CDE Detailed Report
Disease: content
Subdomain Name: Physical/Neurological Examination
CRF: welcome
Displaying 1 - 50 of 52
Subdomain Name: Physical/Neurological Examination
CRF: welcome
Displaying 1 - 50 of 52
| 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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| C14445 | Muscle tone assessment abnormality type | MuscToneAbnrmlyAssmtTyp | The muscle tone abnormality type | The muscle tone abnormality type | If Abnormal, indicate type | Abnormal - Decreased;Abnormal - Increased;Abnormal and bilateral;Abnormal and unilateral;Abnormal–Hypertonia;Abnormal–Hypotonia;Other, specify | Abnormal - Decreased;Abnormal - Increased;Abnormal and bilateral;Abnormal and unilateral;Abnormal–Hypertonia;Abnormal–Hypotonia;Other, specify | Alphanumeric |
Choose one |
Adult;Pediatric | Supplemental | 3.00 | 2013-08-28 16:08:00.453 | Neurological Examination | Physical/Neurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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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 | Adult;Pediatric | Supplemental | 1.00 | 2015-06-02 16:08:00.0 | Neurological Examination | Physical/Neurological Examination | Assessments and Examinations | 4000 |
Free-Form Entry |
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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. |
Adult;Pediatric | Supplemental | 1.00 | 2012-10-05 00:00:00.0 | Neurological Examination | Physical/Neurological Examination | Assessments and Examinations |
Multiple Pre-Defined Values Selected |
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| C14434 | Cranial nerve abnormal identifier type | CranlNerveAbnrmlIdTyp | The identified cranial nerve that assessed as abnormal | The identified cranial nerve that assessed as abnorma | Cranial Nerve Number | CN II;CN III;CN IV;CN V;CN VI;CN VII;CN VIII;CN IX;CN X;CN XI;CN XII | Cranial nerve II;Cranial nerve III;Cranial nerve IV;Cranial nerve V;Cranial nerve VI;Cranial nerve VII;Cranial nerve VIII;Cranial nerve IX;Cranial nerve X;Cranial nerve XI;Cranial nerve XII | Alphanumeric |
Record which of the cranial nerves are abnormal and the side. Choose all that apply. |
Adult;Pediatric | Supplemental | 3.00 | 2013-08-28 16:08:00.453 | Neurological Examination | Physical/Neurological Examination | Assessments and Examinations |
Multiple Pre-Defined Values Selected |
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| C18936 | Muscle tone assessment abnormality other text | MuscToneAbnrmlyAssmtOTH | The free-text field related to 'Muscle tone assessment abnormality type' specifying other text. The muscle tone abnormality type | The free-text field related to 'Muscle tone assessment abnormality type' specifying other text. The muscle tone abnormality type | Other, specify | Alphanumeric | Adult;Pediatric | Supplemental | 3.00 | 2013-08-28 16:08:00.453 | Neurological Examination | Physical/Neurological Examination | Assessments and Examinations | 4000 |
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. |
Adult;Pediatric | Supplemental | 3.00 | 2013-08-28 16:08:00.453 | Neurological Examination | Physical/Neurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C22887 | Gait oxygen cost walking value | GaitOxyCostWalkVal | The metabolic cost of steady-state walking value (mL/kg/m) | The metabolic cost of steady-state walking value (mL/kg/m) | Oxygen cost during walking | Alphanumeric | Adult;Pediatric | Supplemental | 1.00 | 2016-12-05 14:01:41.0 | Neurological Examination | Physical/Neurological 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. |
Adult;Pediatric | Supplemental | 1.00 | 2012-10-05 00:00:00.0 | Neurological Examination | Physical/Neurological Examination | Assessments and Examinations |
Multiple Pre-Defined Values Selected |
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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;Unknown | Yes;No;Cannot Assess;Unknown | Alphanumeric |
Specify type, if yes |
Adult;Pediatric | Supplemental | 1.00 | 2012-10-05 00:00:00.0 | Neurological Examination | Physical/Neurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C18937 | Muscle strength abnormality assessment other text | MuscStrAbnrmlyAssmtOTH | The free-text field related to 'Muscle strength abnormality assessment type' specifying other text. The muscle strength abnormality type | The free-text field related to 'Muscle strength abnormality assessment type' specifying other text. The muscle strength abnormality type | Other, specify | Alphanumeric | Adult;Pediatric | Supplemental | 3.00 | 2013-08-28 16:08:00.453 | Neurological Examination | Physical/Neurological Examination | Assessments and Examinations | 4000 |
