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:

htmlCopy code
<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.