ID

16505

Description

Medical history form, Study hospital, Medical Faculty Münster derived from Medical history form by Dr. Schusdziarra

Keywords

  1. 7/20/16 7/20/16 -
  2. 7/20/16 7/20/16 -
  3. 7/21/16 7/21/16 -
Uploaded on

July 20, 2016

DOI

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License

Creative Commons BY-NC 3.0

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Study hospital, Medical Faculty Münster- Clinical Examination findings

Clinical Examination findings

Demographics
Description

Demographics

Patient Name
Description

Patient Name

Data type

text

Alias
UMLS CUI [1]
C1299487
Patient date of birth
Description

Birth date

Data type

date

Alias
UMLS CUI [1]
C0421451
Patient Occupation
Description

Occupation

Data type

text

Alias
UMLS CUI [1]
C0421456
Physical Examination Date
Description

Physical Examination Date

Data type

date

Alias
UMLS CUI [1,1]
C0031809
UMLS CUI [1,2]
C0011008
Treating physician
Description

Treating physician

Data type

text

Alias
UMLS CUI [1]
C1710470
General Health assessment
Description

General Health assessment

Overall impression
Description

Overall impression

Data type

integer

Alias
UMLS CUI [1]
C2973287
Speech
Description

Speech

Data type

integer

Alias
UMLS CUI [1]
C0037817
Physical strength
Description

Physical strength

Data type

integer

Alias
UMLS CUI [1]
C0237897
Somatotype
Description

Somatotype

Data type

integer

Alias
UMLS CUI [1]
C0037669
Gait
Description

Gait

Data type

integer

Alias
UMLS CUI [1]
C0016928
Gait:Please specify the nature of disability
Description

