CDE Detailed Report

Disease: Spinal Cord Injury
Sub-Domain: Vital Signs and Other Body Measures
CRF: Vital Signs and Tests

Displaying 1 - 50 of 55
CDE ID CDE Name Variable Name Definition Short Description Additional Notes (Question Text) Permissible Values Description Data Type Disease Specific Instructions Disease Specific Reference Population Classification (e.g., Core) Version Number Version Date CRF Name (CRF Module / Guideline) Sub Domain Name Domain Name Size Input Restrictions Min Value Max Value Measurement Type External Id Loinc External Id Snomed External Id caDSR External Id CDISC
C06161 Bladder neck during voiding status BldrNckDurVoidStatus Status of the bladder neck during voiding Status of the bladder neck during voiding Bladder neck during voiding Normal;Closed Normal bladder neck function is when the bladder neck opens, and is continuously relaxed to allow the bladder to be emptied at normal pressure.;Closed bladder neck during voiding (dyssynergia) is when the detrusor contracts concurrent with the bladder neck being closed. Alphanumeric

Choose one

Biering-SØrensen F, Craggs M, Kennelly M, Schick E, Wyndaele J-J. International urinary tract imaging basic spinal cord injury data set. Spinal Cord 2009;47:379-83. Adult Supplemental 3.00 2013-07-17 09:26:36.973 Vital Signs and Tests Vital Signs and Other Body Measures Assessments and Examinations

Single Pre-Defined Value Selected

C19342 Measurement not reported reason MeasrmntNotReptdRsn The reason that a value was not reported for a measurement. The reason that a value was not reported for a measurement. Mark if "Not applicable" or "Unknown" Not applicable;Unknown Not applicable;Unknown Alphanumeric Adult Supplemental 1.00 2014-06-11 13:48:56.0 Vital Signs and Tests Vital Signs and Other Body Measures Assessments and Examinations

Single Pre-Defined Value Selected

C01521 Heart rate HeartRate The participant/subject's pulse or number of contractions (heart beats) per minute The participant/subject's pulse or number of contractions (heart beats) per minute Pulse Numeric Values

Record the pulse of the participant/subject in beats per minute.

Krassioukov A, Alexander MS, Karlsson AK, Donovan W, Mathias CJ, Biering-SØrensen F. International spinal cord injury cardiovascular function basic data set. Spinal Cord. 2010 Aug;48(8):586-90. Adult;Pediatric Supplemental 3.00 2013-08-28 16:08:00.453 Vital Signs and Tests Vital Signs and Other Body Measures Assessments and Examinations

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0 300 beats per minute 2767073
C06263 Bladder function detrusor maximum pressure value BldrFuncDetrusorMaxPressrVal Value of the maximum detrusor pressure on the participant/subject during filling cystometry Value of the maximum detrusor pressure on the participant/subject during filling cystometry Maximum detrusor pressure Numeric Values

Document the maximum detrusor pressure in cm H2O during filling cystometry. Up to three digits without decimals should be used.

Biering-SØrensen F, Craggs M, Kennelly M, Schick E, Wyndaele JJ. International urodynamic basic spinal cord injury data set. Spinal Cord 2008 Jul;46(7):513-6. Adult Supplemental 3.00 2013-07-17 09:26:36.973 Vital Signs and Tests Vital Signs and Other Body Measures Assessments and Examinations

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centimeter of water
C06122 Renography radioactive isotope type RengrphyRadactveistpTyp Type of radioactive isotope used to perform the renography Type of radioactive isotope used to perform the renography Method used DMSA;DTPA;Mag 3 Technetium-99m dimercaptosuccinic acid;Technetium-99m diethylenetriamine pentaacetic acid;Technetium-99m mercaptoacetyltriglycine Alphanumeric

Choose one

Biering-SØrensen F, Craggs M, Kennelly M, Schick E, Wyndaele J-J. International urinary tract imaging basic spinal cord injury data set. Spinal Cord 2009;47:379-83. Adult Supplemental 3.00 2013-07-17 09:26:36.973 Vital Signs and Tests Vital Signs and Other Body Measures Assessments and Examinations

Single Pre-Defined Value Selected

C18145 Procedure perform time ProcedurePerformTime Time of day at which the examination was taken measured in an hour/minute format (HHMM). Time of day at which the examination was taken measured in an hour/minute format (HHMM). Time performed Date or Date & Time

Record the date/time according to the ISO 8601, the International Standard for the representation of dates and times (http://www.iso.org/iso/home.html). The date/time should be recorded to the level of granularity known (e.g., year, year and month, complete date plus hours and minutes, etc.).

Krassioukov A, Alexander MS, Karlsson AK, Donovan W, Mathias CJ, Biering-SØrensen F. International spinal cord injury cardiovascular function basic data set. Spinal Cord. 2010 Aug;48(8):586-90. Adult;Pediatric Supplemental 3.00 2013-07-17 09:26:36.973 Vital Signs and Tests Vital Signs and Other Body Measures Assessments and Examinations

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C06163 Striated urethral sphincter during voiding status StriatUrthSprincDurVoidStatus Status of the striated urethral sphincter during voiding Status of the striated urethral sphincter during voiding Straited urethral sphincter during voiding Normal;Closed Normal urethral function is defined as a urethra that opens, and is continuously relaxed to allow the bladder to be emptied at a normal pressure (Abrams et al. 2002).;Detrusor sphincter dyssynergia is defined as detrusor contraction concurrent with an involuntary contraction of the urethral and/or periurethral striated muscle. Occasionally flow may be prevented altogether (Abrams et al. 2002). Alphanumeric

Choose one
Normal urethral function is defined as a urethra that opens, and is continuously relaxed to allow the bladder to be emptied at a normal pressure (Abrams et al. 2002). Detrusor sphincter dyssynergiais defined as detrusor contraction concurrent with an involuntary contraction of the urethral and/or periurethral striated muscle. Occasionally flow may be prevented altogether (Abrams et al. 2002).

