of0
 
CDE Detailed Report
This report contains detailed information about the selected CDEs.
Note: If at least one CDE was selected from a copyright- or trademark-protected instrument/scale then all of the CDEs from that instrument/scale are included in this report.
Disease: Epilepsy
Sub-Domain: Physical/Neurological Examination
CRF: Physical Exam
Item count: 10 (10 distinct CDEs)
CDE ID
CDE Name
Variable Name
Definition / Description
Question Text
Permissible Value
Description
Data Type
Instructions
References
Population
Classification (e.g., Core)
Version #
Version Date
Aliases for Variable Name
CRF Module / Guideline
© or TM
Sub-Domain
Domain
Previous Title
Size
Input Restrictions
Min Value
Max Value
Measurement Type
LOINC ID
SNOMED
caDSR ID
CDISC ID
C01010
Physical exam date and time
PhysExamDateTime
Date (and time if applicable and known) physical exam was performed
Date of Exam
  
Date or Date & Time
Record the date (and time) the physical exam was performed. 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.).
No references available
Adult;Pediatric
Supplemental
3.0
8/28/2013
EVAL_DT
Physical Exam
Physical/Neurological Examination
Assessments and Examinations
Physical exam date and time
 
Free-Form Entry
     
2004170
 
C18931
Global change since prior examination other text
GlobalChangeSincPriorExamOTH
The free-text field related to 'Global change since prior examination result' specifying other text. Global assessment of the difference between the prior and follow-up examinations
Other, specify
  
Alphanumeric
Record change from prior exam if follow-up exam
No references available
Adult;Pediatric
Supplemental
1.0
10/5/2012
Aliases for variable name not defined
Physical Exam
Physical/Neurological Examination
Assessments and Examinations
 
4000
Free-Form Entry
       
C14429
Global change since prior examination result
GlobalChangeSincPriorExamReslt
Global assessment of the difference between the prior and follow-up examinations
If follow-up exam, change from prior exam
No change;Improved;Worse;Unknown;Other, specify;
No change;Improved;Worse;Unknown;Other, specify;
Alphanumeric
Record change from prior exam if follow-up exam
No references available
Adult;Pediatric
Supplemental
1.0
10/5/2012
Aliases for variable name not defined
Physical Exam
Physical/Neurological Examination
Assessments and Examinations
Global change since prior examination result
 
Single Pre-Defined Value Selected
       
C14430
Tanner stage
TannerStage
Stages of physical development in children, adolescents and adults. The scale defines physical measurements of development based on external primary and secondary sex characteristics, such as the size of the breasts, genitalia, and development of pubic hair.
Tanner Stage
I;II;III;IV;V;
I;II;III;IV;V;
Alphanumeric
Indicate Tanner stage for pediatric studies only
http://www.addison.ac.uk/endocrine_modules/module1/lecturers_material/html_files/END1.14/sld019.htm
Pediatric
Supplemental
1.0
10/5/2012
Aliases for variable name not defined
Physical Exam
Physical/Neurological Examination
Assessments and Examinations
Tanner stage
 
Single Pre-Defined Value Selected
       
C00023
Hand preference type
HandPrefTyp
Hand which the participant/subject uses predominantly, not necessarily the hand he/she writes with exclusively.
Handedness
Left hand;Right hand;Both hands;Unknown;
Left hand;Right hand;Both hands;Unknown;
Alphanumeric
Choose the hand which the participant/subject uses predominantly, not necessarily the hand the participant/subject writes with exclusively
No references available
Adult;Pediatric
Supplemental
3.0
7/25/2013
Aliases for variable name not defined
Physical Exam
Physical/Neurological Examination
Assessments and Examinations
Hand preference type
 