Gait

Data type

text

Alias
UMLS CUI [1]
C0016928
Movements
Description

Movements

Data type

integer

Alias
UMLS CUI [1]
C0026649
Nutritional status
Description

Nutritional status

Data type

integer

Alias
UMLS CUI [1]
C0392209
Body weight
Description

Weight

Data type

float

Alias
UMLS CUI [1]
C0005910
Body height
Description

Height

Data type

float

Alias
UMLS CUI [1]
C0005890
Muscle mass
Description

Muscle mass

Data type

integer

Alias
UMLS CUI [1]
C0240417
Facial expressions
Description

Facial expressions

Data type

integer

Alias
UMLS CUI [1]
C0015457
Body Temperature
Description

Body Temperature

Data type

float

Alias
UMLS CUI [1]
C0005903
Skin assessment
Description

Skin assessment

Skin color
Description

Skin color

Data type

integer

Alias
UMLS CUI [1]
C0599910
Skin lesions
Description

Skin lesions

Data type

integer

Alias
UMLS CUI [1]
C0037284
Bleeding
Description

Bleeding

Data type

integer

Alias
UMLS CUI [1]
C0005779
Vascular markings
Description

Vascular markings

Data type

integer

Alias
UMLS CUI [1]
C4068833
Head assessment
Description

Head assessment

Skull:Shape
Description

Skull

Data type

text

Alias
UMLS CUI [1]
C0037303
Skull: percussion pain
Description

Skull

Data type

text

Alias
UMLS CUI [1]
C0037303
Skull: Hair growth
Description

Skull

Data type

text

Alias
UMLS CUI [1]
C0037303
Facial bones: Asymmetry, scars
Description

Facial bones

Data type

text

Alias
UMLS CUI [1]
C0015455
Nerve exit points
Description

Nerve exit points

Data type

integer

Alias
UMLS CUI [1]
C0848189
Assessment of Lymph nodes
Description

Assessment of Lymph nodes

Lymph nodes: Pressure tenderness
Description

Lymph nodes

Data type

integer

Alias
UMLS CUI [1]
C0024204
Lymph nodes: Size
Description

Lymph nodes

Data type

integer

Alias
UMLS CUI [1]
C0024204
Lymph nodes: Consistency
Description

Lymph nodes

Data type

integer

Alias
UMLS CUI [1]
C0024204
Lymph nodes: displaceability
Description

Lymph nodes

Data type

integer

Alias
UMLS CUI [1]
C0024204
Eyes
Description

Eyes

Eyelids
Description

Eyelids

Data type

integer

Alias
UMLS CUI [1]
C0015426
Sclera:Color
Description

Sclera

Data type

text

Alias
UMLS CUI [1]
C0036410
Pupils
Description

Pupils

Data type

integer

Alias
UMLS CUI [1]
C0034121
Pupil reaction
Description

Pupil reaction

Data type

integer

Alias
UMLS CUI [1,1]
C1287558
UMLS CUI [1,2]
C0205091
Eyeballs
Description

Eyeballs

Data type

integer

Alias
UMLS CUI [1]
C0015392
Visus
Description

Visus

Data type

integer

Alias
UMLS CUI [1]
C0042812
Conjunctiva
Description

Conjunctiva

Data type

integer

Alias
UMLS CUI [1]
C0009758
Ears
Description

Ears

Auricle
Description

Auricle

Data type

text

Alias
UMLS CUI [1]
C0928075
External auditory canal
Description

External auditory canal

Data type

text

Alias
UMLS CUI [1]
C0013444
Hearing
Description

Hearing

Data type

text

Alias
UMLS CUI [1]
C0018767
Nose
Description

Nose

Nasal airway patency
Description

Nasal airway patency

Data type

text

Alias
UMLS CUI [1]
C0429212
Mucous Membrane: Color, secretion
Description

Mucous Membrane

Data type

text

Alias
UMLS CUI [1]
C0026724
Oral cavity
Description

Oral cavity

Tongue: Moisture, plaque, movement
Description

Tongue

Data type

text

Alias
UMLS CUI [1]
C0040408
Tonsils: Size, plaques
Description

Tonsils

Data type

text

Alias
UMLS CUI [1]
C0836921
Tonsils: normal
Description

Tonsils

Data type

boolean

Alias
UMLS CUI [1]
C0836921
Dentures
Description

Dentures

Data type

integer

Alias
UMLS CUI [1]
C0011394
Waldeyers ring
Description

Waldeyers ring

Data type

integer

Alias
UMLS CUI [1]
C0459892
Lips:Color, Moisture, skin lesions
Description

Lips

Data type

text

Alias
UMLS CUI [1]
C0023759
Neck
Description

Neck

Thyroid gland
Description

Thyroid gland

Data type

integer

Alias
UMLS CUI [1]
C0040132
Neck circumference
Description

Neck circumference

Data type

integer

Alias
UMLS CUI [1]
C1630403
Blood vessels
Description

Blood vessels

Data type

integer

Alias
UMLS CUI [1]
C0005847
Larynx
Description

Larynx

Data type

text

Alias
UMLS CUI [1]
C0023078
Thorax
Description

Thorax

Form of thorax
Description

Form of thorax

Data type

integer

Alias
UMLS CUI [1]
C0426786
Breathing
Description

Breathing

Data type

integer

Alias
UMLS CUI [1]
C0035203
Respiratory rate
Description

Respiratory rate

Data type

integer

Alias
UMLS CUI [1]
C0231832
Respiratory rhythm
Description

Respiratory rhythm

Data type

text

Alias
UMLS CUI [1]
C0231842
Inspiratory chest circumference
Description

Inspiratory circumference

Data type

integer

Alias
UMLS CUI [1,1]
C0424683
UMLS CUI [1,2]
C0004048
Exspiratory chest circumference
Description

Exspiratory circumference

Data type

integer

Alias
UMLS CUI [1,1]
C0424683
UMLS CUI [1,2]
C0231800
Vertebral column
Description

Vertebral column

Data type

integer

Alias
UMLS CUI [1]
C0037949
Mammae: Size,Symmetry, distance of mamillae, knots, retractions
Description

Mammae

Data type

text

Lungs
Description

Lungs

Chest percussion
Description

Chest percussion

Data type

integer

Alias
UMLS CUI [1]
C1285807
Inferior margin of lower lobe of lung, right side
Description

Inferior margin of lower lobe of lung

Data type

text

Alias
UMLS CUI [1]
C0507801
Inferior margin of lower lobe of lung, left side
Description

Inferior margin of lower lobe of lung

Data type

text

Alias
UMLS CUI [1]
C0507801
Mobility of right lung margin
Description

Mobility of lung margin

Data type

text

Alias
UMLS CUI [1,1]
C2371451
UMLS CUI [1,2]
C0225690
Mobility of left lung margin
Description

Mobility of lung margin

Data type

text

Alias
UMLS CUI [1,1]
C2371451
UMLS CUI [1,2]
C0225690
Respiratory Sounds
Description

