ID

34799

Description

Discharge Letter Items for semantic analysis in discharge letters of patients diagnosed with Multiple Sclerosis, Neuromyelitis optica spectrum disease or Acute Disseminated Encephalomyelitis from Neurology Department of University Hospital Muenster provided by Prof. Dr. Luisa Klotz.

Keywords

Versions (3)
  1. 2/27/18 2/27/18 -
  2. 1/29/19 1/29/19 - Sarah Riepenhausen
  3. 9/27/21 9/27/21 -
Copyright Holder

Prof. Dr. Luisa Klotz

Uploaded on

January 29, 2019

DOI

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License

Creative Commons BY-NC 3.0
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Discharge Letter Items Neuroinflammatory Demyelinating Diseases

German English Italian

Discharge Letter Items 1229450930 Multiple Sclerosis

12 forms  
Administrative Data
Description

Administrative Data

Alias
UMLS CUI-1
C1320722
Document ID
Description

Document ID

Data type

integer

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

Name

Data type

text

Alias
UMLS CUI [1]
C0421448
Date of birth:
Description

Date of birth

Data type

date

Alias
UMLS CUI [1]
C0421451
Inpatient or Outpatient
Description

Care

Data type

text

Alias
UMLS CUI [1]
C1550330
Date of Appointment/Stay
Description

Date of Appointment

Data type

date

Alias
UMLS CUI [1]
C1320303
Principal Diagnosis
Description

Principal Diagnosis

Diagnosis and Clinical Course
Description

Diagnosis and Clinical Course

Data type

text

Alias
UMLS CUI [1]
C0011900
UMLS CUI [2,1]
C0449259
UMLS CUI [2,2]
C0026769
UMLS CUI [3,1]
C0205394
UMLS CUI [3,2]
C0011302
UMLS CUI [4,1]
C0205394
UMLS CUI [4,2]
C0449259
UMLS CUI [4,3]
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]
C2316983
EDSS
Description

EDSS

Data type

integer

Alias
UMLS CUI [1]
C3830336
Previous Therapy with Copaxone (Glatirameractetat)
Description

Previous Therapy Copaxone

Data type

boolean

Alias
UMLS CUI [1,1]
C2114510
UMLS CUI [1,2]
C0026769
UMLS CUI [2]
C0289884
Time Range of Previous Therapy with Copaxone
Description

Previous Therapy Time Range Copaxone

Data type

text

Alias
UMLS CUI [1,1]
C2114510
UMLS CUI [1,2]
C3173309
UMLS CUI [2,1]
C2114510
UMLS CUI [2,2]
C1531784
Previous Therapie Benefit during Treatment with Copaxone
Description

Previous Therapie Benefit Copaxone

Data type

text

Alias
UMLS CUI [1,1]
C0087113
UMLS CUI [1,2]
C0289884
UMLS CUI [1,3]
C2114510
Previous Therapy with Tysabri (Natalizumab)
Description

Previous Therapy Tysabri

Data type

boolean

Alias
UMLS CUI [1]
C2114510
UMLS CUI [2]
C1172734
Time Range of Previous Therapy with Tysabri
Description

Previous Therapy Time Range

Data type

text

Alias
UMLS CUI [1,1]
C2114510
UMLS CUI [1,2]
C3173309
UMLS CUI [2,1]
C2114510
UMLS CUI [2,2]
C1531784
Previous Therapie Benefit during Treatment with Tysabri (Natalizumab)
Description

Previous Therapie Benefit Tysabri

Data type

text

Alias
UMLS CUI [1,1]
C0087113
UMLS CUI [1,2]
C1172734
UMLS CUI [1,3]
C2114510
Previous Therapy with Lemtrada (Alemtuzumab)
Description

Previous Therapy Alemtuzumab

Data type

boolean

Alias
UMLS CUI [1]
C2114510
UMLS CUI [2]
C0383429
Time Range of Previous Therapy with Alemtuzumab
Description

Previous Therapy Time Range Alemtuzumab

Data type

text

Alias
UMLS CUI [1,1]
C2114510
UMLS CUI [1,2]
C3173309
UMLS CUI [2,1]
C2114510
UMLS CUI [2,2]
C1531784
Risk Stratification of Therapy with Natalizumab
Description

