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feat(skills): add clinical-case-report skill (#581)
* feat(skills): add clinical-case-report skill
Adds a new healthcare skill for generating structured medical case
presentations (SOAP format, conference, and ward rounds).
Files added:
- SKILL.md — od: frontmatter + full agent workflow instructions
- references/checklist.md — P0/P1/P2 medical accuracy validation
- references/case-formats.md — SOAP, conference, and rounds formats
- examples/example-stemi.html — inferior STEMI with cardiogenic shock
Fills the healthcare vertical gap in the current skill catalog.
Includes physiologically consistent vitals, labs, and an
evidence-based management plan using real clinical guidelines.
* fix: address review feedback from lefarcen and mrcfps
- Add prescribing safety gate (Step 5) — warns about missing allergy,
renal, weight, and pregnancy context before drug recommendations
- Soften physiologic rules from 'must follow' to 'typical patterns' —
acknowledges afebrile pneumonia, beta-blocker-blunted shock, etc.
- Preserve user-provided values even if atypical for the diagnosis
- Remove incorrect TIMI 0-7 score (UA/NSTEMI scale) from STEMI example;
retain Killip Class III and Shock Index 1.27
- Fix troponin units: hs-troponin reported as 2400 ng/L (ref <40 ng/L)
instead of conventional 2.4 ng/mL
- Add table accessibility: <caption> and scope='col' on vital signs
and laboratory results tables
- Expand PHI checklist item to cover indirect identifiers (MRNs, dates,
locations, rare conditions, occupation, verbatim stories)
- Disambiguate format selection guide ('ward round' maps to Brief Rounds,
'formal rounds' maps to SOAP)
- Add example.html at skill root for /api/skills/:id/example resolver
* i18n: add clinical-case-report to DE/FR/RU skill fallback lists
* fix: soften checklist P0 vital signs rule to allow clinical variability
* fix: add medication safety checks block before antiplatelet section in examples
* fix: correct eGFR/age in safety block, add prescribing-safety P0 checklist items
* fix: correct age 67 to 58 in pregnancy line of safety block
* fix: defer norepinephrine dose to local protocol until weight confirmed
* fix: wire reference files into workflow; defer beta-blocker until shock resolved
* fix: close html code fence before Step 7 so checklist gate renders as prose
* fix: restrict oxygen to hypoxaemia only; generalise social history for de-identification
* fix: format-conditional P0 HPI gates; Killip III->IV for cardiogenic shock; smoking status consistent
* fix: make Step 2 and 'What you will produce' format-conditional for Brief Rounds
* fix: remove occupation detail from social history to comply with P0 de-identification rule
* fix: add 'ward rounds' plural to Brief Rounds format-selection table
* fix: gate Step 1 clarification on format; accept Killip+Shock Index as ACS risk scores
This commit is contained in:
Muhammad Ali
GitHub
parent
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8 changed files with 1743 additions and 0 deletions
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@ -314,6 +314,7 @@ export const FR_DESIGN_SYSTEM_CATEGORIES: Record<string, string> = {
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};
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export const FR_SKILL_IDS_WITH_EN_FALLBACK = [
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'clinical-case-report',
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'dcf-valuation',
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'flowai-live-dashboard-template',
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'html-ppt-taste-brutalist',
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@ -314,6 +314,7 @@ export const RU_DESIGN_SYSTEM_CATEGORIES: Record<string, string> = {
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};
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export const RU_SKILL_IDS_WITH_EN_FALLBACK = [
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'clinical-case-report',
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'dcf-valuation',
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'flowai-live-dashboard-template',
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'html-ppt-taste-brutalist',
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@ -363,6 +363,7 @@ const DE_DESIGN_SYSTEM_CATEGORIES: Record<string, string> = {
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};
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const DE_SKILL_IDS_WITH_EN_FALLBACK = [
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'clinical-case-report',
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'dcf-valuation',
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'flowai-live-dashboard-template',
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'html-ppt-taste-brutalist',
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209
skills/clinical-case-report/SKILL.md
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209
skills/clinical-case-report/SKILL.md
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@ -0,0 +1,209 @@
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---
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name: clinical-case-report
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description: |
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Structured medical case presentation for clinical rounds, conferences,
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and documentation. Generates SOAP-format or narrative case reports
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with physiologically accurate vitals, labs, and evidence-based plans.
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Use when the brief mentions "case report", "case presentation", "SOAP note",
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"clinical case", "ward rounds", "case summary", or "patient presentation".
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triggers:
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- "case report"
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- "case presentation"
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- "soap note"
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- "clinical case"
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- "ward rounds"
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- "patient presentation"
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- "case summary"
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- "medical case"
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od:
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mode: prototype
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platform: desktop
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scenario: healthcare
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preview:
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type: html
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entry: index.html
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fidelity: high-fidelity
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example_prompt: "58-year-old male with 2 hours of substernal chest pain radiating to the left arm, diaphoresis, and ST elevation in leads II, III, aVF. Generate a full emergency cardiology case presentation."
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---
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# Clinical Case Report Skill
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Generate a structured medical case presentation for clinical rounds,
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conferences, or documentation. The output follows standard medical
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formatting conventions used in hospital settings worldwide.
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## What you will produce
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A single-page HTML case report (`index.html`). Content varies by format
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(see `references/case-formats.md` — selected in Step 0):
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**SOAP / Conference format:**
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- **Patient identification** — age, sex, chief complaint
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- **History of Present Illness (HPI)** — chronological narrative with
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pertinent positives and negatives
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- **Past Medical History, Medications, Allergies**
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- **Review of Systems**
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- **Physical Examination** — systematic findings by system
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- **Vital Signs** — formatted table with reference ranges and flags
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- **Investigations** — laboratory results and imaging findings
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- **Assessment** — primary diagnosis and differential (3–5 items)
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with clinical reasoning for each
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- **Management Plan** — evidence-based, organised by problem
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**Brief Rounds format** (daily review, ward round, handover, ICU, post-call):
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- **ID line** — age, sex, day of admission, primary problem
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- **Interval events / current status** — what has changed since last review
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- **Active problems** — numbered list
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- **Plan-by-problem** — concise actions for each active problem
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- Full HPI and systematic physical examination are **not** included
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---
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## Step-by-step workflow
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### Step 0 — Load reference files
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Before starting, read both reference files:
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1. `references/case-formats.md` — use this to choose the correct output
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format (SOAP, Conference, or Brief Rounds) based on the user's context
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2. `references/checklist.md` — keep P0 gates in mind throughout; you
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must pass all P0 items before emitting the final artifact
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### Step 1 — Parse the brief
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Read the user's prompt and extract:
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- Patient age and sex
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- Chief complaint or presenting problem
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- Any vitals, labs, or imaging the user has provided
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- Clinical context: ED, ward rounds, conference case, outpatient, etc.
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- Specialty context: cardiology, emergency, internal medicine, etc.
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If the chief complaint or presenting problem is missing:
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- **SOAP / Conference**: ask one clarifying question before proceeding. Do not proceed without it.
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- **Brief Rounds**: if the admission problem or ID line is already available (e.g. "day-3 ICU review for septic shock"), proceed directly — a separate chief complaint is not required.
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### Step 2 — Build the clinical narrative
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**For SOAP / Conference outputs:** write the HPI as a continuous prose
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narrative in standard clinical style:
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> "This is a [age]-year-old [sex] with a history of [relevant PMH] who
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> presents with [chief complaint]. Symptoms began [timeline] and are
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> characterised by [quality, severity, radiation]. Associated symptoms
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> include [list]. Pertinent negatives include [list]."
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The HPI must be chronological. Include timeline markers
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("2 hours prior to presentation", "onset yesterday morning").
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**For Brief Rounds outputs** (daily review, ward round, handover, ICU,
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post-call): skip the full HPI and examination. Instead produce:
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- **ID line**: "[Age][sex], Day [N] of admission, [primary problem]"
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- **Interval events / current status**: what has changed since last review
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- **Active problems**: numbered list
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- **Plan-by-problem**: concise action for each active problem
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### Step 3 — Generate physiologically consistent clinical data
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If the user has not provided specific values, generate values that are
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internally consistent with the diagnosis:
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**Consistency checks (typical patterns):**
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- A patient in shock **typically** has: HR >100, SBP <90, raised lactate,
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impaired capillary refill — but medications (beta-blockers), age, or
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shock type (neurogenic, spinal) can alter this pattern
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- Pneumonia **typically** presents with raised WBC, raised CRP,
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temperature >38°C — but afebrile pneumonia exists, especially in
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the elderly or immunocompromised
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- A STEMI **typically** shows ST elevation in contiguous leads and raised
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high-sensitivity troponin — but early presentations may have initially
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normal troponin; CK-MB is not universally required
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- Sepsis **typically** shows raised or low WBC, raised lactate >2,
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temperature abnormality — but compensated early sepsis may present
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with normal vitals
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- Lab units must match convention: creatinine in µmol/L or mg/dL
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(state which), glucose in mmol/L, haemoglobin in g/dL
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**Critical rule — preserve user-provided data:**
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- Never overwrite a value the user has explicitly stated
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- If a user-provided value is atypical for the diagnosis, keep it and
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note the atypical presentation in the assessment rather than
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forcing canonical numbers
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- Never generate a value that contradicts the stated diagnosis
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### Step 4 — Write the assessment
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The assessment section must contain:
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1. **Primary diagnosis** stated clearly on the first line
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2. **Clinical reasoning** — one sentence explaining why this is the
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most likely diagnosis
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3. **Differential diagnosis** — exactly 3 to 5 items, each with one
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sentence of supporting or refuting evidence
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4. **Risk stratification** — include a validated clinical score where
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applicable (TIMI for ACS, GRACE for ACS, Killip class + Shock Index
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for STEMI/cardiogenic shock, CURB-65 for pneumonia, qSOFA for sepsis,
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Wells for PE, etc.). Killip class and Shock Index together are
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accepted as sufficient risk stratification for STEMI/cardiogenic shock cases.
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### Step 5 — Write the management plan
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The plan must be:
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- **Specific**: write drug names, doses, routes, and frequencies.
