CDE Detailed Report

Disease: Stroke
Sub-Domain: Physical/Neurological Examination
CRF: Physical

Displaying 1 - 19 of 19
CDE ID CDE Name Variable Name Definition Short Description Additional Notes (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 / Guideline) Sub Domain Name Domain Name Size Input Restrictions Min Value Max Value Measurement Type External Id Loinc External Id Snomed External Id caDSR External Id CDISC
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 Side Left;Right;Bilateral Left;Right;Bilateral Alphanumeric Adult;Pediatric Supplemental 3.00 2013-08-28 16:08:00.453 Physical/Neurological Exam Physical/Neurological Examination Assessments and Examinations

Single Pre-Defined Value Selected

C21720 Vertigo assessment indicator VertigoAssmtInd Indicator as related to assessment of vertigo. Indicator as related to assessment of vertigo. Vertigo Yes;No;Unknown Yes;No;Unknown Alphanumeric

Choose one

No references available Adult;Pediatric Supplemental 1.00 2016-05-31 13:53:46.0 Physical/Neurological Exam Physical/Neurological Examination Assessments and Examinations

Single Pre-Defined Value Selected

C58816 Frontal lobe function status FrontLobeFuncStat Assess frontal lobe function using the scale from the Northern Manhattan Study (NOMAS) Assess frontal lobe function using the scale from the Northern Manhattan Study (NOMAS) Frontal lobe function Normal: No signs of social disinhibition or abulia;Primitive reflexes such as forced manual exploration of surroundings, grasp, traction response, rooting or snout as the only frontal signs;Mild impairment of frontal lobe function: Some social disinhibition or abulia;Hesitancy in speech functions with stuttering or difficulty speaking strings of consonants;Severe impairment: Gross signs of social disinhibition or abulia;Whispering or mutism;Untestable because of aphasia Normal: No signs of social disinhibition or abulia;Primitive reflexes such as forced manual exploration of surroundings, grasp, traction response, rooting or snout as the only frontal signs;Mild impairment of frontal lobe function: Some social disinhibition or abulia;Hesitancy in speech functions with stuttering or difficulty speaking strings of consonants;Severe impairment: Gross signs of social disinhibition or abulia;Whispering or mutism;Untestable because of aphasia Alphanumeric

Choose one [Derived from the Northern Manhattan Study (NOMAS)]

No references available Adult;Pediatric Exploratory 1.00 2020-05-15 09:32:05.0 Physical/Neurological Exam Physical/Neurological Examination Assessments and Examinations

Single Pre-Defined Value Selected

C58817 Parietal lobe function status ParietLobeFuncStat Assess parietal lobe function using the scale from the Northern Manhattan Study (NOMAS) Assess parietal lobe function using the scale from the Northern Manhattan Study (NOMAS) Parietal lobe function Refusal to acknowledge illness, personal body parts, offers wildly implausible explanations for failure to acknowledge illness or body parts.;Normal: No signs of impairment of auditory, visual, sensory or motor inattention, anosognosia, constructional or ideomotor dyspraxia;Loquacious or garrulous, history filled with irrelevant details. Or semantic verbal paraphasias when reading aloud long sentences or paragraphs or describing history of present illness.;Mild impairment: scattered slight signs of impairment of auditory, visual, sensory or motor inattention, anosognosia, constructional or ideomotor dyspraxia;Neglect for opposite space to visual or auditory testing as the only parietal sign;Severe impairment: signs of impairment of auditory, visual, sensory or motor inattention, anosognosia, constructional or ideomotor dyspraxia.;Untestable because of aphasia Refusal to acknowledge illness, personal body parts, offers wildly implausible explanations for failure to acknowledge illness or body parts.;Normal: No signs of impairment of auditory, visual, sensory or motor inattention, anosognosia, constructional or ideomotor dyspraxia;Loquacious or garrulous, history filled with irrelevant details. Or semantic verbal paraphasias when reading aloud long sentences or paragraphs or describing history of present illness.;Mild impairment: scattered slight signs of impairment of auditory, visual, sensory or motor inattention, anosognosia, constructional or ideomotor dyspraxia;Neglect for opposite space to visual or auditory testing as the only parietal sign;Severe impairment: signs of impairment of auditory, visual, sensory or motor inattention, anosognosia, constructional or ideomotor dyspraxia.;Untestable because of aphasia Alphanumeric

