ARCHETYPE Auscultation of the chest (openEHR-EHR-CLUSTER.auscultation-chest.v1)

ARCHETYPE ID	openEHR-EHR-CLUSTER.auscultation-chest.v1
Concept	Auscultation of the chest
Description	Findings on auscultation of the chest.
Use	To be embedded in an openEHR-EHR-OBSERVATION.exam cluster to express findings determined by auscultation of the chest.
Misuse	Not for use in any other context at present.
Purpose	To record data found on examination of the chest by auscultation/listening.
References
Copyright	copyright (c) 2010 openEHR Foundation
Authors	Author name: Sam Heard Organisation: Ocean Informatics Email: sam.heard@oceaninformatics.com Date originally authored: 7/04/2007
Other Details Language	Author name: Sam Heard Organisation: Ocean Informatics Email: sam.heard@oceaninformatics.com Date originally authored: 7/04/2007
Other Details (Language Independent)	References: MD5-CAM-1.0.1: 3324331C8FE6405B0A545EC8945CFCC5
Keywords	auscultate, listen, auscultation, listening, lungs, chest, bruit, heart, bowel sounds, breath sounds, heart sounds
Lifecycle	AuthorDraft
Language used	en
Citeable Identifier	1013.1.111
items
Normal Statements	Normal Statements: A group of statements about the normality of auscultation.
Normal Statement	Normal Statement: Statements about the normality of the auscultation. at0.1::Clear [No abnormal breath sounds.] at0.2::No rhonchi [No high or low pitched wheezes.] at0.3::No wheeze [No wheezing noises.] at0.4::No crepitations [No high pitched crackling sounds.] at0.5::No crackles [No high pitched crackling sounds.] at0.6::Two heart sounds, no bruits [Normal heart sounds.] at0.7::Two heart sounds, no murmurs [Normal heart sounds.] at0.8::Two normal heart sounds [] at0056::No murmur [No murmur is heard.] at0057::No bruit [No bruit is heard.] 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 [Bowel sounds are normal in intensity and character.] at0085::No abnormality detected [Nothing abnormal on auscultation.]
Clinical Description	Clinical Description: Detailed clinical description of the findings on auscultation.
Findings	Findings: Findings on auscultation.
Heart sounds and bruits	Heart sounds and bruits: *
First heart sound	First heart sound: Findings about the first heart sound.
Volume	Volume: The volume of the first heart sound. 0: at0.18::Not heard [The first heart sound is not heard.] 1: at0.19::Variable [The sound is variable in volume.] 2: at0.20::Soft [The sound is softer than normal.] 3: at0.21::Normal [The sound is of normal volume.] 4: at0.22::Loud [The volume is increased.] Assumed value: 0: Not heard
Splitting	Splitting: Splitting of the heart sound. at0.24::No splitting [The heart sound is not split.] at0.25::Physiological splitting [The heart sound is split due to physiological changes.] at0.26::Fixed splitting [The heart sound is always split.] at0.27::Paradoxical splitting [The variable splitting is not physiological.] at0.28::Exaggerated splitting [The timing of the splitting is physiological but it is more obvious than normal.]
Clinical Description	Clinical Description: Detailed clinical description of the findings on auscultation.
Second heart sound	Second heart sound: Findings about the second heart sound.
Volume	Volume: The volume of the first heart sound. 0: at0.18::Not heard [The first heart sound is not heard.] 1: at0.19::Variable [The sound is variable in volume.] 2: at0.20::Soft [The sound is softer than normal.] 3: at0.21::Normal [The sound is of normal volume.] 4: at0.22::Loud [The volume is increased.] Assumed value: 0: Not heard
Splitting	Splitting: Splitting of the heart sound. at0.24::No splitting [The heart sound is not split.] at0.25::Physiological splitting [The heart sound is split due to physiological changes.] at0.26::Fixed splitting [The heart sound is always split.] at0.27::Paradoxical splitting [The variable splitting is not physiological.] at0.28::Exaggerated splitting [The timing of the splitting is physiological but it is more obvious than normal.]
Clinical Description	Clinical Description: Detailed clinical description of the findings on auscultation.
Added heart sound	Added heart sound: A grouping of discription of one or more added heart sounds.
