pediatric-ai-scribe-v3/public/data/pe-guide.json

{
  "scales": {
    "mrc": {
      "title": "MRC strength grade (0–5)",
      "icon": "fa-hand-fist",
      "rows": [
        [
          "5",
          "Normal power — holds against full resistance"
        ],
        [
          "4",
          "Reduced — moves against gravity + some resistance"
        ],
        [
          "3",
          "Moves against gravity only (no added resistance)"
        ],
        [
          "2",
          "Full range with gravity eliminated (horizontal plane)"
        ],
        [
          "1",
          "Flicker / trace contraction, no joint movement"
        ],
        [
          "0",
          "No contraction"
        ]
      ]
    },
    "dtr": {
      "title": "Deep-tendon reflex grade (0–4+)",
      "icon": "fa-circle-dot",
      "rows": [
        [
          "0",
          "Absent"
        ],
        [
          "1+",
          "Hypoactive — trace, only with reinforcement"
        ],
        [
          "2+",
          "Normal"
        ],
        [
          "3+",
          "Brisk — may still be normal in anxious patients"
        ],
        [
          "4+",
          "Hyperactive with sustained clonus — always abnormal"
        ]
      ]
    },
    "plantar": {
      "title": "Plantar response (Babinski)",
      "icon": "fa-shoe-prints",
      "rows": [
        [
          "Down-going",
          "Normal in anyone ≥ 2 years"
        ],
        [
          "Up-going",
          "Normal < 2 years; abnormal after — UMN lesion"
        ],
        [
          "Asymmetric",
          "Always abnormal at any age"
        ]
      ]
    },
    "beighton": {
      "title": "Beighton hypermobility score (0–9)",
      "icon": "fa-hands",
      "rows": [
        [
          "≤ 3",
          "Normal flexibility"
        ],
        [
          "4",
          "Borderline — consider in context"
        ],
        [
          "≥ 5",
          "Hypermobility spectrum; screen for hEDS if other features present"
        ]
      ]
    },
    "atr": {
      "title": "Scoliometer — angle of trunk rotation",
      "icon": "fa-ruler",
      "rows": [
        [
          "< 5°",
          "Normal, no follow-up"
        ],
        [
          "5–6°",
          "Borderline — re-check at each visit"
        ],
        [
          "≥ 7°",
          "Refer for PA/lateral spine x-ray + orthopedic evaluation"
        ]
      ]
    },
    "rr": {
      "title": "Respiratory rate — upper limit by age (awake)",
      "icon": "fa-lungs",
      "rows": [
        [
          "Newborn",
          "≤ 60 /min"
        ],
        [
          "< 2 months",
          "≤ 60 /min (WHO tachypnea cutoff)"
        ],
        [
          "2–12 months",
          "≤ 50 /min (WHO tachypnea cutoff)"
        ],
        [
          "1–5 years",
          "≤ 40 /min (WHO tachypnea cutoff)"
        ],
        [
          "6–11 years",
          "≤ 30 /min"
        ],
        [
          "≥ 12 years",
          "≤ 20 /min (adult pattern)"
        ]
      ]
    },
    "spo2": {
      "title": "Pulse oximetry (SpO₂) — at room air",
      "icon": "fa-heart-pulse",
      "rows": [
        [
          "≥ 95%",
          "Normal"
        ],
        [
          "92–94%",
          "Mild hypoxemia — investigate cause"
        ],
        [
          "< 92%",
          "Moderate hypoxemia — supplemental O₂"
        ],
        [
          "< 88%",
          "Severe — urgent intervention; target ≥ 90% acutely"
        ]
      ]
    },
    "silverman": {
      "title": "Silverman–Andersen retraction score (neonatal, 0–10)",
      "icon": "fa-baby",
      "rows": [
        [
          "0",
          "No respiratory distress"
        ],
        [
          "1–3",
          "Mild — close observation"
        ],
        [
          "4–6",
          "Moderate distress — consider CPAP / support"
        ],
        [
          "7–10",
          "Severe — imminent respiratory failure, intubate"
        ]
      ]
    },
    "westley": {
      "title": "Westley croup severity score",
      "icon": "fa-stethoscope",
      "rows": [
        [
          "≤ 2",
          "Mild — home management, cool mist, oral dexamethasone"
        ],
        [
          "3–5",
          "Moderate — nebulised epinephrine + dexamethasone"
        ],
        [
          "6–11",
          "Severe — admit, continuous monitoring"
        ],
        [
          "≥ 12",
          "Impending respiratory failure — ICU / airway management"
        ]
      ]
    },
    "murmurGrade": {
      "title": "Heart-murmur grading (Levine 1–6)",
      "icon": "fa-wave-square",
      "rows": [
        [
          "1/6",
          "Very faint — heard only with concentration"
        ],
        [
          "2/6",
          "Soft but readily heard"
        ],
        [
          "3/6",
          "Moderately loud, no thrill"
        ],
        [
          "4/6",
          "Loud WITH a palpable thrill"
        ],
        [
          "5/6",
          "Very loud; audible with stethoscope just off the chest"
        ],
        [
          "6/6",
          "Audible without the stethoscope touching the chest"
        ]
      ]
    },
    "pulseAmp": {
      "title": "Pulse amplitude grade (0–4)",
      "icon": "fa-heart-pulse",
      "rows": [
        [
          "0",
          "Absent"
        ],
        [
          "1+",
          "Diminished, thready"
        ],
        [
          "2+",
          "Normal"
        ],
        [
          "3+",
          "Bounding"
        ],
        [
          "4+",
          "Bounding with visible pulsation (e.g., aortic regurgitation)"
        ]
      ]
    },
    "capRefill": {
      "title": "Capillary refill time",
      "icon": "fa-hand",
      "rows": [
        [
          "< 2 sec",
          "Normal"
        ],
        [
          "2–3 sec",
          "Borderline — consider hydration / perfusion"
        ],
        [
          "≥ 3 sec",
          "Delayed — dehydration, shock, low cardiac output"
        ]
      ]
    }
  },
  "systemScales": {
    "msk": [
      "atr",
      "beighton"
    ],
    "neuro": [
      "mrc",
      "dtr",
      "plantar"
    ],
    "resp": [
      "rr",
      "spo2",
      "silverman",
      "westley"
    ],
    "cv": [
      "murmurGrade",
      "pulseAmp",
      "capRefill"
    ]
  },
  "aptmLegend": [
    {
      "letter": "A",
      "color": "#dc2626",
      "title": "Aortic area",
      "location": "2nd ICS, right sternal border",
      "listen": "S2 (aortic component), aortic stenosis, aortic regurgitation"
    },
    {
      "letter": "P",
      "color": "#2563eb",
      "title": "Pulmonic area",
      "location": "2nd ICS, left sternal border",
      "listen": "S2 (pulmonic component), pulmonic stenosis, PDA, physiologic split of S2",
      "innocent": "Pulmonary flow murmur (children, adolescents) — upper left sternal border"
    },
    {
      "letter": "E",
      "color": "#059669",
      "title": "Erb's point",
      "location": "3rd ICS, left sternal border",
      "listen": "Aortic regurgitation (best here), transitional zone murmurs",
      "innocent": "Still's murmur classically radiates to Erb's / LLSB"
    },
    {
      "letter": "T",
      "color": "#d97706",
      "title": "Tricuspid area",
      "location": "4th–5th ICS, lower left sternal border",
      "listen": "Tricuspid regurgitation, VSD, S3/S4, holosystolic murmurs",
      "innocent": "Still's murmur — vibratory, musical, age 3–7 y (loudest between LLSB and apex)"
    },
    {
      "letter": "M",
      "color": "#7c3aed",
      "title": "Mitral area (apex)",
      "location": "5th ICS, mid-clavicular line",
      "listen": "S1, mitral regurgitation, mitral stenosis (with bell, left-lateral decubitus)"
    }
  ],
  "innocentMurmurs": [
    {
      "name": "Still's (vibratory) murmur",
      "age": "3–7 y (most common in children)",
      "location": "LLSB, radiating to apex",
      "character": "Low-frequency vibratory / musical systolic, grade 2–3/6, mid-systolic, \"twanging-string\" quality",
      "confirm": "Louder supine, softer or disappears on standing or Valsalva. No radiation to neck/back. Normal S2."