Respiratory Sounds

Data type

integer

Alias
UMLS CUI [1]
C0035234
Abnormal breath sounds
Description

Abnormal breath sounds

Data type

integer

Alias
UMLS CUI [1]
C0231856
Heart
Description

Heart

Right heart margin
Description

Heart margin

Data type

integer

Alias
UMLS CUI [1]
C0225818
Left heart margin
Description

Heart margin

Data type

integer

Alias
UMLS CUI [1]
C0225819
Apex beat
Description

Apex beat

Data type

integer

Alias
UMLS CUI [1]
C0277909
Apex beat localization
Description

Position of apex beat

Data type

text

Alias
UMLS CUI [1]
C1287711
Heart sounds
Description

Heart sounds

Data type

integer

Alias
UMLS CUI [1]
C0018820
Cardiac activity
Description

Cardiac activity

Data type

integer

Alias
UMLS CUI [1]
C0443168
Heart rate
Description

Frequency, pulse deficit

Data type

text

Alias
UMLS CUI [1]
C0018810
Blood pressure
Description

Right/left

Data type

text

Alias
UMLS CUI [1]
C0005823
Pulse deficit
Description

Pulse deficit

Data type

integer

Alias
UMLS CUI [1]
C0237313
Abdominal Examination
Description

Abdominal Examination

Abdominal shape symmetrical?
Description

Abdominal shape

Data type

boolean

Alias
UMLS CUI [1]
C2230330
Abdominal wall
Description

Abdominal wall

Data type

integer

Alias
UMLS CUI [1]
C1269041
Hernia
Description

Hernia

Data type

integer

Alias
UMLS CUI [1]
C0019270
Palpation tenderness:localization
Description

Palpation tenderness

Data type

text

Alias
UMLS CUI [1]
C0232498
Palpation tenderness
Description

Palpation tenderness

Data type

integer

Alias
UMLS CUI [1]
C0232498
Intraabdominal resistance:localization
Description

Intraabdominal resistance

Data type

text

Alias
UMLS CUI [1]
C1562335
Intraabdominal resistance: expanse
Description

Intraabdominal resistance

Data type

text

Alias
UMLS CUI [1]
C1562335
Intraabdominal resistance:Consistency
Description

Intraabdominal resistance

Data type

text

Alias
UMLS CUI [1]
C1562335
Intraabdominal resistance:pressure pain
Description

Intraabdominal resistance

Data type

text

Alias
UMLS CUI [1]
C1562335
Intraabdominal resistance:pulsation
Description

Intraabdominal resistance

Data type

text

Alias
UMLS CUI [1]
C1562335
Intraabdominal resistance:None
Description

Intraabdominal resistance

Data type

boolean

Alias
UMLS CUI [1]
C1562335
Ascites
Description

Ascites

Data type

boolean

Alias
UMLS CUI [1]
C0003962
Ascites: abdominal circumference
Description

Ascites

Data type

integer

Alias
UMLS CUI [1]
C0003962
Bowel sounds
Description

Bowel sounds

Data type

integer

Alias
UMLS CUI [1]
C0232693
Liver
Description

Liver

Liver size
Description

Liver size

Data type

integer

Alias
UMLS CUI [1]
C0426688
Liver consistency
Description

Liver consistency

Data type

integer

Alias
UMLS CUI [1]
C1285892
Liver surface
Description

Liver surface

Data type

integer

Alias
UMLS CUI [1]
C0458922
Liver margin
Description

Liver margin

Data type

integer

Alias
UMLS CUI [1]
C2329884
Liver pain
Description

Liver pain

Data type

integer

Alias
UMLS CUI [1]
C0522067
Spleen
Description

Spleen

Spleen palpation: consistency
Description

Spleen palpation: consistency

Data type

text

Alias
UMLS CUI [1]
C0030250
Spleen palpation
Description

Spleen palpation

Data type

integer

Alias
UMLS CUI [1]
C0030250
Fibrous capsule of kidney
Description

Fibrous capsule of kidney

Fibrous capsule of kidney
Description

Fibrous capsule of kidney

Data type

integer

Alias
UMLS CUI [1]
C0227616
Rectal examination
Description

Rectal examination

Rectal inspection
Description

Rectal inspection

Data type

integer

Alias
UMLS CUI [1]
C0582103
Rectal palpation
Description

Rectal palpation

Data type

integer

Alias
UMLS CUI [1]
C1384593
Prostate: Size
Description

Prostate

Data type

text

Alias
UMLS CUI [1]
C0033572
Prostate: Consistency
Description

Prostate

Data type

text

Alias
UMLS CUI [1]
C0033572
Prostate: Nodules
Description

Prostate

Data type

text

Alias
UMLS CUI [1]
C0033572
Prostate: Pressure pain
Description

Prostate

Data type

text

Alias
UMLS CUI [1]
C0033572
Genitalia
Description

Genitalia

Genitalia normal
Description

Genitalia

Data type

boolean

Alias
UMLS CUI [1]
C0017420
Pubic hair
Description

Pubic hair

Data type

text

Alias
UMLS CUI [1]
C1305636
Genitalia shape
Description

Genitalia shape

Data type

text

Alias
UMLS CUI [1]
C1820234
Testicle size
Description

Testicle size

Data type

text

Alias
UMLS CUI [1]
C0426327
Extremities
Description

Extremities

Axis of limb
Description

Axis of limb

Data type

text

Alias
UMLS CUI [1]
C1183516
Active Range of Motion
Description

Active Range of Motion

Data type

text

Alias
UMLS CUI [1]
C1879548
Passive Range of Motion
Description

Passive Range of Motion

Data type

text

Alias
UMLS CUI [1]
C0079991
Skeletal muscle structure
Description

Skeletal muscle structure

Data type

text

Alias
UMLS CUI [1]
C0242692
Joint swelling
Description

Joint swelling

Data type

text

Alias
UMLS CUI [1]
C0152031
Joint pain
Description

Joint pain

Data type

text

Alias
UMLS CUI [1]
C0003862
Flexion
Description

Flexion

Data type

integer

Alias
UMLS CUI [1]
C0231452
Extension
Description

Extension

Data type

integer

Alias
UMLS CUI [1]
C0522009
Joint:specify location
Description

Joint

Data type

text

Alias
UMLS CUI [1]
C0022417
Vascular status
Description

Vascular status

Pulse taking: Palpation of A.carotis communis
Description

Pulse taking

Data type

integer

Alias
UMLS CUI [1,1]
C0034107
UMLS CUI [1,2]
C0162859
Pulse taking: Palpation of A.brachialis
Description

Pulse taking

Data type

integer

Alias
UMLS CUI [1,1]
C0034107
UMLS CUI [1,2]
C1096531
Pulse taking: Palpation of A.radialis
Description

Pulse taking

Data type

integer

Alias
UMLS CUI [1,1]
C0034107
UMLS CUI [1,2]
C0204685
Pulse taking: Palpation of A.femoralis
Description

Pulse taking

Data type

integer

Alias
UMLS CUI [1,1]
C0034107
UMLS CUI [1,2]
C0232148
Pulse taking: Palpation of A.poplitea
Description

Pulse taking

Data type

integer

Alias
UMLS CUI [1,1]
C0034107
UMLS CUI [1,2]
C0232151
Pulse taking: Palpation of A.dorsalis pedis
Description

Pulse taking

Data type

integer

Alias
UMLS CUI [1,1]
C0034107
UMLS CUI [1,2]
C1706488
Pulse taking: Palpation of A.tibialis posterior
Description

