IHTSDO-1157 Distinction between Pain and Tenderness

Word version of analysis:

IHTSDO-1157_FastTrack_PainVSTend.docx

Information

Document review

Statement of problem as requested or initially identified

There is an error in the current concept definition of “Tenderness (finding)” as a subtype of “Pain by sensation quality (finding)”.  While pain is something that is perceived by someone (i.e. a symptom), tenderness is a response (i.e. a sign) that is elicited by the examiner through palpation/touch.

Relevance to International edition

Relevant to all versions of SNOMED CT

Related changes impacted by this content development request

The major change relates to selecting the correct  proximal  primitive parent (i.e. Clinical finding (finding) and adding the FINDING METHOD attribute with the “Palpation (procedure ) value. with

Agreed scope statement

Since the “Tenderness” concept currently has a primitive parent with no other defining relationships, the change is straightforward as in the previous statement..

.

Identify additional changes     

Additional changes may be needed upon review of those concepts that use “Tenderness (finding)” in their concept definitions as stated as well as those that use the term “Tender” or “Tenderness” in their FSN. A list of such terms is included at the end of this document. There are 153 concepts in the Clinical finding hierarchy that include “tender” within their FSNs. 

●      15 are “On Examination..” concepts and are being inactivated this authoring cycle

●      113 are findings that are  Tenderness” subtypes

●      3 concepts that use “non-tender” should be moved to the situation hierarchy to align with all the other “non-tender” concepts

Solution proposed

●      Change parent concept of “Tenderness (finding)” to IS A Clinical finding (finding) with attribute FINDING METHOD = Palpation (procedure).

●      Would change the concept “Pain and tenderness (finding) to include both findings since they have different definitions. An improved FSN would be  “Tenderness co-occurrent with pain (finding)” or “Pain co-occurrent with tenderness (finding). Can keep “Pain and tenderness (finding) as the preferred term or synonym.

Stakeholder input

Input involves correction based on clinical definitions.

Impact assessment

The correction is necessary to reflect the accuracy of the clinical definitions. Since there is only one primitive defining relationship, the impact should be minimal. The review of the subtypes may yield some surprises that need further discussion but upon cursory analysis, this should be minimal and include those mentioned above under “Solution proposed”

Risk assessment

Risks of no change: maintaining inaccurate clinical definitions; may not capture correct information at the point of care or may infer incorrect findings. Changes made may impact current implementations in practice. Implementers may need to update their terminology if the proposed concept changes are realized. This would align with the routine updating that occurs with  each SNOMED CT bi-annual release. All terminology updates have an impact on implementers with product integration. If only the FSNs are being used without reference to their individual models or  placement/analysis within the SNOMED hierarchies , there may be no noticable changes as most of the concepts in this group are being retained with their concept ID’s unchanged.

Approval process

Priority       

☒Very high

☐High

☐Medium

☐Low

Specify the basis for the above priority assignment

Error in clinical definitions

Content editing

Correction of “Tenderness (finding)” concept to use IS A Clinical finding (finding) with the attribute FINDING METHOD Palpation (procedure). After classification, review all impacted subs for accuracy.

Inactive ambiguous concepts (if identified) and ambiguous synonym (i.e. “tender pain”)

Details of content changes

Preliminary testing was done in the tooling.  Change was made to the parent concept of “Tenderness (finding)” to IS A Clinical finding (finding) with the attribute FINDING METHOD Palpation (procedure). After classification, no taxonomy changes were noted in the review panel; there were 304 results, with 106 inferred relationships removed and 187 not previously stated inferred relationships with no equivalency errors. Individual review of each concept is needed in stated view as some IS A parents need removal. For example, those tenderness concepts (that currently include an IS A parent under “Finding of sensation by site (finding) in Stated view (~ 18) will need removal. [e.g Tender mastoid (finding) IS A Finding of sensation of mastoid (finding)]

Manual quality check

Would do manual review of each concept impacted by change after classification.