    },
    {
      "name": "Pulmonary flow murmur",
      "age": "School-age and adolescents, thin chest",
      "location": "Upper left sternal border (2nd–3rd ICS)",
      "character": "Soft blowing early systolic ejection, grade 1–2/6, higher-pitched",
      "confirm": "No ejection click. Physiologic split of S2. Louder supine, softer on standing. No radiation."
    },
    {
      "name": "Venous hum",
      "age": "Ages 3–8, disappears by adolescence",
      "location": "Supraclavicular or infraclavicular area, usually right",
      "character": "Soft continuous hum, louder in diastole. Only innocent continuous murmur.",
      "confirm": "Disappears when supine OR when jugular vein is gently compressed (key maneuver). Turning head to opposite side also alters it."
    },
    {
      "name": "Carotid bruit / supraclavicular bruit",
      "age": "Children and adolescents",
      "location": "Supraclavicular fossa, right > left; may radiate to carotid",
      "character": "Brief early systolic, grade 2–3/6, higher-pitched than Still's",
      "confirm": "Softer or disappears with hyperextension of the shoulders. Normal cardiac exam otherwise. No radiation below the clavicles."
    },
    {
      "name": "Peripheral pulmonary stenosis (PPS, neonatal)",
      "age": "Newborns and infants < 6–12 months",
      "location": "Upper LSB, radiates to BOTH axillae and the back",
      "character": "Soft systolic ejection murmur, grade 1–2/6",
      "confirm": "Typical age + radiation to back/axillae. Resolves by age 1 as branch pulmonary arteries grow. Persistence or louder grade warrants echo."
    }
  ],
  "respiratorySounds": [
    {
      "key": "normal",
      "src": "/audio/respiratory/normal-vesicular.ogg",
      "title": "Normal vesicular breath sounds",
      "where": "Peripheral lung fields",
      "features": "Soft, rustling. Inspiration louder and longer than expiration.",
      "clinical": "Baseline — deviation elsewhere is what you listen for."
    },
    {
      "key": "wheeze",
      "src": "/audio/respiratory/wheeze.ogg",
      "title": "Wheeze",
      "where": "Diffuse in asthma; localised in foreign body",
      "features": "Continuous, high-pitched, musical. Usually expiratory; biphasic if severe.",
      "clinical": "Lower-airway narrowing — asthma, bronchiolitis, foreign body, bronchomalacia. Silent chest in severe asthma is an ominous sign."
    },
    {
      "key": "stridor",
      "src": "/audio/respiratory/stridor.ogg",
      "title": "Stridor",
      "where": "Louder over neck than chest — upper airway",
      "features": "Continuous, high-pitched, harsh. Classically inspiratory (extrathoracic obstruction); biphasic if fixed.",
      "clinical": "Croup, epiglottitis, foreign body, laryngomalacia (infant). Distinguish from wheeze by auscultating the neck — stridor is loudest there."
    },
    {
      "key": "finecrackles",
      "src": "/audio/respiratory/crackles-fine.ogg",
      "title": "Fine (end-inspiratory) crackles",
      "where": "Bibasilar in pulmonary edema/fibrosis; focal in pneumonia",
      "features": "Discontinuous, brief, high-pitched. \"Velcro\" quality. Late inspiratory, do NOT clear with cough.",
      "clinical": "Alveolar opening — pulmonary fibrosis, pulmonary edema, early pneumonia, atelectasis."
    },
    {
      "key": "coarsecrackles",
      "src": "/audio/respiratory/crackles-coarse.ogg",
      "title": "Coarse crackles",
      "where": "Lower lobes; either side",
      "features": "Discontinuous, longer and louder than fine crackles. Lower-pitched. Can be early or late inspiratory; often clear partly with cough.",
      "clinical": "Secretions in larger airways — bronchitis, later pneumonia, bronchiectasis, aspiration."
    },
    {
      "key": "rhonchi",
      "src": "/audio/respiratory/rhonchi.ogg",
      "title": "Rhonchi",
      "where": "Central or anywhere with airway secretions",
      "features": "Continuous, low-pitched, snore-like. Typically expiratory. Clear or change with cough.",
      "clinical": "Large-airway secretions — bronchitis, pneumonia with large-airway involvement, cystic fibrosis, bronchiectasis."
    },
    {
      "key": "pleuralrub",
      "src": "/audio/respiratory/pleural-rub.ogg",
      "title": "Pleural friction rub",
      "where": "Focal, often lateral or posterior lower chest",
      "features": "Grating, creaky — \"leather on leather\". Biphasic (heard in inspiration and expiration). Does NOT clear with cough.",
      "clinical": "Pleural inflammation — pleuritis, pulmonary embolism, pneumonia with pleural involvement, viral pleurisy."
    }
  ],
  "cardiacSounds": [
    {
      "key": "normal",
      "src": "/audio/cardiac/normal.ogg",
      "title": "Normal heart sounds (S1, S2)",
      "where": "All four classic auscultation points",
      "rate": "~61 bpm reference",
      "features": "\"lub-dub\": S1 (closure of mitral + tricuspid) louder at apex; S2 (closure of aortic + pulmonic) louder at base. Physiologic S2 split on inspiration.",
      "clinical": "Reference for rhythm, rate, and the normal S1–S2 interval. Listen for what's changed — not just what's added."
    },
    {
      "key": "infant-normal",
      "src": "/audio/cardiac/infant-normal.ogg",
      "title": "Infant normal heart sounds",
      "where": "Infant chest — rate will be higher than adult",
      "rate": "Pediatric reference (120–160 bpm range)",
      "features": "Same S1–S2 pattern, faster rate. Short diastole makes murmurs easier to miss — careful auscultation needed.",
      "clinical": "Reference for neonatal/infant rhythm. Any murmur in the first 72 h should prompt pre/postductal sat screening."
    },
    {
      "key": "vsd",
      "src": "/audio/cardiac/vsd.wav",
      "title": "Ventricular septal defect (VSD)",
      "where": "Lower left sternal border (4th ICS)",
      "features": "Harsh, blowing, holosystolic (pansystolic) murmur — plateau shape through all of systole. Often accompanied by a thrill if large.",
      "clinical": "Most common congenital heart defect. Small VSD: loud murmur, usually asymptomatic, may close spontaneously. Large VSD: softer murmur (less pressure gradient) but signs of heart failure, pulmonary hypertension."
    },
    {
      "key": "mvp",
      "src": "/audio/cardiac/mitral-prolapse.wav",
      "title": "Mitral valve prolapse (MVP) — click + late systolic murmur",
      "where": "Apex (5th ICS, mid-clavicular line)",
      "features": "Mid-systolic click followed by a late-systolic crescendo murmur. Timing of click changes with maneuvers: earlier with standing or Valsalva, later with squatting.",
      "clinical": "Often benign, especially in thin young women. Features suggesting need for echo: thickened/redundant leaflets, associated MR, symptoms (palpitations, chest pain), arrhythmias."
    },
    {
      "key": "stills",
      "src": "/audio/cardiac/stills-murmur.ogg",
      "title": "Still's murmur (innocent)",
      "where": "LLSB, radiating to apex",
      "rate": "Classic age 3–7 y (this recording is a toddler)",
      "features": "Low-frequency vibratory / musical systolic, grade 2–3/6, mid-systolic, \"twanging-string\" quality.",
      "clinical": "The most common innocent murmur of childhood. Louder supine, softer or disappears on standing or Valsalva. Normal S2. No radiation to neck or back. No workup needed when classic."
    },
    {
      "key": "functional",
      "src": "/audio/cardiac/functional-murmur.wav",
      "title": "Functional (innocent) murmur — adult female",
      "where": "Left sternal border, soft systolic",
      "features": "Soft systolic murmur in a structurally normal heart — often from increased cardiac output, thin chest wall, anemia, hyperthyroidism, or pregnancy.",
      "clinical": "Benign if it meets the 7 S criteria. Investigate if loud (≥3/6), holosystolic, diastolic, radiating, or with thrill / symptoms."
