CDE Detailed Report

Disease: system
Subdomain Name: Physical Examinations
CRF: files

Displaying 101 - 126 of 126
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
C06238 Anal incontinence lifestyle alteration past three months scale AnlInctncLifstylAltPstThrMoScl The scale that assesses lifestyle alteration due to anal incontinence within the last three months. The scale that assesses lifestyle alteration due to anal incontinence within the last three months. Lifestyle alteration due to anal incontinence (within the last three months): Lifestyle altered each day;Lifestyle altered at least once per week but not every day;Lifestyle altered more than once per month but not every week;Lifestyle altered once per month;Lifestyle altered less than once per month;Lifestyle not altered;Not applicable;Unknown Lifestyle altered each day;Lifestyle altered at least once per week but not every day;Lifestyle altered more than once per month but not every week;Lifestyle altered once per month;Lifestyle altered less than once per month;Lifestyle not altered;Not applicable;Unknown Alphanumeric

Choose one. This variable only covers altered lifestyle due to anal incontinence or the risk of anal incontinence. Examples may by avoidance of social activities, traveling, sexual activities etc. The code "Not applicable" is mainly for individuals with stomas.

 Krogh K, Perkash I, Stiens SA, Biering-SØrensen F. International bowel function extended spinal cord injury data set. Spinal Cord. 2009 Mar;47(3):235-41. Adult;Pediatric Supplemental 3.00 2013-07-17 09:26:36.973 Clinical Assessment Physical Examinations Assessments and Examinations

Single Pre-Defined Value Selected
C06436 Neuro-Musculoskeletal condition anatomic site NeuroMuscskltlCondAntmicSite Anatomic site of the neuro-musculoskeletal condition experienced or diagnosed Anatomic site of the neuro-musculoskeletal condition experienced or diagnosed Location Neck/Cervical spine;Shoulder/Humerus;Elbow;Forearm;Wrist;Hand;Upper back/Thoracic spine;Lower back/Lumbar spine;Pelvis;Hip/Femur;Knee;Tibia/Fibula;Ankle;Foot Neck/Cervical spine;Shoulder/Humerus;Elbow;Forearm;Wrist;Hand;Upper back/Thoracic spine;Lower back/Lumbar spine;Pelvis;Hip/Femur;Knee;Tibia/Fibula;Ankle;Foot Alphanumeric

Choose one for each neuro-musculoskeletal condition (fracture, heterotopic ossification, contracture, or degenerative change/overuse)

 Fergusson D, Hutton B and Drodge A. The epidemiology of major joint contractures: A systematic review of the literature. Clinical Orthopaedics and Related Research. 2006;14:22-29. Apple, D, Cody, R, Allen, A. Overuse Syndrome of the Upper Limb in People With Spinal Cord Injury. In: Apple, DF, Editor, Physical Fitness: A guide for individuals with spinal cord injury. Journal of Rehabilitation Research and Development, Chapter 5, 1996 (Clinical Supplement): 97-108<br />Biering-S&Oslash;rensen F, Burns AS, Curt A, Harvey LA, Jane Mulcahey M, Nance PW, Sherwood AM, Sisto SA. International spinal cord injury musculoskeletal basic data set. Spinal Cord. 2012 Nov;50(11):797-802; doi: 10.1038/sc.2012.102. Adult;Pediatric Supplemental 3.00 2013-07-17 09:26:36.973 Clinical Assessment Physical Examinations Assessments and Examinations

Single Pre-Defined Value Selected
C06194 Bowel function medication constipating agent type BwlFUncMedConstAgtTyp Type of medication affecting bowel function / constipating agents Type of medication affecting bowel function / constipating agents If yes, specify medication affecting bowel function/constipating agents Anticholinergics;Narcotics;Other,specify Anticholinergics;Narcotics;Other, specify Alphanumeric

For each medication type indicate if it was used. This element does not only include orally taken agents, patches, suppositories, injections, or laxatives.
A number of drugs affect gastrointestinal motility. The most commonly used among individuals with SCI are probably anticholinergics and narcotics. Other common examples are: calcium antagonists, diuretics, serotonin reuptake inhibitors, and spasmolytics. Many drugs affect gastrointestinal function and it is impractical to give an exact list of them all. It does not only include orally taken agents but also patches, suppositories and injections. It does not include laxatives.
Constipating agents, especially loperamide, taken by a minority of individuals with SCI against fecal incontinence should also be listed here.

