ID

34799

Beschreibung

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.

Stichworte

27.02.18 27.02.18 -
29.01.19 29.01.19 - Sarah Riepenhausen
27.09.21 27.09.21 -

Rechteinhaber

Prof. Dr. Luisa Klotz

Hochgeladen am

29. Januar 2019

DOI

Für eine Beantragung loggen Sie sich ein.

Lizenz

Creative Commons BY-NC 3.0

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Discharge Letter Items Neuroinflammatory Demyelinating Diseases

Modell
Details

Discharge Letter Items 1146401133 Multiple Sclerosis

12 Formulare

StudyEvent: DCMSNMOADEM

Name

Typ

Description | Question | Decode (Coded Value)

Datentyp

Alias

Administrative Data

Item Group

C1320722 (UMLS CUI-1)

Document ID

Item

integer

C1300638 (UMLS CUI [1])

Name

Item

text

C0421448 (UMLS CUI [1])

Date of birth

Item

date

C0421451 (UMLS CUI [1])

Care

Item

text

C1550330 (UMLS CUI [1])

undefined item

Code List

Care

CL Item

(Inpatient)

C0021562 (UMLS CUI-1)

CL Item

(Outpatient)

C0029921 (UMLS CUI-1)

Date of Appointment

Item

date

C1320303 (UMLS CUI [1])

Principal Diagnosis

Item Group

Diagnosis and Clinical Course

Item

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

date

C0574845 (UMLS CUI [1])

Earliest date of diagnosis

Item

date

C2316983 (UMLS CUI [1])

EDSS

Item

integer

C3830336 (UMLS CUI [1])

Previous Therapy Interferone Beta 1a

Item

boolean

C2114510 (UMLS CUI [1])
C0254119 (UMLS CUI [2])

Previous Therapy Benefit Interferon Beta 1a

Item

text

C0850893 (UMLS CUI [1,1])
C0566251 (UMLS CUI [1,2])
C0850893 (UMLS CUI [2,1])
C3840932 (UMLS CUI [2,2])

Previous Therapy Time Range Interferon Beta 1a

Item

text

C2114510 (UMLS CUI [1,1])
C3173309 (UMLS CUI [1,2])
C2114510 (UMLS CUI [2,1])
C1531784 (UMLS CUI [2,2])

Previous Therapy Fingolimod

Item

boolean

C2114510 (UMLS CUI [1])
C1699926 (UMLS CUI [2])

Previous Therapy Time Range Fingolimod

Item

text

C2114510 (UMLS CUI [1,1])
C3173309 (UMLS CUI [1,2])
C2114510 (UMLS CUI [2,1])
C1531784 (UMLS CUI [2,2])

Previous Therapie Benefit Fingolimod

Item

text

C1699926 (UMLS CUI [1,1])
C0087113 (UMLS CUI [1,2])
C2114510 (UMLS CUI [1,3])

Previous Therapy Tysabri

Item

boolean

C2114510 (UMLS CUI [1])
C1172734 (UMLS CUI [1]-2)

Previous Therapy Time Range Tysabri

Item

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

text

C0087113 (UMLS CUI [1,1])
C1172734 (UMLS CUI [1,2])
C2114510 (UMLS CUI [1,3])

Current Therapy Alemtuzumab

Item

boolean

C0383429 (UMLS CUI [1])
C2827774 (UMLS CUI [2])

Alemtuzumab Dosage

Item

integer

C0383429 (UMLS CUI [1,1])
C3174092 (UMLS CUI [1,2])

Alemtuzumab Duration of Therapy

Item

integer

C2114510 (UMLS CUI [1,1])
C1554109 (UMLS CUI [1,2])
C0383429 (UMLS CUI [1,3])

Recurrent optic neuritis

Item

boolean

C3266324 (UMLS CUI [1])

Secondary Diagnosis

Item Group

C0332138 (UMLS CUI-1)

Tension Headache

Item

boolean

C0033893 (UMLS CUI [1])

Migraine Without Aura

Item

boolean

C1389175 (UMLS CUI [1])

Depression

Item

boolean

C0011581 (UMLS CUI [1])

Summary and Assessment

Item Group

C0743221 (UMLS CUI-1)

Introduction: Reason for current Admission

Item

text

C0809949 (UMLS CUI [1,1])
C0392360 (UMLS CUI [1,2])

Introduction: Department

Item

text

C1704729 (UMLS CUI [1])

Medical history

Item

text

C0262926 (UMLS CUI [1])

Current Symptoms

Item

text

C1457887 (UMLS CUI [1])

Previous Therapy Tysabri

Item

boolean

C2114510 (UMLS CUI [1])
C1172734 (UMLS CUI [2])

Previous Therapy Time Range

Item

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

text

C0087113 (UMLS CUI [1,1])
C1172734 (UMLS CUI [1,2])
C2114510 (UMLS CUI [1,3])

