archetype (adl_version=1.4) openEHR-EHR-CLUSTER.auscultation-chest.v1 specialize openEHR-EHR-CLUSTER.auscultation.v1 concept [at0000.1] -- Auscultation of the chest language original_language = <[ISO_639-1::en]> description original_author = < ["name"] = <"Sam Heard"> ["organisation"] = <"Ocean Informatics"> ["date"] = <"7/04/2007"> ["email"] = <"sam.heard@oceaninformatics.biz"> > details = < ["en"] = < language = <[ISO_639-1::en]> purpose = <"To record data found on examination of the chest by auscultation/listening"> use = <"To be embedded in an openEHR-EHR-OBSERVATION.exam cluster to express findings determined by auscultation of the chest"> keywords = <"auscultate", "listen", "auscultation", "listening", "lungs", "chest", "bruit", "heart", "bowel sounds", "breath sounds", "heart sounds"> misuse = <"Not for use in any other context at present"> > > lifecycle_state = <"Initial"> other_contributors = <"Heather Leslie", ...> definition CLUSTER[at0000.1] matches { -- Auscultation of the chest items cardinality matches {0..*; unordered} matches { CLUSTER[at0001] occurrences matches {0..1} matches { -- Normal Statements items cardinality matches {0..*; unordered} matches { ELEMENT[at0003] occurrences matches {0..*} matches { -- Normal Statement value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0.1, -- Clear at0.2, -- No rhonchi at0.3, -- No wheeze at0.4, -- No crepitations at0.5, -- No crackles at0.6, -- Two heart sounds, no bruits at0.7, -- Two heart sounds, no murmurs at0.8, -- Two normal heart sounds at0056, -- No murmur at0057, -- No bruit at0.9, -- Normal first heart sound at0.10, -- Normal second heart sound at0.11, -- No Bronchial breathing at0.12, -- No Amphoric breathing at0.13, -- Normal Vocal Resonance at0.14, -- No abnormal added sounds at0073, -- Normal bowel sounds at0085] -- No abnormality detected } } } } } } ELEMENT[at0004] occurrences matches {0..1} matches { -- Clinical Description value matches { DV_TEXT matches {*} } } CLUSTER[at0002] occurrences matches {0..1} matches { -- Findings items cardinality matches {0..*; unordered} matches { CLUSTER[at0.15] occurrences matches {0..1} matches { -- Heart sounds and bruits items cardinality matches {0..*; unordered} matches { CLUSTER[at0.16] occurrences matches {0..1} matches { -- First heart sound items cardinality matches {0..*; unordered} matches { ELEMENT[at0.17] occurrences matches {0..1} matches { -- Volume value matches { 0|[local::at0.18], -- Not heard 1|[local::at0.19], -- Variable 2|[local::at0.20], -- Soft 3|[local::at0.21], -- Normal 4|[local::at0.22]; -- Loud 0 -- assumed value } } ELEMENT[at0.23] occurrences matches {0..1} matches { -- Splitting value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0.24, -- No splitting at0.25, -- Physiological splitting at0.26, -- Fixed splitting at0.27, -- Paradoxical splitting at0.28] -- Exaggerated splitting } } } } use_node ELEMENT /items[at0004] } } CLUSTER[at0.29] occurrences matches {0..1} matches { -- Second heart sound items cardinality matches {0..*; unordered} matches { use_node ELEMENT /items[at0002]/items[at0.15]/items[at0.16]/items[at0.17] use_node ELEMENT /items[at0002]/items[at0.15]/items[at0.16]/items[at0.23] use_node ELEMENT /items[at0004] } } CLUSTER[at0.75] occurrences matches {0..*} matches { -- Added heart sound items cardinality matches {0..*; unordered} matches { ELEMENT[at0.76] occurrences matches {0..*} matches { -- Specific sound value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0.30, -- Opening snap at0.32, -- Ejection click at0.33, -- Pericardial rub at0.57, -- Third heart sound at0.58, -- Fourth heart sound at0.65, -- Prosthetic valve sound at0.66] -- Gallop rythm } } } } ELEMENT[at0.43] occurrences matches {0..