 Krogh K, Perkash I, Stiens SA, Biering-S&Oslash;rensen F. International bowel function basic spinal cord injury data set. Spinal Cord. 2009 Mar;47(3):230-4 Adult;Pediatric Supplemental 3.00 2013-07-17 09:26:36.973 Clinical Assessment Physical Examinations Assessments and Examinations

Multiple Pre-Defined Values Selected
C21629 Hip instability indicator HipInstabilityInd Indicator related to whether the participant/subject has any hip instability, subluxation or pelvic obiquity Indicator related to whether the participant/subject has any hip instability, subluxation or pelvic obiquity Hip instability, subluxation and pelvic obiquity No;Yes No;Yes Alphanumeric

Choose one

 Adult;Pediatric Supplemental 3.00 2013-07-17 09:26:36.973 Clinical Assessment Physical Examinations Assessments and Examinations

Single Pre-Defined Value Selected
C06315 Orgasmic function scale OrgasmicFunctScale Scale that assesses orgasmic function. Females: Orgasm is the perception of sensation of feeling good through sexual stimulation, of reaching a climax after which the woman feels gratified. May be accompanied by an overall increase and then decrease in muscle tone. The potential is based on history. Males: Orgasm is the perception of sensation of a peak feeling of sexual release, or climax, after which the man feels gratified. It may be accompanied by an overall increase and then decrease in muscle tone and may or may not be accompanied by ejaculation. The potential is based on history Psychogenic genital arousal usually manifests itself as the presence of clitoral engorgement and vaginal lubrication, amongst other signs, and occurs from arousal generated from the brain e.g. through hearing, seeing, feeling or fantasy (erotic thoughts) Orgasmic Function Normal;Reduced/altered;Absent;Unknown Normal;Reduced/altered;Absent;Unknown Alphanumeric

Choose one
Normal refers to reports by individuals that there is no change in their ability to achieve orgasm or sensations or orgasm subsequent to their spinal cord lesion.
Reduced/altered, orgasm occurs after spinal cord lesion even if itis reported to take longer to occur and/or the feelings associated with orgasm are different, i.e. may be possible, though partially impaired.
Absent refers to inability to achieve orgasm after spinalcord lesion despite trying to achieve orgasm on multiple occasions.
Unknown refers to reports by individuals that they have not been sexually active thus they do not know if they are able to achieve orgasm after spinal cord lesion.

 Alexander MS, Biering-S&Oslash;rensen F, Elliott S, Kreuter M, S&Oslash;nksen J. International Spinal Cord Injury Female Sexual and Reproductive Function Basic Data Set. Spinal Cord. 2011 Jul;49(7):787-90. Adult;Pediatric Supplemental 3.00 2013-07-17 09:26:36.973 Clinical Assessment Physical Examinations Assessments and Examinations

Single Pre-Defined Value Selected
C17417 Urine dipstick test nitrite status UrDipstckTstNitrStatus Status of nitrite presence in urine dipstick test Status of nitrite presence in urine dipstick test Urine dipstick test for nitrite (tick one only): Negative;Positive;Unknown Negative;Positive;Unknown Alphanumeric

The results can be recorded as negative, positive or unknown. An unknown result could occur from the test being unreadable, unusable, or not done.

 Goetz LL, Cardenas DD, Kennelly M, Bonne Lee BS, Linsenmeyer T, Moser C, Pannek J, Wyndaele JJ, Biering-Sorensen F. International spinal cord injury urinary tract infection basic data set. Spinal Cord. 2013 Sep;51(9):700-4. doi: 10.1038/sc.2013.72. Adult;Pediatric Supplemental 3.00 2013-07-17 09:26:36.973 Clinical Assessment Physical Examinations Assessments and Examinations