Pulse taking

Data type

integer

Alias
UMLS CUI [1,1]
C0034107
UMLS CUI [1,2]
C2366939
UMLS CUI [1,3]
C2366972
Auscultation of Aortic murmur and heart murmur
Description

Auscultation of Aortic murmur and heart murmur

Data type

text

Alias
UMLS CUI [1,1]
C0586288
UMLS CUI [1,2]
C0004339
UMLS CUI [2,1]
C0586288
UMLS CUI [2,2]
C0232222
Neurologic status
Description

Neurologic status

Assessment of neurologic status
Description

Assessment of neurologic status

Data type

text

Alias
UMLS CUI [1]
C0746866
Central nervous system
Description

Central nervous system

Consciousness
Description

Consciousness

Data type

integer

Alias
UMLS CUI [1]
C0517960
Orientation as to time, place and personal
Description

Orientation

Data type

text

Alias
UMLS CUI [1]
C0029266
Mood
Description

Mood

Data type

integer

Alias
UMLS CUI [1]
C0026516
Psychomotor
Description

Psychomotor

Data type

integer

Alias
UMLS CUI [1]
C0033923
Peripheral nervous system
Description

Peripheral nervous system

Active innervation and function of head and extremities
Description

Active innervation and function of head and extremities

Data type

integer

Alias
UMLS CUI [1]
C0026828
Physiological reflexes
Description

Biceps reflex, Triceps reflex, brachioradial reflex, patellar reflex, Triceps-surae-Reflex, multisynaptic reflex of abdominal skin

Data type

integer

Alias
UMLS CUI [1]
C0034929
Abnormal reflexes: Babinsky reflex
Description

Abnormal reflexes

Data type

integer

Alias
UMLS CUI [1]
C0034935
Coordination
Description

Coordination

Data type

text

Alias
UMLS CUI [1]
C0242414
Sensitivity
Description

Sensitivity

Data type

text

Alias
UMLS CUI [1]
C1522640
Combined Functions:Romberg, Unterberger
Description

Combined Functions

Data type

text

Alias
UMLS CUI [1]
C1260928
UMLS CUI [2]
C0456756
Diagnosis
Description

Diagnosis

Diagnosis or tentative diagnosis
Description

Diagnosis or tentative diagnosis based on medical history and clinical examination