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Do not write "start antibiotics" — write
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"Piperacillin-Tazobactam 4.5g IV q8h for 5 days"
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- **Organised by problem** using numbered headers
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- **Evidence-based**: management must reflect current standard of care
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for the diagnosis
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- **Complete**: include investigations to order, monitoring parameters,
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consults to request, and disposition
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If you are uncertain about a specific dose, write
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"[drug name] — dose per local formulary/protocol" rather than
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inventing a dose.
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### Important — Prescribing Safety
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Generated plans must:
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- Be marked as educational/simulated, not a substitute for clinician judgment
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- Use "per local formulary/protocol" language when required patient variables
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(weight, renal function, allergies) are missing from the brief
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- List key contraindications and unknowns before medication recommendations
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when relevant patient data has not been provided
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- Never claim a plan is "definitive" or "standard of care" without full
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patient context (allergy status, renal/hepatic function, pregnancy
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status, weight, anticoagulation/bleeding risk)
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- Include a disclaimer footer in the HTML output stating the case is for
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educational and documentation purposes only
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### Step 6 — Write `index.html`
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Requirements for the HTML output:
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- Professional medical document typography
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(Georgia or system serif font preferred)
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- White background, dark text — suitable for printing
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- Vital signs and lab results in HTML `<table>` elements
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- Critical findings (ST elevation, raised troponin, low BP, etc.)
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highlighted in a visually distinct callout box with red left border
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- @media print CSS rules so the document prints cleanly on A4/Letter
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- Tag every major section with `data-od-id` for comment-mode targeting:
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```html
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<section data-od-id="hpi">...</section>
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<section data-od-id="vitals">...</section>
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<section data-od-id="pmh">...</section>
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<section data-od-id="examination">...</section>
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<section data-od-id="investigations">...</section>
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<section data-od-id="assessment">...</section>
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<section data-od-id="plan">...</section>
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```
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### Step 7 — Self-check against `references/checklist.md`
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Before emitting `<artifact>`, run every P0 item in `references/checklist.md`.
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All P0 items must pass. Fix any failures before emitting.
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698
skills/clinical-case-report/example.html
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698
skills/clinical-case-report/example.html
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<!DOCTYPE html>
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<html lang="en">
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<head>
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<meta charset="UTF-8">
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<meta name="viewport" content="width=device-width, initial-scale=1.0">
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<title>Clinical Case Report — Inferior STEMI with Cardiogenic Shock</title>
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<style>
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*, *::before, *::after { box-sizing: border-box; margin: 0; padding: 0; }
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body {
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font-family: Georgia, 'Times New Roman', serif;
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font-size: 14px;
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line-height: 1.7;
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color: #111;
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background: #fff;
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max-width: 900px;
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margin: 0 auto;
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padding: 40px 48px;
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}
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/* ── Document Header ───────────────────────────────────────────── */
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.doc-header {
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border-top: 3px solid #111;
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border-bottom: 1px solid #111;
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padding: 16px 0 14px;
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margin-bottom: 28px;
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}
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.doc-header h1 {
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font-size: 18px;
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font-weight: bold;
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letter-spacing: 0.4px;
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text-transform: uppercase;
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}
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.doc-header .meta-grid {
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display: grid;
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grid-template-columns: repeat(4, 1fr);
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gap: 8px 16px;
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margin-top: 10px;
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}
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.doc-header .meta-item {
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font-size: 12.5px;
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}
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.doc-header .meta-item .label {
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font-weight: bold;
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text-transform: uppercase;
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letter-spacing: 0.5px;
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font-size: 10px;
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color: #555;
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display: block;
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}
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/* ── Section Headings ──────────────────────────────────────────── */
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h2 {
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font-size: 11px;
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font-weight: bold;
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text-transform: uppercase;
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letter-spacing: 1.2px;
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color: #333;
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border-bottom: 1px solid #ccc;
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padding-bottom: 4px;
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margin: 28px 0 12px;
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}
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/* ── Body Text ─────────────────────────────────────────────────── */
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p { margin-bottom: 10px; }
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ul, ol { padding-left: 22px; margin-bottom: 10px; }
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li { margin-bottom: 5px; }
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strong { font-weight: bold; }
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/* ── Critical Alert Box ────────────────────────────────────────── */
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.alert {
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background: #fff8f8;
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border-left: 4px solid #c00;
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border: 1px solid #f5c6c6;
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border-left: 4px solid #c00;
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padding: 10px 14px;
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margin: 12px 0;
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font-size: 13px;
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}
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.alert .alert-label {
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font-weight: bold;
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color: #c00;
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text-transform: uppercase;
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font-size: 11px;
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letter-spacing: 0.6px;
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display: block;
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margin-bottom: 4px;
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}
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/* ── Tables ────────────────────────────────────────────────────── */
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table {
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width: 100%;
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border-collapse: collapse;
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font-size: 13px;
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margin-bottom: 14px;
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}
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th {
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background: #f4f4f4;
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font-weight: bold;
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text-align: left;
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padding: 7px 10px;
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border: 1px solid #ccc;
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font-size: 11.5px;
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text-transform: uppercase;
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letter-spacing: 0.3px;
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}
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td {
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padding: 6px 10px;
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border: 1px solid #ddd;
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vertical-align: top;
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}
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tr:nth-child(even) td { background: #fafafa; }
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.val-high { color: #c00; font-weight: bold; }
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.val-low { color: #c00; font-weight: bold; }
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.val-normal { color: #1a6b1a; }
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/* ── Differential List ─────────────────────────────────────────── */
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.differential-item {
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margin-bottom: 12px;
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padding-left: 14px;
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border-left: 3px solid #e0e0e0;
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}
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.differential-item .dx-title {
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font-weight: bold;
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font-size: 13.5px;
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}
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.differential-item .dx-likelihood {
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display: inline-block;
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font-size: 10.5px;
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font-weight: bold;
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text-transform: uppercase;
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letter-spacing: 0.4px;
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padding: 1px 6px;
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border-radius: 2px;
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margin-left: 6px;
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vertical-align: middle;
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}
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.likely { background: #fce8e8; color: #c00; }
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.possible { background: #fff4e0; color: #a06000; }
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.unlikely { background: #f0f0f0; color: #555; }
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/* ── Plan Items ────────────────────────────────────────────────── */
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.plan-block {
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margin-bottom: 18px;
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}
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.plan-block .plan-title {
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font-weight: bold;
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font-size: 13.5px;
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margin-bottom: 6px;
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padding: 5px 10px;
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background: #f4f4f4;
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border-left: 3px solid #555;
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}
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/* ── Risk Score ────────────────────────────────────────────────── */
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.risk-score {
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display: inline-block;
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background: #fff3f3;
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border: 1px solid #f5c6c6;
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border-radius: 3px;
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padding: 6px 12px;
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font-size: 13px;
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margin: 8px 0 12px;
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}
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.risk-score strong { color: #c00; }
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/* ── Footer ────────────────────────────────────────────────────── */
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.doc-footer {
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margin-top: 40px;
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padding-top: 12px;
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border-top: 1px solid #ccc;
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font-size: 11px;
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color: #777;
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display: flex;
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justify-content: space-between;
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}
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/* ── Print ─────────────────────────────────────────────────────── */
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@media print {
|
||||
body { padding: 16px 20px; font-size: 12px; }
|
||||
.alert { border-left: 3px solid #c00; }
|
||||
.plan-block .plan-title { background: none; border-left: 2px solid #333; }
|
||||
h2 { margin-top: 20px; }
|
||||
}
|
||||
</style>
|
||||
</head>
|
||||
<body>
|
||||
|
||||
<!-- ── Document Header ─────────────────────────────────────── -->
|
||||
<div class="doc-header" data-od-id="header">
|
||||
<h1>Clinical Case Report</h1>
|
||||
<div class="meta-grid">
|
||||
<div class="meta-item">
|
||||
<span class="label">Patient</span>
|
||||
58-year-old Male
|
||||
</div>
|
||||
<div class="meta-item">
|
||||
<span class="label">Setting</span>
|
||||
Emergency Department
|
||||
</div>
|
||||
<div class="meta-item">
|
||||
<span class="label">Specialty</span>
|
||||
Emergency / Cardiology
|
||||
</div>
|
||||
<div class="meta-item">
|
||||
<span class="label">Format</span>
|
||||
SOAP
|
||||
</div>
|
||||
</div>
|
||||
</div>
|
||||
|
||||
<!-- ── Chief Complaint ──────────────────────────────────────── -->
|
||||
<section data-od-id="chief-complaint">
|
||||
<h2>Chief Complaint</h2>
|
||||
<p>
|
||||
Severe substernal chest pain for 2 hours with radiation to the left arm
|
||||
and jaw, associated with profuse diaphoresis and nausea.
|
||||
</p>
|
||||
</section>
|
||||
|
||||
<!-- ── History of Present Illness ──────────────────────────── -->
|
||||
<section data-od-id="hpi">
|
||||
<h2>History of Present Illness</h2>
|
||||
<p>
|
||||
This is a 58-year-old male with a background history of hypertension,
|
||||
type 2 diabetes mellitus, and hyperlipidaemia who presents to the
|
||||
emergency department with a 2-hour history of severe, 9/10 intensity,
|
||||
pressure-like chest pain localised substernally. The pain began abruptly
|
||||
at rest at approximately 14:30 and radiates to the left arm and jaw.
|
||||
</p>
|
||||
<p>
|
||||
The pain is associated with profuse diaphoresis, nausea, and one episode
|
||||
of non-bloody vomiting. The patient reports no dyspnoea, no palpitations,
|
||||
and no pre-syncopal symptoms. There is no pleuritic component, no
|
||||
positional variation, and no relief with antacids.
|
||||
</p>
|
||||
<p>
|
||||
The patient has never experienced this type of pain before. He denies
|
||||
recent travel, prolonged immobility, or lower limb swelling. He has not
|
||||
taken any nitrates prior to arrival. His regular medications were taken
|
||||
this morning. He has a 30 pack-year smoking history (10 cigarettes/day,
|
||||
ongoing) and drinks alcohol occasionally. His father died of a myocardial
|
||||
infarction at age 62.