Single Pre-Defined Value Selected
C18787 Defecation method bowel care procedure used past four week supplementary other text DefctnMthdBwlProcedUseSuppOTH The free-text field related to 'Defecation method bowel care procedure used past four week supplementary type' specifying other text. Type or types of supplemental defecation methods and bowel care procedures used within the last four weeks. Supplementary methods should be performed at least once every week The free-text field related to 'Defecation method bowel care procedure used past four week supplementary type' specifying other text. Type or types of supplemental defecation methods and bowel care procedures used within the last four weeks. Supplementary methods should be performed at least once every wee Other, specify Alphanumeric Krogh K, Perkash I, Stiens SA, Biering-S&Oslash;rensen F. International bowel function basic spinal cord injury data set. Spinal Cord. 2009 Mar;47(3):230-4 Adult;Pediatric Supplemental 3.00 2013-07-17 09:26:36.973 Clinical Assessment Physical Examinations Assessments and Examinations 4000

Free-Form Entry
C06219 Flatus incontinence frequency FltsIncntncFreq The frequency of flatus incontinence within the last three months. The frequency of flatus incontinence within the last three months. Frequency of flatus incontinence (within the last three months): Daily;Not every day but at least once per week;Not every week but at least once per month;Less than once per month;Never;Not applicable;Unknown Daily;Not every day but at least once per week;Not every week but at least once per month;Less than once per month;Never;Not applicable;Unknown Alphanumeric

Choose one. The code "Not applicable" is mainly for individuals with stomas.

 Krogh K, Perkash I, Stiens SA, Biering-S&Oslash;rensen F. International bowel function extended spinal cord injury data set. Spinal Cord. 2009 Mar;47(3):235-41. Adult;Pediatric Supplemental 3.00 2013-07-17 09:26:36.973 Clinical Assessment Physical Examinations Assessments and Examinations

Single Pre-Defined Value Selected
C06406 Hypohidrosis past three months status HypohdrPstThreeMoStatus Status of whether the subject had hypohidrosis after spinal cord lesion within the last three months. Hypohidrosis is defined as a loss of ability to sweat and is normally seen below the level of injury due to disruption of sympathetic outflow. Hypohidrosis may be total or partial Status of whether the subject had hypohidrosis after spinal cord lesion within the last three months. Hypohidrosis is defined as a loss of ability to sweat and is normally seen below the level of injury due to disruption of sympathetic outflow. Hypohidrosis may be total or partia Thermoregulation history after spinal cord lesion within the last three months Hypohidrosis Above lesion;Below lesion;Unknown Above lesion;Below lesion;Unknown Alphanumeric

Choose one

 Karlsson AK, Krassioukov A, Alexander MS, Donovan W, Biering-S&Oslash;rensen F. International spinal cord injury skin and thermoregulation function basic data set. Spinal Cord. 2012 Jul;50(7):512-6. doi: 10.1038/sc.2011.167. Adult;Pediatric Supplemental 3.00 2013-07-17 09:26:36.973 Clinical Assessment Physical Examinations Assessments and Examinations

Single Pre-Defined Value Selected
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 Pain locations sites Left;Right Left;Right Alphanumeric Adult;Pediatric Supplemental 3.00 2013-08-28 16:08:00.453 Clinical Assessment Physical Examinations Assessments and Examinations

Single Pre-Defined Value Selected
C06110 Pneumonia episode treat antibiotic past year number PnmnaEpsdTrtAntibtcPstYrNum Number of pneumonia episodes treated with antibiotics occurring after the spinal cord lesion and within the last year Number of pneumonia episodes treated with antibiotics occurring after the spinal cord lesion and within the last year Number of episodes treated with antibiotics Numeric Values

Only answer if there is a history of pneumonia after spinal cord lesion and within the last year. If number of episodes is unknown then code 999 (999 = Unknown).