Risk Stratification of Therapy with Natalizumab

Alias
UMLS CUI [2,1]
C0150323
UMLS CUI [2,2]
C1172734
Previous Immunosuppressive Therapy
Description

Previous Immunosuppressive Therapy

Data type

boolean

Alias
UMLS CUI [1,1]
C2114510
UMLS CUI [1,2]
C0021079
Months of use of Natalizumab
Description

Use of Natalizumab

Data type

text

Measurement units
  • months
Alias
UMLS CUI [1,1]
C1172734
UMLS CUI [1,2]
C0444917
months
JCV Antibodies
Description

JCV Antibodies

Data type

text

Alias
UMLS CUI [1]
C3511565
Date of JCV-Antibody Measurement
Description

of JCV

Data type

date

Alias
UMLS CUI [1,1]
C3511565
UMLS CUI [1,2]
C0011008
L-Selectin-State of Risk
Description

PML-Risikostratifizierung unter Tysabri-Langzeittherapie

Data type

text

Alias
UMLS CUI [1]
C0125090
Secondary Diagnosis
Description

Secondary Diagnosis

Alias
UMLS CUI-1
C0332138
Arterial Hypertension
Description

Arterial Hypertension

Data type

boolean

Alias
UMLS CUI [1]
C0020538
Chronic venous insufficiency
Description

CVI

Data type

boolean

Alias
UMLS CUI [1]
C1306557
Recurrent Cystitis
Description

Recurrent Cystitis

Data type

boolean

Alias
UMLS CUI [1]
C0581366
Hints of a Collagen Disease?
Description

Hints of a Collagen Disease

Data type

boolean

Alias
UMLS CUI [1]
C0009326
Collagen Disease: Anti-nuclear antibody measurement
Description

Collagen Disease: ANA

Data type

text

Alias
UMLS CUI [1]
C0587178
Collagen Disease: Antibodies, Antinuclear
Description

Collagen Disease: ENA

Data type

boolean

Alias
UMLS CUI [1]
C0003243
Collagen Disease: Results of Indirect Immunofluorescence Staining
Description

Collagen Disease: IFT

Data type

text

Alias
UMLS CUI [1]
C0282646
Mixed Connective Tissue Disease-Screening
Description

Collagen Disease: CTD-Screen

Data type

text

Alias
UMLS CUI [1]
C0026272
Anti-dsDNA Antibody present
Description

Collagen Disease: anti-ds-DNA

Data type

text

Alias
UMLS CUI [1]
C0236300
Beta 2 glycoprotein I IgG antibody test positive/negative?
Description

Collagen Disease: Beta-2-Glycoprotein IgG-Antibodies

Data type

text

Alias
UMLS CUI [1]
C2208744
Capillary Microscopy Results
Description

Collagen Disease: Capillary Microscopy

Data type

text

Alias
UMLS CUI [1]
C0262428
Recurrent Depressive Episodes
Description

Recurrent Depressive Episodes

Data type

text

Alias
UMLS CUI [1]
C0349217
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]
C0809949
UMLS CUI [1,2]
C0392360
Introduction: Department
Description

Introduction: Department

Data type

text

Alias
UMLS CUI [1]
C1704729
Medical history
Description

Medical history

Data type

text

Alias
UMLS CUI [1]
C0262926
Current Symptoms
Description

Current Symptoms

Data type

text

Alias
UMLS CUI [1]
C1457887
Quality of life decreased
Description

Quality of life

Data type

boolean

Alias
UMLS CUI [1]
C1963786
Stress
Description

Stress

Data type

text

Alias
UMLS CUI [1]
C0038435
Susceptibility to infections increased?
Description

Susceptibility to infections

Data type

boolean

Alias
UMLS CUI [1]
C0521978
Laboratory Results abnormal?
Description

Laboratory Results

Data type

boolean

Alias
UMLS CUI [1]
C0587081
Pathological findings of neurological examination
Description

Findings of neurological Examination

Data type

text

Alias
UMLS CUI [1]
C0437208
Walking Distance
Description

Walking Distance

Data type

float

Measurement units
  • km
Alias
UMLS CUI [1]
C0429886
km
Gait, Manner of walking
Description

