diff --git a/apps/web/src/i18n/content.fr.ts b/apps/web/src/i18n/content.fr.ts index 9703d4406..60b09e6ae 100644 --- a/apps/web/src/i18n/content.fr.ts +++ b/apps/web/src/i18n/content.fr.ts @@ -314,6 +314,7 @@ export const FR_DESIGN_SYSTEM_CATEGORIES: Record = { }; export const FR_SKILL_IDS_WITH_EN_FALLBACK = [ + 'clinical-case-report', 'dcf-valuation', 'flowai-live-dashboard-template', 'html-ppt-taste-brutalist', diff --git a/apps/web/src/i18n/content.ru.ts b/apps/web/src/i18n/content.ru.ts index 61a90aec6..5a0006b54 100644 --- a/apps/web/src/i18n/content.ru.ts +++ b/apps/web/src/i18n/content.ru.ts @@ -314,6 +314,7 @@ export const RU_DESIGN_SYSTEM_CATEGORIES: Record = { }; export const RU_SKILL_IDS_WITH_EN_FALLBACK = [ + 'clinical-case-report', 'dcf-valuation', 'flowai-live-dashboard-template', 'html-ppt-taste-brutalist', diff --git a/apps/web/src/i18n/content.ts b/apps/web/src/i18n/content.ts index ef567207f..7665fe9ff 100644 --- a/apps/web/src/i18n/content.ts +++ b/apps/web/src/i18n/content.ts @@ -363,6 +363,7 @@ const DE_DESIGN_SYSTEM_CATEGORIES: Record = { }; const DE_SKILL_IDS_WITH_EN_FALLBACK = [ + 'clinical-case-report', 'dcf-valuation', 'flowai-live-dashboard-template', 'html-ppt-taste-brutalist', diff --git a/skills/clinical-case-report/SKILL.md b/skills/clinical-case-report/SKILL.md new file mode 100644 index 000000000..cd32be08d --- /dev/null +++ b/skills/clinical-case-report/SKILL.md @@ -0,0 +1,209 @@ +--- +name: clinical-case-report +description: | + Structured medical case presentation for clinical rounds, conferences, + and documentation. Generates SOAP-format or narrative case reports + with physiologically accurate vitals, labs, and evidence-based plans. + Use when the brief mentions "case report", "case presentation", "SOAP note", + "clinical case", "ward rounds", "case summary", or "patient presentation". +triggers: + - "case report" + - "case presentation" + - "soap note" + - "clinical case" + - "ward rounds" + - "patient presentation" + - "case summary" + - "medical case" +od: + mode: prototype + platform: desktop + scenario: healthcare + preview: + type: html + entry: index.html + fidelity: high-fidelity + 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." +--- + +# Clinical Case Report Skill + +Generate a structured medical case presentation for clinical rounds, +conferences, or documentation. The output follows standard medical +formatting conventions used in hospital settings worldwide. + +## What you will produce + +A single-page HTML case report (`index.html`). Content varies by format +(see `references/case-formats.md` — selected in Step 0): + +**SOAP / Conference format:** +- **Patient identification** — age, sex, chief complaint +- **History of Present Illness (HPI)** — chronological narrative with + pertinent positives and negatives +- **Past Medical History, Medications, Allergies** +- **Review of Systems** +- **Physical Examination** — systematic findings by system +- **Vital Signs** — formatted table with reference ranges and flags +- **Investigations** — laboratory results and imaging findings +- **Assessment** — primary diagnosis and differential (3–5 items) + with clinical reasoning for each +- **Management Plan** — evidence-based, organised by problem + +**Brief Rounds format** (daily review, ward round, handover, ICU, post-call): +- **ID line** — age, sex, day of admission, primary problem +- **Interval events / current status** — what has changed since last review +- **Active problems** — numbered list +- **Plan-by-problem** — concise actions for each active problem +- Full HPI and systematic physical examination are **not** included + +--- + +## Step-by-step workflow + +### Step 0 — Load reference files + +Before starting, read both reference files: + +1. `references/case-formats.md` — use this to choose the correct output + format (SOAP, Conference, or Brief Rounds) based on the user's context +2. `references/checklist.md` — keep P0 gates in mind throughout; you + must pass all P0 items before emitting the final artifact + +### Step 1 — Parse the brief + +Read the user's prompt and extract: + +- Patient age and sex +- Chief complaint or presenting problem +- Any vitals, labs, or imaging the user has provided +- Clinical context: ED, ward rounds, conference case, outpatient, etc. +- Specialty context: cardiology, emergency, internal medicine, etc. + +If the chief complaint or presenting problem is missing: +- **SOAP / Conference**: ask one clarifying question before proceeding. Do not proceed without it. +- **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. + +### Step 2 — Build the clinical narrative + +**For SOAP / Conference outputs:** write the HPI as a continuous prose +narrative in standard clinical style: + +> "This is a [age]-year-old [sex] with a history of [relevant PMH] who +> presents with [chief complaint]. Symptoms began [timeline] and are +> characterised by [quality, severity, radiation]. Associated symptoms +> include [list]. Pertinent negatives include [list]." + +The HPI must be chronological. Include