|
||||
</p>
|
||||
</section>
|
||||
|
||||
<!-- ── PMH / Medications / Allergies ────────────────────────── -->
|
||||
<section data-od-id="pmh">
|
||||
<h2>Past Medical History</h2>
|
||||
<ul>
|
||||
<li>Hypertension — diagnosed 8 years ago, on treatment</li>
|
||||
<li>Type 2 Diabetes Mellitus — diagnosed 5 years ago, on oral hypoglycaemics</li>
|
||||
<li>Hyperlipidaemia — diagnosed 5 years ago, on statin therapy</li>
|
||||
<li>No prior cardiac history. No previous myocardial infarction.</li>
|
||||
<li>No history of stroke, peripheral vascular disease, or renal disease</li>
|
||||
</ul>
|
||||
|
||||
<p style="margin-top:14px"><strong>Current Medications:</strong></p>
|
||||
<ul>
|
||||
<li>Metformin 1g PO twice daily</li>
|
||||
<li>Amlodipine 5mg PO once daily</li>
|
||||
<li>Atorvastatin 40mg PO at night</li>
|
||||
</ul>
|
||||
|
||||
<p style="margin-top:14px"><strong>Allergies:</strong>
|
||||
No known drug allergies. No known food allergies.
|
||||
</p>
|
||||
|
||||
<p style="margin-top:14px"><strong>Social History:</strong>
|
||||
Lives with family and has good home supports.
|
||||
Current smoker — 10 cigarettes/day, 30 pack-years.
|
||||
Alcohol: occasional, less than 14 units/week.
|
||||
</p>
|
||||
</section>
|
||||
|
||||
<!-- ── Vital Signs ───────────────────────────────────────────── -->
|
||||
<section data-od-id="vitals">
|
||||
<h2>Vital Signs</h2>
|
||||
|
||||
<div class="alert">
|
||||
<span class="alert-label">⚠ Critical — Activate Cath Lab</span>
|
||||
ST elevation ≥3mm in leads II, III, aVF with reciprocal changes in I and aVL.
|
||||
Patient meets STEMI criteria. Door-to-balloon time target: <90 minutes.
|
||||
</div>
|
||||
|
||||
<table>
|
||||
<caption>Vital Signs</caption>
|
||||
<thead>
|
||||
<tr>
|
||||
<th scope="col">Parameter</th>
|
||||
<th scope="col">Value</th>
|
||||
<th scope="col">Reference Range</th>
|
||||
<th scope="col">Status</th>
|
||||
</tr>
|
||||
</thead>
|
||||
<tbody>
|
||||
<tr>
|
||||
<td>Blood Pressure (Systolic/Diastolic)</td>
|
||||
<td class="val-low">88 / 60 mmHg</td>
|
||||
<td>90–140 / 60–90 mmHg</td>
|
||||
<td class="val-low">⬇ Hypotensive</td>
|
||||
</tr>
|
||||
<tr>
|
||||
<td>Heart Rate</td>
|
||||
<td class="val-high">112 bpm</td>
|
||||
<td>60–100 bpm</td>
|
||||
<td class="val-high">⬆ Tachycardia</td>
|
||||
</tr>
|
||||
<tr>
|
||||
<td>Respiratory Rate</td>
|
||||
<td class="val-high">22 breaths/min</td>
|
||||
<td>12–20 breaths/min</td>
|
||||
<td class="val-high">⬆ Elevated</td>
|
||||
</tr>
|
||||
<tr>
|
||||
<td>Oxygen Saturation (SpO₂) — room air</td>
|
||||
<td class="val-low">94%</td>
|
||||
<td>≥96%</td>
|
||||
<td class="val-low">⬇ Low</td>
|
||||
</tr>
|
||||
<tr>
|
||||
<td>Temperature</td>
|
||||
<td class="val-normal">37.1°C</td>
|
||||
<td>36.5–37.5°C</td>
|
||||
<td class="val-normal">Normal</td>
|
||||
</tr>
|
||||
<tr>
|
||||
<td>Glasgow Coma Scale</td>
|
||||
<td class="val-normal">15 / 15</td>
|
||||
<td>15</td>
|
||||
<td class="val-normal">Normal</td>
|
||||
</tr>
|
||||
<tr>
|
||||
<td>Capillary Refill Time</td>
|
||||
<td class="val-high">3 seconds</td>
|
||||
<td><2 seconds</td>
|
||||
<td class="val-high">⬆ Prolonged</td>
|
||||
</tr>
|
||||
</tbody>
|
||||
</table>
|
||||
</section>
|
||||
|
||||
<!-- ── Physical Examination ──────────────────────────────────── -->
|
||||
<section data-od-id="examination">
|
||||
<h2>Physical Examination</h2>
|
||||
|
||||
<p><strong>General:</strong>
|
||||
Diaphoretic, pale, and in obvious discomfort. Alert and oriented to
|
||||
person, place, and time. Appears acutely unwell.
|
||||
</p>
|
||||
<p><strong>Cardiovascular:</strong>
|
||||
Jugular venous pressure elevated at approximately 4cm above the sternal
|
||||
angle. Heart sounds S1 + S2 present, no murmurs, no added sounds.
|
||||
Peripheral pulses palpable but weak bilaterally. Capillary refill
|
||||
3 seconds peripherally. No peripheral oedema.
|
||||
</p>
|
||||
<p><strong>Respiratory:</strong>
|
||||
Respiratory rate 22/min. Air entry bilaterally. Fine bibasal
|
||||
crepitations present, right greater than left. No wheeze. Dull to
|
||||
percussion at right base. No use of accessory muscles.
|
||||
</p>
|
||||
<p><strong>Abdomen:</strong>
|
||||
Soft, non-distended, non-tender. No organomegaly. Bowel sounds present
|
||||
and normal. No renal angle tenderness.
|
||||
</p>
|
||||
<p><strong>Neurological:</strong>
|
||||
GCS 15/15. Pupils equal and reactive 3mm bilaterally. No focal
|
||||
neurological deficits. Cranial nerves grossly intact.
|
||||
</p>
|
||||
<p><strong>Skin / Peripheries:</strong>
|
||||
Pallor and diaphoresis. No rash, no jaundice, no cyanosis.
|
||||
</p>
|
||||
</section>
|
||||
|
||||
<!-- ── Investigations ────────────────────────────────────────── -->
|
||||
<section data-od-id="investigations">
|
||||
<h2>Investigations</h2>
|
||||
|
||||
<p><strong>12-Lead ECG:</strong></p>
|
||||
<div class="alert">
|
||||
<span class="alert-label">ECG — STEMI Criteria Met</span>
|
||||
Sinus tachycardia at 112 bpm. ST elevation 3mm in leads II, III, aVF.
|
||||
Reciprocal ST depression in leads I and aVL. PR interval and QRS
|
||||
morphology otherwise normal. No left bundle branch block.
|
||||
Right-sided leads (V3R–V6R) ordered to exclude RV infarction.
|
||||
</div>
|
||||
|
||||
<p style="margin-top:14px"><strong>Laboratory Results:</strong></p>
|
||||
<table>
|
||||
<caption>Laboratory Results</caption>
|
||||
<thead>
|
||||
<tr>
|
||||
<th scope="col">Investigation</th>
|
||||
<th scope="col">Result</th>
|
||||
<th scope="col">Reference Range</th>
|
||||
</tr>
|
||||
</thead>
|
||||
<tbody>
|
||||
<tr>
|
||||
<td>Troponin I (high-sensitivity)</td>
|
||||
<td class="val-high">2400 ng/L ⬆</td>
|
||||
<td><40 ng/L</td>
|
||||
</tr>
|
||||
<tr>
|
||||
<td>CK-MB</td>
|
||||
<td class="val-high">48 U/L ⬆</td>
|
||||
<td><25 U/L</td>
|
||||
</tr>
|
||||
<tr>
|
||||
<td>BNP (B-type Natriuretic Peptide)</td>
|
||||
<td class="val-high">520 pg/mL ⬆</td>
|
||||
<td><100 pg/mL</td>
|
||||
</tr>
|
||||
<tr>
|
||||
<td>Haemoglobin</td>
|
||||
<td class="val-normal">13.8 g/dL</td>
|
||||
<td>13.5–17.5 g/dL</td>
|
||||
</tr>
|
||||
<tr>
|
||||
<td>White Blood Cells</td>
|
||||
<td>11.2 × 10⁹/L</td>
|
||||
<td>4.0–11.0 × 10⁹/L</td>
|
||||
</tr>
|
||||
<tr>
|
||||
<td>Platelets</td>
|
||||
<td class="val-normal">224 × 10⁹/L</td>
|
||||
<td>150–400 × 10⁹/L</td>
|
||||
</tr>
|
||||
<tr>
|
||||
<td>Sodium</td>
|
||||
<td class="val-normal">138 mmol/L</td>
|
||||
<td>135–145 mmol/L</td>
|
||||
</tr>
|
||||
<tr>
|
||||
<td>Potassium</td>
|
||||
<td class="val-normal">4.1 mmol/L</td>
|
||||
<td>3.5–5.0 mmol/L</td>
|
||||
</tr>
|
||||
<tr>
|
||||
<td>Creatinine</td>
|
||||
<td class="val-normal">98 µmol/L</td>
|
||||
<td>62–106 µmol/L</td>
|
||||
</tr>
|
||||
<tr>
|
||||
<td>eGFR</td>
|
||||
<td class="val-normal">72 mL/min/1.73m²</td>
|
||||
<td>≥60 mL/min/1.73m²</td>
|
||||
</tr>
|
||||
<tr>
|
||||
<td>Glucose (random)</td>
|
||||
<td class="val-high">9.4 mmol/L ⬆</td>
|
||||
<td>4.0–7.8 mmol/L</td>
|
||||
</tr>
|
||||
<tr>
|
||||
<td>HbA1c</td>
|
||||
<td class="val-high">7.8% ⬆</td>
|
||||
<td><7.0% (diabetic target)</td>
|
||||
</tr>
|
||||
<tr>
|
||||
<td>Total Cholesterol</td>
|
||||
<td class="val-high">5.9 mmol/L ⬆</td>
|
||||
<td><5.2 mmol/L</td>
|
||||
</tr>
|
||||
<tr>
|
||||
<td>LDL Cholesterol</td>
|
||||
<td class="val-high">3.8 mmol/L ⬆</td>
|
||||
<td><2.0 mmol/L (high-risk target)</td>
|
||||
</tr>
|
||||
<tr>
|
||||
<td>INR</td>
|
||||
<td class="val-normal">1.1</td>
|
||||
<td>0.8–1.2</td>
|
||||
</tr>
|
||||
<tr>
|
||||
<td>Lactate</td>
|
||||
<td class="val-high">2.8 mmol/L ⬆</td>
|
||||
<td><2.0 mmol/L</td>
|
||||
</tr>
|
||||
<tr>
|
||||
<td>Arterial pH</td>
|
||||
<td class="val-low">7.31 ⬇</td>
|
||||
<td>7.35–7.45</td>
|
||||
</tr>
|
||||
</tbody>
|
||||
</table>
|
||||
|
||||
<p><strong>Chest X-Ray (Portable AP):</strong>
|
||||
Mild cardiomegaly. Pulmonary vascular congestion with upper lobe
|
||||
diversion. Small right pleural effusion. No pneumothorax.
