CDE Detailed Report
Subdomain Name: Physical/Neurological Examination
CRF: Physical Exam
Displaying 1 - 10 of 10
| 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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 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 | 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 system | Body System | Allergic/Immunologic;Cardiovascular;Constitutional symptoms (e.g., fever, weight loss);Ears, Nose, Mouth, Throat;Endocrine;Eyes;Gastrointestinal;Genitourinary;Hematologic/Lymphatic;Integumentary (skin and/or breast);Musculoskeletal;Neurological;Psychiatric;Respiratory | Allergic/Immunologic;Cardiovascular;Constitutional symptoms (e.g., fever, weight loss);Ears, Nose, Mouth, Throat;Endocrine;Eyes;Gastrointestinal;Genitourinary;Hematologic/Lymphatic;Integumentary (skin and/or breast);Musculoskeletal;Neurological;Psychiatric;Respiratory | 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 | 3.00 | 2013-07-25 08:54:08.2 | Physical Exam | Physical/Neurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
2002895 | |||||||
| C01010 | Physical exam date and time | PhysExamDateTime | Date (and time if applicable and known) physical exam was performed | 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 | 3.00 | 2013-08-28 16:08:00.453 | Physical Exam | Physical/Neurological Examination | Assessments and Examinations |
Free-Form Entry |
2004170 | |||||||||
| C01012 | Physical exam body system result type | PhysExamBodySysResltTyp | Assessment result of each body system examined | 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 | 3.00 | 2013-07-25 08:54:08.2 | Physical Exam | Physical/Neurological Examination | Assessments and Examinations |
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 | 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 | 3.00 | 2013-07-25 08:54:08.2 | Physical Exam | Physical/Neurological Examination | Assessments and Examinations | 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) | 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 | 3.00 | 2013-08-28 16:08:00.453 | Physical Exam | Physical/Neurological Examination | Assessments and Examinations | 255 |
Free-Form Entry |
||||||||||
| C14429 | Global change since prior examination result | GlobalChangeSincPriorExamReslt | Global assessment of the difference between the prior and follow-up examinations | 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 | 1.00 | 2012-10-05 00:00:00.0 | Physical Exam | Physical/Neurological Examination | Assessments and Examinations |
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 | 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 hai | 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 | 1.00 | 2012-10-05 00:00:00.0 | Physical Exam | Physical/Neurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
||||||||
| C18666 | Body system category other text | BodySysCatOTH | 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 | 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 | 1.10 | 2023-11-07 08:40:35.0 | Physical Exam | Physical/Neurological Examination | Assessments and Examinations | 4000 |
Free-Form Entry |
2002895 | ||||||||
| 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 | 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 | 1.00 | 2012-10-05 00:00:00.0 | Physical Exam | Physical/Neurological Examination | Assessments and Examinations | 4000 |
Free-Form Entry |
|||||||||
| C00023 | Hand preference type | HandPrefTyp | Hand which the participant/subject uses predominantly, not necessarily the hand he/she writes with exclusively | Hand which the participant/subject uses predominantly, not necessarily the hand he/she writes with exclusivel | 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 | 3.00 | 2013-07-25 08:54:08.2 | Physical Exam | Physical/Neurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
2180147 |
