| 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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