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;Cannot Assess | Yes;No;Not assessed;Unknown;Cannot Assess | Alphanumeric |
Choose one for each anatomic site |
Adult;Pediatric | Supplemental | 3.00 | 2013-08-28 16:08:00.453 | Neurological Examination | Physical/Neurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C22888 | Gait daily step count | GaitDailyStepCt | The mean number of total steps taken in a full, usual day | The mean number of total steps taken in a full, usual day | Daily step counts | Alphanumeric | Adult;Pediatric | Supplemental | 1.00 | 2016-12-05 14:03:50.0 | Neurological Examination | Physical/Neurological 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;Crouch Gait;Jump Gait | Ataxic Gait;Hemiparetic Gait - Left side;Hemiparetic Gait - Right side;Diplegic Gait;Parkinsonian Gait;Other gait abnormalities;Crouch Gait;Jump Gait | Alphanumeric |
Choose best response. |
Adult;Pediatric | Supplemental | 3.00 | 2013-08-28 16:08:00.453 | Neurological Examination | Physical/Neurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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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) |
Adult;Pediatric | Supplemental | 1.00 | 2012-10-05 00:00:00.0 | Neurological Examination | Physical/Neurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C18938 | Muscle weakness brain pattern other text | MuscWeakBrainPattrnOTH | The free-text field related to 'Muscle weakness brain pattern type' specifying other text. Patterns describing weakness in location of brain | The free-text field related to 'Muscle weakness brain pattern type' specifying other text. Patterns describing weakness in location of brain | Other, specify | Alphanumeric | Adult;Pediatric | Supplemental | 3.00 | 2013-08-28 16:08:00.453 | Neurological Examination | Physical/Neurological 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;Abnormal and bilateral;Abnormal and unilateral;Abnormal–Hypertonia;Abnormal–Hypotonia;Other, specify | Abnormal - Decreased;Abnormal - Increased;Abnormal and bilateral;Abnormal and unilateral;Abnormal–Hypertonia;Abnormal–Hypotonia;Other, specify | Alphanumeric |
Choose one |
Adult;Pediatric | Supplemental | 3.00 | 2013-08-28 16:08:00.453 | Neurological Examination | Physical/Neurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C22889 | Sensory system abnormality symptom description text | SensySysAbnrmlySymptmDescTxt | Text representing the patient's description of his/her abnormal symptoms in his/her sensory system | Text representing the patient's description of his/her abnormal symptoms in his/her sensory syste | Patient Description of abnormal symptoms | Alphanumeric | Adult;Pediatric | Supplemental | 1.00 | 2016-12-05 14:10:55.0 | Neurological Examination | Physical/Neurological Examination | Assessments and Examinations | 255 |
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 asssessment | Abnormal;Normal;Cannot Assess;Other, specify | Abnormal;Normal;Cannot Assess;Other, specify | Alphanumeric |
Choose one. If abnormal answer questions 15a–15d. |
Adult;Pediatric | Supplemental | 1.00 | 2012-10-05 00:00:00.0 | Neurological Examination | Physical/Neurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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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;Unknown | Yes;No;Cannot Assess;Unknown | Alphanumeric |
Choose one for each global assessment type. |
Adult;Pediatric | Supplemental | 3.00 | 2013-08-28 16:08:00.453 | Neurological Examination | 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 | Adult;Pediatric | Supplemental | 3.00 | 2013-08-28 16:08:00.453 | Neurological Examination | Physical/Neurological Examination | Assessments and Examinations | 4000 |
Free-Form Entry |
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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, Unilateral;Left Unilateral;Bilateral | Right Hemiparesis;Left Hemiparesis;Diplegia / Paraparesis;Quadriplegia / Quadraparesis;Peripheral Nerve Lesion(s), Neuropathic Weakness;Neuropathic weakness;Myopathic Weakness;Other, specify;Right, Unilateral;Left Unilateral;Bilateral | Alphanumeric | Adult;Pediatric | Supplemental | 3.00 | 2013-08-28 16:08:00.453 | Neurological Examination | 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. |