    }
  ],
  "peData": {
    "newborn": {
      "label": "Newborn (0–28 days)",
      "msk": {
        "overview": "Exam done warm, quiet, undressed. Focus: birth injury, DDH, congenital anomaly. All steps symmetric.",
        "components": [
          {
            "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": "Primitive reflexes present and symmetric. Tone assessed passively and actively. Full exam 3–5 min on a quiet, fed infant.",
        "components": [
          {
            "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"
            ]
          }
        ]
      },
      "resp": {
        "overview": "Newborn respiratory transition — RDS, TTN, pneumonia, meconium aspiration dominate the differential. Normal RR ≤ 60. Grunting is an alarm sign.",
        "components": [
          {
            "name": "Inspection",
            "significance": "Detects distress and localises cause. Silverman score quantifies retraction severity.",
            "pearl": "Grunting is physiologic PEEP against a partially closed glottis — always a sign of significant lung pathology in a newborn. Never dismiss it as fussy breathing.",
            "steps": [
              {
                "label": "Respiratory rate",
                "method": "Count over full 60 s, quiet and undisturbed.",
                "normal": "40–60 /min; tachypnea > 60"
              },
              {
                "label": "Work of breathing (Silverman)",
                "method": "Inspect for upper-chest retraction, lower-chest retraction, xiphoid retraction, nasal flaring, grunting. Score 0–2 for each.",
                "normal": "Total Silverman 0 — no distress"
              },
              {
                "label": "Audible sounds",
                "method": "Listen without stethoscope — stridor? grunting? wheeze across the room?",
                "normal": "Quiet respirations"
              },
              {
                "label": "Colour",
                "method": "Inspect trunk and mucous membranes for central cyanosis; acrocyanosis (blue hands/feet) is normal in the first days.",
                "normal": "Pink trunk and mucous membranes"
              },
              {
                "label": "Chest shape",
                "method": "Inspect AP:transverse diameter and symmetry.",
                "normal": "Slightly barrel-shaped is normal; symmetric"
              }
            ],
            "abnormalHints": [
              "Grunting — RDS, pneumonia, sepsis, CHD",
              "Retractions + tachypnea — RDS, TTN, pneumothorax",
              "Central cyanosis — cyanotic CHD, severe lung disease, persistent pulmonary HTN",
              "Asymmetric chest movement — pneumothorax, diaphragmatic hernia"
            ]
          },
          {
            "name": "Auscultation",
            "significance": "Short stethoscope time in neonates because they fuss easily — get the most important zones first.",
            "pearl": "Listen at the axilla, not just the anterior chest — pneumothorax can sound normal anteriorly. Auscultate both axillae systematically.",
            "steps": [
              {
                "label": "Air entry — anterior",
                "method": "Listen bilaterally at the upper and lower anterior chest.",
                "normal": "Symmetric bilateral air entry"
              },
              {
                "label": "Air entry — axillary",
                "method": "Listen bilaterally at each axilla — this is the most sensitive area for detecting a small pneumothorax.",
                "normal": "Clear and symmetric"
              },
              {
                "label": "Adventitious sounds",
                "method": "Listen for transmitted upper-airway sounds, crackles (RDS, pneumonia), grunting sounds.",
                "normal": "No crackles, no wheeze, clear sounds"
              },
              {
                "label": "Inspiration:expiration ratio",
                "method": "Observe breath-sound timing.",
                "normal": "Inspiration > expiration in length"
              }
            ],
            "abnormalHints": [
              "Asymmetric air entry — pneumothorax, diaphragmatic hernia, endobronchial intubation",
              "Fine crackles — RDS, TTN, pneumonia",
              "Absent breath sounds unilaterally — pneumothorax or selective intubation"
            ]
          }
        ]
      },
      "cv": {
        "overview": "Neonatal CV exam screens for CHD — the window of presentation is short and some lesions (duct-dependent) decompensate within hours of birth. Pre/postductal saturations + femoral pulses are the two fastest screens.",
        "components": [
          {
            "name": "Inspection and pre/postductal saturations",
            "significance": "Pre/postductal SpO₂ differential > 3% suggests a duct-dependent lesion or persistent pulmonary HTN. Universal CCHD screening uses this.",
            "pearl": "Pulse ox on the right hand = preductal (proximal to PDA insertion). Foot = postductal. Both arms and both legs should match; a differential is a red flag for critical CHD.",
            "steps": [
              {
                "label": "Central cyanosis",
                "method": "Inspect tongue, lips, oral mucosa.",
                "normal": "Pink mucous membranes"
              },
              {
                "label": "Pre/postductal SpO₂",
                "method": "Measure SpO₂ in right hand (preductal) AND either foot (postductal). Baby must be ≥24 hr old for CCHD screening.",
                "normal": "Both ≥ 95% AND difference < 3%"
              },
              {
                "label": "Peripheral perfusion",
                "method": "Capillary refill on sternum; note mottling or distal cyanosis.",
                "normal": "Capillary refill < 2 s, warm pink extremities"
              },
              {
                "label": "Precordial activity",
                "method": "Inspect anterior chest for hyperactive precordium.",
                "normal": "Not visible or minimally visible"
              }
            ],
            "abnormalHints": [
              "Central cyanosis with SpO₂ < 95% → cyanotic CHD workup (4-extremity BP, ECG, hyperoxia test, echo)",
              "Differential > 3% (pre > post) → duct-dependent systemic flow (HLHS, coarctation, interrupted arch)",
              "Preductal < postductal — persistent pulmonary HTN with reversed shunt"
            ]
          },
          {
            "name": "Palpation and auscultation",
            "significance": "Absent femoral pulses + arm-leg BP gradient = coarctation. Many CHD lesions manifest murmurs only after ductus closes (48–72 h).",
            "pearl": "Always palpate femoral pulses before discharging any newborn. Absent femorals in a well-appearing baby can be the only finding in a ductal-dependent coarctation — catastrophic if missed.",
            "steps": [
              {
                "label": "Apex beat",
                "method": "Palpate at the 4th ICS left of sternum (apex is higher in newborns).",
                "normal": "Palpable at 4th ICS, mid-clavicular or just lateral"
              },
              {
                "label": "Femoral pulses",
                "method": "Palpate both femoral pulses at the mid-inguinal point while simultaneously feeling the right brachial pulse — detects delay.",
                "normal": "Present, symmetric, equal timing with brachial"
              },
              {
                "label": "Auscultate each cardiac area",
                "method": "Use pediatric diaphragm at each classic point; baby quiet if possible.",
                "normal": "S1 S2 crisp; physiologic flow murmur sometimes present in the first 24–48 h"
              },
              {
                "label": "Continuous murmur",
                "method": "Listen below the left clavicle for a continuous (\"machinery\") murmur of PDA.",
                "normal": "No continuous murmur after the first day of life in a term baby"
              },
              {
                "label": "Four-limb BP (if any concern)",
                "method": "Right arm, left arm, both legs.",
                "normal": "Within 10 mmHg across limbs"
              }
            ],
            "abnormalHints": [
              "Absent femoral pulses — coarctation of the aorta (surgical emergency if duct-dependent)",
              "Harsh holosystolic at LLSB — VSD",
              "Continuous machinery murmur — PDA (expected in preterm; in term > 48 h is abnormal)",
              "Gallop S3/S4 — heart failure",
              "Single S2 — transposition, truncus, severe AS/PS"
            ]
          }
        ]
      }
    },
    "infant": {
      "label": "Infant (1–12 months)",
      "msk": {
        "overview": "Continued DDH screen through 6 months. Watch motor progression and symmetry of tone/movement.",
        "components": [
          {
            "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": "Primitive reflexes fading on schedule; protective reflexes emerging; gross motor and tone interlinked.",
        "components": [
          {
            "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"
            ]
          }
        ]
      },
      "resp": {
        "overview": "Infant respiratory disease centers on bronchiolitis, reactive airways, and pneumonia. Normal RR ≤ 50 (< 2 mo: ≤ 60). Infants are obligate nose-breathers — nasal congestion alone can cause significant WOB.",
        "components": [
          {
            "name": "Inspection",
            "significance": "Infant distress signs escalate fast. Nasal flaring, tracheal tug, head bobbing = significant WOB. Apnea in an infant < 2 mo is an emergency.",
            "pearl": "A quiet infant with retractions is more worrying than a crying one — exhausted infants stop crying and become hypoxic silently.",
            "steps": [
              {
                "label": "Respiratory rate",
                "method": "Count over full 60 s while quiet.",
                "normal": "< 2 mo: ≤ 60; 2–12 mo: ≤ 50"
              },
              {
                "label": "Work of breathing",
