CDE Detailed Report

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

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
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

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

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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

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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

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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

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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

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

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

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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

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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

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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

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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

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

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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

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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

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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

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 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

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

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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

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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

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 examination. 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 leg. 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

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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

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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 Neurological Exam Physical/Neurological Examination Assessments and Examinations

Single Pre-Defined Value Selected

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 arm. 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

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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

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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

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 leg. 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

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/Neurological Examination Assessments and Examinations

Multiple Pre-Defined Values 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/Neurological Examination Assessments and Examinations 4000

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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/Neurological Examination Assessments and Examinations

Single Pre-Defined Value Selected

CSV