Physical Examination Date
Item
Date of Assessment
date
C2826643 (UMLS CUI [1])
Item
1. Hair and skin
text
C0031809 (UMLS CUI [1,1])
C0018494 (UMLS CUI [1,2])
C0031809 (UMLS CUI [2,1])
C1123023 (UMLS CUI [2,2])
Code List
1. Hair and skin
CL Item
Abnormal (Abnormal)
Physical examination Hair Description | Physical examination Skin Description
Item
If ABNORMAL, describe concisely:
text
C0031809 (UMLS CUI [1,1])
C0018494 (UMLS CUI [1,2])
C0678257 (UMLS CUI [1,3])
C0031809 (UMLS CUI [2,1])
C1123023 (UMLS CUI [2,2])
C0678257 (UMLS CUI [2,3])
Item
2. Lymph nodes
text
C0031809 (UMLS CUI [1,1])
C0024204 (UMLS CUI [1,2])
CL Item
Abnormal (Abnormal)
Physical examination Lymph nodes Description
Item
If ABNORMAL, describe concisely:
text
C0031809 (UMLS CUI [1,1])
C0024204 (UMLS CUI [1,2])
C0678257 (UMLS CUI [1,3])
Item
3. Eyes
text
C0031809 (UMLS CUI [1,1])
C0015392 (UMLS CUI [1,2])
CL Item
Abnormal (Abnormal)
Physical examination Eyes Description
Item
If ABNORMAL, describe concisely:
text
C0031809 (UMLS CUI [1,1])
C0015392 (UMLS CUI [1,2])
C0678257 (UMLS CUI [1,3])
Item
4. Ears, Nose and Throat
text
C0031809 (UMLS CUI [1,1])
C0278350 (UMLS CUI [1,2])
Code List
4. Ears, Nose and Throat
CL Item
Abnormal (Abnormal)
Physical examination ENT Description
Item
If ABNORMAL, describe concisely:
text
C0031809 (UMLS CUI [1,1])
C0278350 (UMLS CUI [1,2])
C0678257 (UMLS CUI [1,3])
Item
5. Breasts
text
C0031809 (UMLS CUI [1,1])
C0199850 (UMLS CUI [1,2])
CL Item
Abnormal (Abnormal)
CL Item
Not Done (Not Done)
Physical Examination Breasts Description
Item
If ABNORMAL, describe concisely:
text
C0031809 (UMLS CUI [1,1])
C0199850 (UMLS CUI [1,2])
C0678257 (UMLS CUI [1,3])
Item
6. Respiratiory
text
C0031809 (UMLS CUI [1,1])
C0035237 (UMLS CUI [1,2])
Code List
6. Respiratiory
CL Item
Abnormal (Abnormal)
Physical examination Respiratory Description
Item
If ABNORMAL, describe concisely:
text
C0031809 (UMLS CUI [1,1])
C0035237 (UMLS CUI [1,2])
C0678257 (UMLS CUI [1,3])
Item
7. Cardiovascular
text
C0031809 (UMLS CUI [1,1])
C0007226 (UMLS CUI [1,2])
Code List
7. Cardiovascular
CL Item
Abnormal (Abnormal)
Physical examination Cardiovascular Description
Item
If ABNORMAL, describe concisely:
text
C0031809 (UMLS CUI [1,1])
C0007226 (UMLS CUI [1,2])
C0678257 (UMLS CUI [1,3])
Item
8. Abdomen
text
C0031809 (UMLS CUI [1,1])
C0000726 (UMLS CUI [1,2])
CL Item
Abnormal (Abnormal)
Physical examination Abdomen Description
Item
If ABNORMAL, describe concisely:
text
C0031809 (UMLS CUI [1,1])
C0000726 (UMLS CUI [1,2])
C0678257 (UMLS CUI [1,3])
Item
9. Urogenital
text
C0031809 (UMLS CUI [1,1])
C1828035 (UMLS CUI [1,2])
CL Item
Abnormal (Abnormal)
CL Item
Not Done (Not Done)
Physical examination Urogenital Description
Item
If ABNORMAL, describe concisely:
text
C0031809 (UMLS CUI [1,1])
C1828035 (UMLS CUI [1,2])
C0678257 (UMLS CUI [1,3])
Item
10. Pelvic
text
C0031809 (UMLS CUI [1,1])
C0030797 (UMLS CUI [1,2])
CL Item
Abnormal (Abnormal)
CL Item
Not Done (Not Done)
Physical examination Pelvis Description
Item
If ABNORMAL, describe concisely:
text
C0031809 (UMLS CUI [1,1])
C0030797 (UMLS CUI [1,2])
C0678257 (UMLS CUI [1,3])
Item
11. Rectal
text
C0031809 (UMLS CUI [1,1])
C0199900 (UMLS CUI [1,2])
CL Item
Abnormal (Abnormal)
CL Item
Not Done (Not Done)
Physical examination Rectal Description
Item
If ABNORMAL, describe concisely:
text
C0031809 (UMLS CUI [1,1])
C0199900 (UMLS CUI [1,2])
C0678257 (UMLS CUI [1,3])
Item
12. Musculoskeletal
text
C0031809 (UMLS CUI [1,1])
C0026860 (UMLS CUI [1,2])
Code List
12. Musculoskeletal
CL Item
Abnormal (Abnormal)
Physical examination Musculoskeletal Description
Item
If ABNORMAL, describe concisely:
text
C0031809 (UMLS CUI [1,1])
C0026860 (UMLS CUI [1,2])
C0678257 (UMLS CUI [1,3])
Item
13. Neurological
text
C0031809 (UMLS CUI [1,1])
C0027853 (UMLS CUI [1,2])
Code List
13. Neurological
CL Item
Abnormal (Abnormal)
Physical Examination Neurological Description
Item
If ABNORMAL, describe concisely:
text
C0031809 (UMLS CUI [1,1])
C0027853 (UMLS CUI [1,2])
C0678257 (UMLS CUI [1,3])
Item
14. Mental Status
text
C0031809 (UMLS CUI [1,1])
C0278060 (UMLS CUI [1,2])
Code List
14. Mental Status
CL Item
Abnormal (Abnormal)
Physical examination Mental status Description
Item
If ABNORMAL, describe concisely:
text
C0031809 (UMLS CUI [1,1])
C0278060 (UMLS CUI [1,2])
C0678257 (UMLS CUI [1,3])