Biering-SØrensen F, Craggs M, Kennelly M, Schick E, Wyndaele J-J. International urinary tract imaging basic spinal cord injury data set. Spinal Cord 2009;47:379-83. Adult Supplemental 3.00 2013-07-17 09:26:36.973 Vital Signs and Tests Vital Signs and Other Body Measures Assessments and Examinations

Single Pre-Defined Value Selected

C01522 Height measurement HgtMeasr Measurement of participant's/subject's height. Measurement of participant's/subject's height. Height (or length) Numeric Values

Record the height (or length for the very young) of the participant/ subject. To be collected at the visit, not self-reported. Also, indicate whether height was measured in inches (in) or centimeters (cm).

Bauman WA, Biering-SØrensen F, Krassioukov A. The international spinal cord injury endocrine and metabolic function basic data set. Spinal Cord. 2011 Oct;49(10):1068-72. doi: 10.1038/sc.2011.51. Adult;Pediatric Supplemental 3.00 2013-08-28 16:08:00.453 Vital Signs and Tests Vital Signs and Other Body Measures Assessments and Examinations

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0 400 centimeter 649
C06264 Bladder function bladder capacity value BldrFuncBldrCapacityVal Value of the bladder capacity of participant/subject during cystometry Value of the bladder capacity of participant/subject during cystometry Cystometric bladder capacity Numeric Values

Document the cystometric bladder capacity in mL during filling cystometry. Up to four digits without decimals should be used.

Abrams P, Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten U, van Kerrebroeck P, Victor A, Wein A. The Standardisation of Terminology of Lower Urinary Tract Function: Report from the Standardisation Sub-committee of the International Continence Society. Neurourology and Urodynamics 2002:21;167-78. Biering-SØrensen F, Craggs M, Kennelly M, Schick E, Wyndaele JJ. International urodynamic basic spinal cord injury data set. Spinal Cord 2008 Jul;46(7):513-6. Adult Supplemental 3.00 2013-07-17 09:26:36.973 Vital Signs and Tests Vital Signs and Other Body Measures Assessments and Examinations

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milliliter
C06126 Kidney right excretory function measurement KdnyRtExcrtryFuncMeasr The percentage of excretory function for the right kidney. The combined excretory function for the two kidneys is 100 %. The percentage of excretory function for each kidney. The combined excretory function for the two kidneys is 100 %. Right side Numeric Values

Document the excretory function percentage for each kidney to the nearest integer. If only one kidney is functioning, the coding will be 100 % for the functioning kidney and 0 % for the non-functioning kidney.

Biering-SØrensen F, Craggs M, Kennelly M, Schick E, Wyndaele J-J. International urinary tract imaging basic spinal cord injury data set. Spinal Cord 2009;47:379-83. Adult Supplemental 3.00 2013-07-17 09:26:36.973 Vital Signs and Tests Vital Signs and Other Body Measures Assessments and Examinations

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C18146 HDL cholesterol value HDLCholstrlVal HDL cholesterol measured HDL cholesterol measured HDL cholesterol Numeric Values Bauman WA, Biering-SØrensen F, Krassioukov A. The international spinal cord injury endocrine and metabolic function basic data set. Spinal Cord. 2011 Oct;49(10):1068-72. doi: 10.1038/sc.2011.51. Adult Supplemental 3.00 2013-07-17 09:26:36.973 Vital Signs and Tests Vital Signs and Other Body Measures Assessments and Examinations

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0 500 milligram per deciliter
C06243 Gastrointestinal colonic transit time measurement GastIntstnlColncTransTmMeasr The total gastrointestinal or colonic transit time assessed by means of radioopaque markers and measured in hours. The total gastrointestinal or colonic transit time assessed by means of radioopaque markers and measured in hours. Total gastrointestinal or colonic transit time Numeric Values

Total gastrointestinal and colonic transit times are prolonged in many individuals with SCI. Transit time through the stomach and small intestine is usually just a few hours. Colonic transit time is, however, much longer. Some authors present transit times as total gastrointestinal transit time and others prefer colonic transit time. Unless multiple x-rays are taken the most correct term is total gastrointestinal transit time. Generally, transit time is prolonged throughout thecolon in individuals with supraconal SCI. In contrast individuals with conal or cauda equina lesions often have severely prolonged rectosigmoid or left colonic transit times. The intrasubjective variation remains to be studied and due to poor correlations between total gastrointestinal /colonic transit time and colorectal symptoms after SCI the clinical relevance of transit time measurement has been questioned (Leduc 2002). Future studies are needed to clarify this. Several types of radiopaque markers and protocols for determining total gastrointestinal and colonic transit times exist. However, no evidence exists to recommend one from the others. The code Unknown is used if the transit time is not determined.

Krogh K, Perkash I, Stiens SA, Biering-SØrensen F. International bowel function extended spinal cord injury data set. Spinal Cord. 2009 Mar;47(3):235-41. Adult Supplemental 3.00 2013-07-17 09:26:36.973 Vital Signs and Tests Vital Signs and Other Body Measures Assessments and Examinations

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C01539 Temperature measurement TempMeasr Measurement of the participant's/subject's body temperature. Measurement of the participant's/subject's body temperature. Temperature measured Numeric Values

Record the temperature of the participant/ subject. Also indicate the scale used to capture temperature.

Karlsson AK, Krassioukov A, Alexander MS, Donovan W, Biering-SØrensen F. International spinal cord injury skin and thermoregulation function basic data set. Spinal Cord. 2012 Jul;50(7):512-6. doi: 10.1038/sc.2011.167. Adult;Pediatric Supplemental 3.00 2013-08-28 16:08:00.453 Vital Signs and Tests Vital Signs and Other Body Measures Assessments and Examinations

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0 50 degree Celsius 2644401
C06265 Bladder function post void volume value BldrFuncPostVoidVolVal Value for the residual bladder volume of participant/subject after cystometry Value for the residual bladder volume of participant/subject after cystometry Post void residual volume Numeric Values

Document the post void residual volume. Up to four digits without decimals should be used.