|
||||
No mediastinal widening.
|
||||
</p>
|
||||
<p><strong>Bedside Echocardiogram (Emergency):</strong>
|
||||
Inferior and inferolateral wall hypokinesia. Estimated ejection fraction
|
||||
40%. No pericardial effusion. No obvious valvular pathology on this
|
||||
limited study. Right ventricle appears mildly dilated — formal
|
||||
right-sided assessment pending.
|
||||
</p>
|
||||
</section>
|
||||
|
||||
<!-- ── Assessment ────────────────────────────────────────────── -->
|
||||
<section data-od-id="assessment">
|
||||
<h2>Assessment</h2>
|
||||
|
||||
<p>
|
||||
<strong>Primary Diagnosis:</strong>
|
||||
Inferior ST-Elevation Myocardial Infarction (STEMI) complicated by
|
||||
cardiogenic shock. Most likely culprit vessel: Right Coronary Artery
|
||||
(RCA) based on inferior lead involvement.
|
||||
</p>
|
||||
|
||||
<div class="risk-score">
|
||||
<strong>Killip Class: IV</strong> — Cardiogenic shock (hypotension + end-organ hypoperfusion).
|
||||
|
|
||||
<strong>Shock Index: 1.27</strong> (HR/SBP — normal <0.7)
|
||||
</div>
|
||||
|
||||
<p style="margin-top:4px"><strong>Differential Diagnosis:</strong></p>
|
||||
|
||||
<div class="differential-item">
|
||||
<span class="dx-title">1. Inferior STEMI — RCA Territory</span>
|
||||
<span class="dx-likelihood likely">Most Likely</span>
|
||||
<p style="margin-top:6px; font-size:13px;">
|
||||
ST elevation in leads II, III, aVF with reciprocal depression in I
|
||||
and aVL is the hallmark ECG pattern of inferior STEMI. Elevated
|
||||
troponin I (60× upper limit of normal) and inferior wall hypokinesia
|
||||
on bedside echo confirm ongoing myocardial injury. Cardiogenic shock
|
||||
(SBP 88, elevated lactate 2.8, BNP 520) indicates significant
|
||||
haemodynamic compromise. Right ventricular involvement must be
|
||||
excluded with right-sided leads before initiating fluid therapy.
|
||||
</p>
|
||||
</div>
|
||||
|
||||
<div class="differential-item">
|
||||
<span class="dx-title">2. Type A Aortic Dissection</span>
|
||||
<span class="dx-likelihood possible">Considered, Less Likely</span>
|
||||
<p style="margin-top:6px; font-size:13px;">
|
||||
Severe chest pain with radiation to the jaw raises dissection in the
|
||||
differential. However, the pain character is pressure-like rather
|
||||
than tearing, there is no pulse deficit, no limb ischaemia, and no
|
||||
mediastinal widening on CXR. The ECG and troponin pattern is more
|
||||
consistent with primary ACS. Dissection is lower probability but
|
||||
cannot be fully excluded without CT aortogram if clinical doubt
|
||||
persists after ECG correlation.
|
||||
</p>
|
||||
</div>
|
||||
|
||||
<div class="differential-item">
|
||||
<span class="dx-title">3. Massive Pulmonary Embolism</span>
|
||||
<span class="dx-likelihood unlikely">Unlikely</span>
|
||||
<p style="margin-top:6px; font-size:13px;">
|
||||
Haemodynamic instability and low SpO₂ are consistent with massive PE.
|
||||
However, the patient has no PE risk factors (no recent travel,
|
||||
immobility, or DVT history), the ECG shows inferior ST elevation
|
||||
rather than right heart strain or S1Q3T3 pattern, and the troponin
|
||||
rise matches ACS kinetics. Bedside echo shows inferior wall
|
||||
hypokinesia rather than RV dilation as the dominant finding.
|
||||
PE is considered unlikely.
|
||||
</p>
|
||||
</div>
|
||||
|
||||
<div class="differential-item">
|
||||
<span class="dx-title">4. NSTEMI / Unstable Angina</span>
|
||||
<span class="dx-likelihood unlikely">Excluded</span>
|
||||
<p style="margin-top:6px; font-size:13px;">
|
||||
The presence of ≥1mm ST elevation in two contiguous inferior leads,
|
||||
combined with the degree of troponin elevation, meets full STEMI
|
||||
criteria. NSTEMI is excluded by the ECG findings.
|
||||
</p>
|
||||
</div>
|
||||
</section>
|
||||
|
||||
<!-- ── Management Plan ───────────────────────────────────────── -->
|
||||
<section data-od-id="plan">
|
||||
<h2>Management Plan</h2>
|
||||
|
||||
<div class="plan-block">
|
||||
<div class="plan-title">1. Immediate — Revascularisation (Priority)</div>
|
||||
<ul>
|
||||
<li>Activate cardiac catheterisation laboratory — target
|
||||
door-to-balloon time <90 minutes</li>
|
||||
<li>Primary Percutaneous Coronary Intervention (PCI) of culprit
|
||||
lesion (RCA) — preferred strategy over thrombolysis</li>
|
||||
<li>Urgent cardiology consult — notify interventional cardiologist
|
||||
immediately</li>
|
||||
<li>Obtain right-sided leads (V3R–V6R) before any fluid
|
||||
administration to exclude RV MI</li>
|
||||
</ul>
|
||||
</div>
|
||||
|
||||
<div class="plan-block" style="border-left:3px solid #e6a817;padding-left:12px;">
|
||||
<div class="plan-title" style="color:#b07a00;">⚠ Medication Safety Checks — confirm before prescribing</div>
|
||||
<ul>
|
||||
<li><strong>Known (from this case):</strong> No documented drug allergies; eGFR 72 mL/min/1.73m² (renal function currently preserved — monitor closely around contrast and acute illness); no current anticoagulants documented; patient is male, age 58</li>
|
||||
<li><strong>Weight not provided</strong> — weight-based dosing (e.g. heparin bolus) should follow <em>local formulary/protocol</em> once weight is confirmed</li>
|
||||
<li><strong>Bleeding risk not assessed</strong> — confirm no active bleeding, recent surgery, or prior intracranial haemorrhage before dual antiplatelet therapy</li>
|
||||
<li><strong>Hepatic function not documented</strong> — review prior to high-dose statin and ACE inhibitor initiation</li>
|
||||
<li><strong>Pregnancy status not applicable</strong> (patient is male, age 58)</li>
|
||||
<li><em>All doses below are educational/simulated. Verify against your local formulary, current guidelines, and full patient context before administering.</em></li>
|
||||
</ul>
|
||||
</div>
|
||||
|
||||
<div class="plan-block">
|
||||
<div class="plan-title">2. Antiplatelet and Anticoagulation</div>
|
||||
<ul>
|
||||
<li>Aspirin 300mg PO loading dose — stat, then 75mg PO once daily</li>
|
||||
<li>Ticagrelor 180mg PO loading dose — stat, then 90mg PO twice daily
|
||||
(preferred over clopidogrel for STEMI per ESC guidelines)</li>
|
||||
<li>Unfractionated heparin — IV bolus per cath lab protocol prior to PCI</li>
|
||||
<li>Do not administer GPIIb/IIIa inhibitor pre-PCI; consider
|
||||
intra-procedure per operator discretion</li>
|
||||
</ul>
|
||||
</div>
|
||||
|
||||
<div class="plan-block">
|
||||
<div class="plan-title">3. Cardiogenic Shock</div>
|
||||
<ul>
|
||||
<li>Hold IV fluids until right-sided leads reviewed — if RV infarct
|
||||
present, cautious fluid challenge 250mL normal saline</li>
|
||||
<li>If MAP <65mmHg despite fluids: commence norepinephrine infusion
|
||||
per local vasoactive-infusion protocol once weight and concentration
|
||||
are confirmed; titrate to MAP ≥65mmHg</li>
|
||||
<li>ICU/CCU bed request — post-PCI high-dependency monitoring</li>
|
||||
<li>Consider intra-aortic balloon pump or Impella device if shock
|
||||
refractory post-PCI — per cardiology discretion</li>
|
||||
</ul>
|
||||
</div>
|
||||
|
||||
<div class="plan-block">
|
||||
<div class="plan-title">4. Respiratory / Oxygenation</div>
|
||||
<ul>
|
||||
<li>Supplemental O₂ only if hypoxaemic (SpO₂ <94%) or in
|
||||
respiratory distress — use the lowest-flow device (nasal cannula
|
||||
or simple face mask) needed to maintain SpO₂ 94–98%; do not give
|
||||
routine high-flow oxygen in normoxic STEMI (may worsen
|
||||
ischaemia)</li>
|
||||
<li>If pulmonary oedema worsens and haemodynamics permit:
|
||||
Furosemide 40mg IV once</li>
|
||||
<li>Escalate to non-rebreather mask, CPAP, or intubation per local
|
||||
protocol if SpO₂ falls below 90% or respiratory distress
|
||||
worsens despite initial measures</li>
|
||||
</ul>
|
||||
</div>
|
||||
|
||||
<div class="plan-block">
|
||||
<div class="plan-title">5. Monitoring</div>
|
||||
<ul>
|
||||
<li>Continuous 12-lead ECG monitoring and pulse oximetry</li>
|
||||
<li>Arterial line for continuous BP monitoring given haemodynamic
|
||||
instability</li>
|
||||
<li>Repeat troponin at 3 hours and 6 hours post-admission</li>
|
||||
<li>Repeat ECG immediately post-PCI and at 1 hour</li>
|
||||
<li>Hourly urine output via urinary catheter — target ≥0.5mL/kg/hr</li>
|
||||
<li>Strict fluid balance chart</li>
|
||||
<li>Blood glucose monitoring q2h — target 6–10 mmol/L</li>
|
||||
</ul>
|
||||
</div>
|
||||
|
||||
<div class="plan-block">
|
||||
<div class="plan-title">6. Secondary Prevention (commence post-stabilisation)</div>
|
||||
<ul>
|
||||
<li>Beta-blocker: Bisoprolol — <strong>defer until fully stabilised</strong>:
|
||||
shock resolved, off vasopressors/inotropes, euvolaemic, no
|
||||
bradycardia or heart block, SBP >100mmHg and HR <110bpm;
|
||||
early beta-blockade in cardiogenic shock/Killip IV can worsen
|
||||
haemodynamics. Initiate at 1.25mg PO once daily per cardiology
|
||||
review post-stabilisation.</li>
|
||||
<li>ACE inhibitor: Ramipril 1.25mg PO once daily — commence within
|
||||
24 hours if tolerated; uptitrate over weeks</li>
|
||||
<li>Statin: Atorvastatin 80mg PO at night — high-intensity statin
|
||||
regardless of baseline cholesterol</li>
|
||||
<li>Diabetes: Hold Metformin — renal function and contrast exposure
|
||||
risk. Resume 48 hours post-procedure if creatinine stable</li>
|
||||
<li>Dual antiplatelet therapy: Aspirin 75mg + Ticagrelor 90mg BD
|
||||
for minimum 12 months post-PCI</li>
|
||||
<li>Cardiac rehabilitation referral before discharge</li>
|
||||
<li>Smoking cessation counselling and pharmacotherapy referral</li>
|
||||
<li>Repeat echocardiogram at 6–8 weeks to reassess ejection fraction</li>
|
||||
</ul>
|
||||
</div>
|
||||
|
||||
<div class="plan-block">
|
||||
<div class="plan-title">7. Disposition</div>
|
||||
<ul>
|
||||
<li>Admit to Coronary Care Unit (CCU) post-PCI</li>