                "method": "Inspect nasal flaring, subcostal/intercostal/suprasternal retractions, tracheal tug, head-bobbing, accessory muscle use.",
                "normal": "No retractions, effortless breathing"
              },
              {
                "label": "Audible sounds",
                "method": "Stridor? Wheeze across the room? Grunting? Prolonged expiration?",
                "normal": "Quiet respirations"
              },
              {
                "label": "Colour and feeding history",
                "method": "Central cyanosis? Poor feeding (feeding is an effort marker in infants)?",
                "normal": "Pink, feeds well"
              },
              {
                "label": "Apnea observation",
                "method": "Watch for ≥ 20-s pauses or pauses < 20 s with bradycardia/cyanosis.",
                "normal": "No apneas"
              }
            ],
            "abnormalHints": [
              "Grunting / persistent retractions — pneumonia, bronchiolitis, CHF",
              "Wheeze — bronchiolitis (RSV), asthma, foreign body",
              "Stridor — croup (6 mo–6 y), laryngomalacia (infant), foreign body",
              "Apnea — bronchiolitis, sepsis, pertussis, seizure"
            ]
          },
          {
            "name": "Auscultation",
            "significance": "Infants have a thin chest wall — sounds transmit widely. Symmetry, wheeze, and crackles are the main findings.",
            "pearl": "In bronchiolitis, the classical finding is widespread end-inspiratory fine crackles PLUS expiratory wheeze. Tachypnea + retractions in an RSV-season infant confirms.",
            "steps": [
              {
                "label": "Air entry — bilateral",
                "method": "Warm stethoscope; listen at anterior chest and both axillae, both sides.",
                "normal": "Symmetric air entry"
              },
              {
                "label": "Wheeze",
                "method": "Listen in expiration. Diffuse wheeze = lower airway; focal wheeze = foreign body or local obstruction.",
                "normal": "No wheeze"
              },
              {
                "label": "Crackles",
                "method": "Listen in late inspiration. Focal = pneumonia; diffuse fine = bronchiolitis.",
                "normal": "No crackles"
              },
              {
                "label": "Prolonged expiration",
                "method": "Note expiration:inspiration length ratio.",
                "normal": "Inspiration ≥ expiration"
              }
            ],
            "abnormalHints": [
              "Focal crackles + fever — pneumonia",
              "Diffuse wheeze + fine crackles in an RSV-season infant — bronchiolitis",
              "Silent chest with extreme WOB — impending respiratory failure"
            ]
          }
        ]
      },
      "cv": {
        "overview": "Most CHD manifests in the first year as pulmonary blood-flow changes and the ductus closes. Infant CV exam = growth review + inspection + femoral pulses + auscultation. A harsh pan-systolic LLSB murmur in a 6-week-old = VSD until proven otherwise.",
        "components": [
          {
            "name": "Inspection and functional assessment",
            "significance": "Heart failure in infants presents as poor feeding, sweating during feeds (diaphoresis), tachypnea, and poor weight gain. These historical features predict bad exam findings.",
            "pearl": "Ask \"Does the baby sweat while feeding?\" — infant CHF presents with diaphoresis on the forehead during feeds, well before peripheral edema appears.",
            "steps": [
              {
                "label": "Growth trajectory",
                "method": "Plot weight-for-age on WHO chart. Failure to thrive raises CHD concern.",
                "normal": "Tracking ≥ 10th percentile or stable on personal curve"
              },
              {
                "label": "Feeding history",
                "method": "Ask about feed duration, sweating with feeds, tachypnea with feeds, tiring easily.",
                "normal": "Feeds < 20 min, no diaphoresis, no tachypnea"
              },
              {
                "label": "Central cyanosis",
                "method": "Inspect tongue and oral mucosa.",
                "normal": "Pink"
              },
              {
                "label": "Clubbing",
                "method": "Inspect finger nail beds (subtle in infants).",
                "normal": "No clubbing"
              },
              {
                "label": "Peripheral perfusion",
                "method": "Cap refill, warmth of extremities.",
                "normal": "Cap refill < 2 s, warm extremities"
              }
            ],
            "abnormalHints": [
              "Poor weight gain — consider CHF from L-to-R shunt (VSD, PDA, AVSD)",
              "Diaphoresis with feeds — infant CHF",
              "Tiring with feeds — significant CHD",
              "Central cyanosis — cyanotic CHD (ToF, TGA, TA, etc.)"
            ]
          },
          {
            "name": "Palpation and auscultation",
            "significance": "Femoral pulses + 4-limb BP screen coarctation. A harsh holosystolic murmur at LLSB is almost always a VSD in this age.",
            "pearl": "Listen over each of the 5 classic points as in the adult exam — the locations shift slightly with infant chest size but relative positions are the same. Also listen at the back: coarctation murmurs radiate there.",
            "steps": [
              {
                "label": "Apex beat",
                "method": "Palpate at 4th ICS mid-clavicular line.",
                "normal": "Palpable at 4th ICS in infants"
              },
              {
                "label": "Femoral pulses",
                "method": "Palpate bilaterally, simultaneously with right brachial.",
                "normal": "Present, equal, no delay vs brachial"
              },
              {
                "label": "Listen at each classic area (APTM)",
                "method": "See APTM diagram. Use pediatric stethoscope with both diaphragm and bell.",
                "normal": "S1 and S2 crisp, no murmur or physiologic only"
              },
              {
                "label": "Listen over the back (interscapular)",
                "method": "Check for radiation of coarctation murmurs.",
                "normal": "No radiating murmur"
              }
            ],
            "abnormalHints": [
              "Harsh holosystolic LLSB murmur — VSD",
              "Continuous \"machinery\" murmur below left clavicle — PDA",
              "Systolic ejection at ULSB + fixed split S2 — ASD",
              "Ejection murmur at ULSB + cyanosis — tetralogy of Fallot",
              "Absent femorals + radio-femoral delay — coarctation",
              "Gallop + tachycardia — heart failure"
            ]
          }
        ]
      }
    },
    "toddler": {
      "label": "Toddler (1–3 years)",
      "msk": {
        "overview": "Gait, physiologic alignment changes, in-toeing, joint range. Cooperation unpredictable — use play.",
        "components": [
          {
            "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": "Shifting to adult-pattern exam. Primitive reflexes should be absent. Use play-based techniques.",
        "components": [
          {
            "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)"
            ]
          }
        ]
      },
      "resp": {
        "overview": "Toddler respiratory disease: viral URIs, reactive airways, croup (6 mo–6 y classical age), foreign-body aspiration (age 1–3 is peak). Normal RR ≤ 40.",
        "components": [
          {
            "name": "Inspection",
            "pearl": "Sudden onset of unilateral wheeze + choking history in a toddler = foreign body until proven otherwise. CXR in expiration (or decubitus) helps show the trapped air.",
            "steps": [
              {
                "label": "Respiratory rate",
                "method": "Count over full 60 s if possible.",
                "normal": "≤ 40 /min"
              },
              {
                "label": "Work of breathing",
                "method": "Retractions, nasal flaring, tracheal tug.",
                "normal": "No retractions"
              },
              {
                "label": "Audible sounds",
                "method": "Stridor (croup), wheeze, barking cough.",
                "normal": "Quiet respirations"
              },
              {
                "label": "Drooling / posture",
                "method": "Tripod positioning, drooling (epiglottitis in unvaccinated child).",
                "normal": "No drooling, normal posture"
              }
            ],
            "abnormalHints": [
              "Barking cough + stridor — croup",
              "Drooling + tripod + toxic — epiglottitis (emergency)",
              "Sudden unilateral wheeze — foreign body aspiration"
            ]
          },
          {
            "name": "Auscultation",
            "steps": [
              {
                "label": "Air entry",
                "method": "Cooperation variable — listen quickly and systematically.",
                "normal": "Symmetric"
              },
              {
                "label": "Adventitious sounds",
                "method": "Wheeze, crackles, stridor at the neck.",
                "normal": "Clear lung fields"
              },
              {
                "label": "Unilateral findings",
                "method": "Focal wheeze, decreased air entry, or asymmetry — think foreign body or pneumonia.",
                "normal": "Symmetric bilateral"
              }
            ],
            "abnormalHints": [
              "Unilateral decreased breath sounds + wheeze — foreign body",
              "Focal crackles — pneumonia",
              "Diffuse wheeze — asthma/RAD"
            ]
          }
        ]
      },
      "cv": {
        "overview": "Most hemodynamically significant CHD has been detected by this age. Innocent murmurs peak here (Still's murmur, venous hum). The exam is adult-pattern but with smaller chest and less cooperation.",
        "components": [
          {
            "name": "Inspection and palpation",
