ARCHETYPE Palpation of the external ear (openEHR-EHR-CLUSTER.palpation-external_ear.v1)

ARCHETYPE IDopenEHR-EHR-CLUSTER.palpation-external_ear.v1
ConceptPalpation of the external ear
DescriptionFindings on palpation of the external ear.
UseTo be embedded in the openEHR-EHR-OBSERVATION.exam cluster to express findings determined by palpation.
MisuseNot for use in any other context at present.
PurposeFindings identified through palpation of the external ear.
References
Copyrightcopyright (c) 2010 openEHR Foundation
AuthorsAuthor name: Ian McNicoll
Organisation: Ocean Informatics
Date originally authored: 02/11/2007
Other Details LanguageAuthor name: Ian McNicoll
Organisation: Ocean Informatics
Date originally authored: 02/11/2007
Other Details (Language Independent)
  • References:
  • MD5-CAM-1.0.1: 951379AC698DE8983753C0393AC1A89A
Keywordspalpate, ear
LifecycleAuthorDraft
Language useden
Citeable Identifier1013.1.243
items
Normal statementsNormal statements: A group of statements about the normality of the palpation.
Normal statementNormal statement: A specific statement of normality.
  • Normal [The palpation is normal.]
  • Probably normal [The palpation is apparently normal but some uncertainty exists.]
  • No abnormality detected [No abnormality was detected by palpation.]
  • Soft [The palpation revealed no distension, masses or rigidity.]
  • No tenderness [Palpation revealed no tenderness.]
  • No masses [No masses palpable.]
  • No foreign bodies [No foreign bodies are palpable.]
  • No hernias [Palpation revealed no hernias.]
Clinical descriptionClinical description: Textural statement of the findings on palpation.
FindingsFindings: Group of findings.
Part of the ear palpatedPart of the ear palpated: Specific parts of the ear.
  • Auricle [*]
  • Mastoid [*]
  • External meatus [*]
Other siteOther site: The region, site or organ that is the object of localised palpation.
TendernessTenderness: A group of statements about a tenderness finding.
Depth of palpationDepth of palpation: The depth of palpation.
  • Superficial [Superficial palpation of the skin and superficial muscles.]
  • Deep [Palpation of the deep structures beneath superficial muscles.]
DegreeDegree: The amount or degree of tenderness found on palpation.
  • absent [No tenderness on palpation.]
  • mild [There is some feeling of pain or discomfort on palpation.]
  • moderate [There is definite pain on palpation.]
  • marked [Gentle palpation leads to moderate pain.]
  • extreme [Gentle palpation leads to severe pain.]
CategoryCategory: The type of tenderness found on palpation.
  • Superficial tenderness [Tender in the superficial layers.]
  • Deep tenderness [Tenderness in the deep structures.]
  • Rebound tenderness [Tenderness on releasing palpation pressure.]
  • Tenderness [A group of statements about a tenderness finding.]
  • Rigidity [The abdomen is rigid to palpation.]
Other siteOther site: The region, site or organ that is the object of localised palpation.
TemperatureTemperature: The temperature on palpation.
  • Cold [The feeling of cold.]
  • Cool [The temperature feels cooler than normal.]
  • Normal [The temperature feels normal.]
  • Warm [The temperature feels warmer than normal.]
  • Hot [The temperature feels hot.]
GuardingGuarding: Tensing of underlying muscles on palpation.
DegreeDegree: The degree of guarding.
  • Not present [Guarding is not present.]
  • Mild [There is some guarding with deep palpation.]
  • Moderate [There is guarding on moderate palpation.]
  • Gross [There is guarding on very gentle palpation.]
NatureNature: The nature of the guarding.
  • Voluntary [The guarding is apparently deliberate on the part of the person.]
  • Involuntary [The guarding is occuring without intent from the person.]
  • Uncertain [The guarding is not clearly involuntary or voluntary.]
Localised palpationLocalised palpation: Palpation of a localised area.
Cough impulseCough impulse: Presence of a cough impulse felt on palpation.
Allowed values: {true}
Cluster: Localised palpationCluster: Localised palpation: Localised palpation
Include:
openEHR-EHR-CLUSTER.palpation.v1
(Surface/Border)(Surface/Border): Findings related to the surface or border of the object of palpation.
Runtime name constraint:
  • Surface [The surface of the object of palpation.]
  • Edge [The border of the object of palpation.]
Site descriptionSite description: Details of the location of the surface or border palpated.
ConsistencyConsistency: The consistency of the surface or border of the object of palpation.
  • Hard/Rigid [The surface is hard or rigid.]
  • Firm [The surface is firm.]
  • Soft [The surface is soft.]
  • Boggy [The surface is soft with a boggy quality.]
  • Indents [The border or surface retains indentation after firm pressure is applied.]
FeaturesFeatures: Features of the surface or border.
  • Smooth [The surface or border is smooth.]
  • Craggy [Large irregularities.]
  • Irregular [The surface or border is irregular.]
  • Nodular [The surface contains nodules.]
DetailDetail: Detailed examination of things found on palpation.
Cluster: Exam detailsCluster: Exam details: Exam details
Include:
openEHR-EHR-CLUSTER.exam.v1 or
openEHR-EHR-CLUSTER.exam-mass.v1
Exclude:
All not explicitly included archetypes
Other contributors
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