CDE Detailed Report
Disease: content
Subdomain Name: Physical%2FNeurological Examination
CRF: welcome
Displaying 1 - 50 of 75
Subdomain Name: Physical%2FNeurological Examination
CRF: welcome
Displaying 1 - 50 of 75
| 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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| C14442 | Muscle bulk assessment abnormality type | MuscBulkAbnrmlyAssmtTyp | The muscle bulk abnormality type | The muscle bulk abnormality type | If abnormal, indicate type: | Abnormal - Increased;Abnormal - Decreased;Other, specify | Abnormal - Increased;Abnormal - Decreased;Other, specify | Alphanumeric |
Choose one |
No references available | Adult;Pediatric | Supplemental | 3.00 | 2013-08-28 16:08:00.453 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
||||||||
| C18512 | Reflex right leg assessment status | RflxRtLegAssmtStatus | The status of the relfex assessment for the right leg | The status of the relfex assessment for the right le | Right Leg | Increased with clonus;Increased without clonus;Hypoactive;Absent | Increased with clonus;Increased without clonus;Hypoactive;Absent | Alphanumeric | No references available | Adult;Pediatric | Supplemental | 3.00 | 2013-07-30 14:29:49.047 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
|||||||||
| 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 | No references available | Adult;Pediatric | Supplemental | 3.00 | 2013-08-28 16:08:00.453 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations | 4000 |
Free-Form Entry |
||||||||||
| 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 |
No references available | Adult;Pediatric | Supplemental | 1.00 | 2012-10-05 00:00:00.0 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
||||||||
| 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 |
Choose one. If abnormal answer questions A-D. |
No references available | Adult;Pediatric | Supplemental | 1.00 | 2012-10-05 00:00:00.0 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations | 4000 |
Free-Form Entry |
|||||||||
| 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 |
No references available | Adult;Pediatric | Supplemental | 1.00 | 2012-10-05 00:00:00.0 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
||||||||
| C14468 | Sensory system abnormality anatomic site | SensySysAbnrmlySymmAntmicSite | The location of abnormality for sensory system | The location of abnormality for sensory system | Location of Abnormality | Stocking;Stocking/Glove;Dermatome;Sensory Nerve;Other, specify | Stocking;Stocking/Glove;Dermatome;Sensory Nerve;Other, specify | Alphanumeric |
Choose all that apply. If other, explain. |
No references available | Adult;Pediatric | Supplemental | 1.00 | 2012-10-05 00:00:00.0 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations |
Multiple Pre-Defined Values Selected |
||||||||
| 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 |
No references available | Adult;Pediatric | Supplemental | 3.00 | 2013-08-28 16:08:00.453 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
||||||||
| C18513 | Sensory system abnormality dermatome present text | SensySysAbnrmlyDermtPresTxt | The free-text field to describe the dermatome sensory abnormality, the area of skin supplied with afferent nerve fibers by a single posterior spinal root | The free-text field to describe the dermatome sensory abnormality, the area of skin supplied with afferent nerve fibers by a single posterior spinal roo | Dermatome, explain | Alphanumeric | No references available | Adult;Pediatric | Supplemental | 3.00 | 2013-07-30 14:29:49.047 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations | 255 |
Free-Form Entry |
||||||||||
| 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 | No references available | Adult;Pediatric | Supplemental | 3.00 | 2013-08-28 16:08:00.453 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations | 4000 |
Free-Form Entry |
||||||||||
| 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. |
No references available | Adult;Pediatric | Supplemental | 3.00 | 2013-08-28 16:08:00.453 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
||||||||
| C18948 | Sensory system abnormality anatomic other text | SensySysAbnrmlySymmAntmicOTH | The free-text field related to 'Sensory system abnormality anatomic site' specifying other text. The location of abnormality for sensory system | The free-text field related to 'Sensory system abnormality anatomic site' specifying other text. The location of abnormality for sensory system | Location of Abnormality | Alphanumeric |
Choose all that apply. If other, explain. |
No references available | Adult;Pediatric | Supplemental | 1.00 | 2012-10-05 00:00:00.0 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations | 4000 |
Free-Form Entry |
|||||||||