|
||||
<li>Expected length of stay: 3–5 days if uncomplicated post-PCI course</li>
|
||||
<li>Notify next of kin — serious illness discussion</li>
|
||||
</ul>
|
||||
</div>
|
||||
</section>
|
||||
|
||||
<!-- ── Footer ────────────────────────────────────────────────── -->
|
||||
<div class="doc-footer">
|
||||
<span>Generated using Open Design — clinical-case-report skill</span>
|
||||
<span>For educational and documentation purposes only</span>
|
||||
</div>
|
||||
|
||||
</body>
|
||||
</html>
|
||||
698
skills/clinical-case-report/examples/example-stemi.html
Normal file
698
skills/clinical-case-report/examples/example-stemi.html
Normal file
|
|
@ -0,0 +1,698 @@
|
|||
<!DOCTYPE html>
|
||||
<html lang="en">
|
||||
<head>
|
||||
<meta charset="UTF-8">
|
||||
<meta name="viewport" content="width=device-width, initial-scale=1.0">
|
||||
<title>Clinical Case Report — Inferior STEMI with Cardiogenic Shock</title>
|
||||
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|
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|
||||
|
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|
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|
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|
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|
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|
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|
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|
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|
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|
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|
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|
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|
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display: grid;
|
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grid-template-columns: repeat(4, 1fr);
|
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|
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|
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|
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|
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|
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|
||||
display: block;
|
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|
||||
|
||||
/* ── Section Headings ──────────────────────────────────────────── */
|
||||
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|
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font-size: 11px;
|
||||
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|
||||
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|
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|
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color: #333;
|
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border-bottom: 1px solid #ccc;
|
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padding-bottom: 4px;
|
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|
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|
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|
||||
/* ── Body Text ─────────────────────────────────────────────────── */
|
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|
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|
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|
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strong { font-weight: bold; }
|
||||
|
||||
/* ── Critical Alert Box ────────────────────────────────────────── */
|
||||
.alert {
|
||||
background: #fff8f8;
|
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border-left: 4px solid #c00;
|
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|
||||
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|
||||
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|
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font-size: 13px;
|
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}
|
||||
.alert .alert-label {
|
||||
font-weight: bold;
|
||||
color: #c00;
|
||||
text-transform: uppercase;
|
||||
font-size: 11px;
|
||||
letter-spacing: 0.6px;
|
||||
display: block;
|
||||
margin-bottom: 4px;
|
||||
}
|
||||
|
||||
/* ── Tables ────────────────────────────────────────────────────── */
|
||||
table {
|
||||
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|
||||
border-collapse: collapse;
|
||||
font-size: 13px;
|
||||
margin-bottom: 14px;
|
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|
||||
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|
||||
background: #f4f4f4;
|
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font-weight: bold;
|
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text-align: left;
|
||||
padding: 7px 10px;
|
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border: 1px solid #ccc;
|
||||
font-size: 11.5px;
|
||||
text-transform: uppercase;
|
||||
letter-spacing: 0.3px;
|
||||
}
|
||||
td {
|
||||
padding: 6px 10px;
|
||||
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|
||||
vertical-align: top;
|
||||
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|
||||
tr:nth-child(even) td { background: #fafafa; }
|
||||
.val-high { color: #c00; font-weight: bold; }
|
||||
.val-low { color: #c00; font-weight: bold; }
|
||||
.val-normal { color: #1a6b1a; }
|
||||
|
||||
/* ── Differential List ─────────────────────────────────────────── */
|
||||
.differential-item {
|
||||
margin-bottom: 12px;
|
||||
padding-left: 14px;
|
||||
border-left: 3px solid #e0e0e0;
|
||||
}
|
||||
.differential-item .dx-title {
|
||||
font-weight: bold;
|
||||
font-size: 13.5px;
|
||||
}
|
||||
.differential-item .dx-likelihood {
|
||||
display: inline-block;
|
||||
font-size: 10.5px;
|
||||
font-weight: bold;
|
||||
text-transform: uppercase;
|
||||
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|
||||
padding: 1px 6px;
|
||||
border-radius: 2px;
|
||||
margin-left: 6px;
|
||||
vertical-align: middle;
|
||||
}
|
||||
.likely { background: #fce8e8; color: #c00; }
|
||||
.possible { background: #fff4e0; color: #a06000; }
|
||||
.unlikely { background: #f0f0f0; color: #555; }
|
||||
|
||||
/* ── Plan Items ────────────────────────────────────────────────── */
|
||||
.plan-block {
|
||||
margin-bottom: 18px;
|
||||
}
|
||||
.plan-block .plan-title {
|
||||
font-weight: bold;
|
||||
font-size: 13.5px;
|
||||
margin-bottom: 6px;
|
||||
padding: 5px 10px;
|
||||
background: #f4f4f4;
|
||||
border-left: 3px solid #555;
|
||||
}
|
||||
|
||||
/* ── Risk Score ────────────────────────────────────────────────── */
|
||||
.risk-score {
|
||||
display: inline-block;
|
||||
background: #fff3f3;
|
||||
border: 1px solid #f5c6c6;
|
||||
border-radius: 3px;
|
||||
padding: 6px 12px;
|
||||
font-size: 13px;
|
||||
margin: 8px 0 12px;
|
||||
}
|
||||
.risk-score strong { color: #c00; }
|
||||
|
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/* ── Footer ────────────────────────────────────────────────────── */
|
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.doc-footer {
|
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margin-top: 40px;
|
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padding-top: 12px;
|
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border-top: 1px solid #ccc;
|
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font-size: 11px;
|
||||
color: #777;
|
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display: flex;
|
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justify-content: space-between;
|
||||
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|
||||
|
||||
/* ── Print ─────────────────────────────────────────────────────── */
|
||||
@media print {
|
||||
body { padding: 16px 20px; font-size: 12px; }
|
||||
.alert { border-left: 3px solid #c00; }
|
||||
.plan-block .plan-title { background: none; border-left: 2px solid #333; }
|
||||
h2 { margin-top: 20px; }
|
||||
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|
||||
</style>
|
||||
</head>
|
||||
<body>
|
||||
|
||||
<!-- ── Document Header ─────────────────────────────────────── -->
|
||||
<div class="doc-header" data-od-id="header">
|
||||
<h1>Clinical Case Report</h1>
|
||||
<div class="meta-grid">
|
||||
<div class="meta-item">
|
||||
<span class="label">Patient</span>
|
||||
58-year-old Male
|
||||
</div>
|
||||
<div class="meta-item">
|
||||
<span class="label">Setting</span>
|
||||
Emergency Department
|
||||
</div>
|
||||
<div class="meta-item">
|
||||
<span class="label">Specialty</span>
|
||||
Emergency / Cardiology
|
||||
</div>
|
||||
<div class="meta-item">
|
||||
<span class="label">Format</span>
|
||||
SOAP
|
||||
</div>
|
||||
</div>
|
||||
</div>
|
||||
|
||||
<!-- ── Chief Complaint ──────────────────────────────────────── -->
|
||||
<section data-od-id="chief-complaint">
|
||||
<h2>Chief Complaint</h2>
|
||||
<p>
|
||||
Severe substernal chest pain for 2 hours with radiation to the left arm
|
||||
and jaw, associated with profuse diaphoresis and nausea.
|
||||
</p>
|
||||
</section>
|
||||
|
||||
<!-- ── History of Present Illness ──────────────────────────── -->
|
||||
<section data-od-id="hpi">
|
||||
<h2>History of Present Illness</h2>
|
||||
<p>
|
||||
This is a 58-year-old male with a background history of hypertension,
|
||||
type 2 diabetes mellitus, and hyperlipidaemia who presents to the
|
||||
emergency department with a 2-hour history of severe, 9/10 intensity,
|
||||
pressure-like chest pain localised substernally. The pain began abruptly
|
||||
at rest at approximately 14:30 and radiates to the left arm and jaw.
|
||||
</p>
|
||||
<p>
|
||||
The pain is associated with profuse diaphoresis, nausea, and one episode
|
||||
of non-bloody vomiting. The patient reports no dyspnoea, no palpitations,
|
||||
and no pre-syncopal symptoms. There is no pleuritic component, no
|
||||
positional variation, and no relief with antacids.
