CDE Detailed Report
Disease: content
Subdomain Name: Physical/Neurological Examination
CRF: welcome
Displaying 1 - 23 of 23
Subdomain Name: Physical/Neurological Examination
CRF: welcome
Displaying 1 - 23 of 23
| CDE ID | CDE Name | Variable Name | Definition | Short Description | 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 / Guidance) | Subdomain Name | Domain Name | Size | Input Restrictions | Min Value | Max Value | Measurement Type | External Id Loinc | External Id Snomed | External Id caDSR | External Id CDISC |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| C11040 | Reflex examination result | ReflexExamReslt | Result of the examination of the reflexes of the specific muscle group | Result of the examination of the reflexes of the specific muscle group | Reflexes | Absent;Diminished;Normal;Brisk | Absent;Diminished;Normal;Brisk | Alphanumeric |
Answer for the specific muscle in both the right and left arms. Choose one. |
No references available | Adult | Supplemental | 3.00 | 2013-07-22 16:57:17.79 | Neuromuscular Examination | Physical/Neurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C11061 | Gait assessment result | GaitAssmtReslt | Result of the gait assessment | Result of the gait assessment | Gait Assessment | Normal;Abnormal;Not assessed | Normal;Abnormal;Not assessed | Alphanumeric |
Record the gait assessment result for each type of gait. Choose one. |
No references available | Adult;Pediatric | Supplemental | 3.00 | 2013-07-22 16:57:17.79 | Neuromuscular Examination | Physical/Neurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C02411 | Laterality type | LatTyp | Laterality type relative to the anatomic site of the body examined or affected | Laterality type relative to the anatomic site of the body examined or affected | Bilateral;Left;Right;Unknown;Midline | Bilateral;Left;Right;Unknown;Midline | Alphanumeric |
Record the neuromuscular examination results for both the right and left arms. |
Kendall. Muscles: Testing and Function with Posture and Pain, 5th ed. Florence JM, Pandya S, King WM et al. Intrarater reliability of manual muscle test (Medical Research Council Scale) grades in Duchenne's muscular dystrophy. Phys Ther 1992;72:115-126. | Adult;Pediatric | Supplemental | 3.00 | 2013-08-28 16:08:00.453 | Neuromuscular Examination | Physical/Neurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C11042 | Muscle fasciculations indicator | MuscleFasciculationsInd | Indicator whether there are fasciculations in the specific muscle or muscle group examined | Indicator whether there are fasciculations in the specific muscle or muscle group examined | Fasciculations | Yes;No;Not assessed | Yes;No;Not assessed | Alphanumeric |
Choose one for each muscle or muscle group |
No references available | Adult | Supplemental | 3.00 | 2013-07-22 16:57:17.79 | Neuromuscular Examination | Physical/Neurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C17831 | Neuromuscular exam additional comments text | NeuromusExamAddCommentsTxt | Text field to add any comments regarding the examined body segment | Text field to add any comments regarding the examined body segment | Additional Comments: | Alphanumeric | No references available | Adult | Supplemental | 3.00 | 2013-07-22 16:57:17.79 | Neuromuscular Examination | Physical/Neurological Examination | Assessments and Examinations | 255 |
Free-Form Entry |
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| C11019 | Neuromuscular exam segment type | NeuromuscularExamSegmentTyp | Type of neuromuscular segment examined | Type of neuromuscular segment examined | Cranial;Cervical;Thoracic;Lumbosacral | Cranial;Cervical;Thoracic;Lumbosacral | Alphanumeric | No references available | Adult | Supplemental | 3.00 | 2013-07-22 16:57:17.79 | Neuromuscular Examination | Physical/Neurological Examination | Assessments and Examinations |
Multiple Pre-Defined Values Selected |
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| C11043 | Muscle tone result | MuscleToneReslt | Result of the muscle tone assessment | Result of the muscle tone assessment | Muscle Tone | Normal;Flaccid;Spastic | Normal;Flaccid;Spastic | Alphanumeric |
Answer for both sides of the arms and legs. Choose one for each. |
No references available | Adult | Supplemental | 3.00 | 2013-07-22 16:57:17.79 | Neuromuscular Examination | Physical/Neurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C11026 | Neuromuscular Exam Muscle weakness indicator | NeuromuExmCranlMuscleWeaknInd | Indicator whether there is muscle weakness in the muscle or muscle group examined | Whether there is muscle weakness in the muscle or muscle group examined | Weakness | Yes;No;Not assessed;Unknown | Yes;No;Not assessed;Unknown | Alphanumeric |