Specific sound	Specific sound: Specific auscultatory findings related to examination of the heart. at0.30::Opening snap [Opening sound of the mitral valve.] at0.32::Ejection click [Systolic click when the heart contracts.] at0.33::Pericardial rub [Rubbing noise during contractions on the pericardium.] at0.57::Third heart sound [A heart sound in early diastole.] at0.58::Fourth heart sound [A heart sound in late diastole.] at0.65::Prosthetic valve sound [Sound due to a prosthetic heart valve.] at0.66::Gallop rythm [Audible rythm similar to a horse galloping due to added heart sounds.]
Phase of heart cycle	Phase of heart cycle: The timing in relation to the contraction of the heart. 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 [*]
Volume	Volume: The volume of the sound. 0: at0.60::Not audible [The sound is not audible.] 1: at0.61::Variable [The sound is variable.] 2: at0.62::Soft [The sound is soft.] 3: at0.63::Moderate [The sound is at about the expected level the first heart sound.] 4: at0.64::Loud [The sound is louder than the first heart sound.] Assumed value: 0: Not audible
Clinical Description	Clinical Description: Detailed clinical description of the findings on auscultation.
Bruits	Bruits: Group of findings about auscultation of the heart.
Maximal Location	Maximal Location: Site where finding is heard maximally.
Radiation	Radiation: Sites where finding is heard in addition to maximal site.
Grading	Grading: Grading of the loudness of a heart murmur. 1: at0.37::Grade 1 [very faint to recognize the murmur even after listening for a while.] 2: at0.38::Grade 2 [faint, but easy to recognize the murmur right after the stethoscope is placed on the chest.] 3: at0.39::Grade 3 [intermediate loudness between II/VI -IV/VI.] 4: at0.40::Grade 4 [with loud murmur (palpable thrill).] 5: at0.41::Grade 5 [very loud, but you can not hear the murmur, if the stethoscope is away from the chest wall.] 6: at0.42::Grade 6 [the loudest murmur you can hear, even if the stethoscope is off the chest wall.]
Character	Character: The character of the sound.
Pitch	Pitch: The pitch of the sound.
Phase of heart cycle	Phase of heart cycle: The timing in relation to the contraction of the heart. 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 [*]
Clinical Description	Clinical Description: Detailed clinical description of the findings on auscultation.
Drawing	Drawing: Drawing of the sounds of the heart. image/cgm, image/gif, image/png, image/tiff, image/jpeg
Phonogram	Phonogram: Recording of the heart sounds. audio/mpeg, audio/mpeg4-generic
Lung	Lung: Group of findings about auscultation of the lung.
Area	Area: *
Region	Region: The region to which the findings relate.
Phase of respiratory cycle	Phase of respiratory cycle: The timing of the sounds in relation to breathing. at0.73::Inspiratory [During inspiration.] at0.74::Expiratory [During expiration.] at0.77::Early Inspiratory [Soon after inspiration begins.] at0.78::Late inspiratory [At the final stages of inspiration.] at0.79::Early expiratory [Soon after expiration begins.] at0.80::Late expiratory [At the late stages of expiration.]
Findings	Findings: Specific auscultatory findings related to examination of the lungs.
Drawing	Drawing: Drawing of the breath sounds. image/cgm, image/gif, image/png, image/tiff, image/jpeg
Clinical Description	Clinical Description: Detailed clinical description of the findings on auscultation.
Bowel sounds	Bowel sounds: Group of findings about auscultation of the bowel.
Specific Findings	Specific Findings: Specific auscultatory findings related to examination of the bowels. at0078::Absent bowel sounds [No bowel sounds can be heard.] at0079::Decreased bowel sounds [Bowel sounds are less than normal.] at0080::Increased bowel sounds [Bowel sounds are more intense than normal.] at0081::Tinkling bowel sounds [High pitched and very frequent bowel sounds can be heard.]
Clinical Description	Clinical Description: Detailed clinical description of the findings on auscultation.
Vessel bruit	Vessel bruit: Group of findings about auscultation of a major blood vessel.
Vessel name	Vessel name: The name of the vessel to which is being listened.
Maximal Location	Maximal Location: Site where finding is heard maximally.
Description	Description: Description of the bruit.
Other sounds	Other sounds: Recording of sounds of a different nature.
Description	Description: Description of other sounds.
Maximal Location	Maximal Location: Site where finding is heard maximally.
Localised auscultation	Localised auscultation: Auscultation in a particular site.
Site or region	Site or region: The site of the localised findings.
Cluster auscultation	Cluster auscultation: Description of the cluster. Include: openEHR-EHR-CLUSTER.auscultation.v1
Other contributors	Heather Leslie
Translators