CDE Detailed Report

Disease: Epilepsy
Sub-Domain: Physical/Neurological Examination
CRF: Neurological Exam

Displaying 1 - 50 of 75
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
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/Neurological Examination Assessments and Examinations

Single Pre-Defined Value Selected

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/Neurological Examination Assessments and Examinations 4000

Free-Form Entry

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/Neurological Examination Assessments and Examinations

Multiple Pre-Defined Values 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/Neurological 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/Neurological 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 abnormality. Patient Description of abnormal symptoms Alphanumeric No references available Adult;Pediatric Supplemental 3.00 2013-07-30 14:29:49.047 Neurological Exam Physical/Neurological Examination Assessments and Examinations 255

Free-Form Entry

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/Neurological Examination Assessments and Examinations

Single Pre-Defined Value Selected

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/Neurological Examination Assessments and Examinations

Multiple Pre-Defined Values Selected

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/Neurological Examination Assessments and Examinations 4000

Free-Form Entry

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, involuntary movement of the eyeballs, performed. Cannot Assess, explain Alphanumeric No references available Adult;Pediatric Supplemental 3.00 2013-07-30 14:29:49.047 Neurological Exam Physical/Neurological Examination Assessments and Examinations 255

Free-Form Entry

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/Neurological 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 abnormal. 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/Neurological Examination Assessments and Examinations

Multiple Pre-Defined Values 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 abnormality. Sensory Nerve, explain Alphanumeric No references available Adult;Pediatric Supplemental 3.00 2013-07-30 14:29:49.047 Neurological Exam Physical/Neurological 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/Neurological Examination Assessments and Examinations

Single Pre-Defined Value Selected

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/Neurological Examination Assessments and Examinations

Single Pre-Defined Value Selected

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 weakness. 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/Neurological Examination Assessments and Examinations 4000

Free-Form Entry

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 identified. 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/Neurological Examination Assessments and Examinations 255

Free-Form Entry

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/Neurological 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/Neurological 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 pattern. Stocking/Glove, explain Alphanumeric No references available Adult;Pediatric Supplemental 3.00 2013-07-30 14:29:49.047 Neurological Exam Physical/Neurological 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 examination. 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/Neurological Examination Assessments and Examinations

Single Pre-Defined Value Selected

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/Neurological Examination Assessments and Examinations

Single Pre-Defined Value Selected

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/Neurological Examination Assessments and Examinations 4000

Free-Form Entry

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 weakness. Myopathic Weakness, describe Alphanumeric No references available Adult;Pediatric Supplemental 3.00 2013-07-30 14:29:49.047 Neurological Exam Physical/Neurological Examination Assessments and Examinations 255

Free-Form Entry

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/Neurological 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/Neurological Examination Assessments and Examinations

Single Pre-Defined Value Selected

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/Neurological 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 pattern. Stocking, explain Alphanumeric No references available Adult;Pediatric Supplemental 3.00 2013-07-30 14:29:49.047 Neurological Exam Physical/Neurological Examination Assessments and Examinations 255

Free-Form Entry

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/Neurological Examination Assessments and Examinations

Single Pre-Defined Value Selected

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/Neurological 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/Neurological 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 weakness. Neuropathic Weakness, describe Alphanumeric No references available Adult;Pediatric Supplemental 3.00 2013-07-30 14:29:49.047 Neurological Exam Physical/Neurological Examination Assessments and Examinations 255

Free-Form Entry

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/Neurological Examination Assessments and Examinations

Single Pre-Defined Value Selected

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/Neurological 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/Neurological Examination Assessments and Examinations 4000

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/Neurological Examination Assessments and Examinations

Multiple Pre-Defined Values Selected

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/Neurological 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 performed. 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/Neurological Examination Assessments and Examinations

Free-Form Entry

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 weakness. Peripheral Nerve Lesion(s), describe Alphanumeric No references available Adult;Pediatric Supplemental 3.00 2013-07-30 14:29:49.047 Neurological Exam Physical/Neurological Examination Assessments and Examinations 255

Free-Form Entry

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 exam. 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/Neurological Examination Assessments and Examinations

Single Pre-Defined Value Selected

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/Neurological Examination Assessments and Examinations

Multiple Pre-Defined Values Selected

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

Choose only one

No references available Adult;Pediatric Supplemental 1.00 2012-10-05 00:00:00.0 Neurological Exam Physical/Neurological Examination Assessments and Examinations 4000

Free-Form Entry

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.

No references available Adult;Pediatric Supplemental 1.00 2012-10-05 00:00:00.0 Neurological Exam Physical/Neurological Examination Assessments and Examinations

Multiple Pre-Defined Values Selected

C18943 Cerebellar or coordination assessment abnormality explain other text CerbllCoordAssmtAbnrmlyExplOTH The free-text field related to 'Cerebellar or coordination assessment abnormality present type' specifying other text for explaining the type of abnormality found by the cerebellar/coordination assessment The free-text field related to 'Cerebellar or coordination assessment abnormality present type' specifying other text. Type of abnormality found by the cerebellar/coordination assessment 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/Neurological Examination Assessments and Examinations 4000

Free-Form Entry

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 Yes;No Alphanumeric

Choose one. If yes, answer questions A and B.

No references available Adult;Pediatric Supplemental 3.00 2013-08-28 16:08:00.453 Neurological Exam Physical/Neurological Examination Assessments and Examinations

Single Pre-Defined Value Selected

C18509 Reflex left arm assessment status RflxLftArmAssmtStatus The status of the relfex assessment for the left arm. The status of the relfex assessment for the left arm. Left Arm 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/Neurological Examination Assessments and Examinations

Single Pre-Defined Value Selected

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;Other, specify Abnormal and symmetric;Abnormal and asymmetric;Abnormal - Increased;Abnormal - Decreased;Other, specify Alphanumeric

If the global assessment found an abnormality, then record the abnormality type

No references available Adult;Pediatric Supplemental 3.00 2013-08-28 16:08:00.453 Neurological Exam Physical/Neurological Examination Assessments and Examinations

Single Pre-Defined Value Selected

C14451 Muscle weakness neurological anatomic site MuscWeakNeuroAntmicSite Anatomic location of neurological muscle weakness. Neurological location of the muscle weakness Specify the neurological location of the weakness Brain;Spinal Cord;Peripheral Nervous System;Other, specify Brain;Spinal Cord;Peripheral Nervous System;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/Neurological Examination Assessments and Examinations

Multiple Pre-Defined Values Selected

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)

No references available Adult;Pediatric Supplemental 1.00 2012-10-05 00:00:00.0 Neurological Exam Physical/Neurological Examination Assessments and Examinations 4000

Free-Form Entry

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 Ataxic Gait;Hemiparetic Gait - Left side;Hemiparetic Gait - Right side;Diplegic Gait;Parkinsonian Gait;Other gait abnormalities Alphanumeric

Choose best response

No references available Adult;Pediatric Supplemental 3.00 2013-08-28 16:08:00.453 Neurological Exam Physical/Neurological Examination Assessments and Examinations

Single Pre-Defined Value Selected

CSV