CDE Detailed Report
Disease: content
Subdomain Name: Physical%2FNeurological Examination
CRF: welcome
Displaying 1 - 50 of 75
Subdomain Name: Physical%2FNeurological Examination
CRF: welcome
Displaying 1 - 50 of 75
| 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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| C14459 | Reflex exam global assessment result | RflxExmGlobAssmtReslt | The global assessment of the ability and condition of reflexes | The global assessment of the ability and condition of reflexes | Reflexes - global assessment | Abnormal;Normal;Cannot Assess;Other, specify | Abnormal;Normal;Cannot Assess;Other, specify | Alphanumeric |
Choose one. If abnormal answer questions A and B. |
No references available | Adult;Pediatric | Supplemental | 3.00 | 2013-08-28 16:08:00.453 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C18939 | Muscle weakness neurological anatomic other text | MuscWeakNeuroAntmicOTH | The free-text field related to 'Muscle weakness neurological anatomic site' specifying other text. Anatomic location of neurological muscle weakness | The free-text field related to 'Muscle weakness neurological anatomic site' specifying other text. Anatomic location of neurological muscle weaknes | Other, specify | Alphanumeric |
Choose all that apply |
No references available | Adult;Pediatric | Supplemental | 3.00 | 2013-08-28 16:08:00.453 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations | 4000 |
Free-Form Entry |
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| C18504 | Cranial nerves abnormality present text | CranlNerveAbnrmlyPresTxt | The free-text field to explain the abnormality of the cranial nerve identified | The free-text field to explain the abnormality of the cranial nerve identifie | Explain Abnormality | Alphanumeric |
Indicate which of the following cranial nerves are abnormal |
No references available | Adult;Pediatric | Supplemental | 3.00 | 2013-07-30 14:29:49.047 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations | 255 |
Free-Form Entry |
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| C21106 | Gait assessment result other text | GaitAssmtResltOTH | The free-text field to specify the other result of the gait assessment | The free-text field to specify the other result of the gait assessment | Other, specify | Alphanumeric | Adult;Pediatric | Supplemental | 1.00 | 2015-06-02 16:57:18.0 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations | 4000 |
Free-Form Entry |
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| C14435 | Nystagmus indicator | NystagmusInd | Involuntary movements of the eyeballs; its presence or absence is used to diagnose a variety of neurological and visual disorders | 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 | 1.00 | 2012-10-05 00:00:00.0 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C18516 | Sensory system abnormality stocking glove present text | SensySysAbnrmlyStckGlvPresTxt | The free-text field to describe the stocking sensory abnormality, a generalised and gradual loss of peripheral nerve function results in a receding glove and stocking pattern | The free-text field to describe the stocking sensory abnormality, a generalised and gradual loss of peripheral nerve function results in a receding glove and stocking patter | Stocking/Glove, explain | Alphanumeric | No references available | Adult;Pediatric | Supplemental | 3.00 | 2013-07-30 14:29:49.047 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations | 255 |
Free-Form Entry |
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| C14446 | Muscle strength assessment anatomic site | MuscStrAssmtAntmicSite | Anatomic location of the muscle strength as part of the motor examination | Anatomic location of the muscle strength as part of the motor examinatio | Muscle strength - 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 | 3.00 | 2013-08-28 16:08:00.453 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C14460 | Reflex assessment anatomic site | RflxAntmicSite | The location or category for reflex assessment of limbs | The location or category for reflex assessment of limbs | Assessment of Limbs | Right Arm;Left Arm;Right Leg;Left Leg | Right Arm;Left Arm;Right Leg;Left Leg | Alphanumeric |
If reflexes abnormal record the results for each limb |
No references available | Adult;Pediatric | Supplemental | 1.00 | 2012-10-05 00:00:00.0 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C18940 | Tremor assessment other text | TremAssessOTH | The free-text field related to 'Tremor assessment status' specifying other text. The status indicating whether tremors could be detected during the exam | The free-text field related to 'Tremor assessment status' specifying other text. The status indicating whether tremors could be detected during the exam | Other, specify | Alphanumeric |
