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: Neurological Exam
Item count: 75 (75 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
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 form completed
  
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.).
EPILEPSY: Berg AT, Berkovic SF, Brodie MJ, Buchhalter J, et al. Revised terminology and concepts for organization of seizures and epilepsies: report of the ILAE Commission on Classification and Terminology, 2005-2009. Epilepsia. 2010 Apr;51(4):676-85. http://www.ilae-epilepsy.org/Visitors/Centre/ctf/ctfoverview.cfm
Adult;Pediatric
Supplemental
3.0
7/24/2013
Aliases for variable name not defined
Neurological Exam
Physical/Neurological Examination
Assessments and Examinations
Data collected date and time
 
Free-Form Entry
       
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
Neurological 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
Neurological Exam
Physical/Neurological Examination
Assessments and Examinations
Global change since prior examination result
 
Single Pre-Defined Value Selected
       
C14431
Mental status examined type
MentlStatExamTyp
Type of mental status assessment performed
Mental assessments
Attention;Working Memory;Recent Memory;Remote Memory;Spontaneous speech;Comprehension;Naming;Repetition;Reading;Affect;
Attention;Working Memory;Recent Memory;Remote Memory;Spontaneous speech;Language Comprehension;Language Naming;Language Repetition;Language Reading;Affect;
Alphanumeric
Answer where applicable Recommended tests are: Attention-forward digit span (6 is normal for adults), Working Memory-reverse digit span (4 is normal for adults), Recent (Episodic) Memory-immediate recall of 3 objects and then recall again after 3-5 minute delay, Remote (Semantic) Memory-either recall of verifiable personal information from the patient's past (i.e. previous addresses or schools) or well-known current events (i.e. naming the Presidents backwards)
No references available
Adult;Pediatric
Supplemental
1.0
10/5/2012
Aliases for variable name not defined
Neurological Exam
Physical/Neurological Examination
Assessments and Examinations
Mental status examined type
 
Multiple Pre-Defined Values Selected
       
C14432
Mental status exam abnormality indicator
MentlStatExamAbnrmlyInd
Whether the mental assessment showed abnormal results
Abnormality present?
Yes;No;Unknown;
Yes;No;Unknown;
Alphanumeric
Choose only one
No references available
Adult;Pediatric
Supplemental
1.0
10/5/2012
Aliases for variable name not defined
Neurological Exam
Physical/Neurological Examination
Assessments and Examinations
Mental status exam abnormality indicator
 
Single Pre-Defined Value Selected
       
C14433
Cranial nerves global assessment result
CranlNerveGlobAssmtReslt
The condition of Cranial Nerves
Cranial nerves - global assessment
Normal;Abnormal;Cannot Assess;Other, specify;
Normal;Abnormal;Cannot Assess;Other, specify;
Alphanumeric
Choose only one
No references available
Adult;Pediatric
Supplemental
1.0
10/5/2012
Aliases for variable name not defined
Neurological Exam
Physical/Neurological Examination
Assessments and Examinations
Cranial nerves global assessment result
 
Single Pre-Defined Value Selected
       
C18932
Cranial nerves global assessment other text
CranlNerveGlobAssmtOTH
The free-text field related to 'Cranial nerves global assessment result' specifying other text. The condition of Cranial Nerves
Other, specify
  
Alphanumeric
Choose only one
No references available
Adult;Pediatric
Supplemental
1.0
10/5/2012
Aliases for variable name not defined
Neurological Exam
Physical/Neurological Examination
Assessments and Examinations
 
4000
Free-Form Entry
       
C14434
Cranial nerve abnormal identifier type
CranlNerveAbnrmlIdTyp
The identified cranial nerve that assessed as abnormal.
Cranial Nerve Number
CN II;CN III;CN IV;CN V;CN VI;CN VII;CN VIII;CN IX;CN X;CN XI;CN XII;
Cranial nerve II;Cranial nerve III;Cranial nerve IV;Cranial nerve V;Cranial nerve VI;Cranial nerve VII;Cranial nerve VIII;Cranial nerve IX;Cranial nerve X;Cranial nerve XI;Cranial nerve XII;
Alphanumeric
Record which of the cranial nerves are abnormal and the side. Choose all that apply.
No references available
Adult;Pediatric
Supplemental
3.0
8/28/2013
Aliases for variable name not defined
Neurological Exam
Physical/Neurological Examination
Assessments and Examinations
Cranial nerve abnormal identifier
 
Multiple Pre-Defined Values Selected
       
C02411
Laterality type
LatTyp
Laterality type relative to the anatomic site of the body examined or affected
Laterality
  
Alphanumeric
Record which of the cranial nerves are abnormal and the side. Choose only one.
No references available
Adult;Pediatric
Supplemental
3.0
8/28/2013
Aliases for variable name not defined
Neurological Exam
Physical/Neurological Examination
Assessments and Examinations
Laterality type
 
