source: ruby/trunk/adl_parser/tests/openEHR-EHR-CLUSTER.auscultation-chest.v1.adl@ 4

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1archetype (adl_version=1.4)
2 openEHR-EHR-CLUSTER.auscultation-chest.v1
3specialize
4 openEHR-EHR-CLUSTER.auscultation.v1
5
6concept
7 [at0000.1] -- Auscultation of the chest
8language
9 original_language = <[ISO_639-1::en]>
10description
11 original_author = <
12 ["name"] = <"Sam Heard">
13 ["organisation"] = <"Ocean Informatics">
14 ["date"] = <"7/04/2007">
15 ["email"] = <"sam.heard@oceaninformatics.biz">
16 >
17 details = <
18 ["en"] = <
19 language = <[ISO_639-1::en]>
20 purpose = <"To record data found on examination of the chest by auscultation/listening">
21 use = <"To be embedded in an openEHR-EHR-OBSERVATION.exam cluster to express findings determined by auscultation of the chest">
22 keywords = <"auscultate", "listen", "auscultation", "listening", "lungs", "chest", "bruit", "heart", "bowel sounds", "breath sounds", "heart sounds">
23 misuse = <"Not for use in any other context at present">
24 >
25 >
26 lifecycle_state = <"Initial">
27 other_contributors = <"Heather Leslie", ...>
28
29definition
30 CLUSTER[at0000.1] matches { -- Auscultation of the chest
31 items cardinality matches {0..*; unordered} matches {
32 CLUSTER[at0001] occurrences matches {0..1} matches { -- Normal Statements
33 items cardinality matches {0..*; unordered} matches {
34 ELEMENT[at0003] occurrences matches {0..*} matches { -- Normal Statement
35 value matches {
36 DV_CODED_TEXT matches {
37 defining_code matches {
38 [local::
39 at0.1, -- Clear
40 at0.2, -- No rhonchi
41 at0.3, -- No wheeze
42 at0.4, -- No crepitations
43 at0.5, -- No crackles
44 at0.6, -- Two heart sounds, no bruits
45 at0.7, -- Two heart sounds, no murmurs
46 at0.8, -- Two normal heart sounds
47 at0056, -- No murmur
48 at0057, -- No bruit
49 at0.9, -- Normal first heart sound
50 at0.10, -- Normal second heart sound
51 at0.11, -- No Bronchial breathing
52 at0.12, -- No Amphoric breathing
53 at0.13, -- Normal Vocal Resonance
54 at0.14, -- No abnormal added sounds
55 at0073, -- Normal bowel sounds
56 at0085] -- No abnormality detected
57 }
58 }
59 }
60 }
61 }
62 }
63 ELEMENT[at0004] occurrences matches {0..1} matches { -- Clinical Description
64 value matches {
65 DV_TEXT matches {*}
66 }
67 }
68 CLUSTER[at0002] occurrences matches {0..1} matches { -- Findings
69 items cardinality matches {0..*; unordered} matches {
70 CLUSTER[at0.15] occurrences matches {0..1} matches { -- Heart sounds and bruits
71 items cardinality matches {0..*; unordered} matches {
72 CLUSTER[at0.16] occurrences matches {0..1} matches { -- First heart sound
73 items cardinality matches {0..*; unordered} matches {
74 ELEMENT[at0.17] occurrences matches {0..1} matches { -- Volume
75 value matches {
76 0|[local::at0.18], -- Not heard
77 1|[local::at0.19], -- Variable
78 2|[local::at0.20], -- Soft
79 3|[local::at0.21], -- Normal
80 4|[local::at0.22]; -- Loud
81 0 -- assumed value
82 }
83 }
84 ELEMENT[at0.23] occurrences matches {0..1} matches { -- Splitting
85 value matches {
86 DV_CODED_TEXT matches {
87 defining_code matches {
88 [local::
89 at0.24, -- No splitting
90 at0.25, -- Physiological splitting
91 at0.26, -- Fixed splitting
92 at0.27, -- Paradoxical splitting
93 at0.28] -- Exaggerated splitting
94 }
95 }
96 }
97 }
98 use_node ELEMENT /items[at0004]
99 }
100 }
101 CLUSTER[at0.29] occurrences matches {0..1} matches { -- Second heart sound
102 items cardinality matches {0..*; unordered} matches {