Answer for each muscle group. Choose one. |
No references available | Adult;Pediatric | Supplemental | 3.00 | 2013-08-28 16:08:00.453 | Neuromuscular Examination | Physical/Neurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C11044 | Reflex normal indicator | ReflexNormalInd | Indicator whether the reflexes are normal in the anatomic site examined | Indicator whether the reflexes are normal in the anatomic site examined | Normal reflexes? | Yes;No;Not assessed | Yes;No;Not assessed | Alphanumeric |
Cervical Segment Normal Reflexes - If No is answered, complete "Reflex type" and "Reflex examination result." For all other answers skip to "Muscle strength result." Lumbosacral Segment Normal Reflexes - If No is answered complete "Reflex type" and "Reflex examination result." For all other answers, skip to "Muscle strength result." |
No references available | Adult | Supplemental | 3.00 | 2013-07-22 16:57:17.79 | Neuromuscular Examination | Physical/Neurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C11027 | Neuromuscular exam cranial tongue movement result | NeuromuExmCranlTongMvmtReslt | Result of tongue movement examination | Result of tongue movement examination | Tongue movements | Normal;Slow;No movement;Not assessed | Normal;Slow;No movement;Not assessed | Alphanumeric |
Choose one |
No references available | Adult | Supplemental | 3.00 | 2013-07-22 16:57:17.79 | Neuromuscular Examination | Physical/Neurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C11045 | Fasciculations thoracic paraspinal status | FascicThorParaspinStatus | Status, as presence or absence, of thoracic paraspinal fasciculations | Status, as presence or absence, of thoracic paraspinal fasciculations | Thoracic paraspinal fasciculations | Absent;Present;Not assessed | Absent;Present;Not assessed | Alphanumeric |
Choose one |
No references available | Adult | Supplemental | 3.00 | 2013-07-22 16:57:17.79 | Neuromuscular Examination | Physical/Neurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C11028 | Neuromuscular exam cranial dysarthria result | NeuromuExmCranlDysarthrReslt | Result of speech assessment for dysarthria | Result of speech assessment for dysarthria | Dysarthria | None;Dysarthria;Anarthria;Not assessed | None;Dysarthria;Anarthria;Not assessed | Alphanumeric |
Choose one |
No references available | Adult | Supplemental | 3.00 | 2013-07-22 16:57:17.79 | Neuromuscular Examination | Physical/Neurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C11046 | Fasciculations abdominal wall status | FascicAbdWallStatus | Status, as presence or absence, of abdominal wall fasciculations | Status, as presence or absence, of abdominal wall fasciculations | Abdominal wall fasciculations | Absent;Present;Not assessed | Absent;Present;Not assessed | Alphanumeric |
Choose one |
No references available | Adult | Supplemental | 3.00 | 2013-07-22 16:57:17.79 | Neuromuscular Examination | Physical/Neurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C11029 | Neuromuscular exam cranial jaw jerk result | NeuromuExmCranlJawJerkReslt | Result of jaw jerk evaluation | Result of jaw jerk evaluation | Jaw Jerk | Absent;Present;Brisk;Clonus;Not assessed | Absent;Present;Brisk;Clonus;Not assessed | Alphanumeric |
Choose one |
No references available | Adult | Supplemental | 3.00 | 2013-07-22 16:57:17.79 | Neuromuscular Examination | Physical/Neurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C11047 | Reflex superficial abdominal status | ReflexSuperficlAbdominalStatus | Status, as presence or absence, of superficial abdominal reflexes | Status, as presence or absence, of superficial abdominal reflexes | Superficial abdominal reflexes | Absent;Present;Not assessed | Absent;Present;Not assessed | Alphanumeric |
Choose one |
No references available | Adult | Supplemental | 3.00 | 2013-07-22 16:57:17.79 | Neuromuscular Examination | Physical/Neurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C11031 | Neuromuscular exam cervical muscle strength measurement | NeuromExmCranlMuscStrgthMeasr | Measurement of strength of the specific muscle or muscle group examined | Measurement of strength of the specific muscle or muscle group examined | Strength | Numeric Values |
Cervical Segment Neck Strength - Record neck strength using values between 0-5 |
No references available | Adult | Supplemental | 3.00 | 2013-07-22 16:57:17.79 | Neuromuscular Examination | Physical/Neurological Examination | Assessments and Examinations |