Single Pre-Defined Value Selected
       
C14435
Nystagmus indicator
NystagmusInd
Involuntary movements of the eyeballs; its presence or absence is used to diagnose a variety of neurological and visual disorders
Nystagmus
Yes;No;Cannot Assess;
Yes;No;Cannot Assess;
Alphanumeric
Specify type, if yes
No references available
Adult;Pediatric
Supplemental
1.0
10/5/2012
Aliases for variable name not defined
Neurological Exam
Physical/Neurological Examination
Assessments and Examinations
Nystagmus indicator
 
Single Pre-Defined Value Selected
       
C14436
Nystagmus type
NystagmusTyp
Type of involuntary movement of the eyeballs; its presence or absence is used to diagnose a variety of neurological and visual disorders
Type of nystagmus
Physiologic;Abnormal;Other, specify;
Physiologic;Abnormal;Other, specify;
Alphanumeric
Enter type of nystagmus; physiological nystagmus is normal nystagmus (i.e. a few beats at end gaze)
No references available
Adult;Pediatric
Supplemental
1.0
10/5/2012
Aliases for variable name not defined
Neurological Exam
Physical/Neurological Examination
Assessments and Examinations
Nystagmus type
 
Single Pre-Defined Value Selected
       
C18933
Nystagmus other text
NystagmusOTH
The free-text field related to 'Nystagmus type' specifying other text. Type of involuntary movement of the eyeballs; its presence or absence is used to diagnose a variety of neurological and visual disorders
Other, specify
  
Alphanumeric
Enter type of nystagmus; physiological nystagmus is normal nystagmus (i.e. a few beats at end gaze)
No references available
Adult;Pediatric
Supplemental
1.0
10/5/2012
Aliases for variable name not defined
Neurological Exam
Physical/Neurological Examination
Assessments and Examinations
 
4000
Free-Form Entry
       
C14437
Motor exam global assessment type
MotorExamGloblAssmtTyp
Type of global assessment for the motor exam
Motor assessments
Muscle bulk;Muscle tone;Muscle strength;
Muscle bulk;Muscle tone;Muscle strength;
Alphanumeric
For each global assessment type record whether an abnormality is present and if so the type of abnormality
No references available
Adult;Pediatric
Supplemental
1.0
10/5/2012
Aliases for variable name not defined
Neurological Exam
Physical/Neurological Examination
Assessments and Examinations
Motor exam global assessment type
 
Single Pre-Defined Value Selected
       
C18504
Cranial nerves abnormality present text
CranlNerveAbnrmlyPresTxt
The free-text field to explain the abnormality of the cranial nerve identified.
Explain Abnormality
  
Alphanumeric
Indicate which of the following cranial nerves are abnormal
No references available
Adult;Pediatric
Supplemental
3.0
7/30/2013
Aliases for variable name not defined
Neurological Exam
Physical/Neurological Examination
Assessments and Examinations
 
255
Free-Form Entry
       
C14438
Motor exam global abnormality present indicator
MotorExamGloblAbnrmlyPresInd
Global assessment whether an abnormality was present following the motor exam.
Abnormality present?
Yes;No;Cannot Assess;
Yes;No;Cannot Assess;
Alphanumeric
Choose one for each global assessment type
No references available
Adult;Pediatric
Supplemental
3.0
8/28/2013
Aliases for variable name not defined
Neurological Exam
Physical/Neurological Examination
Assessments and Examinations
Motor exam global assessment abnormality indicator
 
Single Pre-Defined Value Selected
       
C14439
Motor exam global assessment abnormality type
MotorExamGloblAbnrmlyAssmtTyp
Global assessment abnormality type found during the motor exam
If abnormal, indicate type
Abnormal and symmetric;Abnormal and asymmetric;Abnormal - Increased;Abnormal - Decreased;Other, specify;
Abnormal and symmetric;Abnormal and asymmetric;Abnormal - Increased;Abnormal - Decreased;Other, specify;
Alphanumeric
If the global assessment found an abnormality, then record the abnormality type
No references available
Adult;Pediatric
Supplemental
3.0
8/28/2013
Aliases for variable name not defined
Neurological Exam
Physical/Neurological Examination
Assessments and Examinations
Motor exam global assessment abnormality type
 
Single Pre-Defined Value Selected
       
C18934
Motor exam global assessment abnormality other text
MotorExamGloblAbnrmlyAssmtOTH
The free-text field related to 'Motor exam global assessment abnormality type' specifying other text. Global assessment abnormality type found during the motor exam
Other, specify
  
Alphanumeric
If the global assessment found an abnormality, then record the abnormality type
No references available
Adult;Pediatric
Supplemental
3.0
8/28/2013
Aliases for variable name not defined
Neurological Exam
Physical/Neurological Examination
Assessments and Examinations
 
