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ID
43561
Description
Discharge Letter Items for Patient diagnosed with Multiple Sclerosis from Neurology Department of University Clinic Muenster
Keywords
Versions (4)
- 5/24/16 5/24/16 -
- 5/27/16 5/27/16 -
- 6/1/16 6/1/16 -
- 9/20/21 9/20/21 -
Uploaded on
September 20, 2021
DOI
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License
Creative Commons BY-NC 3.0
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Discharge Letter Items 1132945139 Multiple Sclerosis
Discharge Letter Items 1132945139 Multiple Sclerosis
- StudyEvent: ODM
Similar models
Discharge Letter Items 1132945139 Multiple Sclerosis
- StudyEvent: ODM
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
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])
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
C0585085 (UMLS CUI [1])
Principal Diagnosis Multiple Sclerosis
Item
Principal Diagnosis Multiple Sclerosis
text
C0332137 (UMLS CUI [1,1])
C0026769 (UMLS CUI [1,2])
C0026769 (UMLS CUI [1,2])
Earliest date of diagnosis
Item
Earliest date of diagnosis
date
C4019001 (UMLS CUI [1])
Date of Onset
Item
Onset
date
C0574845 (UMLS CUI [1])
EDSS
Item
EDSS
integer
C0451246 (UMLS CUI [1])
Number of Lesions
Item
Number of T2-hyperintense Lesions in cMRT
integer
C2238926 (UMLS CUI [1,1])
C0449788 (UMLS CUI [1,2])
C0449788 (UMLS CUI [1,2])
Localisation of Lesions
Item
Localisation of Lesions
text
C2238926 (UMLS CUI [1,1])
C0475264 (UMLS CUI [1,2])
C0475264 (UMLS CUI [1,2])
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])
C0243095 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,3])
Cerebrospinal fluid
Item
Cerebrospinal fluid
text
C0007807 (UMLS CUI [1])
CL Item
positive (positive )
CL Item
negative (negative)
Current Immunosuppressive Therapy
Item
Current Immunosuppressive Therapy
text
C0021079 (UMLS CUI [1,1])
C2827774 (UMLS CUI [1,2])
C2827774 (UMLS CUI [1,2])
Starting Date Therapy Dimethylfumarat
Item
Date of start of therapy Dimethylfumarat (Tecfidera)
date
C0058218 (UMLS CUI [1,1])
C3173309 (UMLS CUI [1,2])
C3173309 (UMLS CUI [1,2])
Study Participation
Item
Does the patient participate in a study ?
boolean
C1997894 (UMLS CUI [1])
Current Therapy Dimethylfumarat
Item
Current Therapy with Dimethylfumarat (Tecfidera)
boolean
C0058218 (UMLS CUI [1,1])
C2827774 (UMLS CUI [1,2])
C2827774 (UMLS CUI [1,2])
Factor V Leiden
Item
Factor V Leiden mutation?
boolean
C0380964 (UMLS CUI [1])
Thrombosis
Item
Thrombosis of vein of lower leg
boolean
C0340707 (UMLS CUI [1])
Reason for admission
Item
Reason for admission
text
C0392360 (UMLS CUI [1,1])
C0809949 (UMLS CUI [1,2])
C0809949 (UMLS CUI [1,2])
Introduction: Reason for current Admission
Item
Introduction: Reason for current Admission
text
C0392360 (UMLS CUI [1,1])
C0809949 (UMLS CUI [1,2])
C0809949 (UMLS CUI [1,2])
Introduction: Department
Item
Introduction: Department
text
Current Immunosuppressive Therapy
Item
Current Immunosuppressive Therapy
text
C2827774 (UMLS CUI [1,1])
C0021079 (UMLS CUI [1,2])
C0021079 (UMLS CUI [1,2])
Adverse Effect
Item
Adverse Effect
text
C0041755 (UMLS CUI [1])
Current Symptoms
Item
Current Symptoms
text
C1457887 (UMLS CUI [1,1])
C0521116 (UMLS CUI [1,2])
C0521116 (UMLS CUI [1,2])
Neurological Examination
Item
Neurological Examination
text
C0437208 (UMLS CUI [1])
Therapeutic Attempt
Item
Therapeutic Attempt
text
C0087111 (UMLS CUI [1,1])
C1516084 (UMLS CUI [1,2])
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
C0235031 (UMLS CUI [1])
Follow-up MRI
Item
Follow-up MRI
text
C0412674 (UMLS CUI [1,1])
C0260832 (UMLS CUI [1,2])
C0260832 (UMLS CUI [1,2])
Recommendation Therapy
Item
Therapy Recommendation
text
Recommendation Differential blood count
Item
Differential blood count
