ARCHETYPE Examination Findings – Posterior Chamber of eye (openEHR-EHR-CLUSTER.exam_posterior_chamber.v1)

ARCHETYPE IDopenEHR-EHR-CLUSTER.exam_posterior_chamber.v1
ConceptExamination Findings – Posterior Chamber of eye
DescriptionFindings on examination of the posterior chamber of the eye which could have clinical relevance
UseIt can be attached to an OBSERVATION type archetypes whenever thay are related to clinical tests studying the posterior chamber of the eye. For example, attached to "OBSERVATION.fundoscopic_examination" it would provide additional information about the findings when examining an eye fundus. Could also be used with "OBSERVATION.ophthalmic_tomography_examination", providing information about findings during an OCT study. This archetype is applied to describe structural findings detected objectively when reviewing images from the posterior chamber of the eye. Therefore, the aim is registering symptoms concerning eye disorders that could have diagnostic interest.
MisuseNot to be used to record findings of the examination of other parts of the eye besides the posterior chamber. Do not get confused with "examination_details" archetypes, which register information about test acquisition, quality, artifacts, ... It should not be used to include subjective findings. There are specific EVALUATION type archetypes for this purpose.
PurposeTo record the clinical findings on examination of the posterior chamber of the eye.
References
Copyright© openEHR Foundation
AuthorsAuthor name: Aitor Eguzkitza
Organisation: Universidad Pública de Navarra - Complejo Hospitalario de Navarra
Email: aitor.eguzkiza@unavarra.es
Date originally authored: 2014-03-18
Other Details LanguageAuthor name: Aitor Eguzkitza
Organisation: Universidad Pública de Navarra - Complejo Hospitalario de Navarra
Email: aitor.eguzkiza@unavarra.es
Date originally authored: 2014-03-18
Other Details (Language Independent)
  • MD5-CAM-1.0.1: CCF202D669778AFE5FF32C119EEF56A8
Keywordseye, posterior chamber, examination
LifecycleOrganisationDraft
Language useden
Citeable Identifier1013.1.1610
items
MaculaMacula: Detection of disorders in macula
Macular descriptionMacular description: Narrative description of findings within the macula
Optic discOptic disc: Detection of disorders in optic disc
Optic Disc descriptionOptic Disc description: Narrative description of findings within the optic disc
Retinal backgroundRetinal background: Detection of disorders in retinal background
Retinal background descriptionRetinal background description: Narrative description of findings within the retinal background
Hard exudatesHard exudates: True if hard exudates are present
Assumed value: false
'Cotton Wool' artefacts'Cotton Wool' artefacts: True if 'cotton wool' artefacts are present
Assumed value: false
Traction retinal detachmentTraction retinal detachment: True if traction retinal detachment is present
Assumed value: false
Photocoagulation scarsPhotocoagulation scars: True if photocoagulation scars are present
Assumed value: false
Retinal vascularRetinal vascular: Detection of disorders in arteries or veins
Retinal arteries descriptionRetinal arteries description: Narrative description of findings within the retinal arteries
Retinal veins descriptionRetinal veins description: Narrative description of findings within the retinal veins
MicroaneurismMicroaneurism: True if microaneurism is present
Assumed value: false
IRMAIRMA: Detection and classification of intraretinal microvascular abnormalities.
Unspecified IRMAUnspecified IRMA: True if intraretinal microvascular abnormalities are present
Assumed value: false
Diabetic venous beadingDiabetic venous beading: True if diabetic venous beading is present
Assumed value: false
Venous LoopsVenous Loops: Venous loops are infrequent and though to develop due to small vessel occlusion and opening of alternative circulation.
Retinal neovascularization Retinal neovascularization : True if new vessels are present
Assumed value: false
Retinal pallorRetinal pallor: A non-specific feature that is best appreciated in hindsight on red-free photographs and on fluorescein angiography, particularly temporal to the macula in patients who appear to have the unexplained presence of new vessels.
White linesWhite lines: White lines may represent vessel wall staining or thrombosed arterioles , which often accompany retinal pallor and are similarly found in areas of extensive capillary closure.
Retinal haemorrhages (macrovascular)Retinal haemorrhages (macrovascular): Identification of retinal haemorrhages if present
EdemaEdema: Detection and classification of found edemas
PapilledemaPapilledema: True if papilledema present
Assumed value: false
Diabetic macular edemaDiabetic macular edema: International clinical Diabetic Macular Edema (DME) scale
VitreousVitreous: Detection of disorders in vitreous
Vitreous descriptionVitreous description: Narrative description of findings within the vitreous humour
Vitreous bleedingVitreous bleeding: True if vitreous bleeding is present
Assumed value: false
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