MRI

Item

text

C0024485 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C0035020 (UMLS CUI [2,1])
C0024485 (UMLS CUI [2,2])

Previous Glucocortcoid Therapy

Item

boolean

C0149783 (UMLS CUI [1,1])
C2114510 (UMLS CUI [1,2])

Hypesthesia Upper Extremity

Item

text

C1140618 (UMLS CUI [1,1])
C0020580 (UMLS CUI [1,2])

Orientation

Item

text

C0029266 (UMLS CUI [1])

Neurological Examination

Item

text

C0437208 (UMLS CUI [1])

Prophylactic Treatment of Herpesvirus Infections

Item

boolean

C0019369 (UMLS CUI [1,1])
C0001367 (UMLS CUI [1,2])
C0199176 (UMLS CUI [1,3])

Prophylactic Treatment with Azithromycin

Item

boolean

C0052796 (UMLS CUI [1,1])
C0199176 (UMLS CUI [1,2])

Current Therapy Alemtuzumab

Item

boolean

C0383429 (UMLS CUI [1])
C2827774 (UMLS CUI [2])

Alemtuzumab Duration of Therapy

Item

integer

C2114510 (UMLS CUI [1,1])
C1554109 (UMLS CUI [1,2])
C0383429 (UMLS CUI [1,3])

Follow Up Visit Date

Item

date

C3694716 (UMLS CUI [1])

Neurological Examination

Item Group

C0027853 (UMLS CUI-1)

Orientation

Item

text

C0029266 (UMLS CUI [1])

Meningism

Item

text

C0025287 (UMLS CUI [1])

Percussion Pain Skull

Item

boolean

C0030987 (UMLS CUI [1,1])
C0030193 (UMLS CUI [1,2])
C0037303 (UMLS CUI [1,3])

Nerve Exit Points

Item

boolean

C0848189 (UMLS CUI [1])

Nerve stretch tests

Item

text

C1287971 (UMLS CUI [1,1])
C1287969 (UMLS CUI [1,2])

Neurological Examination: Cranial Nerves

Item Group

C0558819 (UMLS CUI-1)

Cranial Nerves: Visus

Item

integer

C0042812 (UMLS CUI [1])

Cranial Nerves: Pupils Motor

Item

boolean

C1305720 (UMLS CUI [1])

Cranial Nerves: Eye Movement

Item

text

C0015413 (UMLS CUI [1])

Cranial Nerves: Sensory Function

Item

text

C0234292 (UMLS CUI [1])

Cranial Nerves: Facial Muscles

Item

text

C4073201 (UMLS CUI [1])

Caudal cranial nerves

Item

text

C0010268 (UMLS CUI [1,1])
C0205097 (UMLS CUI [1,2])

Waldeyers ring Red

Item

boolean

C0459892 (UMLS CUI [1])

Neurological Examination: Motor

Item Group

C2237216 (UMLS CUI-1)

Muscle tone

Item

text

C0026841 (UMLS CUI [1])

Paresis

Item

text

C0030552 (UMLS CUI [1])

Paresis

Code List

Paresis

CL Item

(latent)

CL Item

(manifest)

CL Item

(none)

Muscle strength

Item

text

C0451362 (UMLS CUI [1])

Muscular Reflex

Item

text

C0034943 (UMLS CUI [1,1])
C1140618 (UMLS CUI [1,2])

Pyramidal

Item

text

C0234132 (UMLS CUI [1])

Patellar Reflex

Item

text

C0234147 (UMLS CUI [1])

Achilles Reflex

Item

text

C2228420 (UMLS CUI [1])

Neurological Examination: Coordination and Gait

Item Group

Gait

Item

text

C0016928 (UMLS CUI [1])

Standing

Item

text

C0231472 (UMLS CUI [1])

Past Pointing

Item

text

C1635258 (UMLS CUI [1])

Diadochokinesis

Item

text

C0278157 (UMLS CUI [1])

Diadochokinesis

Code List

Diadochokinesis

CL Item

(Eudiadochokinesis)

CL Item

(Dysdiadochokinesis)

Neurological Examination: Sensibility

Item Group

C0439823 (UMLS CUI-1)

Sensibility

Item

boolean

C0439823 (UMLS CUI [1])

EDSS

Item

integer

C3830336 (UMLS CUI [1])

Procedures

Item Group

C2700391 (UMLS CUI-1)

Current Immunosuppressive Therapy

Item

text

C2827774 (UMLS CUI [1])
C0205394 (UMLS CUI [2,1])
C2827774 (UMLS CUI [2,2])

Date Follow-Up Visit

Item

date

C3694716 (UMLS CUI [1])

Recommendation Physical Therapy

Item

boolean

C0949766 (UMLS CUI [1])

