of0
Export
 
CDE Detailed Report
This report contains detailed information about the selected CDEs.
Note: If at least one CDE was selected from a copyright- or trademark-protected instrument/scale then all of the CDEs from that instrument/scale are included in this report.
Disease: Stroke
Sub-Domain: Physical/Neurological Examination
CRF: Physical/Neurological Exam
Item count: 15 (15 distinct CDEs)
CDE ID
CDE Name
Variable Name
Definition / Description
Question Text
Permissible Value
Description
Data Type
Instructions
References
Population
Classification (e.g., Core)
Version #
Version Date
Aliases for Variable Name
CRF Module / Guideline
© or TM
Sub-Domain
Domain
Previous Title
Size
Input Restrictions
Min Value
Max Value
Measurement Type
LOINC ID
SNOMED
caDSR ID
CDISC ID
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 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
3.0
7/24/2013
Aliases for variable name not defined
Physical/Neurological Exam
Physical/Neurological Examination
Assessments and Examinations
Data collected date and time
 
Free-Form Entry
       
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.
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
3.0
6/21/2013
Aliases for variable name not defined
Physical/Neurological Exam
Physical/Neurological Examination
Assessments and Examinations
MMSE total score
 
Free-Form Entry
       
C13514
Consciousness findings result
ConsciousnessFindReslt
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
3.0
6/21/2013
Aliases for variable name not defined
Physical/Neurological Exam
Physical/Neurological Examination
Assessments and Examinations
Consciousness findings result
 
Single Pre-Defined Value Selected
       
C13515
Orientation findings result
OrientFindingReslt
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
3.0
6/21/2013
Aliases for variable name not defined
Physical/Neurological Exam
Physical/Neurological Examination
Assessments and Examinations
Orientation findings result
 
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 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
3.0
7/25/2013
Aliases for variable name not defined
Physical/Neurological Exam
Physical/Neurological Examination
Assessments and Examinations
Hand preference type
 
Single Pre-Defined Value Selected
     
2180147
 
C13516
Hand strength findings result
HandStrengthFindReslt
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
3.0
6/21/2013
Aliases for variable name not defined
Physical/Neurological Exam
Physical/Neurological Examination
Assessments and Examinations
Hand strength findings result
 
Single Pre-Defined Value Selected
       
C13517
Hand function findings result
HandFuncFindReslt
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
3.0
6/21/2013
Aliases for variable name not defined
Physical/Neurological Exam
Physical/Neurological Examination
Assessments and Examinations
Hand function findings result
 
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
Upper limb tone
5;0;
Normal - Near Normal. No frank hypertonia or hypotonia in comparison with the healthy side, even if the jerk reflexes are exaggerated;Overtly spastic or flaccid - Frank hypertonia or hypotonia in comparison with the healthy side. Permanent rigidity, or flexion or extension induced by painful stimuli.;
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
3.0
6/21/2013
Aliases for variable name not defined
Physical/Neurological Exam
Physical/Neurological Examination
Assessments and Examinations
Upper limb tone findings result
 
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
Lower limb tone
5;0;
Normal - Near Normal. No frank hypertonia or hypotonia in comparison with the healthy side, even if the jerk reflexes are exaggerated;Overtly spastic or flaccid - Frank hypertonia or hypotonia in comparison with the healthy side. Permanent rigidity, or flexion or extension induced by painful stimuli.;
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
3.0
6/21/2013
Aliases for variable name not defined
Physical/Neurological Exam
Physical/Neurological Examination
Assessments and Examinations
Lower limb tone findings result
 
Single Pre-Defined Value Selected
       
C13520
Dysphagia indicator
DysphagiaInd
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.
Dysphagia
Yes;No;Unknown;
Yes;No;Unknown;
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
3.0
6/21/2013
Aliases for variable name not defined
Physical/Neurological Exam
Physical/Neurological Examination
Assessments and Examinations
Dysphagia indicator
 
Single Pre-Defined Value Selected
       
C13521
Gait walk unassisted result
GaitWalkUnassistReslt
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
3.0
6/21/2013
Aliases for variable name not defined
Physical/Neurological Exam
Physical/Neurological Examination
Assessments and Examinations
Gait walk ten steps result
 
Single Pre-Defined Value Selected
       
C13522
Monocular visual loss status
MonocularVisLossStatus
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
3.0
6/21/2013
Aliases for variable name not defined
Physical/Neurological Exam
Physical/Neurological Examination
Assessments and Examinations
Monocular visual loss status
 
Single Pre-Defined Value Selected
       
C13523
Dizziness or vertigo indicator
DizzinessVertigoInd
Indicator of whether the participant/subject experienced dizziness or vertigo.
Dizziness/ Vertigo
Yes;No;Unknown;
Yes;No;Unknown;
Alphanumeric
Choose one
No references available
Adult;Pediatric
Supplemental
3.0
6/21/2013
Aliases for variable name not defined
Physical/Neurological Exam
Physical/Neurological Examination
Assessments and Examinations
Dizziness or vertigo indicator
 
Single Pre-Defined Value Selected
       
C13524
Carotid bruit indicator
CarotidBruitInd
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
3.0
6/21/2013
Aliases for variable name not defined
Physical/Neurological Exam
Physical/Neurological Examination
Assessments and Examinations
Carotid bruit indicator
 
Single Pre-Defined Value Selected
       
C13525
Carotid bruit type
CarotidBruitTyp
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
3.0
6/21/2013
Aliases for variable name not defined
Physical/Neurological Exam
Physical/Neurological Examination
Assessments and Examinations
Carotid bruit type
 
Multiple Pre-Defined Values Selected
       
03-25-2019
Page 1 of 1