diff --git a/public/js/peGuide.js b/public/js/peGuide.js
index e3b8bc8..8298140 100644
--- a/public/js/peGuide.js
+++ b/public/js/peGuide.js
@@ -1,15 +1,18 @@
// ============================================================
-// PHYSICAL EXAM GUIDE — OSCE reference + narrative generator
+// PHYSICAL EXAM GUIDE — step-by-step OSCE reference + report generator
// ============================================================
-// Data is embedded here rather than fetched: the knowledge is static and
-// small, and it needs to be available offline-in-browser without an API
-// round-trip. Scope for v1: MSK + Neuro × 6 age groups. Expand later.
+// Sources for the exam content:
+// - Bates' Guide to Physical Examination, 13th edition (technique)
+// - Nelson Textbook of Pediatrics, 22nd edition (age-specific content)
+// - Hutchison's Clinical Methods, 25th edition (systematic approach)
+// - Developmental reflex timing: Fenichel Clinical Pediatric Neurology, 8th ed
//
-// Each exam component has:
-// name — what to document
-// technique — how to perform (OSCE-style)
-// normal — expected finding text (used verbatim when user picks Normal)
-// abnormalHints — red flags / things to document if abnormal (reference only)
+// Data model:
+// PE_DATA[ageGroup][system] = { overview, components: [{ name, steps: [{label, method, normal}], abnormalHints }] }
+// Each step has its own Normal / Abnormal / Skip toggle so the physician
+// ticks the exam off step-by-step and flags specific abnormal findings.
+// Report generation (POST /api/generate-pe-narrative) receives the flat
+// step array and produces a Technique + Findings narrative.
// ============================================================
(function () {
@@ -18,58 +21,96 @@
// DATA
// ────────────────────────────────────────────────────────────
var PE_DATA = {
+
newborn: {
label: 'Newborn (0–28 days)',
msk: {
- overview: 'Focus: birth injuries, congenital anomalies, and DDH screening (universal Barlow/Ortolani through 6 months). Examine warm, quiet, undressed infant.',
+ overview: 'Exam done warm, quiet, undressed. Focus: birth injury, DDH, congenital anomaly. All steps symmetric.',
components: [
- { name: 'Resting posture', technique: 'Observe supine. Note symmetry of limb position.',
- normal: 'Symmetric flexion at hips, knees, elbows; hands loosely fisted',
- abnormalHints: ['Frog-leg (hypotonia)', 'Asymmetric arm posture (brachial plexus, clavicle fx)', 'Opisthotonic posturing (CNS)'] },
- { name: 'Clavicles', technique: 'Palpate each clavicle from sternoclavicular joint to acromion.',
- normal: 'Smooth, continuous bilaterally; no crepitus or step-off',
- abnormalHints: ['Crepitus or step-off (fracture — LGA / shoulder dystocia)', 'Pain with passive arm abduction'] },
- { name: 'Hips (Barlow/Ortolani)', technique: 'Flex hips 90°, grasp thighs with thumbs medial. Barlow: adduct + downward pressure. Ortolani: abduct + lift.',
- normal: 'Hips stable; no clunk on Barlow or Ortolani; symmetric abduction ≥75°',
- abnormalHints: ['Palpable clunk (positive Ortolani = dislocatable or dislocated)', 'Asymmetric thigh/gluteal folds', 'Limited abduction', 'Leg-length discrepancy (Galeazzi)'] },
- { name: 'Spine / back', technique: 'Prone. Palpate midline from C-spine to coccyx. Inspect sacral area.',
- normal: 'Straight midline; no cutaneous markers; skin intact; no sacral mass',
- abnormalHints: ['Sacral dimple >5mm or >2.5cm from anus (imaging)', 'Midline hair tuft, hemangioma, lipoma (occult dysraphism)', 'Palpable defect'] },
- { name: 'Upper extremities', technique: 'Observe spontaneous movement, count digits, inspect palmar creases.',
- normal: 'Symmetric antigravity movement; 5 digits each hand; normal palmar creases',
- abnormalHints: ['Erb/Klumpke palsy (asymmetric movement)', 'Polydactyly, syndactyly', 'Single transverse palmar crease (trisomy 21 — soft sign)'] },
- { name: 'Lower extremities / feet', technique: 'Range hips/knees/ankles. Stroke lateral border of foot. Attempt passive correction.',
- normal: 'Full range; foot correctable to neutral with ease; no hindfoot deformity',
- abnormalHints: ['Rigid clubfoot (talipes equinovarus — non-correctable)', 'Metatarsus adductus (usually flexible)', 'Rocker-bottom foot (trisomy 18)'] }
+ { name: 'Resting posture', steps: [
+ { label: 'Observe posture', method: 'Place supine and undisturbed for 30s', normal: 'Symmetric flexion at hips, knees, elbows' },
+ { label: 'Hand position', method: 'Inspect resting hands', normal: 'Loosely fisted; opens intermittently' },
+ { label: 'Symmetry', method: 'Compare left vs right side at rest', normal: 'Mirror-image posture' }
+ ], abnormalHints: ['Frog-leg (hypotonia)', 'Asymmetric arm (brachial plexus/clavicle fx)', 'Opisthotonos (CNS)', 'Persistent fisting with thumb in palm'] },
+
+ { name: 'Clavicles', steps: [
+ { label: 'Palpate right clavicle', method: 'Trace from sternoclavicular joint to acromion with index finger', normal: 'Smooth, continuous, no step-off' },
+ { label: 'Palpate left clavicle', method: 'Same technique on left side', normal: 'Smooth, continuous' },
+ { label: 'Crepitus check', method: 'Light pressure along length of clavicle while gently abducting arm', normal: 'No crepitus, no pain response' }
+ ], abnormalHints: ['Palpable step-off or callus (fracture — LGA, shoulder dystocia)', 'Asymmetric Moro on affected side'] },
+
+ { name: 'Hips — DDH screen', steps: [
+ { label: 'Thigh/gluteal folds', method: 'Undress completely; compare skin-fold symmetry', normal: 'Symmetric thigh and gluteal folds' },
+ { label: 'Abduction', method: 'Flex hips 90°, abduct simultaneously', normal: 'Both hips abduct to ≥75° symmetrically' },
+ { label: 'Barlow maneuver', method: 'Thumb on medial thigh, flex hip 90°, adduct, apply gentle posterior pressure', normal: 'No clunk or movement felt (negative)' },
+ { label: 'Ortolani maneuver', method: 'From Barlow position: abduct and lift with fingers on greater trochanter', normal: 'No clunk as hip returns (negative)' },
+ { label: 'Galeazzi sign', method: 'Knees flexed together with feet on table; compare knee heights', normal: 'Knees level — no leg-length discrepancy' }
+ ], abnormalHints: ['Palpable Ortolani clunk (dislocated, reducible)', 'Barlow clunk (dislocatable)', 'Limited abduction', 'Positive Galeazzi (shortened femur)'] },
+
+ { name: 'Spine and back', steps: [
+ { label: 'Position prone', method: 'Turn infant prone, support chest', normal: 'Tolerates position, lifts head briefly' },
+ { label: 'Palpate midline', method: 'Run finger from C-spine to coccyx', normal: 'Straight midline, no step-offs or gaps' },
+ { label: 'Sacral inspection', method: 'Inspect sacral dimple if present; measure depth, distance from anus', normal: 'No dimple, or dimple <5mm deep and <2.5cm from anus' },
+ { label: 'Cutaneous markers', method: 'Inspect midline skin from neck to coccyx', normal: 'No hair tuft, hemangioma, lipoma, or sinus tract' }
+ ], abnormalHints: ['Deep sacral dimple (>5mm) or >2.5cm from anus — imaging', 'Hair tuft, hemangioma, lipoma (occult dysraphism)', 'Palpable defect'] },
+
+ { name: 'Upper extremities', steps: [
+ { label: 'Spontaneous movement', method: 'Observe both arms for 30s', normal: 'Symmetric antigravity movement' },
+ { label: 'Digits', method: 'Count and inspect fingers both hands', normal: '5 digits each, no webbing or duplication' },
+ { label: 'Palmar creases', method: 'Inspect palmar creases', normal: 'Normal triradiate creases' }
+ ], abnormalHints: ['Erb/Klumpke palsy (paucity of movement)', 'Polydactyly, syndactyly', 'Single transverse (simian) palmar crease'] },
+
+ { name: 'Lower extremities / feet', steps: [
+ { label: 'Hip and knee range', method: 'Gently flex, extend, internally/externally rotate each', normal: 'Full symmetric range, no contracture' },
+ { label: 'Foot alignment', method: 'Inspect resting foot position', normal: 'Midline or mildly adducted forefoot' },
+ { label: 'Passive correction', method: 'Gently attempt to bring foot to neutral', normal: 'Fully correctable to neutral' },
+ { label: 'Stroke test', method: 'Stroke lateral border of foot', normal: 'Foot dorsiflexes and everts reflexively' }
+ ], abnormalHints: ['Rigid clubfoot (non-correctable talipes equinovarus)', 'Fixed metatarsus adductus', 'Rocker-bottom foot (trisomy 18)', 'Calcaneovalgus'] }
]
},
neuro: {
- overview: 'Focus: primitive reflexes (present and symmetric), tone (passive and active), and absence of focal deficit. A full newborn neuro exam takes 3–5 min on a quiet, satiated baby.',
+ overview: 'Primitive reflexes present and symmetric. Tone assessed passively and actively. Full exam 3–5 min on a quiet, fed infant.',
components: [
- { name: 'Level of alertness', technique: 'Observe spontaneous alertness and response to voice, touch, light.',
- normal: 'Alert periods with spontaneous eye opening; responds to voice and light; consolable',
- abnormalHints: ['Persistent lethargy / hard to arouse', 'Jitteriness', 'Irritability not consoled by feeding'] },
- { name: 'Cranial nerves', technique: 'Pupils to light; symmetric facial movement at rest and with crying; intact suck; visual blink to light.',
- normal: 'Pupils equal and reactive; face symmetric; strong coordinated suck; blinks to bright light',
- abnormalHints: ['Asymmetric facial movement (CN VII injury)', 'Poor or uncoordinated suck', 'Fixed pupil', 'Absent blink'] },
- { name: 'Tone (passive)', technique: 'Pull-to-sit (head lag ≤ minimal at term), ventral suspension (head lifts to horizontal), arm recoil, popliteal angle.',
- normal: 'Age-appropriate flexor tone; brief head lag on pull-to-sit; head level with spine on ventral suspension',
- abnormalHints: ['Significant head lag (hypotonia)', 'Slip-through on vertical suspension', 'Hypertonia / scissoring'] },
- { name: 'Spontaneous movement', technique: 'Observe limb movement for symmetry, range, antigravity effort.',
- normal: 'Symmetric, antigravity movements of all four limbs',
- abnormalHints: ['Focal paucity of movement (stroke, brachial plexus)', 'Jittery movements that stop on passive flexion', 'Clonic or tonic seizure activity'] },
- { name: 'Moro reflex', technique: 'Support head, allow ~30° head drop or clap.',
- normal: 'Symmetric arm extension followed by flexion and often a cry',
- abnormalHints: ['Absent (severe CNS depression)', 'Asymmetric (brachial plexus injury, clavicle fx, hemiparesis)'] },
- { name: 'Rooting / sucking', technique: 'Stroke cheek / touch lips. Insert gloved finger.',
- normal: 'Turns toward stimulus and opens mouth; strong rhythmic suck',
- abnormalHints: ['Absent rooting or suck (CNS depression, prematurity)', 'Uncoordinated suck-swallow'] },
- { name: 'Palmar / plantar grasp', technique: 'Apply pressure to palm; then to ball of foot.',
- normal: 'Strong, symmetric finger flexion; toe curl to plantar pressure',
- abnormalHints: ['Absent or asymmetric palmar grasp', 'Absent plantar grasp'] },
- { name: 'Babinski', technique: 'Stroke lateral sole from heel to toes.',
- normal: 'Up-going great toe with fanning of other toes (expected in neonates)',
- abnormalHints: ['Asymmetric response is always abnormal'] }
+ { name: 'Alertness and behavior', steps: [
+ { label: 'State cycling', method: 'Observe over 1–2 min for alert periods', normal: 'Alert periods with spontaneous eye opening' },
+ { label: 'Response to voice', method: 'Speak softly near ear', normal: 'Quiets to voice or turns toward sound' },
+ { label: 'Consolability', method: 'If crying, attempt to soothe with swaddling or voice', normal: 'Consolable within 1–2 min' }
+ ], abnormalHints: ['Lethargy', 'Jitteriness not stopped by passive flexion', 'Irritability unrelieved by feeding'] },
+
+ { name: 'Cranial nerves', steps: [
