ID

16506

Descripción

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

Palabras clave

Versiones (3)
  1. 20/7/16 20/7/16 -
  2. 20/7/16 20/7/16 -
  3. 21/7/16 21/7/16 -
Subido en

21 de julio de 2016

DOI

Para solicitar uno, por favor iniciar sesión.

Licencia

Creative Commons BY-NC 3.0
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Study hospital, Medical Faculty Münster- Clinical Examination findings

Alemán Inglés

Clinical Examination findings

1 formularios  
Demographics
Descripción

Demographics

Patient Name
Descripción

Patient Name

Tipo de datos

text

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

Birth date

Tipo de datos

date

Alias
UMLS CUI [1]
C0421451
Patient Occupation
Descripción

Occupation

Tipo de datos

text

Alias
UMLS CUI [1]
C0421456
Physical Examination Date
Descripción

Physical Examination Date

Tipo de datos

date

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

Treating physician

Tipo de datos

text

Alias
UMLS CUI [1]
C1710470
General Health assessment
Descripción

General Health assessment

Overall impression
Descripción

Overall impression

Tipo de datos

integer

Alias
UMLS CUI [1]
C2973287
Speech
Descripción

Speech

Tipo de datos

integer

Alias
UMLS CUI [1]
C0037817
Physical strength
Descripción

Physical strength

Tipo de datos

integer

Alias
UMLS CUI [1]
C0237897
Somatotype
Descripción

Somatotype

Tipo de datos

integer

Alias
UMLS CUI [1]
C0037669
Gait
Descripción

Gait

Tipo de datos

integer

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

Gait

Tipo de datos

text

Alias
UMLS CUI [1]
C0016928
Movements
Descripción

Movements

Tipo de datos

integer

Alias
UMLS CUI [1]
C0026649
Nutritional status
Descripción

Nutritional status

Tipo de datos

integer

Alias
UMLS CUI [1]
C0392209
Body weight
Descripción

Weight

Tipo de datos

float

Alias
UMLS CUI [1]
C0005910
Body height
Descripción

Height

Tipo de datos

float

Alias
UMLS CUI [1]
C0005890
Muscle mass
Descripción

Muscle mass

Tipo de datos

integer

Alias
UMLS CUI [1]
C0240417
Facial expressions
Descripción

Facial expressions

Tipo de datos

integer

Alias
UMLS CUI [1]
C0015457
Body Temperature
Descripción

Body Temperature

Tipo de datos

float

Alias
UMLS CUI [1]
C0005903
Skin assessment
Descripción

Skin assessment

Skin color
Descripción

Skin color

Tipo de datos

integer

Alias
UMLS CUI [1]
C0599910
Skin lesions
Descripción

Skin lesions

Tipo de datos

integer

Alias
UMLS CUI [1]
C0037284
Bleeding
Descripción

Bleeding

Tipo de datos

integer

Alias
UMLS CUI [1]
C0005779
Vascular markings
Descripción

Vascular markings

Tipo de datos

integer

Alias
UMLS CUI [1]
C4068833
Head assessment
Descripción

Head assessment

Skull:Shape
Descripción

Skull

Tipo de datos

text

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

Skull

Tipo de datos

text

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

Skull

Tipo de datos

text

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

Facial bones

Tipo de datos

text

Alias
UMLS CUI [1]
C0015455
Nerve exit points
Descripción

Nerve exit points

Tipo de datos

integer

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

Assessment of Lymph nodes

Lymph nodes: Pressure tenderness
Descripción

Lymph nodes

Tipo de datos

integer

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

Lymph nodes

Tipo de datos

integer

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

Lymph nodes

Tipo de datos

integer

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

Lymph nodes

Tipo de datos

integer

Alias
UMLS CUI [1]
C0024204
Eyes
Descripción

Eyes

Eyelids
Descripción

Eyelids

Tipo de datos

integer

Alias
UMLS CUI [1]
C0015426
Sclera:Color
Descripción

Sclera

Tipo de datos

text

Alias
UMLS CUI [1]
C0036410
Pupils
Descripción

Pupils

Tipo de datos

integer

Alias
UMLS CUI [1]
C0034121
Pupil reaction
Descripción

Pupil reaction

Tipo de datos

integer

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

Eyeballs

Tipo de datos

integer

Alias
UMLS CUI [1]
C0015392
Visus
Descripción

Visus

Tipo de datos

integer

Alias
UMLS CUI [1]
C0042812
Conjunctiva
Descripción

Conjunctiva

Tipo de datos

integer

Alias
UMLS CUI [1]
C0009758
Ears
Descripción

Ears

Auricle
Descripción

Auricle

Tipo de datos

text

Alias
UMLS CUI [1]
C0928075
External auditory canal
Descripción

External auditory canal

Tipo de datos

text

Alias
UMLS CUI [1]
C0013444
Hearing
Descripción

Hearing

Tipo de datos

text

Alias
UMLS CUI [1]
C0018767
Nose
Descripción

Nose

Nasal airway patency
Descripción

Nasal airway patency

Tipo de datos

text

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

Mucous Membrane

Tipo de datos

text

Alias
UMLS CUI [1]
C0026724
Oral cavity
Descripción

Oral cavity

Tongue: Moisture, plaque, movement
Descripción

Tongue

Tipo de datos

text

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

Tonsils

Tipo de datos

text

Alias
UMLS CUI [1]
C0836921
Tonsils: normal
Descripción

Tonsils

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0836921
Dentures
Descripción

