CDE Detailed Report

Disease: Epilepsy
Subdomain Name: Physical/Neurological Examination
CRF: Neurological Exam

Displaying 51 - 75 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
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

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 ar 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

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

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

No references available Adult;Pediatric Supplemental 3.00 2013-07-22 16:57:17.79 Neurological Exam Physical/Neurological Examination Assessments and Examinations

Single Pre-Defined Value Selected

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

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

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 4000

Free-Form Entry

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

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

C18510 Reflex left leg assessment status RflxLftLegAssmtStatus The status of the relfex assessment for the left leg The status of the relfex assessment for the left le Left 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/Neurological Examination Assessments and Examinations

Single Pre-Defined Value Selected

C14452 Tremor assessment status TremAssessStatus The status indicating whether tremors could be detected during the exam Whether tremors are detected during the exam Tremor Yes;No;Cannot Assess;Other, specify Yes;No;Cannot Assess;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

Single Pre-Defined Value Selected

C18934 Motor exam global assessment abnormality other text MotorExamGloblAbnrmlyAssmtOTH The free-text field related to 'Motor exam global assessment abnormality type' specifying other text. Global assessment abnormality type found during the motor exam The free-text field related to 'Motor exam global assessment abnormality type' specifying other text. Global assessment abnormality type found during the motor exam 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 4000

Free-Form Entry

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 Neurological Exam Physical/Neurological Examination Assessments and Examinations

Single Pre-Defined Value Selected

C14466 Sensory system global assessment result SensySytGlobAssmtReslt The condition and ability of sensory system The condition and ability of sensory system Sensory System - global assessment Abnormal;Normal;Cannot Assess;Other, specify Abnormal;Normal;Cannot Assess;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/Neurological Examination Assessments and Examinations

Single Pre-Defined Value Selected

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

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

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 Yes;No;Cannot Assess 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

C18511 Reflex right arm assessment status RflxRtArmAssmtStatus The status of the relfex assessment for the right arm The status of the relfex assessment for the right ar Right 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

C14453 Tremor type TremTyp The type of tremor detected during the exam The type of tremor detected during the exam Type of tremor Postural;Rest;Intention;Other, specify Postural;Rest;Intention;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

Single Pre-Defined Value Selected

C18935 Muscle bulk assessment abnormality other text MuscBulkAbnrmlyAssmtOTH The free-text field related to 'Muscle bulk assessment abnormality type' specifying other text. The muscle bulk abnormality type The free-text field related to 'Muscle bulk assessment abnormality type' specifying other text. The muscle bulk abnormality type 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 4000

Free-Form Entry

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;Comprehension;Naming;Repetition;Reading;Affect Attention;Working Memory;Recent Memory;Remote Memory;Spontaneous speech;Language Comprehension;Language Naming;Language Repetition;Language Reading;Affect 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)

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

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

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

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

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

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/Neurological 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/Neurological Examination Assessments and Examinations

Single Pre-Defined Value Selected

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/Neurological 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/Neurological Examination Assessments and Examinations 4000

Free-Form Entry

CSV