+ { label: 'CN II — pupil response', method: 'Shine light in each eye', normal: 'Pupils equal, reactive to light, direct and consensual' },
+ { label: 'CN II — blink to light', method: 'Bright light in the line of sight', normal: 'Reflex blink' },
+ { label: 'CN VII — facial symmetry at rest', method: 'Observe resting face', normal: 'Symmetric nasolabial folds' },
+ { label: 'CN VII — facial symmetry with cry', method: 'Note face during a cry', normal: 'Symmetric grimace' },
+ { label: 'CN IX, X, XII — suck and swallow', method: 'Offer clean gloved finger, pacifier, or during feed', normal: 'Strong coordinated suck-swallow, no choking' }
+ ], abnormalHints: ['Asymmetric face (CN VII injury — usually forceps)', 'Poor suck or uncoordinated swallow', 'Fixed or unequal pupil'] },
+
+ { name: 'Tone — passive', steps: [
+ { label: 'Pull-to-sit', method: 'Grasp hands/wrists, pull smoothly to sit', normal: 'Brief head lag at term; not dramatic' },
+ { label: 'Ventral suspension', method: 'Suspend prone over hand at chest', normal: 'Head briefly lifts to horizontal; extremities flexed' },
+ { label: 'Arm recoil', method: 'Extend both arms fully at elbows, release', normal: 'Rapid return to flexion' },
+ { label: 'Popliteal angle', method: 'Hip flexed 90°, extend knee maximally', normal: '≤110°' }
+ ], abnormalHints: ['Marked head lag (hypotonia)', 'Slip-through on vertical suspension', 'Hypertonia / scissoring', 'Floppy limbs with no recoil'] },
+
+ { name: 'Spontaneous movement', steps: [
+ { label: 'Observe limbs', method: 'Undisturbed over 1 min, note movement', normal: 'Symmetric antigravity movement of all 4 limbs' },
+ { label: 'Quality of movement', method: 'Note smoothness vs jitteriness', normal: 'Smooth, mildly variable movements' }
+ ], abnormalHints: ['Paucity of movement in one limb', 'Coarse jitteriness', 'Clonic jerks', 'Tonic posturing'] },
+
+ { name: 'Primitive reflexes', steps: [
+ { label: 'Moro', method: 'Support head; allow 30° head drop or loud clap', normal: 'Symmetric arm abduction then flexion, often cry' },
+ { label: 'Rooting', method: 'Stroke cheek at corner of mouth', normal: 'Turns head toward stroke and opens mouth' },
+ { label: 'Palmar grasp', method: 'Press into palm with finger', normal: 'Strong, symmetric finger flexion' },
+ { label: 'Plantar grasp', method: 'Press ball of foot below toes', normal: 'Toes flex around finger symmetrically' },
+ { label: 'Stepping', method: 'Hold upright with feet touching surface', normal: 'Alternating stepping movements' },
+ { label: 'Tonic neck (fencing)', method: 'Turn head to one side with infant supine', normal: 'Same-side arm extends, opposite flexes (not obligate)' },
+ { label: 'Galant', method: 'Stroke paravertebrally from shoulder to buttock, one side', normal: 'Trunk curves toward stroked side' }
+ ], abnormalHints: ['Absent or asymmetric Moro — CNS injury, brachial plexus, clavicle fx', 'Absent grasps — CNS depression', 'Obligate tonic neck is abnormal'] },
+
+ { name: 'Babinski (plantar response)', steps: [
+ { label: 'Stroke lateral sole', method: 'Firm stroke from heel toward toes along lateral plantar border', normal: 'Up-going great toe with fanning (normal in newborn)' },
+ { label: 'Symmetry check', method: 'Repeat opposite foot', normal: 'Symmetric response' }
+ ], abnormalHints: ['Asymmetric response is always abnormal'] }
]
}
},
@@ -77,46 +118,68 @@
infant: {
label: 'Infant (1–12 months)',
msk: {
- overview: 'Focus: continued DDH screen through 6 months, gross-motor progression, and symmetry of tone and movement.',
+ overview: 'Continued DDH screen through 6 months. Watch motor progression and symmetry of tone/movement.',
components: [
- { name: 'Hips (Barlow/Ortolani through 6mo; abduction thereafter)', technique: 'Barlow/Ortolani in first 6 months. After 6 months use limited abduction (<70°), Galeazzi sign, asymmetric skin folds.',
- normal: 'Stable hips with symmetric abduction ≥70°; no Galeazzi; symmetric skin folds',
- abnormalHints: ['Positive Ortolani / Barlow (before 3mo)', 'Limited abduction after 3mo', 'Asymmetric thigh folds', 'Galeazzi (shortened femur on affected side)'] },
- { name: 'Gross-motor observation', technique: 'Observe head control in prone and pull-to-sit; rolling; sitting; standing — appropriate to age.',
- normal: 'Age-appropriate motor milestones (e.g., sits without support by 6mo, pulls to stand by 9mo)',
- abnormalHints: ['Asymmetric movement', 'Persistent fisting past 3mo', 'Scissoring', 'Delayed or regressed milestones'] },
- { name: 'Spine', technique: 'Palpate midline when sitting. Observe kyphosis/lordosis as development progresses.',
- normal: 'Midline spine; physiologic gentle kyphosis in young infant; no masses',
- abnormalHints: ['Fixed kyphoscoliosis', 'Sacral dimple with cutaneous marker', 'Palpable step-off'] },
- { name: 'Extremities', technique: 'Passive range of all major joints. Inspect feet.',
- normal: 'Full range of all joints; feet correctable and aligning; no rigid deformity',
- abnormalHints: ['Rigid clubfoot', 'Persistent asymmetric tone', 'Joint swelling / warmth (septic arthritis)'] },
- { name: 'Clavicles', technique: 'Palpate bilaterally (if not done at newborn).',
- normal: 'Intact, smooth, symmetric',
- abnormalHints: ['Healed fracture callus palpable (usually benign finding)'] }
+ { name: 'Hips — continued DDH screen', steps: [
+ { label: 'Thigh-fold symmetry', method: 'Inspect with infant supine, thighs flexed', normal: 'Symmetric folds' },
+ { label: 'Barlow/Ortolani (through 3mo)', method: 'As in newborn — thumb medial, flex 90°, adduct+push then abduct+lift', normal: 'Negative bilaterally' },
+ { label: 'Abduction (any age)', method: 'Flex 90°, abduct simultaneously', normal: '≥70° symmetric abduction' },
+ { label: 'Galeazzi', method: 'Knees flexed feet flat on exam table', normal: 'Knees equal height' }
+ ], abnormalHints: ['Clunk on Barlow/Ortolani (<3mo)', 'Limited abduction', 'Asymmetric folds', 'Positive Galeazzi'] },
+
+ { name: 'Gross-motor milestones (age-appropriate)', steps: [
+ { label: 'Head control', method: 'Prone, pull-to-sit, held upright', normal: 'Age-appropriate: 2mo lifts head 45°; 4mo no head lag' },
+ { label: 'Rolling', method: 'Observe on flat surface', normal: 'Rolls back-to-front by 5–6mo' },
+ { label: 'Sitting', method: 'Place in sitting position', normal: 'Tripod sit by 6mo; sits without support by 7–8mo' },
+ { label: 'Standing', method: 'Support under arms', normal: 'Bears weight by 6mo; pulls to stand by 9mo' }
+ ], abnormalHints: ['Milestone delay by ≥2mo', 'Loss of previously attained milestone', 'Asymmetric use of limbs'] },
+
+ { name: 'Spine', steps: [
+ { label: 'Palpate seated', method: 'Run finger along spine with infant sitting or held upright', normal: 'Midline, no step-offs' },
+ { label: 'Back curvature', method: 'Inspect sitting and lying', normal: 'Physiologic gentle kyphosis in early infancy; lumbar lordosis as sitting develops' }
+ ], abnormalHints: ['Fixed kyphoscoliosis', 'Sacral dimple with cutaneous marker', 'Step-off'] },
+
+ { name: 'Extremities', steps: [
+ { label: 'Passive range', method: 'Through each major joint', normal: 'Full symmetric range' },
+ { label: 'Joint inspection', method: 'Inspect for swelling, warmth, effusion', normal: 'No swelling, warmth, or effusion' },
+ { label: 'Feet alignment', method: 'Observe standing if pulling up, else passive positioning', normal: 'Correctable or aligned feet; flexible' }
+ ], abnormalHints: ['Joint swelling/warmth (septic vs reactive arthritis)', 'Rigid clubfoot', 'Persistent asymmetric tone'] }
]
},
neuro: {
- overview: 'Focus: primitive reflexes should be fading on a predictable schedule; protective reflexes should be emerging; milestones and tone tracked together.',
+ overview: 'Primitive reflexes fading on schedule; protective reflexes emerging; gross motor and tone interlinked.',
components: [
- { name: 'Level of alertness', technique: 'Engage with face, voice, and age-appropriate object (rattle, toy).',
- normal: 'Alert, socially engaged, tracks and reaches appropriately for age',
- abnormalHints: ['Poor social engagement', 'Absent visual tracking past 3mo'] },
- { name: 'Cranial nerves', technique: 'Visual tracking (180° by 3mo), pupil response, facial symmetry with smile/cry, intact suck, symmetric tongue.',
- normal: 'Tracks past midline; pupils equal reactive; symmetric facial movement',
- abnormalHints: ['Persistent nystagmus', 'Strabismus past 4mo', 'Asymmetric facial movement'] },
- { name: 'Tone', technique: 'Pull-to-sit (no head lag by 4mo), ventral suspension, vertical suspension.',
- normal: 'Age-appropriate tone; no head lag by 4mo; no slip-through on vertical suspension',
- abnormalHints: ['Persistent head lag past 4mo (hypotonia)', 'Hypertonia / scissoring (UMN / CP)', 'Mixed tone (dyskinetic)'] },
- { name: 'Primitive reflex status', technique: 'Assess Moro, grasp, tonic neck, Galant — all should be integrated (gone) by 6 months.',
- normal: 'Primitive reflexes fading on schedule (Moro absent by 6mo, palmar grasp by 5–6mo, tonic neck by 4–6mo)',
- abnormalHints: ['Persistence of any primitive reflex past 6mo warrants evaluation (CP, CNS injury)'] },
- { name: 'Protective / parachute reflex', technique: '6–9mo and beyond: hold prone, tilt head-down suddenly. Observe protective arm extension.',
- normal: 'Symmetric arm extension protectively by 9mo (emerges 6–9mo)',
- abnormalHints: ['Absent parachute after 12mo (significant concern)', 'Asymmetric response'] },
- { name: 'Gait (if walking)', technique: 'Observe barefoot walking on flat surface if baby is ambulating.',
- normal: 'Wide-based, arms high guard; improving symmetry; appropriate for age',
- abnormalHints: ['Persistent toe-walking', 'Asymmetric stride / limp', 'Ataxic or scissoring gait'] }
+ { name: 'Alertness and social engagement', steps: [
+ { label: 'Social smile', method: 'Face-to-face interaction', normal: 'Social smile by 6–8 weeks' },
+ { label: 'Tracking', method: 'Move object across visual field', normal: '180° horizontal tracking by 3mo' },
+ { label: 'Engagement', method: 'Face-to-face, voice, toys', normal: 'Age-appropriate reciprocal interaction' }
+ ], abnormalHints: ['No social smile by 3mo', 'Absent tracking past 3mo', 'Poor engagement (developmental concern)'] },
+
+ { name: 'Cranial nerves', steps: [
+ { label: 'Pupils', method: 'Light response each eye', normal: 'Equal reactive' },
+ { label: 'Eye alignment', method: 'Inspect with gaze forward and in all directions', normal: 'No strabismus past 4mo' },
+ { label: 'Facial symmetry', method: 'Observe smile and cry', normal: 'Symmetric' },
+ { label: 'Suck and swallow', method: 'Observe feeding', normal: 'Coordinated, no choking' }
+ ], abnormalHints: ['Persistent nystagmus', 'Strabismus past 4mo', 'Asymmetric face'] },
+
+ { name: 'Tone', steps: [
+ { label: 'Pull-to-sit', method: 'Gently pull wrists/hands', normal: 'No head lag by 4mo' },
+ { label: 'Ventral suspension', method: 'Support prone, observe', normal: 'Head above horizontal, extremities actively flexed (age-dependent)' },
+ { label: 'Vertical suspension', method: 'Support under arms, lift', normal: 'Does not slip through hands' }
+ ], abnormalHints: ['Persistent head lag past 4mo (hypotonia)', 'Hypertonia / scissoring (UMN)', 'Slip-through on vertical suspension'] },
+
+ { name: 'Primitive reflex integration', steps: [
+ { label: 'Moro', method: 'Head drop or clap', normal: 'Absent by 6mo' },
+ { label: 'Palmar grasp', method: 'Press into palm', normal: 'Integrated by 5–6mo; replaced by voluntary grasp' },
+ { label: 'Tonic neck', method: 'Turn head to side', normal: 'Absent by 6mo' },
+ { label: 'Rooting', method: 'Stroke cheek', normal: 'Absent by 3–4mo' }