Adult;Pediatric | Supplemental | 1.00 | 2012-10-05 00:00:00.0 | Neurological Examination | Physical/Neurological 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;Abnormal and bilateral;Abnormal and unilateral | Abnormal and symmetric;Abnormal and asymmetric;Abnormal - Increased;Abnormal - Decreased;Abnormal and bilateral;Abnormal and unilateral | Alphanumeric |
If the global assessment found an abnormality, then record the abnormality type |
Adult;Pediatric | Supplemental | 3.00 | 2013-08-28 16:08:00.453 | Neurological Examination | 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 | Adult;Pediatric | Supplemental | 1.00 | 2012-10-05 00:00:00.0 | Neurological Examination | Physical/Neurological Examination | Assessments and Examinations | 4000 |
Free-Form Entry |
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| C14454 | Cerebellar or coordination assessment type | CerbllrCoordinationAssmtTyp | Type of cerebellar/coordination assessment performed | Type of cerebellar/coordination assessment performed | Cerebellar/Coordination assessments | Finger-to-Nose;Rapid Alternating Movements;Heel-to-Shin | Finger-to-Nose;Rapid Alternating Movements;Heel-to-Shin | Alphanumeric |
For each assessment type record whether an abnormality is present and if so the type of abnormality. |
Adult;Pediatric | Supplemental | 1.00 | 2012-10-05 00:00:00.0 | Neurological Examination | Physical/Neurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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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 | Bilateral;Left;Right;Unknown | Bilateral;Left;Right;Unknown | Alphanumeric |
Record which of the cranial nerves are abnormal and the side. Choose only one. |
Adult;Pediatric | Supplemental | 3.00 | 2013-08-28 16:08:00.453 | Neurological Examination | Physical/Neurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C14469 | Sensory system modalities affected type | SensyModltyAffctTyp | The type and location of the sensory receptor activated by a stimulus plays the primary role in coding the stimulus modality | The type and location of the sensory receptor activated by a stimulus plays the primary role in coding the stimulus modality | Sensory Modalities Affected | Light Touch;Pain and Temperature;Vibration;Proprioception;Other, specify | Light Touch;Pain and Temperature;Vibration;Proprioception;Other, specify | Alphanumeric |
Choose all that apply. |
Adult;Pediatric | Supplemental | 1.00 | 2012-10-05 00:00:00.0 | Neurological Examination | Physical/Neurological Examination | Assessments and Examinations |
Multiple Pre-Defined Values 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 | Adult;Pediatric | Supplemental | 3.00 | 2013-08-28 16:08:00.453 | Neurological Examination | 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 | Adult;Pediatric | Supplemental | 1.00 | 2012-10-05 00:00:00.0 | Neurological Examination | Physical/Neurological Examination | Assessments and Examinations | 4000 |
Free-Form Entry |
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| C14455 | Cerebellar or coordination assessment abnormality present status | CerbllCoordAssmtAbnrmlyPrsStat | Whether the cerebellar/coordination assessment found abnormalities | Whether the cerebellar/coordination assessment found abnormalities | Abnormality Present? | Yes;No;Cannot Assess;Other, specify | Yes;No;Cannot Assess;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. |
Adult;Pediatric | Supplemental | 3.00 | 2013-08-28 16:08:00.453 | Neurological Examination | Physical/Neurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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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;Not assessed;Unknown | Yes;No;Not assessed;Unknown | Alphanumeric | Adult;Pediatric | Supplemental | 3.00 | 2013-08-28 16:08:00.453 | Neurological Examination | Physical/Neurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C18503 | Assessment unable text | AssmtUnableTxt | The free-text field to explain why there was no assessment of nystagmus performed | The free-text field to explain why there was no assessment of nystagmus performe | Cannot access, explain | Alphanumeric | Adult;Pediatric | Supplemental | 3.00 | 2013-07-30 14:29:49.047 | Neurological Examination | Physical/Neurological Examination | Assessments and Examinations | 255 |