Choose only one |
No references available | Adult;Pediatric | Supplemental | 3.00 | 2013-08-28 16:08:00.453 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations | 4000 |
Free-Form Entry |
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| C18506 | Muscle weakness myopathic weakness present text | MuscWeakMyopathWeakPresTxt | The free-text field to describethe myopathic weakness present resultling in muscle weakness | The free-text field to describethe myopathic weakness present resultling in muscle weaknes | Myopathic Weakness, describe | Alphanumeric | No references available | Adult;Pediatric | Supplemental | 3.00 | 2013-07-30 14:29:49.047 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations | 255 |
Free-Form Entry |
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| C21107 | Gait abnormality assessment other text | GaitAbnrmlyAssmtOTH | The free-text field for other type of abnormal gait | The free-text field for other type of abnormal gait | Other Gait Abnormalities, specify | Alphanumeric |
Choose best response |
No references available | Adult;Pediatric | Supplemental | 1.00 | 2015-06-02 16:08:00.0 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations | 4000 |
Free-Form Entry |
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| 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 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 | 1.00 | 2012-10-05 00:00:00.0 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C18517 | Sensory system abnormality stocking present text | SensySysAbnrmlyStockPresTxt | The free-text field to describe the stocking sensory abnormality, a generalised and gradual loss of peripheral nerve function results in a receding stocking pattern | The free-text field to describe the stocking sensory abnormality, a generalised and gradual loss of peripheral nerve function results in a receding stocking patter | Stocking, explain | Alphanumeric | No references available | Adult;Pediatric | Supplemental | 3.00 | 2013-07-30 14:29:49.047 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations | 255 |
Free-Form Entry |
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| C14447 | Muscle strength abnormality assessment indicator | MuscStrAbnrmlyAssmtInd | Whether the muscle strength assessment found any abnormalities | Whether the muscle strength 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 | 3.00 | 2013-08-28 16:08:00.453 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C14461 | Reflex assessment limb result | RflxQual | The results from reflex limb assessment | The results from reflex limb assessment | Assessment of Limbs | Increased with clonus;Increased without clonus;Hypoactive;Absent | Increased with clonus;Increased without clonus;Hypoactive;Absent | Alphanumeric |
Choose one for each limb |
No references available | Adult;Pediatric | Supplemental | 1.00 | 2012-10-05 00:00:00.0 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C18941 | Tremor other text | TremOTH | The free-text field related to 'Tremor type' specifying other text. The type of tremor detected during the exam | The free-text field related to 'Tremor type' specifying other text. The type of tremor detected during the exam | Other, specify | Alphanumeric |
Choose only one |
No references available | Adult;Pediatric | Supplemental | 3.00 | 2013-08-28 16:08:00.453 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations | 4000 |
Free-Form Entry |
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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 | Laterality | Left;Right;Bilateral | Left;Right;Bilateral | Alphanumeric |
Record which of the cranial nerves are abnormal and the side. Choose only one. |
No references available | Adult;Pediatric | Supplemental | 3.00 | 2013-08-28 16:08:00.453 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C18507 | Muscle weakness neuropathic weakness present text | MuscWeakNeuropathWeakPresTxt | The free-text field to describe the neuropathic weakness present resultling in muscle weakness | The free-text field to describe the neuropathic weakness present resultling in muscle weaknes | Neuropathic Weakness, describe | Alphanumeric | No references available | Adult;Pediatric | Supplemental | 3.00 | 2013-07-30 14:29:49.047 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations | 255 |
Free-Form Entry |
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| C14437 | Motor exam global assessment type | MotorExamGloblAssmtTyp | Type of global assessment for the motor exam | 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 | 1.00 | 2012-10-05 00:00:00.0 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| 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 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations | 4000 |
Free-Form Entry |
