archetype (adl_version=1.4) openEHR-EHR-CLUSTER.exam-chest.v1 specialize openEHR-EHR-CLUSTER.exam.v1 concept [at0000.1] -- Examination of the chest language original_language = <[ISO_639-1::en]> description original_author = < ["name"] = <"Sam Heard"> ["organisation"] = <"Ocean Informatics"> ["date"] = <"9/04/2007"> ["email"] = <"Sam.Heard@OceanInformatics.biz"> > details = < ["en"] = < language = <[ISO_639-1::en]> purpose = <"A cluster for recording findings on physical examination of the chest"> use = <""> keywords = <"examination", "physical", "chest", "thorax", "lungs"> misuse = <""> > > lifecycle_state = <"Initial"> other_contributors = <> definition CLUSTER[at0000.1] matches { -- Examination of the chest items cardinality matches {0..*; unordered} matches { CLUSTER[at0004] occurrences matches {0..1} matches { -- Normal statements items cardinality matches {0..*; unordered} matches { ELEMENT[at0005] occurrences matches {0..*} matches { -- Normal statement value matches { DV_TEXT matches {*} } } } } ELEMENT[at0002] occurrences matches {0..1} matches { -- Clinical description value matches { DV_TEXT matches {*} } } CLUSTER[at0008] occurrences matches {0..1} matches { -- Findings items cardinality matches {0..*; unordered} matches { CLUSTER[at0.1] occurrences matches {0..1} matches { -- Chest wall items cardinality matches {0..*; unordered} matches { ELEMENT[at0.2] occurrences matches {0..1} matches { -- Description value matches { DV_CODED_TEXT matches { defining_code matches {[local::]} } } } ELEMENT[at0.28] occurrences matches {0..1} matches { -- Shape value matches { DV_TEXT matches {*} } } CLUSTER[at0.30] occurrences matches {0..1} matches { -- Heart - Apex beat items cardinality matches {0..*; unordered} matches { ELEMENT[at0.31] occurrences matches {0..1} matches { -- Visible value matches { DV_BOOLEAN matches { value matches {True, False} } } } CLUSTER[at0.32] occurrences matches {0..1} matches { -- Palpation items cardinality matches {0..*; unordered} matches { ELEMENT[at0.33] occurrences matches {0..1} matches { -- Palpable value matches { DV_BOOLEAN matches { value matches {True, False} } } } ELEMENT[at0.34] occurrences matches {0..1} matches { -- Maximal location value matches { DV_TEXT matches {*} } } } } } } allow_archetype CLUSTER occurrences matches {0..1} matches { include archetype_id/value matches {/palpation\.v1draft/} archetype_id/value matches {/inspection\.v1draft/} archetype_id/value matches {/auscultation-chest\.v1/} } } } CLUSTER[at0.3] occurrences matches {0..1} matches { -- Respiratory system items cardinality matches {0..*; unordered} matches { ELEMENT[at0.4] occurrences matches {0..1} matches { -- Trachea value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0.5, -- Midline at0.6, -- Deviated to the left at0.7] -- Deviated to the right } } } } CLUSTER[at0.8] occurrences matches {0..1} matches { -- Breathing items cardinality matches {0..*; unordered} matches { ELEMENT[at0.19] occurrences matches {0..1} matches { -- Description value matches { DV_TEXT matches {*} } } ELEMENT[at0.9] occurrences matches {0..1} matches { -- Type value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0.10, -- Diaphragmatic breathing at0.11] -- Thoracic breathing } } } } ELEMENT[at0.12] occurrences matches {0..1} matches { -- Effort value matches { 5|[local::at0.13], -- Normal breathing effort 6|[local::at0.14], -- Mild increase in effort 8|[local::at0.15], -- Moderate increased effort 10|[local::at0.16] -- Major increased effort } } CLUSTER[at0.17] occurrences matches {0..1} matches { -- Signs of increased effort items cardinality matches {0..*; unordered} matches { ELEMENT[at0.18] occurrences matches {0..*} matches { -- Sign value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0.25, -- Using accessory muscles at0.20, -- Intercostal recession at0.24, -- Subcostal recession at0.23, -- Suprasternal recession at0.21, -- Sternal recession at0.22] -- Rib retraction } } } } } } ELEMENT[at0.26] occurrences matches {0..1} matches { -- Paradoxical movement (flail chest) value matches { DV_BOOLEAN matches { value matches {True, False} } } } } } } } CLUSTER[at0003] occurrences matches {0..1} matches { -- Detail items cardinality matches {0..*; unordered} matches { allow_archetype CLUSTER occurrences matches {0..1} matches { include archetype_id/value matches {/exam-generic\.v1/} archetype_id/value matches {/auscultation-chest\.v1/} archetype_id/value matches {/palpation\.v1/} archetype_id/value matches {/inspection\.v1draft/} archetype_id/value matches {/percussion\.v1/} } } } } } CLUSTER[at0.27] occurrences matches {0..1} matches { -- Lymph nodes items cardinality matches {0..