CDE Detailed Report

Disease: Cerebral Palsy
Sub-Domain: Physical/Neurological Examination
CRF: Neurological Examination

Displaying 1 - 50 of 52
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
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;Cannot Assess Increased with clonus;Increased without clonus;Hypoactive;Absent;Cannot Assess Alphanumeric

Choose one for each limb

Adult;Pediatric Supplemental 1.00 2012-10-05 00:00:00.0 Neurological Examination 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 Adult;Pediatric Supplemental 3.00 2013-08-28 16:08:00.453 Neurological Examination Physical/Neurological Examination Assessments and Examinations 4000

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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

Adult;Pediatric Supplemental 1.00 2012-10-05 00:00:00.0 Neurological Examination Physical/Neurological Examination Assessments and Examinations

Single Pre-Defined Value Selected

C21107 Gait abnormality assessment other text GaitAbnrmlyAssmtOTH The free-text field for other type of abnormal gait The free-text field for other type of abnormal gait Other Gait Abnormalities, specify Alphanumeric Adult;Pediatric Supplemental 1.00 2015-06-02 16:08:00.0 Neurological Examination Physical/Neurological Examination Assessments and Examinations 4000

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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;Abnormal and bilateral;Abnormal and unilateral;Abnormal–Hypertonia;Abnormal–Hypotonia;Other, specify Abnormal - Decreased;Abnormal - Increased;Abnormal and bilateral;Abnormal and unilateral;Abnormal–Hypertonia;Abnormal–Hypotonia;Other, specify Alphanumeric

Choose one

Adult;Pediatric Supplemental 3.00 2013-08-28 16:08:00.453 Neurological Examination Physical/Neurological Examination Assessments and Examinations

Single Pre-Defined Value Selected

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.

Adult;Pediatric Supplemental 1.00 2012-10-05 00:00:00.0 Neurological Examination Physical/Neurological Examination Assessments and Examinations

Multiple Pre-Defined Values 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 Adult;Pediatric Supplemental 3.00 2013-08-28 16:08:00.453 Neurological Examination Physical/Neurological Examination Assessments and Examinations 4000

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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.

Adult;Pediatric Supplemental 3.00 2013-08-28 16:08:00.453 Neurological Examination Physical/Neurological Examination Assessments and Examinations

Multiple Pre-Defined Values Selected

C22887 Gait oxygen cost walking value GaitOxyCostWalkVal The metabolic cost of steady-state walking value (mL/kg/m) The metabolic cost of steady-state walking value (mL/kg/m) Oxygen cost during walking Alphanumeric Adult;Pediatric Supplemental 1.00 2016-12-05 14:01:41.0 Neurological Examination Physical/Neurological Examination Assessments and Examinations 4000

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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.

Adult;Pediatric Supplemental 3.00 2013-08-28 16:08:00.453 Neurological Examination Physical/Neurological Examination Assessments and Examinations

Single Pre-Defined Value Selected

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.

Adult;Pediatric Supplemental 1.00 2012-10-05 00:00:00.0 Neurological Examination Physical/Neurological Examination Assessments and Examinations

Multiple Pre-Defined Values 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 Adult;Pediatric Supplemental 3.00 2013-08-28 16:08:00.453 Neurological Examination Physical/Neurological Examination Assessments and Examinations 4000

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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;Unknown Yes;No;Cannot Assess;Unknown Alphanumeric

Specify type, if yes

Adult;Pediatric Supplemental 1.00 2012-10-05 00:00:00.0 Neurological Examination Physical/Neurological Examination Assessments and Examinations

Single Pre-Defined Value Selected

C22888 Gait daily step count GaitDailyStepCt The mean number of total steps taken in a full, usual day The mean number of total steps taken in a full, usual day Daily step counts Alphanumeric Adult;Pediatric Supplemental 1.00 2016-12-05 14:03:50.0 Neurological Examination 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;Cannot Assess Yes;No;Not assessed;Unknown;Cannot Assess Alphanumeric

Choose one for each anatomic site

Adult;Pediatric Supplemental 3.00 2013-08-28 16:08:00.453 Neurological Examination 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;Crouch Gait;Jump Gait Ataxic Gait;Hemiparetic Gait - Left side;Hemiparetic Gait - Right side;Diplegic Gait;Parkinsonian Gait;Other gait abnormalities;Crouch Gait;Jump Gait Alphanumeric

Choose best response.