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| C14448 | Muscle strength abnormality assessment type | MuscStrAbnrmlyAssmtTyp | The muscle strength abnormality type | The muscle strength 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 | 3.00 | 2013-08-28 16:08:00.453 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C14462 | Reflex plantar right response result | RflxPlntrRtRespnsReslt | The results from reflex plantar response on the right side | The results from reflex plantar response on the right side | Plantar Response Right | Flexor;Extensor;Equivocal;Cannot Assess;Other, specify | Flexor;Extensor;Equivocal;Cannot Assess;Other, specify | Alphanumeric |
Choose all that apply. If other, explain. |
No references available | Adult;Pediatric | Supplemental | 1.00 | 2012-10-05 00:00:00.0 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations |
Multiple Pre-Defined Values Selected |
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| C18942 | Cerebellar or coordination assessment abnormality present other text | CerbllCoordAssmtAbnrmlyPrsOTH | The free-text field related to 'Cerebellar or coordination assessment abnormality present status' specifying other text. Whether the cerebellar/coordination assessment found abnormalities | The free-text field related to 'Cerebellar or coordination assessment abnormality present status' specifying other text. Whether the cerebellar/coordination assessment found abnormalities | Other, specify | Alphanumeric |
Choose one for each assessment type. Cannot Assess means the examiner does not know if the patient is normal or not; i.e. an uncooperative patient. |
No references available | Adult;Pediatric | Supplemental | 3.00 | 2013-08-28 16:08:00.453 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations | 4000 |
Free-Form Entry |
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| 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 performe | 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 | 3.00 | 2013-07-24 21:00:23.88 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations |
Free-Form Entry |
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| C18508 | Muscle weakness peripheral nerve lesion present text | MuscWeakPerphrlNervLesnPresTxt | The free-text field to describe the peripheral nerve lesion present resultling in muscle weakness | The free-text field to describe the peripheral nerve lesion present resultling in muscle weaknes | Peripheral Nerve Lesion(s), describe | Alphanumeric | No references available | Adult;Pediatric | Supplemental | 3.00 | 2013-07-30 14:29:49.047 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations | 255 |
Free-Form Entry |
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| C14438 | Motor exam global abnormality present indicator | MotorExamGloblAbnrmlyPresInd | Global assessment whether an abnormality was present following the motor exam | Global assessment whether an abnormality was present following the motor exa | Abnormality present? | Yes;No;Cannot Assess | Yes;No;Cannot Assess | Alphanumeric |
Choose one for each global assessment type |
No references available | Adult;Pediatric | Supplemental | 3.00 | 2013-08-28 16:08:00.453 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C14450 | Muscle weakness brain pattern type | MuscWeakBrainPattrnTyp | Patterns describing weakness in location of brain | Patterns describing weakness in location of brain | Does the weakness suggest one of the following patterns? | Right Hemiparesis;Left Hemiparesis;Diplegia / Paraparesis;Quadriplegia / Quadraparesis;Peripheral Nerve Lesion(s), Neuropathic Weakness;Neuropathic weakness;Myopathic Weakness;Other, specify | Right Hemiparesis;Left Hemiparesis;Diplegia / Paraparesis;Quadriplegia / Quadraparesis;Peripheral Nerve Lesion(s), Neuropathic Weakness;Neuropathic weakness;Myopathic Weakness;Other, specify | Alphanumeric |
Choose all that apply. Describe if applicable. |
No references available | Adult;Pediatric | Supplemental | 3.00 | 2013-08-28 16:08:00.453 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations |
Multiple Pre-Defined Values Selected |
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| 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 | 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 | 1.00 | 2012-10-05 00:00:00.0 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations | 4000 |
Free-Form Entry |
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| C14463 | Reflex plantar left response result | RflxPlntrLftRespnsReslt | The results from reflex plantar response on the left side | The results from reflex plantar response on the left side | Plantar Response Left | Flexor;Extensor;Equivocal;Cannot Assess;Other, specify | Flexor;Extensor;Equivocal;Cannot Assess;Other, specify | Alphanumeric |
Choose all that apply. If other, explain. |
