CDE Detailed Report
Disease: Stroke
Subdomain Name: Physical/Neurological Examination
CRF: content
Displaying 1 - 19 of 19
Subdomain Name: Physical/Neurological Examination
CRF: content
Displaying 1 - 19 of 19
| 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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 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 |
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| C21720 | Vertigo assessment indicator | VertigoAssmtInd | Indicator as related to assessment of vertigo | Indicator as related to assessment of vertig | 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 |
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| 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 |
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| 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 |
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| 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 |
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| C58819 | Dizziness indicator | DizzinessInd | Indicator of whether the participant/subject experienced dizziness | Indicator of whether the participant/subject experienced dizzines | Dizziness | No;Yes;Unknown | No;Yes;Unknown | Alphanumeric |
Choose one |
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 |
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| 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 |
Choose one |
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 |
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| 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 | 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 |
Choose one |
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 |
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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 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 |
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| 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 |
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| 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 |
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| 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 |
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| 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 |
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| 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 |
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| 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 |
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| 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 |
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| 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 |
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| 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 unassiste | 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 |