+ ], abnormalHints: ['Persistence of any primitive reflex past 6mo warrants eval (CP, CNS injury)'] },
+
+ { name: 'Protective and postural reflexes', steps: [
+ { label: 'Parachute', method: 'Held prone, tilt head downward suddenly', normal: 'Symmetric arm extension protectively by 9mo (emerges 6–9mo)' },
+ { label: 'Lateral propping', method: 'Seated infant, gentle tilt to one side', normal: 'Arm extends to catch by 6–7mo' },
+ { label: 'Landau', method: 'Suspend prone', normal: 'Extends head, spine, legs by 6mo' }
+ ], abnormalHints: ['Absent parachute after 12mo (concerning)', 'Asymmetric lateral propping', 'Absent Landau'] }
]
}
},
@@ -124,49 +187,86 @@
toddler: {
label: 'Toddler (1–3 years)',
msk: {
- overview: 'Focus: gait, physiologic alignment changes (bow-legs → knock-knees around age 2–3), in-toeing, and joint range.',
+ overview: 'Gait, physiologic alignment changes, in-toeing, joint range. Cooperation unpredictable — use play.',
components: [
- { name: 'Gait', technique: 'Observe barefoot walking, running if age-appropriate. Note base, symmetry, heel-strike.',
- normal: 'Symmetric stride; base narrowing; heel-strike present; arms swinging reciprocally',
- abnormalHints: ['Persistent toe-walking past 2y (idiopathic vs CP)', 'Limp (Legg-Calvé-Perthes, transient synovitis, SCFE)', 'Wide-based ataxic gait'] },
- { name: 'Alignment — knees', technique: 'Stand with feet together. Measure intercondylar (varum) or intermalleolar (valgum) distance if abnormal.',
- normal: 'Physiologic genu varum resolves by 18–24mo; genu valgum common by 2–4y and peaks at 3–4y',
- abnormalHints: ['Persistent varum past 2y', 'Severe valgum (>8cm intermalleolar)', 'Unilateral alignment abnormality (Blount disease, rickets)'] },
- { name: 'Alignment — feet', technique: 'Observe foot position on gait and stance. Check forefoot adduction, heel alignment.',
- normal: 'Mild in-toeing and flexible flat feet are physiologic',
- abnormalHints: ['Rigid flat foot (tarsal coalition)', 'Fixed metatarsus adductus', 'Persistent severe in-toeing (femoral anteversion, tibial torsion)'] },
- { name: 'Joint range of motion', technique: 'Passive range of hips, knees, ankles, shoulders, elbows, wrists.',
- normal: 'Full symmetric range at all joints; no pain, crepitus, or swelling',
- abnormalHints: ['Joint effusion (septic vs reactive)', 'Guarded motion', 'Asymmetric limitation'] },
- { name: 'Spine', technique: 'Inspect standing. Palpate midline. Observe symmetry of shoulders and hips.',
- normal: 'Midline spine, symmetric shoulders and hips; mild lumbar lordosis is normal',
- abnormalHints: ['Fixed scoliosis', 'Abnormal kyphosis', 'Palpable step-off', 'Pain with palpation'] }
+ { name: 'Gait', steps: [
+ { label: 'Base of support', method: 'Have child walk ~10 feet', normal: 'Wide-based initially, narrowing by 2y' },
+ { label: 'Heel-strike', method: 'Observe foot contact pattern', normal: 'Heel-strike developing by 18mo, consistent by 2y' },
+ { label: 'Arm swing', method: 'Observe reciprocal arm swing', normal: 'Reciprocal arm swing by 18mo' },
+ { label: 'Symmetry', method: 'Watch both sides in stance and swing', normal: 'Symmetric stride length and cadence' }
+ ], abnormalHints: ['Toe-walking past 2y (idiopathic vs CP vs DMD)', 'Limp (Legg-Calvé-Perthes, transient synovitis, trauma)', 'Wide-based ataxia'] },
+
+ { name: 'Knee alignment', steps: [
+ { label: 'Stand feet together', method: 'Feet/medial malleoli touching; inspect knees', normal: 'Genu varum resolving by 18–24mo; mild genu valgum common by 2–3y' },
+ { label: 'Intercondylar or intermalleolar distance', method: 'Measure if alignment appears abnormal', normal: '<5cm intercondylar (varum) or <8cm intermalleolar (valgum)' },
+ { label: 'Symmetry', method: 'Compare sides', normal: 'Symmetric' }
+ ], abnormalHints: ['Persistent varum past 2y', 'Severe valgum >8cm', 'Unilateral (Blount disease, rickets)'] },
+
+ { name: 'Feet alignment', steps: [
+ { label: 'In-toeing / out-toeing', method: 'Observe foot angle during gait', normal: 'Mild in-toeing common (tibial torsion, femoral anteversion)' },
+ { label: 'Arch during stance', method: 'Stand flat, then on tiptoes', normal: 'Flexible flat foot that forms arch on tiptoe' },
+ { label: 'Heel alignment', method: 'View from behind standing', normal: 'Neutral or mildly valgus heel' }
+ ], abnormalHints: ['Rigid flat foot (tarsal coalition)', 'Fixed metatarsus adductus', 'Severe in-toeing >15°'] },
+
+ { name: 'Joint range', steps: [
+ { label: 'Hips', method: 'Flex, abduct, rotate each hip', normal: 'Full symmetric range, no pain' },
+ { label: 'Knees', method: 'Flex, extend; palpate for effusion', normal: 'Full range, no effusion, stable' },
+ { label: 'Ankles', method: 'Dorsiflex, plantarflex, invert, evert', normal: 'Full range' },
+ { label: 'Shoulders, elbows, wrists', method: 'Through full range each', normal: 'Full symmetric range' }
+ ], abnormalHints: ['Joint effusion (septic vs reactive)', 'Guarded or painful motion', 'Asymmetric limitation'] },
+
+ { name: 'Spine', steps: [
+ { label: 'Inspect standing', method: 'View spine from behind', normal: 'Midline, no prominent curve' },
+ { label: 'Palpate midline', method: 'Run finger along spinous processes', normal: 'Midline, no step-off, no tenderness' },
+ { label: 'Shoulder/hip symmetry', method: 'Compare shoulder and hip heights', normal: 'Symmetric' }
+ ], abnormalHints: ['Fixed scoliosis', 'Abnormal kyphosis', 'Asymmetric shoulder/hip', 'Midline tenderness'] }
]
},
neuro: {
- overview: 'Focus: transition to adult-pattern exam. Primitive reflexes should be absent. Cooperation varies — use play-based techniques.',
+ overview: 'Shifting to adult-pattern exam. Primitive reflexes should be absent. Use play-based techniques.',
components: [
- { name: 'Mental status', technique: 'Observe engagement, language use, ability to follow simple commands.',
- normal: 'Alert, interactive, age-appropriate language and commands',
- abnormalHints: ['Language regression', 'Poor engagement', 'Repetitive behaviors (developmental concern)'] },
- { name: 'Cranial nerves', technique: 'Follow finger or toy for EOMs; smile/grimace for facial symmetry; open mouth and tongue protrusion.',
- normal: 'EOMs intact; symmetric face; tongue midline',
- abnormalHints: ['Strabismus', 'Facial asymmetry', 'Tongue deviation'] },
- { name: 'Motor — tone and bulk', technique: 'Passive range all four extremities; observe bulk.',
- normal: 'Normal tone and bulk throughout; no contractures',
- abnormalHints: ['Hypotonia', 'Spasticity (especially catch in lower extremities)', 'Muscle wasting'] },
- { name: 'Motor — strength (functional)', technique: 'Observe rising from floor (Gowers maneuver), climbing, squatting.',
- normal: 'Rises from floor without Gowers; climbs onto furniture without difficulty',
- abnormalHints: ['Gowers sign (proximal weakness — Duchenne muscular dystrophy)', 'Inability to climb at expected age'] },
- { name: 'Deep tendon reflexes', technique: 'Patellar, biceps with distraction (toy). Achilles if tolerated.',
- normal: '2+ symmetric DTRs throughout',
- abnormalHints: ['Hyperreflexia / clonus (UMN)', 'Absent reflexes (LMN, neuropathy)'] },
- { name: 'Coordination / gait', technique: 'Observe walking, running, climbing stairs, kicking ball if age-appropriate.',
- normal: 'Age-appropriate coordination; able to run, climb stairs with rail',
- abnormalHints: ['Ataxic gait', 'Tremor with action', 'Clumsiness beyond age expectation'] },
- { name: 'Plantar response', technique: 'Stroke lateral sole from heel toward toes.',
- normal: 'Down-going (plantar flexion) by age 2',
- abnormalHints: ['Up-going after age 2 is an upper-motor-neuron sign (Babinski positive)'] }
+ { name: 'Mental status and language', steps: [
+ { label: 'Engagement', method: 'Interaction with examiner/parent', normal: 'Alert, interactive, age-appropriate' },
+ { label: 'Language — expressive', method: 'Note spontaneous utterances', normal: '1y: 1–3 words; 2y: 2-word phrases; 3y: short sentences' },
+ { label: 'Language — receptive', method: 'Ask to point to body parts or follow simple commands', normal: 'Follows age-appropriate commands' }
+ ], abnormalHints: ['Language regression (autism, epileptic encephalopathy)', 'Poor engagement', 'No 2-word phrases by 2y'] },
+
+ { name: 'Cranial nerves', steps: [
+ { label: 'CN II — pupil response', method: 'Shine light each eye', normal: 'Pupils equal reactive' },
+ { label: 'CN III, IV, VI — EOM', method: 'Follow toy in H pattern', normal: 'Full smooth tracking, no strabismus' },
+ { label: 'CN V — facial sensation', method: 'Light touch on forehead, cheek, jaw', normal: 'Responds to touch, symmetric' },
+ { label: 'CN VII — face', method: 'Elicit smile, watch eye closure during cry', normal: 'Symmetric face' },
+ { label: 'CN IX, X, XII — mouth', method: 'Say "ahh"; stick out tongue', normal: 'Palate rises symmetrically; tongue midline' }
+ ], abnormalHints: ['Strabismus', 'Facial asymmetry', 'Tongue deviation', 'Absent palate elevation'] },
+
+ { name: 'Motor — tone and bulk', steps: [
+ { label: 'Passive tone', method: 'Move each limb through full range', normal: 'Normal resistance throughout' },
+ { label: 'Bulk inspection', method: 'Inspect muscle bulk of thighs, calves, glutes', normal: 'Symmetric, age-appropriate bulk' },
+ { label: 'Contracture check', method: 'Test for heel-cord tightness, hamstring tightness', normal: 'No contractures' }
+ ], abnormalHints: ['Spasticity (especially catch in ankles)', 'Hypotonia', 'Calf pseudo-hypertrophy (DMD)'] },
+
+ { name: 'Motor — functional strength', steps: [
+ { label: 'Rising from floor', method: 'Place flat on back; ask to stand up', normal: 'Rises without using hands to push off thighs (no Gowers)' },
+ { label: 'Climbing stairs', method: 'Observe or history', normal: 'Climbs holding rail' },
+ { label: 'Squatting/getting up', method: 'Encourage via play', normal: 'Squats and rises without help' }
+ ], abnormalHints: ['Gowers sign (proximal weakness — DMD)', 'Unable to climb stairs at age expected', 'Calf pain on walking (myositis)'] },
+
+ { name: 'Deep tendon reflexes', steps: [
+ { label: 'Patellar', method: 'Sitting or supine with distraction (toy)', normal: '2+ symmetric' },
+ { label: 'Biceps', method: 'Arm at rest, strike thumb on tendon', normal: '2+ symmetric' },
+ { label: 'Achilles', method: 'With distraction', normal: '2+ symmetric' }
+ ], abnormalHints: ['Hyperreflexia or clonus (UMN, CP)', 'Absent reflexes (LMN, neuropathy)', 'Asymmetry'] },
+
+ { name: 'Coordination and gait', steps: [
+ { label: 'Run', method: 'Watch run ~10 feet', normal: 'Runs with reciprocal arm swing by 2y' },
+ { label: 'Stairs', method: 'Observe', normal: 'Climbs with rail' },
+ { label: 'Kick ball', method: 'Place ball; observe kick', normal: 'Kicks by 2y' },
+ { label: 'Ataxia check', method: 'Watch for fluency of movement', normal: 'Smooth, no tremor' }
+ ], abnormalHints: ['Ataxic gait', 'Intention tremor', 'Clumsiness beyond age'] },
+
+ { name: 'Plantar response', steps: [
+ { label: 'Stroke lateral sole', method: 'Firm stroke from heel to toes', normal: 'Down-going great toe (plantar flexion) by age 2' }
+ ], abnormalHints: ['Up-going toe after age 2 = UMN sign (Babinski positive)'] }
]
}
},
@@ -174,49 +274,101 @@
preschool: {
label: 'Preschool (3–5 years)',
msk: {
- overview: 'Focus: functional gait maneuvers, scoliosis screen, and resolving physiologic alignment.',
+ overview: 'Functional gait maneuvers, scoliosis screen, resolving physiologic alignment.',
components: [
- { name: 'Gait (normal, heel, toe, tandem)', technique: 'Have child walk normally, on heels, on toes, heel-to-toe. Hop on one foot (4y+).',