|
||||
</p>
|
||||
<p>
|
||||
The patient has never experienced this type of pain before. He denies
|
||||
recent travel, prolonged immobility, or lower limb swelling. He has not
|
||||
taken any nitrates prior to arrival. His regular medications were taken
|
||||
this morning. He has a 30 pack-year smoking history (10 cigarettes/day,
|
||||
ongoing) and drinks alcohol occasionally. His father died of a myocardial
|
||||
infarction at age 62.
|
||||
</p>
|
||||
</section>
|
||||
|
||||
<!-- ── PMH / Medications / Allergies ────────────────────────── -->
|
||||
<section data-od-id="pmh">
|
||||
<h2>Past Medical History</h2>
|
||||
<ul>
|
||||
<li>Hypertension — diagnosed 8 years ago, on treatment</li>
|
||||
<li>Type 2 Diabetes Mellitus — diagnosed 5 years ago, on oral hypoglycaemics</li>
|
||||
<li>Hyperlipidaemia — diagnosed 5 years ago, on statin therapy</li>
|
||||
<li>No prior cardiac history. No previous myocardial infarction.</li>
|
||||
<li>No history of stroke, peripheral vascular disease, or renal disease</li>
|
||||
</ul>
|
||||
|
||||
<p style="margin-top:14px"><strong>Current Medications:</strong></p>
|
||||
<ul>
|
||||
<li>Metformin 1g PO twice daily</li>
|
||||
<li>Amlodipine 5mg PO once daily</li>
|
||||
<li>Atorvastatin 40mg PO at night</li>
|
||||
</ul>
|
||||
|
||||
<p style="margin-top:14px"><strong>Allergies:</strong>
|
||||
No known drug allergies. No known food allergies.
|
||||
</p>
|
||||
|
||||
<p style="margin-top:14px"><strong>Social History:</strong>
|
||||
Lives with family and has good home supports.
|
||||
Current smoker — 10 cigarettes/day, 30 pack-years.
|
||||
Alcohol: occasional, less than 14 units/week.
|
||||
</p>
|
||||
</section>
|
||||
|
||||
<!-- ── Vital Signs ───────────────────────────────────────────── -->
|
||||
<section data-od-id="vitals">
|
||||
<h2>Vital Signs</h2>
|
||||
|
||||
<div class="alert">
|
||||
<span class="alert-label">⚠ Critical — Activate Cath Lab</span>
|
||||
ST elevation ≥3mm in leads II, III, aVF with reciprocal changes in I and aVL.
|
||||
Patient meets STEMI criteria. Door-to-balloon time target: <90 minutes.
|
||||
</div>
|
||||
|
||||
<table>
|
||||
<caption>Vital Signs</caption>
|
||||
<thead>
|
||||
<tr>
|
||||
<th scope="col">Parameter</th>
|
||||
<th scope="col">Value</th>
|
||||
<th scope="col">Reference Range</th>
|
||||
<th scope="col">Status</th>
|
||||
</tr>
|
||||
</thead>
|
||||
<tbody>
|
||||
<tr>
|
||||
<td>Blood Pressure (Systolic/Diastolic)</td>
|
||||
<td class="val-low">88 / 60 mmHg</td>
|
||||
<td>90–140 / 60–90 mmHg</td>
|
||||
<td class="val-low">⬇ Hypotensive</td>
|
||||
</tr>
|
||||
<tr>
|
||||
<td>Heart Rate</td>
|
||||
<td class="val-high">112 bpm</td>
|
||||
<td>60–100 bpm</td>
|
||||
<td class="val-high">⬆ Tachycardia</td>
|
||||
</tr>
|
||||
<tr>
|
||||
<td>Respiratory Rate</td>
|
||||
<td class="val-high">22 breaths/min</td>
|
||||
<td>12–20 breaths/min</td>
|
||||
<td class="val-high">⬆ Elevated</td>
|
||||
</tr>
|
||||
<tr>
|
||||
<td>Oxygen Saturation (SpO₂) — room air</td>
|
||||
<td class="val-low">94%</td>
|
||||
<td>≥96%</td>
|
||||
<td class="val-low">⬇ Low</td>
|
||||
</tr>
|
||||
<tr>
|
||||
<td>Temperature</td>
|
||||
<td class="val-normal">37.1°C</td>
|
||||
<td>36.5–37.5°C</td>
|
||||
<td class="val-normal">Normal</td>
|
||||
</tr>
|
||||
<tr>
|
||||
<td>Glasgow Coma Scale</td>
|
||||
<td class="val-normal">15 / 15</td>
|
||||
<td>15</td>
|
||||
<td class="val-normal">Normal</td>
|
||||
</tr>
|
||||
<tr>
|
||||
<td>Capillary Refill Time</td>
|
||||
<td class="val-high">3 seconds</td>
|
||||
<td><2 seconds</td>
|
||||
<td class="val-high">⬆ Prolonged</td>
|
||||
</tr>
|
||||
</tbody>
|
||||
</table>
|
||||
</section>
|
||||
|
||||
<!-- ── Physical Examination ──────────────────────────────────── -->
|
||||
<section data-od-id="examination">
|
||||
<h2>Physical Examination</h2>
|
||||
|
||||
<p><strong>General:</strong>
|
||||
Diaphoretic, pale, and in obvious discomfort. Alert and oriented to
|
||||
person, place, and time. Appears acutely unwell.
|
||||
</p>
|
||||
<p><strong>Cardiovascular:</strong>
|
||||
Jugular venous pressure elevated at approximately 4cm above the sternal
|
||||
angle. Heart sounds S1 + S2 present, no murmurs, no added sounds.
|
||||
Peripheral pulses palpable but weak bilaterally. Capillary refill
|
||||
3 seconds peripherally. No peripheral oedema.
|
||||
</p>
|
||||
<p><strong>Respiratory:</strong>
|
||||
Respiratory rate 22/min. Air entry bilaterally. Fine bibasal
|
||||
crepitations present, right greater than left. No wheeze. Dull to
|
||||
percussion at right base. No use of accessory muscles.
|
||||
</p>
|
||||
<p><strong>Abdomen:</strong>
|
||||
Soft, non-distended, non-tender. No organomegaly. Bowel sounds present
|
||||
and normal. No renal angle tenderness.
|
||||
</p>
|
||||
<p><strong>Neurological:</strong>
|
||||
GCS 15/15. Pupils equal and reactive 3mm bilaterally. No focal
|
||||
neurological deficits. Cranial nerves grossly intact.
|
||||
</p>
|
||||
<p><strong>Skin / Peripheries:</strong>
|
||||
Pallor and diaphoresis. No rash, no jaundice, no cyanosis.
|
||||
</p>
|
||||
</section>
|
||||
|
||||
<!-- ── Investigations ────────────────────────────────────────── -->
|
||||
<section data-od-id="investigations">
|
||||
<h2>Investigations</h2>
|
||||
|
||||
<p><strong>12-Lead ECG:</strong></p>
|
||||
<div class="alert">
|
||||
<span class="alert-label">ECG — STEMI Criteria Met</span>
|
||||
Sinus tachycardia at 112 bpm. ST elevation 3mm in leads II, III, aVF.
|
||||
Reciprocal ST depression in leads I and aVL. PR interval and QRS
|
||||
morphology otherwise normal. No left bundle branch block.
|
||||
Right-sided leads (V3R–V6R) ordered to exclude RV infarction.
|
||||
</div>
|
||||
|
||||
<p style="margin-top:14px"><strong>Laboratory Results:</strong></p>
|
||||
<table>
|
||||
<caption>Laboratory Results</caption>
|
||||
<thead>
|
||||
<tr>
|
||||
<th scope="col">Investigation</th>
|
||||
<th scope="col">Result</th>
|
||||
<th scope="col">Reference Range</th>
|
||||
</tr>
|
||||
</thead>
|
||||
<tbody>
|
||||
<tr>
|
||||
<td>Troponin I (high-sensitivity)</td>
|
||||
<td class="val-high">2400 ng/L ⬆</td>
|
||||
<td><40 ng/L</td>
|
||||
</tr>
|
||||
<tr>
|
||||
<td>CK-MB</td>
|
||||
<td class="val-high">48 U/L ⬆</td>
|
||||
<td><25 U/L</td>
|
||||
</tr>
|
||||
<tr>
|
||||
<td>BNP (B-type Natriuretic Peptide)</td>
|
||||
<td class="val-high">520 pg/mL ⬆</td>
|
||||
<td><100 pg/mL</td>
|
||||
</tr>
|
||||
<tr>
|
||||
<td>Haemoglobin</td>
|
||||
<td class="val-normal">13.8 g/dL</td>
|
||||
<td>13.5–17.5 g/dL</td>
|
||||
</tr>
|
||||
<tr>
|
||||
<td>White Blood Cells</td>
|
||||
<td>11.2 × 10⁹/L</td>
|
||||
<td>4.0–11.0 × 10⁹/L</td>
|
||||
</tr>
|
||||
<tr>
|
||||
<td>Platelets</td>
|
||||
<td class="val-normal">224 × 10⁹/L</td>
|
||||
<td>150–400 × 10⁹/L</td>
|
||||
</tr>
|
||||
<tr>
|
||||
<td>Sodium</td>
|
||||
<td class="val-normal">138 mmol/L</td>
|
||||
<td>135–145 mmol/L</td>
|
||||
</tr>
|
||||
<tr>
|
||||
<td>Potassium</td>
|
||||
<td class="val-normal">4.1 mmol/L</td>
|
||||
<td>3.5–5.0 mmol/L</td>
|
||||
</tr>
|
||||
<tr>
|
||||
<td>Creatinine</td>
|
||||
<td class="val-normal">98 µmol/L</td>
|
||||
<td>62–106 µmol/L</td>
|
||||
</tr>
|
||||
<tr>
|
||||
<td>eGFR</td>
|
||||
<td class="val-normal">72 mL/min/1.73m²</td>
|
||||
<td>≥60 mL/min/1.73m²</td>
|
||||
</tr>
|
||||
<tr>
|
||||
<td>Glucose (random)</td>
|
||||
<td class="val-high">9.4 mmol/L ⬆</td>
|
||||
<td>4.0–7.8 mmol/L</td>
|
||||
</tr>
|
||||
<tr>
|
||||
<td>HbA1c</td>
|
||||
<td class="val-high">7.8% ⬆</td>
|
||||
<td><7.0% (diabetic target)</td>
|
||||
</tr>
|
||||
<tr>
|
||||
<td>Total Cholesterol</td>
|
||||
<td class="val-high">5.9 mmol/L ⬆</td>
|
||||
<td><5.2 mmol/L</td>
|
||||
</tr>
|
||||
<tr>
|
||||
<td>LDL Cholesterol</td>
|
||||
<td class="val-high">3.8 mmol/L ⬆</td>
|
||||
<td><2.0 mmol/L (high-risk target)</td>
|
||||
</tr>
|
||||
<tr>
|
||||
<td>INR</td>
|
||||
<td class="val-normal">1.1</td>
|
||||
<td>0.8–1.2</td>
|
||||
</tr>
|
||||
<tr>
|
||||
<td>Lactate</td>
|
||||
<td class="val-high">2.8 mmol/L ⬆</td>
|
||||
<td><2.0 mmol/L</td>
|
||||
</tr>
|
||||
<tr>
|
||||
<td>Arterial pH</td>
|
||||
<td class="val-low">7.31 ⬇</td>
|
||||
<td>7.35–7.45</td>
|
||||
</tr>
|
||||
</tbody>
|
||||
</table>
|
||||
|
||||
<p><strong>Chest X-Ray (Portable AP):</strong>
|
||||
Mild cardiomegaly. Pulmonary vascular congestion with upper lobe
|
||||
diversion. Small right pleural effusion. No pneumothorax.
