| |
 Normal statements, A group of statements about the normality of the examination. Cluster (0..1) optional |
| |
Concept |
Description |
Type |
Cardinality |
Values |
 Normal statement |
A specific statement of normality | Text
| optional, repeating
0..* |
Free or coded text |
|
|
|
Concept |
Description |
Type |
Cardinality |
Values |
| Clinical description |
Textural description of the part examined | Text
| optional
0..1 |
Free or coded text |
| Findings, Clinical findings. Cluster (0..1) optional |
| |
| Chest wall, Findings about the chest wall. Cluster (0..1) optional |
| |
Concept |
Description |
Type |
Cardinality |
Values |
| Description |
The contour of the chest wall | Coded text
| optional
0..1 |
Free or coded text |
| Shape |
The shape of the chest | Text
| optional
0..1 |
Free or coded text |
| Heart - Apex beat, *. Cluster (0..1) optional |
| |
Concept |
Description |
Type |
Cardinality |
Values |
 Visible |
Apex beat is visible | Boolean
| optional
0..1 |
True, False |
| Palpation, *. Cluster (0..1) optional |
| |
Concept |
Description |
Type |
Cardinality |
Values |
| Palpable |
Apex beat is palpable | Boolean
| optional
0..1 |
True, False |
| Maximal location |
Site of maximal location of apex beat | Text
| optional
0..1 |
Free or coded text |
|
|
|
|
|
|
Slot |
Type |
Occurrences |
Constraints |
 |
CLUSTER |
0..* |
Include entries
|
|
|
|
| Respiratory system, Respiratory findings. Cluster (0..1) optional |
| |
Concept |
Description |
Type |
Cardinality |
Values |
| Trachea |
The position of the trachea | Coded text
| optional
0..1 |
Midline
Deviated to the left
Deviated to the right |
| Breathing, Findings about breathing. Cluster (0..1) optional |
| |
Concept |
Description |
Type |
Cardinality |
Values |
| Description |
Description of breathing | Text
| optional
0..1 |
Free or coded text |
| Type |
Type of breathing | Coded text
| optional
0..1 |
Diaphragmatic breathing
Thoracic breathing |
 Effort |
Effort required for breathing | Ordinal
| optional
0..1 |
5, Normal breathing effort
6, Mild increase in effort
8, Moderate increased effort
10, Major increased effort |
| Signs of increased effort, Signs of increased respiratory effort. Cluster (0..1) optional |
| |
Concept |
Description |
Type |
Cardinality |
Values |
| Sign |
Use of accessory respiratory muscles | Coded text
| optional, repeating
0..* |
Using accessory muscles
Intercostal recession
Subcostal recession
Suprasternal recession
Sternal recession
Rib retraction |
|
|
|
Concept |
Description |
Type |
Cardinality |
Values |
| Paradoxical movement (flail chest) |
Any paradoxical movement of the chest wall during respiration | Boolean
| optional
0..1 |
True, False |
|
|
|
|
|
|
| Detail, More focused examination findings. Cluster (0..1) optional |
| |
Slot |
Type |
Occurrences |
Constraints |
|
CLUSTER |
0..* |
Include entries
|
|
|
|
|
|
|
| Lymph nodes, Lymphnodes. Cluster (0..1) optional |
| |
Slot |
Type |
Occurrences |
Constraints |
|
CLUSTER |
0..* |
Include entries
|
|
|
|
Concept |
Description |
Type |
Cardinality |
Values |
 Image |
Drawing or image of the area examined | MultiMedia
| optional, repeating
0..* |
image/gif
image/png
image/jpeg |
|