Choose one [Derived from the Northern Manhattan Study (NOMAS)]

Adult;Pediatric Exploratory 1.00 2020-05-15 09:50:19.0 Physical/Neurological Exam Physical/Neurological Examination Assessments and Examinations

Single Pre-Defined Value Selected

C58818 Dysphagia status DysphagiaStat Did the participant/subject have dysphagia (difficulty swallowing) identified at bedside assessment? The dysphagia screening should utilize a validated tool that incorporates a swallow assessment and an assessment of level of consciousness and neurological function. Did the participant/subject have dysphagia (difficulty swallowing) identified at bedside assessment? The dysphagia screening should utilize a validated tool that incorporates a swallow assessment and an assessment of level of consciousness and neurologic Dysphagia (difficulty swallowing) Partial (swallows solids but not liquids);Normal;Unknown;Severe (cannot swallow, requires NGT feeds and suctioning) Partial (swallows solids but not liquids);Normal;Unknown;Severe (cannot swallow, requires NGT feeds and suctioning) Alphanumeric

The use of the term dysphagia should be based on the results of a standardized bedside assessment rather than a reference in the chart.

Trapl M, Enderle P, Nowotny M, Teuschl Y, Matz K, Dachenhausen A, Brainin M. Dysphagia bedside screening for acute-stroke patients: the Gugging Swallowing Screen. Stroke. 2007 Nov;38(11):2948-52. Epub 2007 Sep 20. Daniels, Stephanie K., McAdam, Colleen P., Brailey, Kevin, Foundas, Anne L. Clinical Assessment of Swallowing and Prediction of Dysphagia Severity. Am J Speech Lang Pathol 1997 6: 17-24. Adult;Pediatric Supplemental 1.00 2020-05-15 11:20:02.0 Physical/Neurological Exam Physical/Neurological Examination Assessments and Examinations

Single Pre-Defined Value Selected

C58819 Dizziness indicator DizzinessInd Indicator of whether the participant/subject experienced dizziness. Indicator of whether the participant/subject experienced dizziness. Dizziness No;Yes;Unknown No;Yes;Unknown Alphanumeric

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No instructions available Adult;Pediatric Supplemental 1.00 2020-05-15 11:27:38.0 Physical/Neurological Exam Physical/Neurological Examination Assessments and Examinations

Single Pre-Defined Value Selected

C13519 Lower limb tone findings result LowerLimbToneFindgsReslt Assess tone of lower limbs on the affected side using the Orgogozo Stroke Scale Assess tone of lower limbs on the affected side using the Orgogozo Stroke Scale Lower limb tone 0;5 Overtly spastic or flaccid - Frank hypertonia or hypotonia in comparison with the opposite side. Permanent rigidity, or flexion or extension induced by painful stimuli.;Normal - Near Normal. No frank hypertonia or hypotonia in comparison with the opposite side, even if the jerk reflexes are exaggerated Numeric values

Numeric scores may not be needed if the full Orgogozo Stroke Scale is not administered.

Orgogozo JM, Capildeo R. "Development of a neurological score for clinical evaluation of infarctions in the Sylvian territory." Presse Med 1983:12(48):3039-44. Adult;Pediatric Exploratory 3.00 2013-06-21 00:00:00.0 Physical/Neurological Exam Physical/Neurological Examination Assessments and Examinations

Single Pre-Defined Value Selected

C13521 Gait walk unassisted result GaitWalkUnassistReslt Ability of the participant/subject to walk multiple steps unassisted. Ability of the participant/subject to walk multiple steps unassisted. Gait Steady but slowed or widebased;Unsteady but self corrects and low risk of falling;Dangerously unsteady;Steady and brisk Steady but slowed or widebased;Unsteady but self corrects and low risk of falling;Dangerously unsteady;Steady and brisk Alphanumeric

Identify if an assistive device is used such as cane, multipronged cane, walker, etc.