- normal: 'Symmetric smooth gait; able to heel-walk, toe-walk, and tandem; hops on one foot by 4–5y',
- abnormalHints: ['Persistent toe-walking', 'Asymmetric stance', 'Difficulty with tandem'] },
- { name: 'Alignment', technique: 'Stand barefoot. Check knees, feet alignment.',
- normal: 'Mild residual genu valgum resolving; neutral by 6–7y; medial arch developing',
- abnormalHints: ['Persistent unilateral varum', 'Rigid flat foot'] },
- { name: 'Scoliosis screen (Adam forward-bend)', technique: 'Child bends forward at waist, arms hanging. Observe for rib or lumbar hump.',
- normal: 'Symmetric paraspinal contour; no rib hump or lumbar prominence',
- abnormalHints: ['Rib hump (thoracic scoliosis)', 'Asymmetric shoulder / scapular height', 'Leg-length discrepancy causing apparent curve'] },
- { name: 'Joint range and stability', technique: 'Active and passive range all joints. Check knee stability, elbow carrying angle.',
- normal: 'Full symmetric range; stable joints; normal carrying angle',
- abnormalHints: ['Hypermobility (Beighton score)', 'Joint effusion', 'Pain with motion'] },
- { name: 'Feet', technique: 'Stand and on tiptoes. Observe arch formation.',
- normal: 'Flexible flat feet common; arch forms on tiptoe (flexible); symmetric',
- abnormalHints: ['Rigid flat foot (does not form arch on tiptoe)', 'Pain'] }
+ { name: 'Gait — multiple patterns', steps: [
+ { label: 'Normal gait', method: 'Walk ~15 feet barefoot', normal: 'Symmetric, smooth, reciprocal arm swing' },
+ { label: 'Heel walking', method: 'Walk on heels only', normal: 'Able by 4y' },
+ { label: 'Toe walking', method: 'Walk on toes only', normal: 'Able by 4y' },
+ { label: 'Tandem walking', method: 'Heel-to-toe along a line for 5 steps', normal: 'Able by 4y with minimal deviation' },
+ { label: 'Hopping', method: 'Hop on one foot', normal: '3–5 hops on preferred foot by 4y' }
+ ], abnormalHints: ['Persistent toe-walking', 'Asymmetric stance/stride', 'Difficulty with any pattern'] },
+
+ { name: 'Alignment', steps: [
+ { label: 'Knee alignment', method: 'Stand feet together', normal: 'Mild residual valgus resolving; neutral by 6–7y' },
+ { label: 'Foot arch', method: 'Standing, then tiptoe', normal: 'Arch forms on tiptoe (flexible flat foot)' },
+ { label: 'Heel position', method: 'View from behind standing', normal: 'Neutral or mild valgus' }
+ ], abnormalHints: ['Persistent unilateral varum', 'Rigid flat foot (no arch on tiptoe)', 'Pes cavus'] },
+
+ { name: 'Scoliosis screen (Adam forward-bend)', steps: [
+ { label: 'Position', method: 'Feet together, bend forward at waist, arms hanging, palms together', normal: 'Arms and head relaxed' },
+ { label: 'View from behind', method: 'Examiner at same height; look along back', normal: 'Symmetric paraspinal contour' },
+ { label: 'View from side', method: 'Side view for kyphosis', normal: 'Smooth thoracic curve' }
+ ], abnormalHints: ['Rib hump (thoracic scoliosis)', 'Lumbar prominence', 'Asymmetric scapular height'] },
+
+ { name: 'Joint range and stability', steps: [
+ { label: 'Active range', method: 'Ask to perform full range at hips, knees, ankles, shoulders, elbows, wrists', normal: 'Full symmetric range, no pain' },
+ { label: 'Knee stability', method: 'Palpate for effusion; assess stability if complaint', normal: 'Stable, no effusion' },
+ { label: 'Carrying angle (elbows)', method: 'Arms at sides, palms forward', normal: 'Normal valgus carrying angle' }
+ ], abnormalHints: ['Joint hypermobility (Beighton score)', 'Effusion', 'Pain with motion', 'Valgus >15°'] },
+
+ { name: 'Feet', steps: [
+ { label: 'Standing inspection', method: 'View from front and behind', normal: 'Symmetric feet, neutral heel, flexible flat feet common' },
+ { label: 'Tiptoe', method: 'Stand on tiptoes', normal: 'Arch forms, symmetric' },
+ { label: 'Pes planus vs cavus', method: 'Note arch height', normal: 'Flexible flat foot or mild arch' }
+ ], abnormalHints: ['Rigid flat foot', 'Pes cavus (Charcot-Marie-Tooth)', 'Pain'] }
]
},
neuro: {
- overview: 'Focus: more formal exam now possible — most 4- and 5-year-olds cooperate with cranial nerves, strength, coordination, and sensory testing.',
+ overview: 'Formal pediatric neuro exam now feasible — most 4- and 5-year-olds cooperate with structured testing.',
components: [
- { name: 'Mental status / language', technique: 'Observe speech intelligibility, complexity, and ability to follow 2- and 3-step commands.',
- normal: 'Speech clear to strangers by 4y; complex sentences; follows multi-step commands',
- abnormalHints: ['Dysarthria', 'Receptive or expressive language delay', 'Poor engagement'] },
- { name: 'Cranial nerves (II–XII)', technique: 'Vision by charts if age-appropriate; EOMs with toy; facial sensation with light touch; symmetric smile; tongue protrusion; shoulder shrug; uvula elevation.',
- normal: 'Intact throughout',
- abnormalHints: ['Strabismus', 'Facial asymmetry', 'Uvula deviation', 'Tongue fasciculations'] },
- { name: 'Motor — tone, bulk, strength', technique: 'Passive range. Test 5/5 strength in major groups (stand from squat, grip squeeze, arm lift against resistance).',
- normal: 'Normal tone and bulk; 5/5 strength symmetrically',
- abnormalHints: ['Spasticity', 'Weakness (Gowers if proximal)', 'Atrophy'] },
- { name: 'Deep tendon reflexes', technique: 'Biceps, patellar, Achilles. Compare side to side.',
- normal: '2+ symmetric DTRs throughout; down-going plantar response bilaterally',
- abnormalHints: ['Hyperreflexia with clonus', 'Asymmetry', 'Up-going plantar (Babinski)'] },
- { name: 'Coordination', technique: 'Finger-to-nose, heel-to-shin, rapid alternating hand movements, tandem walk.',
- normal: 'Smooth finger-to-nose, intact tandem; rapid alternating movements coordinated',
- abnormalHints: ['Dysmetria', 'Dysdiadochokinesia', 'Ataxic tandem'] },
- { name: 'Sensory (light touch)', technique: 'Light touch distally on all four extremities with eyes closed (if cooperative).',
- normal: 'Symmetric light touch throughout',
- abnormalHints: ['Focal sensory loss', 'Stocking-glove pattern'] },
- { name: 'Gait (multiple patterns)', technique: 'Normal, heel, toe, tandem, hop on one foot, Romberg (5y+).',
- normal: 'All maneuvers performed without difficulty',
- abnormalHints: ['Romberg positive (dorsal column)', 'Ataxic tandem (cerebellar)'] }
+ { name: 'Mental status and language', steps: [
+ { label: 'Orientation (age-appropriate)', method: 'Ask name, age, where you are', normal: 'Knows name and age by 3y; location by 4–5y' },
+ { label: 'Speech intelligibility', method: 'Listen to spontaneous speech', normal: 'Strangers understand by 4y' },
+ { label: 'Receptive language', method: '2- and 3-step commands', normal: 'Follows 3-step commands by 4–5y' }
+ ], abnormalHints: ['Dysarthria', 'Expressive or receptive language delay', 'Inattention'] },
+
+ { name: 'Cranial nerves (II–XII)', steps: [
+ { label: 'CN II — visual acuity', method: 'HOTV chart or pictures at 10ft, each eye', normal: '20/30 or better by 4y; 20/25 by 5y' },
+ { label: 'CN II — visual fields', method: 'Confrontation with toys from periphery', normal: 'Full fields' },
+ { label: 'CN II — pupils', method: 'Light response each eye', normal: 'PERRL' },
+ { label: 'CN III, IV, VI — EOM', method: 'Follow toy in H pattern; include convergence', normal: 'Full EOM, convergence present' },
+ { label: 'CN V — sensation', method: 'Light touch forehead, cheek, jaw each side', normal: 'Intact, symmetric' },
+ { label: 'CN V — motor', method: 'Clench teeth, palpate masseter', normal: 'Symmetric strong bulk' },
+ { label: 'CN VII — face', method: 'Smile, wrinkle forehead, close eyes, puff cheeks', normal: 'Symmetric movement of all regions' },
+ { label: 'CN VIII — hearing', method: 'Finger rub each ear or whispered words', normal: 'Intact bilaterally' },
+ { label: 'CN IX, X — palate', method: 'Open mouth, say "ahh"', normal: 'Palate rises symmetrically, uvula midline' },
+ { label: 'CN XI — SCM/trapezius', method: 'Shrug shoulders, turn head against resistance', normal: 'Symmetric strength' },
+ { label: 'CN XII — tongue', method: 'Stick tongue out, move side to side', normal: 'Midline, no atrophy, full movement' }
+ ], abnormalHints: ['Strabismus (amblyopia risk)', 'Facial weakness', 'Tongue deviation/fasciculations', 'Uvula off-midline'] },
+
+ { name: 'Motor — tone, bulk, strength', steps: [
+ { label: 'Tone inspection', method: 'Passive range all four limbs', normal: 'Normal tone throughout' },
+ { label: 'Bulk inspection', method: 'Observe muscle bulk symmetry', normal: 'Symmetric, age-appropriate' },
+ { label: 'Strength — shoulder abduction', method: 'Arms out, push down against resistance', normal: '5/5 bilaterally' },
+ { label: 'Strength — elbow flexion', method: 'Flex elbow against resistance', normal: '5/5 bilaterally' },
+ { label: 'Strength — grip', method: 'Squeeze examiner\'s fingers', normal: '5/5 symmetric' },
+ { label: 'Strength — hip flexion', method: 'Lift leg off table against resistance', normal: '5/5 bilaterally' },
+ { label: 'Strength — knee extension', method: 'Straighten knee against resistance', normal: '5/5 bilaterally' },
+ { label: 'Strength — dorsiflexion', method: 'Pull toes up against resistance', normal: '5/5 bilaterally' }
+ ], abnormalHints: ['Focal weakness', 'Gowers sign', 'Pseudohypertrophy (DMD)', 'Atrophy'] },
+
+ { name: 'Deep tendon reflexes', steps: [
+ { label: 'Biceps', method: 'Thumb on biceps tendon, strike', normal: '2+ symmetric' },
+ { label: 'Patellar', method: 'Knees hanging, strike patellar tendon', normal: '2+ symmetric' },
+ { label: 'Achilles', method: 'Slight dorsiflexion, strike Achilles tendon', normal: '2+ symmetric' },
+ { label: 'Plantar response', method: 'Stroke lateral sole heel-to-toes', normal: 'Down-going great toe' }
+ ], abnormalHints: ['Hyperreflexia or clonus (UMN)', 'Hyporeflexia (LMN)', 'Up-going plantar (Babinski — abnormal past 2y)', 'Asymmetry'] },
+
+ { name: 'Coordination', steps: [
+ { label: 'Finger-to-nose', method: 'Touch examiner\'s finger then own nose, repeat', normal: 'Smooth, no dysmetria' },
+ { label: 'Heel-to-shin', method: 'Run heel down opposite shin', normal: 'Smooth bilaterally' },
+ { label: 'Rapid alternating movements', method: 'Tap palm with opposite hand alternating palm/back', normal: 'Rhythmic, symmetric' },
+ { label: 'Tandem walk', method: 'Heel-to-toe for 5 steps', normal: 'Minimal deviation' }
+ ], abnormalHints: ['Dysmetria', 'Dysdiadochokinesia', 'Intention tremor', 'Ataxic tandem'] },
+
+ { name: 'Sensory', steps: [
+ { label: 'Light touch — hands', method: 'Cotton wisp on palm/dorsum, eyes closed', normal: 'Feels each touch' },
+ { label: 'Light touch — feet', method: 'Same on dorsum of foot bilaterally', normal: 'Feels each touch' }
+ ], abnormalHints: ['Focal sensory loss', 'Stocking-glove loss'] },
+
+ { name: 'Gait and Romberg', steps: [
+ { label: 'Normal gait', method: 'Walk ~20 feet', normal: 'Smooth, symmetric' },
+ { label: 'Heel walk', method: 'Walk on heels', normal: 'Able without difficulty' },
+ { label: 'Toe walk', method: 'Walk on toes', normal: 'Able without difficulty' },
+ { label: 'Tandem', method: 'Heel-to-toe', normal: 'Intact' },
+ { label: 'Romberg (5y+)', method: 'Feet together, eyes closed, stand 10s', normal: 'Stable without sway' }
+ ], abnormalHints: ['Ataxic gait (cerebellar)', 'Romberg positive (dorsal column)', 'Circumduction (UMN)'] }
]
}
},
@@ -224,49 +376,116 @@
school: {
label: 'School-age (6–11 years)',
msk: {
- overview: 'Focus: scoliosis screening (especially peri-puberty), sports-related overuse, and resolution of alignment.',
+ overview: 'Scoliosis screening peri-puberty, sports overuse injuries, resolving alignment.',
components: [