Recommendation MRI Comparison

Item

boolean

C0509575 (UMLS CUI [1,1])
C0412674 (UMLS CUI [1,2])

Multiple sclerosis relapse Therapy Lemtrada

Item

text

C0035020 (UMLS CUI [1,1])
C2827774 (UMLS CUI [1,2])

Further diagnostic procedures

Item

text

C0430022 (UMLS CUI [1])

Other Therapy

Item

text

C0205394 (UMLS CUI [1,1])
C0679868 (UMLS CUI [1,2])

Adverse effects Alemtuzumab: ITP

Item

text

C0272292 (UMLS CUI [1,1])
C0383429 (UMLS CUI [1,2])
C0879626 (UMLS CUI [1,3])

Adverse effects Alemtuzumab: Nephropathy

Item

text

C1404837 (UMLS CUI [1,1])
C0383429 (UMLS CUI [1,2])
C0879626 (UMLS CUI [1,3])

Adverse effects Alemtuzumab: Thryoidea

Item

text

C0040128 (UMLS CUI [1,1])
C0458082 (UMLS CUI [1,2])
C0383429 (UMLS CUI [1,3])

Recommendation Differential blood count

Item

text

C0545131 (UMLS CUI [1])

Recommendation Urine Analysis

Item

text

C0042014 (UMLS CUI [1])

Clinical Presentation ITP

Item

text

C0398650 (UMLS CUI [1,1])
C3540840 (UMLS CUI [1,2])

Clinical Presentation ITP

Code List

Clinical Presentation ITP

CL Item

(haematoma)

CL Item

(mucosal hemorrhage )

CL Item

(petechia)

Follow Up Visit Date

Item

date

C3694716 (UMLS CUI [1])

Prophylactic Treatment of Herpesvirus Infections

Item

boolean

C0019369 (UMLS CUI [1,1])
C0001367 (UMLS CUI [1,2])
C0199176 (UMLS CUI [1,3])

Aciclovir dosage

Item

integer

C0001367 (UMLS CUI [1,1])
C3174092 (UMLS CUI [1,2])

Aciclovir Duration of Treatment

Item

integer

C0444921 (UMLS CUI [1,1])
C0001367 (UMLS CUI [1,2])

Study Participation

Item

boolean

C1997894 (UMLS CUI [1])

Avoid Raw Milk

Item

boolean

C2096017 (UMLS CUI [1,1])
C3687547 (UMLS CUI [1,2])
C0023860 (UMLS CUI [1,3])

Laboratory Results Serum

Item Group

C1550100 (UMLS CUI-1)

Sodium

Item

integer

C0337443 (UMLS CUI [1])

Potassium

Item

float

C0202194 (UMLS CUI [1])

Calcium

Item

float

C0201925 (UMLS CUI [1])

Cholesterol

Item

integer

C0201950 (UMLS CUI [1])

Glucose

Item

integer

C0202042 (UMLS CUI [1])

Uric acid

Item

float

C0041980 (UMLS CUI [1])

Blood Urea Nitrogen

Item

float

C0005845 (UMLS CUI [1])

Creatinin

Item

float

C0201976 (UMLS CUI [1])

Bilirubin Total

Item

float

C1278039 (UMLS CUI [1])

AST

Item

float

C0201899 (UMLS CUI [1])

ALT

Item

float

C0201836 (UMLS CUI [1])

gamma-GT

Item

float

C0202035 (UMLS CUI [1])

Alkaline Phosphatase

Item

text

C0201850 (UMLS CUI [1])

LDH

Item

float

C0202113 (UMLS CUI [1])

Creatinine kinase

Item

float

C0201973 (UMLS CUI [1])

CK MB

Item

integer

C0523584 (UMLS CUI [1])

CRP

Item

float

C0201657 (UMLS CUI [1])

Laboratory Results Small EDTA

Item Group

C0878557 (UMLS CUI-1)

Leucocytes

Item

float

C0023508 (UMLS CUI [1])

Erythrocytes

Item

float

C0014772 (UMLS CUI [1])

Haemoglobin

Item

integer

C0518015 (UMLS CUI [1])

Haematocrit Blood

Item

float

C0018935 (UMLS CUI [1])

MCV

Item

float

C1948043 (UMLS CUI [1])

MCH

Item

float

C0369183 (UMLS CUI [1])

MCHC

Item

float

C0474535 (UMLS CUI [1])

Thrombocytes

Item

float

C0032181 (UMLS CUI [1])

Laboratory Results Differential EDTA

Item Group

C1820731 (UMLS CUI-1)

Neutrophils (rel)

Item

integer

C4028217 (UMLS CUI [1])

Neutrophils (abs)

Item

float

C0948762 (UMLS CUI [1])

Lymphocytes (rel)

Item

integer

C2349983 (UMLS CUI [1])

Lymphocytes (abs)

