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

ARCHETYPE IDopenEHR-EHR-CLUSTER.auscultation-chest.v1
ConceptAuscultation of the chest
DescriptionFindings on auscultation of the chest.
UseTo be embedded in an openEHR-EHR-OBSERVATION.exam cluster to express findings determined by auscultation of the chest.
MisuseNot for use in any other context at present.
PurposeTo record data found on examination of the chest by auscultation/listening.
References
Copyrightcopyright (c) 2010 openEHR Foundation
AuthorsAuthor name: Sam Heard
Organisation: Ocean Informatics
Email: sam.heard@oceaninformatics.com
Date originally authored: 7/04/2007
Other Details LanguageAuthor name: Sam Heard
Organisation: Ocean Informatics
Email: sam.heard@oceaninformatics.com
Date originally authored: 7/04/2007
OtherDetails Language Independent{references=, MD5-CAM-1.0.1=3324331C8FE6405B0A545EC8945CFCC5}
Keywordsauscultate, listen, auscultation, listening, lungs, chest, bruit, heart, bowel sounds, breath sounds, heart sounds
LifecycleAuthorDraft
Language useden
Citeable Identifier1013.1.111
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  • Clear [No abnormal breath sounds.]
  • No rhonchi [No high or low pitched wheezes.]
  • No wheeze [No wheezing noises.]
  • No crepitations [No high pitched crackling sounds.]
  • No crackles [No high pitched crackling sounds.]
  • Two heart sounds, no bruits [Normal heart sounds.]
  • Two heart sounds, no murmurs [Normal heart sounds.]
  • Two normal heart sounds [*]
  • No murmur [No murmur is heard.]
  • No bruit [No bruit is heard.]
  • Normal first heart sound [*]
  • Normal second heart sound [*]
  • No Bronchial breathing [*]
  • No Amphoric breathing [*]
  • Normal Vocal Resonance [*]
  • No abnormal added sounds [*]
  • Normal bowel sounds [Bowel sounds are normal in intensity and character.]
  • No abnormality detected [Nothing abnormal on auscultation.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0004], code=at0004, itemType=ELEMENT, level=1, text=Clinical Description, description=Detailed clinical description of the findings on auscultation., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002], code=at0002, itemType=CLUSTER, level=1, text=Findings, description=Findings on auscultation., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002]/items[at0.15], code=at0.15, itemType=CLUSTER, level=2, text=Heart sounds and bruits, description=*, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002]/items[at0.15]/items[at0.16], code=at0.16, itemType=CLUSTER, level=3, text=First heart sound, description=Findings about the first heart sound., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002]/items[at0.15]/items[at0.16]/items[at0.17], code=at0.17, itemType=ELEMENT, level=4, text=Volume, description=The volume of the first heart sound., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=0: Not heard [The first heart sound is not heard.]
1: Variable [The sound is variable in volume.]
2: Soft [The sound is softer than normal.]
3: Normal [The sound is of normal volume.]
4: Loud [The volume is increased.]

Assumed value: 0: Not heard
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002]/items[at0.15]/items[at0.16]/items[at0.23], code=at0.23, itemType=ELEMENT, level=4, text=Splitting, description=Splitting of the heart sound., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • No splitting [The heart sound is not split.]
  • Physiological splitting [The heart sound is split due to physiological changes.]
  • Fixed splitting [The heart sound is always split.]
  • Paradoxical splitting [The variable splitting is not physiological.]
  • Exaggerated splitting [The timing of the splitting is physiological but it is more obvious than normal.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0004], code=at0004, itemType=ELEMENT, level=4, text=Clinical Description, description=Detailed clinical description of the findings on auscultation., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002]/items[at0.15]/items[at0.29], code=at0.29, itemType=CLUSTER, level=3, text=Second heart sound, description=Findings about the second heart sound., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002]/items[at0.15]/items[at0.16]/items[at0.17], code=at0.17, itemType=ELEMENT, level=4, text=Volume, description=The volume of the first heart sound., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=0: Not heard [The first heart sound is not heard.]
1: Variable [The sound is variable in volume.]
2: Soft [The sound is softer than normal.]
3: Normal [The sound is of normal volume.]
4: Loud [The volume is increased.]

