archetype (adl_version=1.4) openEHR-EHR-CLUSTER.exam-chest.v1 specialise 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"> ["email"] = <"Sam.Heard@OceanInformatics.com"> ["date"] = <"9/04/2007"> > 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 = <""> copyright = <"copyright (c) 2010 openEHR Foundation"> > > lifecycle_state = <"AuthorDraft"> other_contributors = <> other_details = < ["MD5-CAM-1.0.1"] = <"215A2C17D4B48244C07F9920C844CEA4"> ["references"] = <""> > definition CLUSTER[at0000.1] matches { -- Examination of the chest items cardinality matches {1..*; unordered} matches { CLUSTER[at0004] occurrences matches {0..1} matches { -- Normal statements items cardinality matches {1..*; 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 {1..*; 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[at0.35] occurrences matches {0..1} matches { -- Apex beat items cardinality matches {1..*; 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 {1..*; 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 {*} } } } } } } CLUSTER[at0.8] occurrences matches {0..1} matches { -- Breathing items cardinality matches {1..*; 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 {1..*; 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[at0.1] occurrences matches {0..1} matches { -- Chest wall items cardinality matches {1..*; unordered} matches { ELEMENT[at0.2] occurrences matches {0..1} matches { -- Description value matches { DV_TEXT matches {*} } } ELEMENT[at0.28] occurrences matches {0..1} matches { -- Shape value matches { DV_TEXT matches {*} } } allow_archetype CLUSTER[at0.37] occurrences matches {0..1} matches { -- Chest wall detail include archetype_id/value matches {/openEHR-EHR-CLUSTER\.inspection(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.palpation(-[a-zA-Z0-9_]+)*\.v1/} } } } CLUSTER[at0.27] occurrences matches {0..1} matches { -- Lymph nodes items cardinality matches {1..*; unordered} matches { allow_archetype CLUSTER[at0.38] occurrences matches {0..*} matches { -- Lymph node detail include archetype_id/value matches {/openEHR-EHR-CLUSTER\.exam-generic-lymphnode(-[a-zA-Z0-9_]+)*\.v1/} } } } allow_archetype CLUSTER[at0009] occurrences matches {0..*} matches { -- Detail include archetype_id/value matches {/openEHR-EHR-CLUSTER\.exam-generic(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.auscultation(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.inspection(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.palpation(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.percussion(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.physical_properties(-[a-zA-Z0-9_]+)*\.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"] = < text = <"Chest wall"> description = <"Findings about the chest wall."> > ["at0.10"] = < text = <"Diaphragmatic breathing"> description = <"Breathing using the diaphragm and not the chest wall."> > ["at0.11"] = < text = <"Thoracic breathing"> description = <"Breathing using expansion of the chest wall."> > ["at0.12"] = < text = <"Effort"> description = <"Effort required for breathing."> > ["at0.13"] = < text = <"Normal breathing effort"> description = <"Diaphragmatic breathing as at rest."> > ["at0.14"] = < text = <"Mild increase in effort"> description = <"Breathing using obvious chest expansion."> > ["at0.15"] = < text = <"Moderate increased effort"> description = <"Breathing with signs of abnormal breathing."> > ["at0.16"] = < text = <"Major increased effort"> description = <"Many signs of increased breathing effort."> > ["at0.17"] = < text = <"Signs of increased effort"> description = <"Signs of increased respiratory effort."> > ["at0.18"] = < text = <"Sign"> description = <"Use of accessory respiratory muscles."> > ["at0.19"] = < text = <"Description"> description = <"Description of breathing."> > ["at0.2"] = < text = <"Description"> description = <"The contour of the chest wall."> > ["at0.20"] = < text = <"Intercostal recession"> description = <"Drawing in between the ribs on inspiration."> > ["at0.21"] = < text = <"Sternal recession"> description = <"Drawing in of the sternum on inspiration."> > ["at0.22"] = < text = <"Rib retraction"> description = <"Indrawing of the chest wall on inspiration."> > ["at0.23"] = < text = <"Suprasternal recession"> description = <"Indrawing above the sternum on inspiration."> > ["at0.24"] = < text = <"Subcostal recession"> description = <"Indrawing of the subcostal abdominal wall ."> > ["at0.25"] = < text = <"Using accessory muscles"> description = <"Use of accessory respiratory muscles during inspiration."> > ["at0.26"] = < text = <"Paradoxical movement (flail chest)"> description = <"Any paradoxical movement of the chest wall during respiration."> > ["at0.27"] = < text = <"Lymph nodes"> description = <"Findings about lymph nodes."> > ["at0.28"] = < text = <"Shape"> description = <"The shape of the chest."> > ["at0.31"] = < text = <"Visible"> description = <"Apex beat is visible."> > ["at0.32"] = < text = <"Palpation"> description = <"*"> > ["at0.33"] = < text = <"Palpable"> description = <"Apex beat is palpable."> > ["at0.34"] = < text = <"Maximal location"> description = <"Site of maximal apex beat."> > ["at0.35"] = < text = <"Apex beat"> description = <"*"> > ["at0.37"] = < text = <"Chest wall detail"> description = <"Detailed chest wall findings."> > ["at0.38"] = < text = <"Lymph node detail"> description = <"Detailed lymph node findings."> > ["at0.4"] = < text = <"Trachea"> description = <"The position of the trachea."> > ["at0.5"] = < text = <"Midline"> description = <"The trachea is in the midline position."> > ["at0.6"] = < text = <"Deviated to the left"> description = <"The trachea is deviated to the left."> > ["at0.7"] = < text = <"Deviated to the right"> description = <"The trachea is deviated to the right."> > ["at0.8"] = < text = <"Breathing"> description = <"Findings about breathing."> > ["at0.9"] = < text = <"Type"> description = <"Type of breathing."> > ["at0000"] = < text = <"Examination"> description = <"Basic examination cluster for describing findings on physical examination when there is no named focus of examination."> > ["at0000.1"] = < text = <"Examination of the chest"> description = <"For recording findings on physical examination of the chest wall and lungs."> > ["at0002"] = < text = <"Clinical description"> description = <"Textural description of the part examined."> > ["at0003"] = < text = <"Detail"> description = <"More focused examination findings."> > ["at0004"] = < text = <"Normal statements"> description = <"A group of statements about the normality of the examination."> > ["at0005"] = < text = <"Normal statement"> description = <"A specific statement of normality."> > ["at0006"] = < text = <"Image"> description = <"Drawing or image of the area examined."> > ["at0008"] = < text = <"Findings"> description = <"Clinical findings."> > ["at0009"] = < text = <"Detail"> description = <"More focused examination findings."> > > > >