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] — do