Abrams P, Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten U, van Kerrebroeck P, Victor A, Wein A. The Standardisation of Terminology of Lower Urinary Tract Function: Report from the Standardisation Sub-committee of the International Continence Society. Neurourology and Urodynamics 2002:21;167-78. Biering-SØrensen F, Craggs M, Kennelly M, Schick E, Wyndaele JJ. International urodynamic basic spinal cord injury data set. Spinal Cord 2008 Jul;46(7):513-6. Adult;Pediatric Supplemental 3.00 2013-07-17 09:26:36.973 Vital Signs and Tests Vital Signs and Other Body Measures Assessments and Examinations

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milliliter
C06145 Vesicouretic reflux laterality type VscrtcReflxInd The laterality type related to reflux to the ureter observed at the right and/or the left side. The laterality type related to reflux to the ureter observed at the right and/or the left side. Vesicoureteric reflux Right;Left Right;Left Alphanumeric

Choose one
This means reflux to the ureter was observed at the right and/or the left side.

Biering-SØrensen F, Craggs M, Kennelly M, Schick E, Wyndaele J-J. International urinary tract imaging basic spinal cord injury data set. Spinal Cord 2009;47:379-83. Adult Supplemental 4.00 2013-07-17 09:26:37.0 Vital Signs and Tests Vital Signs and Other Body Measures Assessments and Examinations

Single Pre-Defined Value Selected

C18147 LDL cholesterol value LDLCholestrlVal LDL cholesterol measured LDL cholesterol measured LDL cholesterol Numeric Values Bauman WA, Biering-SØrensen F, Krassioukov A. The international spinal cord injury endocrine and metabolic function basic data set. Spinal Cord. 2011 Oct;49(10):1068-72. doi: 10.1038/sc.2011.51. Adult Supplemental 3.00 2013-07-17 09:26:36.973 Vital Signs and Tests Vital Signs and Other Body Measures Assessments and Examinations

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0 500 milligram per deciliter
C06244 Colonic transit right side measurement ColncTransRtSdMeasr The transit time of the caecum, ascending- and transverse colon assessed by means of radioopaque markers and measured in hours. The transit time of the caecum, ascending- and transverse colon assessed by means of radioopaque markers and measured in hours. Right colonic transit time Numeric Values

The physiology and innervation of the right colon (caecum, ascending colon and oral 2/3 of the transverse colon) is different from that of the left colon (splenic flexure, descending colon, and rectosigmoid). The right colon is mainly for storage and absorption and receives its parasympathetic innervation from the vagal nerve. The left colon is mainly a transit organ for defecation at receives its parasympathetic innervation from the sacral segments (S2-S4) of the spinal cord. Accordingly, colonc transit time is usually divided into right and left. Whether this is of clinical significance in SCI remains to be determined. The code Not tested is used if the transit time is not determined.

Krogh K, Perkash I, Stiens SA, Biering-SØrensen F. International bowel function extended spinal cord injury data set. Spinal Cord. 2009 Mar;47(3):235-41. Adult Supplemental 3.00 2013-07-17 09:26:36.973 Vital Signs and Tests Vital Signs and Other Body Measures Assessments and Examinations

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C01541 Weight measurement WgtMeasr Measurement of participant's/subject's weight Measurement of participant's/subject's weight Weight Numeric Values

Record the weight of the participant/subject. To be collected at the visit, not self-reported. Also, indicate whether weight was measured in pounds (lbs) or kilograms (kg).

No references availableBauman WA, Biering-SØrensen F, Krassioukov A. The international spinal cord injury endocrine and metabolic function basic data set. Spinal Cord. 2011 Oct;49(10):1068-72. doi: 10.1038/sc.2011.51. Adult;Pediatric Supplemental 3.00 2013-07-25 08:54:08.2 Vital Signs and Tests Vital Signs and Other Body Measures Assessments and Examinations

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0 500 kilogram 2179689
C06363 Serum lipid anti lipid therapy indicator SermLipAntLipTherpyInd Indicates whether a fasting lipid profile was conducted while the participant/subject was on anti-lipid therapy Indicates whether a fasting lipid profile was conducted while the participant/subject was on anti-lipid therapy During anti-lipid therapy Yes;No;Unknown Yes;No;Unknown Alphanumeric

Choose one

Bauman WA, Biering-SØrensen F, Krassioukov A. The international spinal cord injury endocrine and metabolic function basic data set. Spinal Cord. 2011 Oct;49(10):1068-72. doi: 10.1038/sc.2011.51. Adult Supplemental 3.00 2013-07-17 09:26:36.973 Vital Signs and Tests Vital Signs and Other Body Measures Assessments and Examinations

Single Pre-Defined Value Selected

C06147 Bladder diverticulum indicator BldrDvrtclmInd Indicator of whether there is bladder diverticulum. This means diverticula of any size within the bladder or bladder neck were found. Indicator of whether there is bladder diverticulum. This means diverticula of any size within the bladder or bladder neck were found. Bladder diverticulum Bladder diverticulum Bladder diverticulum Alphanumeric

Choose one
This means diverticula of any size within the bladder or bladder neck were found.

Biering-SØrensen F, Craggs M, Kennelly M, Schick E, Wyndaele J-J. International urinary tract imaging basic spinal cord injury data set. Spinal Cord 2009;47:379-83. Adult Supplemental 3.00 2013-07-17 09:26:36.973 Vital Signs and Tests Vital Signs and Other Body Measures Assessments and Examinations

Single Pre-Defined Value Selected

C18153 Data unknown text DataUnknwnTxt The free-text field to Mark an "X" in to record if data are unknown or not available. The free-text field to Mark an "X" in to record if data are unknown or not available. Or data. Alphanumeric

Check box for Unknown

No references available Adult;Pediatric Supplemental 3.00 2013-07-17 09:26:36.973 Vital Signs and Tests Vital Signs and Other Body Measures Assessments and Examinations 20

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C06252 Compression device type ComprsnDevTyp Any compression device worn by the individual that may affect cardiovascular parameters during the examination. Any compression device worn by the individual that may affect cardiovascular parameters during the examination. Devices in use during testing Abdominal binder;Pressure stockings;None;Unknown Abdominal binder;Pressure stockings;None;Unknown Alphanumeric

The wearing of compression devices (abdominal binder or pressure stockings) could affect cardiovascular parameters during the examination. Therefore, their use during the examination should be documented.