Dentures

Tipo de datos

integer

Alias
UMLS CUI [1]
C0011394
Waldeyers ring
Descripción

Waldeyers ring

Tipo de datos

integer

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

Lips

Tipo de datos

text

Alias
UMLS CUI [1]
C0023759
Neck
Descripción

Neck

Thyroid gland
Descripción

Thyroid gland

Tipo de datos

integer

Alias
UMLS CUI [1]
C0040132
Neck circumference
Descripción

Neck circumference

Tipo de datos

integer

Alias
UMLS CUI [1]
C1630403
Blood vessels
Descripción

Blood vessels

Tipo de datos

integer

Alias
UMLS CUI [1]
C0005847
Larynx
Descripción

Larynx

Tipo de datos

text

Alias
UMLS CUI [1]
C0023078
Thorax
Descripción

Thorax

Form of thorax
Descripción

Form of thorax

Tipo de datos

integer

Alias
UMLS CUI [1]
C0426786
Breathing
Descripción

Breathing

Tipo de datos

integer

Alias
UMLS CUI [1]
C0035203
Respiratory rate
Descripción

Respiratory rate

Tipo de datos

integer

Alias
UMLS CUI [1]
C0231832
Respiratory rhythm
Descripción

Respiratory rhythm

Tipo de datos

text

Alias
UMLS CUI [1]
C0231842
Inspiratory chest circumference
Descripción

Inspiratory circumference

Tipo de datos

integer

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

Exspiratory circumference

Tipo de datos

integer

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

Vertebral column

Tipo de datos

integer

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

Mammae

Tipo de datos

text

Lungs
Descripción

Lungs

Chest percussion
Descripción

Chest percussion

Tipo de datos

integer

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

Inferior margin of lower lobe of lung

Tipo de datos

text

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

Inferior margin of lower lobe of lung

Tipo de datos

text

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

Mobility of lung margin

Tipo de datos

text

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

Mobility of lung margin

Tipo de datos

text

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

Respiratory Sounds

Tipo de datos

integer

Alias
UMLS CUI [1]
C0035234
Abnormal breath sounds
Descripción

Abnormal breath sounds

Tipo de datos

integer

Alias
UMLS CUI [1]
C0231856
Heart
Descripción

Heart

Right heart margin
Descripción

Heart margin

Tipo de datos

integer

Alias
UMLS CUI [1]
C0225818
Left heart margin
Descripción

Heart margin

Tipo de datos

integer

Alias
UMLS CUI [1]
C0225819
Apex beat
Descripción

Apex beat

Tipo de datos

integer

Alias
UMLS CUI [1]
C0277909
Apex beat localization
Descripción

Position of apex beat

Tipo de datos

text

Alias
UMLS CUI [1]
C1287711
Heart sounds
Descripción

Heart sounds

Tipo de datos

integer

Alias
UMLS CUI [1]
C0018820
Cardiac activity
Descripción

Cardiac activity

Tipo de datos

integer

Alias
UMLS CUI [1]
C0443168
Heart rate
Descripción

Frequency, pulse deficit

Tipo de datos

text

Alias
UMLS CUI [1]
C0018810
Blood pressure
Descripción

Right/left

Tipo de datos

text

Alias
UMLS CUI [1]
C0005823
Pulse deficit
Descripción

Pulse deficit

Tipo de datos

integer

Alias
UMLS CUI [1]
C0237313
Abdominal Examination