timeline markers +("2 hours prior to presentation", "onset yesterday morning"). + +**For Brief Rounds outputs** (daily review, ward round, handover, ICU, +post-call): skip the full HPI and examination. Instead produce: + +- **ID line**: "[Age][sex], Day [N] of admission, [primary problem]" +- **Interval events / current status**: what has changed since last review +- **Active problems**: numbered list +- **Plan-by-problem**: concise action for each active problem + +### Step 3 — Generate physiologically consistent clinical data + +If the user has not provided specific values, generate values that are +internally consistent with the diagnosis: + +**Consistency checks (typical patterns):** + +- A patient in shock **typically** has: HR >100, SBP <90, raised lactate, + impaired capillary refill — but medications (beta-blockers), age, or + shock type (neurogenic, spinal) can alter this pattern +- Pneumonia **typically** presents with raised WBC, raised CRP, + temperature >38°C — but afebrile pneumonia exists, especially in + the elderly or immunocompromised +- A STEMI **typically** shows ST elevation in contiguous leads and raised + high-sensitivity troponin — but early presentations may have initially + normal troponin; CK-MB is not universally required +- Sepsis **typically** shows raised or low WBC, raised lactate >2, + temperature abnormality — but compensated early sepsis may present + with normal vitals +- Lab units must match convention: creatinine in µmol/L or mg/dL + (state which), glucose in mmol/L, haemoglobin in g/dL + +**Critical rule — preserve user-provided data:** +- Never overwrite a value the user has explicitly stated +- If a user-provided value is atypical for the diagnosis, keep it and + note the atypical presentation in the assessment rather than + forcing canonical numbers +- Never generate a value that contradicts the stated diagnosis + +### Step 4 — Write the assessment + +The assessment section must contain: + +1. **Primary diagnosis** stated clearly on the first line +2. **Clinical reasoning** — one sentence explaining why this is the + most likely diagnosis +3. **Differential diagnosis** — exactly 3 to 5 items, each with one + sentence of supporting or refuting evidence +4. **Risk stratification** — include a validated clinical score where + applicable (TIMI for ACS, GRACE for ACS, Killip class + Shock Index + for STEMI/cardiogenic shock, CURB-65 for pneumonia, qSOFA for sepsis, + Wells for PE, etc.). Killip class and Shock Index together are + accepted as sufficient risk stratification for STEMI/cardiogenic shock cases. + +### Step 5 — Write the management plan + +The plan must be: + +- **Specific**: write drug names, doses, routes, and frequencies. + Do not write "start antibiotics" — write + "Piperacillin-Tazobactam 4.5g IV q8h for 5 days" +- **Organised by problem** using numbered headers +- **Evidence-based**: management must reflect current standard of care + for the diagnosis +- **Complete**: include investigations to order, monitoring parameters, + consults to request, and disposition + +If you are uncertain about a specific dose, write +"[drug name] — dose per local formulary/protocol" rather than +inventing a dose. + +### Important — Prescribing Safety + +Generated plans must: +- Be marked as educational/simulated, not a substitute for clinician judgment +- Use "per local formulary/protocol" language when required patient variables + (weight, renal function, allergies) are missing from the brief +- List key contraindications and unknowns before medication recommendations + when relevant patient data has not been provided +- Never claim a plan is "definitive" or "standard of care" without full + patient context (allergy status, renal/hepatic function, pregnancy + status, weight, anticoagulation/bleeding risk) +- Include a disclaimer footer in the HTML output stating the case is for + educational and documentation purposes only + +### Step 6 — Write `index.html` + +Requirements for the HTML output: + +- Professional medical document typography + (Georgia or system serif font preferred) +- White background, dark text — suitable for printing +- Vital signs and lab results in HTML `` elements +- Critical findings (ST elevation, raised troponin, low BP, etc.) + highlighted in a visually distinct callout box with red left border +- @media print CSS rules so the document prints cleanly on A4/Letter +- Tag every major section with `data-od-id` for comment-mode targeting: + +```html +
...
+
...
+
...
+
...
+
...
+
...
+
...
+``` + +### Step 7 — Self-check against `references/checklist.md` + +Before emitting ``, run every P0 item in `references/checklist.md`. +All P0 items must pass. Fix any failures before emitting. \ No newline at end of file diff --git a/skills/clinical-case-report/example.html b/skills/clinical-case-report/example.html new file mode 100644 index 000000000..15c2c0c20 --- /dev/null +++ b/skills/clinical-case-report/example.html @@ -0,0 +1,698 @@ + + + + + + Clinical Case Report — Inferior STEMI with Cardiogenic Shock + + + + + +
+