103 use_node ELEMENT /items[at0002]/items[at0.15]/items[at0.16]/items[at0.17]
104 use_node ELEMENT /items[at0002]/items[at0.15]/items[at0.16]/items[at0.23]
105 use_node ELEMENT /items[at0004]
106 }
107 }
108 CLUSTER[at0.75] occurrences matches {0..*} matches { -- Added heart sound
109 items cardinality matches {0..*; unordered} matches {
110 ELEMENT[at0.76] occurrences matches {0..*} matches { -- Specific sound
111 value matches {
112 DV_CODED_TEXT matches {
113 defining_code matches {
114 [local::
115 at0.30, -- Opening snap
116 at0.32, -- Ejection click
117 at0.33, -- Pericardial rub
118 at0.57, -- Third heart sound
119 at0.58, -- Fourth heart sound
120 at0.65, -- Prosthetic valve sound
121 at0.66] -- Gallop rythm
122 }
123 }
124 }
125 }
126 ELEMENT[at0.43] occurrences matches {0..*} matches { -- Phase of heart cycle
127 value matches {
128 DV_CODED_TEXT matches {
129 defining_code matches {
130 [local::
131 at0.44, -- Continuous
132 at0.45, -- Systolic
133 at0.46, -- Diastolic
134 at0.47, -- Pan-systolic
135 at0.48, -- Pan-diastolic
136 at0.49, -- Early systolic
137 at0.50, -- Mid-Systolic
138 at0.51, -- Late Systolic
139 at0.52, -- Early Diastolic
140 at0.53, -- Mid-diastolic
141 at0.54] -- Late Diastolic
142 }
143 }
144 }
145 }
146 ELEMENT[at0.59] occurrences matches {0..1} matches { -- Volume
147 value matches {
148 0|[local::at0.60], -- Not audible
149 1|[local::at0.61], -- Variable
150 2|[local::at0.62], -- Soft
151 3|[local::at0.63], -- Moderate
152 4|[local::at0.64]; -- Loud
153 0 -- assumed value
154 }
155 }
156 use_node ELEMENT /items[at0004]
157 }
158 }
159 CLUSTER[at0.31] occurrences matches {0..*} matches { -- Bruits
160 items cardinality matches {0..*; unordered} matches {
161 ELEMENT[at0.35] occurrences matches {0..1} matches { -- Maximal Location
162 value matches {
163 DV_TEXT matches {*}
164 }
165 }
166 ELEMENT[at0.36] occurrences matches {0..*} matches { -- Radiation
167 value matches {
168 DV_TEXT matches {*}
169 }
170 }
171 ELEMENT[at0.34] occurrences matches {0..1} matches { -- Grading
172 value matches {
173 1|[local::at0.37], -- Grade 1
174 2|[local::at0.38], -- Grade 2
175 3|[local::at0.39], -- Grade 3
176 4|[local::at0.40], -- Grade 4
177 5|[local::at0.41], -- Grade 5
178 6|[local::at0.42] -- Grade 6
179 }
180 }
181 ELEMENT[at0.55] occurrences matches {0..1} matches { -- Character
182 value matches {
183 DV_TEXT matches {*}
184 }
185 }
186 ELEMENT[at0.56] occurrences matches {0..1} matches { -- Pitch
187 value matches {
188 DV_TEXT matches {*}
189 }
190 }
191 use_node ELEMENT /items[at0002]/items[at0.15]/items[at0.75]/items[at0.43]
192 use_node ELEMENT /items[at0004]
193 }
194 }
195 ELEMENT[at0.67] occurrences matches {0..1} matches { -- Drawing
196 value matches {
197 DV_MULTIMEDIA matches {
198 media_type matches {
199 [openEHR::
200 425,
201 426,
202 427,
203 428,
204 429]
205 }
206 }
207 }
208 }
209 ELEMENT[at0.68] occurrences matches {0..1} matches { -- Phonogram
210 value matches {
211 DV_MULTIMEDIA matches {
212 media_type matches {
213 [openEHR::
214 409,
215 410]
216 }
217 }
218 }
219 }
220 }
221 }
222 CLUSTER[at0.69] occurrences matches {0..1} matches { -- Lung
223 items cardinality matches {0..*; unordered} matches {
224 CLUSTER[at0.70] occurrences matches {0..1} matches { -- Area
225 items cardinality matches {0..*; unordered} matches {
226 ELEMENT[at0.83] occurrences matches {0..1} matches { -- Region
227 value matches {
228 DV_TEXT matches {*}
229 }
230 }
231 ELEMENT[at0.72] occurrences matches {0..1} matches { -- Phase of respiratory cycle
232 value matches {