 Biering-S&Oslash;rensen F, Krassioukov A, Alexander MS, Donovan W, Karlsson AK, Mueller G, Perkash I, William Sheel A, Wecht J, Schilero GJ.International Spinal Cord Injury Pulmonary Function Basic Data Set. Spinal Cord. 2012 Jun; 50(6):418-21. Adult;Pediatric Supplemental 3.00 2013-07-17 09:26:36.973 Clinical Assessment Physical Examinations Assessments and Examinations

Free-Form Entry
C19356 Thermoregulation past three months reported type ThermoPastThreeMnthRepTyp The type of reported mechanism to regulate body temperature in the past three months The type of reported mechanism to regulate body temperature in the past three month Thermoregulation history after spinal cord lesion within the last three months Hyperthermia;Hypothermia;Hyperhidrosis;Hypohidrosis;Other, specify;None of the above;Unknown Hyperthermia;Hypothermia;Hyperhidrosis;Hypohidrosis;Other, specify;None of the above;Unknown Alphanumeric

Choose one
Hyperthermia, usually defined as rectal temperature above 38.4 C, as well as hypothermia, defined as rectal temperature below 35 C may be caused by an infection. Hyper and hypothermia may also be caused by non infectious reasons as exercise or by increased or decreased environmental temperature; the individual with spinal cord lesion is prone tobe poikilothermic. Hyperhidrosis is defined as excessive sweating above or below level of injury in the absence of increased ambient temperature. Hyperhidrosis may be a sign of an ongoing pathological process such as syringomyelia, autonomic dysreflexia, or dyspepsia or may accompany micturition and defecation. Hyperhidrosis may also be present without any known cause. Hypohidrosis is defined as a loss of ability to sweat and is normally seen below the level of injury due to disruption of sympathetic outflow. Hypohidrosis may be total or partial. Other thermoregulatory (for example subjective feeling of coldness) and sudomotor findings may be present and should be specified.

 Karlsson AK, Krassioukov A, Alexander MS, Donovan W, Biering-S&Oslash;rensen F. International spinal cord injury skin and thermoregulation function basic data set. Spinal Cord. 2012 Jul;50(7):512-6. doi: 10.1038/sc.2011.167. Adult;Pediatric Supplemental 1.00 2014-06-12 12:12:56.0 Clinical Assessment Physical Examinations Assessments and Examinations

Single Pre-Defined Value Selected
C06239 Constipation lifestyle alteration past three months scale ConstptnLifstylAltPstThrMoScl The scale that assesses lifestyle alteration due to constipation within the last three months. The scale that assesses lifestyle alteration due to constipation within the last three months. Lifestyle alteration due to constipation (within the last three months): Lifestyle altered each day;Lifestyle altered at least once per week but not every day;Lifestyle altered more than once per month but not every week;Lifestyle altered once per month;Lifestyle altered less than once per month;Lifestyle not altered;Not applicable;Unknown Lifestyle altered each day;Lifestyle altered at least once per week but not every day;Lifestyle altered more than once per month but not every week;Lifestyle altered once per month;Lifestyle altered less than once per month;Lifestyle not altered;Not applicable;Unknown Alphanumeric

Choose one. This variable only covers altered lifestyle due constipation related symptoms including difficult bowel evacuation. Examples may by avoidance of social activities, traveling etc.

 Krogh K, Perkash I, Stiens SA, Biering-S&Oslash;rensen F. International bowel function extended spinal cord injury data set. Spinal Cord. 2009 Mar;47(3):235-41. Adult;Pediatric Supplemental 3.00 2013-07-17 09:26:36.973 Clinical Assessment Physical Examinations Assessments and Examinations

Single Pre-Defined Value Selected
C06439 Fracture date FractrDate Date (and time, if applicable and known) the fracture occurred at each site Date (and time, if applicable and known) the fracture occurred at each site Date of fracture 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.).

 Biering-S&Oslash;rensen F, Burns AS, Curt A, Harvey LA, Jane Mulcahey M, Nance PW, Sherwood AM, Sisto SA. International spinal cord injury musculoskeletal basic data set. Spinal Cord. 2012 Nov;50(11):797-802; doi: 10.1038/sc.2012.102. Adult;Pediatric Supplemental 3.00 2013-07-17 09:26:36.973 Clinical Assessment Physical Examinations Assessments and Examinations

Free-Form Entry
C06195 Constipating agent fecal incontinence drug last four week indicator ConAgFeclInconLstFourWkInd Indicator related to whether a constipating agent or drugs against fecal incontinence were used in the last four weeks Indicator related to whether a constipating agent or drugs against fecal incontinence were used in the last four weeks Constipating agents/drugs against fecal incontinence Yes;No;Unknown Yes;No;Unknown Alphanumeric