| C14433 | Cranial nerves global assessment result | CranlNerveGlobAssmtReslt | The condition of Cranial Nerves | The condition of Cranial Nerves | Cranial nerves - global assessment | Normal;Abnormal;Cannot Assess;Other, specify | Normal;Abnormal;Cannot Assess;Other, specify | Alphanumeric |
Choose only one |
No references available | Adult;Pediatric | Supplemental | 1.00 | 2012-10-05 00:00:00.0 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
||||||||
| 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 |
No references available | Adult;Pediatric | Supplemental | 1.00 | 2012-10-05 00:00:00.0 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations |
Multiple Pre-Defined Values Selected |
||||||||
| 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 | Yes;No;Not assessed;Unknown | Alphanumeric |
Choose one for each anatomic site |
No references available | Adult;Pediatric | Supplemental | 3.00 | 2013-08-28 16:08:00.453 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
||||||||
| C18514 | Sensory system abnormality participant description text | SensySysAbnrmlyPrtpDescTxt | The free-text field to capture the participant's description of the sensory abnormality | The free-text field to capture the participant's description of the sensory abnormalit | Patient Description of abnormal symptoms | Alphanumeric | No references available | Adult;Pediatric | Supplemental | 3.00 | 2013-07-30 14:29:49.047 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations | 255 |
Free-Form Entry |
||||||||||
| 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 |
Choose all that apply. Describe if applicable. |
No references available | Adult;Pediatric | Supplemental | 3.00 | 2013-08-28 16:08:00.453 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations | 4000 |
Free-Form Entry |
|||||||||
| 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;Cannot assess due to weakness;Other, specify | Right upper extremity (RUE);Left upper extremity (LUE);Dysmetria;Slowness;Cannot assess due to weakness;Other, specify | 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. |
No references available | Adult;Pediatric | Supplemental | 3.00 | 2013-08-28 16:08:00.453 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations |
Multiple Pre-Defined Values Selected |
||||||||
| 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 |
Choose all that apply |
No references available | Adult;Pediatric | Supplemental | 1.00 | 2012-10-05 00:00:00.0 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations | 4000 |
Free-Form Entry |
|||||||||
| 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. |
No references available | Adult;Pediatric | Supplemental | 3.00 | 2013-08-28 16:08:00.453 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations |
Multiple Pre-Defined Values Selected |
||||||||
| 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 Assess, explain | Alphanumeric | No references available | Adult;Pediatric | Supplemental | 3.00 | 2013-07-30 14:29:49.047 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations | 255 |
Free-Form Entry |
||||||||||
| 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;Other, specify | Abnormal - Decreased;Abnormal - Increased;Other, specify | Alphanumeric |
Choose one |
No references available | Adult;Pediatric | Supplemental | 3.00 | 2013-08-28 16:08:00.453 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
||||||||
| C18515 | Sensory system abnormality sensory nerve present text | SensySysAbnrmlySensNrvPresTxt | The free-text field to describe the sensory nerve abnormality | The free-text field to describe the sensory nerve abnormalit | Sensory Nerve, explain | Alphanumeric | No references available | Adult;Pediatric | Supplemental | 3.00 | 2013-07-30 14:29:49.047 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations | 255 |
Free-Form Entry |
||||||||||
| C18939 | Muscle weakness neurological anatomic other text | MuscWeakNeuroAntmicOTH | The free-text field related to 'Muscle weakness neurological anatomic site' specifying other text. Anatomic location of neurological muscle weakness | The free-text field related to 'Muscle weakness neurological anatomic site' specifying other text. Anatomic location of neurological muscle weaknes | Other, specify | Alphanumeric |
Choose all that apply |
No references available | Adult;Pediatric | Supplemental | 3.00 | 2013-08-28 16:08:00.453 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations | 4000 |
Free-Form Entry |
|||||||||
| 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 A and B. |
No references available | Adult;Pediatric | Supplemental | 3.00 | 2013-08-28 16:08:00.453 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
||||||||
| 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 Exam | Physical%2FNeurological Examination | Assessments and Examinations | 4000 |
Free-Form Entry |
|||||||||||
| 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 | Yes;No;Cannot Assess | Alphanumeric |
Specify type, if yes |