Single Pre-Defined Value Selected
     
2180147
 
C00312
Body system category
BodySysCat
Category or grouping used in the comprehensive assessment of a participant/subject, which includes a subjective history taking component as well as an objective based structured interview and physical examination of all the body systems.
Body System
Constitutional symptoms (e.g., fever, weight loss);Eyes;Ears, Nose, Mouth, Throat;Cardiovascular;Respiratory;Gastrointestinal;Genitourinary;Musculoskeletal;Integumentary (skin and/or breast);Neurological;Psychiatric;Endocrine;Hematologic/Lymphatic;Allergic/Immunologic;
Constitutional symptoms (e.g., fever, weight loss);Eyes;Ears, Nose, Mouth, Throat;Cardiovascular;Respiratory;Gastrointestinal;Genitourinary;Musculoskeletal;Integumentary (skin and/or breast);Neurological;Psychiatric;Endocrine;Hematologic/Lymphatic;Allergic/Immunologic;
Alphanumeric
Choose one. Response is obtained by report of the participant/subject or proxy as soon as possible after visit/admission. Document the date the history was obtained so it can be determined whether this information was obtained prior to study enrollment or later. Recommend collection at least on date of TBI or at time of first medical treatment. Comorbidity prior to injury may influence the disease course and chances of recovery. Serious comorbidity or comorbidity that may influence the assessment of outcome are generally considered exclusion criteria in randomized clinical trials. It is therefore highly relevant to accurately record the significant relevant medical history.
Review of Symptoms from Centers for Medicare and Medicaid Services https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/eval_mgmt_serv_guide-ICN006764.pdf
Adult;Pediatric
Supplemental
3.0
7/25/2013
Aliases for variable name not defined
Physical Exam
Physical/Neurological Examination
Assessments and Examinations
Body system category
 
Single Pre-Defined Value Selected
     
2002895
 
C18666
Body system other text
BodySysOTH
The free-text field related to 'Body system category' specifying other text. Category or grouping used in the comprehensive assessment of a participant/subject, which includes a subjective history taking component as well as an objective based structured
Other, specify
  
Alphanumeric
Choose one. Response is obtained by report of the participant/subject or proxy as soon as possible after visit/admission. Document the date the history was obtained so it can be determined whether this information was obtained prior to study enrollment or later. Recommend collection at least on date of TBI or at time of first medical treatment. Comorbidity prior to injury may influence the disease course and chances of recovery. Serious comorbidity or comorbidity that may influence the assessment of outcome are generally considered exclusion criteria in randomized clinical trials. It is therefore highly relevant to accurately record the significant relevant medical history.
Review of Symptoms from Centers for Medicare and Medicaid Services https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/eval_mgmt_serv_guide-ICN006764.pdf
Adult;Pediatric
Supplemental
1.0
5/27/2014
Aliases for variable name not defined
Physical Exam
Physical/Neurological Examination
Assessments and Examinations
 
4000
Free-Form Entry
     
2002895
 
C01012
Physical exam body system result type
PhysExamBodySysResltTyp
Assessment result of each body system examined
Result
Abnormal;Normal;Not assessed;
Abnormal;Normal;Not assessed;
Alphanumeric
Choose one. Indicate whether each body system examined had any abnormal findings.
No references available
Adult;Pediatric
Supplemental
3.0
7/25/2013
FNG_RSLT_STAT
Physical Exam
Physical/Neurological Examination
Assessments and Examinations
Physical exam body system result type
 
Single Pre-Defined Value Selected
     
2821383
 
C01013
Physical exam description text
PhysExamDescripTxt
Free text field to describe the abnormality in a specific body system or an explanation of why the body system was not examined
   
Alphanumeric
Provide a description of each abnormal result found during the physical exam. Make sure to record any of the following abnormalities: dysmorphic features, neurocutaneous stigmata, and carotid bruits.
SNOMED CT CODES - Problem List (http://www.nlm.nih.gov/research/umls/Snomed/core_subset.html)
Adult;Pediatric
Supplemental
3.0
7/25/2013
PT_ABN_PHYSEX_SPEC
Physical Exam
Physical/Neurological Examination
Assessments and Examinations
Physical exam description text
255
Free-Form Entry
     
2201880
 
C01028
Physical exam condition SNOMED CT code
PhysExamCondSNOMEDCTcode
Medical condition/disease found during the physical examination of the participant/subject. Systematized Nomenclature of Medicine-Clinical Terms (SNOMED CT)
   
Alphanumeric
Code the description of each abnormal result found during the physical exam using the Systematized Nomenclature of Medicine-Clinical Terms (SNOMED CT).
SNOMED CT CODES - Problem List (http://www.nlm.nih.gov/research/umls/Snomed/core_subset.html)
Adult;Pediatric
Supplemental
3.0
8/28/2013
Aliases for variable name not defined
Physical Exam
Physical/Neurological Examination
Assessments and Examinations
Physical exam condition SNOMED CT code
255
Free-Form Entry
       
03-22-2017
Page 1 of 1