--- 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 `<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.