No references available | Adult;Pediatric | Supplemental | 1.00 | 2012-10-05 00:00:00.0 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
||||||||
| 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 |
No references available | Adult;Pediatric | Supplemental | 3.00 | 2013-07-30 14:29:49.047 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations | 255 |
Free-Form Entry |
|||||||||
| 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. |
No references available | Adult;Pediatric | Supplemental | 3.00 | 2013-08-28 16:08:00.453 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
||||||||
| C18516 | Sensory system abnormality stocking glove present text | SensySysAbnrmlyStckGlvPresTxt | The free-text field to describe the stocking sensory abnormality, a generalised and gradual loss of peripheral nerve function results in a receding glove and stocking pattern | The free-text field to describe the stocking sensory abnormality, a generalised and gradual loss of peripheral nerve function results in a receding glove and stocking patter | Stocking/Glove, explain | Alphanumeric | No references available | Adult;Pediatric | Supplemental | 3.00 | 2013-07-30 14:29:49.047 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations | 255 |
Free-Form Entry |
||||||||||
| C18940 | Tremor assessment other text | TremAssessOTH | The free-text field related to 'Tremor assessment status' specifying other text. The status indicating whether tremors could be detected during the exam | The free-text field related to 'Tremor assessment status' specifying other text. The status indicating whether tremors could be detected during the exam | Other, specify | Alphanumeric |
Choose only one |
No references available | Adult;Pediatric | Supplemental | 3.00 | 2013-08-28 16:08:00.453 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations | 4000 |
Free-Form Entry |
|||||||||
| 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 Arm;Left Arm;Right Leg;Left Leg | Alphanumeric |
If reflexes abnormal record the results for each limb |
No references available | Adult;Pediatric | Supplemental | 1.00 | 2012-10-05 00:00:00.0 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
||||||||
| 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 |
Choose best response |
No references available | Adult;Pediatric | Supplemental | 1.00 | 2015-06-02 16:08:00.0 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations | 4000 |
Free-Form Entry |
|||||||||
| 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) |
No references available | Adult;Pediatric | Supplemental | 1.00 | 2012-10-05 00:00:00.0 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
||||||||
| C18506 | Muscle weakness myopathic weakness present text | MuscWeakMyopathWeakPresTxt | The free-text field to describethe myopathic weakness present resultling in muscle weakness | The free-text field to describethe myopathic weakness present resultling in muscle weaknes | Myopathic Weakness, describe | Alphanumeric | No references available | Adult;Pediatric | Supplemental | 3.00 | 2013-07-30 14:29:49.047 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations | 255 |
Free-Form Entry |
||||||||||
| 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 | Yes;No;Not assessed;Unknown | Alphanumeric |
Choose one for each anatomic site |
No references available | Adult;Pediatric | Supplemental | 3.00 | 2013-08-28 16:08:00.453 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
||||||||
| C18517 | Sensory system abnormality stocking present text | SensySysAbnrmlyStockPresTxt | The free-text field to describe the stocking sensory abnormality, a generalised and gradual loss of peripheral nerve function results in a receding stocking pattern | The free-text field to describe the stocking sensory abnormality, a generalised and gradual loss of peripheral nerve function results in a receding stocking patter | Stocking, explain | Alphanumeric | No references available | Adult;Pediatric | Supplemental | 3.00 | 2013-07-30 14:29:49.047 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations | 255 |
Free-Form Entry |
||||||||||
| C18941 | Tremor other text | TremOTH | The free-text field related to 'Tremor type' specifying other text. The type of tremor detected during the exam | The free-text field related to 'Tremor type' specifying other text. The type of tremor detected during the exam | Other, specify | Alphanumeric |
Choose only one |
No references available | Adult;Pediatric | Supplemental | 3.00 | 2013-08-28 16:08:00.453 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations | 4000 |
Free-Form Entry |
|||||||||
| 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 | Left;Right;Bilateral | Left;Right;Bilateral | Alphanumeric |
Record which of the cranial nerves are abnormal and the side. Choose only one. |
