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b5eb8c1647
* feat: general-purpose skills with @-mention composition and user import
Lift skills from "one mode-bound skill per project" to a generic capability
the user can compose per turn:
- Daemon: scan multiple skill roots (user-skills under runtime data, then
the bundled `skills/`); user-imported skills can shadow built-ins by id.
- New `POST /api/skills/import` and `DELETE /api/skills/:id` endpoints,
with CONFLICT/BAD_REQUEST/NOT_FOUND error codes and built-in delete
protection.
- ChatRequest gains `skillIds: string[]`; the chat run concatenates each
picked skill's body (and merges craftRequires) into the system prompt
for that turn only — the project's persistent `skillId` is untouched.
- Web composer: `@` popover now lists skills alongside project files;
picks render as removable chips above the textarea and ride along with
the request as `skillIds`.
- Settings → Library: import form (name/description/triggers/body),
per-card delete for user skills, "user" origin badge.
* chore(web): drop welcome pet teaser + add ds→prompt-template mapping util
- SettingsDialog: remove the inline pet adoption teaser from the welcome
panel so the first-run modal stays focused on configuration.
- New `inferPromptTemplateCategoriesForDs(ds)` helper that maps a design
system's authored metadata to prompt-template gallery categories.
Imported by the design-system gallery wiring on a sibling branch; no
callers in this branch yet.
* feat: split skills/design-templates and add finalize-design API
Phase 0 of the skills/design-templates refactor (specs/current/
skills-and-design-templates.md):
- Move ~104 rendering catalogue entries from skills/ to design-templates/
and keep skills/ for the small set of functional skills that *do work*
on user input (utilities, briefs, packagers).
- Add design-templates/AGENTS.md and skills/AGENTS.md describing the
contract, and a brand-agnostic craft/ surface for opt-in craft rules.
- Daemon: add DESIGN_TEMPLATES_DIR / USER_DESIGN_TEMPLATES_DIR roots and
an /api/design-templates surface mirroring /api/skills. Asset/example
routes still span both registries so existing srcdoc URLs keep
resolving across the rename.
- Web: split LibrarySection into SkillsSection + DesignSystemsSection,
rename the EntryView "Examples" tab to "Templates", and update locales
+ the New-project picker accordingly.
Adds the finalize-design endpoint:
- New apps/daemon/src/finalize-design.ts and packages/contracts/src/api/
finalize.ts — one-shot synthesis of a project's transcript + active
design system + current artifact into <projectDir>/DESIGN.md via the
Anthropic Messages API. Per-project .finalize.lock mirrors the
transcript-export hygiene from PR #493; provider credentials are not
persisted by the daemon.
Other supporting changes:
- README + AGENTS.md updates to document the new directory split and
craft/ surface, plus i18n strings across 13 locales.
- Test refactors and new coverage (finalize-design, runs, sidecar
server, plus refreshed daemon integration tests).
- .gitignore: scope the *.exe ignore to /OpenDesign.exe so legitimate
vendor binaries are no longer hidden.
* fix(merge): move clinical-case-report to design-templates/
Origin/main added the clinical-case-report skill under skills/ before
the skills/design-templates split landed. Its od.mode is prototype, so
per specs/current/skills-and-design-templates.md it is a design template
and belongs alongside the other rendering catalogue entries — not under
the slimmed-down functional skills/ root. Moving it keeps the EntryView
Templates tab consistent with origin/main's intent.
* feat(skills): curated design/creative catalogue + collapsible Settings rows
Seed ~100 curated design/creative skill stubs under skills/ sourced from
awesome-claude-skills (ComposioHQ) and awesome-agent-skills (VoltAgent).
Each stub carries an od.category tag so the new filter pill row in
Settings -> Skills can group them. The seed script
(scripts/seed-curated-design-skills.ts, pnpm seed:curated-design-skills)
is idempotent: it only creates folders that don't already exist, so
hand-edited stubs are never overwritten.
- Daemon: parse and surface od.category on SkillInfo with a strict slug
normaliser; mirror the field on SkillSummary in @open-design/contracts.