No references available Adult;Pediatric Supplemental 3.00 2013-06-21 00:00:00.0 Physical/Neurological Exam Physical/Neurological Examination Assessments and Examinations

Single Pre-Defined Value Selected

C13522 Monocular visual loss status MonocularVisLossStatus Whether the participant/subject has monocular visual loss at bedside assessment Whether the participant/subject has monocular visual loss at bedside assessment Monocular visual loss Normal monocular vision;Partial monocular visual loss or blurring;Complete monocular visual loss or blurring Normal monocular vision;Partial monocular visual loss or blurring;Complete monocular visual loss or blurring Alphanumeric

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No references available Adult;Pediatric Exploratory 3.00 2013-06-21 00:00:00.0 Physical/Neurological Exam Physical/Neurological Examination Assessments and Examinations

Single Pre-Defined Value Selected

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 exclusively. Hand preference Left hand;Right hand;Both hands;Unknown Left hand;Right hand;Both hands;Unknown Alphanumeric

The purpose of this element is to determine dominant hemisphere; therefore, for those who were originally left handed but forced to write right-handed, record left-handed.

No references available Adult;Pediatric Supplemental 3.00 2013-07-25 08:54:08.2 Physical/Neurological Exam Physical/Neurological Examination Assessments and Examinations

Single Pre-Defined Value Selected

2180147
C13524 Carotid bruit indicator CarotidBruitInd Indicator of whether the participant/subject has a carotid bruit upon examination Indicator of whether the participant/subject has a carotid bruit upon examination Carotid bruit Yes;No;Unknown Yes;No;Unknown Alphanumeric

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No references available Adult;Pediatric Supplemental 3.00 2013-06-21 00:00:00.0 Physical/Neurological Exam Physical/Neurological Examination Assessments and Examinations

Single Pre-Defined Value Selected

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 performed. Date information collected 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.).

No references available Adult;Pediatric Supplemental 3.00 2013-07-24 21:00:23.88 Physical/Neurological Exam Physical/Neurological Examination Assessments and Examinations

Free-Form Entry

C13525 Carotid bruit type CarotidBruitTyp Type of carotid bruit found during the examination Type of carotid bruit found during the examination Select all that apply Multi-select cervical;Subclavicular;Cranial;Ocular Multi-select cervical;Subclavicular;Cranial;Ocular Alphanumeric

Choose all that apply

No references available Adult;Pediatric Supplemental 3.00 2013-06-21 00:00:00.0 Physical/Neurological Exam Physical/Neurological Examination Assessments and Examinations

Multiple Pre-Defined Values Selected

C13513 Mini-Mental State Examination (MMSE) - total score MMSETtlScore Total score for the Mini-Mental State Examination (MMSE). The MMSE is a brief, quantitative measure of cognitive status in adults. It can be used to screen for cognitive impairment, to estimate the severity of cognitive impairment at a given point in time, to follow the course of cognitive changes in an individual over time, and to document an individual's response to treatment. The MMSE has demonstrated validity and reliability in psychiatric, neurologic, geriatric, and other medical populations. Total score for the Mini-Mental State Examination (MMSE). MMSE total score Numeric Values

Despite the many free versions of the test that are available on the internet, the official versions are copyrighted and must be ordered through the publisher: MMSE- version 1: http://www3.parinc.com/products/product.aspx?Productid=MMSE MMSE- version 2: http://www.minimental.com/

Crum RM, Anthony JC, Bassett SS, Folstein MF. Population-based norms for the mini-mental state examination by age and educational level. JAMA. 1993;269(18):2386-2391. Folstein MF, Folstein SE, McHugh PR. "Mini-mental state": a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12:189-198. Tombaugh TN, McIntyre NJ. The mini-mental state examination: a comprehensive review. J Am Geriatr Soc. 1992;40(9):922-935. Adult;Pediatric Supplemental 3.00 2013-06-21 00:00:00.0 Physical/Neurological Exam Physical/Neurological Examination Assessments and Examinations

Free-Form Entry

C13514 Consciousness findings result ConsciousnessFindReslt Assess consciousness using the Scandinavian Stroke Scale Assess consciousness using the Scandinavian Stroke Scale Consciousness 6;4;2 Fully conscious;Somnolent, can be awaked to full consciousness;Reacts to verbal command, but is not fully conscious Numeric values

The points associated with the permissible values may be less relevant when the entire Scandinavian Stroke Scale is not being used. This would be an alternative to the NIHSS LOC Items.