Data type

text

Alias
UMLS CUI [1]
C0011900

Similar models

Clinical Examination findings

Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Demographics
Patient Name
Item
Patient Name
text
C1299487 (UMLS CUI [1])
Birth date
Item
Patient date of birth
date
C0421451 (UMLS CUI [1])
Occupation
Item
Patient Occupation
text
C0421456 (UMLS CUI [1])
Physical Examination Date
Item
Physical Examination Date
date
C0031809 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Treating physician
Item
Treating physician
text
C1710470 (UMLS CUI [1])
Item Group
General Health assessment
Item
Overall impression
integer
C2973287 (UMLS CUI [1])
Code List
Overall impression
CL Item
Normal (1)
CL Item
Feeble (2)
CL Item
Critically ill (3)
Item
Speech
integer
C0037817 (UMLS CUI [1])
Code List
Speech
CL Item
Normal (1)
CL Item
Slurred speech (2)
CL Item
Hoarse (3)
CL Item
Stutter (4)
Item
Physical strength
integer
C0237897 (UMLS CUI [1])
Code List
Physical strength
CL Item
Normal (1)
CL Item
Reduced (2)
CL Item
Trained (3)
Item
Somatotype
integer
C0037669 (UMLS CUI [1])
Code List
Somatotype
CL Item
ectomorph (1)
CL Item
endomorph (2)
CL Item
mesomorph (3)
CL Item
cross type (4)
Item
Gait
integer
C0016928 (UMLS CUI [1])
Code List
Gait
CL Item
Normal (1)
CL Item
Erect (2)
CL Item
Piked (3)
CL Item
Disability (specify) (4)
Gait
Item
Gait:Please specify the nature of disability
text
C0016928 (UMLS CUI [1])
Item
Movements
integer
C0026649 (UMLS CUI [1])
Code List
Movements
CL Item
Normal (1)
CL Item
Impaired (2)
CL Item
Restless (3)
CL Item
Tremor (4)
Item
Nutritional status
integer
C0392209 (UMLS CUI [1])
Code List
Nutritional status
CL Item
Normal (1)
CL Item
Skinny (2)
CL Item
Cachexia (3)
CL Item
Adipose (4)
Weight
Item
Body weight
float
C0005910 (UMLS CUI [1])
Height
Item
Body height
float
C0005890 (UMLS CUI [1])
Item
Muscle mass
integer
C0240417 (UMLS CUI [1])
Code List
Muscle mass
CL Item
Average (1)
CL Item
Strong (2)
CL Item
Atrophic (3)
Item
Facial expressions
integer
C0015457 (UMLS CUI [1])
Code List
Facial expressions
CL Item
Normal (1)
CL Item
Face rigidity (2)
Body Temperature
Item
Body Temperature
float
C0005903 (UMLS CUI [1])
Item Group
Skin assessment
Item
Skin color
integer
C0599910 (UMLS CUI [1])
Code List
Skin color
CL Item
Normal (1)
CL Item
Pale (2)
CL Item
Reddened (3)
CL Item
Cyanotic (4)
CL Item
Jaundice (5)
CL Item
Pigmented (6)
Item
Skin lesions
integer
C0037284 (UMLS CUI [1])
Code List
Skin lesions
CL Item
Urticaria (1)
CL Item
Papules (2)
CL Item
Abcesses (3)
CL Item
Skin lesions (4)
CL Item
Ulcers (5)
CL Item
Fissures (6)
Item
Bleeding
integer
C0005779 (UMLS CUI [1])
Code List
Bleeding
CL Item
Petechiae (1)
CL Item
Ecchymosis (2)
CL Item
Suggillation (3)
CL Item
Suffusions (4)
Item
Vascular markings
integer
C4068833 (UMLS CUI [1])
Code List
Vascular markings
CL Item
Telangiectasia (1)
CL Item
Spider naevus (2)
CL Item
Angioma (3)
Item Group
Head assessment
Skull
Item
Skull:Shape
text
C0037303 (UMLS CUI [1])
Skull
Item
Skull: percussion pain
text
C0037303 (UMLS CUI [1])
Skull
Item
Skull: Hair growth
text
C0037303 (UMLS CUI [1])
Facial bones
Item
Facial bones: Asymmetry, scars
text
C0015455 (UMLS CUI [1])
Item
Nerve exit points
integer
C0848189 (UMLS CUI [1])
Code List
Nerve exit points
CL Item
Normal (1)
CL Item
Pressure tenderness (2)
Item Group
Assessment of Lymph nodes
Item
Lymph nodes: Pressure tenderness
integer
C0024204 (UMLS CUI [1])
Code List
Lymph nodes: Pressure tenderness
CL Item
submandibular (1)
CL Item
cervical (2)
CL Item
preauricular (3)
CL Item
retroauricular (4)
CL Item
suboccipital (5)
CL Item
supraclavicular (6)
CL Item
axillary (7)
CL Item
inguinal (8)
Item
Lymph nodes: Size
integer
C0024204 (UMLS CUI [1])
Code List
Lymph nodes: Size
CL Item
submandibular (1)
CL Item
cervical (2)
CL Item
preauricular (3)
CL Item
retroauricular (4)
CL Item
suboccipital (5)
CL Item
supraclavicular (6)
CL Item
axillary (7)
CL Item
inguinal (8)
Item
Lymph nodes: Consistency
integer
C0024204 (UMLS CUI [1])
Code List
Lymph nodes: Consistency
CL Item
submandibular (1)
CL Item
cervical (2)
CL Item
preauricular (3)
CL Item
retroauricular (4)
CL Item
suboccipital (5)
CL Item
supraclavicular (6)
CL Item
axillary (7)
CL Item
inguinal (8)
Item
Lymph nodes: displaceability
integer
C0024204 (UMLS CUI [1])
Code List
Lymph nodes: displaceability
CL Item
submandibular (1)
CL Item
cervical (2)
CL Item
preauricular (3)
CL Item
retroauricular (4)
CL Item
suboccipital (5)
CL Item
supraclavicular (6)
