clinical-case-report

# 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 `<table>` 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 <section data-od-id="hpi">...</section> <section data-od-id="vitals">...</section> <section data-od-id="pmh">...</section> <section data-od-id="examination">...</section> <section data-od-id="investigations">...</section> <section data-od-id="assessment">...</section> <section data-od-id="plan">...</section> ``` ### Step 7 — Self-check against `references/checklist.md` Before emitting `<artifact>`, run every P0 item in `references/checklist.md`. All P0 items must pass. Fix any failures before emitting.