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;Unknown | Yes;No;Cannot Assess;Unknown | Alphanumeric | Adult;Pediatric | Supplemental | 3.00 | 2013-08-28 16:08:00.453 | Neurological Examination | Physical/Neurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C18947 | Sensory system global assessment other text | SensySysGlobAssmtOTH | The free-text field related to 'Sensory system global assessment result' specifying other text. The condition and ability of sensory system | The free-text field related to 'Sensory system global assessment result' specifying other text. The condition and ability of sensory system | Other, specify | Alphanumeric | Adult;Pediatric | Supplemental | 1.00 | 2012-10-05 00:00:00.0 | Neurological Examination | Physical/Neurological Examination | Assessments and Examinations | 4000 |
Free-Form Entry |
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| C14456 | Cerebellar or coordination assessment abnormality present type | CerbllCoordAssmtAbnrmlyPresTyp | Type of abnormality found by the cerebellar/coordination assessment | Type of abnormality found by the cerebellar/coordination assessment | If Abnormal, explain | RUE;LUE;Dysmetria;Slowness;Other, specify;Cannot Assess | Right upper extremity (RUE);Left upper extremity (LUE);Dysmetria;Slowness;Other, specify;Cannot Assess | 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. |
Adult;Pediatric | Supplemental | 3.00 | 2013-08-28 16:08:00.453 | Neurological Examination | Physical/Neurological Examination | Assessments and Examinations |
Multiple Pre-Defined Values Selected |
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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. |
Adult;Pediatric | Supplemental | 3.00 | 2013-07-22 16:57:17.79 | Neurological Examination | Physical/Neurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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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. |
Adult;Pediatric | Supplemental | 3.00 | 2013-07-30 14:29:49.047 | Neurological Examination | Physical/Neurological Examination | Assessments and Examinations | 255 |
Free-Form Entry |
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| C14442 | Muscle bulk assessment abnormality type | MuscBulkAbnrmlyAssmtTyp | The muscle bulk abnormality type | The muscle bulk abnormality type | If abnormal, indicate type | Abnormal and symmetric;Abnormal and asymmetric;Abnormal - Increased;Abnormal - Decreased;Abnormal and bilateral;Abnormal and unilateral | Abnormal and symmetric;Abnormal and asymmetric;Abnormal - Increased;Abnormal - Decreased;Abnormal and bilateral;Abnormal and unilateral | Alphanumeric |
Choose one. |
Adult;Pediatric | Supplemental | 3.00 | 2013-08-28 16:08:00.453 | Neurological Examination | Physical/Neurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C18949 | Sensory system modalities affected other text | SensyModltyAffctOTH | The free-text field related to 'Sensory system modalities affected type' specifying other text. The type and location of the sensory receptor activated by a stimulus plays the primary role in coding the stimulus modality | The free-text field related to 'Sensory system modalities affected type' specifying other text. The type and location of the sensory receptor activated by a stimulus plays the primary role in coding the stimulus modality | Other, specify | Alphanumeric | Adult;Pediatric | Supplemental | 1.00 | 2012-10-05 00:00:00.0 | Neurological Examination | Physical/Neurological Examination | Assessments and Examinations | 4000 |
Free-Form Entry |
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| 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 11a and 11b. |
Adult;Pediatric | Supplemental | 3.00 | 2013-08-28 16:08:00.453 | Neurological Examination | Physical/Neurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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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;Affect;Language;Language Naming;Language Reading;Language Repetition;Speech | Attention;Working Memory;Recent Memory;Remote Memory;Spontaneous speech;Affect;Language;Language Naming;Language Reading;Language Repetition;Speech | 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) |