Gait

Data type

text

Alias
UMLS CUI [1]
C0016928
Muscle strength of legs
Description

Muscle strength Lower Extemity

Data type

text

Alias
UMLS CUI [1,1]
C0023216
UMLS CUI [1,2]
C0451362
EDSS
Description

EDSS

Data type

integer

Alias
UMLS CUI [1]
C3830336
Procedures
Description

Procedures

Alias
UMLS CUI-1
C2700391
Current Immunosuppressive Therapy
Description

Current Immunosuppressive Therapy

Data type

text

Alias
UMLS CUI [1]
C2827774
UMLS CUI [2,1]
C0205394
UMLS CUI [2,2]
C2827774
Date Follow-Up Visit
Description

Date Follow-Up Visit

Data type

date

Alias
UMLS CUI [1]
C3694716
Recommendation to bring a current blood count, CRP and Urine status
Description

Recommendation Blood count

Data type

boolean

Alias
UMLS CUI [1]
C0545131
Physical Therapy has been recommended?
Description

Recommendation Physical Therapy

Data type

boolean

Alias
UMLS CUI [1]
C0949766
Recommendation to compare MRI images
Description

Recommendation MRI Comparison

Data type

boolean

Alias
UMLS CUI [1]
C0024485
Multiple sclerosis relapse during therapy with Lemtrada
Description

Multiple sclerosis relapse Therapy Lemtrada

Data type

text

Alias
UMLS CUI [1,1]
C0035020
UMLS CUI [1,2]
C2827774
Further diagnostic procedures planned during hospitalisation
Description

Further diagnostic procedures

Data type

text

Alias
UMLS CUI [1]
C0430022
Induction of other therapy to stop MS flare
Description

Other Therapy

Data type

text

Alias
UMLS CUI [1,1]
C0679868
UMLS CUI [1,2]
C0205394
Neurological Examination: Cranial Nerves
Description

Neurological Examination: Cranial Nerves

Alias
UMLS CUI-1
C0558819
Orientation
Description

Orientation

Data type

text

Alias
UMLS CUI [1]
C0029266
Meningism
Description

Meningism

Data type

text

Alias
UMLS CUI [1]
C0025287
Lhermitte's sign
Description

Lhermittes sign

Data type

text

Alias
UMLS CUI [1]
C0576702
Percussion Pain Skull
Description

Kalottenklopfschmerz

Data type

boolean

Alias
UMLS CUI [1,1]
C0030987
UMLS CUI [1,2]
C0030193
UMLS CUI [1,3]
C0037303
Cranial Nerves: Visus
Description

Cranial Nerves: Visus

Data type

integer

Alias
UMLS CUI [1]
C0042812
Pupils regularity
Description

Cranial Nerves: Pupils regularity

Data type

text

Alias
UMLS CUI [1]
C0437592
Consensual pupil reaction to light
Description

Cranial Nerves: Consensual pupil reaction to light

Data type

text

Alias
UMLS CUI [1]
C0700372
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
Visual Field Fingerperimetric
Description

Fingerperimetric

Data type

text

Alias
UMLS CUI [1]
C0858409
Examination of Eye Movement
Description

Cranial Nerves: Eye Movement

Data type

text

Alias
UMLS CUI [1]
C0015413
Saccades
Description

Cranial Nerves: Saccades

Data type

boolean

Alias
UMLS CUI [1]
C0036019
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 Sensory Function
Description

Cranial Nerves: Sensory Function

Data type

text

Alias
UMLS CUI [1]
C0234292
M.temporalis strength
Description

Cranial Nerves: M.temporalis

Data type

text

Alias
UMLS CUI [1,1]
C1275494
UMLS CUI [1,2]
C0517349
M. masseter strength
Description

Cranial Nerves: M. masseter

Data type

text

Alias
UMLS CUI [1,1]
C0024876
UMLS CUI [1,2]
C0517349
Facial Muscles abnormal?
Description

Cranial Nerves: Facial Muscles

Data type

text

Alias
UMLS CUI [1]
C4073201
Findings on finger rub auditory screening test
Description