Descripción

Abdominal Examination

Abdominal shape symmetrical?
Descripción

Abdominal shape

Tipo de datos

boolean

Alias
UMLS CUI [1]
C2230330
Abdominal wall
Descripción

Abdominal wall

Tipo de datos

integer

Alias
UMLS CUI [1]
C1269041
Hernia
Descripción

Hernia

Tipo de datos

integer

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

Palpation tenderness

Tipo de datos

text

Alias
UMLS CUI [1]
C0232498
Palpation tenderness
Descripción

Palpation tenderness

Tipo de datos

integer

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

Intraabdominal resistance

Tipo de datos

text

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

Intraabdominal resistance

Tipo de datos

text

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

Intraabdominal resistance

Tipo de datos

text

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

Intraabdominal resistance

Tipo de datos

text

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

Intraabdominal resistance

Tipo de datos

text

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

Intraabdominal resistance

Tipo de datos

boolean

Alias
UMLS CUI [1]
C1562335
Ascites
Descripción

Ascites

Tipo de datos

boolean

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

Ascites

Tipo de datos

integer

Alias
UMLS CUI [1]
C0003962
Bowel sounds
Descripción

Bowel sounds

Tipo de datos

integer

Alias
UMLS CUI [1]
C0232693
Liver
Descripción

Liver

Liver size
Descripción

Liver size

Tipo de datos

integer

Alias
UMLS CUI [1]
C0426688
Liver consistency
Descripción

Liver consistency

Tipo de datos

integer

Alias
UMLS CUI [1]
C1285892
Liver surface
Descripción

Liver surface

Tipo de datos

integer

Alias
UMLS CUI [1]
C0458922
Liver margin
Descripción

Liver margin

Tipo de datos

integer

Alias
UMLS CUI [1]
C2329884
Liver pain
Descripción

Liver pain

Tipo de datos

integer

Alias
UMLS CUI [1]
C0522067
Spleen
Descripción

Spleen

Spleen palpation: consistency
Descripción

Spleen palpation: consistency

Tipo de datos

text

Alias
UMLS CUI [1]
C0030250
Spleen palpation
Descripción

Spleen palpation

Tipo de datos

integer

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

Fibrous capsule of kidney

Fibrous capsule of kidney
Descripción

Fibrous capsule of kidney

Tipo de datos

integer

Alias
UMLS CUI [1]
C0227616
Rectal examination
Descripción

Rectal examination

Rectal inspection
Descripción

Rectal inspection

Tipo de datos

integer

Alias
UMLS CUI [1]
C0582103
Rectal palpation
Descripción

Rectal palpation

Tipo de datos

integer

Alias
UMLS CUI [1]
C1384593
Prostate: Size
Descripción

Prostate

Tipo de datos

text

Alias
UMLS CUI [1]
C0033572
Prostate: Consistency
Descripción

Prostate

Tipo de datos

text

Alias
UMLS CUI [1]
C0033572
Prostate: Nodules
Descripción

Prostate

Tipo de datos

text

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

Prostate

Tipo de datos

text

Alias
UMLS CUI [1]
C0033572
Genitalia
Descripción

Genitalia

Genitalia normal
Descripción

Genitalia

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0017420
Pubic hair
Descripción