*; unordered} matches { allow_archetype CLUSTER occurrences matches {0..1} matches { include archetype_id/value matches {/exam-generic-lympnode\.v1/} } } } ELEMENT[at0006] occurrences matches {0..*} matches { -- Image value matches { DV_MULTIMEDIA matches { media_type matches { [openEHR:: 426, 427, 429] } } } } } } ontology term_definitions = < ["en"] = < items = < ["at0.1"] = < description = <"Findings about the chest wall"> text = <"Chest wall"> > ["at0.10"] = < description = <"Breathing using the diaphragm and not the chest wall"> text = <"Diaphragmatic breathing"> > ["at0.11"] = < description = <"Breathing using expansion of the chest wall"> text = <"Thoracic breathing"> > ["at0.12"] = < description = <"Effort required for breathing"> text = <"Effort"> > ["at0.13"] = < description = <"Diaphragmatic breathing as at rest"> text = <"Normal breathing effort"> > ["at0.14"] = < description = <"Breathing using obvious chest expansion"> text = <"Mild increase in effort"> > ["at0.15"] = < description = <"Breathing with signs of abnormal breathing"> text = <"Moderate increased effort"> > ["at0.16"] = < description = <"Many signs of increased breathing effort"> text = <"Major increased effort"> > ["at0.17"] = < description = <"Signs of increased respiratory effort"> text = <"Signs of increased effort"> > ["at0.18"] = < description = <"Use of accessory respiratory muscles"> text = <"Sign"> > ["at0.19"] = < description = <"Description of breathing"> text = <"Description"> > ["at0.2"] = < description = <"The contour of the chest wall"> text = <"Description"> > ["at0.20"] = < description = <"Drawing in between the ribs on inspiration"> text = <"Intercostal recession"> > ["at0.21"] = < description = <"Drawing in of the sternum on inspiration"> text = <"Sternal recession"> > ["at0.22"] = < description = <"Indrawing of the chest wall on inspiration"> text = <"Rib retraction"> > ["at0.23"] = < description = <"Indrawing above the sternum on inspiration"> text = <"Suprasternal recession"> > ["at0.24"] = < description = <"Indrawing of the subcostal abdominal wall "> text = <"Subcostal recession"> > ["at0.25"] = < description = <"Use of accessory respiratory muscles during inspiration"> text = <"Using accessory muscles"> > ["at0.26"] = < description = <"Any paradoxical movement of the chest wall during respiration"> text = <"Paradoxical movement (flail chest)"> > ["at0.27"] = < description = <"Lymphnodes"> text = <"Lymph nodes"> > ["at0.28"] = < description = <"The shape of the chest"> text = <"Shape"> comment = <"ChestShape SNOMED query"> > ["at0.29"] = < description = <"Pidgeon chest, with prominent lower sternum"> text = <"Pectus carinatum"> > ["at0.3"] = < description = <"Respiratory findings"> text = <"Respiratory system"> > ["at0.30"] = < description = <"*"> text = <"Heart - Apex beat"> > ["at0.31"] = < description = <"Apex beat is visible"> text = <"Visible"> > ["at0.32"] = < description = <"*"> text = <"Palpation"> > ["at0.33"] = < description = <"Apex beat is palpable"> text = <"Palpable"> > ["at0.34"] = < description = <"Site of maximal location of apex beat"> text = <"Maximal location"> > ["at0.4"] = < description = <"The position of the trachea"> text = <"Trachea"> > ["at0.5"] = < description = <"The trachea is in the midline position"> text = <"Midline"> > ["at0.6"] = < description = <"The trachea is deviated to the left"> text = <"Deviated to the left"> > ["at0.7"] = < description = <"The trachea is deviated to the right"> text = <"Deviated to the right"> > ["at0.8"] = < description = <"Findings about breathing"> text = <"Breathing"> > ["at0.9"] = < description = <"Type of breathing"> text = <"Type"> > ["at0000"] = < description = <"Basic examination cluster for describing findings on physical examination when there is no named focus of examination"> text = <"Examination"> > ["at0000.1"] = < description = <"For recording findings on physical examination of the chest wall and lungs"> text = <"Examination of the chest"> > ["at0002"] = < description = <"Textural description of the part examined"> text = <"Clinical description"> > ["at0003"] = < description = <"More focused examination findings"> text = <"Detail"> > ["at0004"] = < description = <"A group of statements about the normality of the examination"> text = <"Normal statements"> > ["at0005"] = < description = <"A specific statement of normality"> text = <"Normal statement"> > ["at0006"] = < description = <"Drawing or image of the area examined"> text = <"Image"> > ["at0008"] = < description = <"Clinical findings"> text = <"Findings"> > > > >