233 DV_CODED_TEXT matches {
234 defining_code matches {
235 [local::
236 at0.73, -- Inspiratory
237 at0.74, -- Expiratory
238 at0.77, -- Early Inspiratory
239 at0.78, -- Late inspiratory
240 at0.79, -- Early expiratory
241 at0.80] -- Late expiratory
242 }
243 }
244 }
245 }
246 ELEMENT[at0.81] occurrences matches {0..1} matches { -- Findings
247 value matches {
248 DV_TEXT matches {*}
249 }
250 }
251 }
252 }
253 ELEMENT[at0.82] occurrences matches {0..1} matches { -- Drawing
254 value matches {
255 DV_MULTIMEDIA matches {
256 media_type matches {
257 [openEHR::
258 425,
259 426,
260 427,
261 428,
262 429]
263 }
264 }
265 }
266 }
267 use_node ELEMENT /items[at0004]
268 }
269 }
270 CLUSTER[at0009] occurrences matches {0..1} matches { -- Bowel sounds
271 items cardinality matches {0..*; unordered} matches {
272 ELEMENT[at0074] occurrences matches {0..*} matches { -- Specific Findings
273 value matches {
274 DV_CODED_TEXT matches {
275 defining_code matches {
276 [local::
277 at0078, -- Absent bowel sounds
278 at0079, -- Decreased bowel sounds
279 at0080, -- Increased bowel sounds
280 at0081] -- Tinkling bowel sounds
281 }
282 }
283 }
284 }
285 use_node ELEMENT /items[at0004]
286 }
287 }
288 CLUSTER[at0010] occurrences matches {0..1} matches { -- Vessel bruit
289 items cardinality matches {0..*; unordered} matches {
290 ELEMENT[at0088] matches { -- Vessel name
291 value matches {
292 DV_TEXT matches {*}
293 }
294 }
295 ELEMENT[at0030] occurrences matches {0..1} matches { -- Maximal Location
296 value matches {
297 DV_TEXT matches {*}
298 }
299 }
300 ELEMENT[at0091] occurrences matches {0..1} matches { -- Description
301 value matches {
302 DV_TEXT matches {*}
303 }
304 }
305 }
306 }
307 CLUSTER[at0089] occurrences matches {0..1} matches { -- Other sounds
308 items cardinality matches {0..*; unordered} matches {
309 ELEMENT[at0090] matches { -- Description
310 value matches {
311 DV_TEXT matches {*}
312 }
313 }
314 use_node ELEMENT /items[at0002]/items[at0010]/items[at0030]
315 }
316 }
317 CLUSTER[at0086] occurrences matches {0..*} matches { -- Localised auscultation
318 items cardinality matches {0..*; unordered} matches {
319 ELEMENT[at0087] matches { -- Site or region
320 value matches {
321 DV_TEXT matches {*}
322 }
323 }
324 allow_archetype CLUSTER occurrences matches {0..1} matches {
325 include
326 archetype_id/value matches {/auscultation\.v1/}
327 }
328 }
329 }
330 }
331 }
332 }
333 }
334
335ontology
336 term_definitions = <
337 ["en"] = <
338 items = <
339 ["at0.1"] = <
340 description = <"No abnormal breath sounds">
341 text = <"Clear">
342 >
343 ["at0.10"] = <
344 description = <"*">
345 text = <"Normal second heart sound">
346 >
347 ["at0.11"] = <
348 description = <"*">
349 text = <"No Bronchial breathing">
350 >
351 ["at0.12"] = <
352 description = <"*">
353 text = <"No Amphoric breathing">
354 >
355 ["at0.13"] = <
356 description = <"*">
357 text = <"Normal Vocal Resonance">
358 >
359 ["at0.14"] = <
360 description = <"*">
361 text = <"No abnormal added sounds">
362 >
363 ["at0.15"] = <
364 description = <"*">
365 text = <"Heart sounds and bruits">
366 >
367 ["at0.16"] = <
368 description = <"Findings about the first heart sound">
369 text = <"First heart sound">
370 >
371 ["at0.17"] = <
372 description = <"The volume of the first heart sound">
373 text = <"Volume">
374 >
375 ["at0.18"] = <
376 description = <"The first heart sound is not heard">
377 text = <"Not heard">
378 >
379 ["at0.19"] = <
380 description = <"The sound is variable in volume">
381 text = <"Variable">
