1 | archetype (adl_version=1.4)
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2 | openEHR-EHR-CLUSTER.exam-chest.v1
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3 | specialize
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4 | openEHR-EHR-CLUSTER.exam.v1
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5 |
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6 | concept
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7 | [at0000.1] -- Examination of the chest
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8 | language
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9 | original_language = <[ISO_639-1::en]>
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10 | description
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11 | original_author = <
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12 | ["name"] = <"Sam Heard">
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13 | ["organisation"] = <"Ocean Informatics">
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14 | ["date"] = <"9/04/2007">
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15 | ["email"] = <"Sam.Heard@OceanInformatics.biz">
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16 | >
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17 | details = <
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18 | ["en"] = <
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19 | language = <[ISO_639-1::en]>
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20 | purpose = <"A cluster for recording findings on physical examination of the chest">
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21 | use = <"">
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22 | keywords = <"examination", "physical", "chest", "thorax", "lungs">
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23 | misuse = <"">
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24 | >
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25 | >
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26 | lifecycle_state = <"Initial">
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27 | other_contributors = <>
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28 |
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29 | definition
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30 | CLUSTER[at0000.1] matches { -- Examination of the chest
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31 | items cardinality matches {0..*; unordered} matches {
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32 | CLUSTER[at0004] occurrences matches {0..1} matches { -- Normal statements
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33 | items cardinality matches {0..*; unordered} matches {
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34 | ELEMENT[at0005] occurrences matches {0..*} matches { -- Normal statement
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35 | value matches {
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36 | DV_TEXT matches {*}
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37 | }
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38 | }
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39 | }
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40 | }
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41 | ELEMENT[at0002] occurrences matches {0..1} matches { -- Clinical description
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42 | value matches {
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43 | DV_TEXT matches {*}
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44 | }
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45 | }
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46 | CLUSTER[at0008] occurrences matches {0..1} matches { -- Findings
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47 | items cardinality matches {0..*; unordered} matches {
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48 | CLUSTER[at0.1] occurrences matches {0..1} matches { -- Chest wall
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49 | items cardinality matches {0..*; unordered} matches {
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50 | ELEMENT[at0.2] occurrences matches {0..1} matches { -- Description
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51 | value matches {
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52 | DV_CODED_TEXT matches {
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53 | defining_code matches {[local::]}
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54 | }
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55 | }
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56 | }
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57 | ELEMENT[at0.28] occurrences matches {0..1} matches { -- Shape
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58 | value matches {
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59 | DV_TEXT matches {*}
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60 | }
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61 | }
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62 | CLUSTER[at0.30] occurrences matches {0..1} matches { -- Heart - Apex beat
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63 | items cardinality matches {0..*; unordered} matches {
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64 | ELEMENT[at0.31] occurrences matches {0..1} matches { -- Visible
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65 | value matches {
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66 | DV_BOOLEAN matches {
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67 | value matches {True, False}
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68 | }
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69 | }
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70 | }
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71 | CLUSTER[at0.32] occurrences matches {0..1} matches { -- Palpation
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72 | items cardinality matches {0..*; unordered} matches {
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73 | ELEMENT[at0.33] occurrences matches {0..1} matches { -- Palpable
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74 | value matches {
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75 | DV_BOOLEAN matches {
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76 | value matches {True, False}
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77 | }
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78 | }
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79 | }
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80 | ELEMENT[at0.34] occurrences matches {0..1} matches { -- Maximal location
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81 | value matches {
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82 | DV_TEXT matches {*}
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83 | }
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84 | }
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85 | }
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86 | }
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87 | }
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88 | }
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89 | allow_archetype CLUSTER occurrences matches {0..1} matches {
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90 | include
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91 | archetype_id/value matches {/palpation\.v1draft/}
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92 | archetype_id/value matches {/inspection\.v1draft/}
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93 | archetype_id/value matches {/auscultation-chest\.v1/}
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94 | }
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95 | }
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96 | }
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97 | CLUSTER[at0.3] occurrences matches {0..1} matches { -- Respiratory system
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98 | items cardinality matches {0..*; unordered} matches {
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99 | ELEMENT[at0.4] occurrences matches {0..1} matches { -- Trachea
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100 | value matches {
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101 | DV_CODED_TEXT matches {
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102 | defining_code matches {
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103 | [local::
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104 | at0.5, -- Midline
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105 | at0.6, -- Deviated to the left
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106 | at0.7] -- Deviated to the right
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107 | }
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108 | }
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109 | }
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110 | }
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111 | CLUSTER[at0.8] occurrences matches {0..1} matches { -- Breathing
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112 | items cardinality matches {0..*; unordered} matches {
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113 | ELEMENT[at0.19] occurrences matches {0..1} matches { -- Description
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114 | value matches {
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115 | DV_TEXT matches {*}
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116 | }
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117 | }
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118 | ELEMENT[at0.9] occurrences matches {0..1} matches { -- Type
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119 | value matches {
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120 | DV_CODED_TEXT matches {
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121 | defining_code matches {
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122 | [local::
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123 | at0.10, -- Diaphragmatic breathing
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124 | at0.11] -- Thoracic breathing
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125 | }