Krassioukov A, Alexander MS, Karlsson AK, Donovan W, Mathias CJ, Biering-S&Oslash;rensen F. International spinal cord injury cardiovascular function basic data set. Spinal Cord. 2010 Aug;48(8):586-90. <br />Hopman,M.T., Monroe,M., Dueck,C., Phillips,W.T. & Skinner,J.S. Blood redistribution and circulatory responses to submaximal arm exercise in persons with spinal cord injury. Scand. J. Rehabil. Med. 30, 167-174 (1998). Adult Supplemental 3.00 2013-07-17 09:26:36.973 Vital Signs and Tests Vital Signs and Other Body Measures Assessments and Examinations

Single Pre-Defined Value Selected

C01553 Blood pressure measurement position type BldPressrMeasrPositionTyp Indicator of the participant/subject's position during the blood pressure measurement. Indicator of the participant/subject's position during the blood pressure measurement. Position during testing Sitting;Supine;Unknown Sitting;Supine;Unknown Alphanumeric

Record the position the participant/ subject was in when the blood pressure was measured.

No references availableKrassioukov A, Alexander MS, Karlsson AK, Donovan W, Mathias CJ, Biering-S&Oslash;rensen F. International spinal cord injury cardiovascular function basic data set. Spinal Cord. 2010 Aug;48(8):586-90. Adult;Pediatric Supplemental 3.00 2013-08-28 16:08:00.453 Vital Signs and Tests Vital Signs and Other Body Measures Assessments and Examinations

Single Pre-Defined Value Selected

2008432
C06416 Colonic transit left side measurement ColncTransLftSdMeasr The transit time of the descending colon (including the splenic flexure) and the rectosigmoid assessed by means of radioopaque markers and measured in hours. The transit time of the descending colon (including the splenic flexure) and the rectosigmoid assessed by means of radioopaque markers and measured in hours. Left colonic transit time Numeric Values

The physiology and innervation of the right colon (caecum, ascending colon and oral 2/3 of the transverse colon) is different from that of the left colon (splenic flexure, descending colon, and rectosigmoid). The right colon is mainly for storage and absorption and receives its parasympathetic innervation from the vagal nerve. The left colon is mainly a transit organ for defecation at receives its parasympathetic innervation from the sacral segments (S2-S4) of the spinal cord. Accordingly, colonc transit time is usually divided into right and left. Whether this is of clinical significance in SCI remains to be determined. The code Not tested is used if the transit time is not determined.

Krogh K, Perkash I, Stiens SA, Biering-S&Oslash;rensen F. International bowel function extended spinal cord injury data set. Spinal Cord. 2009 Mar;47(3):235-41. Adult Supplemental 3.00 2013-07-17 09:26:36.973 Vital Signs and Tests Vital Signs and Other Body Measures Assessments and Examinations

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C06149 Bladder neck rest status BldrNckRstStatus Bladder neck is evaluated to be either open or closed at rest. Bladder neck is evaluated to be either open or closed at rest. Bladder neck at rest Open;Closed Open;Closed Alphanumeric

Choose one
The bladder neck is evaluated to be either open or closed at rest.

Biering-S&Oslash;rensen F, Craggs M, Kennelly M, Schick E, Wyndaele J-J. International urinary tract imaging basic spinal cord injury data set. Spinal Cord 2009;47:379-83. Adult Supplemental 3.00 2013-07-17 09:26:36.973 Vital Signs and Tests Vital Signs and Other Body Measures Assessments and Examinations

Single Pre-Defined Value Selected

C18168 Total cholesterol value TotCholstrlVal Total cholesterol level measured Total cholesterol level measured Total cholesterol (TC) Numeric Values Bauman WA, Biering-S&Oslash;rensen F, Krassioukov A. The international spinal cord injury endocrine and metabolic function basic data set. Spinal Cord. 2011 Oct;49(10):1068-72. doi: 10.1038/sc.2011.51. Adult Supplemental 3.00 2013-07-17 09:26:36.973 Vital Signs and Tests Vital Signs and Other Body Measures Assessments and Examinations

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milligrams per deciliter
C06253 Heart rate status HeartRateStatus Findings after taking a participant's pulse during the examination. Findings after taking a participant's pulse during the examination. Pulse Regular;Irregular Regular;Irregular Alphanumeric

Choose one. Both abnormal heart rate and rhythm are commonly observed in individuals with cervical and high thoracic spinal cord lesions.

Krassioukov A, Alexander MS, Karlsson AK, Donovan W, Mathias CJ, Biering-S&Oslash;rensen F. International spinal cord injury cardiovascular function basic data set. Spinal Cord. 2010 Aug;48(8):586-90. Claydon,V.E., Elliott,S.L., Sheel,A.W. & Krassioukov,A. Card Adult Supplemental 3.00 2013-07-17 09:26:36.973 Vital Signs and Tests Vital Signs and Other Body Measures Assessments and Examinations

Single Pre-Defined Value Selected

C01554 Oxygen saturation measurement O2SatMeasr Value, as a percent, of baseline O2 saturation (SPO2) in nocturnal oximetry, as part of Nocturnal Oximetry. Value, as a percent, of baseline O2 saturation (SPO2) in nocturnal oximetry, as part of Nocturnal Oximetry. Oxygen saturation (%) Numeric Values

The suggested range is 0-100. Add date stamp for when assessed. Recommended for collection on admission and daily as required by protocol.

