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

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

Geüploaded op

29 januari 2019

DOI

Voor een aanvraag inloggen.

Licentie

Creative Commons BY-NC 3.0

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Discharge Letter Items Neuroinflammatory Demyelinating Diseases

model
Details

Discharge Letter Items 1215271678 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 of Discharge Letter

integer

C1300638 (UMLS CUI [1])

Name of Patient

Item

Patient`s Name

text

C0421448 (UMLS CUI [1])

Date of birth

Item

Patients date of birth

date

C0421451 (UMLS CUI [1])

Date of Appointment

Item

Date of Appointment/Stay

date

C1320303 (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)

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])

Retrobulbar Neuritis

Item

History of Retrobulbar Neuritis

boolean

C0085582 (UMLS CUI [1,1])
C0455483 (UMLS CUI [1,2])

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

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

Introduction: Department

Item

Introduction: Department

text

C1704729 (UMLS CUI [1])

PMH

Item

Past medical history

text

C0262926 (UMLS CUI [1])

Item

Previous MRI findings

text

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

VEP

Item

Visual evoked potential findings

text

C0546834 (UMLS CUI [1,1])
C1274040 (UMLS CUI [1,2])

CMEP

Item

Central motor evoked potential results

text

C2210335 (UMLS CUI [1])

Cerebrospinal fluid

Item

Cerebrospinal fluid

text

C0007806 (UMLS CUI [1,1])
C0936012 (UMLS CUI [1,2])

Oligoclonal Bands

Item

Oligoclonal Bands

text

C0201942 (UMLS CUI [1])

IgG in CSF

Item

Immunoglobulin G synthesis in Cerebrospinal fluid

text

C1269632 (UMLS CUI [1])

CSF Viral Antibodies

Item

Cerebrospinal fluid viral antibody test(measles, rubella, varicella)

text

C2368116 (UMLS CUI [1])

Previous Therapy Medication

Item

Previous Therapy Medication

text

C2114510 (UMLS CUI [1,1])
C0026769 (UMLS CUI [1,2])

Previous Therapie Benefit

Item

Previous Therapie Benefit

text

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

Loss of Bladder Function Control

Item

Did a loss of bladder function control occur?

boolean

C0542565 (UMLS CUI [1])

Loss of Bowel Function Control

Item

Did a loss of Bowel function control occur?

boolean

C1290944 (UMLS CUI [1])

Fatigue

Item

Does an impairment of everyday life occur due to fatigue?

boolean

C0015672 (UMLS CUI [1])

Follow-up MRI

Item

Follow-up MRI

text

C0412674 (UMLS CUI [1,1])
C0260832 (UMLS CUI [1,2])
C1261322 (UMLS CUI [2,1])
C0242656 (UMLS CUI [2,2])

Number of Lesions

Item

Number of T2-hyperintense Lesions in cMRT

integer

C2238926 (UMLS CUI [1,1])
C0449788 (UMLS CUI [1,2])

Localisation of Lesions

Item

Localisation of Lesions

text

C2238926 (UMLS CUI [1,1])
C0475264 (UMLS CUI [1,2])

Dissemination Time

Item

Criteria Dissemination in Time

boolean

C0205221 (UMLS CUI [1,1])
C0040223 (UMLS CUI [1,2])

Dissemination Space

Item

Criteria Dissemination in Space

boolean

C0205221 (UMLS CUI [1,1])
C1515974 (UMLS CUI [1,2])

Neurological Examination

Item

Neurological Examination

text

C0437208 (UMLS CUI [1])

Therapeutic Options

Item

Therapeutic Options

text

C0683525 (UMLS CUI [1])

Study Participation

Item

Study Participation

boolean

C1997894 (UMLS CUI [1])

Procedures

Item Group

Procedures

C2700391 (UMLS CUI-1)

Anti-aquaporin-4 antibody

Item

Anti-aquaporin-4 antibody Blood Test

text

C2919772 (UMLS CUI [1])

Borrelia test

Item

Borrelia test

text

C2748236 (UMLS CUI [1])

Vasculitis Blood tests

Item

Vasculitis Laboratory Tests

text

C0042384 (UMLS CUI [1,1])
C0022885 (UMLS CUI [1,2])

Recommendation Therapy

Item

Therapy Recommendation

text

C0034866 (UMLS CUI [1])

Recommendation Neurological Exam

Item

Neurological Exam

text

C0027853 (UMLS CUI [1,1])
C0585339 (UMLS CUI [1,2])