Clinical Case Report

+
+
+ Patient + 58-year-old Male +
+
+ Setting + Emergency Department +
+
+ Specialty + Emergency / Cardiology +
+
+ Format + SOAP +
+
+
+ + +
+

Chief Complaint

+

+ Severe substernal chest pain for 2 hours with radiation to the left arm + and jaw, associated with profuse diaphoresis and nausea. +

+
+ + +
+

History of Present Illness

+

+ 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. +

+

+ 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. +

+

+ 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. +

+
+ + +
+

Past Medical History

+
    +
  • Hypertension — diagnosed 8 years ago, on treatment
    • +
  • Type 2 Diabetes Mellitus — diagnosed 5 years ago, on oral hypoglycaemics
    • +
  • Hyperlipidaemia — diagnosed 5 years ago, on statin therapy
    • +
  • No prior cardiac history. No previous myocardial infarction.
    • +
  • No history of stroke, peripheral vascular disease, or renal disease
    • +
+ +

Current Medications:

+
    +
  • Metformin 1g PO twice daily
    • +
  • Amlodipine 5mg PO once daily
    • +
  • Atorvastatin 40mg PO at night
    • +
+ +

Allergies: + No known drug allergies. No known food allergies. +

+ +

Social History: + Lives with family and has good home supports. + Current smoker — 10 cigarettes/day, 30 pack-years. + Alcohol: occasional, less than 14 units/week. +

+
+ + +
+

Vital Signs

+ +
+ ⚠ Critical — Activate Cath Lab + 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. +
+ +
+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +
Vital Signs
ParameterValueReference RangeStatus
Blood Pressure (Systolic/Diastolic)88 / 60 mmHg90–140 / 60–90 mmHg⬇ Hypotensive
Heart Rate112 bpm60–100 bpm⬆ Tachycardia
Respiratory Rate22 breaths/min12–20 breaths/min⬆ Elevated
Oxygen Saturation (SpO₂) — room air94%≥96%⬇ Low
Temperature37.1°C36.5–37.5°CNormal
Glasgow Coma Scale15 / 1515Normal
Capillary Refill Time3 seconds<2 seconds⬆ Prolonged
+ + + +
+

Physical Examination

+ +

General: + Diaphoretic, pale, and in obvious discomfort. Alert and oriented to + person, place, and time. Appears acutely unwell. +

+

Cardiovascular: + 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. +

+

Respiratory: + 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. +

+

Abdomen: + Soft, non-distended, non-tender. No organomegaly. Bowel sounds present + and normal. No renal angle tenderness. +