4000
Free-Form Entry
       
C14440
Muscle bulk assessment anatomic site
MuscBulkAssmtAntmicSite
Anatomic location of the muscle bulk exam as part of the motor examination.
Muscle Bulk - global assessment
Right upper extremity;Left upper extremity;Right lower extremity;Left lower extremity;
Right upper extremity (RUE);Left upper extremity (LUE);Right lower extremity (RLE);Left lower extremity (LLE);
Alphanumeric
Evaluate all extremities
No references available
Adult;Pediatric
Supplemental
3.0
8/28/2013
Aliases for variable name not defined
Neurological Exam
Physical/Neurological Examination
Assessments and Examinations
Muscle bulk assessment anatomic site
 
Single Pre-Defined Value Selected
       
C18503
Assessment unable text
AssmtUnableTxt
The free-text field to explain why there was no assessment of nystagmus performed.
Cannot Assess, explain
  
Alphanumeric
No instructions available
No references available
Adult;Pediatric
Supplemental
3.0
7/30/2013
Aliases for variable name not defined
Neurological Exam
Physical/Neurological Examination
Assessments and Examinations
 
255
Free-Form Entry
       
C14441
Muscle bulk assessment abnormality indicator
MuscBulkAbnrmlyAssmtInd
Whether the muscle bulk assessment found any abnormalities
Abnormality present?
Yes;No;Cannot Assess;
Yes;No;Cannot Assess;
Alphanumeric
Choose one for each anatomic site
No references available
Adult;Pediatric
Supplemental
3.0
8/28/2013
Aliases for variable name not defined
Neurological Exam
Physical/Neurological Examination
Assessments and Examinations
Muscle bulk assessment abnormality indicator
 
Single Pre-Defined Value Selected
       
C14442
Muscle bulk assessment abnormality type
MuscBulkAbnrmlyAssmtTyp
The muscle bulk abnormality type
If abnormal, indicate type:
Abnormal - Decreased;Abnormal - Increased;Other, specify;
Abnormal - Decreased;Abnormal - Increased;Other, specify;
Alphanumeric
Choose one
No references available
Adult;Pediatric
Supplemental
3.0
8/28/2013
Aliases for variable name not defined
Neurological Exam
Physical/Neurological Examination
Assessments and Examinations
Muscle bulk assessment abnormality type
 
Single Pre-Defined Value Selected
       
C18935
Muscle bulk assessment abnormality other text
MuscBulkAbnrmlyAssmtOTH
The free-text field related to 'Muscle bulk assessment abnormality type' specifying other text. The muscle bulk abnormality type
Other, specify
  
Alphanumeric
Choose one
No references available
Adult;Pediatric
Supplemental
3.0
8/28/2013
Aliases for variable name not defined
Neurological Exam
Physical/Neurological Examination
Assessments and Examinations
 
4000
Free-Form Entry
       
C14443
Muscle tone assessment anatomic site
MuscToneAssmtAntmicSite
Anatomic location of the muscle tone as part of the motor examination.
Muscle Tone - global assessment
Right upper extremity;Left upper extremity;Right lower extremity;Left lower extremity;Truncal tone;
Right upper extremity (RUE);Left upper extremity (LUE);Right lower extremity (RLE);Left lower extremity (LLE);Truncal tone;
Alphanumeric
Evaluate all extremities. Truncal tone - is recommended for pediatric studies only
No references available
Adult;Pediatric
Supplemental
3.0
8/28/2013
Aliases for variable name not defined
Neurological Exam
Physical/Neurological Examination
Assessments and Examinations
Muscle tone assessment anatomic site
 
Single Pre-Defined Value Selected
       
C14444
Muscle tone assessment abnormality indicator
MuscToneAbnrmlyAssmtInd
Whether the muscle tone assessment found any abnormalities
Abnormality present?
Yes;No;Not assessed;Unknown;
Yes;No;Not assessed;Unknown;
Alphanumeric
Choose one for each anatomic site
No references available
Adult;Pediatric
Supplemental
3.0
8/28/2013
Aliases for variable name not defined
Neurological Exam
Physical/Neurological Examination
Assessments and Examinations
Muscle tone assessment abnormality indicator
 
Single Pre-Defined Value Selected
       
C14445
Muscle tone assessment abnormality type
MuscToneAbnrmlyAssmtTyp
The muscle tone abnormality type
If abnormal, indicate type
Abnormal - Decreased;Abnormal - Increased;Other, specify;
Abnormal - Decreased;Abnormal - Increased;Other, specify;
Alphanumeric
Choose one
No references available
Adult;Pediatric
Supplemental
3.0
8/28/2013
Aliases for variable name not defined
Neurological Exam
Physical/Neurological Examination
Assessments and Examinations
Muscle tone assessment abnormality type
 
Single Pre-Defined Value Selected
       
C18936
Muscle tone assessment abnormality other text
MuscToneAbnrmlyAssmtOTH
The free-text field related to 'Muscle tone assessment abnormality type' specifying other text. The muscle tone abnormality type
Other, specify
  
Alphanumeric
No instructions available
No references available
Adult;Pediatric
Supplemental
3.0
8/28/2013
Aliases for variable name not defined
Neurological Exam
Physical/Neurological Examination
Assessments and Examinations
 
4000
Free-Form Entry
       
05-26-2017
Page 1 of 3