Adult;Pediatric Supplemental 3.00 2013-08-28 16:08:00.453 Neurological Examination Physical/Neurological Examination Assessments and Examinations

Single Pre-Defined Value 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 Adult;Pediatric Supplemental 3.00 2013-08-28 16:08:00.453 Neurological Examination Physical/Neurological Examination Assessments and Examinations 4000

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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)

Adult;Pediatric Supplemental 1.00 2012-10-05 00:00:00.0 Neurological Examination Physical/Neurological Examination Assessments and Examinations

Single Pre-Defined Value Selected

C22889 Sensory system abnormality symptom description text SensySysAbnrmlySymptmDescTxt Text representing the patient's description of his/her abnormal symptoms in his/her sensory system. Text representing the patient's description of his/her abnormal symptoms in his/her sensory system. Patient Description of abnormal symptoms Alphanumeric Adult;Pediatric Supplemental 1.00 2016-12-05 14:10:55.0 Neurological Examination 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;Abnormal and bilateral;Abnormal and unilateral;Abnormal–Hypertonia;Abnormal–Hypotonia;Other, specify Abnormal - Decreased;Abnormal - Increased;Abnormal and bilateral;Abnormal and unilateral;Abnormal–Hypertonia;Abnormal–Hypotonia;Other, specify Alphanumeric

Choose one

Adult;Pediatric Supplemental 3.00 2013-08-28 16:08:00.453 Neurological Examination 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 asssessment Abnormal;Normal;Cannot Assess;Other, specify Abnormal;Normal;Cannot Assess;Other, specify Alphanumeric

Choose one. If abnormal answer questions 15a–15d.

Adult;Pediatric Supplemental 1.00 2012-10-05 00:00:00.0 Neurological Examination 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 Adult;Pediatric Supplemental 3.00 2013-08-28 16:08:00.453 Neurological Examination Physical/Neurological Examination Assessments and Examinations 4000

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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;Unknown Yes;No;Cannot Assess;Unknown Alphanumeric

Choose one for each global assessment type.

Adult;Pediatric Supplemental 3.00 2013-08-28 16:08:00.453 Neurological Examination 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, Unilateral;Left Unilateral;Bilateral Right Hemiparesis;Left Hemiparesis;Diplegia / Paraparesis;Quadriplegia / Quadraparesis;Peripheral Nerve Lesion(s), Neuropathic Weakness;Neuropathic weakness;Myopathic Weakness;Other, specify;Right, Unilateral;Left Unilateral;Bilateral Alphanumeric Adult;Pediatric Supplemental 3.00 2013-08-28 16:08:00.453 Neurological Examination 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.

Adult;Pediatric Supplemental 1.00 2012-10-05 00:00:00.0 Neurological Examination 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 Adult;Pediatric Supplemental 1.00 2012-10-05 00:00:00.0 Neurological Examination Physical/Neurological Examination Assessments and Examinations 4000

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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;Abnormal and bilateral;Abnormal and unilateral Abnormal and symmetric;Abnormal and asymmetric;Abnormal - Increased;Abnormal - Decreased;Abnormal and bilateral;Abnormal and unilateral Alphanumeric

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

Adult;Pediatric Supplemental 3.00 2013-08-28 16:08:00.453 Neurological Examination 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.

Adult;Pediatric Supplemental 1.00 2012-10-05 00:00:00.0 Neurological Examination Physical/Neurological Examination Assessments and Examinations

Single Pre-Defined Value Selected

C14469 Sensory system modalities affected type SensyModltyAffctTyp The type and location of the sensory receptor activated by a stimulus plays the primary role in coding the stimulus modality The type and location of the sensory receptor activated by a stimulus plays the primary role in coding the stimulus modality Sensory Modalities Affected Light Touch;Pain and Temperature;Vibration;Proprioception;Other, specify Light Touch;Pain and Temperature;Vibration;Proprioception;Other, specify Alphanumeric

Choose all that apply.