|
||||
No mediastinal widening.
|
||||
</p>
|
||||
<p><strong>Bedside Echocardiogram (Emergency):</strong>
|
||||
Inferior and inferolateral wall hypokinesia. Estimated ejection fraction
|
||||
40%. No pericardial effusion. No obvious valvular pathology on this
|
||||
limited study. Right ventricle appears mildly dilated — formal
|
||||
right-sided assessment pending.
|
||||
</p>
|
||||
</section>
|
||||
|
||||
<!-- ── Assessment ────────────────────────────────────────────── -->
|
||||
<section data-od-id="assessment">
|
||||
<h2>Assessment</h2>
|
||||
|
||||
<p>
|
||||
<strong>Primary Diagnosis:</strong>
|
||||
Inferior ST-Elevation Myocardial Infarction (STEMI) complicated by
|
||||
cardiogenic shock. Most likely culprit vessel: Right Coronary Artery
|
||||
(RCA) based on inferior lead involvement.
|
||||
</p>
|
||||
|
||||
<div class="risk-score">
|
||||
<strong>Killip Class: IV</strong> — Cardiogenic shock (hypotension + end-organ hypoperfusion).
|
||||
|
|
||||
<strong>Shock Index: 1.27</strong> (HR/SBP — normal <0.7)
|
||||
</div>
|
||||
|
||||
<p style="margin-top:4px"><strong>Differential Diagnosis:</strong></p>
|
||||
|
||||
<div class="differential-item">
|
||||
<span class="dx-title">1. Inferior STEMI — RCA Territory</span>
|
||||
<span class="dx-likelihood likely">Most Likely</span>
|
||||
<p style="margin-top:6px; font-size:13px;">
|
||||
ST elevation in leads II, III, aVF with reciprocal depression in I
|
||||
and aVL is the hallmark ECG pattern of inferior STEMI. Elevated
|
||||
troponin I (60× upper limit of normal) and inferior wall hypokinesia
|
||||
on bedside echo confirm ongoing myocardial injury. Cardiogenic shock
|
||||
(SBP 88, elevated lactate 2.8, BNP 520) indicates significant
|
||||
haemodynamic compromise. Right ventricular involvement must be
|
||||
excluded with right-sided leads before initiating fluid therapy.
|
||||
</p>
|
||||
</div>
|
||||
|
||||
<div class="differential-item">
|
||||
<span class="dx-title">2. Type A Aortic Dissection</span>
|
||||
<span class="dx-likelihood possible">Considered, Less Likely</span>
|
||||
<p style="margin-top:6px; font-size:13px;">
|
||||
Severe chest pain with radiation to the jaw raises dissection in the
|
||||
differential. However, the pain character is pressure-like rather
|
||||
than tearing, there is no pulse deficit, no limb ischaemia, and no
|
||||
mediastinal widening on CXR. The ECG and troponin pattern is more
|
||||
consistent with primary ACS. Dissection is lower probability but
|
||||
cannot be fully excluded without CT aortogram if clinical doubt
|
||||
persists after ECG correlation.
|
||||
</p>
|
||||
</div>
|
||||
|
||||
<div class="differential-item">
|
||||
<span class="dx-title">3. Massive Pulmonary Embolism</span>
|
||||
<span class="dx-likelihood unlikely">Unlikely</span>
|
||||
<p style="margin-top:6px; font-size:13px;">
|
||||
Haemodynamic instability and low SpO₂ are consistent with massive PE.
|
||||
However, the patient has no PE risk factors (no recent travel,
|
||||
immobility, or DVT history), the ECG shows inferior ST elevation
|
||||
rather than right heart strain or S1Q3T3 pattern, and the troponin
|
||||
rise matches ACS kinetics. Bedside echo shows inferior wall
|
||||
hypokinesia rather than RV dilation as the dominant finding.
|
||||
PE is considered unlikely.
|
||||
</p>
|
||||
</div>
|
||||
|
||||
<div class="differential-item">
|
||||
<span class="dx-title">4. NSTEMI / Unstable Angina</span>
|
||||
<span class="dx-likelihood unlikely">Excluded</span>
|
||||
<p style="margin-top:6px; font-size:13px;">
|
||||
The presence of ≥1mm ST elevation in two contiguous inferior leads,
|
||||
combined with the degree of troponin elevation, meets full STEMI
|
||||
criteria. NSTEMI is excluded by the ECG findings.
|
||||
</p>
|
||||
</div>
|
||||
</section>
|
||||
|
||||
<!-- ── Management Plan ───────────────────────────────────────── -->
|
||||
<section data-od-id="plan">
|
||||
<h2>Management Plan</h2>
|
||||
|
||||
<div class="plan-block">
|
||||
<div class="plan-title">1. Immediate — Revascularisation (Priority)</div>
|
||||
<ul>
|
||||
<li>Activate cardiac catheterisation laboratory — target
|
||||
door-to-balloon time <90 minutes</li>
|
||||
<li>Primary Percutaneous Coronary Intervention (PCI) of culprit
|
||||
lesion (RCA) — preferred strategy over thrombolysis</li>
|
||||
<li>Urgent cardiology consult — notify interventional cardiologist
|
||||
immediately</li>
|
||||
<li>Obtain right-sided leads (V3R–V6R) before any fluid
|
||||
administration to exclude RV MI</li>
|
||||
</ul>
|
||||
</div>
|
||||
|
||||
<div class="plan-block" style="border-left:3px solid #e6a817;padding-left:12px;">
|
||||
<div class="plan-title" style="color:#b07a00;">⚠ Medication Safety Checks — confirm before prescribing</div>
|
||||
<ul>
|
||||
<li><strong>Known (from this case):</strong> No documented drug allergies; eGFR 72 mL/min/1.73m² (renal function currently preserved — monitor closely around contrast and acute illness); no current anticoagulants documented; patient is male, age 58</li>
|
||||
<li><strong>Weight not provided</strong> — weight-based dosing (e.g. heparin bolus) should follow <em>local formulary/protocol</em> once weight is confirmed</li>
|
||||
<li><strong>Bleeding risk not assessed</strong> — confirm no active bleeding, recent surgery, or prior intracranial haemorrhage before dual antiplatelet therapy</li>
|
||||
<li><strong>Hepatic function not documented</strong> — review prior to high-dose statin and ACE inhibitor initiation</li>
|
||||
<li><strong>Pregnancy status not applicable</strong> (patient is male, age 58)</li>
|
||||
<li><em>All doses below are educational/simulated. Verify against your local formulary, current guidelines, and full patient context before administering.</em></li>
|
||||
</ul>
|
||||
</div>
|
||||
|
||||
<div class="plan-block">
|
||||
<div class="plan-title">2. Antiplatelet and Anticoagulation</div>
|
||||
<ul>
|
||||
<li>Aspirin 300mg PO loading dose — stat, then 75mg PO once daily</li>
|
||||
<li>Ticagrelor 180mg PO loading dose — stat, then 90mg PO twice daily
|
||||
(preferred over clopidogrel for STEMI per ESC guidelines)</li>
|
||||
<li>Unfractionated heparin — IV bolus per cath lab protocol prior to PCI</li>
|
||||
<li>Do not administer GPIIb/IIIa inhibitor pre-PCI; consider
|
||||
intra-procedure per operator discretion</li>
|
||||
</ul>
|
||||
</div>
|
||||
|
||||
<div class="plan-block">
|
||||
<div class="plan-title">3. Cardiogenic Shock</div>
|
||||
<ul>
|
||||
<li>Hold IV fluids until right-sided leads reviewed — if RV infarct
|
||||
present, cautious fluid challenge 250mL normal saline</li>
|
||||
<li>If MAP <65mmHg despite fluids: commence norepinephrine infusion
|
||||
per local vasoactive-infusion protocol once weight and concentration
|
||||
are confirmed; titrate to MAP ≥65mmHg</li>
|
||||
<li>ICU/CCU bed request — post-PCI high-dependency monitoring</li>
|
||||
<li>Consider intra-aortic balloon pump or Impella device if shock
|
||||
refractory post-PCI — per cardiology discretion</li>
|
||||
</ul>
|
||||
</div>
|
||||
|
||||
<div class="plan-block">
|
||||
<div class="plan-title">4. Respiratory / Oxygenation</div>
|
||||
<ul>
|
||||
<li>Supplemental O₂ only if hypoxaemic (SpO₂ <94%) or in
|
||||
respiratory distress — use the lowest-flow device (nasal cannula
|
||||
or simple face mask) needed to maintain SpO₂ 94–98%; do not give
|
||||
routine high-flow oxygen in normoxic STEMI (may worsen
|
||||
ischaemia)</li>
|
||||
<li>If pulmonary oedema worsens and haemodynamics permit:
|
||||
Furosemide 40mg IV once</li>
|
||||
<li>Escalate to non-rebreather mask, CPAP, or intubation per local
|
||||
protocol if SpO₂ falls below 90% or respiratory distress
|
||||
worsens despite initial measures</li>
|
||||
</ul>
|
||||
</div>
|
||||
|
||||
<div class="plan-block">
|
||||
<div class="plan-title">5. Monitoring</div>
|
||||
<ul>
|
||||
<li>Continuous 12-lead ECG monitoring and pulse oximetry</li>
|
||||
<li>Arterial line for continuous BP monitoring given haemodynamic
|
||||
instability</li>
|
||||
<li>Repeat troponin at 3 hours and 6 hours post-admission</li>
|
||||
<li>Repeat ECG immediately post-PCI and at 1 hour</li>
|
||||
<li>Hourly urine output via urinary catheter — target ≥0.5mL/kg/hr</li>
|
||||
<li>Strict fluid balance chart</li>
|
||||
<li>Blood glucose monitoring q2h — target 6–10 mmol/L</li>
|
||||
</ul>
|
||||
</div>
|
||||
|
||||
<div class="plan-block">
|
||||
<div class="plan-title">6. Secondary Prevention (commence post-stabilisation)</div>
|
||||
<ul>
|
||||
<li>Beta-blocker: Bisoprolol — <strong>defer until fully stabilised</strong>:
|
||||
shock resolved, off vasopressors/inotropes, euvolaemic, no
|
||||
bradycardia or heart block, SBP >100mmHg and HR <110bpm;
|
||||
early beta-blockade in cardiogenic shock/Killip IV can worsen
|
||||
haemodynamics. Initiate at 1.25mg PO once daily per cardiology
|
||||
review post-stabilisation.</li>
|
||||
<li>ACE inhibitor: Ramipril 1.25mg PO once daily — commence within
|
||||
24 hours if tolerated; uptitrate over weeks</li>
|
||||
<li>Statin: Atorvastatin 80mg PO at night — high-intensity statin
|
||||
regardless of baseline cholesterol</li>
|
||||
<li>Diabetes: Hold Metformin — renal function and contrast exposure
|
||||
risk. Resume 48 hours post-procedure if creatinine stable</li>
|
||||
<li>Dual antiplatelet therapy: Aspirin 75mg + Ticagrelor 90mg BD
|
||||
for minimum 12 months post-PCI</li>
|
||||
<li>Cardiac rehabilitation referral before discharge</li>
|
||||