            "pearl": "Innocent murmurs are a normal finding in well toddlers — soft, systolic, at the LLSB, musical, and they change with position. Anything that doesn't fit that pattern deserves referral.",
            "steps": [
              {
                "label": "General appearance + growth",
                "method": "Happy, active, tracking growth.",
                "normal": "Normal growth and activity"
              },
              {
                "label": "Colour and clubbing",
                "method": "Inspect tongue, nail beds.",
                "normal": "Pink, no clubbing"
              },
              {
                "label": "Apex beat",
                "method": "Palpate at 5th ICS mid-clavicular line.",
                "normal": "Located at 5th ICS MCL, tapping quality"
              },
              {
                "label": "Peripheral pulses",
                "method": "Brachial + femoral, symmetric and simultaneous.",
                "normal": "Symmetric, no delay"
              }
            ],
            "abnormalHints": [
              "Tiring with play, poor growth — missed CHD",
              "Cyanosis + clubbing — cyanotic CHD",
              "Absent femorals — coarctation"
            ]
          },
          {
            "name": "Auscultation",
            "steps": [
              {
                "label": "All 5 classic points",
                "method": "See APTM diagram above — Aortic, Pulmonic, Erb's, Tricuspid, Mitral.",
                "normal": "Crisp S1, S2 with physiologic split at pulmonic area"
              },
              {
                "label": "Evaluate any murmur",
                "method": "Timing, location, radiation, grade. Apply the \"7 S\" innocent-murmur criteria.",
                "normal": "No murmur, or soft (≤ grade 2) innocent murmur"
              },
              {
                "label": "Change with position",
                "method": "Have toddler sit, stand, lie down — does the murmur change? Innocent murmurs typically disappear or soften with standing.",
                "normal": "Murmur (if any) changes with position"
              }
            ],
            "abnormalHints": [
              "Harsh, loud (≥3/6), radiating, or diastolic murmur — not innocent, refer",
              "Cyanosis + murmur — CHD workup",
              "Fixed split S2 — ASD"
            ]
          }
        ]
      }
    },
    "preschool": {
      "label": "Preschool (3–5 years)",
      "msk": {
        "overview": "Functional gait maneuvers, scoliosis screen, resolving physiologic alignment.",
        "components": [
          {
            "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": "Formal pediatric neuro exam now feasible — most 4- and 5-year-olds cooperate with structured testing.",
        "components": [
          {
            "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)"
            ]
          }
        ]
      },
      "resp": {
        "overview": "Adult-pattern but shorter. Cooperation better than toddler. RR ≤ 30. Common: asthma/RAD, pneumonia, URIs.",
        "components": [
          {
            "name": "Inspection",
            "steps": [
              {
                "label": "Respiratory rate",
                "method": "Count over full 60 s quietly.",
                "normal": "≤ 30 /min"
              },
              {
                "label": "Work of breathing",
                "method": "Retractions, nasal flaring, accessory muscle use.",
                "normal": "Effortless breathing"
              },
              {
                "label": "Audible sounds",
                "method": "Wheeze, stridor, cough quality (barking = croup).",
                "normal": "Quiet"
              },
              {
                "label": "Chest shape",
                "method": "AP:transverse, hyperinflation signs.",
                "normal": "Not barrel-chested"
              }
            ],
            "abnormalHints": [
              "Barrel chest — chronic asthma, cystic fibrosis",
              "Retractions + wheeze — asthma exacerbation"
            ]
          },
          {
            "name": "Auscultation",
            "steps": [
              {
                "label": "Systematic zones",
                "method": "Upper, mid, lower fields anteriorly and posteriorly; axillae bilaterally. Cooperative deep breaths through mouth.",
                "normal": "Symmetric vesicular sounds"
              },
              {
                "label": "Wheeze",
                "method": "Expiratory, diffuse (asthma) or focal (foreign body, rare at this age).",
                "normal": "No wheeze"
              },
              {
                "label": "Crackles",
                "method": "Focal = pneumonia; diffuse fine = interstitial disease (rare in kids).",
                "normal": "No crackles"
              }
            ],
            "abnormalHints": [
              "Focal crackles + fever — pneumonia",
              "Diffuse wheeze — asthma",
              "Prolonged expiration with wheeze — lower airway obstruction"
            ]
          }
        ]
      },
      "cv": {
        "overview": "Most CHD is detected by this age. Innocent murmurs peak in this range. Sports participation exams require thorough CV screening.",
        "components": [
          {
            "name": "Inspection and palpation",
            "steps": [
              {
                "label": "General and growth",
                "method": "Track on growth curve; activity tolerance.",
                "normal": "Normal growth, active"
              },
              {
                "label": "Apex beat",
                "method": "5th ICS mid-clavicular line.",
                "normal": "Normal position and character"
              },
              {
                "label": "Peripheral pulses",
                "method": "Brachial + femoral simultaneously. BP in arm and leg if HTN.",
                "normal": "Symmetric, no delay"
              }
            ],
            "abnormalHints": [
              "Absent femorals or arm-leg BP gradient — coarctation (always check in HTN screening)",
              "Displaced apex — cardiomegaly"
            ]
          },
          {
            "name": "Auscultation",
            "pearl": "The 7 \"S\" criteria and the 5 classic innocent murmurs (see panel above) handle most murmurs you'll find in this age group. Still's murmur is the single most common.",
            "steps": [
              {
                "label": "All 5 classic points",
                "method": "Walk through A → P → E → T → M with diaphragm then bell.",
                "normal": "S1 S2 clear, physiologic S2 split at pulmonic, no added sounds"
              },
              {
                "label": "Any murmur",
                "method": "Characterise: timing, location, radiation, grade, character. Apply 7 S criteria + compare to innocent-murmur panel.",
                "normal": "No murmur, or innocent flow murmur meeting all 7 S criteria"
              },
              {
                "label": "Position change",
                "method": "Standing vs supine. Innocent murmurs typically soften or disappear on standing.",
                "normal": "Murmur (if any) changes with position"
              },
              {
                "label": "Sports screening extras (if applicable)",
                "method": "Screen for HOCM — murmur intensifies with Valsalva and standing (opposite of most).",
                "normal": "No murmur worsening on Valsalva"
              }
            ],
            "abnormalHints": [
              "Murmur breaking any of the 7 S criteria — refer",
              "Harsh systolic at LUSB + fixed split S2 — ASD",
              "Murmur louder with Valsalva — HOCM (sports participation risk)",
              "Diastolic murmur — always pathologic"
            ]
          }
        ]
      }
    },
    "school": {
      "label": "School-age (6–11 years)",
      "msk": {
        "overview": "Scoliosis screening peri-puberty, sports overuse injuries, resolving alignment.",
        "components": [
          {
            "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": "Adult-pattern six-component exam: mental status, CN, motor, reflexes, sensory, coordination/gait.",
        "components": [
          {
            "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"
            ]
          }
        ]
      },
      "resp": {
        "overview": "Nearly adult-pattern. Exam the same as adolescent with slightly more flexibility in cooperation. RR ≤ 30 in younger school-age, ≤ 20 in older. Sports history relevant (exercise-induced asthma).",
        "components": [
          {
            "name": "Inspection",
            "steps": [
              {
                "label": "Respiratory rate",
                "method": "Count over 60 s.",
                "normal": "≤ 30 (6–11 y)"
              },
              {
                "label": "Work of breathing",
                "method": "Retractions, accessory muscles.",
                "normal": "Effortless"
              },
              {
                "label": "Audible sounds",
                "method": "Listen for wheeze, stridor.",
                "normal": "Quiet"
              },
              {
                "label": "Chest shape",
                "method": "Barrel chest, pectus deformities.",
                "normal": "Normal shape"
              },
              {
                "label": "Clubbing",
                "method": "Schamroth window test.",
                "normal": "No clubbing"
              }
            ],
            "abnormalHints": [
              "Clubbing — CF, chronic hypoxemia, bronchiectasis",
              "Barrel chest — chronic asthma, CF"
            ]
          },
          {
            "name": "Palpation and percussion",
            "steps": [
              {
                "label": "Tracheal position",
                "method": "Middle finger in suprasternal notch.",
                "normal": "Midline"
              },
              {
                "label": "Chest expansion",
