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
Overall impression
integer
C2973287 (UMLS CUI [1])
Code List
Overall impression
CL Item
Critically ill (3)
Item
Speech
integer
C0037817 (UMLS CUI [1])
CL Item
Slurred speech (2)
Item
Physical strength
integer
C0237897 (UMLS CUI [1])
Code List
Physical strength
Item
Somatotype
integer
C0037669 (UMLS CUI [1])
Item
Gait
integer
C0016928 (UMLS CUI [1])
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])
Item
Nutritional status
integer
C0392209 (UMLS CUI [1])
Code List
Nutritional status
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])
Item
Facial expressions
integer
C0015457 (UMLS CUI [1])
Code List
Facial expressions
CL Item
Face rigidity (2)
Body Temperature
Item
Body Temperature
float
C0005903 (UMLS CUI [1])
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
Pressure tenderness (2)
Item
Lymph nodes: Pressure tenderness
integer
C0024204 (UMLS CUI [1])
Code List
Lymph nodes: Pressure tenderness
CL Item
submandibular (1)
CL Item
retroauricular (4)
CL Item
supraclavicular (6)
Item
Lymph nodes: Size
integer
C0024204 (UMLS CUI [1])
Code List
Lymph nodes: Size
CL Item
submandibular (1)
CL Item
retroauricular (4)
CL Item
supraclavicular (6)
Item
Lymph nodes: Consistency
integer
C0024204 (UMLS CUI [1])
Code List
Lymph nodes: Consistency
CL Item
submandibular (1)
CL Item
retroauricular (4)
CL Item
supraclavicular (6)
Item
Lymph nodes: displaceability
integer
C0024204 (UMLS CUI [1])
Code List
Lymph nodes: displaceability
CL Item
submandibular (1)
CL Item
retroauricular (4)
CL Item
supraclavicular (6)
Item
Eyelids
integer
C0015426 (UMLS CUI [1])
Sclera
Item
Sclera:Color
text
C0036410 (UMLS CUI [1])
Item
Pupils
integer
C0034121 (UMLS CUI [1])
Item
Pupil reaction
integer
C1287558 (UMLS CUI [1,1])
C0205091 (UMLS CUI [1,2])
CL Item
reaction to light (1)
CL Item
Accommodation (4)
Item
Eyeballs
integer
C0015392 (UMLS CUI [1])
Item
Visus
integer
C0042812 (UMLS CUI [1])
CL Item
Corrected (Glasses) (3)
Item
Conjunctiva
integer
C0009758 (UMLS CUI [1])
Nasal airway patency
Item
Nasal airway patency
text
C0429212 (UMLS CUI [1])
Mucous Membrane
Item
Mucous Membrane: Color, secretion
text
C0026724 (UMLS CUI [1])
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])
Item
Waldeyers ring
integer
C0459892 (UMLS CUI [1])
Lips
Item
Lips:Color, Moisture, skin lesions
text
C0023759 (UMLS CUI [1])
Item
Form of thorax
integer
C0426786 (UMLS CUI [1])
Item
Breathing
integer
C0035203 (UMLS CUI [1])
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
Enhanced chest kyphosis and lumbar lordosis (2)
Mammae
Item
Mammae: Size,Symmetry, distance of mamillae, knots, retractions
text
Item
Chest percussion
integer
C1285807 (UMLS CUI [1])
Code List
Chest percussion
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
bronchial breathing (3)
Item
Abnormal breath sounds
integer
C0231856 (UMLS CUI [1])
Code List
Abnormal breath sounds
CL Item
Whistling sound (2)
CL Item
Humming sound (3)
CL Item
Sounding rales (7)
CL Item
Non-sounding rales (8)
Abdominal shape
Item
Abdominal shape symmetrical?
boolean
C2230330 (UMLS CUI [1])
Item
Abdominal wall
integer
C1269041 (UMLS CUI [1])
CL Item
abdominal rigidity (5)
Item
Hernia
integer
C0019270 (UMLS CUI [1])
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
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])
Spleen palpation: consistency
Item
Spleen palpation: consistency
text
C0030250 (UMLS CUI [1])
Item
Spleen palpation
integer
C0030250 (UMLS CUI [1])
Code List
Spleen palpation
Item
Fibrous capsule of kidney
integer
C0227616 (UMLS CUI [1])
Code List
Fibrous capsule of kidney
CL Item
Painful on percussion (2)
CL Item
Pressure pain (3)
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])
Item
Extension
integer
C0522009 (UMLS CUI [1])
Joint
Item
Joint:specify location
text
C0022417 (UMLS CUI [1])
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 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 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 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 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 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 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 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])
Assessment of neurologic status
Item
Assessment of neurologic status
text
C0746866 (UMLS CUI [1])
Item
Consciousness
integer
C0517960 (UMLS CUI [1])
Orientation
Item
Orientation as to time, place and personal
text
C0029266 (UMLS CUI [1])
Item
Mood
integer
C0026516 (UMLS CUI [1])
Item
Psychomotor
integer
C0033923 (UMLS CUI [1])
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
Muscle Spasticity (4)
CL Item
Muscle Rigidity (5)
Item
Physiological reflexes
integer
C0034929 (UMLS CUI [1])
Code List
Physiological reflexes
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])
Diagnosis or tentative diagnosis
Item
Diagnosis or tentative diagnosis
text
C0011900 (UMLS CUI [1])