Cranial Nerves: Hearing Screen

Data type

text

Alias
UMLS CUI [1]
C0500425
Soft Palate Movement
Description

Soft Palate Movement

Data type

text

Alias
UMLS CUI [1]
C2239128
Deviation of uvula
Description

Cranial Nerves: Deviation of uvula

Data type

boolean

Alias
UMLS CUI [1,1]
C0426994
Tongue deviation
Description

Cranial Nerves: Tongue Deviation

Data type

boolean

Alias
UMLS CUI [1]
C1328516
M. sternocleidomastoideus
Description

Cranial Nerves: M. sternocleidomastoideus

Data type

text

Alias
UMLS CUI [1,1]
C0224153
UMLS CUI [1,2]
C0517349
M. trapezius strength
Description

Cranial Nerves: M. trapezius

Data type

text

Alias
UMLS CUI [1,1]
C0224361
UMLS CUI [1,2]
C0517349
Taste Perception abnormal
Description

Taste Perception

Data type

boolean

Alias
UMLS CUI [1]
C0039336
Smell Perception abnormal?
Description

Smell Perception

Data type

boolean

Alias
UMLS CUI [1]
C0037361
Neurological Examination: Motor
Description

Neurological Examination: Motor

Alias
UMLS CUI-1
C2237216
Trophic change of Muscles
Description

Trophic of Muscles

Data type

text

Alias
UMLS CUI [1,1]
C0437261
UMLS CUI [1,2]
C0026845
Muscle Tonus
Description

Motor tone

Data type

text

Alias
UMLS CUI [1]
C0026841
Involuntary muscle movements
Description

Muscle movement involuntary

Data type

boolean

Alias
UMLS CUI [1]
C0221722
Paresis of Lower Exremity
Description

Information for right and left leg

Data type

text

Alias
UMLS CUI [1]
C0751410
Muscle strength of Hip Flexion
Description

Oxford scale Information for right and left leg

Data type

text

Alias
UMLS CUI [1,1]
C2237371
UMLS CUI [1,2]
C0451362
Muscle strength Knee extension
Description

Information for right and left leg

Data type

text

Alias
UMLS CUI [1,1]
C2237139
UMLS CUI [1,2]
C0451362
Pronator Drift Test
Description

Information for left and right arm

Data type

text

Alias
UMLS CUI [1]
C1504476
Function of Muscular reflex (MER) on arm
Description

MER = Muskeleigenreflex

Data type

text

Alias
UMLS CUI [1,1]
C0034943
UMLS CUI [1,2]
C1140618
Babinski Reflex
Description

Information for both sides

Data type

text

Alias
UMLS CUI [1]
C0034935
Neurological Examination: Coordination and Gait
Description

Neurological Examination: Coordination and Gait

Gait, Manner of walking
Description

Gait

Data type

text

Alias
UMLS CUI [1]
C0016928
Heel to toe gait possible
Description

Heel to toe gait

Data type

text

Alias
UMLS CUI [1]
C0231779
Toe-walking gait possible
Description

Toe-walking gait

Data type

text

Alias
UMLS CUI [1]
C0427144
Heel Gait possible
Description

Heel Gait

Data type

text

Alias
UMLS CUI [1]
C2243016
Rhomberg Test abnormal?
Description

Information for both sides

Data type

text

Alias
UMLS CUI [1]
C1656968
Diadochokinesis abnormal?
Description

Diadochokinesis

Data type

text

Alias
UMLS CUI [1]
C0278157
Finger-to-nose test abnormal?
Description

Finger-to-nose test

Data type

text

Alias
UMLS CUI [1]
C0278158
Heel-to-knee test abnormal?
Description

Heel-to-knee test

Data type

text

Alias
UMLS CUI [1]
C0278160
Neurological Examination: Sensibility
Description

Neurological Examination: Sensibility

Alias
UMLS CUI-1
C0439823
Hypesthesia Upper Extremity
Description

for both sides

Data type

text

Alias
UMLS CUI [1,1]
C1140618
UMLS CUI [1,2]
C0020580
Hypesthesia Lower Extremity
Description

