ARCHETYPE Examination of the chest (openEHR-EHR-CLUSTER.exam-chest.v1)

ARCHETYPE IDopenEHR-EHR-CLUSTER.exam-chest.v1
ConceptExamination of the chest
DescriptionFor recording findings on physical examination of the chest wall and lungs.
PurposeA cluster for recording findings on physical examination of the chest.
References
Copyrightcopyright (c) 2010 openEHR Foundation
AuthorsAuthor name: Sam Heard
Organisation: Ocean Informatics
Email: Sam.Heard@OceanInformatics.com
Date originally authored: 9/04/2007
Other Details LanguageAuthor name: Sam Heard
Organisation: Ocean Informatics
Email: Sam.Heard@OceanInformatics.com
Date originally authored: 9/04/2007
Other Details (Language Independent)
  • References:
  • MD5-CAM-1.0.1: 215A2C17D4B48244C07F9920C844CEA4
Keywordsexamination, physical, chest, thorax, lungs
LifecycleAuthorDraft
Language useden
Citeable Identifier1013.1.221
items
Normal statementsNormal statements: A group of statements about the normality of the examination.
Normal statementNormal statement: A specific statement of normality.
Clinical descriptionClinical description: Textural description of the part examined.
FindingsFindings: Clinical findings.
TracheaTrachea: The position of the trachea.
  • Midline [The trachea is in the midline position.]
  • Deviated to the left [The trachea is deviated to the left.]
  • Deviated to the right [The trachea is deviated to the right.]
Apex beatApex beat: *
VisibleVisible: Apex beat is visible.
PalpationPalpation: *
PalpablePalpable: Apex beat is palpable.
Maximal locationMaximal location: Site of maximal apex beat.
BreathingBreathing: Findings about breathing.
DescriptionDescription: Description of breathing.
TypeType: Type of breathing.
  • Diaphragmatic breathing [Breathing using the diaphragm and not the chest wall.]
  • Thoracic breathing [Breathing using expansion of the chest wall.]
EffortEffort: Effort required for breathing.
5: Normal breathing effort [Diaphragmatic breathing as at rest.]
6: Mild increase in effort [Breathing using obvious chest expansion.]
8: Moderate increased effort [Breathing with signs of abnormal breathing.]
10: Major increased effort [Many signs of increased breathing effort.]
Signs of increased effortSigns of increased effort: Signs of increased respiratory effort.
SignSign: Use of accessory respiratory muscles.
  • Using accessory muscles [Use of accessory respiratory muscles during inspiration.]
  • Intercostal recession [Drawing in between the ribs on inspiration.]
  • Subcostal recession [Indrawing of the subcostal abdominal wall .]
  • Suprasternal recession [Indrawing above the sternum on inspiration.]
  • Sternal recession [Drawing in of the sternum on inspiration.]
  • Rib retraction [Indrawing of the chest wall on inspiration.]
Paradoxical movement (flail chest)Paradoxical movement (flail chest): Any paradoxical movement of the chest wall during respiration.
Chest wallChest wall: Findings about the chest wall.
DescriptionDescription: The contour of the chest wall.
ShapeShape: The shape of the chest.
Chest wall detailChest wall detail: Detailed chest wall findings.
Include:
openEHR-EHR-CLUSTER.inspection.v1 and specialisations or
openEHR-EHR-CLUSTER.palpation.v1 and specialisations
Lymph nodesLymph nodes: Findings about lymph nodes.
Lymph node detailLymph node detail: Detailed lymph node findings.
Include:
openEHR-EHR-CLUSTER.exam-generic-lymphnode.v1 and specialisations
DetailDetail: More focused examination findings.
Include:
openEHR-EHR-CLUSTER.exam-generic.v1 and specialisations or
openEHR-EHR-CLUSTER.auscultation.v1 and specialisations or
openEHR-EHR-CLUSTER.inspection.v1 and specialisations or
openEHR-EHR-CLUSTER.palpation.v1 and specialisations or
openEHR-EHR-CLUSTER.percussion.v1 and specialisations or
openEHR-EHR-CLUSTER.physical_properties.v1 and specialisations
ImageImage: Drawing or image of the area examined.
image/gif, image/png, image/jpeg
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