(within the last four weeks)

 Krogh K, Perkash I, Stiens SA, Biering-S&Oslash;rensen F. International bowel function basic spinal cord injury data set. Spinal Cord. 2009 Mar;47(3):230-4 Adult;Pediatric Supplemental 3.00 2013-07-17 09:26:36.973 Clinical Assessment Physical Examinations Assessments and Examinations

Single Pre-Defined Value Selected
C21630 Instability assessment method type InstabAssmntMethdTyp Type of method(s) used to determine the presence of hip instability Type of method(s) used to determine the presence of hip instabilit If yes, method of assessment Observation;Palpation;Radiographs Observation;Palpation;Radiographs Alphanumeric

(Check all that apply)

 O'Brien MF. (2005). Spinal Deformity Study Group Radiographic Measurement Manual Medtronic Sofamor Danek USA, Inc. Adult;Pediatric Supplemental 3.00 2013-07-17 09:26:36.973 Clinical Assessment Physical Examinations Assessments and Examinations

Multiple Pre-Defined Values Selected
C06316 Menstruation scale MenstruationScale Scale for how the female participant's menstruation is affected by the spinal cord injury Scale for how the female participant's menstruation is affected by the spinal cord injur Menstruation Normal;Reduced/altered;Unknown;Not applicable (For female);Not applicable (Patient male) Refers to no change in duration, frequency or quantity of menstrual flow and no change in subjective experience or symptoms of menstruation after the spinal cord lesion;i.e. Menstruation has been initiated, though partially impaired or changed. This refers to a change in the duration, frequency or amount of menstrual blood flow after spinal cord lesion. It can also refer to a change in the quality of sensations or other autonomic phenomena associated with menses;Means the impact of the spinal cord lesion on menstruation is unknown;Means the woman was not menstruating at the time of spinal cord lesion, thus there is not an impact on menstruation; Alphanumeric

Choose one
Normal refers to no change in duration, frequency or quantity of menstrual flow and no change in subjective experience or symptoms of menstruation after the spinal cord lesion.
Reduced/altered, i.e. menstruation has been initiated, though partially impaired or changed. This refers to a change in theduration, frequency or amount of menstrual blood flow after spinal cord lesion. It can also refer to a change in the quality of sensations or other autonomic phenomena associated with menses.
Unknown means the impact of the spinal cord lesion on menstruation is unknown.
Not applicable means the woman was not menstruating at the time of spinal cord lesion, thus there is not an impact on menstruation.

 Alexander MS, Biering-S&Oslash;rensen F, Elliott S, Kreuter M, S&Oslash;nksen J. International Spinal Cord Injury Female Sexual and Reproductive Function Basic Data Set. Spinal Cord. 2011 Jul;49(7):787-90. Adult;Pediatric Supplemental 3.00 2013-07-17 09:26:36.973 Clinical Assessment Physical Examinations Assessments and Examinations

Single Pre-Defined Value Selected
C17418 Urine dipstick test leukocyte esterase status UrDipstckTstLeukEstrseStatus Status of leukocyte esterase presence in urine dipstick test which indicates the presence of white blood cells in a urine sample Status of leukocyte esterase presence in urine dipstick test which indicates the presence of white blood cells in a urine sampl Urine dipstick test for leukocyte esterase (tick one only): Negative;Positive;Unknown Negative;Positive;Unknown Alphanumeric

The results can be recorded as negative, positive or unknown. An unknown result could occur from the test being unreadable, unusable, or not done.

 Goetz LL, Cardenas DD, Kennelly M, Bonne Lee BS, Linsenmeyer T, Moser C, Pannek J, Wyndaele JJ, Biering-Sorensen F. International spinal cord injury urinary tract infection basic data set. Spinal Cord. 2013 Sep;51(9):700-4. doi: 10.1038/sc.2013.72. Adult;Pediatric Supplemental 3.00 2013-07-17 09:26:36.973 Clinical Assessment Physical Examinations Assessments and Examinations

Single Pre-Defined Value Selected
C18790 Perianal problem other text PerianlProbOTH The free-text field related to Perianal problem type' specifying other text. Type of problem with the anus found in the perianal space The free-text field related to Perianal problem type' specifying other text. Type of problem with the anus found in the perianal space Other, specify Alphanumeric

For each perianal problem indicate if it was experienced. Perianal problems may change with time and only those present within the last year should be noted.