382 >
383 ["at0.2"] = <
384 description = <"No high or low pitched wheezes">
385 text = <"No rhonchi">
386 >
387 ["at0.20"] = <
388 description = <"The sound is softer than normal">
389 text = <"Soft">
390 >
391 ["at0.21"] = <
392 description = <"The sound is of normal volume">
393 text = <"Normal">
394 >
395 ["at0.22"] = <
396 description = <"The volume is increased">
397 text = <"Loud">
398 >
399 ["at0.23"] = <
400 description = <"Splitting of the heart sound">
401 text = <"Splitting">
402 >
403 ["at0.24"] = <
404 description = <"The heart sound is not split">
405 text = <"No splitting">
406 >
407 ["at0.25"] = <
408 description = <"The heart sound is split due to physiological changes">
409 text = <"Physiological splitting">
410 >
411 ["at0.26"] = <
412 description = <"The heart sound is always split">
413 text = <"Fixed splitting">
414 >
415 ["at0.27"] = <
416 description = <"The variable splitting is not physiological">
417 text = <"Paradoxical splitting">
418 >
419 ["at0.28"] = <
420 description = <"The timing of the splitting is physiological but it is more obvious than normal">
421 text = <"Exaggerated splitting">
422 >
423 ["at0.29"] = <
424 description = <"Findings about the second heart sound">
425 text = <"Second heart sound">
426 >
427 ["at0.3"] = <
428 description = <"No wheezing noises">
429 text = <"No wheeze">
430 >
431 ["at0.30"] = <
432 description = <"Opening sound of the mitral valve">
433 text = <"Opening snap">
434 >
435 ["at0.31"] = <
436 description = <"Group of findings about auscultation of the heart">
437 text = <"Bruits">
438 >
439 ["at0.32"] = <
440 description = <"Systolic click when the heart contracts">
441 text = <"Ejection click">
442 >
443 ["at0.33"] = <
444 description = <"Rubbing noise during contractions on the pericardium">
445 text = <"Pericardial rub">
446 >
447 ["at0.34"] = <
448 description = <"Grading of the loudness of a heart murmur">
449 text = <"Grading">
450 >
451 ["at0.35"] = <
452 description = <"Site where finding is heard maximally">
453 text = <"Maximal Location">
454 >
455 ["at0.36"] = <
456 description = <"Sites where finding is heard in addition to maximal site">
457 text = <"Radiation">
458 >
459 ["at0.37"] = <
460 description = <"very faint to recognize the murmur even after listening for a while">
461 text = <"Grade 1">
462 >
463 ["at0.38"] = <
464 description = <"faint, but easy to recognize the murmur right after the stethoscope is placed on the chest">
465 text = <"Grade 2">
466 >
467 ["at0.39"] = <
468 description = <"intermediate loudness between II/VI -IV/VI">
469 text = <"Grade 3">
470 >
471 ["at0.4"] = <
472 description = <"No high pitched crackling sounds">
473 text = <"No crepitations">
474 >
475 ["at0.40"] = <
476 description = <"with loud murmur (palpable thrill)">
477 text = <"Grade 4">
478 >
479 ["at0.41"] = <
480 description = <"very loud, but you can not hear the murmur, if the stethoscope is away from the chest wall">
481 text = <"Grade 5">
482 >
483 ["at0.42"] = <
484 description = <"the loudest murmur you can hear, even if the stethoscope is off the chest wall">
485 text = <"Grade 6">
486 >
487 ["at0.43"] = <
488 description = <"The timing in relation to the contraction of the heart">
489 text = <"Phase of heart cycle">
490 >
491 ["at0.44"] = <
492 description = <"*">
493 text = <"Continuous">
494 >
495 ["at0.45"] = <
496 description = <"*">
497 text = <"Systolic">
498 >
499 ["at0.46"] = <
500 description = <"*">
501 text = <"Diastolic">
502 >
503 ["at0.47"] = <
504 description = <"*">
505 text = <"Pan-systolic">