Automated quality check

Best to use classifier to view/measure change

Publish to release branch

July 2020

List of findings that include “tender” within their FSNs

275895008       On examination - tenderness (finding)

274292006       On examination - left iliac fossa tender (finding)

163267004       On examination - liver tender (finding)

268941000       On examination - abdominal pain on palpation (finding)

164222001       On examination - pain over mastoid (finding)

268994009       On examination - tenderness/pain (finding)

163236001       On examination - rebound tenderness (finding)

164160002       On examination - lymph nodes tender (finding)

164426001       On examination - tenderness of skin (finding)

310482008       On examination - snuff box tenderness (finding)

310534004       On examination - per rectum - prostate tender (finding)

163358002       On examination - renal angle tenderness (finding)

163410005       On examination - vaginal examination - uterine tenderness (finding)

164246008       On examination - maxillary sinus tenderness (finding)

164247004       On examination - frontal sinus tenderness (finding)

247348008       Tenderness (finding)

298740004       Rib tender (finding)

301195007       Nose tender (finding)

278998008       Tender scar (finding)

278999000       Skin tenderness (finding)

110288007       Tenderness of joint (finding)

289492003       Vulva tender (finding)

289842007       Ovary tender (finding)

300103004       Pinna tender (finding)

300235007       Tooth tender (finding)

300942003       Tender lymph node (finding)

417009006       Tender point (finding)

102627005       Liver tender (finding)

277247007       Tender larynx (finding)

289667007       Tender body of uterus (finding)

289815006       Cervix tender (finding)

300446008       Kidney tender (finding)

300489007       Tender testes (finding)

300566002       Spleen tender (finding)

277210007       Tender mastoid (finding)

22166009         Skeletal muscle tender (finding)

298729007       Sternum tender (finding)

300459000       Bladder tender (finding)

55222007         Breast tenderness (finding)

102830001       Renal angle tenderness (finding)

300535008       Prostate tender (finding)

278997003       Bone tenderness (finding)

203131005       Tender heel pad (finding)

299307002       Tenderness of hip joint (finding)

225944008       Wound tenderness (finding)

75851004         Scalp tenderness (finding)

299632005       Tenderness of toe joint (finding)

300501005       Epididymis tender (finding)

225574009       Nipple tenderness (finding)

278995006       Facial tenderness (finding)

299372009       Tenderness of knee joint (finding)

299512002       Tenderness of foot joint (finding)

309522006       Tenderness of neck (finding)

289594004       Vaginal tenderness (finding)

297123002       Adnexal tenderness (finding)

299017002       Tenderness of wrist joint (finding)

300348008       Gallbladder tender (finding)

301421000       Tenderness in limb (finding)

110341006       Tenderness of gums (finding)

35611005         Rebound tenderness (finding)

299446004       Tenderness of ankle joint (finding)

299198008       Tenderness of thumb joint (finding)

298928007       Tenderness of elbow joint (finding)

102591006       Chest wall tenderness (finding)

298289005       Muscle tender point (finding)

300507009       Vas deferens tender (finding)

37226004         Pain and tenderness (finding)

299111003       Tenderness of finger joint (finding)

298268001       Tenderness of tendon (finding)

43478001         Abdominal tenderness (finding)

298477006       Cervical spine tender (finding)

298578004       Thoracic spine - tender (finding)

298673002       Lumbar spine - tender (finding)

302073009       Tenderness of thyroid (finding)

299553005       Tenderness of subtalar joint (finding)

298856001       Tenderness of shoulder joint (finding)

298290001       Tenderness at muscle insertion (finding)

277167007       Tenderness in ear canal (finding)

298251000       Tenderness of sacroiliac joint (finding)

298751004       Tenderness of upper limb (finding)

299375006       Infrapatellar tenderness (finding)

301394002       Genitourinary tenderness (finding)

301395001       Urinary tract tenderness (finding)