Recommendation MRI Follow-Up

Item

MRI Follow-Up

text

C0260832 (UMLS CUI [1,1])
C0412674 (UMLS CUI [1,2])

Medication

Item Group

Medication

C0013227 (UMLS CUI-1)

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])

Nerve stretch tests

Item

Nerve stretch tests

text

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

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)

Cranial Nerves: Visual Field

Item

Visual Field Fingerperimetric

text

C0858409 (UMLS CUI [1])

Cranial Nerves: Pupils Size

Item

Pupils Size

text

C0437590 (UMLS CUI [1])

Cranial Nerves: Pupils regularity

Item

Pupils regularity

text

C0437592 (UMLS CUI [1])

Cranial Nerves: Pupils reaction

Item

Pupils reaction

text

C0437599 (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: Consensual pupil reaction to light

Item

Consensual pupil reaction to light

text

C0700372 (UMLS CUI [1])

Cranial Nerves: Eye Movement

Item

Examination of Eye Movement

text

C0015413 (UMLS CUI [1])

Cranial Nerves: Nystagmus

Item

Nystagmus Test

text

C0200205 (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: Facial Paralysis

Item

Facial Paralysis

text

C0015469 (UMLS CUI [1])

Cranial Nerves: Trigeminal Sensory Function

Item

Trigeminal Sensory Function

text

C0234284 (UMLS CUI [1])

Cranial Nerves: Trigeminal Motor Function

Item

Trigeminal Motor Function abnormal?

boolean

C0234282 (UMLS CUI [1])

Cranial Nerves: Caudal cranial nerves

Item

Function of caudal cranial nerves

text

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

Übrig

Item Group

Übrig

Date of Finding

Item

Date of Finding of Lesion

date

C2238926 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,3])

Current Immunosuppressive Therapy

Item

Current Immunosuppressive Therapy

text

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

Starting Date Therapy

Item

Date of start of therapy

date

C3173309 (UMLS CUI [1,1])
C2827774 (UMLS CUI [1,2])
C3173309 (UMLS CUI [2,1])
C0679868 (UMLS CUI [2,2])

Current Immunosuppressive Therapy

Item

Current Immunosuppressive Therapy

text

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

Adverse Effect

Item

Adverse Effect

text

C0877248 (UMLS CUI [1])
C0566251 (UMLS CUI [2,1])
C0746919 (UMLS CUI [2,2])
C3840932 (UMLS CUI [3,1])
C0746919 (UMLS CUI [3,2])

Current Symptoms

Item

Current Symptoms

text

C1457887 (UMLS CUI [1])

Therapeutic Attempt

Item

Therapeutic Attempt

text

C0087111 (UMLS CUI [1,1])
C1516084 (UMLS CUI [1,2])

SEP

Item

SEP (Somatosensory Evoked Potentials)

text

C0015216 (UMLS CUI [1])

Results of further investigations

Item

Results of further investigations

text

C0497120 (UMLS CUI [1])

Walking Distance

Item

Walking Distance

float

C0429886 (UMLS CUI [1])

Neurologic Symptoms

Item

Neurologic Symptoms

text

C1457887 (UMLS CUI [1])

Clinical Findings

Item

Clinical Findings

text

C0205563 (UMLS CUI [1])

Clinical Findings

Code List

Clinical Findings

Medication Name

Item

Medication Name

text

C2360065 (UMLS CUI [1])

Medication Trade Name

Item

Medication Trade Name

text

C0592503 (UMLS CUI [1])

Drug Dosage

Item

Drug Dosage

integer

C3174092 (UMLS CUI [1])

Amount of Medication

Item

Amount of Medication

integer

C1265611 (UMLS CUI [1,1])
C3469597 (UMLS CUI [1,2])

eGFR

Item

eGFR (CKD-EPI)

integer

C3811844 (UMLS CUI [1])

Urine Specific Gravity

Item

Urine Specific Gravity

float

C0202517 (UMLS CUI [1])

Urine pH

Item

Urine pH

float

C0042044 (UMLS CUI [1])

Urine leukocytes

Item

Urine leukocytes

text

C1256582 (UMLS CUI [1])

Urine leukocytes

Code List

Urine leukocytes

CL Item

neg (neg )

CL Item

pos (pos)

Urine Nitrite

Item

Urine Nitrite

text

C0580333 (UMLS CUI [1])

Urine Nitrite

Code List

Urine Nitrite

CL Item

neg (neg)

CL Item

pos (pos)

Urine Protein

Item

Urine Protein

text

C0262923 (UMLS CUI [1])