CL Item
axillary (7)
CL Item
inguinal (8)
Item Group
Eyes
Item
Eyelids
integer
C0015426 (UMLS CUI [1])
Code List
Eyelids
CL Item
Ptosis (1)
CL Item
Edema (2)
Sclera
Item
Sclera:Color
text
C0036410 (UMLS CUI [1])
Item
Pupils
integer
C0034121 (UMLS CUI [1])
Code List
Pupils
CL Item
round (1)
CL Item
miosis (2)
CL Item
mydriasis (3)
CL Item
asymmetric (4)
Item
Pupil reaction
integer
C1287558 (UMLS CUI [1,1])
C0205091 (UMLS CUI [1,2])
Code List
Pupil reaction
CL Item
reaction to light  (1)
CL Item
direct (2)
CL Item
indirect (3)
CL Item
Accommodation (4)
Item
Eyeballs
integer
C0015392 (UMLS CUI [1])
Code List
Eyeballs
CL Item
Movements (1)
CL Item
Strabism (2)
CL Item
Nystagmus (3)
CL Item
Exophthalmus (4)
CL Item
Enophthalmus (5)
Item
Visus
integer
C0042812 (UMLS CUI [1])
Code List
Visus
CL Item
Normal (1)
CL Item
Reduced (2)
CL Item
Corrected (Glasses) (3)
Item
Conjunctiva
integer
C0009758 (UMLS CUI [1])
Code List
Conjunctiva
CL Item
Pale (1)
CL Item
Reddened (2)
Item Group
Ears
Auricle
Item
Auricle
text
C0928075 (UMLS CUI [1])
External auditory canal
Item
External auditory canal
text
C0013444 (UMLS CUI [1])
Hearing
Item
Hearing
text
C0018767 (UMLS CUI [1])
Item Group
Nose
Nasal airway patency
Item
Nasal airway patency
text
C0429212 (UMLS CUI [1])
Mucous Membrane
Item
Mucous Membrane: Color, secretion
text
C0026724 (UMLS CUI [1])
Item Group
Oral cavity
Tongue
Item
Tongue: Moisture, plaque, movement
text
C0040408 (UMLS CUI [1])
Tonsils
Item
Tonsils: Size, plaques
text
C0836921 (UMLS CUI [1])
Tonsils
Item
Tonsils: normal
boolean
C0836921 (UMLS CUI [1])
Item
Dentures
integer
C0011394 (UMLS CUI [1])
Code List
Dentures
CL Item
Restored (1)
CL Item
Caries (2)
CL Item
False teeth (3)
Item
Waldeyers ring
integer
C0459892 (UMLS CUI [1])
Code List
Waldeyers ring
CL Item
Normal (1)
CL Item
Reddened (2)
CL Item
Mucus (3)
CL Item
Purulence (4)
Lips
Item
Lips:Color, Moisture, skin lesions
text
C0023759 (UMLS CUI [1])
Item Group
Neck
Item
Thyroid gland
integer
C0040132 (UMLS CUI [1])
Code List
Thyroid gland
CL Item
Normal (1)
CL Item
Enlarged (2)
CL Item
Thyroid nodules (3)
CL Item
Whizz (4)
Neck circumference
Item
Neck circumference
integer
C1630403 (UMLS CUI [1])
Item
Blood vessels
integer
C0005847 (UMLS CUI [1])
Code List
Blood vessels
CL Item
Venous Engorgement (1)
CL Item
Bruit (2)
Larynx
Item
Larynx
text
C0023078 (UMLS CUI [1])
Item Group
Thorax
Item
Form of thorax
integer
C0426786 (UMLS CUI [1])
Code List
Form of thorax
CL Item
Normal (1)
CL Item
Barrel chest (2)
Item
Breathing
integer
C0035203 (UMLS CUI [1])
Code List
Breathing
CL Item
Normal (1)
CL Item
Symmetric (2)
Respiratory rate
Item
Respiratory rate
integer
C0231832 (UMLS CUI [1])
Respiratory rhythm
Item
Respiratory rhythm
text
C0231842 (UMLS CUI [1])
Inspiratory circumference
Item
Inspiratory chest circumference
integer
C0424683 (UMLS CUI [1,1])
C0004048 (UMLS CUI [1,2])
Exspiratory circumference
Item
Exspiratory chest circumference
integer
C0424683 (UMLS CUI [1,1])
C0231800 (UMLS CUI [1,2])
Item
Vertebral column
integer
C0037949 (UMLS CUI [1])
Code List
Vertebral column
CL Item
Normal (1)
CL Item
Enhanced chest kyphosis and lumbar lordosis (2)
CL Item
Scoliosis (3)
Mammae
Item
Mammae: Size,Symmetry, distance of mamillae, knots, retractions
text
Item Group
Lungs
Item
Chest percussion
integer
C1285807 (UMLS CUI [1])
Code List
Chest percussion
CL Item
sonoric (1)
CL Item
dull (2)
CL Item
hypersonoric (3)
CL Item
tympanitic (4)
Inferior margin of lower lobe of lung
Item
Inferior margin of lower lobe of lung, right side
text
C0507801 (UMLS CUI [1])
Inferior margin of lower lobe of lung
Item
Inferior margin of lower lobe of lung, left side
text
C0507801 (UMLS CUI [1])
Mobility of lung margin
Item
Mobility of right lung margin
text
C2371451 (UMLS CUI [1,1])
C0225690 (UMLS CUI [1,2])
Mobility of lung margin
Item
Mobility of left lung margin
text
C2371451 (UMLS CUI [1,1])
C0225690 (UMLS CUI [1,2])
Item
Respiratory Sounds
integer
C0035234 (UMLS CUI [1])
Code List
Respiratory Sounds
CL Item
vesicular (1)
CL Item
reduced (2)
CL Item
bronchial breathing (3)
Item
Abnormal breath sounds
integer
C0231856 (UMLS CUI [1])
Code List
Abnormal breath sounds
CL Item
Wheezing (1)
CL Item
Whistling sound (2)
CL Item
Humming sound (3)
CL Item
Fine rales (4)
CL Item
Medium rales (5)
CL Item
Coarse rales (6)
CL Item
Sounding rales (7)
CL Item
Non-sounding rales (8)
CL Item
Pleural Rub (9)
Item Group
Heart
Item
Right heart margin
integer
C0225818 (UMLS CUI [1])
