| ARCHETYPE ID | openEHR-EHR-CLUSTER.inspection-tympanic_membrane.v1 |
|---|---|
| Concept | Inspection of Tympanic Membrane |
| Description | The findings on physical examination by inspection of the tympanic membrane |
| Use | For use with the exam clusters for recording findings on inspection of the tmpanic membrane |
| Misuse | Should only be used in the exam observation |
| Purpose | For recording the findings on inspection of the tympanic membrane |
| References | |
| Copyright | copyright (c) 2009 openEHR Foundation |
| Authors | Author name: Ian McNicoll Organisation: Ocean Informatics Date originally authored: 02/11/2007 |
| Other Details Language | Author name: Ian McNicoll Organisation: Ocean Informatics Date originally authored: 02/11/2007 |
| Other Details (Language Independent) |
|
| Keywords | inspect, visual, ear, tympanic, perforation, drum |
| Lifecycle | AuthorDraft |
| Language used | en |
| Citeable Identifier | 1013.1.241 |
| items | |
| Normal statements | Normal statements: An optional group of statements about the normality of the inspection |
| Normal statement | Normal statement: A specific statement about the normality of inspection
|
| Clinical Description | Clinical Description: Clinical description of the findings on inspection |
| Findings | Findings: Specific findings on inspection |
| Colour description | Colour description: The colour of the object under inspection |
| Location | Location: The location of any findings |
| Description | Description: Description of the location of the findings |
| Shape or distribution | Shape or distribution: The shape or distribution of the object inspected |
| Description | Description: Description of the |
| Symmetrical | Symmetrical: Whether the distribution is symmetrical |
| Surface | Surface: A description of the surface
|
| Surrounds | Surrounds: Description of immediate surrounds to object |
| Edge | Edge: Findings about the edge of the object under inspection |
| Description | Description: Description of the edge or border of the object of inspection |
| Definition | Definition: The nature of the edge of the object of examination
|
| Translucent | Translucent: Is the object of inspection translucent? |
| Adequacy of View | Adequacy of View: How good is the view of the membrane? 0: Unobscured [The TM is not obscured] 1: Slightly obscured [The TM is slightly obscured] 2: Moderately obscured [The TM is moderately obscured] 3: Mostly obscured [The TM is mostly obscured] 4: Totally obscured [The TM is totally obscured] |
| Specific Appearance | Specific Appearance: The appearance of the drum |
| Clinical Description | Clinical Description: The general appearance of the tympanic membrane |
| Light Reflex present | Light Reflex present: * |
| Contour | Contour: The contour of the object of inspection |
| Retraction | Retraction: Degree of tympanic membrane retraction (Sade classification) 0: No retraction [Normal TM without retraction] 1: Slightly retracted [TM slighly retracted i.e tothe level of the annualt ligament] 2: touches the ossicular chain [TM touchs the ossicular chain] 3: reaches the level of the promontory [TM reaches the promontory without adhering to it ] 4: adheres to the promontory [TM reaches the promontory and adheres to it] Assumed value: 0: No retraction |
| Air/Fluid level visible? | Air/Fluid level visible?: Is a fluid level visible behind the membrane? |
| Scarring | Scarring: * |
| Description of scarring | Description of scarring: *
|
| Clinical Description | Clinical Description: Text Description of the appearance of the drum |
| Ventilation Tube | Ventilation Tube: Details of any ventilation tube inserted |
| Cluster: Ventilation tube | Cluster: Ventilation tube: * Include: openEHR-EHR-CLUSTER.tympanic_ |
| Perforation | Perforation: Details of any perforation |
| Cluster: Perforation | Cluster: Perforation: * Include: openEHR-EHR-CLUSTER.inspection-tympanic_ |
| Detail | Detail: Detailed examination of a finding on inspection |
| Cluster: Exam | Cluster: Exam: Exam details Include: openEHR-EHR-CLUSTER.exam.v1 |
| Drawing | Drawing: An image of the findings on inspection - drawing, photo or video image/cgm, image/gif, image/png, image/tiff, image/jpeg |
| Other contributors | Heather Leslie |
| Translators |