Assumed value: 0: Not heard
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002]/items[at0.15]/items[at0.16]/items[at0.23], code=at0.23, itemType=ELEMENT, level=4, text=Splitting, description=Splitting of the heart sound., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • No splitting [The heart sound is not split.]
  • Physiological splitting [The heart sound is split due to physiological changes.]
  • Fixed splitting [The heart sound is always split.]
  • Paradoxical splitting [The variable splitting is not physiological.]
  • Exaggerated splitting [The timing of the splitting is physiological but it is more obvious than normal.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0004], code=at0004, itemType=ELEMENT, level=4, text=Clinical Description, description=Detailed clinical description of the findings on auscultation., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002]/items[at0.15]/items[at0.75], code=at0.75, itemType=CLUSTER, level=3, text=Added heart sound, description=A grouping of discription of one or more added heart sounds., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002]/items[at0.15]/items[at0.75]/items[at0.76], code=at0.76, itemType=ELEMENT, level=4, text=Specific sound, description=Specific auscultatory findings related to examination of the heart., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Opening snap [Opening sound of the mitral valve.]
  • Ejection click [Systolic click when the heart contracts.]
  • Pericardial rub [Rubbing noise during contractions on the pericardium.]
  • Third heart sound [A heart sound in early diastole.]
  • Fourth heart sound [A heart sound in late diastole.]
  • Prosthetic valve sound [Sound due to a prosthetic heart valve.]
  • Gallop rythm [Audible rythm similar to a horse galloping due to added heart sounds.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002]/items[at0.15]/items[at0.75]/items[at0.43], code=at0.43, itemType=ELEMENT, level=4, text=Phase of heart cycle, description=The timing in relation to the contraction of the heart., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Continuous [*]
  • Systolic [*]
  • Diastolic [*]
  • Pan-systolic [*]
  • Pan-diastolic [*]
  • Early systolic [*]
  • Mid-Systolic [*]
  • Late Systolic [*]
  • Early Diastolic [*]
  • Mid-diastolic [*]
  • Late Diastolic [*]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002]/items[at0.15]/items[at0.75]/items[at0.59], code=at0.59, itemType=ELEMENT, level=4, text=Volume, description=The volume of the sound., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=0: Not audible [The sound is not audible.]
1: Variable [The sound is variable.]
2: Soft [The sound is soft.]
3: Moderate [The sound is at about the expected level the first heart sound.]
4: Loud [The sound is louder than the first heart sound.]

Assumed value: 0: Not audible
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0004], code=at0004, itemType=ELEMENT, level=4, text=Clinical Description, description=Detailed clinical description of the findings on auscultation., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002]/items[at0.15]/items[at0.31], code=at0.31, itemType=CLUSTER, level=3, text=Bruits, description=Group of findings about auscultation of the heart., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002]/items[at0.15]/items[at0.31]/items[at0.35], code=at0.35, itemType=ELEMENT, level=4, text=Maximal Location, description=Site where finding is heard maximally., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002]/items[at0.15]/items[at0.31]/items[at0.36], code=at0.36, itemType=ELEMENT, level=4, text=Radiation, description=Sites where finding is heard in addition to maximal site., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002]/items[at0.15]/items[at0.31]/items[at0.34], code=at0.34, itemType=ELEMENT, level=4, text=Grading, description=Grading of the loudness of a heart murmur., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=1: Grade 1 [very faint to recognize the murmur even after listening for a while.]
2: Grade 2 [faint, but easy to recognize the murmur right after the stethoscope is placed on the chest.]
3: Grade 3 [intermediate loudness between II/VI -IV/VI.]
4: Grade 4 [with loud murmur (palpable thrill).]
5: Grade 5 [very loud, but you can not hear the murmur, if the stethoscope is away from the chest wall.]
6: Grade 6 [the loudest murmur you can hear, even if the stethoscope is off the chest wall.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002]/items[at0.15]/items[at0.31]/items[at0.55], code=at0.55, itemType=ELEMENT, level=4, text=Character, description=The character of the sound., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002]/items[at0.15]/items[at0.31]/items[at0.56], code=at0.56, itemType=ELEMENT, level=4, text=Pitch, description=The pitch of the sound., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002]/items[at0.15]/items[at0.75]/items[at0.43], code=at0.43, itemType=ELEMENT, level=4, text=Phase of heart cycle, description=The timing in relation to the contraction of the heart., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Continuous [*]
  • Systolic [*]
  • Diastolic [*]
  • Pan-systolic [*]
  • Pan-diastolic [*]
  • Early systolic [*]
  • Mid-Systolic [*]
  • Late Systolic [*]
  • Early Diastolic [*]
  • Mid-diastolic [*]
  • Late Diastolic [*]
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  • Inspiratory [During inspiration.]
  • Expiratory [During expiration.]
  • Early Inspiratory [Soon after inspiration begins.]
  • Late inspiratory [At the final stages of inspiration.]
  • Early expiratory [Soon after expiration begins.]
  • Late expiratory [At the late stages of expiration.]
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  • Absent bowel sounds [No bowel sounds can be heard.]
  • Decreased bowel sounds [Bowel sounds are less than normal.]
  • Increased bowel sounds [Bowel sounds are more intense than normal.]
  • Tinkling bowel sounds [High pitched and very frequent bowel sounds can be heard.]
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  • Clear [No abnormal breath sounds.]
  • No rhonchi [No high or low pitched wheezes.]
  • No wheeze [No wheezing noises.]
  • No crepitations [No high pitched crackling sounds.]
  • No crackles [No high pitched crackling sounds.]
  • Two heart sounds, no bruits [Normal heart sounds.]
  • Two heart sounds, no murmurs [Normal heart sounds.]
  • Two normal heart sounds [*]
  • No murmur [No murmur is heard.]
  • No bruit [No bruit is heard.]
  • Normal first heart sound [*]
  • Normal second heart sound [*]
  • No Bronchial breathing [*]
  • No Amphoric breathing [*]
  • Normal Vocal Resonance [*]
  • No abnormal added sounds [*]
  • Normal bowel sounds [Bowel sounds are normal in intensity and character.]
  • No abnormality detected [Nothing abnormal on auscultation.]
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1: Variable [The sound is variable in volume.]
2: Soft [The sound is softer than normal.]
3: Normal [The sound is of normal volume.]
4: Loud [The volume is increased.]