Item

float

C0200635 (UMLS CUI [1])

Monocytes (rel)

Item

integer

C0587345 (UMLS CUI [1])

Monocytes (abs)

Item

float

C0200637 (UMLS CUI [1])

Eosinophils (rel)

Item

integer

C1171399 (UMLS CUI [1])

Eosinophils (abs)

Item

float

C0200638 (UMLS CUI [1])

Basophils (rel)

Item

integer

C1318432 (UMLS CUI [1])

Basophils (abs)

Item

float

C1883362 (UMLS CUI [1])

MPV

Item

float

C0200665 (UMLS CUI [1])

Granulocytes immature

Item

float

C3272953 (UMLS CUI [1])

Laboratory Results Blood coagulation tests

Item Group

C0005790 (UMLS CUI-1)

TPZ

Item

integer

C0491338 (UMLS CUI [1])

INR

Item

float

C0525032 (UMLS CUI [1])

PTT

Item

float

C0030605 (UMLS CUI [1])

Laboratory Results Urine

Item Group

C1610733 (UMLS CUI-1)

Urine Specific Gravity

Item

float

C0202517 (UMLS CUI [1])

Urine pH

Item

float

C0042044 (UMLS CUI [1])

Urine leukocytes

Item

text

C1256582 (UMLS CUI [1])

Urine leukocytes

Code List

Urine leukocytes

CL Item

(neg )

CL Item

(pos)

Urine Nitrite

Item

text

C0580333 (UMLS CUI [1])

Urine Nitrite

Code List

Urine Nitrite

CL Item

(neg)

CL Item

(pos)

Urine Protein

Item

text

C0262923 (UMLS CUI [1])

Urine Protein

Code List

Urine Protein

CL Item

(neg)

CL Item

(pos)

Urine Glucose

Item

text

C0004076 (UMLS CUI [1])

Urine Ketone Bodies

Item

integer

C0860805 (UMLS CUI [1])

Urine Urobilinogen

Item

text

C0427736 (UMLS CUI [1])

Urine Bilirubin

Item

text

C0042040 (UMLS CUI [1])

Urine Erythrocytes

Item

integer

C1254564 (UMLS CUI [1])

Laboratory Results Urine Analysis FACS

Item Group

C0042014 (UMLS CUI-1)

Urine Erythrocytes (FACS)

Item

integer

C1114250 (UMLS CUI [1,1])
C0079366 (UMLS CUI [1,2])

Urine leukocytes (FACS)

Item

text

C1256582 (UMLS CUI [1,1])
C0079366 (UMLS CUI [1,2])

Urine leukocytes (FACS)

Code List

Urine leukocytes (FACS)

CL Item

(neg )

CL Item

(pos)

Urine Epithelial Cells (FACS)

Item

integer

C1273342 (UMLS CUI [1,1])
C0079366 (UMLS CUI [1,2])

Urine Cylinder Cells (FACS)

Item

integer

C0946010 (UMLS CUI [1,1])
C1114250 (UMLS CUI [1,2])
C0079366 (UMLS CUI [1,3])

Urine Bacteria (FACS)

Item

integer

C0430380 (UMLS CUI [1,1])
C0079366 (UMLS CUI [1,2])

Urine Crystals (FACS)

Item

integer

C0427897 (UMLS CUI [1,1])
C0079366 (UMLS CUI [1,2])

Urine Yeast (FACS)

Item

integer

C2188427 (UMLS CUI [1,1])
C0079366 (UMLS CUI [1,2])

Urine Pathological Cylinder (FACS)

Item

integer

C0946010 (UMLS CUI [1,1])
C0007634 (UMLS CUI [1,2])
C0079366 (UMLS CUI [1,3])

Urine Round Epithelial Cell Count (FACS)

Item

integer

C2699115 (UMLS CUI [1,1])
C0079366 (UMLS CUI [1,2])

Laboratory Results Pregnancy

Item Group

C0850355 (UMLS CUI-1)

Pregnancy test

Item

text

C0032976 (UMLS CUI [1])

Pregnancy test

Code List

Pregnancy test

CL Item

(positive)

CL Item

(negative)

Laboratory Results Thyroid Function Tests

Item Group

C0040130 (UMLS CUI-1)

TSH

Item

float

C0202230 (UMLS CUI [1])

Laboratory Results Calculated

Item Group

C1293919 (UMLS CUI-1)

eGFR

Item

integer

C3811844 (UMLS CUI [1])

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ID

Beschreibung

Stichworte

Versionen (3)

Rechteinhaber

Hochgeladen am

DOI

Lizenz

Modell Kommentare :

Itemgroup Kommentare für :

Item Kommentare für :

Discharge Letter Items Neuroinflammatory Demyelinating Diseases

Discharge Letter Items 1146401133 Multiple Sclerosis

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