TEMPLATE Neuro examination findings - JM (Neuro examination findings - JM)

TEMPLATE IDNeuro examination findings - JM
ConceptNeuro examination findings - JM
DescriptionNot Specified
PurposeNot Specified
References
Authorsdate: 2023-06-15
Other Details Languagedate: 2023-06-15
Other Details (Language Independent)
  • Licence: This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/.
  • Custodian Organisation: openEHR Foundation
  • Original Namespace: org.openehr
  • Original Publisher: openEHR Foundation
  • Custodian Namespace: org.openehr
  • MD5-CAM-1.0.1: f420e3479272f8785626ab80044d6a8c
  • Sem Ver: 5.0.0
  • PARENT:MD5-CAM-1.0.1: 61D18256DA550BBFD431F41EF7307BE0
  • Original Language: ISO_639-1::en
Language useden
Citeable Identifier1013.26.935
Root archetype idopenEHR-EHR-OBSERVATION.exam.v1
Neuro examination findingsNeuro examination findings: Findings observed during the physical examination of a subject of care.
Data
Any eventAny event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Muscle power findingMuscle power finding: Findings observed during the physical examination of power in a muscle group or a limb.
Body siteBody site: Identification of the limb or muscle group tested.
  • Right arm (proximal)
  • Right arm (distal)
  • Left arm (proximal)
  • Left arm (distal)
  • Right leg(proximal)
  • Right leg (distal)
  • Left leg (proximal)
  • Left leg (distal)
StrengthStrength: Observed level of power in the identified limb or muscle group.
  •  Text
  •  Ordinal
    • 0: No visible muscle contraction 
    • 1: Visible muscle contraction with no or trace movement 
    • 2: Limb movement, but not against gravity 
    • 3: Movement against gravity but not resistance 
    • 4: Movement against at least some resistance supplied by the examiner 
    • 5: Full strength 
Deep tendon reflex responseDeep tendon reflex response: Findings observed during the physical examination of a single deep tendon reflex.
ReflexReflex: Identification of the deep tendon reflex or group of reflexes being examined.
  • Right arm (proximal)
  • Right arm (distal)
  • Left arm (proximal)
  • Left arm (distal)
  • Right leg(proximal)
  • Right leg (distal)
  • Left leg (proximal)
  • Left leg (distal)
Graded responseGraded response: The elicited reflex response represented as a grade.
  •  Ordinal
    • 0: Absent 
    • 1: Slight 
    • 2: Normal 
    • 3: Brisk 
    • 4: Non-sustained clonus 
    • 5: Sustained clonus 
  •  Text
Muscle tone findingMuscle tone finding: Findings observed during the physical examination of tone in a limb.
Body siteBody site: Identification of the body site examined.
  • Right arm (proximal)
  • Right arm (distal)
  • Left arm (proximal)
  • Left arm (distal)
  • Right leg(proximal)
  • Right leg (distal)
  • Left leg (proximal)
  • Left leg (distal)
Relative toneRelative tone: The muscle tone observed, relative to 'normal' tone.
  •  Coded Text
    • Normal 
    • Increased 
    • Decreased 
  •  Text
Sensory levelSensory level: The most caudal, normally innervated, dermatome level observed in response to light touch, pain or temperature stimuli.
ModalityModality: The type of sensation tested.
  • Pain 
StimulusStimulus: Description of the stimulus used.
For example: testing light touch with cotton wool; or pain using a needle.
  • Pinprick
LevelLevel: The most caudal, normally innervated dermatome tested.
For example: T12 or C5/C6.
Vibration findingVibration finding: The observed response of applying a vibratory stimulus to an identified bony protuberance.
Body siteBody site: Identification of the bony prominence or body site being tested.
  • Ankle
  • Knee
  • Hip
  • Sternum
ResponseResponse: The elicited response to the stimulus.
  • Present 
  • Absent