No references available | Adult;Pediatric | Supplemental | 3.00 | 2013-08-28 16:08:00.453 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
||||||||
| 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 | Increased with clonus;Increased without clonus;Hypoactive;Absent | Alphanumeric |
Choose one for each limb |
No references available | Adult;Pediatric | Supplemental | 1.00 | 2012-10-05 00:00:00.0 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
||||||||
| C14437 | Motor exam global assessment type | MotorExamGloblAssmtTyp | Type of global assessment for the motor exam | Type of global assessment for the motor exam | Motor assessments | Muscle bulk;Muscle tone;Muscle strength | Muscle bulk;Muscle tone;Muscle strength | Alphanumeric |
For each global assessment type record whether an abnormality is present and if so the type of abnormality |
No references available | Adult;Pediatric | Supplemental | 1.00 | 2012-10-05 00:00:00.0 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
||||||||
| C18507 | Muscle weakness neuropathic weakness present text | MuscWeakNeuropathWeakPresTxt | The free-text field to describe the neuropathic weakness present resultling in muscle weakness | The free-text field to describe the neuropathic weakness present resultling in muscle weaknes | Neuropathic Weakness, describe | Alphanumeric | No references available | Adult;Pediatric | Supplemental | 3.00 | 2013-07-30 14:29:49.047 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations | 255 |
Free-Form Entry |
||||||||||
| 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;Other, specify | Abnormal - Decreased;Abnormal - Increased;Other, specify | Alphanumeric |
Choose one |
No references available | Adult;Pediatric | Supplemental | 3.00 | 2013-08-28 16:08:00.453 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
||||||||
| 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 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations | 4000 |
Free-Form Entry |
|||||||||
| C18942 | Cerebellar or coordination assessment abnormality present other text | CerbllCoordAssmtAbnrmlyPrsOTH | The free-text field related to 'Cerebellar or coordination assessment abnormality present status' specifying other text. Whether the cerebellar/coordination assessment found abnormalities | The free-text field related to 'Cerebellar or coordination assessment abnormality present status' specifying other text. Whether the cerebellar/coordination assessment found abnormalities | 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. |
No references available | Adult;Pediatric | Supplemental | 3.00 | 2013-08-28 16:08:00.453 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations | 4000 |
Free-Form Entry |
|||||||||
| 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 form completed | 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.). |
EPILEPSY: Berg AT, Berkovic SF, Brodie MJ, Buchhalter J, et al. Revised terminology and concepts for organization of seizures and epilepsies: report of the ILAE Commission on Classification and Terminology, 2005-2009. Epilepsia. 2010 Apr;51(4):676-85. http://www.ilae-epilepsy.org/Visitors/Centre/ctf/ctfoverview.cfm | Adult;Pediatric | Supplemental | 3.00 | 2013-07-24 21:00:23.88 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations |
Free-Form Entry |
||||||||||
| 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. |
No references available | Adult;Pediatric | Supplemental | 1.00 | 2012-10-05 00:00:00.0 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations |
Multiple Pre-Defined Values Selected |
||||||||
| 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 | Yes;No;Cannot Assess | Alphanumeric |
Choose one for each global assessment type |
No references available | Adult;Pediatric | Supplemental | 3.00 | 2013-08-28 16:08:00.453 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
||||||||
| C18508 | Muscle weakness peripheral nerve lesion present text | MuscWeakPerphrlNervLesnPresTxt | The free-text field to describe the peripheral nerve lesion present resultling in muscle weakness | The free-text field to describe the peripheral nerve lesion present resultling in muscle weaknes | Peripheral Nerve Lesion(s), describe | Alphanumeric | No references available | Adult;Pediatric | Supplemental | 3.00 | 2013-07-30 14:29:49.047 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations | 255 |
Free-Form Entry |
||||||||||
| 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 Hemiparesis;Left Hemiparesis;Diplegia / Paraparesis;Quadriplegia / Quadraparesis;Peripheral Nerve Lesion(s), Neuropathic Weakness;Neuropathic weakness;Myopathic Weakness;Other, specify | Alphanumeric |
Choose all that apply. Describe if applicable. |
No references available | Adult;Pediatric | Supplemental | 3.00 | 2013-08-28 16:08:00.453 | Neurological Exam | Physical%2FNeurological Examination | Assessments and Examinations |
Multiple Pre-Defined Values Selected |