No references available Adult;Pediatric Supplemental 3.00 2013-07-22 16:57:17.79 Vital Signs and Tests Vital Signs and Other Body Measures Assessments and Examinations

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0 100 percent
C18123 Xray study urinary tract global result type XrayStdyUrnTctGlblResltNormInd The result type related to the X-ray study of the urinary tract found functional and anatomical conditions. The result type related to the X-ray study of the urinary tract found functional and anatomical conditions. X-ray of the urinary tract – Kidney Ureter Bladder (KUB) Normal;Kidney stone;Stone in ureter;Bladder stone;Other findings Normal;Kidney stone;Stone in ureter;Bladder stone;Other findings Alphanumeric

Normal: Normal anatomical conditions werefound at the investigation; in particular, no stones in the kidneys, ureters or bladder.
Kidney stone: This means urinary stone(s) was/were found in the renal pelvis or renal parenchyma at the right and/or the left side.
Stone in ureter: This means urinary stone(s) was/were found in the ureter at the right and/or the left side.
Bladder stone: This means urinary stone(s) was/were found in the urinary bladder. Stones of any kind or size qualify for documentation.
Other findings: Findings of any specific deviations from the normal state not documented above can be stated in a text-field, from where it will be possible to retrieve more detailed data whenever necessary. Because many possible findings exist, it is not practical to give an exact list of findings.

Biering-S&Oslash;rensen F, Craggs M, Kennelly M, Schick E, Wyndaele J-J. International urinary tract imaging basic spinal cord injury data set. Spinal Cord 2009 May;47(5):379-83. Adult;Pediatric Supplemental 4.00 2013-07-17 09:26:37.0 Vital Signs and Tests Vital Signs and Other Body Measures Assessments and Examinations

Single Pre-Defined Value Selected

C06150 Urography method type UrgrphyMethdTyp Identifies which methods were performed on the urinary tract Identifies which methods were performed on the urinary tract Method used Intravenous pyelography/Urography;CT urography;Ultrasound of the urinary tract Intravenous pyelography/Urography;CT urography;Ultrasound of the urinary tract Alphanumeric

Choose one. If more than one method was performed on the same date then enter the results separately.

Biering-S&Oslash;rensen F, Craggs M, Kennelly M, Schick E, Wyndaele J-J. International urinary tract imaging basic spinal cord injury data set. Spinal Cord 2009;47:379-83. Adult Supplemental 3.00 2013-07-17 09:26:36.973 Vital Signs and Tests Vital Signs and Other Body Measures Assessments and Examinations

Single Pre-Defined Value Selected

C18169 Triglycerides value TriglcrdVal Triglycerides measured Triglycerides measured Triglycerides (TG) Numeric Values Bauman WA, Biering-S&Oslash;rensen F, Krassioukov A. The international spinal cord injury endocrine and metabolic function basic data set. Spinal Cord. 2011 Oct;49(10):1068-72. doi: 10.1038/sc.2011.51. Adult Supplemental 3.00 2013-07-17 09:26:36.973 Vital Signs and Tests Vital Signs and Other Body Measures Assessments and Examinations

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milligrams per deciliter
C06258 Bladder function bladder sensation type BldrFuncBldrSensationTyp Documents the bladder sensation during filling cystometry. Although the bladder sensation is assessed during filling cystometry the assumption that it is sensation from the bladder alone, without urethral or pelvic components may be false (Abrams et al. 2002). Normal bladder sensation can be judged by three defined points noted during filling cystometry and evaluated in relation to the bladder volume at that moment and in relation to the patient's symptomatic complaints. Type of bladder sensation of the participant/subject during filling cystometry Bladder sensation during filling cystometry Normal;Increased;Reduced;Absent;Non-specific;Unknown Can be judged by three defined points noted (see CDE instructions) during filling cystometry and evaluated in relation to the bladder volume at that moment and in relation to the patient's symptomatic complaints.;Bladder sensation is defined, during filling cystometry, as an early first sensation of bladder filling (or an early desire to void) and/or an early strong desire to void, which occurs at low bladder volume and which persists.;Is defined, during filling cystometry, as diminished sensation throughout bladder filling.;Bladder sensation means that, during filling cystometry, the individual has no bladder sensation.;Bladder sensation, during filling cystometry, may make the individual aware of bladder filling, for example, abdominal fullness or vegetative symptoms.;Is used if the observation regarding bladder sensation during filing cystometry is not available. Alphanumeric

Choose one. The three defined points noted during filling cystometry are as follows: 1. First sensation of bladder filling is the feeling the patient has, during filling cystometry, when he/she first becomes aware of the bladder filling. 2. First desire to void is defined as the feeling, during filling cystometry, that would lead the patient to pass urine at the next convenient moment, but voiding can be delayed if necessary. 3. Strong desire to void this is defined, during filling cystometry, as a persistent desire to void without the fear of leakage.

Abrams P, Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten U, van Kerrebroeck P, Victor A, Wein A. The Standardisation of Terminology of Lower Urinary Tract Function: Report from the Standardisation Sub-committee of the International Continence Society. Neurourology and Urodynamics 2002:21;167-78. Biering-S&Oslash;rensen F, Craggs M, Kennelly M, Schick E, Wyndaele JJ. International urodynamic basic spinal cord injury data set. Spinal Cord 2008 Jul;46(7):513-6. Adult Supplemental 3.00 2013-07-17 09:26:36.973 Vital Signs and Tests Vital Signs and Other Body Measures Assessments and Examinations

Single Pre-Defined Value Selected

C01565 Blood pressure systolic measurement BldPressrSystMeasr Measurement of pressure of the participant's/subject's blood against the artery walls during systole (the contraction phase) in millimeters of mercury (mmHg) Measurement of pressure of the participant's/subject's blood against the artery walls during systole (the contraction phase) in millimeters of mercury (mmHg) Blood Pressure Numeric Values

Record the systolic blood pressure of the participant/ subject. The standard unit for measuring blood pressure is mmHg, which is approximately equivalent to Torr.

No references availableKrassioukov A, Alexander MS, Karlsson AK, Donovan W, Mathias CJ, Biering-S&Oslash;rensen F. International spinal cord injury cardiovascular function basic data set. Spinal Cord. 2010 Aug;48(8):586-90. Adult;Pediatric Supplemental 3.00 2013-07-25 08:54:08.2 Vital Signs and Tests Vital Signs and Other Body Measures Assessments and Examinations

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0 300 millimeter of mercury 2004289 C25298
C18127 Xray urinary tract other finding text XrayUrnTrctOthFindInd Free-text field to specify other findings from the urinary tract X-ray study. Free-text field to specify other findings from the urinary tract X-ray study. Other findings Alphanumeric

Findings of any specific deviations from the normal state not documented above can be stated in a text-field, from where it will be possible to retrieve more detailed data whenever necessary. Because many possible findings exist, it is not practical to give an exact list of findings.