*} matches { -- Phase of heart cycle value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0.44, -- Continuous at0.45, -- Systolic at0.46, -- Diastolic at0.47, -- Pan-systolic at0.48, -- Pan-diastolic at0.49, -- Early systolic at0.50, -- Mid-Systolic at0.51, -- Late Systolic at0.52, -- Early Diastolic at0.53, -- Mid-diastolic at0.54] -- Late Diastolic } } } } ELEMENT[at0.59] occurrences matches {0..1} matches { -- Volume value matches { 0|[local::at0.60], -- Not audible 1|[local::at0.61], -- Variable 2|[local::at0.62], -- Soft 3|[local::at0.63], -- Moderate 4|[local::at0.64]; -- Loud 0 -- assumed value } } use_node ELEMENT /items[at0004] } } CLUSTER[at0.31] occurrences matches {0..*} matches { -- Bruits items cardinality matches {0..*; unordered} matches { ELEMENT[at0.35] occurrences matches {0..1} matches { -- Maximal Location value matches { DV_TEXT matches {*} } } ELEMENT[at0.36] occurrences matches {0..*} matches { -- Radiation value matches { DV_TEXT matches {*} } } ELEMENT[at0.34] occurrences matches {0..1} matches { -- Grading value matches { 1|[local::at0.37], -- Grade 1 2|[local::at0.38], -- Grade 2 3|[local::at0.39], -- Grade 3 4|[local::at0.40], -- Grade 4 5|[local::at0.41], -- Grade 5 6|[local::at0.42] -- Grade 6 } } ELEMENT[at0.55] occurrences matches {0..1} matches { -- Character value matches { DV_TEXT matches {*} } } ELEMENT[at0.56] occurrences matches {0..1} matches { -- Pitch value matches { DV_TEXT matches {*} } } use_node ELEMENT /items[at0002]/items[at0.15]/items[at0.75]/items[at0.43] use_node ELEMENT /items[at0004] } } ELEMENT[at0.67] occurrences matches {0..1} matches { -- Drawing value matches { DV_MULTIMEDIA matches { media_type matches { [openEHR:: 425, 426, 427, 428, 429] } } } } ELEMENT[at0.68] occurrences matches {0..1} matches { -- Phonogram value matches { DV_MULTIMEDIA matches { media_type matches { [openEHR:: 409, 410] } } } } } } CLUSTER[at0.69] occurrences matches {0..1} matches { -- Lung items cardinality matches {0..*; unordered} matches { CLUSTER[at0.70] occurrences matches {0..1} matches { -- Area items cardinality matches {0..*; unordered} matches { ELEMENT[at0.83] occurrences matches {0..1} matches { -- Region value matches { DV_TEXT matches {*} } } ELEMENT[at0.72] occurrences matches {0..1} matches { -- Phase of respiratory cycle value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0.73, -- Inspiratory at0.74, -- Expiratory at0.77, -- Early Inspiratory at0.78, -- Late inspiratory at0.79, -- Early expiratory at0.80] -- Late expiratory } } } } ELEMENT[at0.81] occurrences matches {0..1} matches { -- Findings value matches { DV_TEXT matches {*} } } } } ELEMENT[at0.82] occurrences matches {0..1} matches { -- Drawing value matches { DV_MULTIMEDIA matches { media_type matches { [openEHR:: 425, 426, 427, 428, 429] } } } } use_node ELEMENT /items[at0004] } } CLUSTER[at0009] occurrences matches {0..1} matches { -- Bowel sounds items cardinality matches {0..*; unordered} matches { ELEMENT[at0074] occurrences matches {0..*} matches { -- Specific Findings value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0078, -- Absent bowel sounds at0079, -- Decreased bowel sounds at0080, -- Increased bowel sounds at0081] -- Tinkling bowel sounds } } } } use_node ELEMENT /items[at0004] } } CLUSTER[at0010] occurrences matches {0..1} matches { -- Vessel bruit items cardinality matches {0..