ID

34799

Beschrijving

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.

Trefwoorden

G35

27-02-18 27-02-18 -
29-01-19 29-01-19 - Sarah Riepenhausen
27-09-21 27-09-21 -

Houder van rechten

Prof. Dr. Luisa Klotz

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29 januari 2019

DOI

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Creative Commons BY-NC 3.0

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Discharge Letter Items Neuroinflammatory Demyelinating Diseases

model
Details

Discharge Letter Items 1229450930 Multiple Sclerosis

12 Formulieren

StudyEvent: DCMSNMOADEM

Name

Type

Description | Question | Decode (Coded Value)

Datatype

Alias

Administrative Data

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])

Care

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])

Principal Diagnosis

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])

Risk Stratification of Therapy with Natalizumab

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])

Secondary Diagnosis

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])

Collagen Disease: ANA

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])

Collagen Disease: CTD-Screen

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)

Collagen Disease: anti-ds-DNA

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)

Collagen Disease: Beta-2-Glycoprotein IgG-Antibodies

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])

Reason for Admission

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])

Summary and Assessment

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])

Muscle strength Lower Extemity

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])

Procedures

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])

Neurological Examination: Cranial Nerves

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])

Lhermittes sign

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])

Neurological Examination: Motor

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])

Muscle strength Hip Flexion

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)

Muscle strength Knee extension

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])

Neurological Examination: Coordination and Gait

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])

Diadochokinesis

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])

Neurological Examination: Sensibility

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])

Pallesthesia of Ankle

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)

Pallesthesia of Knee

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)

Psychological findings

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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ID

Beschrijving

Trefwoorden

Versies (3)

Houder van rechten

Geüploaded op

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Licentie

Model Commentaren :

Itemgroep Commentaren voor :

Item Commentaren voor :

Discharge Letter Items Neuroinflammatory Demyelinating Diseases

Discharge Letter Items 1229450930 Multiple Sclerosis

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