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126 | }
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127 | }
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128 | }
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129 | ELEMENT[at0.12] occurrences matches {0..1} matches { -- Effort
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130 | value matches {
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131 | 5|[local::at0.13], -- Normal breathing effort
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132 | 6|[local::at0.14], -- Mild increase in effort
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133 | 8|[local::at0.15], -- Moderate increased effort
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134 | 10|[local::at0.16] -- Major increased effort
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135 | }
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136 | }
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137 | CLUSTER[at0.17] occurrences matches {0..1} matches { -- Signs of increased effort
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138 | items cardinality matches {0..*; unordered} matches {
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139 | ELEMENT[at0.18] occurrences matches {0..*} matches { -- Sign
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140 | value matches {
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141 | DV_CODED_TEXT matches {
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142 | defining_code matches {
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143 | [local::
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144 | at0.25, -- Using accessory muscles
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145 | at0.20, -- Intercostal recession
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146 | at0.24, -- Subcostal recession
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147 | at0.23, -- Suprasternal recession
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148 | at0.21, -- Sternal recession
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149 | at0.22] -- Rib retraction
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150 | }
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151 | }
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152 | }
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153 | }
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154 | }
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155 | }
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156 | ELEMENT[at0.26] occurrences matches {0..1} matches { -- Paradoxical movement (flail chest)
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157 | value matches {
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158 | DV_BOOLEAN matches {
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159 | value matches {True, False}
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160 | }
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161 | }
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162 | }
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163 | }
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164 | }
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165 | }
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166 | }
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167 | CLUSTER[at0003] occurrences matches {0..1} matches { -- Detail
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168 | items cardinality matches {0..*; unordered} matches {
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169 | allow_archetype CLUSTER occurrences matches {0..1} matches {
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170 | include
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171 | archetype_id/value matches {/exam-generic\.v1/}
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172 | archetype_id/value matches {/auscultation-chest\.v1/}
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173 | archetype_id/value matches {/palpation\.v1/}
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174 | archetype_id/value matches {/inspection\.v1draft/}
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175 | archetype_id/value matches {/percussion\.v1/}
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176 | }
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177 | }
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178 | }
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179 | }
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180 | }
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181 | CLUSTER[at0.27] occurrences matches {0..1} matches { -- Lymph nodes
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182 | items cardinality matches {0..*; unordered} matches {
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183 | allow_archetype CLUSTER occurrences matches {0..1} matches {
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184 | include
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185 | archetype_id/value matches {/exam-generic-lympnode\.v1/}
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186 | }
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187 | }
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188 | }
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189 | ELEMENT[at0006] occurrences matches {0..*} matches { -- Image
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190 | value matches {
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191 | DV_MULTIMEDIA matches {
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192 | media_type matches {
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193 | [openEHR::
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194 | 426,
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195 | 427,
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196 | 429]
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197 | }
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198 | }
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199 | }
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200 | }
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201 | }
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202 | }
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203 |
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204 | ontology
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205 | term_definitions = <
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206 | ["en"] = <
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207 | items = <
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208 | ["at0.1"] = <
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209 | description = <"Findings about the chest wall">
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210 | text = <"Chest wall">
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211 | >
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212 | ["at0.10"] = <
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213 | description = <"Breathing using the diaphragm and not the chest wall">
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214 | text = <"Diaphragmatic breathing">
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215 | >
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216 | ["at0.11"] = <
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217 | description = <"Breathing using expansion of the chest wall">
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218 | text = <"Thoracic breathing">
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219 | >
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220 | ["at0.12"] = <
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221 | description = <"Effort required for breathing">
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222 | text = <"Effort">
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223 | >
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224 | ["at0.13"] = <
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225 | description = <"Diaphragmatic breathing as at rest">
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226 | text = <"Normal breathing effort">
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227 | >
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228 | ["at0.14"] = <
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229 | description = <"Breathing using obvious chest expansion">
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230 | text = <"Mild increase in effort">
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231 | >
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232 | ["at0.15"] = <
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233 | description = <"Breathing with signs of abnormal breathing">
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234 | text = <"Moderate increased effort">
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235 | >
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236 | ["at0.16"] = <
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237 | description = <"Many signs of increased breathing effort">
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238 | text = <"Major increased effort">
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239 | >
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240 | ["at0.17"] = <
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241 | description = <"Signs of increased respiratory effort">
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242 | text = <"Signs of increased effort">
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243 | >
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244 | ["at0.18"] = <
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245 | description = <"Use of accessory respiratory muscles">
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246 | text = <"Sign">
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247 | >
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248 | ["at0.19"] = <
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249 | description = <"Description of breathing">
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250 | text = <"Description">
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251 | >
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252 | ["at0.2"] = <
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253 | description = <"The contour of the chest wall">