+

Neurological: + GCS 15/15. Pupils equal and reactive 3mm bilaterally. No focal + neurological deficits. Cranial nerves grossly intact. +

+

Skin / Peripheries: + Pallor and diaphoresis. No rash, no jaundice, no cyanosis. +

+
+ + +
+

Investigations

+ +

12-Lead ECG:

+
+ ECG — STEMI Criteria Met + 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. +
+ +

Laboratory Results:

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +
Laboratory Results
InvestigationResultReference Range
Troponin I (high-sensitivity)2400 ng/L ⬆<40 ng/L
CK-MB48 U/L ⬆<25 U/L
BNP (B-type Natriuretic Peptide)520 pg/mL ⬆<100 pg/mL
Haemoglobin13.8 g/dL13.5–17.5 g/dL
White Blood Cells11.2 × 10⁹/L4.0–11.0 × 10⁹/L
Platelets224 × 10⁹/L150–400 × 10⁹/L
Sodium138 mmol/L135–145 mmol/L
Potassium4.1 mmol/L3.5–5.0 mmol/L
Creatinine98 µmol/L62–106 µmol/L
eGFR72 mL/min/1.73m²≥60 mL/min/1.73m²
Glucose (random)9.4 mmol/L ⬆4.0–7.8 mmol/L
HbA1c7.8% ⬆<7.0% (diabetic target)
Total Cholesterol5.9 mmol/L ⬆<5.2 mmol/L
LDL Cholesterol3.8 mmol/L ⬆<2.0 mmol/L (high-risk target)
INR1.10.8–1.2
Lactate2.8 mmol/L ⬆<2.0 mmol/L
Arterial pH7.31 ⬇7.35–7.45
+ +

Chest X-Ray (Portable AP): + Mild cardiomegaly. Pulmonary vascular congestion with upper lobe + diversion. Small right pleural effusion. No pneumothorax. + No mediastinal widening. +

+

Bedside Echocardiogram (Emergency): + 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. +

+
+ + +
+

Assessment

+ +

+ Primary Diagnosis: + Inferior ST-Elevation Myocardial Infarction (STEMI) complicated by + cardiogenic shock. Most likely culprit vessel: Right Coronary Artery + (RCA) based on inferior lead involvement. +

+ +
+ Killip Class: IV — Cardiogenic shock (hypotension + end-organ hypoperfusion). +  |  + Shock Index: 1.27 (HR/SBP — normal <0.7) +
+ +

Differential Diagnosis:

+ +
+ 1. Inferior STEMI — RCA Territory + Most Likely +

+ 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. +

+
+ +
+ 2. Type A Aortic Dissection + Considered, Less Likely +

+ 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. +

+
+ +
+ 3. Massive Pulmonary Embolism + Unlikely +

+ 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. +

+
+ +
+ 4. NSTEMI / Unstable Angina + Excluded +

+ 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. +

+
+
+ + +
+

Management Plan

+ +
+
1. Immediate — Revascularisation (Priority)
+
    +
  • Activate cardiac catheterisation laboratory — target + door-to-balloon time <90 minutes
    • +
  • Primary Percutaneous Coronary Intervention (PCI) of culprit + lesion (RCA) — preferred strategy over thrombolysis
    • +
  • Urgent cardiology consult — notify interventional cardiologist + immediately
    • +
  • Obtain right-sided leads (V3R–V6R) before any fluid + administration to exclude RV MI
    • +
+
+ +
+
⚠ Medication Safety Checks — confirm before prescribing
+
    +
  • Known (from this case): 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
    • +
  • Weight not provided — weight-based dosing (e.g. heparin bolus) should follow local formulary/protocol once weight is confirmed
    • +
  • Bleeding risk not assessed — confirm no active bleeding, recent surgery, or prior intracranial haemorrhage before dual antiplatelet therapy
    • +
  • Hepatic function not documented — review prior to high-dose statin and ACE inhibitor initiation
    • +
  • Pregnancy status not applicable (patient is male, age 58)
    • +
  • All doses below are educational/simulated. Verify against your local formulary, current guidelines, and full patient context before administering.
    • +
+
+ +
+
2. Antiplatelet and Anticoagulation
+
    +
  • Aspirin 300mg PO loading dose — stat, then 75mg PO once daily
    • +
  • Ticagrelor 180mg PO loading dose — stat, then 90mg PO twice daily + (preferred over clopidogrel for STEMI per ESC guidelines)
    • +
  • Unfractionated heparin — IV bolus per cath lab protocol prior to PCI
    • +
  • Do not administer GPIIb/IIIa inhibitor pre-PCI; consider + intra-procedure per operator discretion
    • +
+
+ +
+
3. Cardiogenic Shock
+
    +
  • Hold IV fluids until right-sided leads reviewed — if RV infarct + present, cautious fluid challenge 250mL normal saline
    • +
  • If MAP <65mmHg despite fluids: commence norepinephrine infusion + per local vasoactive-infusion protocol once weight and concentration + are confirmed; titrate to MAP ≥65mmHg
    • +
  • ICU/CCU bed request — post-PCI high-dependency monitoring
    • +
  • Consider intra-aortic balloon pump or Impella device if shock + refractory post-PCI — per cardiology discretion
    • +
+
+ +
+
4. Respiratory / Oxygenation
+
    +
  • 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)
    • +
  • If pulmonary oedema worsens and haemodynamics permit: + Furosemide 40mg IV once
    • +
  • Escalate to non-rebreather mask, CPAP, or intubation per local + protocol if SpO₂ falls below 90% or respiratory distress + worsens despite initial measures
    • +
+
+ +
+
5. Monitoring
+
    +
  • Continuous 12-lead ECG monitoring and pulse oximetry
    • +
  • Arterial line for continuous BP monitoring given haemodynamic + instability
    • +
  • Repeat troponin at 3 hours and 6 hours post-admission
    • +
  • Repeat ECG immediately post-PCI and at 1 hour
    • +
  • Hourly urine output via urinary catheter — target ≥0.5mL/kg/hr
    • +
  • Strict fluid balance chart
    • +
  • Blood glucose monitoring q2h — target 6–10 mmol/L
    • +
+
+ +
+
6. Secondary Prevention (commence post-stabilisation)
+
    +
  • Beta-blocker: Bisoprolol — defer until fully stabilised: + 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.
    • +
  • ACE inhibitor: Ramipril 1.25mg PO once daily — commence within + 24 hours if tolerated; uptitrate over weeks
    • +
  • Statin: Atorvastatin 80mg PO at night — high-intensity statin + regardless of baseline cholesterol
    • +
  • Diabetes: Hold Metformin — renal function and contrast exposure + risk. Resume 48 hours post-procedure if creatinine stable
    • +
  • Dual antiplatelet therapy: Aspirin 75mg + Ticagrelor 90mg BD + for minimum 12 months post-PCI
    • +
  • Cardiac rehabilitation referral before discharge
    • +
  • Smoking cessation counselling and pharmacotherapy referral
    • +
  • Repeat echocardiogram at 6–8 weeks to reassess ejection fraction
    • +
+
+ +
+
7. Disposition
+
    +
  • Admit to Coronary Care Unit (CCU) post-PCI
    • +
  • Expected length of stay: 3–5 days if uncomplicated post-PCI course
    • +
  • Notify next of kin — serious illness discussion
    • +
+
+
+ + +
+ Generated using Open Design — clinical-case-report skill + For educational and documentation purposes only +
+ + + \ No newline at end of file diff --git a/skills/clinical-case-report/examples/example-stemi.html b/skills/clinical-case-report/examples/example-stemi.html new file mode 100644 index 000000000..15c2c0c20 --- /dev/null +++ b/skills/clinical-case-report/examples/example-stemi.html @@ -0,0 +1,698 @@ + + + + + + Clinical Case Report — Inferior STEMI with Cardiogenic Shock + + + + + +
+

Clinical Case Report

+
+
+ Patient + 58-year-old Male +
+
+ Setting + Emergency Department +
+
+ Specialty + Emergency / Cardiology +
+
+ Format + SOAP +
+
+
+ + +
+