- { name: 'Scoliosis screen (forward-bend)', technique: 'Adam forward-bend test. Consider scoliometer if available (angle of trunk rotation).',
- normal: 'No rib or lumbar prominence; ATR < 5°; symmetric shoulders and hips',
- abnormalHints: ['Rib hump', 'ATR ≥ 7° warrants referral', 'Shoulder or scapular asymmetry'] },
- { name: 'Alignment', technique: 'Standing exam of knees and feet.',
- normal: 'Neutral knee alignment; medial arch present; symmetric',
- abnormalHints: ['Residual valgum', 'Pes cavus (possible CMT)', 'Asymmetric alignment'] },
- { name: 'Joint stability and range', technique: 'Active range all joints. Knee Lachman/anterior drawer if sports-active. Shoulder impingement tests.',
- normal: 'Full stable range at all joints',
- abnormalHints: ['Joint laxity or hypermobility', 'Sports-related instability', 'Pain with specific maneuvers'] },
- { name: 'Gait and functional movement', technique: 'Observe gait, running, squatting, single-leg stance.',
- normal: 'Symmetric efficient gait; able to squat and single-leg stand',
- abnormalHints: ['Trendelenburg sign (hip abductor weakness)', 'Antalgic gait', 'Asymmetric squat depth'] },
- { name: 'Sports-specific exam (if relevant)', technique: 'Targeted to activity — shoulder, knee, ankle per chief complaint.',
- normal: 'No pain, instability, or impingement in tested maneuvers',
- abnormalHints: ['Overuse injury signs (Osgood-Schlatter, Sever, osteochondritis dissecans)', 'Apophysitis'] }
+ { name: 'Scoliosis screen (forward-bend + scoliometer)', steps: [
+ { label: 'Standing inspection', method: 'Shoulders and iliac crest heights', normal: 'Symmetric shoulder and pelvic heights' },
+ { label: 'Forward bend (Adam test)', method: 'Feet together, bend forward at waist, arms hanging palms together', normal: 'Symmetric paraspinal contour' },
+ { label: 'Rib hump', method: 'View tangentially from behind at level of curve', normal: 'No rib hump' },
+ { label: 'Lumbar prominence', method: 'Same view at lumbar level', normal: 'No prominence' },
+ { label: 'Scoliometer (if available)', method: 'Place scoliometer across rib hump, read angle of trunk rotation', normal: 'ATR < 5°; ≥7° → refer' }
+ ], abnormalHints: ['Rib hump', 'ATR ≥7°', 'Asymmetric shoulders or pelvis', 'Decompensation (plumb line offset)'] },
+
+ { name: 'Back and spine', steps: [
+ { label: 'Posture inspection', method: 'Standing, view front/back/side', normal: 'Normal spinal curves; plumb line centered' },
+ { label: 'Palpate spinous processes', method: 'From C2 to S1', normal: 'No tenderness, no step-off' },
+ { label: 'Range of motion', method: 'Flex, extend, lateral bend, rotate', normal: 'Full painless range' }
+ ], abnormalHints: ['Midline tenderness', 'Step-off (spondylolisthesis)', 'Limited motion with pain'] },
+
+ { name: 'Alignment', steps: [
+ { label: 'Knees', method: 'Feet together, inspect', normal: 'Neutral alignment by 6–7y' },
+ { label: 'Feet', method: 'Stand, then tiptoes', normal: 'Medial arch present, symmetric' },
+ { label: 'Leg lengths', method: 'Supine, measure ASIS to medial malleolus if asymmetric', normal: 'Equal within 1cm' }
+ ], abnormalHints: ['Residual valgum', 'Pes cavus', 'Leg-length discrepancy >1cm'] },
+
+ { name: 'Joint stability and sports exam (if active)', steps: [
+ { label: 'Active range all joints', method: 'Through full range', normal: 'Full symmetric range, no pain or crepitus' },
+ { label: 'Knee — Lachman (if sports-active)', method: 'Knee 20° flexion, stabilize femur, pull tibia forward', normal: 'Firm endpoint, no laxity' },
+ { label: 'Knee — McMurray', method: 'Flexed knee, rotate tibia while extending', normal: 'No pain or click' },
+ { label: 'Shoulder — impingement (Neer/Hawkins)', method: 'Passive shoulder flexion with arm in internal rotation', normal: 'No pain' },
+ { label: 'Ankle stability', method: 'Anterior drawer and talar tilt', normal: 'No laxity' }
+ ], abnormalHints: ['ACL laxity (positive Lachman)', 'Meniscal click', 'Shoulder impingement', 'Ankle instability'] },
+
+ { name: 'Gait and functional movement', steps: [
+ { label: 'Normal gait', method: 'Walk 20 feet', normal: 'Smooth, symmetric' },
+ { label: 'Single-leg stance', method: 'Stand on one foot 10s each side', normal: 'Stable without Trendelenburg drop' },
+ { label: 'Squat', method: 'Full squat and rise', normal: 'Full squat without pain or asymmetry' },
+ { label: 'Hop on one foot', method: '5 hops each side', normal: 'Able and symmetric' }
+ ], abnormalHints: ['Trendelenburg sign (hip abductor weakness)', 'Antalgic gait', 'Asymmetric squat', 'Pain with hop'] }
]
},
neuro: {
- overview: 'Focus: adult-pattern exam across all six components (mental status, cranial nerves, motor, reflexes, sensory, coordination/gait).',
+ overview: 'Adult-pattern six-component exam: mental status, CN, motor, reflexes, sensory, coordination/gait.',
components: [
- { name: 'Mental status', technique: 'Orientation, attention (count backward), memory (3-item recall), appropriate language.',
- normal: 'Alert, oriented, attention intact, age-appropriate language',
- abnormalHints: ['Inattention / ADHD signs', 'Language concerns', 'Memory deficit'] },
- { name: 'Cranial nerves (II–XII)', technique: 'Full formal exam including visual fields, EOMs, facial sensation, hearing, palate elevation, tongue.',
- normal: 'All cranial nerves intact',
- abnormalHints: ['Any focal cranial nerve deficit warrants workup'] },
- { name: 'Motor', technique: 'Inspect bulk; test tone; strength 5/5 in major groups (deltoids, biceps, triceps, grip, hip flexors, knee extensors, dorsiflexion).',
- normal: 'Normal bulk and tone; 5/5 strength symmetric',
- abnormalHints: ['Focal weakness', 'Spasticity', 'Atrophy'] },
- { name: 'Deep tendon reflexes', technique: 'Biceps, triceps, brachioradialis, patellar, Achilles. Plantar response.',
- normal: '2+ symmetric DTRs; down-going plantar',
- abnormalHints: ['Hyperreflexia with clonus (UMN)', 'Hyporeflexia (LMN, neuropathy)', 'Asymmetry', 'Up-going Babinski'] },
- { name: 'Sensory', technique: 'Light touch and pain distally; vibration at distal IP joints; proprioception at great toe.',
- normal: 'Intact light touch, pain, vibration, proprioception throughout',
- abnormalHints: ['Stocking-glove loss', 'Dermatomal pattern', 'Loss of vibration or proprioception (dorsal column)'] },
- { name: 'Coordination', technique: 'Finger-nose-finger, heel-shin, rapid alternating movements.',
- normal: 'Smooth coordinated movements bilaterally',
- abnormalHints: ['Dysmetria', 'Intention tremor', 'Dysdiadochokinesia'] },
- { name: 'Gait and Romberg', technique: 'Normal, heel, toe, tandem. Romberg with eyes closed.',
- normal: 'All gait patterns smooth and symmetric; Romberg negative',
- abnormalHints: ['Wide-based gait (cerebellar)', 'Steppage (peripheral neuropathy)', 'Romberg positive (dorsal column)'] }
+ { name: 'Mental status', steps: [
+ { label: 'Orientation', method: 'Name, age, school, city, day of week', normal: 'Oriented x 4' },
+ { label: 'Attention', method: 'Count backward from 20; days of week backward', normal: 'Intact' },
+ { label: '3-item recall', method: 'Ball-flag-tree; ask at 3 and 5 min', normal: '3/3 recall at 5 min' },
+ { label: 'Language', method: 'Name common objects; repeat a sentence', normal: 'Fluent, no paraphasia' }
+ ], abnormalHints: ['Inattention (ADHD features)', 'Memory deficits', 'Word-finding difficulty', 'Perseveration'] },
+
+ { name: 'Cranial nerves (II–XII)', steps: [
+ { label: 'CN II — acuity', method: 'Snellen at 20ft each eye with corrective lenses if worn', normal: '20/20 or baseline' },
+ { label: 'CN II — fields', method: 'Confrontation, 4 quadrants each eye', normal: 'Full fields' },
+ { label: 'CN II — fundoscopy (if indicated)', method: 'Direct ophthalmoscopy — disc, vessels, macula', normal: 'Sharp disc, normal cup-disc ratio, no papilledema' },
+ { label: 'CN II, III — pupils', method: 'Direct and consensual light, accommodation', normal: 'PERRLA' },
+ { label: 'CN III, IV, VI — EOM', method: 'Follow finger in H pattern; convergence', normal: 'Full EOM, no nystagmus, convergence intact' },
+ { label: 'CN V — sensation', method: 'Light touch V1 (forehead), V2 (cheek), V3 (jaw) each side', normal: 'Intact, symmetric' },
+ { label: 'CN V — motor', method: 'Clench teeth, palpate masseter/temporalis; jaw opening', normal: 'Symmetric strength' },
+ { label: 'CN VII', method: 'Raise eyebrows, close eyes tight, smile/show teeth, puff cheeks', normal: 'Symmetric movement, all regions' },
+ { label: 'CN VIII', method: 'Finger rub each ear; Weber/Rinne if deficit', normal: 'Hears bilaterally' },
+ { label: 'CN IX, X', method: 'Palate elevation with "ahh"; uvula midline; voice quality', normal: 'Symmetric elevation, uvula midline, normal voice' },
+ { label: 'CN XI', method: 'Shrug shoulders against resistance; head turn against resistance', normal: '5/5 SCM and trapezius' },
+ { label: 'CN XII', method: 'Stick tongue out; side-to-side', normal: 'Midline, no atrophy or fasciculations' }
+ ], abnormalHints: ['Papilledema (increased ICP)', 'Focal cranial nerve deficit — any warrants workup', 'Tongue fasciculations (LMN/MND)'] },
+
+ { name: 'Motor — bulk, tone, strength', steps: [
+ { label: 'Bulk inspection', method: 'Shoulders, thighs, calves, intrinsic hand muscles', normal: 'Symmetric, no atrophy' },
+ { label: 'Tone', method: 'Passive range at elbows, wrists, knees, ankles', normal: 'Normal resistance throughout' },
+ { label: 'Strength — deltoids', method: 'Shoulder abduction against resistance', normal: '5/5 bilaterally' },
+ { label: 'Strength — biceps', method: 'Elbow flexion against resistance', normal: '5/5' },
+ { label: 'Strength — triceps', method: 'Elbow extension against resistance', normal: '5/5' },
+ { label: 'Strength — grip', method: 'Squeeze 2 fingers', normal: '5/5 symmetric' },
+ { label: 'Strength — finger abduction', method: 'Spread fingers against resistance', normal: '5/5' },
+ { label: 'Strength — hip flexion', method: 'Lift leg supine against resistance', normal: '5/5' },
+ { label: 'Strength — knee extension', method: 'Straighten knee against resistance', normal: '5/5' },
+ { label: 'Strength — dorsiflexion', method: 'Pull toes up against resistance', normal: '5/5' },
+ { label: 'Strength — plantarflexion', method: 'Push foot down against resistance', normal: '5/5' }
+ ], abnormalHints: ['Focal weakness (localize)', 'Spasticity (UMN)', 'Atrophy', 'Fasciculations'] },
+
+ { name: 'Deep tendon reflexes', steps: [
+ { label: 'Biceps (C5-C6)', method: 'Thumb on tendon, strike', normal: '2+ symmetric' },
+ { label: 'Triceps (C7-C8)', method: 'Strike triceps tendon', normal: '2+ symmetric' },
+ { label: 'Brachioradialis (C5-C6)', method: 'Strike distal radius', normal: '2+ symmetric' },
+ { label: 'Patellar (L3-L4)', method: 'Knees hanging, strike tendon', normal: '2+ symmetric' },
+ { label: 'Achilles (S1)', method: 'Slight dorsiflexion, strike tendon', normal: '2+ symmetric' },
+ { label: 'Plantar response', method: 'Stroke lateral sole heel-to-toes', normal: 'Down-going bilaterally' },
+ { label: 'Clonus', method: 'Rapid dorsiflexion at ankle', normal: 'No sustained clonus' }
+ ], abnormalHints: ['Hyperreflexia with clonus (UMN: stroke, MS, cord lesion)', 'Hyporeflexia (LMN, neuropathy, myopathy)', 'Asymmetry', 'Up-going Babinski', 'Sustained clonus'] },
+
+ { name: 'Sensory', steps: [
+ { label: 'Light touch — upper', method: 'Cotton wisp dorsum of hands, eyes closed', normal: 'Intact, symmetric' },
+ { label: 'Light touch — lower', method: 'Same on dorsum of feet', normal: 'Intact, symmetric' },
+ { label: 'Pain — upper', method: 'Broken Q-tip or pin on hands', normal: 'Intact, symmetric' },
+ { label: 'Pain — lower', method: 'Same on feet', normal: 'Intact, symmetric' },