Hypesthesia Lower Extremity

Data type

text

Alias
UMLS CUI [1,1]
C0023216
UMLS CUI [1,2]
C0020580
Pallesthesia of ankle
Description

both sides

Data type

text

Alias
UMLS CUI [1,1]
C0003086
UMLS CUI [1,2]
C0234198
Pallesthesia of knee
Description

Pallesthesia of Knee

Data type

text

Alias
UMLS CUI [1,1]
C0022742
UMLS CUI [1,2]
C0234198
Psychological findings
Description

Psychological findings

Alias
UMLS CUI-1
C0205486
UMLS CUI-2
C0243095
Mood alterations with depressive symptoms
Description

Depressive Mood

Data type

boolean

Alias
UMLS CUI [1]
C0852545
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Similar models

Discharge Letter Items 1229450930 Multiple Sclerosis

12 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Administrative Data
C1320722 (UMLS CUI-1)
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])
Item
Inpatient or Outpatient
text
C1550330 (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)
Date of Appointment
Item
Date of Appointment/Stay
date
C1320303 (UMLS CUI [1])
Item Group
Principal Diagnosis
Diagnosis and Clinical Course
Item
Diagnosis and Clinical Course
text
C0011900 (UMLS CUI [1])
C0449259 (UMLS CUI [2,1])
C0026769 (UMLS CUI [2,2])
C0205394 (UMLS CUI [3,1])
C0011302 (UMLS CUI [3,2])
C0205394 (UMLS CUI [4,1])
C0449259 (UMLS CUI [4,2])
C0026769 (UMLS CUI [4,3])
Date of Onset
Item
Onset
date
C0574845 (UMLS CUI [1])
Earliest date of diagnosis
Item
Earliest date of diagnosis
date
C2316983 (UMLS CUI [1])
EDSS
Item
EDSS
integer
C3830336 (UMLS CUI [1])
Previous Therapy Copaxone
Item
Previous Therapy with Copaxone (Glatirameractetat)
boolean
C2114510 (UMLS CUI [1,1])
C0026769 (UMLS CUI [1,2])
C0289884 (UMLS CUI [2])
Previous Therapy Time Range Copaxone
Item
Time Range of Previous Therapy with Copaxone
text
C2114510 (UMLS CUI [1,1])
C3173309 (UMLS CUI [1,2])
C2114510 (UMLS CUI [2,1])
C1531784 (UMLS CUI [2,2])
Previous Therapie Benefit Copaxone
Item
Previous Therapie Benefit during Treatment with Copaxone
text
C0087113 (UMLS CUI [1,1])
C0289884 (UMLS CUI [1,2])
C2114510 (UMLS CUI [1,3])
Previous Therapy Tysabri
Item
Previous Therapy with Tysabri (Natalizumab)
boolean
C2114510 (UMLS CUI [1])
C1172734 (UMLS CUI [2])
Previous Therapy Time Range
Item
Time Range of Previous Therapy with Tysabri
text
C2114510 (UMLS CUI [1,1])
C3173309 (UMLS CUI [1,2])
C2114510 (UMLS CUI [2,1])
C1531784 (UMLS CUI [2,2])
Previous Therapie Benefit Tysabri
Item
Previous Therapie Benefit during Treatment with Tysabri (Natalizumab)
text
C0087113 (UMLS CUI [1,1])
C1172734 (UMLS CUI [1,2])
C2114510 (UMLS CUI [1,3])
Previous Therapy Alemtuzumab
Item
Previous Therapy with Lemtrada (Alemtuzumab)
boolean
C2114510 (UMLS CUI [1])
C0383429 (UMLS CUI [2])
Previous Therapy Time Range Alemtuzumab
Item
Time Range of Previous Therapy with Alemtuzumab
text
C2114510 (UMLS CUI [1,1])
C3173309 (UMLS CUI [1,2])
C2114510 (UMLS CUI [2,1])
C1531784 (UMLS CUI [2,2])
Item Group
Risk Stratification of Therapy with Natalizumab
C0150323 (UMLS CUI [2,1])
C1172734 (UMLS CUI [2,2])
Previous Immunosuppressive Therapy
Item
Previous Immunosuppressive Therapy
boolean