Biering-S&Oslash;rensen F, Craggs M, Kennelly M, Schick E, Wyndaele J-J. International urinary tract imaging basic spinal cord injury data set. Spinal Cord 2009;47:379-83. Adult;Pediatric Supplemental 4.00 2013-07-17 09:26:37.0 Vital Signs and Tests Vital Signs and Other Body Measures Assessments and Examinations 255

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C06152 Imaging study urinary tract global result type ImgStdyUrnTrctGlblResltNormInd The type of results related to urinary tract from imaging of two kidneys. The type of results related to urinary tract from imaging of two kidneys. Result Normal;Stasis/dilatation in upper urinary tract;Kidney stone;Stone in ureter;Bladder stone;Other findings Normal;Stasis/dilatation in upper urinary tract;Kidney stone;Stone in ureter;Bladder stone;Other findings Alphanumeric

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Normal: Normal anatomical conditions werefound at the investigation; in particular, no stasis or dilatation of the upper urinary tract or stones in the kidneys, ureters or bladder.
Stasis/dilatation in upper urinary tract: This means stasis or dilatation was found of the renal pelvis (hydronephrosis) and/or ureter (hydroureteris) at the right and/or the left side.
Kidney stone: This means urinary stone(s) was/were found in the renal pelvis or renal parenchyma at the right and/or the left side.
Stone in ureter: This means urinary stone(s) was/were found in the ureter at the right and/or the left side.
Bladder stone: This means urinary stone(s) was/were found in the urinary bladder. Stones of any kind or size qualify for documentation.
Other findings: Findings of any specific deviations from the normal state not documented above can be stated in a text-field, from where it will be possible to retrieve more detailed data whenever necessary. Because many possible findings exist, it is not practical to give an exact list of findings.

Biering-S&Oslash;rensen F, Craggs M, Kennelly M, Schick E, Wyndaele J-J. International urinary tract imaging basic spinal cord injury data set. Spinal Cord 2009;47:379-83. Adult Supplemental 4.00 2013-07-17 09:26:37.0 Vital Signs and Tests Vital Signs and Other Body Measures Assessments and Examinations

Single Pre-Defined Value Selected

C18608 Kidney left excretory function measurement KdnyLtExcrtryFuncMeasr The percentage of excretory function for the left kidney. The combined excretory function for the two kidneys is 100 %. The percentage of excretory function for the left kidney. The combined excretory function for the two kidneys is 100 %. Left side Numeric Values

Document the excretory function percentage for each kidney to the nearest integer. If only one kidney is functioning, the coding will be 100 % for the functioning kidney and 0 % for the non-functioning kidney.

Biering-S&Oslash;rensen F, Craggs M, Kennelly M, Schick E, Wyndaele J-J. International urinary tract imaging basic spinal cord injury data set. Spinal Cord 2009;47:379-83. Adult Supplemental 1.00 2013-08-29 00:00:00.0 Vital Signs and Tests Vital Signs and Other Body Measures Assessments and Examinations

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C06259 Bladder function detrusor function type BldrFuncDetrusorFunctionTyp Type of magnitude of the detrusor function on the participant/subject Type of magnitude of the detrusor function on the participant/subject Detrusor function Normal;Neurogenic detrusor overactivity;Underactive detrusor;Acontractile detrusor;Unknown Detrusor function allows bladder filling with little or no change in pressure. No involuntary phasic contractions occur despite provocation. Normal voiding is achieved by a voluntary initiated continuous detrusor contraction that leads to complete bladder emptying within a normal time span, and in the absence of obstruction. For a given detrusor contraction, the magnitude of the recorded pressure rise will depend on the degree of outlet resistance (Abrams et al. 2002).;Is a urodynamic observation in individuals with a neurological condition characterized by involuntary detrusor contractions during the filling phase which may be spontaneous or provoked (Abrams et al. 2002).;Is defined as a contraction of reduced strength and/or duration, resulting in prolonged bladder emptying and/or a failure to achieve complete bladder emptying within a normal time span (Abrams et al. 2002).;Is one that cannot be demonstrated to contract during urodynamic studies (Abrams et al. 2002).;Is used if the observation regarding detrusor function is not available. Alphanumeric

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Abrams P, Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten U, van Kerrebroeck P, Victor A, Wein A. The Standardisation of Terminology of Lower Urinary Tract Function: Report from the Standardisation Sub-committee of the International Continence Society. Neurourology and Urodynamics 2002:21;167-78. Biering-S&Oslash;rensen F, Craggs M, Kennelly M, Schick E, Wyndaele JJ. International urodynamic basic spinal cord injury data set. Spinal Cord 2008 Jul;46(7):513-6. Adult Supplemental 3.00 2013-07-17 09:26:36.973 Vital Signs and Tests Vital Signs and Other Body Measures Assessments and Examinations

Single Pre-Defined Value Selected

C06005 Data collected date and time DataCollDateTime Date (and time, if applicable and known) the data were collected. This may be the date/time a particular examination or procedure was performed. Date (and time, if applicable and known) the data were collected. This may be the date/time a particular examination or procedure was performed. Date performed Date or Date & Time

Record the date/time according to the ISO 8601, the International Standard for the representation of dates and times (http://www.iso.org/iso/home.html). The date/time should be recorded to the level of granularity known (e.g., year, year and month, complete date plus hours and minutes, etc.).

Bauman WA, Biering-S&Oslash;rensen F, Krassioukov A. The international spinal cord injury endocrine and metabolic function basic data set. Spinal Cord. 2011 Oct;49(10):1068-72. doi: 10.1038/sc.2011.51. Adult;Pediatric Supplemental 3.00 2013-07-24 21:00:23.88 Vital Signs and Tests Vital Signs and Other Body Measures Assessments and Examinations

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C18130 Renography urinary tract other finding text RengrphyUrnTrctOthFindTxt The free-text field for other findings from the urinary tract renography study. The free-text field for other findings from the urinary tract renography study. Other findings Alphanumeric

Findings of any specific deviations from the normal state not documented above can be stated in a text-field, from where it will be possible to retrieve more detailed data on the computer whenevernecessary. Because many possible findings exist,it is not practical to givean exact list of findings.