No references available | Adult;Pediatric | Supplemental | 1.00 | 2012-10-05 00:00:00.0 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations |
Multiple Pre-Defined Values Selected |
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| C18943 | Cerebellar or coordination assessment abnormality explain other text | CerbllCoordAssmtAbnrmlyExplOTH | The free-text field related to 'Cerebellar or coordination assessment abnormality present type' specifying other text for explaining the type of abnormality found by the cerebellar/coordination assessment | The free-text field related to 'Cerebellar or coordination assessment abnormality present type' specifying other text. Type of abnormality found by the cerebellar/coordination assessment | Other, specify | Alphanumeric |
Choose all that apply. If abnormal, explain. "Cannot Assess due to Weakness" meant that the test of coordination is abnormal, but abnormal because of weakness (presumably not cerebellar in origin) rather than cerebellar dysfunction. |
No references available | Adult;Pediatric | Supplemental | 3.00 | 2013-08-28 16:08:00.453 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations | 4000 |
Free-Form Entry |
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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 | Yes;No | Alphanumeric |
Choose one. If yes, answer questions A and B. |
No references available | Adult;Pediatric | Supplemental | 3.00 | 2013-08-28 16:08:00.453 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C18509 | Reflex left arm assessment status | RflxLftArmAssmtStatus | The status of the relfex assessment for the left arm | The status of the relfex assessment for the left ar | Left Arm | Increased with clonus;Increased without clonus;Hypoactive;Absent | Increased with clonus;Increased without clonus;Hypoactive;Absent | Alphanumeric | No references available | Adult;Pediatric | Supplemental | 3.00 | 2013-07-30 14:29:49.047 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C14439 | Motor exam global assessment abnormality type | MotorExamGloblAbnrmlyAssmtTyp | Global assessment abnormality type found during the motor exam | 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 | 3.00 | 2013-08-28 16:08:00.453 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C14451 | Muscle weakness neurological anatomic site | MuscWeakNeuroAntmicSite | Anatomic location of neurological muscle weakness | Neurological location of the muscle weakness | Specify the neurological location of the weakness | Brain;Spinal Cord;Peripheral Nervous System;Other, specify | Brain;Spinal Cord;Peripheral Nervous System;Other, specify | Alphanumeric |
Choose all that apply |
No references available | Adult;Pediatric | Supplemental | 3.00 | 2013-08-28 16:08:00.453 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations |
Multiple Pre-Defined Values Selected |
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| 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 | 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 | 1.00 | 2012-10-05 00:00:00.0 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations | 4000 |
Free-Form Entry |
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| C14465 | Gait abnormality assessment type | GaitAbnrmlyAssmtTyp | Type of abnormal gait | Type of abnormal gait | Type of Abnormal Gait | Ataxic Gait;Hemiparetic Gait - Left side;Hemiparetic Gait - Right side;Diplegic Gait;Parkinsonian Gait;Other gait abnormalities | Ataxic Gait;Hemiparetic Gait - Left side;Hemiparetic Gait - Right side;Diplegic Gait;Parkinsonian Gait;Other gait abnormalities | Alphanumeric |
Choose best response |
No references available | Adult;Pediatric | Supplemental | 3.00 | 2013-08-28 16:08:00.453 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C18944 | Reflex exam global assessment other text | RflxExmGlobAssmtOTH | The free-text field related to 'Reflex exam global assessment result' specifying other text. The global assessment of the ability and condition of reflexes | The free-text field related to 'Reflex exam global assessment result' specifying other text. The global assessment of the ability and condition of reflexes | Other, specify | Alphanumeric |
Choose one. If abnormal answer questions A and B. |
No references available | Adult;Pediatric | Supplemental | 3.00 | 2013-08-28 16:08:00.453 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations | 4000 |
Free-Form Entry |
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| C11061 | Gait assessment result | GaitAssmtReslt | Result of the gait assessment | Result of the gait assessment | Gait - global assessment | Normal;Abnormal;Cannot Assess;Other, specify | Normal;Abnormal;Cannot Assess;Other, specify | Alphanumeric |
Choose one. Indicate type if abnormal |