 Krogh K, Perkash I, Stiens SA, Biering-S&Oslash;rensen F. International bowel function basic spinal cord injury data set. Spinal Cord. 2009 Mar;47(3):230-4 Adult;Pediatric Supplemental 3.00 2013-07-17 09:26:36.973 Clinical Assessment Physical Examinations Assessments and Examinations 4000

Free-Form Entry
C06220 Fecal incontinence liquid stools frequency FclIncntncLiqStlFreq The frequency of fecal incontinence to liquid stools within the last three months. The frequency of fecal incontinence to liquid stools within the last three months. Frequency of incontinence to liquid stools (within the last three months): Two or more episodes per day;Once daily;Not every day but at least once per week;Not every week but more than once per month;Once per month;Less than once per month;Never;Not applicable;Unknown Two or more episodes per day;Once daily;Not every day but at least once per week;Not every week but more than once per month;Once per month;Less than once per month;Never;Not applicable;Unknown Alphanumeric

Choose one. If the individual has not had liquid stools within the last three months the code "Never" and not the code "Unknown" should be used. In individuals with episodes of fecal incontinence to liquid stools before the last three months without any episodes within in the last three months the code "Never" and not the code "Less than once per month" be should used. The code "Not applicable" is mainly for individuals with stomas.

 Krogh K, Perkash I, Stiens SA, Biering-S&Oslash;rensen F. International bowel function extended spinal cord injury data set. Spinal Cord. 2009 Mar;47(3):235-41. Adult;Pediatric Supplemental 3.00 2013-07-17 09:26:36.973 Clinical Assessment Physical Examinations Assessments and Examinations

Single Pre-Defined Value Selected
C06407 Thermoregulation other issue past three month result text ThermOthIssPstThreeMoResltTxt Indicator of whether the subject had other types of thermoregulation conditions or events after spinal cord lesion within the last three months Indicator of whether the subject had other types of thermoregulation conditions or events after spinal cord lesion within the last three month Thermoregulation history after spinal cord lesion within the last three months Other, specify Alphanumeric

Choose one. If yes than specify the condition.

 Karlsson AK, Krassioukov A, Alexander MS, Donovan W, Biering-S&Oslash;rensen F. International spinal cord injury skin and thermoregulation function basic data set. Spinal Cord. 2012 Jul;50(7):512-6. doi: 10.1038/sc.2011.167. Adult;Pediatric Supplemental 3.00 2013-07-17 09:26:36.973 Clinical Assessment Physical Examinations Assessments and Examinations 4000

Free-Form Entry
C05452 Spinal injury anatomic site SpnlInjAntmicSit Anatomic site(s) of the spine injury represented as level(s) of the spinal-injured vertebrae Anatomic site(s) of the spine injury represented as level(s) of the spinal-injured vertebra Spinal column injury level C0;C1;C2;C3;C4;C5;C6;C7;L1;L2;L3;L4;L5;S1;S2;S3;S4-5;T1;T2;T3;T4;T5;T6;T7;T8;T9;T10;T11;T12 C0;C1;C2;C3;C4;C5;C6;C7;L1;L2;L3;L4;L5;S1;S2;S3;S4-5;T1;T2;T3;T4;T5;T6;T7;T8;T9;T10;T11;T12 Alphanumeric

The element may be included if relevant to the study. For additional details like permissible values, see the data dictionary associated with this CRF.
The element may be included if relevant to the study. For additional details like permissible values, see the data dictionary associated with this CRF.
vC00 represents C0 and is the occiput.
The code vX99 should be used only if the level is completely unknown.
In the case of multiple spinal injuries, a separate entry will be completed for each spinal column injury level.