C2114510 (UMLS CUI [1,1])
C0021079 (UMLS CUI [1,2])
Use of Natalizumab
Item
Months of use of Natalizumab
text
C1172734 (UMLS CUI [1,1])
C0444917 (UMLS CUI [1,2])
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])
L-Selectin
Item
L-Selectin-State of Risk
text
C0125090 (UMLS CUI [1])
Item Group
Secondary Diagnosis
C0332138 (UMLS CUI-1)
Arterial Hypertension
Item
Arterial Hypertension
boolean
C0020538 (UMLS CUI [1])
CVI
Item
Chronic venous insufficiency
boolean
C1306557 (UMLS CUI [1])
Recurrent Cystitis
Item
Recurrent Cystitis
boolean
C0581366 (UMLS CUI [1])
Hints of a Collagen Disease
Item
Hints of a Collagen Disease?
boolean
C0009326 (UMLS CUI [1])
Item
Collagen Disease: Anti-nuclear antibody measurement
text
C0587178 (UMLS CUI [1])
Collagen Disease: ANA
Code List
Collagen Disease: Anti-nuclear antibody measurement
CL Item
positive (positive )
CL Item
negative (negative)
Collagen Disease: ENA
Item
Collagen Disease: Antibodies, Antinuclear
boolean
C0003243 (UMLS CUI [1])
Collagen Disease: IFT
Item
Collagen Disease: Results of Indirect Immunofluorescence Staining
text
C0282646 (UMLS CUI [1])
Item
Mixed Connective Tissue Disease-Screening
text
C0026272 (UMLS CUI [1])
Collagen Disease: CTD-Screen
Code List
Mixed Connective Tissue Disease-Screening
CL Item
positive (positive)
CL Item
negative (negative)
Item
Anti-dsDNA Antibody present
text
C0236300 (UMLS CUI [1])
Collagen Disease: anti-ds-DNA
Code List
Anti-dsDNA Antibody present
CL Item
negative (negative)
CL Item
positive (positive)
Item
Beta 2 glycoprotein I IgG antibody test positive/negative?
text
C2208744 (UMLS CUI [1])
Collagen Disease: Beta-2-Glycoprotein IgG-Antibodies
Code List
Beta 2 glycoprotein I IgG antibody test positive/negative?
CL Item
negative (negative)
CL Item
positive (positive)
Collagen Disease: Capillary Microscopy
Item
Capillary Microscopy Results
text
C0262428 (UMLS CUI [1])
Recurrent Depressive Episodes
Item
Recurrent Depressive Episodes
text
C0349217 (UMLS CUI [1])
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
C0809949 (UMLS CUI [1,1])
C0392360 (UMLS CUI [1,2])
Introduction: Department
Item
Introduction: Department
text
C1704729 (UMLS CUI [1])
Medical history
Item
Medical history
text
C0262926 (UMLS CUI [1])
Current Symptoms
Item
Current Symptoms
text
C1457887 (UMLS CUI [1])
Quality of life
Item
Quality of life decreased
boolean
C1963786 (UMLS CUI [1])
Stress
Item
Stress
text
C0038435 (UMLS CUI [1])
Susceptibility to infections
Item
Susceptibility to infections increased?
boolean
C0521978 (UMLS CUI [1])
Laboratory Results
Item
Laboratory Results abnormal?
boolean
C0587081 (UMLS CUI [1])
Findings of neurological Examination
Item
Pathological findings of neurological examination
text
C0437208 (UMLS CUI [1])
Walking Distance
Item
Walking Distance
float
C0429886 (UMLS CUI [1])
Gait
Item
Gait, Manner of walking
text
C0016928 (UMLS CUI [1])
Item
Muscle strength of legs
text
C0023216 (UMLS CUI [1,1])
C0451362 (UMLS CUI [1,2])
Muscle strength
Code List
Muscle strength of legs
CL Item
worse than before (worse than before)
CL Item
same (same)
CL Item
better than before (better than before)