No references available | Adult;Pediatric | Supplemental | 3.00 | 2013-07-22 16:57:17.79 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C18510 | Reflex left leg assessment status | RflxLftLegAssmtStatus | The status of the relfex assessment for the left leg | The status of the relfex assessment for the left le | Left Leg | Increased with clonus;Increased without clonus;Hypoactive;Absent | Increased with clonus;Increased without clonus;Hypoactive;Absent | Alphanumeric | No references available | Adult;Pediatric | Supplemental | 3.00 | 2013-07-30 14:29:49.047 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C14440 | Muscle bulk assessment anatomic site | MuscBulkAssmtAntmicSite | Anatomic location of the muscle bulk exam as part of the motor examination | Anatomic location of the muscle bulk exam as part of the motor examinatio | 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 | 3.00 | 2013-08-28 16:08:00.453 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C14452 | Tremor assessment status | TremAssessStatus | The status indicating whether tremors could be detected during the exam | Whether tremors are detected during the exam | Tremor | Yes;No;Cannot Assess;Other, specify | Yes;No;Cannot Assess;Other, specify | Alphanumeric |
Choose only one |
No references available | Adult;Pediatric | Supplemental | 3.00 | 2013-08-28 16:08:00.453 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| 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 | 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 | 3.00 | 2013-08-28 16:08:00.453 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations | 4000 |
Free-Form Entry |
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| C14466 | Sensory system global assessment result | SensySytGlobAssmtReslt | The condition and ability of sensory system | The condition and ability of sensory system | Sensory System - global assessment | Abnormal;Normal;Cannot Assess;Other, specify | Abnormal;Normal;Cannot Assess;Other, specify | Alphanumeric |
Choose one. If abnormal answer questions A-D. |
No references available | Adult;Pediatric | Supplemental | 1.00 | 2012-10-05 00:00:00.0 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C18945 | Reflex plantar right response other text | RflxPlntrRtRespnsOTH | The free-text field related to 'Reflex plantar right response result' specifying other text. The results from reflex plantar response on the right side | The free-text field related to 'Reflex plantar right response result' specifying other text. The results from reflex plantar response on the right side | Other, specify | Alphanumeric |
Choose all that apply. If other, explain. |
No references available | Adult;Pediatric | Supplemental | 1.00 | 2012-10-05 00:00:00.0 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations | 4000 |
Free-Form Entry |
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| 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 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C18511 | Reflex right arm assessment status | RflxRtArmAssmtStatus | The status of the relfex assessment for the right arm | The status of the relfex assessment for the right ar | Right Arm | Increased with clonus;Increased without clonus;Hypoactive;Absent | Increased with clonus;Increased without clonus;Hypoactive;Absent | Alphanumeric | No references available | Adult;Pediatric | Supplemental | 3.00 | 2013-07-30 14:29:49.047 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C14441 | Muscle bulk assessment abnormality indicator | MuscBulkAbnrmlyAssmtInd | Whether the muscle bulk assessment found any abnormalities | 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 | 3.00 | 2013-08-28 16:08:00.453 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C14453 | Tremor type | TremTyp | The type of tremor detected during the exam | The type of tremor detected during the exam | Type of tremor | Postural;Rest;Intention;Other, specify | Postural;Rest;Intention;Other, specify | Alphanumeric |
Choose only one |
No references available | Adult;Pediatric | Supplemental | 3.00 | 2013-08-28 16:08:00.453 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| 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 | 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 | 3.00 | 2013-08-28 16:08:00.453 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations | 4000 |
Free-Form Entry |
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| C14467 | Sensory system abnormality symmetry type | SensySysAbnrmlySymmTyp | Symmetry of abnormality for sensory system results | Symmetry of abnormality for sensory system results | Symmetry of Abnormality | Symmetric;Asymmetric | Symmetric;Asymmetric | Alphanumeric |
Choose only one |
No references available | Adult;Pediatric | Supplemental | 1.00 | 2012-10-05 00:00:00.0 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