Category is purely a UI hint — system-prompt composition is unchanged.
- Web: rewrite SkillsSection from a left-list / right-detail grid into a
vertical stack of collapsible rows mirroring the External MCP panel
(header always visible with name + mode/source/category pills + per-row
enable toggle; SKILL.md preview, file tree and inline edit form expand
on demand). Add a Category filter row above the list. Reorder Settings
nav so Skills + External MCP sit above the Composio/MCP cluster. Update
composer placeholder/hint across 17 locales to advertise '@ files or
skills · / for commands'.
- Docs: extend skills/AGENTS.md with the curated catalogue rules
(idempotency, category vocabulary, no upstream vendoring).
Co-authored-by: Cursor <cursoragent@cursor.com>
* test(skills): teach localized-content + system-prompt tests about the skills/design-templates split
mrcfps blocking review on PR #955: the skills/design-templates split
(b5993385) moved ~110 SKILL.md entries out of `skills/` and into
`design-templates/`, but two repo-level tests still hard-coded the
single-root layout, so CI gates went red on the merged branch:
- `e2e/tests/localized-content.test.ts` only scanned `<repo>/skills`
while the locale `skillCopy` map keeps id-keyed entries spanning
both roots (ExamplesTab/Templates uses one lookup regardless of
origin). Teach the helper to read both `skills/` and
`design-templates/`, deduplicating ids so the union matches the
localized claim.
- `apps/daemon/tests/prompts/system.test.ts` read
`skills/live-artifact/SKILL.md`, which now lives under
`design-templates/live-artifact/`. Update the absolute path so
composeSystemPrompt's coverage of the live-artifact preamble is
exercised again.
Also enroll the curated design/creative catalogue (PR #955, ~91
stubs sourced from awesome-claude-skills / awesome-agent-skills) in
the DE / FR / RU `_SKILL_IDS_WITH_EN_FALLBACK` lists. The stubs are
English-only by design (frontmatter advertises an upstream URL); the
fallback list is exactly the place to acknowledge "we know this id
exists, English copy is fine here" so the localized-content coverage
gate passes without forcing a translation task per locale.
Co-authored-by: Cursor <cursoragent@cursor.com>
* fix(skills): always quote frontmatter name so importUserSkill round-trips numeric / boolean ids
mrcfps PR #955 review: `buildSkillMarkdown` emitted `name:
${escapeYamlString(name)}` without quotes, so YAML coerced names
like `123`, `true`, `false`, or `null` into non-string scalars on
re-parse. listSkills() then read `data.name` as a number/boolean
and the import flow's follow-up `findSkillById(skills, result.id)`
missed it, falling into `/api/skills/import`'s "imported skill
could not be re-read" 500 path for those ids.
Switch the emitter to a quoted scalar (`name: "..."`) — the
double-escape already in `escapeYamlString` makes the quoted form
safe — and add a round-trip test covering `123`, `true`, `false`,
`null`, and `0` to lock in the contract.
Co-authored-by: Cursor <cursoragent@cursor.com>
* fix(web): drop staged-skill chips when the matching @<id> token leaves the draft
mrcfps PR #955 review: `submit()` always forwarded every id in
`stagedSkills`, but that state was only mutated on picker click and
chip removal. Hand-deleting an `@<id>` token from the textarea left
the chip staged, so the request still carried `skillIds: [<id>]` and
the daemon composed a skill the prompt no longer referenced.
Sync the chips with the draft inside `handleChange()` by pruning
`stagedSkills` whenever the new value no longer contains the
`@<id>` token (using the same whitespace boundary as
`removeStagedSkill`'s strip regex). Comment explains why this
prune does not run for `staged` file attachments — users frequently
add files via the upload button without leaving an `@<path>` token,
so a symmetric prune there would erase legitimate uploads.