Code List
Right heart margin
CL Item
normal (1)
CL Item
enlarged (2)
Item
Left heart margin
integer
C0225819 (UMLS CUI [1])
Code List
Left heart margin
CL Item
normal (1)
CL Item
enlarged (2)
Item
Apex beat
integer
C0277909 (UMLS CUI [1])
Code List
Apex beat
CL Item
not palpable (1)
CL Item
widened (2)
CL Item
raising (3)
Position of apex beat
Item
Apex beat localization
text
C1287711 (UMLS CUI [1])
Item
Heart sounds
integer
C0018820 (UMLS CUI [1])
Code List
Heart sounds
CL Item
Normal (1)
CL Item
Light (2)
CL Item
Pronounced (3)
CL Item
Split (4)
CL Item
Extra sounds (5)
CL Item
Heart murmur (6)
Item
Cardiac activity
integer
C0443168 (UMLS CUI [1])
Code List
Cardiac activity
CL Item
Regular rhythm (1)
CL Item
Arrhythmia absoluta (2)
CL Item
Extrasystoles (3)
Heart rate
Item
Heart rate
text
C0018810 (UMLS CUI [1])
Blood pressure
Item
Blood pressure
text
C0005823 (UMLS CUI [1])
Item
integer
C0237313 (UMLS CUI [1])
Code List
Pulse deficit
CL Item
 (1)
CL Item
 (2)
Item Group
Abdominal Examination
Abdominal shape
Item
Abdominal shape symmetrical?
boolean
C2230330 (UMLS CUI [1])
Item
Abdominal wall
integer
C1269041 (UMLS CUI [1])
Code List
Abdominal wall
CL Item
Soft (1)
CL Item
Sunken (2)
CL Item
adipose (3)
CL Item
scar(s) (4)
CL Item
abdominal rigidity (5)
Item
Hernia
integer
C0019270 (UMLS CUI [1])
Code List
Hernia
CL Item
Inguinal hernia (1)
CL Item
Umbilical hernia (2)
CL Item
Incisional hernia (3)
CL Item
Closed hernia (4)
Palpation tenderness
Item
Palpation tenderness:localization
text
C0232498 (UMLS CUI [1])
Item
Palpation tenderness
integer
C0232498 (UMLS CUI [1])
Code List
Palpation tenderness
CL Item
Circumscript (1)
CL Item
Diffuse (2)
Intraabdominal resistance
Item
Intraabdominal resistance:localization
text
C1562335 (UMLS CUI [1])
Intraabdominal resistance
Item
Intraabdominal resistance: expanse
text
C1562335 (UMLS CUI [1])
Intraabdominal resistance
Item
Intraabdominal resistance:Consistency
text
C1562335 (UMLS CUI [1])
Intraabdominal resistance
Item
Intraabdominal resistance:pressure pain
text
C1562335 (UMLS CUI [1])
Intraabdominal resistance
Item
Intraabdominal resistance:pulsation
text
C1562335 (UMLS CUI [1])
Intraabdominal resistance
Item
Intraabdominal resistance:None
boolean
C1562335 (UMLS CUI [1])
Ascites
Item
Ascites
boolean
C0003962 (UMLS CUI [1])
Ascites
Item
Ascites: abdominal circumference
integer
C0003962 (UMLS CUI [1])
Item
Bowel sounds
integer
C0232693 (UMLS CUI [1])
Code List
Bowel sounds
CL Item
Normal (1)
CL Item
Reduced (2)
CL Item
Dead silent (3)
CL Item
Increased (4)
Item Group
Liver
Liver size
Item
Liver size
integer
C0426688 (UMLS CUI [1])
Item
Liver consistency
integer
C1285892 (UMLS CUI [1])
Code List
Liver consistency
CL Item
Elasic (1)
CL Item
Soft (2)
CL Item
Coarse (3)
CL Item
Hard (4)
Item
Liver surface
integer
C0458922 (UMLS CUI [1])
Code List
Liver surface
CL Item
Smooth (1)
CL Item
Nodular liver (2)
Item
Liver margin
integer
C2329884 (UMLS CUI [1])
Code List
Liver margin
CL Item
Blunt (1)
CL Item
Pointed (2)
Item
Liver pain
integer
C0522067 (UMLS CUI [1])
Code List
Liver pain
CL Item
Indolent (1)
CL Item
Painful (2)
Item Group
Spleen
Spleen palpation: consistency
Item
Spleen palpation: consistency
text
C0030250 (UMLS CUI [1])
Item
Spleen palpation
integer
C0030250 (UMLS CUI [1])
Code List
Spleen palpation
CL Item
palpable (1)
CL Item
not palpable (2)
Item Group
Fibrous capsule of kidney
Item
Fibrous capsule of kidney
integer
C0227616 (UMLS CUI [1])
Code List
Fibrous capsule of kidney
CL Item
Normal (1)
CL Item
Painful on percussion (2)
CL Item
Pressure pain (3)
Item Group
Rectal examination
Item
Rectal inspection
integer
C0582103 (UMLS CUI [1])
Code List
Rectal inspection
CL Item
Fissures (1)
CL Item
Fistula (2)
CL Item
Hemorrhoides (3)
CL Item
Prolapse (4)
Item
Rectal palpation
integer
C1384593 (UMLS CUI [1])
Code List
Rectal palpation
CL Item
Ampulla recti normal (1)
CL Item
Palpable resistencies (2)
Prostate
Item
Prostate: Size
text
C0033572 (UMLS CUI [1])
Prostate
Item
Prostate: Consistency
text
C0033572 (UMLS CUI [1])
Prostate
Item
Prostate: Nodules
text
C0033572 (UMLS CUI [1])
Prostate
Item
Prostate: Pressure pain
text
C0033572 (UMLS CUI [1])
Item Group
Genitalia
Genitalia
Item
Genitalia normal
boolean
C0017420 (UMLS CUI [1])
Pubic hair
Item
Pubic hair
text
C1305636 (UMLS CUI [1])
Genitalia shape
Item
Genitalia shape
text
C1820234 (UMLS CUI [1])
Testicle size
Item
Testicle size
text
C0426327 (UMLS CUI [1])
Item Group
Extremities