                "method": "Hands laterally, thumbs meeting at spine. Deep breath.",
                "normal": "Symmetric 3–5 cm"
              },
              {
                "label": "Tactile fremitus",
                "method": "Ulnar side of hand; \"ninety-nine\". Compare sides.",
                "normal": "Symmetric"
              },
              {
                "label": "Percussion",
                "method": "Pleximeter + plexor technique. Compare sides.",
                "normal": "Resonant throughout"
              }
            ],
            "abnormalHints": [
              "Deviated trachea — pneumothorax, effusion, collapse",
              "Dull percussion — consolidation, effusion",
              "Hyper-resonant — pneumothorax, hyperinflation"
            ]
          },
          {
            "name": "Auscultation",
            "steps": [
              {
                "label": "Systematic zones",
                "method": "Six anterior + four lateral + six posterior zones, compare side-to-side.",
                "normal": "Symmetric vesicular sounds"
              },
              {
                "label": "Adventitious sounds",
                "method": "Wheeze, crackles, rhonchi, rub, stridor at neck. Use sounds library for reference.",
                "normal": "No added sounds"
              },
              {
                "label": "Cough re-listen",
                "method": "Secretions (rhonchi, coarse crackles) should clear; fibrosis crackles do not.",
                "normal": "Secretion-based sounds clear with cough"
              }
            ],
            "abnormalHints": [
              "Focal crackles + fever — pneumonia",
              "Diffuse fine crackles — early interstitial disease",
              "Expiratory wheeze — asthma / RAD"
            ]
          }
        ]
      },
      "cv": {
        "overview": "Nearly adult-pattern. Sports participation screening is a key indication in this age. HOCM screening (family history of sudden cardiac death, exertional syncope, murmur louder with Valsalva) is specifically relevant.",
        "components": [
          {
            "name": "Inspection and palpation",
            "pearl": "For sports participation exams, always ask about exertional symptoms (syncope, chest pain, unexpected fatigue) AND family history of sudden cardiac death before age 50. Screening exam alone catches only ~3% of HOCM.",
            "steps": [
              {
                "label": "General and growth",
                "method": "Track on growth curve; review activity tolerance.",
                "normal": "Normal growth, age-appropriate activity"
              },
              {
                "label": "Colour and clubbing",
                "method": "Inspect mucous membranes and nail beds.",
                "normal": "Pink, no clubbing"
              },
              {
                "label": "Apex beat",
                "method": "Palpate at 5th ICS mid-clavicular line.",
                "normal": "Normal position, tapping character"
              },
              {
                "label": "Peripheral pulses",
                "method": "Simultaneous brachial + femoral.",
                "normal": "Symmetric, no delay"
              },
              {
                "label": "Blood pressure",
                "method": "Measure BP with appropriately sized cuff. If elevated, check both arms and one leg.",
                "normal": "Age-appropriate (< 120/80 roughly by 10+ years)"
              }
            ],
            "abnormalHints": [
              "Exertional syncope — HOCM, arrhythmia, LQTS",
              "BP differential — coarctation",
              "Displaced apex — cardiomegaly"
            ]
          },
          {
            "name": "Auscultation",
            "steps": [
              {
                "label": "All 5 classic points",
                "method": "See APTM diagram. A → P → E → T → M with diaphragm and bell.",
                "normal": "S1, S2 clear with physiologic split at P, no added sounds"
              },
              {
                "label": "Grade any murmur",
                "method": "Levine 1–6 (see scales above); characterise timing, location, radiation.",
                "normal": "No murmur, or innocent flow murmur meeting all 7 S criteria"
              },
              {
                "label": "Innocent vs pathologic",
                "method": "Apply 7 S criteria; compare to innocent-murmur panel.",
                "normal": "Innocent murmur (if present) clearly fits all 7 S features"
              },
              {
                "label": "Dynamic maneuvers",
                "method": "Standing: HOCM louder; most others soften. Valsalva: HOCM louder.",
                "normal": "Murmur (if any) softens on standing and Valsalva"
              }
            ],
            "abnormalHints": [
              "Murmur louder with Valsalva / standing — HOCM (sports disqualification considerations)",
              "Any diastolic murmur",
              "Murmur ≥ grade 3, radiating, or with thrill"
            ]
          }
        ]
      }
    },
    "adolescent": {
      "label": "Adolescent (12–21 years)",
      "msk": {
        "overview": "Sports-related injuries, adolescent scoliosis, apophyseal overuse, hypermobility screening.",
        "components": [
          {
            "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": "Full adult-pattern neuro exam across six pillars: mental status, cranial nerves, motor, reflexes, sensory, coordination/gait. In adolescents, screen concussion sequelae if sports-active; frontal release signs must be absent.",
        "components": [
          {
            "name": "Mental status",
            "significance": "Detects cognitive change (concussion, substance use, mood disorder, rare neurodegenerative disease).",
            "pearl": "Attention precedes memory. A patient who can't attend (serial 7s, months backward) will fail memory even with intact hippocampus — distinguish before calling it a memory problem.",
            "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)",
            "significance": "Localises brainstem, base-of-skull, and specific nerve pathology. Subtle deficits (RAPD, mild facial weakness, Horner) are easily missed — exam discipline matters.",
            "pearl": "The fastest screen for a CN deficit is asking the patient to speak, smile, look around, and swallow water. What's preserved in everyday function tells you what's likely intact — then examine formally to confirm and to catch the subtle.",
            "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",
            "significance": "Localises lesion to UMN vs LMN vs muscle vs junction. Pattern of weakness (proximal vs distal, symmetric vs focal) narrows differential.",
            "pearl": "Pronator drift is the most sensitive screen for subtle UMN weakness — a normal-feeling arm that drifts down with eyes closed still has corticospinal tract dysfunction. Always do it even when formal strength is 5/5.",
            "steps": [
              {
                "label": "Bulk inspection",
                "method": "Inspect shoulders, biceps, thighs, calves, dorsal interossei (between metacarpals) of hands.",
                "normal": "Symmetric bulk; no atrophy, no pseudohypertrophy"
              },
              {
                "label": "Tone — upper",
                "method": "Passive flex-extend elbow and pronate-supinate wrist at slow then quick speeds. Then pronator drift: arms outstretched, palms up, eyes closed for 10 s.",
                "normal": "Smooth passive range; no drift, no pronation of the outstretched hand"
              },
              {
                "label": "Tone — lower",
                "method": "Passive knee flexion-extension; quick ankle dorsiflexion to check for catch. Heel-slap test: roll thigh and watch for ankle swing.",
                "normal": "Normal resistance, no catch, symmetric"
              },
              {
                "label": "Strength — deltoid (C5)",
                "method": "Patient abducts both arms to 90°. Examiner pushes down on each arm just above the elbow while patient resists. Compare sides.",
                "normal": "Holds against full resistance — MRC 5/5 bilaterally"
              },
              {
                "label": "Strength — biceps (C5–C6)",
                "method": "Elbow flexed 90°, supinated. Examiner grasps wrist and pulls to extend while patient resists.",
                "normal": "Holds against full resistance — 5/5"
              },
              {
                "label": "Strength — triceps (C7)",
                "method": "Elbow flexed 90°. Examiner pushes wrist toward shoulder while patient extends against resistance.",
                "normal": "Extends against full resistance — 5/5"
              },
              {
                "label": "Strength — wrist extension (C6–C7)",
                "method": "Patient makes fist, extends wrist. Examiner pushes down on knuckles while patient holds wrist up.",
                "normal": "Holds against full resistance — 5/5"
              },
              {
                "label": "Strength — finger flexion / grip (C8)",
                "method": "Patient grips two of examiner's crossed fingers as hard as possible. Compare sides.",
                "normal": "Strong symmetric grip — 5/5"
              },
              {
                "label": "Strength — finger abduction (T1)",
                "method": "Patient spreads fingers wide. Examiner squeezes index and little fingers together while patient resists.",
                "normal": "Holds fingers apart — 5/5"
              },
              {
                "label": "Strength — hip flexion (L2–L3)",
                "method": "Supine. Patient lifts straight leg 30° off table. Examiner pushes down on thigh just above knee while patient resists.",
                "normal": "Holds thigh up against full resistance — 5/5"
              },
              {
                "label": "Strength — knee extension (L3–L4)",
                "method": "Sitting, knee 90°. Patient straightens knee while examiner pushes distal shin down.",
                "normal": "Extends against full resistance — 5/5"