<li>Smoking cessation counselling and pharmacotherapy referral</li>
|
||||
<li>Repeat echocardiogram at 6–8 weeks to reassess ejection fraction</li>
|
||||
</ul>
|
||||
</div>
|
||||
|
||||
<div class="plan-block">
|
||||
<div class="plan-title">7. Disposition</div>
|
||||
<ul>
|
||||
<li>Admit to Coronary Care Unit (CCU) post-PCI</li>
|
||||
<li>Expected length of stay: 3–5 days if uncomplicated post-PCI course</li>
|
||||
<li>Notify next of kin — serious illness discussion</li>
|
||||
</ul>
|
||||
</div>
|
||||
</section>
|
||||
|
||||
<!-- ── Footer ────────────────────────────────────────────────── -->
|
||||
<div class="doc-footer">
|
||||
<span>Generated using Open Design — clinical-case-report skill</span>
|
||||
<span>For educational and documentation purposes only</span>
|
||||
</div>
|
||||
|
||||
</body>
|
||||
</html>
|
||||
94
skills/clinical-case-report/references/case-formats.md
Normal file
94
skills/clinical-case-report/references/case-formats.md
Normal file
|
|
@ -0,0 +1,94 @@
|
|||
# Case Presentation Formats
|
||||
|
||||
Use this reference to choose the correct format for the user's context.
|
||||
Read the brief carefully — the format should match the clinical setting.
|
||||
|
||||
---
|
||||
|
||||
## Format 1: SOAP (Default)
|
||||
|
||||
Use for: emergency presentations, ward documentation, clinic letters.
|
||||
|
||||
**S — Subjective**
|
||||
Chief complaint, HPI (chronological narrative), past medical history,
|
||||
medications, allergies, family history, social history.
|
||||
|
||||
**O — Objective**
|
||||
Vital signs (table), physical examination (by system), investigations
|
||||
(labs table, imaging findings, ECG).
|
||||
|
||||
**A — Assessment**
|
||||
Primary diagnosis with reasoning, differential diagnosis list (3–5 items)
|
||||
each with one sentence of supporting or excluding evidence, risk score.
|
||||
|
||||
**P — Plan**
|
||||
Management steps organised by problem number. Each problem gets:
|
||||
investigations ordered, treatments started, consults requested,
|
||||
monitoring parameters, and disposition.
|
||||
|
||||
---
|
||||
|
||||
## Format 2: Conference / Grand Rounds
|
||||
|
||||
Use for: teaching cases, grand rounds, case conferences, interesting
|
||||
or rare presentations.
|
||||
|
||||
Structure:
|
||||
|
||||
1. **Opening statement**
|
||||
"We present a [age]-year-old [sex] with [chief complaint]."
|
||||
|
||||
2. **Clinical summary**
|
||||
Condensed narrative HPI, 2–4 sentences.
|
||||
|
||||
3. **Key findings**
|
||||
Bulleted list of critical exam and investigation abnormalities.
|
||||
|
||||
4. **Diagnostic challenge**
|
||||
One paragraph explaining what made this case educationally valuable
|
||||
(unusual presentation, diagnostic difficulty, rare diagnosis, etc.)
|
||||
|
||||
5. **Differential discussion**
|
||||
Walk through 3–5 diagnoses in order of likelihood with reasoning.
|
||||
|
||||
6. **Final diagnosis**
|
||||
State the confirmed diagnosis with supporting evidence.
|
||||
|
||||
7. **Management**
|
||||
Summary of what was done, in chronological order.
|
||||
|
||||
8. **Outcome**
|
||||
Patient's course and disposition.
|
||||
|
||||
9. **Learning points**
|
||||
2–3 bullet points summarising what clinicians should take from this case.
|
||||
|
||||
---
|
||||
|
||||
## Format 3: Brief Ward Rounds
|
||||
|
||||
Use for: daily ward rounds, post-call handover, ICU reviews.
|
||||
This format is short. One screen, fast to read.
|
||||
|
||||
Structure:
|
||||
|
||||
- **ID line**: [Age][sex] | Day [N] of admission | Admitted for [diagnosis]
|
||||
- **Overnight/interval events**: Bulleted. New results, procedures, changes.
|
||||
- **Current vitals**: Trend arrow (↑ ↓ →). Flag abnormals.
|
||||
- **Active problem list**: Numbered.
|
||||
- **Plan by problem**: One line per problem.
|
||||
|
||||
Do not include full HPI or examination in this format.
|
||||
The reader knows the patient. They need the delta.
|
||||
|
||||
---
|
||||
|
||||
## Format Selection Guide
|
||||
|
||||
| User says | Use format |
|
||||
|---|---|
|
||||
| "case presentation", "formal rounds", "clinic" | SOAP |
|
||||
| "conference", "grand rounds", "teaching case", "interesting case", "rare case" | Conference |
|
||||
| "daily review", "ward round", "ward rounds", "handover", "ICU", "post-call" | Brief Rounds |
|
||||
| "discharge summary", "clinic letter" | SOAP (narrative variant) |
|
||||
| No format specified | SOAP |
|
||||
41
skills/clinical-case-report/references/checklist.md
Normal file
41
skills/clinical-case-report/references/checklist.md
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# Clinical Case Report — Quality Checklist
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## P0 — Must Pass Before Emitting Artifact
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- [ ] Chief complaint or ID line is clearly stated in the opening line
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- [ ] **SOAP / Conference format only:** HPI is written as a chronological prose narrative with at least one timeline marker (e.g. "2 hours prior to presentation"); skip for Brief Rounds
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- [ ] **Brief Rounds format only:** ID line present; interval events / current status documented; active problems listed; plan-by-problem present; full HPI and examination sections are not required
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- [ ] Vital signs are present and physiologically plausible
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- [ ] Vital signs are internally consistent with the diagnosis (allowing for clinical variability — bradycardic shock, medication-blunted tachycardia, afebrile pneumonia, early STEMI with normal troponin, etc.)
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- [ ] Assessment contains a clearly stated primary diagnosis
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- [ ] Plan is present and directly addresses the primary diagnosis
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- [ ] If the plan includes medications: a prescribing-safety block is present before drug recommendations, confirming known inputs (allergies, renal/hepatic function, anticoagulants) and calling out unknowns (weight, bleeding risk, pregnancy); doses defer to "per local formulary/protocol" when key variables are missing
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- [ ] Medication plan is labelled as educational/simulated — not a substitute for clinician judgment
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- [ ] No real patient identifiers (direct or indirect): no names, MRNs, exact dates, locations, images, rare condition combos, occupation details, or verbatim stories from real cases
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- [ ] All data is synthetic, de-identified, or clearly fictional
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- [ ] If based on a real case, apply formal de-identification before use
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- [ ] HTML renders without errors in a browser
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- [ ] All major sections tagged with `data-od-id`
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## P1 — Should Pass
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- [ ] Past medical history includes conditions relevant to the presentation
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- [ ] Medications list is present
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- [ ] Physical examination findings are organised by system
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- [ ] Differential diagnosis contains 3 to 5 items
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- [ ] Each differential item includes one sentence of supporting or refuting evidence
|
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- [ ] Lab values use correct units and are within realistic ranges for the diagnosis
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- [ ] Plan is specific — drug names, doses, routes, and frequencies are written out where safety inputs are known; unknown variables defer to "per local formulary/protocol"
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- [ ] Plan is organised by problem using numbered headers
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- [ ] Critical findings are visually highlighted (red callout box)
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- [ ] Document is print-friendly (white background, `@media print` rules present)
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- [ ] A validated risk score is included where applicable (TIMI, GRACE, Killip class + Shock Index for STEMI/cardiogenic shock, CURB-65, qSOFA, Wells)
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## P2 — Nice to Have
|
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- [ ] Pertinent negatives documented in HPI and Review of Systems
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- [ ] Imaging findings described in investigations section
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- [ ] Specialist consult noted where clinically indicated
|
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- [ ] Disposition or follow-up plan included
|
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- [ ] Monitoring parameters specified (e.g. repeat troponin at 3h and 6h)
|
||||
- [ ] Secondary prevention addressed for chronic disease presentations
|
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