Axis of limb
Item
Axis of limb
text
C1183516 (UMLS CUI [1])
Active Range of Motion
Item
Active Range of Motion
text
C1879548 (UMLS CUI [1])
Passive Range of Motion
Item
Passive Range of Motion
text
C0079991 (UMLS CUI [1])
Skeletal muscle structure
Item
Skeletal muscle structure
text
C0242692 (UMLS CUI [1])
Joint swelling
Item
Joint swelling
text
C0152031 (UMLS CUI [1])
Joint pain
Item
Joint pain
text
C0003862 (UMLS CUI [1])
Item
Flexion
integer
C0231452 (UMLS CUI [1])
Code List
Flexion
CL Item
normal (1)
CL Item
reduced (2)
Item
Extension
integer
C0522009 (UMLS CUI [1])
Code List
Extension
CL Item
normal (1)
CL Item
reduced (2)
Joint
Item
Joint:specify location
text
C0022417 (UMLS CUI [1])
Item Group
Vascular status
Item
Pulse taking: Palpation of A.carotis communis
integer
C0034107 (UMLS CUI [1,1])
C0162859 (UMLS CUI [1,2])
Code List
Pulse taking: Palpation of A.carotis communis
CL Item
palpable (1)
CL Item
not palpable (2)
CL Item
palpable but reduced (3)
Item
Pulse taking: Palpation of A.brachialis
integer
C0034107 (UMLS CUI [1,1])
C1096531 (UMLS CUI [1,2])
Code List
Pulse taking: Palpation of A.brachialis
CL Item
palpable (1)
CL Item
not palpable (2)
CL Item
palpable but reduced (3)
Item
Pulse taking: Palpation of A.radialis
integer
C0034107 (UMLS CUI [1,1])
C0204685 (UMLS CUI [1,2])
Code List
Pulse taking: Palpation of A.radialis
CL Item
palpable (1)
CL Item
not palpable (2)
CL Item
palpable but reduced (3)
Item
Pulse taking: Palpation of A.femoralis
integer
C0034107 (UMLS CUI [1,1])
C0232148 (UMLS CUI [1,2])
Code List
Pulse taking: Palpation of A.femoralis
CL Item
palpable (1)
CL Item
not palpable (2)
CL Item
palpable but reduced (3)
Item
Pulse taking: Palpation of A.poplitea
integer
C0034107 (UMLS CUI [1,1])
C0232151 (UMLS CUI [1,2])
Code List
Pulse taking: Palpation of A.poplitea
CL Item
palpable (1)
CL Item
not palpable (2)
CL Item
palpable but reduced (3)
Item
Pulse taking: Palpation of A.dorsalis pedis
integer
C0034107 (UMLS CUI [1,1])
C1706488 (UMLS CUI [1,2])
Code List
Pulse taking: Palpation of A.dorsalis pedis
CL Item
palpable (1)
CL Item
not palpable (2)
CL Item
palpable but reduced (3)
Item
Pulse taking: Palpation of A.tibialis posterior
integer
C0034107 (UMLS CUI [1,1])
C2366939 (UMLS CUI [1,2])
C2366972 (UMLS CUI [1,3])
Code List
Pulse taking: Palpation of A.tibialis posterior
CL Item
palpable (1)
CL Item
not palpable (2)
CL Item
palpable but reduced (3)
Auscultation of Aortic murmur and heart murmur
Item
Auscultation of Aortic murmur and heart murmur
text
C0586288 (UMLS CUI [1,1])
C0004339 (UMLS CUI [1,2])
C0586288 (UMLS CUI [2,1])
C0232222 (UMLS CUI [2,2])
Item Group
Neurologic status
Assessment of neurologic status
Item
Assessment of neurologic status
text
C0746866 (UMLS CUI [1])
Item Group
Central nervous system
Item
Consciousness
integer
C0517960 (UMLS CUI [1])
Code List
Consciousness
CL Item
Normal (1)
CL Item
Stuporous (2)
CL Item
Somnolent (3)
CL Item
Semicoma (4)
CL Item
Comatose (5)
Orientation
Item
Orientation as to time, place and personal
text
C0029266 (UMLS CUI [1])
Item
Mood
integer
C0026516 (UMLS CUI [1])
Code List
Mood
CL Item
Euphorical (1)
CL Item
Irritable (2)
CL Item
Anxious (3)
CL Item
Depressed (4)
Item
Psychomotor
integer
C0033923 (UMLS CUI [1])
Code List
Psychomotor
CL Item
Disinhibited (1)
CL Item
Impulsive (2)
CL Item
Retarded (3)
CL Item
Passive (4)
Item Group
Peripheral nervous system
Item
Active innervation and function of head and extremities
integer
C0026828 (UMLS CUI [1])
Code List
Active innervation and function of head and extremities
CL Item
Hemiplegia (1)
CL Item
Hemiparesis (2)
CL Item
Tetraparesis (3)
CL Item
Muscle Spasticity (4)
CL Item
Muscle Rigidity (5)
CL Item
Tremor (6)
Item
Physiological reflexes
integer
C0034929 (UMLS CUI [1])
Code List
Physiological reflexes
CL Item
Normal (1)
CL Item
Symmetrical (2)
CL Item
Brisk (3)
CL Item
Reduced (4)
Item
Abnormal reflexes: Babinsky reflex
integer
C0034935 (UMLS CUI [1])
Code List
Abnormal reflexes: Babinsky reflex
CL Item
Clonus exhaustible (1)
CL Item
Clonus inexhaustible (2)
Coordination
Item
Coordination
text
C0242414 (UMLS CUI [1])
Sensitivity
Item
Sensitivity
text
C1522640 (UMLS CUI [1])
Combined Functions
Item
Combined Functions:Romberg, Unterberger
text
C1260928 (UMLS CUI [1])
C0456756 (UMLS CUI [2])
Item Group
Diagnosis
Diagnosis or tentative diagnosis
Item
Diagnosis or tentative diagnosis
text
C0011900 (UMLS CUI [1])

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