Biering-S&Oslash;rensen F, Craggs M, Kennelly M, Schick E, Wyndaele J-J. International urinary tract imaging basic spinal cord injury data set. Spinal Cord 2009;47:379-83. Adult;Pediatric Supplemental 3.00 2013-07-17 09:26:36.973 Vital Signs and Tests Vital Signs and Other Body Measures Assessments and Examinations 255

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C06154 Stasis dilation upper urinary tract laterality type StasDialUpUrnTrctInd The laterality type related to stasis/ dilatation in upper urinary tract. This means stasis or dilatation was found of the renal pelvis (hydronephrosis) and/or ureter (hydroureteris) on either side. The laterality type related to stasis/ dilatation in upper urinary tract. This means stasis or dilatation was found of the renal pelvis (hydronephrosis) and/or ureter (hydroureteris) on either side. Stasis dilation in upper urinary tract Right side;Left side Right side;Left side Alphanumeric

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Biering-S&Oslash;rensen F, Craggs M, Kennelly M, Schick E, Wyndaele J-J. International urinary tract imaging basic spinal cord injury data set. Spinal Cord 2009;47:379-83. Adult Supplemental 4.00 2013-07-17 09:26:37.0 Vital Signs and Tests Vital Signs and Other Body Measures Assessments and Examinations

Single Pre-Defined Value Selected

C19079 Method Used Type MethdUsedTyp The type of method used for measuring temperature The type of method used for measuring temperature Method used Rectal;Ear;Oral;Axillary;Unknown Rectal;Ear;Oral;Axillary;Unknown Alphanumeric

Present body temperature at the day of investigation should be documented. It should be noted that rectal investigation of body core temperature is most reliable.

Karlsson AK, Krassioukov A, Alexander MS, Donovan W, Biering-S&Oslash;rensen F. International spinal cord injury skin and thermoregulation function basic data set. Spinal Cord. 2012 Jul;50(7):512-6. doi: 10.1038/sc.2011.167. Adult;Pediatric Supplemental 1.00 2014-05-27 09:50:43.0 Vital Signs and Tests Vital Signs and Other Body Measures Assessments and Examinations

Single Pre-Defined Value Selected

C06260 Bladder function bladder compliance type BldrFuncBladderComplianceTyp Type of bladder compliance of the participant/subject during filling cystometry Type of bladder compliance of the participant/subject during filling cystometry Compliance during filing cystometry: Low (< 10 mL/cm H20) Yes;No;Unknown Yes;No;Unknown Alphanumeric

The International Continence Society recommends to calculate the bladder compliance using two standard points: 1) the detrusor pressure at the start on the bladder filling and the corresponding bladder volume (usually zero), and 2) the detrusor pressure (and corresponding bladder volume) at cystometric capacity or immediately before the start of any detrusor contraction that causes significant leakage (and therefore causes the bladder volume to decrease, affecting compliance calculation). Both points are measured excluding any detrusor contraction (Abrams et al. 2002). Unknown is used if the observation regarding bladder compliance during filling cystometry is not available.

Abrams P, Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten U, van Kerrebroeck P, Victor A, Wein A. The Standardisation of Terminology of Lower Urinary Tract Function: Report from the Standardisation Sub-committee of the International Continence Society. Neurourology and Urodynamics 2002:21;167-78. Biering-S&Oslash;rensen F, Craggs M, Kennelly M, Schick E, Wyndaele JJ. International urodynamic basic spinal cord injury data set. Spinal Cord 2008 Jul;46(7):513-6. Weld KJ, Graney MJ, Dmochowski RR. Differences in bladder compliance with time and associations of bladder management with compliance in spinal cord injured patients. J Urol 2000;163:1228-33. Adult Supplemental 3.00 2013-07-17 09:26:36.973 Vital Signs and Tests Vital Signs and Other Body Measures Assessments and Examinations

Single Pre-Defined Value Selected

C06115 Force vital capacity measurement FrceVitalCpctyMeasr Forced vital capacity (FVC) value measured in liters using simple spirometry. FVC is defined as the total volume of air that a person can forcibly exhale during a maximal expiratory effort. Forced vital capacity (FVC) value measured in liters using simple spirometry. FVC is defined as the total volume of air that a person can forcibly exhale during a maximal expiratory effort. Forced vital capacity (FVC) Numeric Values

Forced vital capacity (FVC) should be reported in liters (99.9 = Unknown)

Biering-S&Oslash;rensen F, Krassioukov A, Alexander MS, Donovan W, Karlsson AK, Mueller G, Perkash I, William Sheel A, Wecht J, Schilero GJ.International Spinal Cord Injury Pulmonary Function Basic Data Set. Spinal Cord. 2012 Jun; 50(6):418-21. Adult Supplemental 3.00 2013-07-17 09:26:36.973 Vital Signs and Tests Vital Signs and Other Body Measures Assessments and Examinations

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C18133 Cystogram performed date CystogramDate Date Cystogram was performed Date Cystogram was performed Date performed: Date or Date & Time

Record the date/time according to the ISO 8601, the International Standard for the representation of dates and times (http://www.iso.org/iso/home.html). The date/time should be recorded to the level of granularity known (e.g., year, year and month, complete date plus hours and minutes, etc.).