Chief Complaint

+

+ Severe substernal chest pain for 2 hours with radiation to the left arm + and jaw, associated with profuse diaphoresis and nausea. +

+
+ + +
+

History of Present Illness

+

+ 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. +

+

+ 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. +

+

+ 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. +

+
+ + +
+

Past Medical History

+
    +
  • Hypertension — diagnosed 8 years ago, on treatment
    • +
  • Type 2 Diabetes Mellitus — diagnosed 5 years ago, on oral hypoglycaemics
    • +
  • Hyperlipidaemia — diagnosed 5 years ago, on statin therapy
    • +
  • No prior cardiac history. No previous myocardial infarction.
    • +
  • No history of stroke, peripheral vascular disease, or renal disease
    • +
+ +

Current Medications:

+
    +
  • Metformin 1g PO twice daily
    • +
  • Amlodipine 5mg PO once daily
    • +
  • Atorvastatin 40mg PO at night
    • +
+ +

Allergies: + No known drug allergies. No known food allergies. +

+ +

Social History: + Lives with family and has good home supports. + Current smoker — 10 cigarettes/day, 30 pack-years. + Alcohol: occasional, less than 14 units/week. +

+
+ + +
+

Vital Signs

+ +
+ ⚠ Critical — Activate Cath Lab + 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. +
+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +
Vital Signs
ParameterValueReference RangeStatus
Blood Pressure (Systolic/Diastolic)88 / 60 mmHg90–140 / 60–90 mmHg⬇ Hypotensive
Heart Rate112 bpm60–100 bpm⬆ Tachycardia
Respiratory Rate22 breaths/min12–20 breaths/min⬆ Elevated
Oxygen Saturation (SpO₂) — room air94%≥96%⬇ Low
Temperature37.1°C36.5–37.5°CNormal
Glasgow Coma Scale15 / 1515Normal
Capillary Refill Time3 seconds<2 seconds⬆ Prolonged
+
+ + +
+

Physical Examination

+ +

General: + Diaphoretic, pale, and in obvious discomfort. Alert and oriented to + person, place, and time. Appears acutely unwell. +

+

Cardiovascular: + 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. +

+

Respiratory: + 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. +

+

Abdomen: + Soft, non-distended, non-tender. No organomegaly. Bowel sounds present + and normal. No renal angle tenderness. +

+

Neurological: + GCS 15/15. Pupils equal and reactive 3mm bilaterally. No focal + neurological deficits. Cranial nerves grossly intact. +

+

Skin / Peripheries: + Pallor and diaphoresis. No rash, no jaundice, no cyanosis. +

+
+ + +
+

Investigations

+ +

12-Lead ECG:

+
+ ECG — STEMI Criteria Met + 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. +
+ +

Laboratory Results:

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +
Laboratory Results
InvestigationResultReference Range
Troponin I (high-sensitivity)2400 ng/L ⬆<40 ng/L
CK-MB48 U/L ⬆<25 U/L
BNP (B-type Natriuretic Peptide)520 pg/mL ⬆<100 pg/mL
Haemoglobin13.8 g/dL13.5–17.5 g/dL
White Blood Cells11.2 × 10⁹/L4.0–11.0 × 10⁹/L
Platelets224 × 10⁹/L150–400 × 10⁹/L
Sodium138 mmol/L135–145 mmol/L
Potassium4.1 mmol/L3.5–5.0 mmol/L
Creatinine98 µmol/L62–106 µmol/L
eGFR72 mL/min/1.73m²≥60 mL/min/1.73m²
Glucose (random)9.4 mmol/L ⬆4.0–7.8 mmol/L
HbA1c7.8% ⬆<7.0% (diabetic target)
Total Cholesterol5.9 mmol/L ⬆<5.2 mmol/L
LDL Cholesterol3.8 mmol/L ⬆<2.0 mmol/L (high-risk target)
INR1.10.8–1.2
Lactate2.8 mmol/L ⬆<2.0 mmol/L
Arterial pH7.31 ⬇7.35–7.45
+ +

Chest X-Ray (Portable AP): + Mild cardiomegaly. Pulmonary vascular congestion with upper lobe + diversion. Small right pleural effusion. No pneumothorax. + No mediastinal widening. +