*; unordered} matches { ELEMENT[at0088] matches { -- Vessel name value matches { DV_TEXT matches {*} } } ELEMENT[at0030] occurrences matches {0..1} matches { -- Maximal Location value matches { DV_TEXT matches {*} } } ELEMENT[at0091] occurrences matches {0..1} matches { -- Description value matches { DV_TEXT matches {*} } } } } CLUSTER[at0089] occurrences matches {0..1} matches { -- Other sounds items cardinality matches {0..*; unordered} matches { ELEMENT[at0090] matches { -- Description value matches { DV_TEXT matches {*} } } use_node ELEMENT /items[at0002]/items[at0010]/items[at0030] } } CLUSTER[at0086] occurrences matches {0..*} matches { -- Localised auscultation items cardinality matches {0..*; unordered} matches { ELEMENT[at0087] matches { -- Site or region value matches { DV_TEXT matches {*} } } allow_archetype CLUSTER occurrences matches {0..1} matches { include archetype_id/value matches {/auscultation\.v1/} } } } } } } } ontology term_definitions = < ["en"] = < items = < ["at0.1"] = < description = <"No abnormal breath sounds"> text = <"Clear"> > ["at0.10"] = < description = <"*"> text = <"Normal second heart sound"> > ["at0.11"] = < description = <"*"> text = <"No Bronchial breathing"> > ["at0.12"] = < description = <"*"> text = <"No Amphoric breathing"> > ["at0.13"] = < description = <"*"> text = <"Normal Vocal Resonance"> > ["at0.14"] = < description = <"*"> text = <"No abnormal added sounds"> > ["at0.15"] = < description = <"*"> text = <"Heart sounds and bruits"> > ["at0.16"] = < description = <"Findings about the first heart sound"> text = <"First heart sound"> > ["at0.17"] = < description = <"The volume of the first heart sound"> text = <"Volume"> > ["at0.18"] = < description = <"The first heart sound is not heard"> text = <"Not heard"> > ["at0.19"] = < description = <"The sound is variable in volume"> text = <"Variable"> > ["at0.2"] = < description = <"No high or low pitched wheezes"> text = <"No rhonchi"> > ["at0.20"] = < description = <"The sound is softer than normal"> text = <"Soft"> > ["at0.21"] = < description = <"The sound is of normal volume"> text = <"Normal"> > ["at0.22"] = < description = <"The volume is increased"> text = <"Loud"> > ["at0.23"] = < description = <"Splitting of the heart sound"> text = <"Splitting"> > ["at0.24"] = < description = <"The heart sound is not split"> text = <"No splitting"> > ["at0.25"] = < description = <"The heart sound is split due to physiological changes"> text = <"Physiological splitting"> > ["at0.26"] = < description = <"The heart sound is always split"> text = <"Fixed splitting"> > ["at0.27"] = < description = <"The variable splitting is not physiological"> text = <"Paradoxical splitting"> > ["at0.28"] = < description = <"The timing of the splitting is physiological but it is more obvious than normal"> text = <"Exaggerated splitting"> > ["at0.29"] = < description = <"Findings about the second heart sound"> text = <"Second heart sound"> > ["at0.3"] = < description = <"No wheezing noises"> text = <"No wheeze"> > ["at0.30"] = < description = <"Opening sound of the mitral valve"> text = <"Opening snap"> > ["at0.31"] = < description = <"Group of findings about auscultation of the heart"> text = <"Bruits"> > ["at0.32"] = < description = <"Systolic click when the heart contracts"> text = <"Ejection click"> > ["at0.33"] = < description = <"Rubbing noise during contractions on the pericardium"> text = <"Pericardial rub"> > ["at0.34"] = < description = <"Grading of the loudness of a heart murmur"> text = <"Grading"> > ["at0.35"] = < description = <"Site where finding is heard maximally"> text = <"Maximal Location"> > ["at0.36"] = < description = <"Sites where finding is heard in