EDSS
Item
EDSS
integer
C3830336 (UMLS CUI [1])
Item Group
Procedures
C2700391 (UMLS CUI-1)
Current Immunosuppressive Therapy
Item
Current Immunosuppressive Therapy
text
C2827774 (UMLS CUI [1])
C0205394 (UMLS CUI [2,1])
C2827774 (UMLS CUI [2,2])
Date Follow-Up Visit
Item
Date Follow-Up Visit
date
C3694716 (UMLS CUI [1])
Recommendation Blood count
Item
Recommendation to bring a current blood count, CRP and Urine status
boolean
C0545131 (UMLS CUI [1])
Recommendation Physical Therapy
Item
Physical Therapy has been recommended?
boolean
C0949766 (UMLS CUI [1])
Recommendation MRI Comparison
Item
Recommendation to compare MRI images
boolean
C0024485 (UMLS CUI [1])
Multiple sclerosis relapse Therapy Lemtrada
Item
Multiple sclerosis relapse during therapy with Lemtrada
text
C0035020 (UMLS CUI [1,1])
C2827774 (UMLS CUI [1,2])
Further diagnostic procedures
Item
Further diagnostic procedures planned during hospitalisation
text
C0430022 (UMLS CUI [1])
Other Therapy
Item
Induction of other therapy to stop MS flare
text
C0679868 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
Item Group
Neurological Examination: Cranial Nerves
C0558819 (UMLS CUI-1)
Orientation
Item
Orientation
text
C0029266 (UMLS CUI [1])
Meningism
Item
Meningism
text
C0025287 (UMLS CUI [1])
Item
Lhermitte's sign
text
C0576702 (UMLS CUI [1])
Lhermittes sign
Code List
Lhermitte's sign
CL Item
positive (positive)
CL Item
negative (negative)
Percussion Pain Skull
Item
Percussion Pain Skull
boolean
C0030987 (UMLS CUI [1,1])
C0030193 (UMLS CUI [1,2])
C0037303 (UMLS CUI [1,3])
Cranial Nerves: Visus
Item
Cranial Nerves: Visus
integer
C0042812 (UMLS CUI [1])
Cranial Nerves: Pupils regularity
Item
Pupils regularity
text
C0437592 (UMLS CUI [1])
Cranial Nerves: Consensual pupil reaction to light
Item
Consensual pupil reaction to light
text
C0700372 (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: Visual Field
Item
Visual Field Fingerperimetric
text
C0858409 (UMLS CUI [1])
Cranial Nerves: Eye Movement
Item
Examination of Eye Movement
text
C0015413 (UMLS CUI [1])
Cranial Nerves: Saccades
Item
Saccades
boolean
C0036019 (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: Sensory Function
Item
Facial Sensory Function
text
C0234292 (UMLS CUI [1])
Cranial Nerves: M.temporalis
Item
M.temporalis strength
text
C1275494 (UMLS CUI [1,1])
C0517349 (UMLS CUI [1,2])
Cranial Nerves: M. masseter
Item
M. masseter strength
text
C0024876 (UMLS CUI [1,1])
C0517349 (UMLS CUI [1,2])
Cranial Nerves: Facial Muscles
Item
Facial Muscles abnormal?
text
C4073201 (UMLS CUI [1])
Cranial Nerves: Hearing Screen
Item
Findings on finger rub auditory screening test
text
C0500425 (UMLS CUI [1])
Soft Palate Movement
Item
Soft Palate Movement
text
C2239128 (UMLS CUI [1])
Cranial Nerves: Deviation of uvula
Item
Deviation of uvula
boolean
C0426994 (UMLS CUI [1,1])
Cranial Nerves: Tongue Deviation
Item
Tongue deviation
boolean
C1328516 (UMLS CUI [1])
Cranial Nerves: M. sternocleidomastoideus
Item
M. sternocleidomastoideus
text
C0224153 (UMLS CUI [1,1])
C0517349 (UMLS CUI [1,2])
Cranial Nerves: M. trapezius
Item