Urine Protein

Code List

Urine Protein

CL Item

neg (neg)

CL Item

pos (pos)

Urine Glucose

Item

Urine Glucose

text

C0004076 (UMLS CUI [1])

Urine Ketone Bodies

Item

Urine Ketone Bodies

integer

C0860805 (UMLS CUI [1])

Urine Urobilinogen

Item

Urine Urobilinogen

text

C0427736 (UMLS CUI [1])

Urine Bilirubin

Item

Urine Bilirubin

text

C0042040 (UMLS CUI [1])

Urine Erythrocytes

Item

Urine Erythrocytes

integer

C1254564 (UMLS CUI [1])

Neutrophils (rel)

Item

Neutrophils relative

integer

C4028217 (UMLS CUI [1])

Neutrophils (abs)

Item

Neutrophils absolute

float

C0948762 (UMLS CUI [1])

Lymphocytes (rel)

Item

Lymphocytes relative

integer

C2349983 (UMLS CUI [1])

Lymphocytes (abs)

Item

Lymphocytes absolute

float

C0200635 (UMLS CUI [1])

Monocytes (rel)

Item

Monocytes relative

integer

C0587345 (UMLS CUI [1])

Monocytes (abs)

Item

Monocytes absolute

float

C0200637 (UMLS CUI [1])

Eosinophils (rel)

Item

Eosinophils relative

integer

C1171399 (UMLS CUI [1])

Eosinophils (abs)

Item

Eosinophils absolute

float

C0200638 (UMLS CUI [1])

Basophils (rel)

Item

Basophils relative

integer

C1318432 (UMLS CUI [1])

Basophils (abs)

Item

Basophils absolute

float

C1883362 (UMLS CUI [1])

MPV

Item

Mean Platelet Volume

float

C0200665 (UMLS CUI [1])

Granulocytes immature

Item

Immature Granulocytes

float

C3272953 (UMLS CUI [1])

Leucocytes

Item

Leucocytes

float

C0023508 (UMLS CUI [1])

Erythrocytes

Item

Erythrocytes

float

C0014772 (UMLS CUI [1])

Haemoglobin

Item

Haemoglobin

integer

C0518015 (UMLS CUI [1])

Haematocrit Blood

Item

Haematocrit

float

C0018935 (UMLS CUI [1])

MCV

Item

Mean Corpuscular Volume

float

C1948043 (UMLS CUI [1])

MCH

Item

MCH

float

C0369183 (UMLS CUI [1])

MCHC

Item

Mean corpuscular hemoglobin concentration

float

C0474535 (UMLS CUI [1])

Thrombocytes

Item

Thrombocytes

float

C0032181 (UMLS CUI [1])

Sodium

Item

Sodium Measurement

integer

C0337443 (UMLS CUI [1])

Potassium

Item

Potassium

float

C0202194 (UMLS CUI [1])

Calcium

Item

Calcium

float

C0201925 (UMLS CUI [1])

Chloride

Item

Chloride

integer

C0201952 (UMLS CUI [1])

Phosphate

Item

Phosphate

float

C0523826 (UMLS CUI [1])

Glucose

Item

Glucose

integer

C0202042 (UMLS CUI [1])

Blood Urea Nitrogen

Item

Blood Urea Nitrogen

float

C0005845 (UMLS CUI [1])

Creatinin

Item

Creatinin

float

C0201976 (UMLS CUI [1])

Bilirubin Total

Item

Bilirubin Total

float

C1278039 (UMLS CUI [1])

AST

Item

AST (SGOT)

float

C0201899 (UMLS CUI [1])

ALT

Item

Alanine transaminase (ALT) (SGPT)

float

C0201836 (UMLS CUI [1])

gamma-GT

Item

gamma-GT

float

C0202035 (UMLS CUI [1])

Alkaline Phosphatase

Item

Alkaline Phosphatase

text

C0201850 (UMLS CUI [1])

Albumin

Item

Albumin

float

C0201838 (UMLS CUI [1])

Date

Item

Date of Blood Sample

date

C0022885 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])

Muscular reflex

Item

Function of Muscular reflex

text

C0034943 (UMLS CUI [1])

Ankle Clonus

Item

Can an Ankle Clonus be provoked?

text

C0238651 (UMLS CUI [1])

Upper motor neuron signs

Item

Upper motor neuron signs

text

C0749870 (UMLS CUI [1])

Pronator Drift Test

Item

Pronator Drift Test

text

C1504476 (UMLS CUI [1])

