ChEkmMpoxManifestation: final pre-/post-coordination (DEMIS-aligned) + language-supplement $expand limitation

[oliveregger]

ChEkmMpoxManifestation — final pre-/post-coordination setup (DEMIS-aligned) + language-supplement limitation

Value set for the Mpox Manifestation form item (TODO.md issue #1), bound to Condition.evidence.code.
Defined in input/fsh/terminology/ChEkmMpoxManifestation.fsh.

Unlike Gonorrhoea (reduced to symptomatic/asymptomatic), the Mpox form enumerates specific manifestations, so this is a granular clinical value set (skin lesions by body site + systemic symptoms). The skin-lesion axis is aligned with the German DEMIS Mpox notification codes (base 95324001 |Skin lesion| + grouped finding-site refinement) for cross-border comparability.

Final code set

Form item (DE)	SNOMED code	Coordination
Hautläsionen wie Bläschen/Pusteln/Krusten	95324001 Skin lesion	pre-coordinated
Hautläsion genital/anal	95324001:{363698007=280158000} (Skin lesion : Finding site = Skin of anogenital region)	post-coordinated
Hautläsion Gesicht	95324001:{363698007=73897004} (… = Skin of face)	post-coordinated
Hautläsion Extremitäten	95324001:{363698007=116370005} (… = Skin of extremity)	post-coordinated
Hautläsion andere Lokalisationen	95324001 Skin lesion	a specific "other" site could be captured as free text in Condition.evidence.code.text (TBD)
Lymphadenopathie	30746006	pre-coordinated
Myalgie	68962001	pre-coordinated
Kopfschmerzen	25064002	pre-coordinated
Rückenschmerzen	161891005 Backache	pre-coordinated
Asthenie	13791008	pre-coordinated
Fieber	386661006	pre-coordinated
andere / Keine / unbekannt	via ChEkmOtherNoneUnknown (74964007 / 373572006 / 261665006)	included VS

Design decisions

• Base concept 95324001 |Skin lesion (disorder)| (not 271807003 |Eruption/Rash|) — matches the form wording "Hautläsionen wie Bläschen/Pusteln/Krusten" and the DEMIS base.
• 280158000 |Skin of anogenital region| is an exact match for the combined "genital/anal" checkbox. (An earlier draft used 442279002 |Rash of genitalia|, which is genital-only and missed anal — corrected.)
• Grouped refinement syntax { 363698007 = … } mirrors DEMIS exactly; verified it $expands on tx.fhir.ch.
• andere Lokalisationen is a form catch-all, not a body site → generic base 95324001; a specific "other" site is captured as free text in Condition.evidence.code.text (form field andere: ___).
• Gesicht uses generic 73897004 |Skin of face|. DEMIS additionally distinguishes 110488009 |perioral| / 836005 |oral| (characteristic Mpox mouth lesions); the CH form only has one "Gesicht" checkbox, so the generic face structure is used.
• de/fr/it designations for all newly introduced codes added to CodeSystemSupplements.fsh (ChEkmSnomedLanguageSupplement), DRAFT — to be validated against the official SNOMED CT Swiss extension.

DEMIS reference expressions (for comparison):

95324001:{363698007=110488009}  perioral            (Skin structure of perioral region of face)
95324001:{363698007=280158000}  im Anogenitalbereich (Skin structure of anogenital region)
95324001:{363698007=836005}     oral                (Structure of oral region of face)

⚠️ Limitation: language supplement is NOT applied to post-coordinated expressions on $expand

When expanding with displayLanguage + useSupplement, tx.fhir.ch applies the supplement designation to pre-coordinated codes but not to the post-coordinated expressions — for an expression the server returns the normal-form display string, ignoring the de-CH/fr-CH/it-CH designation we authored for it.

Verified on tx.fhir.ch (ValueSet/$expand, displayLanguage=de-CH, supplement supplied as tx-resource + useSupplement):

Code	de-CH display returned by tx
386661006 Fever (pre-coordinated)	Fieber ✅
95324001 Skin lesion (pre-coordinated)	Hautläsion ✅
95324001:{363698007=116370005} (Extremitäten, expression)	normal-form string ❌ (supplement ignored)

Consequence: a live renderer that expands against the tx server (e.g. Smart Forms / fhirsmith) shows the untranslated normal-form label for the post-coordinated skin-lesion options.

Workaround in place: the preview builder tests/build-preview-questionnaire.py overrides the display client-side for post-coordinated codes, reading the designation directly from the local supplement, so the baked-in options read e.g. Hautläsion an den Extremitäten. This only fixes the pre-expanded preview, not live server expansion.

Open questions

• How to handle Hautläsionen wie Bläschen/Pusteln/Krusten / Hautläsion andere Lokalisationen they should not have the same SNOMED CT code

  95324001 |Skin lesion| is deliberately morphology- and stage-agnostic (Mpox lesions evolve macule→papule→vesicle→pustule→crust — that's why DEMIS uses the generic base, not a vesicle-specific code). So "lesions present, generally" and "lesion at an other/unspecified site" both land on the same bare code. The fix has to be structural.
  The decision hinges on one thing I can't determine from the sheet: is "Hautläsionen wie Bläschen/Pusteln/Krusten" actually a selectable answer, or the heading for the four indented location checkboxes?

• Validate the de/fr/it designations against the official SNOMED CT CH extension.

[oliveregger]

DEMIS verwendet auch post snomed ct expressions:
https://simplifier.net/guide/rki.demis.disease/Home/resources/terminologies/valuesets/guide-answerSetLocationSkinLesionsMPXD.guide.md?version=current

Code	Display	900000000000003001 (en-US)	1119454002 (en-US)
74964007	Andere	Other (qualifier value)
95324001	generalisiert	Skin lesion (disorder)
95324001:{363698007=110488009}	perioral		95324001 | Skin lesion (disorder) | : {363698007 | Finding site (attribute) | = 110488009 | Skin structure of perioral region of face (body structure) |}
95324001:{363698007=280158000}	im Anogenitalbereich		95324001 | Skin lesion (disorder) | : {363698007 | Finding site (attribute) | = 280158000 | Skin structure of anogenital region (body structure) |}
95324001:{363698007=836005}	oral		95324001 | Skin lesion (disorder) | : {363698007 | Finding site (attribute) | = 836005 | Structure of oral region of face (body structure) |}

Code Display
ASKU asked but unknown
NASK not asked

[oliveregger]

manifestations DEMIS: https://simplifier.net/guide/rki.demis.disease/Home/resources/terminologies/valuesets/guide-evidenceMPXD.guide.md?version=current

[oliveregger]

Condition Profile: repeats on evidence for manifestations:

https://simplifier.net/guide/rki.demis.disease/Home/resources/structuredefinitions/disease/Disease/guide-diseasempxd.guide.md?version=current