              },
              {
                "label": "Strength — ankle dorsiflexion (L4–L5)",
                "method": "Patient pulls toes and foot up toward shin. Examiner pushes foot down at the dorsum.",
                "normal": "Holds dorsiflexion against full resistance — 5/5; preserved heel-walk"
              },
              {
                "label": "Strength — great toe extension (L5)",
                "method": "Patient extends great toe up while examiner pushes it down with thumb.",
                "normal": "Holds against full resistance — 5/5 (classic L5 test)"
              },
              {
                "label": "Strength — ankle plantarflexion (S1)",
                "method": "Patient pushes foot down against examiner's hand at the ball. OR ask patient to toe-walk 10 steps (more sensitive — unilateral plantarflexion weakness shows immediately).",
                "normal": "Full power; toe-walks symmetrically — 5/5"
              }
            ],
            "abnormalHints": [
              "Focal weakness → localise by myotome",
              "Pronator drift (subtle UMN, always check even with 5/5)",
              "Spasticity / catch (UMN)",
              "Atrophy (LMN, disuse)",
              "Fasciculations (MND, ALS)",
              "Pseudohypertrophy of calves (DMD in a young male)"
            ]
          },
          {
            "name": "Deep tendon reflexes",
            "significance": "Reflex pattern (increased, decreased, asymmetric) localises UMN vs LMN vs root vs peripheral nerve. Inexpensive and fast, but asymmetry is the most informative finding.",
            "pearl": "A reinforced reflex is still a reflex. If you can't elicit it initially, use Jendrassik (teeth clench or pull interlocked fingers apart) to boost — absent reflexes without reinforcement aren't truly absent.",
            "steps": [
              {
                "label": "Biceps (C5–C6)",
                "method": "Patient's arm relaxed across lap. Examiner places thumb firmly on biceps tendon at the cubital fossa, strikes thumb with reflex hammer. Compare both sides sequentially.",
                "normal": "2+ symmetric — visible contraction of biceps, slight elbow flexion"
              },
              {
                "label": "Brachioradialis (C5–C6)",
                "method": "Arm relaxed. Strike the distal radius about 3 cm proximal to the wrist, on its radial (thumb) side.",
                "normal": "2+ symmetric — elbow flexion and slight forearm supination"
              },
              {
                "label": "Triceps (C7)",
                "method": "Support the patient's arm at the wrist with elbow at 90°. Strike the triceps tendon just above the olecranon.",
                "normal": "2+ symmetric — triceps contraction, slight elbow extension"
              },
              {
                "label": "Finger flexors — Hoffmann sign",
                "method": "Grasp the middle finger's distal phalanx, flick it downward quickly and release. Watch the thumb and index finger.",
                "normal": "Negative — no thumb flexion, no index flexion (positive = corticospinal tract dysfunction)"
              },
              {
                "label": "Patellar (L3–L4)",
                "method": "Patient sits with knees hanging freely off the table. Strike the patellar tendon just below the patella.",
                "normal": "2+ symmetric — quadriceps contraction with knee extension"
              },
              {
                "label": "Achilles (S1)",
                "method": "Patient's knee slightly flexed and leg externally rotated, or kneeling on a chair. Slightly dorsiflex the foot and strike the Achilles tendon.",
                "normal": "2+ symmetric — plantar flexion of the foot"
              },
              {
                "label": "Plantar response (Babinski)",
                "method": "Stroke the lateral aspect of the sole firmly from the heel toward the little toe, then curve across the ball of the foot.",
                "normal": "Toes flex downward (plantar flexion, \"down-going\") bilaterally in anyone ≥ 2 years"
              },
              {
                "label": "Ankle clonus",
                "method": "Knee slightly bent. Support the shin with one hand, quickly and sharply dorsiflex the foot with the other, hold in dorsiflexion.",
                "normal": "≤ 3 non-sustained beats is acceptable; sustained rhythmic oscillation = pathological clonus (UMN)"
              }
            ],
            "abnormalHints": [
              "Hyperreflexia + sustained clonus = UMN (MS, myelopathy, cord lesion, stroke)",
              "Symmetric hyporeflexia = peripheral polyneuropathy, GBS, myopathy, hypothyroid, B12 deficiency",
              "Asymmetric hyporeflexia = radiculopathy at that segment",
              "Hoffmann positive = corticospinal tract dysfunction at cervical cord or above",
              "Up-going Babinski after age 2 = UMN (always abnormal)"
            ]
          },
          {
            "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"
            ]
          }
        ]
      },
      "resp": {
        "overview": "Systematic respiratory exam: inspection → palpation → percussion → auscultation → special maneuvers. Always start from observation — rate, pattern, work of breathing, and audible sounds (stridor, grunting) can be diagnostic before the stethoscope touches the chest.",
        "components": [
          {
            "name": "Inspection — observation before touching",
            "significance": "Detects respiratory distress and localises the level of airway compromise before any equipment is used. High yield: RR, WOB, audible sounds, chest shape, colour.",
            "pearl": "Audible stridor at rest from across the room = upper-airway obstruction, often urgent. Grunting in an infant = significant distress — never dismiss as fussiness.",
            "steps": [
              {
                "label": "Respiratory rate",
                "method": "Count over a full 60 seconds (not 15×4) — children normally breathe irregularly. Count while the patient is calm, before any interaction.",
                "normal": "Within age-appropriate range (see scales card above)"
              },
              {
                "label": "Respiratory pattern",
                "method": "Observe depth, regularity, and inspiration:expiration ratio. Watch for prolonged expiration, paradoxical chest-abdominal movement, or apneas.",
                "normal": "Regular, I:E ratio ~1:2, no pauses > 10 s in an infant"
              },
              {
                "label": "Work of breathing",
                "method": "Inspect for nasal flaring, suprasternal/intercostal/subcostal retractions, accessory muscle use (SCM, abdominals), tripod positioning, head-bobbing in infants.",
                "normal": "No retractions; breathing effortless"
              },
              {
                "label": "Audible sounds (no stethoscope)",
                "method": "Listen at the bedside without the stethoscope. Grunting? Stridor? Wheezing audible across the room? Hoarse voice?",
                "normal": "No audible stridor, grunting, or wheeze"
              },
              {
                "label": "Chest shape and symmetry",
                "method": "Inspect from front and lateral. Note AP-to-transverse diameter, pectus excavatum/carinatum, chest wall asymmetry.",
                "normal": "AP:transverse ~1:2 (not barrel-chested); symmetric"
              },
              {
                "label": "Colour and perfusion",
                "method": "Inspect lips, tongue, nail beds for central cyanosis. Check peripheral perfusion (capillary refill, mottling).",
                "normal": "Pink, cap refill < 2 s, no cyanosis"
              },
              {
                "label": "Clubbing",
                "method": "Inspect fingernails: Schamroth sign (reverse a finger against its mirror — normal forms a diamond-shaped window, clubbed does not).",
                "normal": "Normal nail angle, Schamroth window present"
              }
            ],
            "abnormalHints": [
              "Audible stridor — upper airway (croup, epiglottitis, foreign body, laryngomalacia)",
              "Grunting in infant — significant distress",
              "Tripod positioning, accessory muscle use — severe distress",
              "Barrel chest — chronic air-trapping (asthma, CF)",
              "Central cyanosis — significant hypoxemia",
              "Clubbing in a child — cystic fibrosis, chronic hypoxemia, bronchiectasis, cyanotic CHD"
            ]
          },
          {
            "name": "Palpation",
            "significance": "Localises pathology: consolidation increases tactile fremitus; pneumothorax/effusion decreases it. Trachea deviates AWAY from expanding lesions and TOWARD collapsing ones.",
            "pearl": "Tracheal deviation is one of the fastest bedside clues to mediastinal shift — tension pneumothorax pushes it away, lobar collapse pulls it toward. Palpate with the middle finger in the suprasternal notch.",
            "steps": [
              {
                "label": "Tracheal position",
                "method": "Patient sitting upright, neck slightly extended. Place middle finger in the suprasternal notch, check equal distance to each SCM.",
                "normal": "Midline"
              },
              {
                "label": "Chest expansion — symmetry",
                "method": "Hands on lateral chest wall with thumbs meeting at the spine (posterior) or xiphoid (anterior). Patient takes a deep breath. Watch thumbs separate symmetrically.",
                "normal": "Symmetric 3–5 cm separation"
              },
              {
                "label": "Tactile fremitus",
                "method": "Ulnar surface of hand on chest wall. Ask patient to say \"ninety-nine\" repeatedly. Move hand systematically across each zone, comparing sides.",
                "normal": "Equal mild vibration bilaterally over lung fields"
              },
              {
                "label": "Chest wall tenderness",
