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

ARCHETYPE IDopenEHR-EHR-CLUSTER.exam-ears.v1
ConceptExamination of the ears
DescriptionExamination cluster for describing findings on physical examination of the eyes.
MisuseDo not use for recording audiology findings Should normally be contained within an OBSERVATION
PurposeFor recording findings on physical examination of the ears.
References
Copyrightcopyright (c) 2010 openEHR Foundation
AuthorsAuthor name: Ian McNicoll
Organisation: Ocean Informatics
Email: ian.mcnicoll@oceaninformatics.com
Date originally authored: 02/11/2007
Other Details LanguageAuthor name: Ian McNicoll
Organisation: Ocean Informatics
Email: ian.mcnicoll@oceaninformatics.com
Date originally authored: 02/11/2007
Other Details (Language Independent)
  • References:
  • MD5-CAM-1.0.1: 4C3FA1F70C90356DC3CA61F87EDAD866
Keywordsexamination, physical, ears, ENT, tympanic, mastoid, Rinne, Weber
LifecycleAuthorDraft
Language useden
Citeable Identifier1013.1.222
items
Normal statementsNormal statements: A group of statements about the normality of the examination.
Normal statementNormal statement: A specific statement of normality.
  • Both ears normal [Both ears are normal.]
  • Left ear normal [The left ear is normal.]
  • Right ear normal [The right ear is normal.]
Clinical descriptionClinical description: Textural description of the part examined.
Lateral FindingsLateral Findings: Clinical findings related to a single ear.
SideSide: Left or Right ear examined?
  • Left [Left ear.]
  • Right [Right ear.]
PhysicalPhysical: Physical examination of the ear.
External ear detailExternal ear detail: Detailed findings related to the external ear.
Include:
openEHR-EHR-CLUSTER.palpation-external_ear.v1 and specialisations or
openEHR-EHR-CLUSTER.inspection-external_ear.v1 and specialisations
Auditory canal detailAuditory canal detail: Detailed findings related to the audiory canal.
Include:
openEHR-EHR-CLUSTER.inspection-ear_canal.v1 and specialisations
Tympanic membrane detailTympanic membrane detail: Detailed findings related to the tmpanic membrane or perforation.
Include:
openEHR-EHR-CLUSTER.inspection-tympanic_perforation.v1 and specialisations or
openEHR-EHR-CLUSTER.inspection-tympanic_membrane.v1 and specialisations
FunctionalFunctional: Lateral tests of ear function.
Whisper testWhisper test: A simple hearing test.
Rinne TestRinne Test: A test to compare bone and air conduction of sound.
0: Negative [The Rinne test is positive.]
1: Positive [The Rinne test is negative.]

Assumed value: 0: Negative
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
Central findingsCentral findings: Clinical findings related to both ears.
FunctionalFunctional: Central functional auditory tests.
Weber TestWeber Test: A test to distinguish conductive and sensoineural hearing loss.
0: Normal [The Weber test is not lateralised - normal.]
1: Lateralising Left [The result of the Weber test is lateralising to the left.]
2: Lateralising Right [The result of the Weber test is lateralising to the right.]

Assumed value: 0: Normal
DetailDetail: Further detailed functional findings.
Include:
All not explicitly excluded archetypes
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