Co-authored-by: Cursor <cursoragent@cursor.com>
* fix(daemon): stage @-composed skills' side files alongside the active skill
codex PR #955 review: composing a per-turn `@`-picked skill into the
system prompt appended its body (with the `withSkillRootPreamble`
guidance pointing at relative paths under `<cwd>/.od-skills/<folder>/`)
but never staged the actual folder. `startChatRun` only copied
`activeSkillDir`, so when the project's primary skill was different
(or absent) the composed skill's references/, examples/, and scripts/
files lived only at their absolute repo path — agents that honour
the cwd-relative form (or that don't get `--add-dir`, e.g. Codex with
allowlisted gpt-image projects) couldn't reach them.
Thread the composed skills' dirs out of `composeDaemonSystemPrompt`
as `extraSkillDirs` and stage each one through the same
`stageActiveSkill` API used for the primary skill. Dedupe by folder
basename so a project whose primary skill is also `@`-composed isn't
copied twice. Each preamble already advertises its own folder, so the
prompt and the staged tree stay aligned without further changes.
Co-authored-by: Cursor <cursoragent@cursor.com>
* fix(web): respect the Library disable toggle in the project @-mention picker
codex PR #955 review: only `EntryView` received `enabledSkills`
(filtered against `config.disabledSkills`); active projects still
got `skills={skills}` raw, so a skill the user disabled in Settings
kept appearing in the project's `@`-mention popover and could ride
along to the daemon via `skillIds`. That broke the Library toggle
for any project opened on the post-split branch.
Compute a functional-skills-only enabled subset
(`enabledFunctionalSkills`) and pass it into `<ProjectView>` instead.
Templates stay separate — design-templates are filtered through their
own `enabledDesignTemplates` memo for the Templates gallery — so
ProjectView's chat composer still only sees skills, never templates,
matching the pre-split prop surface.
Co-authored-by: Cursor <cursoragent@cursor.com>
* test(e2e): mock /api/design-templates for example-use-prompt flow
The Templates tab in EntryView fetches from /api/design-templates after
the skills/design-templates split (specs/current/skills-and-design-templates.md).
The example-use-prompt Playwright scenario only mocked /api/skills, so the
gallery card never appeared and the test timed out waiting on
example-card-warm-utility-example. Serve the same fixture summary on both
endpoints so the templates gallery renders the card the test clicks.
Co-authored-by: Cursor <cursoragent@cursor.com>
* test(tools-pack): create design-templates fixture for resources test
The packaging resources copy now bundles the new design-templates tree
alongside skills (see resources.ts BUNDLED_RESOURCE_TREES). The
copyBundledResourceTrees fixture only created skills, design-systems,
craft, etc., so the recursive copy crashed with ENOENT on
design-templates before it could check the prompt-templates assertion.
Add the missing fixture directory so the test exercises the same set
of resource trees the packaged build does.
Co-authored-by: Cursor <cursoragent@cursor.com>
* fix(skills): clone built-in side files into the shadow on first edit
mrcfps PR #955 review: editing a built-in skill wrote a USER_SKILLS_DIR
shadow folder that contained only a new SKILL.md. The next listSkills()
pass surfaced the shadow as the active dir, but every side-file resolver
(/api/skills/:id/files, /example, /assets/*, the system-prompt preamble,
and the per-turn cwd staging) reads through skill.dir. With nothing but
SKILL.md in the shadow, the bundled assets/, references/, scripts/, and
examples/ disappeared the moment the user hit save — a built-in like
last30days or live-artifact would break immediately after edit instead
of just having its body overridden.
Teach updateUserSkill() to take a `sourceDir` and clone every entry
except SKILL.md / dotfiles into the shadow on the very first edit. The
shadow stays self-contained, so all the resolvers keep working without
fallback bookkeeping. Subsequent edits detect the existing shadow and
skip the clone, so user tweaks under the side tree survive a re-save.
Wire `sourceDir: skill.dir` from server.ts's PUT /api/skills/:id handler
and add two regression tests:
- 'clones built-in side files into the shadow on the first edit' walks
the file tree after save and asserts assets/template.html, references/
notes.md, and scripts/helper.sh all round-trip from the built-in.
- 'preserves user-edited side files on subsequent edits' edits the
staged assets/template.html, re-saves, and confirms the user content
is still there.