text
C0545131 (UMLS CUI [1,1])
C0585336 (UMLS CUI [1,2])
C0585336 (UMLS CUI [1,2])
Recommendation Neurological Exam
Item
Neurological Exam
text
C0027853 (UMLS CUI [1,1])
C0585339 (UMLS CUI [1,2])
C0585339 (UMLS CUI [1,2])
Date Follow-Up Visit
Item
Date Follow-Up Visit
date
C3694716 (UMLS CUI [1])
Recommendation MRI Follow-Up
Item
MRI Follow-Up
text
C0260832 (UMLS CUI [1,1])
C0412674 (UMLS CUI [1,2])
C0412674 (UMLS CUI [1,2])
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
C0870450 (UMLS CUI [1])
Amount of Medication
Item
Amount of Medication
integer
C1265611 (UMLS CUI [1,1])
C3469597 (UMLS CUI [1,2])
C3469597 (UMLS CUI [1,2])
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])
C1287969 (UMLS CUI [1,2])
CL Item
positive (positive)
CL Item
negative (negative)
Percussion Pain Spine
Item
Percussion Pain Spine
boolean
C0030987 (UMLS CUI [1,1])
C0030193 (UMLS CUI [1,2])
C0037949 (UMLS CUI [1,3])
C0030193 (UMLS CUI [1,2])
C0037949 (UMLS CUI [1,3])
Percussion Pain Skull
Item
Percussion Pain Skull
boolean
C0030987 (UMLS CUI [1,1])
C0030193 (UMLS CUI [1,2])
C0037303 (UMLS CUI [1,3])
C0030193 (UMLS CUI [1,2])
C0037303 (UMLS CUI [1,3])
Visus
Item
Visus measurement
float
C0042812 (UMLS CUI [1])
Eye Movement
Item
Examination of Eye Movement
text
C0015413 (UMLS CUI [1])
Nystagmus Test
Item
Nystagmus Test
text
C0200205 (UMLS CUI [1])
Gaze Palsy
Item
Gaze Palsy
text
C1112261 (UMLS CUI [1])
Diplopia
Item
Diplopia
text
C0012569 (UMLS CUI [1])
Visual Field
Item
Visual Field Fingerperimetric
text
C0858409 (UMLS CUI [1])
Pupils Size
Item
Pupils Size
text
C0437590 (UMLS CUI [1])
Pupils regularity
Item
Pupils regularity
text
C0437592 (UMLS CUI [1])
Pupils reaction
Item
Pupils reaction
text
C0437599 (UMLS CUI [1])
Direct pupil reaction to light
Item
Direct pupil reaction to light
text
C0700372 (UMLS CUI [1,1])
C1947931 (UMLS CUI [1,2])
C1947931 (UMLS CUI [1,2])
Consensual pupil reaction to light
Item
Consensual pupil reaction to light
text
C0700372 (UMLS CUI [1])
Trigeminal Sensory Function
Item
Trigeminal Sensory Function
text
C0234284 (UMLS CUI [1])
Facial Paralysis
Item
Facial Paralysis
text
C0015469 (UMLS CUI [1])
Caudal cranial nerves
Item
Function of caudal cranial nerves
text
C0010268 (UMLS CUI [1,1])
C0205097 (UMLS CUI [1,2])
C0205097 (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
Palsy dorsiflexion
Item
Palsy dorsiflexion
text
C1838247 (UMLS CUI [1])
Item
Muscle strength (Oxford Scale)
text
C0451362 (UMLS CUI [1,1])
C0231770 (UMLS CUI [1,2])
C0231770 (UMLS CUI [1,2])
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])
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])
C0240114 (UMLS CUI [1,2])
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])
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])
CL Item
Eudiadochokinesis (Eudiadochokinesis)
CL Item
Dysdiadochokinesis (Dysdiadochokinesis)
Pallesthesia
Item
Pallesthesia
boolean
C0234198 (UMLS CUI [1])
CL Item
right (right )
CL Item
left (left)
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])
Date
Item
Date of Blood Sample
date
C0022885 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,2])
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
C0337438 (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])
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])
Item Group
Laboratory Results Differential EDTA
C1820731 (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])
Urine Specific Gravity
Item
Urine Specific Gravity
float
C0202517 (UMLS CUI [1])
Urine pH
Item
Urine pH
float
C0042044 (UMLS CUI [1])
CL Item
neg (neg )
CL Item
pos (pos)
CL Item
neg (neg)
CL Item
pos (pos)
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])
eGFR
Item
eGFR (CKD-EPI)
integer
C3811844 (UMLS CUI [1])