+ { label: 'Vibration', method: '128 Hz tuning fork at distal IP joint of great toes', normal: 'Feels vibration; counts down seconds' },
+ { label: 'Proprioception', method: 'Move great toe up/down with eyes closed', normal: 'Identifies direction correctly' }
+ ], abnormalHints: ['Dermatomal loss (nerve root)', 'Stocking-glove (neuropathy)', 'Loss of vibration/proprioception (dorsal column — B12, tabes, MS)'] },
+
+ { name: 'Coordination', steps: [
+ { label: 'Finger-nose-finger', method: 'Touch examiner finger then own nose, examiner moves target', normal: 'Smooth, accurate, no dysmetria' },
+ { label: 'Heel-to-shin', method: 'Supine: heel down opposite shin', normal: 'Smooth, on-target' },
+ { label: 'Rapid alternating movements', method: 'Supinate/pronate hand on knee rapidly', normal: 'Rhythmic, symmetric' },
+ { label: 'Fine motor', method: 'Finger tapping (thumb to each finger in sequence)', normal: 'Rhythmic, accurate' }
+ ], abnormalHints: ['Dysmetria (past-pointing, overshoot)', 'Intention tremor', 'Dysdiadochokinesia'] },
+
+ { name: 'Gait and Romberg', steps: [
+ { label: 'Normal gait', method: 'Walk 20 feet', normal: 'Narrow-based, smooth, reciprocal arm swing' },
+ { label: 'Heel walk', method: 'Walk on heels', normal: 'Able without difficulty' },
+ { label: 'Toe walk', method: 'Walk on toes', normal: 'Able without difficulty' },
+ { label: 'Tandem', method: 'Heel-to-toe along a line', normal: 'Minimal deviation, 10+ steps' },
+ { label: 'Romberg', method: 'Feet together, eyes closed, 30s', normal: 'Stable without fall or significant sway' }
+ ], abnormalHints: ['Wide-based (cerebellar)', 'Steppage (peripheral neuropathy)', 'Scissoring (UMN)', 'Romberg positive (dorsal column)', 'Circumduction'] }
]
}
},
@@ -274,62 +493,158 @@
adolescent: {
label: 'Adolescent (12–21 years)',
msk: {
- overview: 'Focus: sports-related injuries, late-onset scoliosis, apophyseal overuse injuries, and screening for hypermobility spectrum.',
+ overview: 'Sports-related injuries, adolescent scoliosis, apophyseal overuse, hypermobility screening.',
components: [
- { name: 'Scoliosis screen', technique: 'Adam forward-bend with scoliometer if available. Consider recurrent screening through adolescent growth spurt.',
- normal: 'No rib or lumbar prominence; ATR < 5°',
- abnormalHints: ['Progressive scoliosis (especially girls 10–14)', 'ATR ≥ 7°', 'Shoulder asymmetry'] },
- { name: 'Back / spine', technique: 'Palpate midline and paraspinal muscles. Single-leg hyperextension test if back pain present (spondylolysis).',
- normal: 'Non-tender spine and paraspinals; no pain with hyperextension',
- abnormalHints: ['Midline tenderness (spondylolysis/spondylolisthesis)', 'Positive stork test', 'Radicular symptoms'] },
- { name: 'Joint stability and sports-specific exam', technique: 'Shoulder, knee, ankle exams per activity and complaint. Beighton score if hypermobile presentation.',
- normal: 'Stable joints; no effusion; Beighton < 4',
- abnormalHints: ['ACL/MCL laxity', 'Shoulder apprehension', 'Ankle instability', 'Beighton ≥ 5 (hypermobility spectrum)'] },
- { name: 'Alignment and gait', technique: 'Observe standing posture and walking.',
- normal: 'Neutral alignment; symmetric efficient gait',
- abnormalHints: ['Antalgic gait', 'Leg-length discrepancy', 'Trendelenburg'] },
- { name: 'Overuse / apophysitis screen', technique: 'Palpate tibial tubercle, calcaneal apophysis, iliac apophyses if sports-active.',
- normal: 'Non-tender apophyses',
- abnormalHints: ['Osgood-Schlatter (tibial tubercle)', 'Sever (calcaneal)', 'Iliac apophysitis in sprinters'] }
+ { name: 'Scoliosis screen', steps: [
+ { label: 'Standing inspection', method: 'Patient undressed to waist (keep privacy); compare shoulders, iliac crests, scapular heights', normal: 'Symmetric shoulders and pelvis' },
+ { label: 'Forward bend (Adam)', method: 'Feet together, bend forward, arms hanging palms together', normal: 'Symmetric paraspinal contour' },
+ { label: 'Scoliometer', method: 'Place across thoracic and lumbar regions at maximum prominence', normal: 'ATR <5°; 5–6° monitor; ≥7° refer' },
+ { label: 'Plumb line check', method: 'Drop plumb from C7; note where it falls', normal: 'Passes through gluteal cleft (compensated)' },
+ { label: 'Leg lengths', method: 'Supine; ASIS to medial malleolus each side', normal: 'Within 1cm' }
+ ], abnormalHints: ['Rib/lumbar hump', 'ATR ≥7°', 'Decompensation (plumb off gluteal cleft)', 'Leg-length discrepancy driving apparent curve'] },
+
+ { name: 'Back pain evaluation (if complaint)', steps: [
+ { label: 'Inspect and palpate', method: 'Spinous processes, paraspinal muscles, SI joints', normal: 'Non-tender' },
+ { label: 'Range of motion', method: 'Flex, extend, lateral bend, rotate', normal: 'Full painless range' },
+ { label: 'Single-leg hyperextension (stork)', method: 'Stand on one foot, extend back — each side', normal: 'No pain (negative for spondylolysis)' },
+ { label: 'Straight-leg raise', method: 'Supine, lift straight leg to 70°+', normal: 'No radicular pain to 70°' },
+ { label: 'SI joint tests', method: 'FABER, SI compression', normal: 'No pain' }
+ ], abnormalHints: ['Spondylolysis (positive stork test)', 'Radicular pain (disc herniation)', 'SI joint pathology', 'Inflammatory back pain pattern'] },
+
+ { name: 'Joint stability — sports-specific', steps: [
+ { label: 'Knee — Lachman', method: 'Knee 20° flexion, stabilize femur, pull tibia anteriorly', normal: 'Firm endpoint, no laxity (ACL intact)' },
+ { label: 'Knee — anterior drawer', method: 'Knee 90°, pull tibia forward', normal: 'No excess anterior translation' },
+ { label: 'Knee — varus/valgus stress', method: 'Stress at 0 and 30° flexion', normal: 'No gap opening (LCL/MCL intact)' },
+ { label: 'Knee — McMurray', method: 'Flex, rotate tibia while extending', normal: 'No pain or click' },
+ { label: 'Shoulder — apprehension', method: 'Abduct and externally rotate', normal: 'No apprehension' },
+ { label: 'Shoulder — Neer/Hawkins', method: 'Passive flexion with internal rotation', normal: 'No pain' },
+ { label: 'Ankle — anterior drawer', method: 'Pull heel forward with tibia stabilized', normal: 'No laxity' },
+ { label: 'Ankle — talar tilt', method: 'Invert heel with tibia stabilized', normal: 'No excess tilt' }
+ ], abnormalHints: ['ACL/PCL tear', 'MCL/LCL laxity', 'Meniscal injury', 'Shoulder instability/impingement', 'Ankle ligament laxity'] },
+
+ { name: 'Apophysitis and overuse screen', steps: [
+ { label: 'Tibial tubercle', method: 'Palpate with knee flexed', normal: 'Non-tender' },
+ { label: 'Calcaneal apophysis', method: 'Palpate posterior calcaneus', normal: 'Non-tender' },
+ { label: 'Iliac apophyses', method: 'Palpate ASIS, AIIS, iliac crest', normal: 'Non-tender' },
+ { label: 'Rotator cuff', method: 'Empty-can (Jobe) test', normal: 'No pain or weakness' }
+ ], abnormalHints: ['Osgood-Schlatter (tibial tubercle tender)', 'Sever (calcaneal tender)', 'Iliac apophysitis', 'Rotator cuff tendinopathy'] },
+
+ { name: 'Hypermobility screen (Beighton)', steps: [
+ { label: 'Fifth finger extension', method: 'Passive extension of fifth MCP to >90°', normal: 'No hyperextension (1 pt each side if positive)' },
+ { label: 'Thumb to forearm', method: 'Passive flexion of thumb to touch forearm', normal: 'Does not reach (1 pt each side if positive)' },
+ { label: 'Elbow hyperextension', method: 'Hyperextension >10°', normal: 'No hyperextension (1 pt each side if positive)' },
+ { label: 'Knee hyperextension', method: 'Hyperextension >10°', normal: 'No hyperextension (1 pt each side if positive)' },
+ { label: 'Palms to floor', method: 'Feet together, bend forward, palms flat on floor with knees straight', normal: 'Cannot reach (1 pt if positive)' }
+ ], abnormalHints: ['Beighton ≥5/9 suggests hypermobility spectrum (hEDS workup if with other features)'] },
+
+ { name: 'Alignment and gait', steps: [
+ { label: 'Standing alignment', method: 'View knees, feet', normal: 'Neutral alignment, medial arch' },
+ { label: 'Normal gait', method: 'Walk 20 feet', normal: 'Symmetric, smooth' },
+ { label: 'Functional movements', method: 'Squat, single-leg stance, hop', normal: 'Full symmetric function' }
+ ], abnormalHints: ['Antalgic gait', 'Trendelenburg', 'Asymmetric squat'] }
]
},
neuro: {
- overview: 'Focus: adult-pattern full exam. Screen specifically for concussion sequelae if sports-active; frontal release signs should be absent.',
+ overview: 'Full adult-pattern neuro exam. Screen for concussion sequelae in sports-active adolescents; frontal release signs should be absent.',
components: [
- { name: 'Mental status', technique: 'Orientation, attention, memory, language, executive function (MMSE-style questions tailored to age).',
- normal: 'Alert, oriented, attention/memory intact, age-appropriate executive function',
- abnormalHints: ['Post-concussion cognitive symptoms', 'Mood changes', 'Subtle executive dysfunction'] },
- { name: 'Cranial nerves (II–XII)', technique: 'Full formal adult-pattern exam.',
- normal: 'All cranial nerves intact',
- abnormalHints: ['Any focal deficit'] },
- { name: 'Motor', technique: 'Bulk, tone, 5/5 strength in all major groups. Fine motor (finger tapping).',
- normal: 'Normal bulk, tone, strength throughout',
- abnormalHints: ['Focal weakness', 'Spasticity', 'Subtle tremor'] },
- { name: 'Deep tendon reflexes', technique: 'Biceps, triceps, brachioradialis, patellar, Achilles. Plantar response.',
- normal: '2+ symmetric; down-going plantar',
- abnormalHints: ['Hyperreflexia, clonus, or up-going Babinski (UMN)', 'Hyporeflexia (peripheral nerve, myopathy, hypothyroid)'] },
- { name: 'Sensory', technique: 'Light touch, pain, vibration, proprioception, two-point discrimination.',
- normal: 'Intact modalities throughout',
- abnormalHints: ['Dermatomal loss', 'Length-dependent sensory loss', 'Dorsal column signs'] },
- { name: 'Coordination', technique: 'Finger-nose-finger, heel-shin, rapid alternating, tandem gait.',
- normal: 'Smooth coordinated movements; tandem intact',
- abnormalHints: ['Cerebellar signs', 'Intention tremor'] },
- { name: 'Gait and Romberg', technique: 'Normal, heel, toe, tandem, Romberg.',
- normal: 'All smooth; Romberg negative',
- abnormalHints: ['Ataxic gait', 'Steppage', 'Romberg positive'] },
- { name: 'Frontal release / primitive reflexes', technique: 'Test grasp, snout, glabellar, palmomental. Should be absent.',
- normal: 'Absent — no frontal release signs',
- abnormalHints: ['Presence suggests frontal lobe pathology, neurodegenerative disease, or severe TBI — consider in post-concussion setting'] }
+ { name: 'Mental status', steps: [
+ { label: 'Orientation', method: 'Name, age, date, location, situation', normal: 'Oriented x 4' },
+ { label: 'Attention', method: 'Count backward from 100 by 7s (serial 7s) or months of year backward', normal: 'Intact' },
+ { label: 'Short-term memory', method: '3-item registration and recall at 5 min', normal: '3/3 recall' },
+ { label: 'Language', method: 'Object naming; sentence repetition; reading; writing', normal: 'Fluent, no paraphasia, comprehends written and spoken' },
+ { label: 'Executive function', method: 'Similarities (apple/orange); interpret proverb', normal: 'Abstract, age-appropriate' }
+ ], abnormalHints: ['Post-concussion cognitive changes', 'Mood or personality changes', 'Subtle executive dysfunction', 'Word-finding difficulty'] },
+
+ { name: 'Cranial nerves (II–XII, full formal exam)', steps: [
+ { label: 'CN I (if indicated)', method: 'Coffee or cinnamon each nostril separately', normal: 'Identifies both' },
+ { label: 'CN II — acuity', method: 'Snellen at 20ft each eye; corrective lenses if worn', normal: '20/20 or baseline' },