506 >
507 ["at0.48"] = <
508 description = <"*">
509 text = <"Pan-diastolic">
510 >
511 ["at0.49"] = <
512 description = <"*">
513 text = <"Early systolic">
514 >
515 ["at0.5"] = <
516 description = <"No high pitched crackling sounds">
517 text = <"No crackles">
518 >
519 ["at0.50"] = <
520 description = <"*">
521 text = <"Mid-Systolic">
522 >
523 ["at0.51"] = <
524 description = <"*">
525 text = <"Late Systolic">
526 >
527 ["at0.52"] = <
528 description = <"*">
529 text = <"Early Diastolic">
530 >
531 ["at0.53"] = <
532 description = <"*">
533 text = <"Mid-diastolic">
534 >
535 ["at0.54"] = <
536 description = <"*">
537 text = <"Late Diastolic">
538 >
539 ["at0.55"] = <
540 description = <"The character of the sound">
541 text = <"Character">
542 >
543 ["at0.56"] = <
544 description = <"The pitch of the sound">
545 text = <"Pitch">
546 >
547 ["at0.57"] = <
548 description = <"A heart sound in early diastole">
549 text = <"Third heart sound">
550 >
551 ["at0.58"] = <
552 description = <"A heart sound in late diastole">
553 text = <"Fourth heart sound">
554 >
555 ["at0.59"] = <
556 description = <"The volume of the sound">
557 text = <"Volume">
558 >
559 ["at0.6"] = <
560 description = <"Normal heart sounds">
561 text = <"Two heart sounds, no bruits">
562 >
563 ["at0.60"] = <
564 description = <"The sound is not audible">
565 text = <"Not audible">
566 >
567 ["at0.61"] = <
568 description = <"The sound is variable">
569 text = <"Variable">
570 >
571 ["at0.62"] = <
572 description = <"The sound is soft">
573 text = <"Soft">
574 >
575 ["at0.63"] = <
576 description = <"The sound is at about the expected level the first heart sound">
577 text = <"Moderate">
578 >
579 ["at0.64"] = <
580 description = <"The sound is louder than the first heart sound">
581 text = <"Loud">
582 >
583 ["at0.65"] = <
584 description = <"Sound due to a prosthetic heart valve">
585 text = <"Prosthetic valve sound">
586 >
587 ["at0.66"] = <
588 description = <"Audible rythm similar to a horse galloping due to added heart sounds">
589 text = <"Gallop rythm">
590 >
591 ["at0.67"] = <
592 description = <"Drawing of the sounds of the heart">
593 text = <"Drawing">
594 >
595 ["at0.68"] = <
596 description = <"Recording of the heart sounds">
597 text = <"Phonogram">
598 >
599 ["at0.69"] = <
600 description = <"Group of findings about auscultation of the lung">
601 text = <"Lung">
602 >
603 ["at0.7"] = <
604 description = <"Normal heart sounds">
605 text = <"Two heart sounds, no murmurs">
606 >
607 ["at0.70"] = <
608 description = <"*">
609 text = <"Area">
610 >
611 ["at0.72"] = <
612 description = <"The timing of the sounds in relation to breathing">
613 text = <"Phase of respiratory cycle">
614 >
615 ["at0.73"] = <
616 description = <"During inspiration">
617 text = <"Inspiratory">
618 >
619 ["at0.74"] = <
620 description = <"During expiration">
621 text = <"Expiratory">
622 >
623 ["at0.75"] = <
624 description = <"A grouping of discription of one or more added heart sounds">
625 text = <"Added heart sound">
626 >
627 ["at0.76"] = <
628 description = <"Specific auscultatory findings related to examination of the heart">
629 text = <"Specific sound">
630 >
631 ["at0.77"] = <
632 description = <"Soon after inspiration begins">
633 text = <"Early Inspiratory">
634 >
635 ["at0.78"] = <
636 description = <"At the final stages of inspiration">
637 text = <"Late inspiratory">
638 >
639 ["at0.79"] = <
640 description = <"Soon after expiration begins">
641 text = <"Early expiratory">
642 >
643 ["at0.8"] = <
