User feedback: the exam steps were too generic (e.g. "Shoulder abduction
— 5/5 bilaterally" never explained what 5/5 means or HOW to test it).
The guide needs to serve as a teaching tool, not just a checkbox list.
Three changes:
1. GRADING SCALES reference card (new). Collapsible panel at the top of
each system showing the relevant scales:
- Neuro: MRC strength (0-5), DTR (0-4+), Plantar response
- MSK: Scoliometer ATR, Beighton hypermobility score
Each scale shows the grade AND its clinical meaning in a compact
table. No more orphan "5/5 bilaterally" without definition.
2. Per-component SIGNIFICANCE + PEARL fields (optional). Adolescent
neuro components enriched with:
- Significance: one-line clinical relevance (what this component is
actually for — what pathologies it detects)
- Teaching pearl: a Hutchison/Bates/Nelson-style tip that helps the
learner see past the mechanics to the reasoning
Visually distinct — pearl gets a warm amber accent, significance is
a crosshair icon under the name.
3. Method strings REWRITTEN for every adolescent strength step. Before:
"Shoulder abduction — 5/5 bilaterally". After: "Patient abducts both
arms to 90°. Examiner pushes down on each arm just above the elbow
while patient resists. Compare sides. — Holds against full resistance
— MRC 5/5 bilaterally". Same treatment for all 14 strength steps,
all 8 DTR steps, and tone/pronator-drift.
UI redesign:
- Accent bars on cards (cyan for MSK, purple for neuro) for visual
anchor
- Numbered step circles instead of "1." prefix
- HOW / NORMAL label badges on each step
- Watch-for block with red left-border for red-flag grouping
- System-level header with icon (bone for MSK, brain for neuro)
Other age groups (newborn through school-age) keep the old data shape
(steps without pearls) — they still render correctly, just without the
pearl/significance blocks. Enriching them is an incremental follow-up.
Replaces the generic one-line-per-component format with a step-level
checklist. Each exam component now contains 3–13 discrete steps, each
with its own Normal/Abnormal/Skip toggle and optional abnormal note.
Physician ticks the exam off step-by-step; report generation
summarises at the component level but knows exactly which steps were
performed.
Example — previously the adolescent "Cranial nerves (II–XII)" was a
single row: "How to perform: Full formal adult-pattern exam. Expected:
All cranial nerves intact." That's unhelpful. Now it's 14 discrete
steps: CN I, CN II acuity, CN II fields, CN II fundoscopy, CN II/III
pupils, CN III/IV/VI EOM, CN V sensation V1/V2/V3, CN V motor, CN V
corneal, CN VII forehead/eye-close/smile/puff, CN VIII, CN IX/X, CN
XI, CN XII — each with specific method and expected finding. Same
depth for MSK: scoliosis = 5 discrete steps (standing inspection,
Adam forward-bend, rib-hump check, scoliometer, plumb-line), joint
stability = 8 named tests (Lachman, anterior drawer, varus/valgus,
McMurray, apprehension, Neer/Hawkins, anterior drawer ankle, talar
tilt), Beighton = 5 per-joint measurements, etc.
Sources cited in code header: Bates' Guide 13th ed, Nelson Textbook
22nd ed, Hutchison's Clinical Methods 25th ed, Fenichel Clinical
Pediatric Neurology 8th ed.
Backend route accepts the flat step array (grouped by component on
the server), passes structured text to the AI with methods and
expected findings per step. Prompts updated to summarise at the
component level rather than step-by-step, so output is clinically
readable.
Scope: MSK + Neuro × 6 age groups (newborn, infant, toddler, preschool,
school-age, adolescent). More systems follow the same pattern —
append to PE_DATA.
New top-level tab (positioned after Catch-Up Schedule) combining two
functions:
1. Study reference — for each (age group, system) shows OSCE-style
components with technique, expected normal finding, and abnormal-
feature watch-list.
2. Documentation generator — physician marks each component
Normal / Abnormal (with free-text detail) / Skip; AI produces a
two-section report (Technique + Findings), narrative or structured
list format.
Scope v1: MSK + Neuro × 6 age groups (newborn, infant, toddler,
preschool, school-age, adolescent). More systems can be added to the
embedded PE_DATA in peGuide.js without route changes.
Files:
- src/routes/peGuide.js — POST /api/generate-pe-narrative (mirrors
milestone-narrative pattern: AppRole-level
injection guard, clinical audit category,
PHI redaction upstream already in place)
- src/utils/prompts.js — peGuideNarrative + peGuideList prompts,
structured two-section output
- public/components/pe-guide.html — demographics bar + sub-pills + cards
- public/js/peGuide.js — embedded PE_DATA (all clinical content),
render + state + AI call
- public/index.html — tab button, section, script include
- server.js — mount route at /api
No schema change. No PHI stored — findings live in memory only, exported
via existing copy/read-aloud/Nextcloud actions.