Co-authored-by: Cursor <cursoragent@cursor.com>
* test(e2e): rename home tab from Examples to Templates
The Examples tab was renamed to Templates in EntryView (b5993385's
skills/design-templates split — entry.tabExamples became entry.tabTemplates
and the tab value moved from 'examples' to 'templates'), but
entry-chrome-flows still asserted the old label and testId. Update both.
* fix(skills+web): preserve template body in API mode and dir-based skill delete
Two follow-ups from PR #955 review:
1. ProjectView only received `enabledFunctionalSkills`, but
`composedSystemPrompt()` still resolved `project.skillId` through that
prop and `fetchSkill()`. Projects created from the new
`/api/design-templates` surface keep a template id in `project.skillId`,
so opening one in API mode dropped the template body from the system
prompt and the upstream request ran without the project's primary
template instructions. Now ProjectView takes a separate
`designTemplates` prop (the unfiltered template list, so a
later-disabled template still loads for projects already created from
it) and `composedSystemPrompt()` plus the metadata / `isDeck` lookups
fall back to that list, with `fetchDesignTemplate()` as the body-fetch
fallback to `fetchSkill()`. The chat composer's `@`-picker keeps
receiving only the enabled functional skills.
2. `DELETE /api/skills/:id` used `deleteUserSkill(USER_SKILLS_DIR, skill.id)`
which re-slugified the frontmatter id and removed
`<userSkillsDir>/<slug>/`. That matched the import shape but missed the
install shape — `installFromTarget` writes the folder at
`sanitizeRepoName(url)` (GitHub) or `path.basename(realpath)` (local
symlink), neither of which is guaranteed to equal the slugified
frontmatter `name`. A duplicate `app.delete('/api/skills/:id', ...)`
handler at the install routes never fired because Express resolved the
earlier registration first, leaving the install/uninstall path without
working teardown. The handler now removes `skill.dir` (the absolute
path listSkills already discovered) under a USER_SKILLS_DIR safety
check, using `lstat` + `unlinkSync` so symlinked local installs unlink
cleanly without recursing into the user's source tree. The dead
duplicate handler is removed; `deleteUserSkill` is dropped from the
server.ts import set (still exported and unit-tested in skills.ts).
Regression coverage in `apps/daemon/tests/skills-delete-route.test.ts`
pins both shapes plus the symlink-preserves-source case.
* test(daemon): point hyperframes system-prompt test at design-templates
The merge with main brought in a hyperframes system-prompt test that
reads `skills/hyperframes/SKILL.md`, but this branch's split moved
`hyperframes` into `design-templates/` (same migration as `live-artifact`
already handled above in this file). CI was failing with ENOENT on the
old path.
---------
Co-authored-by: Cursor <cursoragent@cursor.com>
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<h1>Clinical Case Report</h1>
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<span class="label">Patient</span>
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58-year-old Male
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Emergency Department
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Emergency / Cardiology
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<span class="label">Format</span>
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SOAP
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<!-- ── Chief Complaint ──────────────────────────────────────── -->
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<h2>Chief Complaint</h2>
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<p>
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Severe substernal chest pain for 2 hours with radiation to the left arm
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and jaw, associated with profuse diaphoresis and nausea.
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</p>
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</section>
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<!-- ── History of Present Illness ──────────────────────────── -->
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<section data-od-id="hpi">
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<h2>History of Present Illness</h2>
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<p>
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This is a 58-year-old male with a background history of hypertension,
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type 2 diabetes mellitus, and hyperlipidaemia who presents to the
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emergency department with a 2-hour history of severe, 9/10 intensity,
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pressure-like chest pain localised substernally. The pain began abruptly
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at rest at approximately 14:30 and radiates to the left arm and jaw.
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</p>
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<p>
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The pain is associated with profuse diaphoresis, nausea, and one episode
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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 ────────────────────────────────────────────────── -->
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<div class="doc-footer">
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<span>Generated using Open Design — clinical-case-report skill</span>
|
||
<span>For educational and documentation purposes only</span>
|
||
</div>
|
||
|
||
</body>
|
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</html> |