644 description = <"*">
645 text = <"Two normal heart sounds">
646 >
647 ["at0.80"] = <
648 description = <"At the late stages of expiration">
649 text = <"Late expiratory">
650 >
651 ["at0.81"] = <
652 description = <"Specific auscultatory findings related to examination of the lungs">
653 text = <"Findings">
654 >
655 ["at0.82"] = <
656 description = <"Drawing of the breath sounds">
657 text = <"Drawing">
658 >
659 ["at0.83"] = <
660 description = <"The region to which the findings relate">
661 text = <"Region">
662 >
663 ["at0.9"] = <
664 description = <"*">
665 text = <"Normal first heart sound">
666 >
667 ["at0000"] = <
668 description = <"Findings on Auscultation">
669 text = <"Auscultation">
670 >
671 ["at0000.1"] = <
672 description = <"Findings on auscultation of the chest">
673 text = <"Auscultation of the chest">
674 >
675 ["at0001"] = <
676 description = <"A group of statements about the normality of auscultation">
677 text = <"Normal Statements">
678 >
679 ["at0002"] = <
680 description = <"Findings on auscultation">
681 text = <"Findings">
682 >
683 ["at0003"] = <
684 description = <"Statements about the normality of the auscultation">
685 text = <"Normal Statement">
686 >
687 ["at0004"] = <
688 description = <"Detailed clinical description of the findings on auscultation">
689 text = <"Clinical Description">
690 >
691 ["at0009"] = <
692 description = <"Group of findings about auscultation of the bowel">
693 text = <"Bowel sounds">
694 >
695 ["at0010"] = <
696 description = <"Group of findings about auscultation of a major blood vessel">
697 text = <"Vessel bruit">
698 >
699 ["at0030"] = <
700 description = <"Site where finding is heard maximally">
701 text = <"Maximal Location">
702 >
703 ["at0056"] = <
704 description = <"No murmur is heard">
705 text = <"No murmur">
706 >
707 ["at0057"] = <
708 description = <"No bruit is heard">
709 text = <"No bruit">
710 >
711 ["at0073"] = <
712 description = <"Bowel sounds are normal in intensity and character">
713 text = <"Normal bowel sounds">
714 >
715 ["at0074"] = <
716 description = <"Specific auscultatory findings related to examination of the bowels">
717 text = <"Specific Findings">
718 >
719 ["at0078"] = <
720 description = <"No bowel sounds can be heard">
721 text = <"Absent bowel sounds">
722 >
723 ["at0079"] = <
724 description = <"Bowel sounds are less than normal">
725 text = <"Decreased bowel sounds">
726 >
727 ["at0080"] = <
728 description = <"Bowel sounds are more intense than normal">
729 text = <"Increased bowel sounds">
730 >
731 ["at0081"] = <
732 description = <"High pitched and very frequent bowel sounds can be heard">
733 text = <"Tinkling bowel sounds">
734 >
735 ["at0085"] = <
736 description = <"Nothing abnormal on auscultation">
737 text = <"No abnormality detected">
738 >
739 ["at0086"] = <
740 description = <"Auscultation in a particular site">
741 text = <"Localised auscultation">
742 >
743 ["at0087"] = <
744 description = <"The site of the localised findings">
745 text = <"Site or region">
746 >
747 ["at0088"] = <
748 description = <"The name of the vessel to which is being listened">
749 text = <"Vessel name">
750 >
751 ["at0089"] = <
752 description = <"Recording of sounds of a different nature">
753 text = <"Other sounds">
754 >
755 ["at0090"] = <
756 description = <"Description of other sounds">
757 text = <"Description">
758 >
759 ["at0091"] = <
760 description = <"Description of the bruit">
761 text = <"Description">
762 >
763 >
764 >
765 >
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