Pubic hair

Tipo de datos

text

Alias
UMLS CUI [1]
C1305636
Genitalia shape
Descripción

Genitalia shape

Tipo de datos

text

Alias
UMLS CUI [1]
C1820234
Testicle size
Descripción

Testicle size

Tipo de datos

text

Alias
UMLS CUI [1]
C0426327
Extremities
Descripción

Extremities

Axis of limb
Descripción

Axis of limb

Tipo de datos

text

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

Active Range of Motion

Tipo de datos

text

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

Passive Range of Motion

Tipo de datos

text

Alias
UMLS CUI [1]
C0079991
Skeletal muscle structure
Descripción

Skeletal muscle structure

Tipo de datos

text

Alias
UMLS CUI [1]
C0242692
Joint swelling
Descripción

Joint swelling

Tipo de datos

text

Alias
UMLS CUI [1]
C0152031
Joint pain
Descripción

Joint pain

Tipo de datos

text

Alias
UMLS CUI [1]
C0003862
Flexion
Descripción

Flexion

Tipo de datos

integer

Alias
UMLS CUI [1]
C0231452
Extension
Descripción

Extension

Tipo de datos

integer

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

Joint

Tipo de datos

text

Alias
UMLS CUI [1]
C0022417
Vascular status
Descripción

Vascular status

Pulse taking: Palpation of A.carotis communis
Descripción

Pulse taking

Tipo de datos

integer

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

Pulse taking

Tipo de datos

integer

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

Pulse taking

Tipo de datos

integer

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

Pulse taking

Tipo de datos

integer

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

Pulse taking

Tipo de datos

integer

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

Pulse taking

Tipo de datos

integer

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

Pulse taking

Tipo de datos

integer

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

Auscultation of Aortic murmur and heart murmur

Tipo de datos

text

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

Neurologic status

Assessment of neurologic status
Descripción

Assessment of neurologic status

Tipo de datos

text

Alias
UMLS CUI [1]
C0746866
Central nervous system
Descripción

Central nervous system

Consciousness
Descripción

Consciousness

Tipo de datos

integer

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

Orientation

Tipo de datos

text

Alias
UMLS CUI [1]
C0029266
Mood
Descripción

Mood

Tipo de datos

integer

Alias
UMLS CUI [1]
C0026516
Psychomotor
Descripción

Psychomotor

Tipo de datos

integer

Alias
UMLS CUI [1]
C0033923
Peripheral nervous system
Descripción

Peripheral nervous system

Active innervation and function of head and extremities
Descripción

Active innervation and function of head and extremities

Tipo de datos

integer

Alias
UMLS CUI [1]
C0026828
Physiological reflexes
Descripción

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

Tipo de datos

integer

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

Abnormal reflexes

Tipo de datos

integer

Alias
UMLS CUI [1]
C0034935
Coordination
Descripción

Coordination

Tipo de datos

text

Alias
UMLS CUI [1]
C0242414
Sensitivity
Descripción

Sensitivity

Tipo de datos

text

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

Combined Functions

Tipo de datos

text

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

Diagnosis

Diagnosis or tentative diagnosis
Descripción

Diagnosis or tentative diagnosis based on medical history and clinical examination

Tipo de datos

text

Alias
UMLS CUI [1]
C0011900
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Similar models