M. trapezius strength
text
C0224361 (UMLS CUI [1,1])
C0517349 (UMLS CUI [1,2])
Taste Perception
Item
Taste Perception abnormal
boolean
C0039336 (UMLS CUI [1])
Smell Perception
Item
Smell Perception abnormal?
boolean
C0037361 (UMLS CUI [1])
Item Group
Neurological Examination: Motor
C2237216 (UMLS CUI-1)
Trophic of Muscles
Item
Trophic change of Muscles
text
C0437261 (UMLS CUI [1,1])
C0026845 (UMLS CUI [1,2])
Motor tone
Item
Muscle Tonus
text
C0026841 (UMLS CUI [1])
Muscle movement involuntary
Item
Involuntary muscle movements
boolean
C0221722 (UMLS CUI [1])
Paresis Lower Exremity
Item
Paresis of Lower Exremity
text
C0751410 (UMLS CUI [1])
Item
Muscle strength of Hip Flexion
text
C2237371 (UMLS CUI [1,1])
C0451362 (UMLS CUI [1,2])
Muscle strength
Code List
Muscle strength of Hip Flexion
CL Item
worse than before (worse than before)
CL Item
same (same)
CL Item
better than before (better than before)
Item
Muscle strength Knee extension
text
C2237139 (UMLS CUI [1,1])
C0451362 (UMLS CUI [1,2])
Muscle strength Knee flexion
Code List
Muscle strength Knee extension
CL Item
0/5 (0/5)
CL Item
1/5 (1/5)
CL Item
2/5 (2/5)
CL Item
3/5 (3/5)
CL Item
4/5 (4/5)
CL Item
5/5 (5/5)
Pronator Drift Test
Item
Pronator Drift Test
text
C1504476 (UMLS CUI [1])
Muscular Reflex
Item
Function of Muscular reflex (MER) on arm
text
C0034943 (UMLS CUI [1,1])
C1140618 (UMLS CUI [1,2])
Babinski Reflex
Item
Babinski Reflex
text
C0034935 (UMLS CUI [1])
Item Group
Neurological Examination: Coordination and Gait
Gait
Item
Gait, Manner of walking
text
C0016928 (UMLS CUI [1])
Heel to toe gait
Item
Heel to toe gait possible
text
C0231779 (UMLS CUI [1])
Toe-walking gait
Item
Toe-walking gait possible
text
C0427144 (UMLS CUI [1])
Heel Gait
Item
Heel Gait possible
text
C2243016 (UMLS CUI [1])
Rhomberg Test
Item
Rhomberg Test abnormal?
text
C1656968 (UMLS CUI [1])
Item
Diadochokinesis abnormal?
text
C0278157 (UMLS CUI [1])
Diadochokinesis
Code List
Diadochokinesis abnormal?
CL Item
Eudiadochokinesis (Eudiadochokinesis)
CL Item
Dysdiadochokinesis (Dysdiadochokinesis)
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])
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])
Hypesthesia Lower Extremity
Item
Hypesthesia Lower Extremity
text
C0023216 (UMLS CUI [1,1])
C0020580 (UMLS CUI [1,2])
Item
Pallesthesia of ankle
text
C0003086 (UMLS CUI [1,1])
C0234198 (UMLS CUI [1,2])
Pallesthesia of Ankle
Code List
Pallesthesia of ankle
CL Item
0/8 (0/8)
CL Item
1/8 (1/8)
CL Item
2/8 (2/8)
CL Item
3/8 (3/8)
CL Item
4/8 (4/8)
CL Item
5/8 (5/8)
CL Item
6/8 (6/8)
CL Item
7/8 (7/8)
CL Item
8/8 (8/8)
Item
Pallesthesia of knee
text
C0022742 (UMLS CUI [1,1])
C0234198 (UMLS CUI [1,2])
Pallesthesia of Ankle
Code List
Pallesthesia of knee
CL Item
0/8 (0/8)
CL Item
1/8 (1/8)
CL Item
2/8 (2/8)
CL Item
3/8 (3/8)
CL Item
4/8 (4/8)
CL Item
5/8 (5/8)
CL Item
6/8 (6/8)
CL Item
7/8 (7/8)
CL Item
8/8 (8/8)
Item Group
Psychological findings
C0205486 (UMLS CUI-1)
C0243095 (UMLS CUI-2)
Depressive Mood
Item
Mood alterations with depressive symptoms
boolean
C0852545 (UMLS CUI [1])
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