Biering-S&Oslash;rensen F, Craggs M, Kennelly M, Schick E, Wyndaele J-J. International urinary tract imaging basic spinal cord injury data set. Spinal Cord 2009;47:379-83. Adult Supplemental 3.00 2013-07-17 09:26:36.973 Vital Signs and Tests Vital Signs and Other Body Measures Assessments and Examinations

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C06156 Kidney stone laterality type KdnyStnInd The laterality type related to kidney stones present. This means urinary stone(s) was/were found in the renal pelvis or renal parenchyma on either side. The laterality type related to kidney stones present. This means urinary stone(s) was/were found in the renal pelvis or renal parenchyma on either side. Kidney stone Right side;Left side Right side;Left side Alphanumeric

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Biering-S&Oslash;rensen F, Craggs M, Kennelly M, Schick E, Wyndaele J-J. International urinary tract imaging basic spinal cord injury data set. Spinal Cord 2009;47:379-83. Adult Supplemental 3.00 2013-07-17 09:26:36.973 Vital Signs and Tests Vital Signs and Other Body Measures Assessments and Examinations

Single Pre-Defined Value Selected

C19340 Mean arterial pressure measurement value MeanArtPressrMeasrVal Result of a mean average pressure determination, expressed as a numeric value in millimeters of mercury (mmHg) to the nearest even number. The average pressure on the arteries from the beginning of one heartbeat to the beginning of the next heartbeat. Formally, it is the product of the cardiac output and the systemic vascular resistance, plus the central venous pressure. Result of a mean average pressure determination, expressed as a numeric value in millimeters of mercury (mmHg) to the nearest even number. Mean arterial pressure measurement (mmHg) Numeric Values Adult;Pediatric Supplemental 1.00 2014-06-11 10:20:24.0 Vital Signs and Tests Vital Signs and Other Body Measures Assessments and Examinations

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millimeters of mercury 2475893
C06261 Bladder function urethral function type BldrFuncUrethralFuncTyp Type of urethral function of the participant/subject during voiding Type of urethral function of the participant/subject during voiding Urethral function during voiding Normal;Detrusor sphincter dyssynergia;Non-relaxing urethral sphincter obstruction;Not applicable;Unknown Is defined as a urethra that opens and is continuous relaxed to allow the bladder to be emptied at a normal pressure (Abrams et al. 2002).;Is defined as detrusor contraction concurrent with an involuntary contraction of the urethral and/or periurethral striated muscle. Occasionally flow may be prevented altogether (Abrams et al. 2002).;Is characterised by a non-relaxing, obstructing urethra resulting in reduced urine flow (Abrams et al. 2002).;Should be used if the individual with a spinal cord lesion for example has acontractile detrusor.;Is used if the observation regarding function during voiding is not available. Alphanumeric

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Abrams P, Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten U, van Kerrebroeck P, Victor A, Wein A. The Standardisation of Terminology of Lower Urinary Tract Function: Report from the Standardisation Sub-committee of the International Continence Society. Neurourology and Urodynamics 2002:21;167-78. Biering-S&Oslash;rensen F, Craggs M, Kennelly M, Schick E, Wyndaele JJ. International urodynamic basic spinal cord injury data set. Spinal Cord 2008 Jul;46(7):513-6. Adult Supplemental 3.00 2013-07-17 09:26:36.973 Vital Signs and Tests Vital Signs and Other Body Measures Assessments and Examinations

Single Pre-Defined Value Selected

C06116 Force expiratory volume measurement FrceExpirtryVolMeasr Forced expiratory volume in one second (FEV1) value measured in liters using simple spirometry. FEV1 is the volume expired in the first second of the forced vital capacity (FVC) maneuver. Forced expiratory volume in one second (FEV1) value measured in liters using simple spirometry. FEV1 is the volume expired in the first second of the forced vital capacity (FVC) maneuver. Forced expiratory volume in one second (FEV1) Numeric Values

FEV1 should be reported in liters (99.9 = Unknown)

Biering-S&Oslash;rensen F, Krassioukov A, Alexander MS, Donovan W, Karlsson AK, Mueller G, Perkash I, William Sheel A, Wecht J, Schilero GJ.International Spinal Cord Injury Pulmonary Function Basic Data Set. Spinal Cord. 2012 Jun; 50(6):418-21. Adult Supplemental 3.00 2013-07-17 09:26:36.973 Vital Signs and Tests Vital Signs and Other Body Measures Assessments and Examinations

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liter
C18134 Cystogram result type CystogramResTyp The type as related to the cystrogram result The type as related to the cystrogram result Cystogram Bladder stone;Vesicoureteric reflux;Normal;Other findings;Bladder diverticulum;Bladder neck at rest Bladder stone;Vesicoureteric reflux;Normal;Other findings;Bladder diverticulum;Bladder neck at rest Alphanumeric

Normal: Normal anatomical conditions werefound at the investigation; in particular, no stones in the bladder,vesicoureteral reflux, or bladder diverticulum.
Bladder stone: This means urinary stone(s) was/were found in the urinary bladder. Stones of any kind or size qualify for documentation.
Vesicoureteric reflux: This means reflux to the ureter was observed at the right and/or the left side.
Bladder diverticulum: This means diverticula of any size within the bladder or bladder neck were found.
Bladder neck at rest: The bladder neck is evaluated to be either open or closed at rest.
Other findings: Findings of any specific deviations from the normal state not documented above can be stated in a text-field, from where it will be possible to retrieve more detailed data on the computer whenevernecessary. Because many possible findings exist, it is not practical to givean exact list of findings.

Biering-S&Oslash;rensen F, Craggs M, Kennelly M, Schick E, Wyndaele J-J. International urinary tract imaging basic spinal cord injury data set. Spinal Cord 2009;47:379-83. Adult Supplemental 3.00 2013-07-17 09:26:36.973 Vital Signs and Tests Vital Signs and Other Body Measures Assessments and Examinations

Single Pre-Defined Value Selected

C06158 Ureter stone laterality type UrtrStnInd The laterality type related to stone present in the ureter. This means urinary stone(s) was/were found in the ureter on either side. The laterality type related to stone present in the ureter. This means urinary stone(s) was/were found in the ureter on either side. Stone in ureter Right side;Left side Right side;Left side Alphanumeric

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Biering-S&Oslash;rensen F, Craggs M, Kennelly M, Schick E, Wyndaele J-J. International urinary tract imaging basic spinal cord injury data set. Spinal Cord 2009;47:379-83. Adult Supplemental 3.00 2013-07-17 09:26:36.973 Vital Signs and Tests Vital Signs and Other Body Measures Assessments and Examinations

Single Pre-Defined Value Selected

CSV