+ { label: 'CN II — fields', method: 'Confrontation, 4 quadrants each eye', normal: 'Full fields' },
+ { label: 'CN II — fundoscopy', method: 'Direct ophthalmoscopy — disc, vessels, macula', normal: 'Sharp disc, normal cup/disc, no papilledema' },
+ { label: 'CN II, III — pupils', method: 'Direct, consensual, swinging flashlight, accommodation', normal: 'PERRLA, no RAPD' },
+ { label: 'CN III, IV, VI — EOM', method: 'H pattern, convergence, note nystagmus or ptosis', normal: 'Full conjugate movement, no nystagmus, convergence intact' },
+ { label: 'CN V — sensation', method: 'Light touch V1, V2, V3 each side', normal: 'Intact, symmetric' },
+ { label: 'CN V — motor', method: 'Clench jaw, palpate masseter/temporalis; lateral jaw movement', normal: 'Symmetric strength and bulk' },
+ { label: 'CN V — corneal reflex (if indicated)', method: 'Cotton wisp to cornea', normal: 'Blinks bilaterally' },
+ { label: 'CN VII', method: 'Wrinkle forehead, close eyes against resistance, smile/bare teeth, puff cheeks', normal: 'Symmetric all four movements' },
+ { label: 'CN VIII — hearing', method: 'Finger rub each ear; Weber (midline) + Rinne (air > bone) if deficit', normal: 'Equal bilaterally' },
+ { label: 'CN IX, X', method: 'Palate elevation with "ahh"; uvula midline; voice; gag (if indicated)', normal: 'Symmetric palate, uvula midline, normal voice' },
+ { label: 'CN XI', method: 'Shoulder shrug and head turn against resistance', normal: '5/5 SCM and trapezius bilaterally' },
+ { label: 'CN XII', method: 'Tongue protrusion, side to side; inspect for fasciculations/atrophy', normal: 'Midline, no atrophy or fasciculations, full movement' }
+ ], abnormalHints: ['Any focal cranial nerve deficit', 'Papilledema', 'RAPD', 'Nystagmus', 'Facial asymmetry', 'Tongue deviation'] },
+
+ { name: 'Motor — bulk, tone, strength', steps: [
+ { label: 'Bulk inspection', method: 'Shoulders, arms, thighs, calves, interossei', normal: 'Symmetric, no atrophy' },
+ { label: 'Tone — upper', method: 'Passive range elbows, wrists; pronator drift test', normal: 'Normal tone, no drift' },
+ { label: 'Tone — lower', method: 'Passive knee and ankle range', normal: 'Normal tone, no catch' },
+ { label: 'Strength — deltoid (C5)', method: 'Shoulder abduction', normal: '5/5 bilaterally' },
+ { label: 'Strength — biceps (C5-C6)', method: 'Elbow flexion', normal: '5/5' },
+ { label: 'Strength — triceps (C7)', method: 'Elbow extension', normal: '5/5' },
+ { label: 'Strength — wrist extension (C6-C7)', method: 'Dorsiflex wrist against resistance', normal: '5/5' },
+ { label: 'Strength — finger flexion (C8)', method: 'Grip strength', normal: '5/5 symmetric' },
+ { label: 'Strength — finger abduction (T1)', method: 'Spread fingers', normal: '5/5' },
+ { label: 'Strength — hip flexion (L2-L3)', method: 'Lift thigh supine', normal: '5/5' },
+ { label: 'Strength — knee extension (L3-L4)', method: 'Straighten knee', normal: '5/5' },
+ { label: 'Strength — ankle dorsiflexion (L4-L5)', method: 'Pull toes up', normal: '5/5' },
+ { label: 'Strength — great toe extension (L5)', method: 'Dorsiflex great toe against resistance', normal: '5/5' },
+ { label: 'Strength — ankle plantarflexion (S1)', method: 'Push foot down; toe-walk', normal: '5/5 bilaterally' }
+ ], abnormalHints: ['Focal weakness (localize by myotome)', 'Pronator drift (subtle UMN)', 'Spasticity', 'Atrophy', 'Fasciculations'] },
+
+ { name: 'Deep tendon reflexes', steps: [
+ { label: 'Biceps (C5-C6)', method: 'Thumb on tendon, strike', normal: '2+ symmetric' },
+ { label: 'Brachioradialis (C5-C6)', method: 'Strike distal radius', normal: '2+ symmetric' },
+ { label: 'Triceps (C7)', method: 'Strike triceps tendon', normal: '2+ symmetric' },
+ { label: 'Finger flexors (Hoffmann)', method: 'Flick distal phalanx of middle finger', normal: 'No thumb flexion (negative Hoffmann)' },
+ { label: 'Patellar (L3-L4)', method: 'Knees hanging, strike tendon', normal: '2+ symmetric' },
+ { label: 'Achilles (S1)', method: 'Slight dorsiflexion, strike tendon', normal: '2+ symmetric' },
+ { label: 'Plantar response (Babinski)', method: 'Stroke lateral sole heel to toes', normal: 'Down-going bilaterally' },
+ { label: 'Ankle clonus', method: 'Rapid dorsiflexion', normal: 'No sustained clonus (≤3 beats)' }
+ ], abnormalHints: ['Hyperreflexia with clonus (UMN: MS, myelopathy, cord lesion)', 'Hyporeflexia (GBS, neuropathy, myopathy, hypothyroid)', 'Asymmetry', 'Positive Hoffmann (corticospinal)', 'Up-going Babinski', 'Sustained clonus'] },
+
+ { name: 'Sensory', steps: [
+ { label: 'Light touch — upper', method: 'Cotton wisp, dorsum of hands, eyes closed', normal: 'Intact, symmetric' },
+ { label: 'Light touch — lower', method: 'Dorsum of feet', normal: 'Intact, symmetric' },
+ { label: 'Pain — upper', method: 'Broken Q-tip sharp end, hands', normal: 'Intact, symmetric' },
+ { label: 'Pain — lower', method: 'Same on feet', normal: 'Intact, symmetric' },
+ { label: 'Temperature (if indicated)', method: 'Cold tuning fork each area', normal: 'Intact' },
+ { label: 'Vibration', method: '128 Hz tuning fork at distal IP of great toes; count seconds to fade', normal: 'Feels vibration; appropriate duration' },
+ { label: 'Proprioception', method: 'Move great toe up/down with eyes closed', normal: 'Identifies direction correctly' },
+ { label: 'Two-point discrimination (if indicated)', method: 'Blunt calipers on fingertip', normal: '<5mm on fingertip' },
+ { label: 'Stereognosis (if indicated)', method: 'Identify coin/key in hand with eyes closed', normal: 'Correct identification' }
+ ], abnormalHints: ['Dermatomal loss (nerve root)', 'Stocking-glove loss (length-dependent neuropathy)', 'Dorsal column loss (B12, tabes, MS — positive Romberg, vibration loss)', 'Cortical deficit (astereognosis, impaired 2-pt)'] },
+
+ { name: 'Coordination', steps: [
+ { label: 'Finger-nose-finger', method: 'Alternate examiner\'s finger and own nose; examiner moves target', normal: 'Smooth, accurate bilaterally' },
+ { label: 'Heel-to-shin', method: 'Supine: heel down opposite shin and back', normal: 'Smooth, accurate' },
+ { label: 'Rapid alternating (Dysdiadochokinesis)', method: 'Supinate/pronate hand rapidly on thigh', normal: 'Rhythmic, symmetric' },
+ { label: 'Finger tapping', method: 'Thumb to each finger in sequence rapidly', normal: 'Rhythmic, smooth, symmetric' }
+ ], abnormalHints: ['Dysmetria (cerebellar)', 'Intention tremor', 'Dysdiadochokinesia', 'Decomposed movement'] },
+
+ { name: 'Gait and Romberg', steps: [
+ { label: 'Normal gait', method: 'Walk 20 feet', normal: 'Narrow-based, smooth, reciprocal arm swing' },
+ { label: 'Heel walk', method: 'Walk on heels only', normal: 'Able without difficulty' },
+ { label: 'Toe walk', method: 'Walk on toes only', normal: 'Able without difficulty' },
+ { label: 'Tandem', method: 'Heel-to-toe along a line, 10+ steps', normal: 'Minimal deviation' },
+ { label: 'Romberg', method: 'Feet together, eyes open then closed, 30s', normal: 'Stable — no significant sway or fall with eyes closed' },
+ { label: 'Single-leg stance', method: '10s each side, eyes open', normal: 'Stable without drift' }
+ ], abnormalHints: ['Ataxic (wide-based — cerebellar)', 'Steppage (peripheral neuropathy / foot drop)', 'Circumduction (UMN hemiparesis)', 'Scissoring', 'Romberg positive (dorsal column)'] },
+
+ { name: 'Frontal release / primitive reflexes', steps: [
+ { label: 'Grasp reflex', method: 'Stroke palm', normal: 'Absent' },
+ { label: 'Snout reflex', method: 'Tap upper lip', normal: 'No lip pucker' },
+ { label: 'Glabellar tap', method: 'Tap between eyebrows — should habituate after 3–4 taps', normal: 'Habituates (no sustained blink)' },
+ { label: 'Palmomental', method: 'Stroke thenar eminence', normal: 'No ipsilateral chin twitch' }
+ ], abnormalHints: ['Presence suggests frontal lobe pathology, neurodegenerative disease, or severe TBI — rare in adolescence but relevant in post-concussion workup'] }
]
}
}
};
// ────────────────────────────────────────────────────────────
- // RENDER + STATE
+ // STATE + RENDER
// ────────────────────────────────────────────────────────────
var _inited = false;
- var state = {}; // key = 'msk-0' etc → { name, status, note, normal_finding }
+ // state keyed as 'system-componentIdx-stepIdx' → { label, method, normal, status, note }
+ var state = {};
var currentSystem = 'msk';
var currentAgeGroup = '';
@@ -387,34 +702,46 @@
html += ' ' + esc(section.overview) + '
';
html += '';
- section.components.forEach(function (c, i) {
- var key = currentSystem + '-' + i;
- if (!state[key]) state[key] = { name: c.name, status: null, note: '', normal_finding: c.normal, technique: c.technique };
- html += '';
- html += ' '; // end card
});
content.innerHTML = html;
- // Wire events
content.querySelectorAll('[data-pe-status]').forEach(function (btn) {
btn.addEventListener('click', function () { handleStatus(btn); });
});
@@ -431,16 +758,16 @@
var status = btn.dataset.peStatus;
if (!state[key]) return;
state[key].status = (status === 'skip') ? null : status;
- // Redraw this card's buttons + abnormal input visibility
- var card = btn.closest('[data-pe-key]');
- if (card) {
- card.querySelectorAll('[data-pe-status]').forEach(function (b) {
+ var row = btn.closest('.pe-step');
+ if (row) {
+ row.style.background = state[key].status === 'normal' ? '#ecfdf5' : state[key].status === 'abnormal' ? '#fef2f2' : '';
+ row.querySelectorAll('[data-pe-status]').forEach(function (b) {
b.classList.remove('done', 'refused', 'not-due');
if (b.dataset.peStatus === 'normal' && state[key].status === 'normal') b.classList.add('done');
if (b.dataset.peStatus === 'abnormal' && state[key].status === 'abnormal') b.classList.add('refused');
if (b.dataset.peStatus === 'skip' && state[key].status === null) b.classList.add('not-due');
});
- var detail = card.querySelector('.pe-abnormal-detail');
+ var detail = row.querySelector('.pe-abnormal-detail');
if (detail) detail.style.display = (state[key].status === 'abnormal') ? '' : 'none';
}
}
@@ -456,12 +783,12 @@
function generate() {
if (!currentAgeGroup || !PE_DATA[currentAgeGroup]) return;
- var components = Object.keys(state)
+ var steps = Object.keys(state)
.filter(function (k) { return k.indexOf(currentSystem + '-') === 0; })
.map(function (k) { return state[k]; });
- var assessed = components.filter(function (c) { return c.status !== null; });
- if (assessed.length === 0) { showToast('Mark at least one component Normal or Abnormal', 'error'); return; }
+ var assessed = steps.filter(function (s) { return s.status !== null; });
+ if (assessed.length === 0) { showToast('Mark at least one step Normal or Abnormal', 'error'); return; }
var btn = document.getElementById('pe-generate-btn');
btn.disabled = true; btn.innerHTML = ' Generating...';
@@ -474,7 +801,7 @@
method: 'POST',
headers: getAuthHeaders(),
body: JSON.stringify({
- components: components,
+ steps: steps,
ageGroup: PE_DATA[currentAgeGroup].label,
system: currentSystem,
patientAge: document.getElementById('pe-age').value,
diff --git a/src/routes/peGuide.js b/src/routes/peGuide.js
index cd5453e..578ce6d 100644
--- a/src/routes/peGuide.js
+++ b/src/routes/peGuide.js
@@ -1,11 +1,11 @@
// ============================================================
-// PHYSICAL EXAM GUIDE — narrative + list generation
+// PHYSICAL EXAM GUIDE — step-level narrative + list generation
// ============================================================
-// Takes an age group, system (msk | neuro), and a set of assessed
-// components (each flagged Normal or Abnormal, abnormal with optional
-// note) and returns a professional narrative paragraph or structured
-// list. Mirrors the milestone-narrative pattern exactly: same guardrails,
-// same injection wrapping, same audit log category.