Multicenter trial of hemodilution in ischemic stroke--background and study protocol. Scandinavian Stroke Study Group. Stroke 1985 Sep-Oct; 16(5):885-90. Adult;Pediatric Exploratory 3.00 2013-06-21 00:00:00.0 Physical/Neurological Exam Physical/Neurological Examination Assessments and Examinations

Single Pre-Defined Value Selected

C13515 Orientation findings result OrientFindingReslt Assess orientation using the Scandinavian Stroke Scale Assess orientation using the Scandinavian Stroke Scale Orientation 6;4;2;0 Correct for time, place and person;Two of these;One of these;Completely disorientated Numeric values

The points associated with the permissible values may be less relevant when the entire Scandinavian Stroke Scale is not being used. This would be an alternative to the NIHSS LOC Items.

Multicenter trial of hemodilution in ischemic stroke--background and study protocol. Scandinavian Stroke Study Group. Stroke 1985 Sep-Oct; 16(5):885-90. Adult;Pediatric Exploratory 3.00 2013-06-21 00:00:00.0 Physical/Neurological Exam Physical/Neurological Examination Assessments and Examinations

Single Pre-Defined Value Selected

C13516 Hand strength findings result HandStrengthFindReslt Assess hand strength/ motor power on the affected side using the Scandinavian Stroke Scale Assess hand strength/ motor power on the affected side using the Scandinavian Stroke Scale Hand strength 6;4;2;0 Normal strength;Reduced strength in full range;Some movement, fingertips do not reach palm;Paralysis Numeric values

The points associated with the permissible values may be less relevant when the entire Scandinavian Stroke Scale is not being used.

Multicenter trial of hemodilution in ischemic stroke--background and study protocol. Scandinavian Stroke Study Group. Stroke 1985 Sep-Oct; 16(5):885-90. Adult;Pediatric Exploratory 3.00 2013-06-21 00:00:00.0 Physical/Neurological Exam Physical/Neurological Examination Assessments and Examinations

Single Pre-Defined Value Selected

C13517 Hand function findings result HandFuncFindReslt Assess hand function on the affected side using the Orgogozo Stroke Scale Assess hand function on the affected side using the Orgogozo Stroke Scale Hand function 15;10;5;0 Normal - No restriction upon the performance of any movement , even if there is a minimal weakness;Skilled - Restriction of fine movements. The more complex movements are impaired, but there is no restriction upon the performance of common, daily-life movements, even if these are executed slowly or clumsily , antagonistic movements between finger and thumb possible;Useful - Gross movements possible. Delicate movements cannot be performed, but patient can handle and carry objects of at least match-box size, use a fork or a pencil in approximate fashion, can handle a cane or grip a hand rail;Useless - Useful movements impossible. Patient cannot hold or carry objects, even if some elementary movements can be performed. Alphanumeric

Numeric scores may not be needed if the full Orgogozo Stroke Scale is not administered.

Orgogozo JM, Capildeo R. "Development of a neurological score for clinical evaluation of infarctions in the Sylvian territory." Presse Med 1983:12(48):3039-44. Adult;Pediatric Exploratory 3.00 2013-06-21 00:00:00.0 Physical/Neurological Exam Physical/Neurological Examination Assessments and Examinations

Single Pre-Defined Value Selected

C13518 Upper limb tone findings result UpperLimTonFindReslt Assess tone of upper limbs on the affected side using the Orgogozo Stroke Scale Assess tone of upper limbs on the affected side using the Orgogozo Stroke Scale Upper limb tone 0;5 Overtly spastic or flaccid - Frank hypertonia or hypotonia in comparison with the opposite side. Permanent rigidity, or flexion or extension induced by painful stimuli.;Normal - Near Normal. No frank hypertonia or hypotonia in comparison with the opposite side, even if the jerk reflexes are exaggerated Numeric values

Numeric scores may not be needed if the full Orgogozo Stroke Scale is not administered.

Orgogozo JM, Capildeo R. "Development of a neurological score for clinical evaluation of infarctions in the Sylvian territory." Presse Med 1983:12(48):3039-44. Adult;Pediatric Exploratory 3.00 2013-06-21 00:00:00.0 Physical/Neurological Exam Physical/Neurological Examination Assessments and Examinations

Single Pre-Defined Value Selected

CSV