CDE Detailed Report
Subdomain Name: Physical/Neurological Examination
CRF: welcome
Displaying 51 - 75 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 |
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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/Neurological 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/Neurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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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/Neurological 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/Neurological Examination | Assessments and Examinations | 4000 |
Free-Form Entry |
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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/Neurological 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/Neurological 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/Neurological 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/Neurological 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/Neurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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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/Neurological 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/Neurological Examination | Assessments and Examinations | 4000 |
Free-Form Entry |
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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/Neurological 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/Neurological 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/Neurological 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/Neurological 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/Neurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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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/Neurological 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/Neurological Examination | Assessments and Examinations | 4000 |
Free-Form Entry |
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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/Neurological 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/Neurological 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/Neurological 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/Neurological Examination | Assessments and Examinations | 4000 |
Free-Form Entry |
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C14431 | Mental status examined type | MentlStatExamTyp | Type of mental status assessment performed | 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 | 1.00 | 2012-10-05 00:00:00.0 | Neurological Exam | Physical/Neurological Examination | Assessments and Examinations |
Multiple Pre-Defined Values Selected |
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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/Neurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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C18946 | Reflex plantar left response other text | RflxPlntrLftRespnsOTH | The free-text field related to 'Reflex plantar left response result' specifying other text. The results from reflex plantar response on the left side | The free-text field related to 'Reflex plantar left response result' specifying other text. The results from reflex plantar response on the left 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/Neurological Examination | Assessments and Examinations | 4000 |
Free-Form Entry |