+// Receives a flat array of exam STEPS (each with component name, label,
+// method, expected normal, status, and optional abnormal note). Returns
+// a professional two-section report (Technique performed + Findings).
+// Mirrors the milestone-narrative pattern: same AppRole-injection guard,
+// same clinical audit category.
var express = require('express');
var router = express.Router();
@@ -16,41 +16,58 @@ var logger = require('../utils/logger');
router.post('/generate-pe-narrative', authMiddleware, async function (req, res) {
try {
- var { components, ageGroup, system, patientAge, patientGender, model, format } = req.body;
- if (!Array.isArray(components) || components.length === 0) {
- return res.status(400).json({ error: 'No components provided' });
+ var { steps, ageGroup, system, patientAge, patientGender, model, format } = req.body;
+ if (!Array.isArray(steps) || steps.length === 0) {
+ return res.status(400).json({ error: 'No steps provided' });
}
// Partition by assessment status
- var normal = components.filter(function (c) { return c.status === 'normal'; });
- var abnormal = components.filter(function (c) { return c.status === 'abnormal'; });
+ var normal = steps.filter(function (s) { return s.status === 'normal'; });
+ var abnormal = steps.filter(function (s) { return s.status === 'abnormal'; });
if (normal.length === 0 && abnormal.length === 0) {
return res.json({
- success: true,
- narrative: 'No physical-exam components were assessed.',
- summary: { normal: 0, abnormal: 0, notAssessed: components.length }
+ success: true,
+ narrative: 'No physical-exam steps were assessed.',
+ summary: { normal: 0, abnormal: 0, notAssessed: steps.length }
});
}
- // Structured text for the model — includes both technique (how the exam
- // component was performed) and the finding. The prompt instructs the AI
- // to produce a "Technique" preamble + "Findings" narrative.
+ // Group by component for readability — AI works better with structure.
+ function groupByComponent(list) {
+ var groups = {};
+ list.forEach(function (s) {
+ var key = s.component || 'Other';
+ if (!groups[key]) groups[key] = [];
+ groups[key].push(s);
+ });
+ return groups;
+ }
+ var normalGroups = groupByComponent(normal);
+ var abnormalGroups = groupByComponent(abnormal);
+
+ // Build structured text for the model
var text = '';
- if (normal.length > 0) {
- text += 'NORMAL findings:\n';
- normal.forEach(function (c) {
- text += ' - ' + c.name + '\n';
- text += ' technique: ' + (c.technique || 'standard method') + '\n';
- text += ' normal finding: ' + (c.normal_finding || 'unspecified') + '\n';
+ if (Object.keys(normalGroups).length) {
+ text += 'NORMAL FINDINGS (grouped by exam component):\n';
+ Object.keys(normalGroups).forEach(function (comp) {
+ text += '\n[' + comp + ']\n';
+ normalGroups[comp].forEach(function (s) {
+ text += ' • ' + s.label + '\n';
+ text += ' method: ' + (s.method || 'standard method') + '\n';
+ text += ' expected normal: ' + (s.normal || 'unspecified') + '\n';
+ });
});
}
- if (abnormal.length > 0) {
- text += '\nABNORMAL findings:\n';
- abnormal.forEach(function (c) {
- text += ' - ' + c.name + '\n';
- text += ' technique: ' + (c.technique || 'standard method') + '\n';
- text += ' physician note: ' + (c.note || 'abnormal, no detail provided') + '\n';
+ if (Object.keys(abnormalGroups).length) {
+ text += '\nABNORMAL FINDINGS (grouped by exam component):\n';
+ Object.keys(abnormalGroups).forEach(function (comp) {
+ text += '\n[' + comp + ']\n';
+ abnormalGroups[comp].forEach(function (s) {
+ text += ' • ' + s.label + '\n';
+ text += ' method: ' + (s.method || 'standard method') + '\n';
+ text += ' physician note: ' + (s.note || 'abnormal, no detail provided') + '\n';
+ });
});
}
@@ -63,8 +80,8 @@ router.post('/generate-pe-narrative', authMiddleware, async function (req, res)
'Patient: ' + (patientAge || 'Unknown') + ', ' + (patientGender || 'Unknown') + '\n' +
'Age group: ' + (ageGroup || 'Unknown') + '\n' +
'Exam system: ' + systemLabel + '\n\n' +
- wrapUserText('pe_components', text) +
- '\n\nAssessed: ' + (normal.length + abnormal.length) +
+ wrapUserText('pe_steps', text) +
+ '\n\nAssessed steps: ' + (normal.length + abnormal.length) +
' | Normal: ' + normal.length +
' | Abnormal: ' + abnormal.length
}
@@ -74,7 +91,7 @@ router.post('/generate-pe-narrative', authMiddleware, async function (req, res)
success: true,
narrative: result.content,
model: result.model,
- summary: { normal: normal.length, abnormal: abnormal.length, notAssessed: components.length - normal.length - abnormal.length }
+ summary: { normal: normal.length, abnormal: abnormal.length, notAssessed: steps.length - normal.length - abnormal.length }
});
logger.audit(req.user.id, 'generate_pe_narrative', 'Generated PE narrative (' + systemLabel + ')', req, { category: 'clinical' });
} catch (err) {
diff --git a/src/utils/prompts.js b/src/utils/prompts.js
index ccddbc0..334931c 100644
--- a/src/utils/prompts.js
+++ b/src/utils/prompts.js
@@ -214,28 +214,46 @@ Sentence 3: Any concerns or delays. If none, state no concerns identified.
EXACTLY 3 sentences. Professional language. Only mention assessed milestones.`,
// ======================== PHYSICAL EXAM GUIDE ========================
+ // The route sends data grouped by exam COMPONENT (e.g. "Cranial nerves
+ // II–XII") with the individual STEPS that were performed inside each
+ // component (e.g. CN II acuity, CN III EOM, CN VII face). The AI
+ // summarises at the component level, weaving in the techniques used.
peGuideNarrative: `You are a pediatric documentation specialist.
Generate a professional OSCE-style physical-exam report with TWO sections.
${CORE_RULES}
+Input shape: steps are grouped under an exam COMPONENT (e.g. "Deep tendon
+reflexes"). Each step has a specific label (e.g. "Biceps C5-C6"), the method
+used, and either the expected-normal phrase (if marked normal) or the
+physician's abnormal note.
+
Structure the output as:
Technique:
-A short paragraph describing HOW the examination was performed. Mention the
-maneuvers, tests, or methods used for each assessed component, using the
-"technique" strings provided. Weave them into prose — do NOT list them
-bullet-by-bullet. Omit techniques for components that were not assessed.
+A short paragraph describing HOW the examination was performed, grouped by
+component. Mention the specific maneuvers or tests used (e.g. "Cranial
+nerves were assessed including visual acuity by Snellen, visual fields by
+confrontation, pupillary response, EOMs in H pattern, facial sensation to
+light touch in V1/V2/V3 distributions, facial symmetry with smile and eye
+closure, hearing to finger rub, palatal elevation, shoulder shrug and head
+turn against resistance, and tongue protrusion"). Weave into prose — do NOT
+list bullet-by-bullet. Omit components that had no assessed steps.
Findings:
-A narrative paragraph or two describing what was observed.
-- ONLY components that were assessed (Normal or Abnormal)
-- Normal findings: use concise language describing the specific normal result
- (e.g. "Hips stable to Barlow and Ortolani" not "Hips normal")
-- Abnormal findings: lead with the physician's note verbatim, then add a
- brief clinical qualifier only if the note is clearly incomplete
-- Group related findings by region when natural (upper extremities together,
- spine separately, etc.)
-- End with a single-phrase overall impression
+A narrative paragraph or two describing what was observed, grouped
+naturally by region or system. Summarise at the component level — do not
+parrot every individual step unless clinically important. Example good
+finding: "Cranial nerves II through XII are intact except for a left-sided
+facial droop involving only the lower face, consistent with central
+weakness." NOT: "CN II: intact. CN III: intact. CN IV: intact. ..."
+
+Rules:
+- ONLY report on steps that were assessed (marked Normal or Abnormal)
+- Normal findings: use specific clinical language, not "normal"
+ (e.g. "2+ symmetric deep tendon reflexes throughout with down-going plantar response" NOT "DTRs normal")
+- Abnormal findings: lead with the physician's note verbatim, add a brief
+ localisation or clinical qualifier only if the note is clearly incomplete
+- End with a single-sentence overall impression
- Do NOT fabricate measurements, grades, or adverbs not provided
- Do NOT mention components that were not assessed`,
@@ -243,20 +261,26 @@ A narrative paragraph or two describing what was observed.
Generate an OSCE-style physical-exam report as a STRUCTURED numbered LIST.
${CORE_RULES}
+Input shape: steps grouped under exam COMPONENT. Condense at the component
+level unless a specific step had an abnormal finding worth flagging.
+
Produce TWO sections, each as a numbered list:
Technique performed:
-1. [method for component 1]
-2. [method for component 2]
-... using the "technique" strings provided — one per assessed component.
+1. [Component 1] — brief description of maneuvers used
+2. [Component 2] — brief description of maneuvers used
+...
Findings:
-1. [finding for component 1]
-2. [finding for component 2]
-... one line per assessed component.
+1. [Component 1]: specific normal finding, or abnormal description
+2. [Component 2]: same
+...
+
+Rules:
+- One numbered item per assessed COMPONENT (not per step)
- Normal findings: describe the specific normal result, not just "normal"
-- Abnormal findings: start with the physician's note, then qualifier if provided
-- One-line overall impression at the end
+- Abnormal findings: start with physician's note, add qualifier if provided
+- Final item: one-line overall impression
- No markdown, no symbols, plain numbered list`,
// ======================== REFINE ========================