Leg drift test

Item

Leg drift test

text

C4036162 (UMLS CUI [1])
C4036161 (UMLS CUI [2])

Palsy dorsiflexion

Item

Palsy dorsiflexion

text

C1838247 (UMLS CUI [1])

Muscle strength Dorsiflexion

Item

Muscle strength (Oxford Scale)

text

C0451362 (UMLS CUI [1,1])
C0231770 (UMLS CUI [1,2])

Muscle strength

Code List

Muscle strength (Oxford Scale)

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)

Paralysed knee flexion

Item

Paralysed knee flexion

text

C0240114 (UMLS CUI [1,1])
C0522224 (UMLS CUI [1,2])

Muscle strength Knee flexion

Item

Muscle strength Knee flexion (Oxford Scale)

text

C0451362 (UMLS CUI [1,1])
C0240114 (UMLS CUI [1,2])

Spastic Gait

Item

Spastic Gait

text

C0437304 (UMLS CUI [1])

Gait Spastic

Code List

Spastic Gait

CL Item

left side (left sides)

CL Item

right side (right sides)

CL Item

both sides (both sides)

Toe-walking gait

Item

Toe-walking gait possible

text

C0427144 (UMLS CUI [1])

Heel to toe gait

Item

Heel to toe gait possible

text

C0231779 (UMLS CUI [1])

Heel Gait

Item

Heel Gait possible

text

C2243016 (UMLS CUI [1])

One Leg Jump

Item

One Leg Jump possible

text

C1140621 (UMLS CUI [1,1])
C0560451 (UMLS CUI [1,2])

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])

Diadochokinesis

Item

Diadochokinesis abnormal?

text

C0278157 (UMLS CUI [1])

Diadochokinesis

Code List

Diadochokinesis abnormal?

CL Item

Eudiadochokinesis (Eudiadochokinesis)

CL Item

Dysdiadochokinesis (Dysdiadochokinesis)

Pallesthesia

Item

Pallesthesia

boolean

C0234198 (UMLS CUI [1])

Location of Pallesthesia

Item

Location of Pallesthesia

text

C1515974 (UMLS CUI [1])

Location of Pallesthesia

Code List

Location of Pallesthesia

CL Item

right (right )

CL Item

left (left)

Grade of Pallesthesia

Item

Grade of Pallesthesia

text

C3468874 (UMLS CUI [1])

Grade of Pallesthesia

Code List

Grade of Pallesthesia

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)

Rhomberg Test

Item

Rhomberg Test abnormal?

text

C1656968 (UMLS CUI [1])

Aphasia

Item

Aphasia?

boolean

C0003537 (UMLS CUI [1])

Apraxia

Item

Apraxia?

text

C0234520 (UMLS CUI [1])

Neglect

Item

Neglect

boolean

C0422887 (UMLS CUI [1])

Neurological Examination: Motor

Item Group

Neurological Examination: Motor

C2237216 (UMLS CUI-1)

Paresis

Item

Pareses

text

C0030552 (UMLS CUI [1])

Paresis

Code List

Pareses

CL Item

present (1)

CL Item

not present (2)

CL Item

not examined (3)

Pronator Drift Test

Item

Pronator Drift Test

text

C1504476 (UMLS CUI [1])

Leg drift test

Item

Leg drift test

text

C4036162 (UMLS CUI [1])
C4036161 (UMLS CUI [2])

Motor tone

Item

Muscle Tonus

text

C0026841 (UMLS CUI [1])

Fine motor skills

Item

Fine motor skills abnormal?

text

C0678857 (UMLS CUI [1])

Gait

Item

Gait, Manner of walking

text

C0016928 (UMLS CUI [1])

Standing

Item

Standing, Manner of Standing

text

C0231472 (UMLS CUI [1])

Muscular reflex

Item

Function of Muscular reflex

text

C0034943 (UMLS CUI [1])

Pyramidal

Item

Pyramidal signs

text

C0234132 (UMLS CUI [1])

Sensibility

Item

Sensibility on neurological exam abnormal?

boolean

C0439823 (UMLS CUI [1])

Motor Coordination Tests

Item

Abnormal motor coordination tests?

text

C0237543 (UMLS CUI [1,1])
C0039593 (UMLS CUI [1,2])

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Versies (3)

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Geüploaded op

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Model Commentaren :

Itemgroep Commentaren voor :

Item Commentaren voor :

Discharge Letter Items Neuroinflammatory Demyelinating Diseases

Discharge Letter Items 1215271678 Multiple Sclerosis

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