
Ears
integer
C0455216 (UMLS CUI [1])
Ears
Code List
Ears
CL Item
nad (1)
C0559229 (UMLS CUI-1)
(Comment:en)
CL Item
Hearing loss (2)
C3887873 (UMLS CUI-1)
(Comment:en)
CL Item
injury (3)
C3263723 (UMLS CUI-1)
(Comment:en)
CL Item
Liquorrhea (4)
C0860578 (UMLS CUI-1)
(Comment:en)
Item
Nose
integer
C0028429 (UMLS CUI [1])
Nose
Code List
Nose
CL Item
nad (1)
C0559229 (UMLS CUI-1)
(Comment:en)
CL Item
Liquorrhea (2)
C0860578 (UMLS CUI-1)
(Comment:en)
CL Item
injury (3)
C3263723 (UMLS CUI-1)
(Comment:en)
CL Item
impaired breathing (4)
C0548979 (UMLS CUI-1)
(Comment:en)
Item
Lips
integer
C0023759 (UMLS CUI [1])
Lips
Code List
Lips
CL Item
nad (1)
C0559229 (UMLS CUI-1)
(Comment:en)
CL Item
Rhagades (2)
C1948010 (UMLS CUI-1)
(Comment:en)
CL Item
Herpes simplex (3)
C0019345 (UMLS CUI-1)
(Comment:en)
CL Item
injury (4)
C3263723 (UMLS CUI-1)
(Comment:en)
CL Item
tumor (5)
C0006826 (UMLS CUI-1)
(Comment:en)
Item
Tongue
integer
C0031809 (UMLS CUI [1,1])
C1274040 (UMLS CUI [1,2])
Tongue
Code List
Tongue
CL Item
nad (1)
C0559229 (UMLS CUI-1)
(Comment:en)
CL Item
dry (2)
C0151908 (UMLS CUI-1)
(Comment:en)
CL Item
inflammation (3)
C0021368 (UMLS CUI-1)
(Comment:en)
Item
Pharyngeal structure
integer
C0031354 (UMLS CUI [1])
Pharyngeal structure
Code List
Pharyngeal structure
CL Item
nad (1)
C0559229 (UMLS CUI-1)
(Comment:en)
CL Item
inflammation (2)
C0021368 (UMLS CUI-1)
(Comment:en)
CL Item
Pharyngitis (3)
C0031350 (UMLS CUI-1)
(Comment:en)
Dentures
Item
Dentures
integer
C0011394 (UMLS CUI [1])
Item
Neck
integer
C2228463 (UMLS CUI [1])
Neck
Code List
Neck
CL Item
nad (1)
CL Item
struma (2)
CL Item
stridor (3)
CL Item
venous stasis (4)
Item Group
Chest
Item
Chest
integer
C0850563 (UMLS CUI [1])
Chest
Code List
Chest
CL Item
nad (1)
C0559229 (UMLS CUI-1)
(Comment:en)
CL Item
Deformity (2)
C0302142 (UMLS CUI-1)
(Comment:en)
CL Item
injury (3)
C3263723 (UMLS CUI-1)
(Comment:en)
Item
Mamma
integer
C1268990 (UMLS CUI [1])
Mamma
Code List
Mamma
CL Item
nad (1)
C0559229 (UMLS CUI-1)
(Comment:en)
CL Item
tumor (2)
C1458155 (UMLS CUI-1)
(Comment:en)
CL Item
bleeding (3)
C0019080 (UMLS CUI-1)
(Comment:en)
CL Item
eczema (4)
C0013595 (UMLS CUI-1)
(Comment:en)
Item Group
Lungs
Item
lung borders
integer
C3671937 (UMLS CUI [1])
lung borders
Code List
lung borders
CL Item
nad (1)
C0559229 (UMLS CUI-1)
(Comment:en)
CL Item
effusion (2)
C0013687 (UMLS CUI-1)
(Comment:en)
CL Item
Pneumothorax (3)
C0032326 (UMLS CUI-1)
(Comment:en)
CL Item
Emphysem (4)
C0034067 (UMLS CUI-1)
(Comment:en)
CL Item
tumor (5)
C1274082 (UMLS CUI-1)
(Comment:en)
Item
percussion sound
integer
C1291006 (UMLS CUI [1])
percussion sound
Code List
percussion sound
CL Item
nad (1)
C0559229 (UMLS CUI-1)
(Comment:en)
CL Item
sonance (2)
C3671941 (UMLS CUI-1)
(Comment:en)
CL Item
Hyperresonance (3)
C0231882 (UMLS CUI-1)
(Comment:en)
CL Item
Fremitus (4)
C0231890 (UMLS CUI-1)
(Comment:en)
Respiratory Sounds
Item
Respiratory Sounds
text
C0035234 (UMLS CUI [1])
Item Group
Heart
Item
Heart
integer
C0562319 (UMLS CUI [1,1])
C0457109 (UMLS CUI [1,2])
Heart
Code List
Heart
CL Item
nad (1)
C0559229 (UMLS CUI-1)
(Comment:en)
Apex beat
Item
Apex beat
integer
Item
Heart sounds
integer
Heart sounds
Code List
Heart sounds
CL Item
Murmurs (1)
C0018808 (UMLS CUI-1)
(Comment:en)
Item
Pulse
integer
C0232117 (UMLS CUI [1])
Pulse
Code List
Pulse
CL Item
nad (1)
C0559229 (UMLS CUI-1)
(Comment:en)
Item
Artery
integer
C0003842 (UMLS CUI [1])
Artery
Code List
Artery
CL Item
nad (1)
C0559229 (UMLS CUI-1)
(Comment:en)
Item
Vein
integer
C0042449 (UMLS CUI [1])
Vein
Code List
Vein
CL Item
nad (1)
C0559229 (UMLS CUI-1)
(Comment:en)
Item Group
Abdomen
Item
Abdominal wall
integer
C1269041 (UMLS CUI [1])
Abdominal wall
Code List
Abdominal wall
CL Item
nad (1)
C0559229 (UMLS CUI-1)
(Comment:en)
CL Item
pressure pain (2)
C3647129 (UMLS CUI-1)
(Comment:en)
CL Item
abdominal defense (3)
(Comment:en)
CL Item
Epigastrium (4)
C0230185 (UMLS CUI-1)
(Comment:en)
Item
Rupture
text
C0948106 (UMLS CUI [1])
Rupture
Code List
Rupture
CL Item
umbilical herni (umbilical herni)
C0019322 (UMLS CUI-1)
(Comment:en)
CL Item
Inguinal hernia (Inguinal hernia)
C0019294 (UMLS CUI-1)
(Comment:en)
CL Item
femoral hernia (femoral hernia)
C0019288 (UMLS CUI-1)
(Comment:en)
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