NIH | National Cancer Institute | NCI Wiki  
Long NamePhysical Examination NCI Standard Template
DefinitionThe collection of CDEs used in the physical examination module.
ContextcaBIG
Protocol Long NameNCI Standard Template Forms
WorkflowRELEASED
TypeCRF
Public ID2739214
Version1.0
Module Long NameModule InstructionsQuestionCDECDE Public IDCDE VersionQuestion InstructionsValue Domain Data TypeValue Domain Unit of MeasureDisplay FormatValid ValueForm Value Meaning TextForm Value Meaning Desc.
Mandatory Physical Examination QuestionsMust be included when this data is collected for reporting
Evaluation DateEvaluation Date20041703.0Enter the date the physical examination is performed.DATEDD/MON/YYYY
Optional Physical Examination QuestionsThere are business rules to indicate situations under which these elements should be used on a case report form.
Body SystemBody System Type20028954.0Enter the body systemCHARACTER
VulvovaginalVulvovaginalVulvovaginal
ABDOMENABDOMENABDOMEN
Allergy/Drug SensitivityAllergy or Drug Sensitivity HistoryAllergy or Drug Sensitivity History
AppearanceAppearancethe outward or visible aspect of a person or thing.
Body as a WholeBODY AS A WHOLEBODY AS A WHOLE
BREASTSBREASTSBREASTS
CARDIOVASCULARCARDIOVASCULARCARDIOVASCULAR
Central Nervous SystemCentral Nervous SystemThe main information-processing organs of the nervous system, consisting of the brain, spinal cord, and meninges.
ChestCHESTThe part of the human body between the neck and the diaphragm or the corresponding part in other vertebrates.
ConstitutionalConstitutionalSystemic findings reflective of the basic human structure, such as temperature, energy/fatigue, and weight.
DERMATOLOGICDERMATOLOGICDERMATOLOGIC
EndocrineEndocrine SystemCollective designation for those tissues capable of secreting hormones.
ENDOCRINE/METABOLICENDOCRINE/METABOLICENDOCRINE/METABOLIC
ExtremitiesExtremitiesBody limbs, consisting of right upper and lower (arm and leg) and left upper and lower (arm and leg).
GASTROINTESTINALGASTROINTESTINALGASTROINTESTINAL
GENITALIAGENITALIAGENITALIA
GenitourinaryGenitourinaryof or related to the genital and urinary organs or their functions.
H/E/E/N/TH/E/E/N/TH/E/E/N/T
HEMATOLOGICHEMATOLOGICHEMATOLOGIC
HEMATOPOIETIC/LYMPHHEMATOPOIETIC/LYMPHHEMATOPOIETIC/LYMPH
HepaticHepaticRefers to the liver.
IMMUNEIMMUNEImmune system
Integumentary/HairIntegumentary/HairAll of the derivatives of the epidermis, e.g., hairs, nails, sudoriferous and sebaceous glands.
MUSCULOSKELETALMUSCULOSKELETALMUSCULOSKELETAL
NECKNECKThe region that connects the head to the rest of the body.
NEUROLOGICNEUROLOGICNEUROLOGIC
OTHEROTHERDifferent than the one(s) previously specified or mentioned.
PELVISPELVISThe structure of the vertebrate skeleton supporting the lower limbs in humans and the hind limbs or corresponding parts in other vertebrates.
Peripheral VascularPERIPHERAL VASCULAR SYSTEMNo value exists
PsychiatricPSYCHIATRICNo Value Exists
PSYCHOLOGICPSYCHOLOGICPsychologic
PulmonaryPulmonaryRelating to the lungs.
RectalRectalRelated to the rectum
RenalRenalNo value exists
Reproductive HistoryReproductive HistoryAn important aggregate factor in epidemiological studies of women's health. The concept usually includes the number and timing of pregnancies and their outcomes, the incidence of breast feeding, and may include age of menarche and menopause, regularity of menstruation, fertility, gynecological or obstetric problems, or contraceptive usage.
RESPIRATORYRESPIRATORYRESPIRATORY
SpleenSpleenAn organ that produces lymphocytes, filters the blood, stores blood cells, and destroys those that are aging. It is located on the left side of the abdomen near the stomach. (OCC)
Substance abuse/DependencySubstance abuse/DependencySubstance abuse/Dependency
Transfusion HistoryTransfusion HistoryA subject's past experiences related to the receipt of blood, WBC, platelets, and/or other blood components.
URINARYURINARYURINARY
Specify Other Body System/SiteOther Body System/Site Text21826711.0Enter description of other body system/site.CHARACTER
Finding DescriptionPatient Abnormal Physical Examination Specify22018801.0Enter the physical exam description or relevant findings for the body system. Required if the Finding Result is Abnormal.CHARACTER
Finding ResultPhysical Examination Finding Type31924551.0Enter the result of the assessment for a particular body system.CHARACTER
Not ExaminedNone ExaminedNo person or thing, nobody, not any.: Examined; having been subjected to an examination.
AbnormalAbnormalDeviating from the norm.
NormalNormalBeing approximately average or within certain limits; conforming with or constituting a norm or standard or level or type or social norm. (NCI)
Overall Physical Exam PerformedPatient Physical Examination Ind-222017501.0Enter whether the overall physical exam is performed. If yes, report all abnormal findings on Medical History CRF.CHARACTER
NoNONO
YesYESYES