301423002       Tenderness in lower limb (finding)

445386003       Tenderness of periumbilical region (finding)

298288002       Diffuse muscle tenderness (finding)

300105006       Focal tenderness in pinna (finding)

301400000       Tenderness of body region (finding)

301403003       Tenderness of epigastrium (finding)

301408007       Tenderness of left lumbar (finding)

301399007       Musculoskeletal tenderness (finding)

301407002       Tenderness of right lumbar (finding)

301409004       Tenderness of hypogastrium (finding)

301387000       Tenderness of eye structure (finding)

301388005       Tenderness of ear structure (finding)

278069006       Tenderness in vaginal fornix (finding)

289695007       Tender scar of gravid uterus (finding)

301386009       Tenderness of body structure (finding)

301396000       Tenderness of male genitalia (finding)

301406006       Tenderness of central region (finding)

277241008       Tenderness over frontal sinus (finding)

299376007       Tenderness in popliteal fossa (finding)

290080002       Localized tenderness of breast (finding)

298375002       Tenderness of temporomandibular joint (finding)

301397009       Tenderness of female genitalia (finding)

301411008       Tenderness of left iliac fossa (finding)

302003005       Premenstrual breast tenderness (finding)

277238004       Tenderness over maxillary sinus (finding)

300104005       Generalized tenderness in pinna (finding)

301402008       Tenderness of truncal structure (finding)

301410009       Tenderness of right iliac fossa (finding)

290079000       Generalized tenderness of breast (finding)

301405005       Tenderness of left hypochondrium (finding)

440220007       Generalized abdominal tenderness (finding)

301393008       Tenderness of digestive structure (finding)

301398004       Tenderness of endocrine structure (finding)

301404009       Tenderness of right hypochondrium (finding)

301412001       Rebound tenderness of epigastrium (finding)

301417007       Rebound tenderness of left lumbar (finding)

833289001       Tenderness of anatomical snuffbox (finding)

301401001       Tenderness of head and neck region (finding)

301416003       Rebound tenderness of right lumbar (finding)

301418002       Rebound tenderness of hypogastrium (finding)

301389002       Tenderness of respiratory structure (finding)

301392003       Tenderness of oral cavity structure (finding)

102554000       Cervical spinous process tenderness (finding)

289696008       Tender scar of upper uterine segment (finding)

289697004       Tender scar of lower uterine segment (finding)

301415004       Rebound tenderness of central region (finding)

301424008       Postprocedural finding of tenderness (finding)

301390006       Tenderness of cardiovascular structure (finding)

301420004       Rebound tenderness of left iliac fossa (finding)

833290005       Rebound tenderness of umbilical region (finding)

299373004       Tenderness on medial joint line of knee (finding)

301391005       Tenderness of lymphoreticular structure (finding)

301419005       Rebound tenderness of right iliac fossa (finding)

299374005       Tenderness on lateral joint line of knee (finding)

301414000       Rebound tenderness of left hypochondrium (finding)

301413006       Rebound tenderness of right hypochondrium (finding)

1.22428E+16     Tenderness of left temporomandibular joint (finding)

277168002       Tenderness in ear canal on distracting pinna (finding)

439774009       Abdominal tenderness of left lower quadrant (finding)

1.22428E+16     Tenderness of right temporomandibular joint (finding)

1.5884E+16      Tenderness of bilateral temporomandibular joints (finding)

109659002       Tenderness of temporomandibular joint on palpation (finding)

448660000       Tenderness of left upper quadrant of abdomen (finding)

448265002       Tenderness of right upper quadrant of abdomen (finding)

448661001       Tenderness of right lower quadrant of abdomen (finding)

109591005       Tooth tender to percussion (disorder)

725010007       Neck pain co-occurrent with tenderness of neck following whiplash injury to neck (disorder)

300490003       Non-tender testes (finding)

300188005       Non-tender mastoid (finding)

289698009       Non-tender scar of gravid uterus (finding)