Adult;Pediatric Supplemental 1.00 2012-10-05 00:00:00.0 Neurological Examination Physical/Neurological Examination Assessments and Examinations

Multiple Pre-Defined Values 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 Laterality Bilateral;Left;Right;Unknown Bilateral;Left;Right;Unknown Alphanumeric

Record which of the cranial nerves are abnormal and the side. Choose only one.

Adult;Pediatric Supplemental 3.00 2013-08-28 16:08:00.453 Neurological Examination 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 Adult;Pediatric Supplemental 1.00 2012-10-05 00:00:00.0 Neurological Examination Physical/Neurological Examination Assessments and Examinations 4000

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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 Adult;Pediatric Supplemental 3.00 2013-08-28 16:08:00.453 Neurological Examination Physical/Neurological Examination Assessments and Examinations

Single Pre-Defined Value Selected

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.

Adult;Pediatric Supplemental 3.00 2013-08-28 16:08:00.453 Neurological Examination Physical/Neurological Examination Assessments and Examinations

Single Pre-Defined Value Selected

C18503 Assessment unable text AssmtUnableTxt The free-text field to explain why there was no assessment of nystagmus performed. The free-text field to explain why there was no assessment of nystagmus, involuntary movement of the eyeballs, performed. Cannot access, explain Alphanumeric Adult;Pediatric Supplemental 3.00 2013-07-30 14:29:49.047 Neurological Examination Physical/Neurological Examination Assessments and Examinations 255

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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;Not assessed;Unknown Yes;No;Not assessed;Unknown Alphanumeric Adult;Pediatric Supplemental 3.00 2013-08-28 16:08:00.453 Neurological Examination Physical/Neurological Examination Assessments and Examinations

Single Pre-Defined Value Selected

C18947 Sensory system global assessment other text SensySysGlobAssmtOTH The free-text field related to 'Sensory system global assessment result' specifying other text. The condition and ability of sensory system The free-text field related to 'Sensory system global assessment result' specifying other text. The condition and ability of sensory system Other, specify Alphanumeric Adult;Pediatric Supplemental 1.00 2012-10-05 00:00:00.0 Neurological Examination Physical/Neurological Examination Assessments and Examinations 4000

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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;Unknown Yes;No;Cannot Assess;Unknown Alphanumeric Adult;Pediatric Supplemental 3.00 2013-08-28 16:08:00.453 Neurological Examination 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;Other, specify;Cannot Assess Right upper extremity (RUE);Left upper extremity (LUE);Dysmetria;Slowness;Other, specify;Cannot Assess 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.

Adult;Pediatric Supplemental 3.00 2013-08-28 16:08:00.453 Neurological Examination Physical/Neurological Examination Assessments and Examinations

Multiple Pre-Defined Values Selected

C18504 Cranial nerves abnormality present text CranlNerveAbnrmlyPresTxt The free-text field to explain the abnormality of the cranial nerve identified. The free-text field to explain the abnormality of the cranial nerve identified. Explain Abnormality Alphanumeric

Indicate which of the following cranial nerves are abnormal.

Adult;Pediatric Supplemental 3.00 2013-07-30 14:29:49.047 Neurological Examination Physical/Neurological Examination Assessments and Examinations 255

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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.