Adult;Pediatric | Supplemental | 1.00 | 2012-10-05 00:00:00.0 | Neurological Examination | Physical/Neurological 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 | Adult;Pediatric | Supplemental | 1.00 | 2012-10-05 00:00:00.0 | Neurological Examination | Physical/Neurological Examination | Assessments and Examinations | 4000 |
Free-Form Entry |
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| C14443 | Muscle tone assessment anatomic site | MuscToneAssmtAntmicSite | Anatomic location of the muscle tone as part of the motor examination | Anatomic location of the muscle tone as part of the motor examinatio | Muscle Tone - global assessment | Right upper extremity;Left upper extremity;Right lower extremity;Left lower extremity;Truncal tone | Right upper extremity (RUE);Left upper extremity (LUE);Right lower extremity (RLE);Left lower extremity (LLE);Truncal tone | Alphanumeric |
Evaluate all extremities. Truncal tone – is recommended for pediatric studies only. |
Adult;Pediatric | Supplemental | 3.00 | 2013-08-28 16:08:00.453 | Neurological Examination | Physical/Neurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C19500 | Assessment performed date | AssessmentPerformedDate | The date of assessment of the examination being performed | The date of assessment of the examination being performed | Date of Exam | Date or Date & Time | Adult;Pediatric | Supplemental | 1.00 | 2014-06-18 08:10:12.0 | Neurological Examination | Physical/Neurological Examination | Assessments and Examinations |
Free-Form Entry |
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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 Elbow Flexors (Biceps Brachii);Left Elbow Flexors (Biceps Brachii);Right Leg Adductors;Left Leg Adductors;Right Knee Extensors (Quadriceps);Right Knee Flexors (Hamstrings);Left Knee Extensors (Quadriceps);Left Knee Flexors (Hamstrings);Right Plantar Flexors (Triceps Surae);Left Plantar Flexors (Triceps Surae) | Right Arm;Left Arm;Right Leg;Left Leg;Right Elbow Flexors (Biceps Brachii);Left Elbow Flexors (Biceps Brachii);Right Leg Adductors;Left Leg Adductors;Right Knee Extensors (Quadriceps);Right Knee Flexors (Hamstrings);Left Knee Extensors (Quadriceps);Left Knee Flexors (Hamstrings);Right Plantar Flexors (Triceps Surae);Left Plantar Flexors (Triceps Surae) | Alphanumeric |
If reflexes abnormal record the results for each limb. |
Adult;Pediatric | Supplemental | 1.00 | 2012-10-05 00:00:00.0 | Neurological Examination | Physical/Neurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C14432 | Mental status exam abnormality indicator | MentlStatExamAbnrmlyInd | Whether the mental assessment showed abnormal results | Whether the mental assessment showed abnormal results | Abnormality Present? | Yes;No;Unknown | Yes;No;Unknown | Alphanumeric |
Choose only one |
Adult;Pediatric | Supplemental | 1.00 | 2012-10-05 00:00:00.0 | Neurological Examination | Physical/Neurological Examination | Assessments and Examinations |
Single Pre-Defined Value 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) |
Adult;Pediatric | Supplemental | 1.00 | 2012-10-05 00:00:00.0 | Neurological Examination | Physical/Neurological Examination | Assessments and Examinations | 4000 |
Free-Form Entry |
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| C14444 | Muscle tone assessment abnormality indicator | MuscToneAbnrmlyAssmtInd | Whether the muscle tone assessment found any abnormalities | Whether the muscle tone assessment found any abnormalities | Abnormality Present? | Yes;No;Not assessed;Unknown;Cannot Assess | Yes;No;Not assessed;Unknown;Cannot Assess | Alphanumeric |
Choose one for each anatomic site. |
Adult;Pediatric | Supplemental | 3.00 | 2013-08-28 16:08:00.453 | Neurological Examination | Physical/Neurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
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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 Examination | Physical/Neurological Examination | Assessments and Examinations | 4000 |
Free-Form Entry |
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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;Cannot Assess | Increased with clonus;Increased without clonus;Hypoactive;Absent;Cannot Assess | Alphanumeric |
Choose one for each limb |
Adult;Pediatric | Supplemental | 1.00 | 2012-10-05 00:00:00.0 | Neurological Examination | Physical/Neurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