+

Bedside Echocardiogram (Emergency): + 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. +

+
+ + +
+

Assessment

+ +

+ Primary Diagnosis: + Inferior ST-Elevation Myocardial Infarction (STEMI) complicated by + cardiogenic shock. Most likely culprit vessel: Right Coronary Artery + (RCA) based on inferior lead involvement. +

+ +
+ Killip Class: IV — Cardiogenic shock (hypotension + end-organ hypoperfusion). +  |  + Shock Index: 1.27 (HR/SBP — normal <0.7) +
+ +

Differential Diagnosis:

+ +
+ 1. Inferior STEMI — RCA Territory + Most Likely +

+ 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. +

+
+ +
+ 2. Type A Aortic Dissection + Considered, Less Likely +

+ 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. +

+
+ +
+ 3. Massive Pulmonary Embolism + Unlikely +

+ 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. +

+
+ +
+ 4. NSTEMI / Unstable Angina + Excluded +

+ 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. +

+
+
+ + +
+

Management Plan

+ +
+
1. Immediate — Revascularisation (Priority)
+
    +
  • Activate cardiac catheterisation laboratory — target + door-to-balloon time <90 minutes
    • +
  • Primary Percutaneous Coronary Intervention (PCI) of culprit + lesion (RCA) — preferred strategy over thrombolysis
    • +
  • Urgent cardiology consult — notify interventional cardiologist + immediately
    • +
  • Obtain right-sided leads (V3R–V6R) before any fluid + administration to exclude RV MI
    • +
+
+ +
+
⚠ Medication Safety Checks — confirm before prescribing
+
    +
  • Known (from this case): 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
    • +
  • Weight not provided — weight-based dosing (e.g. heparin bolus) should follow local formulary/protocol once weight is confirmed
    • +
  • Bleeding risk not assessed — confirm no active bleeding, recent surgery, or prior intracranial haemorrhage before dual antiplatelet therapy
    • +
  • Hepatic function not documented — review prior to high-dose statin and ACE inhibitor initiation
    • +
  • Pregnancy status not applicable (patient is male, age 58)
    • +
  • All doses below are educational/simulated. Verify against your local formulary, current guidelines, and full patient context before administering.
    • +
+
+ +
+
2. Antiplatelet and Anticoagulation
+
    +
  • Aspirin 300mg PO loading dose — stat, then 75mg PO once daily
    • +
  • Ticagrelor 180mg PO loading dose — stat, then 90mg PO twice daily + (preferred over clopidogrel for STEMI per ESC guidelines)
    • +
  • Unfractionated heparin — IV bolus per cath lab protocol prior to PCI
    • +
  • Do not administer GPIIb/IIIa inhibitor pre-PCI; consider + intra-procedure per operator discretion
    • +
+
+ +
+
3. Cardiogenic Shock
+
    +
  • Hold IV fluids until right-sided leads reviewed — if RV infarct + present, cautious fluid challenge 250mL normal saline
    • +
  • If MAP <65mmHg despite fluids: commence norepinephrine infusion + per local vasoactive-infusion protocol once weight and concentration + are confirmed; titrate to MAP ≥65mmHg
    • +
  • ICU/CCU bed request — post-PCI high-dependency monitoring
    • +
  • Consider intra-aortic balloon pump or Impella device if shock + refractory post-PCI — per cardiology discretion
    • +
+
+ +
+
4. Respiratory / Oxygenation
+
    +
  • 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)
    • +
  • If pulmonary oedema worsens and haemodynamics permit: + Furosemide 40mg IV once
    • +
  • Escalate to non-rebreather mask, CPAP, or intubation per local + protocol if SpO₂ falls below 90% or respiratory distress + worsens despite initial measures
    • +
+
+ +
+
5. Monitoring
+
    +
  • Continuous 12-lead ECG monitoring and pulse oximetry
    • +
  • Arterial line for continuous BP monitoring given haemodynamic + instability
    • +
  • Repeat troponin at 3 hours and 6 hours post-admission
    • +
  • Repeat ECG immediately post-PCI and at 1 hour
    • +
  • Hourly urine output via urinary catheter — target ≥0.5mL/kg/hr
    • +
  • Strict fluid balance chart
    • +
  • Blood glucose monitoring q2h — target 6–10 mmol/L
    • +
+
+ +
+