 Dvorak MF, Wing PC, Fehlings MG, Vaccaro AR, Itshayek E, Biering-Sorensen F, Noonan VK. International Spinal Cord Injury Spinal Column Injury Basic Data Set. Spinal Cord. 2012 Nov;50(11):817-821; doi: 10.1038/sc.2012.60. Adult;Pediatric Supplemental 3.00 2013-07-20 10:21:25.65 Clinical Assessment Physical Examinations Assessments and Examinations

Multiple Pre-Defined Values Selected
C06111 Pneumonia episode require hospitalization past year number PnmnaEpsdReqHsptlztnPstYrNum Number of pneumonia episodes requiring hospitalization occurring after the spinal cord lesion and within the last year Number of pneumonia episodes requiring hospitalization occurring after the spinal cord lesion and within the last year Number of episodes requiring hospitalization Numeric Values

Only answer if there is a history of pneumonia after spinal cord lesion and within the last year. If number of episodes is unknown then code 999 (999 = Unknown).

 Biering-S&Oslash;rensen F, Krassioukov A, Alexander MS, Donovan W, Karlsson AK, Mueller G, Perkash I, William Sheel A, Wecht J, Schilero GJ.International Spinal Cord Injury Pulmonary Function Basic Data Set. Spinal Cord. 2012 Jun; 50(6):418-21. Adult;Pediatric Supplemental 3.00 2013-07-17 09:26:36.973 Clinical Assessment Physical Examinations Assessments and Examinations

Free-Form Entry
C19357 Diagnosis new during hospital stay indicator DiagNewDuringHospStayInd New diagnoses during hospital stay New diagnoses during hospital stay New diagnosis (indicate SNOMED term and code), describe No;Yes;Unknown No;Yes;Unknown Alphanumeric

Choose one

 Adult;Pediatric Supplemental 1.00 2014-06-12 12:38:52.0 Clinical Assessment Physical Examinations Assessments and Examinations

Single Pre-Defined Value Selected
C06240 Bowel dysfunction impact life quality scale BwlDysfnctnImpctLifQualtyScale The self report scale that describes impact on quality of life caused by neurogenic bowel dysfunction. The self report scale that describes impact on quality of life caused by neurogenic bowel dysfunction. Self reported impact on quality of life due to bowel dysfunction Major impact;Some impact;Little impact;No impact;Unknown Major impact;Some impact;Little impact;No impact;Unknown Alphanumeric

Choose one. Self reported impact on quality of life caused by neurogenic bowel dysfunction covers the subject's own assessment of the impact of all aspects of neurogenic bowel dysfunction.

 Krogh K, Perkash I, Stiens SA, Biering-S&Oslash;rensen F. International bowel function extended spinal cord injury data set. Spinal Cord. 2009 Mar;47(3):235-41. Adult;Pediatric Supplemental 3.00 2013-07-17 09:26:36.973 Clinical Assessment Physical Examinations Assessments and Examinations

Single Pre-Defined Value Selected
C06447 Spasticity spasm indicator SpasctySpsmInd Indicator of the presence of spasticity/spasms Indicator of the presence of spasticity/spasms Presence of spasticity/spasms Yes;No;Unknown Yes;No;Unknown Alphanumeric

The presence of spasticity / spasms in the upper and lower extremities is captured using the modified Ashworth scale (MAS), i.e. greater than 1 on the MAS, or observation of spasms.

 Bohannon RW, Smith MB. Interrater reliability of a Modified Ashworth Scale of muscle spasticity. Physical Therapy. 1987:67:206-7.<br />Biering-S&Oslash;rensen F, Burns AS, Curt A, Harvey LA, Jane Mulcahey M, Nance PW, Sherwood AM, Sisto SA. International spinal cord injury musculoskeletal basic data set. Spinal Cord. 2012 Nov;50(11):797-802; doi: 10.1038/sc.2012.102.<br />Biering-S&Oslash;rensen F, Burns AS, Curt A, Harvey LA, Jane Mulcahey M, Nance PW, Sherwood AM, Sisto SA. International spinal cord injury musculoskeletal basic data set. Spinal Cord. 2012 Nov;50(11):797-802; doi: 10.1038/sc.2012.102. Adult;Pediatric Supplemental 3.00 2013-07-17 09:26:36.973 Clinical Assessment Physical Examinations Assessments and Examinations

Single Pre-Defined Value Selected
CSV