Free-Form Entry |
0 | 5 | ||||||||
| C11051 | Plantar reflex result | PlantarReflexReslt | Result of the examination of the plantar reflex | Result of the examination of the plantar reflex | Plantar | Normal;Extensor;Indeterminate | Normal;Extensor;Indeterminate | Alphanumeric |
Answer for both right and left legs. Choose one. |
No references available | Adult | Supplemental | 3.00 | 2013-07-22 16:57:17.79 | Neuromuscular Examination | Physical/Neurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C11032 | Neuromuscular exam muscle type | NeuromuscularExamMuscleTyp | Type of muscle or muscle group examined | Type of muscle or muscle group examined | Muscle Group | Upper face;Lower face;Tongue;Neck flexion;Neck extension;Shoulder abduction;Elbow flexors;Elbow extensors;Wrist flexors;Wrist extensors;Finger flexors;Finger extensors;First Dorsal Interosseous;Abductor Digiti Minimi;Abductor pollicis brevis;Hip flexion;Hip extension;Hip abduction;Hip adduction;Knee flexion;Knee extension;Ankle dorsiflexion;Ankle plantar flexion;Ankle inversion;Ankle eversion;Toe extensors;Toe flexors | Upper face;Lower face;Tongue;Neck flexion;Neck extension;Shoulder abduction;Elbow flexors;Elbow extensors;Wrist flexors;Wrist extensors;Finger flexors;Finger extensors;First Dorsal Interosseous (FDI);Abductor Digiti Minimi (ADM);Abductor pollicis brevis (APB);Hip flexion;Hip extension;Hip abduction;Hip adduction;Knee flexion;Knee extension;Ankle dorsiflexion;Ankle plantar flexion;Ankle inversion;Ankle eversion;Toe extensors;Toe flexors | Alphanumeric |
Document the results of the examination of each muscle group or specific muscle |
No references available | Adult | Supplemental | 3.00 | 2013-07-22 16:57:17.79 | Neuromuscular Examination | Physical/Neurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C11054 | Reflex type | ReflexTyp | Type of reflexes examined | Type of reflexes examined | Reflexes | Elbow flexors;Brachioradialis;Elbow extensors;Patellar;Ankle | Elbow flexors;Brachioradialis;Elbow extensors;Patellar;Ankle | Alphanumeric |
Record the results of the reflex assessments for both right and left legs. |
No references available | Adult | Supplemental | 3.00 | 2013-07-22 16:57:17.79 | Neuromuscular Examination | Physical/Neurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C11036 | Hoffman reflex result | HoffmanReflexReslt | Result of the examination of the Hoffman reflex | Result of the examination of the Hoffman reflex | Hoffman | Absent;Present;Not assessed | Absent;Present;Not assessed | Alphanumeric |
Answer for both right and left arms. Choose one. |
No references available | Adult | Supplemental | 3.00 | 2013-07-22 16:57:17.79 | Neuromuscular Examination | Physical/Neurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C11059 | Muscle strength result | MuscleStrengthReslt | Result of the global muscle strength assessment of an arm or leg | Result of the global muscle strength assessment of an arm or leg | Strength | Abnormal;Normal;Not assessed | Abnormal;Normal;Not assessed | Alphanumeric |
Cervical Segment Strength - If Normal is checked for right or left arms, leave "Muscle strength measurement" blank. If Abnormal is checked for right or left arms, complete "Muscle strength measurement." Lumbosacral Segment Strength - If Normal is checked for right or left legs, leave "Muscle strength measurement" blank. If Abnormal is checked for right or left legs, complete "Muscle strength measurement." |
No references available | Adult | Supplemental | 3.00 | 2013-07-22 16:57:17.79 | Neuromuscular Examination | Physical/Neurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C11039 | Muscle atrophy indicator | MuscleAtrophyInd | Indicator whether the examination reveals atrophy in the specific muscle or muscle group | Indicator whether the examination reveals atrophy in the specific muscle or muscle group | Atrophy | Yes;No;Not assessed | Yes;No;Not assessed | Alphanumeric |
Cranial segment atrophy-To be answered only for tongue |
No references available | Adult | Supplemental | 3.00 | 2013-07-22 16:57:17.79 | Neuromuscular Examination | Physical/Neurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C11060 | Gait type | GaitTyp | Type of gait examined | Type of gait examined | Gait Type | Gait;Gait on heels;Gait on toes | Gait;Gait on heels;Gait on toes | Alphanumeric |
For each gait type record the results of the gait assessment. |
No references available | Adult | Supplemental | 3.00 | 2013-07-22 16:57:17.79 | Neuromuscular Examination | Physical/Neurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