6. Secondary Prevention (commence post-stabilisation)
+
    +
  • Beta-blocker: Bisoprolol — defer until fully stabilised: + 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.
    • +
  • ACE inhibitor: Ramipril 1.25mg PO once daily — commence within + 24 hours if tolerated; uptitrate over weeks
    • +
  • Statin: Atorvastatin 80mg PO at night — high-intensity statin + regardless of baseline cholesterol
    • +
  • Diabetes: Hold Metformin — renal function and contrast exposure + risk. Resume 48 hours post-procedure if creatinine stable
    • +
  • Dual antiplatelet therapy: Aspirin 75mg + Ticagrelor 90mg BD + for minimum 12 months post-PCI
    • +
  • Cardiac rehabilitation referral before discharge
    • +
  • Smoking cessation counselling and pharmacotherapy referral
    • +
  • Repeat echocardiogram at 6–8 weeks to reassess ejection fraction
    • +
+
+ +
+
7. Disposition
+
    +
  • Admit to Coronary Care Unit (CCU) post-PCI
    • +
  • Expected length of stay: 3–5 days if uncomplicated post-PCI course
    • +
  • Notify next of kin — serious illness discussion
    • +
+
+
+ + +
+ Generated using Open Design — clinical-case-report skill + For educational and documentation purposes only +
+ + + \ No newline at end of file diff --git a/skills/clinical-case-report/references/case-formats.md b/skills/clinical-case-report/references/case-formats.md new file mode 100644 index 000000000..3c97e0e23 --- /dev/null +++ b/skills/clinical-case-report/references/case-formats.md @@ -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 | \ No newline at end of file diff --git a/skills/clinical-case-report/references/checklist.md b/skills/clinical-case-report/references/checklist.md new file mode 100644 index 000000000..ddf90a560 --- /dev/null +++ b/skills/clinical-case-report/references/checklist.md @@ -0,0 +1,41 @@ +# Clinical Case Report — Quality Checklist + +## P0 — Must Pass Before Emitting Artifact + +- [ ] Chief complaint or ID line is clearly stated in the opening line +- [ ] **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 +- [ ] **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 +- [ ] Vital signs are present and physiologically plausible +- [ ] 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.) +- [ ] Assessment contains a clearly stated primary diagnosis +- [ ] Plan is present and directly addresses the primary diagnosis +- [ ] 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 +- [ ] Medication plan is labelled as educational/simulated — not a substitute for clinician judgment +- [ ] 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 +- [ ] All data is synthetic, de-identified, or clearly fictional +- [ ] If based on a real case, apply formal de-identification before use +- [ ] HTML renders without errors in a browser +- [ ] All major sections tagged with `data-od-id` + +## P1 — Should Pass + +- [ ] Past medical history includes conditions relevant to the presentation +- [ ] Medications list is present +- [ ] Physical examination findings are organised by system +- [ ] Differential diagnosis contains 3 to 5 items +- [ ] Each differential item includes one sentence of supporting or refuting evidence +- [ ] Lab values use correct units and are within realistic ranges for the diagnosis +- [ ] 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" +- [ ] Plan is organised by problem using numbered headers +- [ ] Critical findings are visually highlighted (red callout box) +- [ ] Document is print-friendly (white background, `@media print` rules present) +- [ ] A validated risk score is included where applicable (TIMI, GRACE, Killip class + Shock Index for STEMI/cardiogenic shock, CURB-65, qSOFA, Wells) + +## P2 — Nice to Have + +- [ ] Pertinent negatives documented in HPI and Review of Systems +- [ ] Imaging findings described in investigations section +- [ ] Specialist consult noted where clinically indicated +- [ ] Disposition or follow-up plan included +- [ ] Monitoring parameters specified (e.g. repeat troponin at 3h and 6h) +- [ ] Secondary prevention addressed for chronic disease presentations \ No newline at end of file