addition to maximal site"> text = <"Radiation"> > ["at0.37"] = < description = <"very faint to recognize the murmur even after listening for a while"> text = <"Grade 1"> > ["at0.38"] = < description = <"faint, but easy to recognize the murmur right after the stethoscope is placed on the chest"> text = <"Grade 2"> > ["at0.39"] = < description = <"intermediate loudness between II/VI -IV/VI"> text = <"Grade 3"> > ["at0.4"] = < description = <"No high pitched crackling sounds"> text = <"No crepitations"> > ["at0.40"] = < description = <"with loud murmur (palpable thrill)"> text = <"Grade 4"> > ["at0.41"] = < description = <"very loud, but you can not hear the murmur, if the stethoscope is away from the chest wall"> text = <"Grade 5"> > ["at0.42"] = < description = <"the loudest murmur you can hear, even if the stethoscope is off the chest wall"> text = <"Grade 6"> > ["at0.43"] = < description = <"The timing in relation to the contraction of the heart"> text = <"Phase of heart cycle"> > ["at0.44"] = < description = <"*"> text = <"Continuous"> > ["at0.45"] = < description = <"*"> text = <"Systolic"> > ["at0.46"] = < description = <"*"> text = <"Diastolic"> > ["at0.47"] = < description = <"*"> text = <"Pan-systolic"> > ["at0.48"] = < description = <"*"> text = <"Pan-diastolic"> > ["at0.49"] = < description = <"*"> text = <"Early systolic"> > ["at0.5"] = < description = <"No high pitched crackling sounds"> text = <"No crackles"> > ["at0.50"] = < description = <"*"> text = <"Mid-Systolic"> > ["at0.51"] = < description = <"*"> text = <"Late Systolic"> > ["at0.52"] = < description = <"*"> text = <"Early Diastolic"> > ["at0.53"] = < description = <"*"> text = <"Mid-diastolic"> > ["at0.54"] = < description = <"*"> text = <"Late Diastolic"> > ["at0.55"] = < description = <"The character of the sound"> text = <"Character"> > ["at0.56"] = < description = <"The pitch of the sound"> text = <"Pitch"> > ["at0.57"] = < description = <"A heart sound in early diastole"> text = <"Third heart sound"> > ["at0.58"] = < description = <"A heart sound in late diastole"> text = <"Fourth heart sound"> > ["at0.59"] = < description = <"The volume of the sound"> text = <"Volume"> > ["at0.6"] = < description = <"Normal heart sounds"> text = <"Two heart sounds, no bruits"> > ["at0.60"] = < description = <"The sound is not audible"> text = <"Not audible"> > ["at0.61"] = < description = <"The sound is variable"> text = <"Variable"> > ["at0.62"] = < description = <"The sound is soft"> text = <"Soft"> > ["at0.63"] = < description = <"The sound is at about the expected level the first heart sound"> text = <"Moderate"> > ["at0.64"] = < description = <"The sound is louder than the first heart sound"> text = <"Loud"> > ["at0.65"] = < description = <"Sound due to a prosthetic heart valve"> text = <"Prosthetic valve sound"> > ["at0.66"] = < description = <"Audible rythm similar to a horse galloping due to added heart sounds"> text = <"Gallop rythm"> > ["at0.67"] = < description = <"Drawing of the sounds of the heart"> text = <"Drawing"> > ["at0.68"] = < description = <"Recording of the heart sounds"> text = <"Phonogram"> > ["at0.69"] = < description = <"Group of findings about auscultation of the lung"> text = <"Lung"> > ["at0.7"] = < description = <"Normal heart sounds"> text = <"Two heart sounds, no murmurs"> > ["at0.70"] = < description = <"*"> text = <"Area"> > ["at0.72"] = < description = <"The timing of the sounds in relation to breathing"> text = <"Phase of respiratory cycle"> > ["at0.73"] = < description = <"During inspiration"> text = <"Inspiratory"> > ["at0.74"] = < description = <"During expiration"> text = <"Expiratory"> > ["at0.75"] = < description = <"A grouping of discription of one or more added heart sounds"> text = <"Added heart sound"> > ["at0.76"] = < description = <"Specific auscultatory findings related to examination of the heart"> text = <"Specific sound"> > ["at0.77"] = < description = <"Soon after inspiration begins"> text = <"Early Inspiratory"> > ["at0.78"] = < description = <"At the final stages of inspiration"> text = <"Late inspiratory"> > ["at0.79"] = < description = <"Soon after expiration begins"> text = <"Early expiratory"> > ["at0.8"] = < description = <"*"> text = <"Two normal heart sounds"> > ["at0.80"] = < description = <"At the late stages of expiration"> text = <"Late expiratory"> > ["at0.81"] = < description = <"Specific auscultatory findings related to examination of the lungs"> text = <"Findings"> > ["at0.82"] = < description = <"Drawing of the breath sounds"> text = <"Drawing"> > ["at0.83"] = < description = <"The region to which the findings relate"> text = <"Region"> > ["at0.9"] = < description = <"*"> text = <"Normal first heart sound"> > ["at0000"] = < description = <"Findings on Auscultation"> text = <"Auscultation"> > ["at0000.1"] = < description = <"Findings on auscultation of the chest"> text = <"Auscultation of the chest"> > ["at0001"] = < description = <"A group of statements about the normality of auscultation"> text = <"Normal Statements"> > ["at0002"] = < description = <"Findings on auscultation"> text = <"Findings"> > ["at0003"] = < description = <"Statements about the normality of the auscultation"> text = <"Normal Statement"> > ["at0004"] = < description = <"Detailed clinical description of the findings on auscultation"> text = <"Clinical Description"> > ["at0009"] = < description = <"Group of findings about auscultation of the bowel"> text = <"Bowel sounds"> > ["at0010"] = < description = <"Group of findings about auscultation of a major blood vessel"> text = <"Vessel bruit"> > ["at0030"] = < description = <"Site where finding is heard maximally"> text = <"Maximal Location"> > ["at0056"] = < description = <"No murmur is heard"> text = <"No murmur"> > ["at0057"] = < description = <"No bruit is heard"> text = <"No bruit"> > ["at0073"] = < description = <"Bowel sounds are normal in intensity and character"> text = <"Normal bowel sounds"> > ["at0074"] = < description = <"Specific auscultatory findings related to examination of the bowels"> text = <"Specific Findings"> > ["at0078"] = < description = <"No bowel sounds can be heard"> text = <"Absent bowel sounds"> > ["at0079"] = < description = <"Bowel sounds are less than normal"> text = <"Decreased bowel sounds"> > ["at0080"] = < description = <"Bowel sounds are more intense than normal"> text = <"Increased bowel sounds"> > ["at0081"] = < description = <"High pitched and very frequent bowel sounds can be heard"> text = <"Tinkling bowel sounds"> > ["at0085"] = < description = <"Nothing abnormal on auscultation"> text = <"No abnormality detected"> > ["at0086"] = < description = <"Auscultation in a particular site"> text = <"Localised auscultation"> > ["at0087"] = < description = <"The site of the localised findings"> text = <"Site or region"> > ["at0088"] = < description = <"The name of the vessel to which is being listened"> text = <"Vessel name"> > ["at0089"] = < description = <"Recording of sounds of a different nature"> text = <"Other sounds"> > ["at0090"] = < description = <"Description of other sounds"> text = <"Description"> > ["at0091"] = < description = <"Description of the bruit"> text = <"Description"> > > > >