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254 | text = <"Description">
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255 | >
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256 | ["at0.20"] = <
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257 | description = <"Drawing in between the ribs on inspiration">
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258 | text = <"Intercostal recession">
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259 | >
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260 | ["at0.21"] = <
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261 | description = <"Drawing in of the sternum on inspiration">
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262 | text = <"Sternal recession">
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263 | >
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264 | ["at0.22"] = <
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265 | description = <"Indrawing of the chest wall on inspiration">
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266 | text = <"Rib retraction">
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267 | >
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268 | ["at0.23"] = <
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269 | description = <"Indrawing above the sternum on inspiration">
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270 | text = <"Suprasternal recession">
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271 | >
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272 | ["at0.24"] = <
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273 | description = <"Indrawing of the subcostal abdominal wall ">
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274 | text = <"Subcostal recession">
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275 | >
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276 | ["at0.25"] = <
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277 | description = <"Use of accessory respiratory muscles during inspiration">
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278 | text = <"Using accessory muscles">
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279 | >
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280 | ["at0.26"] = <
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281 | description = <"Any paradoxical movement of the chest wall during respiration">
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282 | text = <"Paradoxical movement (flail chest)">
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283 | >
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284 | ["at0.27"] = <
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285 | description = <"Lymphnodes">
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286 | text = <"Lymph nodes">
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287 | >
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288 | ["at0.28"] = <
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289 | description = <"The shape of the chest">
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290 | text = <"Shape">
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291 | comment = <"ChestShape SNOMED query">
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292 | >
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293 | ["at0.29"] = <
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294 | description = <"Pidgeon chest, with prominent lower sternum">
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295 | text = <"Pectus carinatum">
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296 | >
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297 | ["at0.3"] = <
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298 | description = <"Respiratory findings">
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299 | text = <"Respiratory system">
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300 | >
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301 | ["at0.30"] = <
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302 | description = <"*">
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303 | text = <"Heart - Apex beat">
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304 | >
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305 | ["at0.31"] = <
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306 | description = <"Apex beat is visible">
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307 | text = <"Visible">
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308 | >
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309 | ["at0.32"] = <
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310 | description = <"*">
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311 | text = <"Palpation">
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312 | >
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313 | ["at0.33"] = <
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314 | description = <"Apex beat is palpable">
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315 | text = <"Palpable">
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316 | >
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317 | ["at0.34"] = <
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318 | description = <"Site of maximal location of apex beat">
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319 | text = <"Maximal location">
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320 | >
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321 | ["at0.4"] = <
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322 | description = <"The position of the trachea">
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323 | text = <"Trachea">
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324 | >
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325 | ["at0.5"] = <
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326 | description = <"The trachea is in the midline position">
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327 | text = <"Midline">
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328 | >
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329 | ["at0.6"] = <
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330 | description = <"The trachea is deviated to the left">
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331 | text = <"Deviated to the left">
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332 | >
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333 | ["at0.7"] = <
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334 | description = <"The trachea is deviated to the right">
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335 | text = <"Deviated to the right">
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336 | >
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337 | ["at0.8"] = <
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338 | description = <"Findings about breathing">
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339 | text = <"Breathing">
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340 | >
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341 | ["at0.9"] = <
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342 | description = <"Type of breathing">
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343 | text = <"Type">
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344 | >
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345 | ["at0000"] = <
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346 | description = <"Basic examination cluster for describing findings on physical examination when there is no named focus of examination">
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347 | text = <"Examination">
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348 | >
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349 | ["at0000.1"] = <
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350 | description = <"For recording findings on physical examination of the chest wall and lungs">
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351 | text = <"Examination of the chest">
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352 | >
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353 | ["at0002"] = <
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354 | description = <"Textural description of the part examined">
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355 | text = <"Clinical description">
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356 | >
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357 | ["at0003"] = <
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358 | description = <"More focused examination findings">
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359 | text = <"Detail">
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360 | >
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361 | ["at0004"] = <
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362 | description = <"A group of statements about the normality of the examination">
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363 | text = <"Normal statements">
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364 | >
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365 | ["at0005"] = <
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366 | description = <"A specific statement of normality">
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367 | text = <"Normal statement">
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368 | >
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369 | ["at0006"] = <
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370 | description = <"Drawing or image of the area examined">
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371 | text = <"Image">
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372 | >
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373 | ["at0008"] = <
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374 | description = <"Clinical findings">
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375 | text = <"Findings">
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376 | >
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377 | >
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378 | >
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379 | >
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