Adult;Pediatric Supplemental 3.00 2013-07-22 16:57:17.79 Neurological Examination Physical/Neurological Examination Assessments and Examinations

Single Pre-Defined Value Selected

C18949 Sensory system modalities affected other text SensyModltyAffctOTH The free-text field related to 'Sensory system modalities affected type' specifying other text. The type and location of the sensory receptor activated by a stimulus plays the primary role in coding the stimulus modality The free-text field related to 'Sensory system modalities affected type' specifying other text. The type and location of the sensory receptor activated by a stimulus plays the primary role in coding the stimulus modality Other, specify Alphanumeric Adult;Pediatric Supplemental 1.00 2012-10-05 00:00:00.0 Neurological Examination Physical/Neurological Examination Assessments and Examinations 4000

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C14442 Muscle bulk assessment abnormality type MuscBulkAbnrmlyAssmtTyp The muscle bulk abnormality type The muscle bulk abnormality type If abnormal, indicate type Abnormal and symmetric;Abnormal and asymmetric;Abnormal - Increased;Abnormal - Decreased;Abnormal and bilateral;Abnormal and unilateral Abnormal and symmetric;Abnormal and asymmetric;Abnormal - Increased;Abnormal - Decreased;Abnormal and bilateral;Abnormal and unilateral Alphanumeric

Choose one.

Adult;Pediatric Supplemental 3.00 2013-08-28 16:08:00.453 Neurological Examination 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 11a and 11b.

Adult;Pediatric Supplemental 3.00 2013-08-28 16:08:00.453 Neurological Examination Physical/Neurological Examination Assessments and Examinations

Single Pre-Defined Value 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 Adult;Pediatric Supplemental 1.00 2012-10-05 00:00:00.0 Neurological Examination 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;Affect;Language;Language Naming;Language Reading;Language Repetition;Speech Attention;Working Memory;Recent Memory;Remote Memory;Spontaneous speech;Affect;Language;Language Naming;Language Reading;Language Repetition;Speech 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)

Adult;Pediatric Supplemental 1.00 2012-10-05 00:00:00.0 Neurological Examination Physical/Neurological Examination Assessments and Examinations

Multiple Pre-Defined Values Selected

C19500 Assessment performed date AssessmentPerformedDate The date of assessment of the examination being performed. The date of assessment of the examination being performed. Date of Exam Date or Date & Time Adult;Pediatric Supplemental 1.00 2014-06-18 08:10:12.0 Neurological Examination Physical/Neurological Examination Assessments and Examinations

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C14443 Muscle tone assessment anatomic site MuscToneAssmtAntmicSite Anatomic location of the muscle tone as part of the motor examination. Anatomic location of the muscle tone as part of the motor examination. Muscle Tone - global assessment Right upper extremity;Left upper extremity;Right lower extremity;Left lower extremity;Truncal tone Right upper extremity (RUE);Left upper extremity (LUE);Right lower extremity (RLE);Left lower extremity (LLE);Truncal tone Alphanumeric

Evaluate all extremities. Truncal tone – is recommended for pediatric studies only.

Adult;Pediatric Supplemental 3.00 2013-08-28 16:08:00.453 Neurological Examination 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 Elbow Flexors (Biceps Brachii);Left Elbow Flexors (Biceps Brachii);Right Leg Adductors;Left Leg Adductors;Right Knee Extensors (Quadriceps);Right Knee Flexors (Hamstrings);Left Knee Extensors (Quadriceps);Left Knee Flexors (Hamstrings);Right Plantar Flexors (Triceps Surae);Left Plantar Flexors (Triceps Surae) Right Arm;Left Arm;Right Leg;Left Leg;Right Elbow Flexors (Biceps Brachii);Left Elbow Flexors (Biceps Brachii);Right Leg Adductors;Left Leg Adductors;Right Knee Extensors (Quadriceps);Right Knee Flexors (Hamstrings);Left Knee Extensors (Quadriceps);Left Knee Flexors (Hamstrings);Right Plantar Flexors (Triceps Surae);Left Plantar Flexors (Triceps Surae) Alphanumeric

If reflexes abnormal record the results for each limb.

Adult;Pediatric Supplemental 1.00 2012-10-05 00:00:00.0 Neurological Examination Physical/Neurological Examination Assessments and Examinations

Single Pre-Defined Value 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)

Adult;Pediatric Supplemental 1.00 2012-10-05 00:00:00.0 Neurological Examination 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

Adult;Pediatric Supplemental 1.00 2012-10-05 00:00:00.0 Neurological Examination Physical/Neurological Examination Assessments and Examinations

Single Pre-Defined Value Selected

CSV