Clinical Examination findings

1 formularios
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
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])
Overall impression
Code List
Overall impression
CL Item
Normal (1)
CL Item
Feeble (2)
CL Item
Critically ill (3)
Item
Speech
integer
C0037817 (UMLS CUI [1])
Speech
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])
Physical strength
Code List
Physical strength
CL Item
Normal (1)
CL Item
Reduced (2)
CL Item
Trained (3)
Item
Somatotype
integer
C0037669 (UMLS CUI [1])
Somatotype
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])
Gait
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])
Movements
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])
Nutritional status
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])
Muscle mass
Code List
Muscle mass
CL Item
Average (1)
CL Item
Strong (2)
CL Item
Atrophic (3)
Item
Facial expressions
integer
C0015457 (UMLS CUI [1])
Facial expressions
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])
Skin color
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])
Skin lesions
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])
Bleeding
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])
Vascular markings
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])
Nerve exit points
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])
Lymph nodes
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])
Lymph nodes
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])
Lymph nodes
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])
Lymph nodes
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])
Eyelids
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])
Pupils
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])
Pupil reaction
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])
Eyeballs
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])
Visus
Code List
Visus
CL Item
Normal (1)
CL Item
Reduced (2)
CL Item
Corrected (Glasses) (3)
Item
Conjunctiva
integer
C0009758 (UMLS CUI [1])
Conjunctiva
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])
Dentures
Code List
Dentures
CL Item
Restored (1)
CL Item
Caries (2)
CL Item
False teeth (3)
Item
Waldeyers ring
integer
C0459892 (UMLS CUI [1])
Waldeyers ring
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])
Thyroid gland
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])
Blood vessels
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])
Form of thorax
Code List
Form of thorax
CL Item
Normal (1)
CL Item
Barrel chest (2)
Item
Breathing
integer
C0035203 (UMLS CUI [1])
Breathing
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])
Vertebral column
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])
Chest percussion
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])
Respiratory Sounds
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])
Abnormal breath sounds
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])
Heart margin
Code List
Right heart margin
CL Item
normal (1)
CL Item
enlarged (2)
Item
Left heart margin
integer
C0225819 (UMLS CUI [1])
Heart margin
Code List
Left heart margin
CL Item
normal (1)
CL Item
enlarged (2)
Item
Apex beat
integer
C0277909 (UMLS CUI [1])
Apex beat
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])
Heart sounds
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])
Cardiac activity
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
Pulse deficit
integer
C0237313 (UMLS CUI [1])
Pulse deficit
Code List
Pulse deficit
CL Item
peripheral (1)
CL Item
central (2)
Item Group
Abdominal Examination
Abdominal shape
Item
Abdominal shape symmetrical?
boolean
C2230330 (UMLS CUI [1])
Item
Abdominal wall
integer
C1269041 (UMLS CUI [1])
Abdominal wall
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])
Hernia
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])
Palpation tenderness
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])
Bowel sounds
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])
Liver consistency
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])
Liver surface
Code List
Liver surface
CL Item
Smooth (1)
CL Item
Nodular liver (2)
Item
Liver margin
integer
C2329884 (UMLS CUI [1])
Liver margin
Code List
Liver margin
CL Item
Blunt (1)
CL Item
Pointed (2)
Item
Liver pain
integer
C0522067 (UMLS CUI [1])
Liver pain
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])
Spleen palpation
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])
Fibrous capsule of kidney
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])
Rectal inspection
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])
Rectal palpation
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])
Flexion
Code List
Flexion
CL Item
normal (1)
CL Item
reduced (2)
Item
Extension
integer
C0522009 (UMLS CUI [1])
Flexion
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])
Pulse taking
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])
Pulse taking
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])
Pulse taking
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])
Pulse taking
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])
Pulse taking
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])
Pulse taking
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])
Pulse taking
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])
Consciousness
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])
Mood
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])
Psychomotor
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])
Active innervation and function of head and extremities
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])
Reflexes
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])
Abnormal reflexes
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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