Assumed value: 0: Not heard
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  • No splitting [The heart sound is not split.]
  • Physiological splitting [The heart sound is split due to physiological changes.]
  • Fixed splitting [The heart sound is always split.]
  • Paradoxical splitting [The variable splitting is not physiological.]
  • Exaggerated splitting [The timing of the splitting is physiological but it is more obvious than normal.]
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1: Variable [The sound is variable in volume.]
2: Soft [The sound is softer than normal.]
3: Normal [The sound is of normal volume.]
4: Loud [The volume is increased.]

Assumed value: 0: Not heard
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  • No splitting [The heart sound is not split.]
  • Physiological splitting [The heart sound is split due to physiological changes.]
  • Fixed splitting [The heart sound is always split.]
  • Paradoxical splitting [The variable splitting is not physiological.]
  • Exaggerated splitting [The timing of the splitting is physiological but it is more obvious than normal.]
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  • Opening snap [Opening sound of the mitral valve.]
  • Ejection click [Systolic click when the heart contracts.]
  • Pericardial rub [Rubbing noise during contractions on the pericardium.]
  • Third heart sound [A heart sound in early diastole.]
  • Fourth heart sound [A heart sound in late diastole.]
  • Prosthetic valve sound [Sound due to a prosthetic heart valve.]
  • Gallop rythm [Audible rythm similar to a horse galloping due to added heart sounds.]
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  • Continuous [*]
  • Systolic [*]
  • Diastolic [*]
  • Pan-systolic [*]
  • Pan-diastolic [*]
  • Early systolic [*]
  • Mid-Systolic [*]
  • Late Systolic [*]
  • Early Diastolic [*]
  • Mid-diastolic [*]
  • Late Diastolic [*]
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1: Variable [The sound is variable.]
2: Soft [The sound is soft.]
3: Moderate [The sound is at about the expected level the first heart sound.]
4: Loud [The sound is louder than the first heart sound.]

Assumed value: 0: Not audible
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2: Grade 2 [faint, but easy to recognize the murmur right after the stethoscope is placed on the chest.]
3: Grade 3 [intermediate loudness between II/VI -IV/VI.]
4: Grade 4 [with loud murmur (palpable thrill).]
5: Grade 5 [very loud, but you can not hear the murmur, if the stethoscope is away from the chest wall.]
6: Grade 6 [the loudest murmur you can hear, even if the stethoscope is off the chest wall.]
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  • Continuous [*]
  • Systolic [*]
  • Diastolic [*]
  • Pan-systolic [*]
  • Pan-diastolic [*]
  • Early systolic [*]
  • Mid-Systolic [*]
  • Late Systolic [*]
  • Early Diastolic [*]
  • Mid-diastolic [*]
  • Late Diastolic [*]
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  • Inspiratory [During inspiration.]
  • Expiratory [During expiration.]
  • Early Inspiratory [Soon after inspiration begins.]
  • Late inspiratory [At the final stages of inspiration.]
  • Early expiratory [Soon after expiration begins.]
  • Late expiratory [At the late stages of expiration.]
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  • Absent bowel sounds [No bowel sounds can be heard.]
  • Decreased bowel sounds [Bowel sounds are less than normal.]
  • Increased bowel sounds [Bowel sounds are more intense than normal.]
  • Tinkling bowel sounds [High pitched and very frequent bowel sounds can be heard.]
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