CDE Detailed Report

Disease: content
Sub-Domain: Physical/Neurological Examination
CRF: welcome

Displaying 1 - 10 of 10
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
C01028 Physical exam condition SNOMED CT code PhysExamCondSNOMEDCTcode Medical condition/disease found during the physical examination of the participant/subject. Systematized Nomenclature of Medicine-Clinical Terms (SNOMED CT) Medical condition/disease found during the physical examination of the participant/subject. Systematized Nomenclature of Medicine-Clinical Terms (SNOMED CT) Alphanumeric

Code the description of each abnormal result found during the physical exam using the Systematized Nomenclature of Medicine-Clinical Terms (SNOMED CT).

SNOMED CT CODES - Problem List (http://www.nlm.nih.gov/research/umls/Snomed/core_subset.html) Adult;Pediatric Supplemental 3.00 2013-08-28 16:08:00.453 Physical Exam Physical/Neurological Examination Assessments and Examinations 255

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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 Physical Exam Physical/Neurological Examination Assessments and Examinations

Single Pre-Defined Value Selected

C14430 Tanner stage TannerStage Stages of physical development in children, adolescents and adults. The scale defines physical measurements of development based on external primary and secondary sex characteristics, such as the size of the breasts, genitalia, and development of pubic hair. Stages of physical development in children, adolescents and adults. The scale defines physical measurements of development based on external primary and secondary sex characteristics, such as size of the breasts, genitalia, and development of pubic hair. Tanner Stage I;II;III;IV;V I;II;III;IV;V Alphanumeric

Indicate Tanner stage for pediatric studies only

http://www.addison.ac.uk/endocrine_modules/module1/lecturers_material/html_files/END1.14/sld019.htm Pediatric Supplemental 1.00 2012-10-05 00:00:00.0 Physical Exam Physical/Neurological Examination Assessments and Examinations

Single Pre-Defined Value Selected

C18666 Body system other text BodySysOTH The free-text field related to 'Body system category' specifying other text. Category or grouping used in the comprehensive assessment of a participant/subject, which includes a subjective history taking component as well as an objective based structured Free-text category or grouping used in the comprehensive assessment of a participant/subject, which includes a subjective history taking component as well as an objective based structured interview and physical examination of all the body systems. Other, specify Alphanumeric

Choose one. Response is obtained by report of the participant/subject or proxy as soon as possible after visit/admission. Document the date the history was obtained so it can be determined whether this information was obtained prior to study enrollment or later. Recommend collection at least on date of TBI or at time of first medical treatment. Comorbidity prior to injury may influence the disease course and chances of recovery. Serious comorbidity or comorbidity that may influence the assessment of outcome are generally considered exclusion criteria in randomized clinical trials. It is therefore highly relevant to accurately record the significant relevant medical history.

Review of Symptoms from Centers for Medicare and Medicaid Services https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/eval_mgmt_serv_guide-ICN006764.pdf Adult;Pediatric Supplemental 1.00 2014-05-27 13:34:46.0 Physical Exam Physical/Neurological Examination Assessments and Examinations 4000

Free-Form Entry

2002895
C18931 Global change since prior examination other text GlobalChangeSincPriorExamOTH The free-text field related to 'Global change since prior examination result' specifying other text. Global assessment of the difference between the prior and follow-up examinations The free-text field related to 'Global change since prior examination result' specifying other text. Global assessment of the difference between the prior and follow-up examinations 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 Physical Exam Physical/Neurological Examination Assessments and Examinations 4000

Free-Form Entry

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. Handedness Left hand;Right hand;Both hands;Unknown Left hand;Right hand;Both hands;Unknown Alphanumeric

Choose the hand which the participant/subject uses predominantly, not necessarily the hand the participant/subject writes with exclusively

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

Single Pre-Defined Value Selected

2180147
C00312 Body system category BodySysCat Category or grouping used in the comprehensive assessment of a participant/subject, which includes a subjective history taking component as well as an objective based structured interview and physical examination of all the body systems. Category or grouping used in the comprehensive assessment of a participant/subject, which includes a subjective history taking component as well as an objective based structured interview and physical examination of all the body systems. Body System Allergic/Immunologic;Cardiovascular;Constitutional symptoms (e.g., fever, weight loss);Ears, Nose, Mouth, Throat;Endocrine;Eyes;Gastrointestinal;Genitourinary;Hematologic/Lymphatic;Integumentary (skin and/or breast);Musculoskeletal;Neurological;Psychiatric;Respiratory Allergic/Immunologic;Cardiovascular;Constitutional symptoms (e.g., fever, weight loss);Ears, Nose, Mouth, Throat;Endocrine;Eyes;Gastrointestinal;Genitourinary;Hematologic/Lymphatic;Integumentary (skin and/or breast);Musculoskeletal;Neurological;Psychiatric;Respiratory Alphanumeric

Choose one. Response is obtained by report of the participant/subject or proxy as soon as possible after visit/admission. Document the date the history was obtained so it can be determined whether this information was obtained prior to study enrollment or later. Recommend collection at least on date of TBI or at time of first medical treatment. Comorbidity prior to injury may influence the disease course and chances of recovery. Serious comorbidity or comorbidity that may influence the assessment of outcome are generally considered exclusion criteria in randomized clinical trials. It is therefore highly relevant to accurately record the significant relevant medical history.

Review of Symptoms from Centers for Medicare and Medicaid Services https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/eval_mgmt_serv_guide-ICN006764.pdf Adult;Pediatric Supplemental 3.00 2013-07-25 08:54:08.2 Physical Exam Physical/Neurological Examination Assessments and Examinations

Single Pre-Defined Value Selected

2002895
C01010 Physical exam date and time PhysExamDateTime Date (and time if applicable and known) physical exam was performed Date (and time if applicable and known) physical exam was performed Date of Exam Date or Date & Time

Record the date (and time) the physical exam was performed. 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 2013-08-28 16:08:00.453 Physical Exam Physical/Neurological Examination Assessments and Examinations

Free-Form Entry

2004170
C01012 Physical exam body system result type PhysExamBodySysResltTyp Assessment result of each body system examined Assessment result of each body system examined Result Abnormal;Normal;Not assessed Abnormal;Normal;Not assessed Alphanumeric

Choose one. Indicate whether each body system examined had any abnormal findings.

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

Single Pre-Defined Value Selected

2821383
C01013 Physical exam description text PhysExamDescripTxt Free text field to describe the abnormality in a specific body system or an explanation of why the body system was not examined Free text field to describe the abnormality in a specific body system or an explanation of why the body system was not examined Alphanumeric

Provide a description of each abnormal result found during the physical exam. Make sure to record any of the following abnormalities: dysmorphic features, neurocutaneous stigmata, and carotid bruits.

SNOMED CT CODES - Problem List (http://www.nlm.nih.gov/research/umls/Snomed/core_subset.html) Adult;Pediatric Supplemental 3.00 2013-07-25 08:54:08.2 Physical Exam Physical/Neurological Examination Assessments and Examinations 255

Free-Form Entry

2201880
CSV