                "method": "Palpate ribs, costochondral junctions, sternum, and intercostal spaces.",
                "normal": "No tenderness"
              },
              {
                "label": "Subcutaneous emphysema",
                "method": "Gentle palpation along clavicles, neck, chest wall.",
                "normal": "No crepitus under skin"
              }
            ],
            "abnormalHints": [
              "Tracheal deviation — tension pneumothorax, large pleural effusion (away); upper lobe collapse (toward)",
              "Asymmetric expansion — pneumothorax, large effusion, lobar collapse, phrenic palsy",
              "Increased fremitus — consolidation (pneumonia), lobar pneumonia",
              "Decreased/absent fremitus — pleural effusion, pneumothorax, obstruction",
              "Costochondral tenderness — costochondritis, trauma",
              "Subcutaneous emphysema — pneumothorax, tracheobronchial injury"
            ]
          },
          {
            "name": "Percussion",
            "significance": "Differentiates air (hyper-resonant), fluid (dull), and consolidated lung (dull) without imaging. Well-performed percussion detects a pleural effusion > 300 mL or a pneumothorax with ~90% sensitivity.",
            "pearl": "Pleximeter fingertip must be flat against the chest wall — lift other fingers off. The \"feel\" of a percussion note is as informative as the sound: dullness has a dense, reflected quality; hyper-resonance feels hollow and springy.",
            "steps": [
              {
                "label": "Technique",
                "method": "Place middle finger of non-dominant hand (pleximeter) flat on chest wall; strike distal IP joint with tip of dominant middle finger (plexor) using a quick wrist flick.",
                "normal": "N/A — technique step"
              },
              {
                "label": "Systematic zones",
                "method": "Percuss from apex to base, comparing side-to-side at each level. Include anterior, lateral (mid-axillary), and posterior fields.",
                "normal": "Resonant throughout lung fields"
              },
              {
                "label": "Cardiac dullness",
                "method": "Percuss from resonant lung toward the heart border. Left sternal border dullness starts at the 3rd–5th ICS.",
                "normal": "Dullness beginning at the expected cardiac border"
              },
              {
                "label": "Hepatic dullness",
                "method": "Right 5th–6th ICS mid-clavicular line transitions from resonant to dull.",
                "normal": "Liver edge dullness at expected level"
              },
              {
                "label": "Diaphragmatic excursion",
                "method": "Patient inhales fully then exhales fully; mark level of dullness at each end. Difference is diaphragm excursion.",
                "normal": "3–5 cm excursion bilaterally"
              }
            ],
            "abnormalHints": [
              "Hyper-resonant — pneumothorax, emphysematous bulla, severe asthma attack",
              "Dull — consolidation, pleural effusion (stony dull), atelectasis, pleural thickening, large mass",
              "Raised diaphragm (loss of excursion) — effusion, paralysis, subdiaphragmatic pathology"
            ]
          },
          {
            "name": "Auscultation — normal breath sounds",
            "significance": "Breath sound quality varies by location. Bronchial sounds heard peripherally = consolidation; absent breath sounds = pneumothorax, effusion, obstruction.",
            "pearl": "Always compare corresponding points side-to-side sequentially — your ear calibrates to \"normal\" one side and immediately hears asymmetry. Listen through a full respiratory cycle at each zone.",
            "steps": [
              {
                "label": "Technique",
                "method": "Diaphragm of stethoscope directly on skin (not over clothing). Patient breathes slowly and deeply through an open mouth.",
                "normal": "N/A — technique"
              },
              {
                "label": "Vesicular sounds (peripheral)",
                "method": "Listen over lung fields away from the sternum. Play the \"Normal vesicular\" sample above for reference.",
                "normal": "Soft, low-pitched, inspiration > expiration in length and loudness"
              },
              {
                "label": "Bronchovesicular (over main bronchi)",
                "method": "Listen at the 1st–2nd ICS anteriorly and between scapulae posteriorly.",
                "normal": "Intermediate pitch, inspiration = expiration"
              },
              {
                "label": "Bronchial (over trachea)",
                "method": "Listen directly over the manubrium or trachea.",
                "normal": "Harsh, high-pitched, expiration > inspiration"
              },
              {
                "label": "Systematic comparison",
                "method": "Six zones anteriorly (upper/mid/lower × L/R), four lateral, six posterior. Compare side-to-side at each zone.",
                "normal": "Symmetric breath sounds at every paired zone"
              }
            ],
            "abnormalHints": [
              "Bronchial sounds heard peripherally — consolidation (pneumonia)",
              "Absent/diminished breath sounds — pneumothorax, effusion, severe obstruction, obesity / muscular chest",
              "Prolonged expiration — lower airway obstruction (asthma, bronchiolitis)"
            ]
          },
          {
            "name": "Auscultation — adventitious sounds",
            "significance": "Adventitious (added) sounds are the key diagnostic finding. Timing (inspiratory vs expiratory vs biphasic), character (continuous vs discontinuous), and location are all informative.",
            "pearl": "Ask the patient to cough and re-listen. Secretions (rhonchi, some coarse crackles) clear or change; fine crackles of fibrosis or early pneumonia do not. The cough test separates two differential groups in one maneuver.",
            "steps": [
              {
                "label": "Listen for wheeze",
                "method": "Continuous musical sounds, typically expiratory. Use the \"Wheeze\" sample for reference.",
                "normal": "No wheeze"
              },
              {
                "label": "Listen for crackles — fine",
                "method": "Short, high-pitched, discontinuous \"Velcro\" sounds. Typically end-inspiratory, bibasilar. Use the \"Fine crackles\" sample.",
                "normal": "No crackles"
              },
              {
                "label": "Listen for crackles — coarse",
                "method": "Longer, lower-pitched, louder than fine. Use the \"Coarse crackles\" sample.",
                "normal": "No crackles"
              },
              {
                "label": "Listen for rhonchi",
                "method": "Low-pitched, continuous, snore-like. Often change with cough. Use the \"Rhonchi\" sample.",
                "normal": "No rhonchi"
              },
              {
                "label": "Listen for pleural rub",
                "method": "Grating, creaky, biphasic, does NOT clear with cough. Use the \"Pleural rub\" sample.",
                "normal": "No pleural rub"
              },
              {
                "label": "Listen at the neck (for stridor)",
                "method": "Place stethoscope over the anterior neck. Stridor is loudest here and differentiates from wheeze (loudest over chest). Use the \"Stridor\" sample.",
                "normal": "No stridor"
              },
              {
                "label": "Listen for expiratory grunting (infants)",
                "method": "Often audible without a stethoscope at the bedside — short, low-pitched sound at the end of each expiration (glottal closure against exhaled air).",
                "normal": "No grunting"
              },
              {
                "label": "Cough re-listen",
                "method": "Have patient cough forcefully; re-listen to any abnormal area. Note if the sound clears or changes.",
                "normal": "Any secretion-based sound should clear or change with cough"
              }
            ],
            "abnormalHints": [
              "Wheeze — asthma, bronchiolitis, foreign body (localised), anaphylaxis",
              "Fine crackles — pulmonary edema, interstitial lung disease, early pneumonia",
              "Coarse crackles — bronchitis, pneumonia, bronchiectasis, aspiration",
              "Rhonchi — large-airway secretions",
              "Pleural rub — pleurisy, PE, pneumonia with pleural involvement",
              "Stridor — upper airway obstruction (croup, epiglottitis, FB)"
            ]
          },
          {
            "name": "Special maneuvers — transmitted voice sounds",
            "significance": "Vocal resonance tests detect consolidation (increased transmission) and effusion/pneumothorax (decreased). Useful when auscultation suggests asymmetry.",
            "pearl": "Whispered pectoriloquy is the most sensitive of the three — whispered words transmitted clearly through consolidated lung. If \"one, two, three\" whispered becomes clearly audible over one lung zone, there is consolidation underneath.",
            "steps": [
              {
                "label": "Bronchophony",
                "method": "Patient says \"ninety-nine\" in normal voice. Listen at each lung zone with the stethoscope.",
                "normal": "Muffled, indistinct sound"
              },
              {
                "label": "Egophony",
                "method": "Patient says \"ee\" continuously. Listen over any suspicious area.",
                "normal": "\"Ee\" sounds like \"ee\" (no change)"
              },
              {
                "label": "Whispered pectoriloquy",
                "method": "Patient whispers \"one, two, three\" or \"ninety-nine\". Listen over each zone.",
                "normal": "Whisper is faint and indistinct"
              }
            ],
            "abnormalHints": [
              "Bronchophony increased — consolidation",
              "Egophony positive (\"ee\" → \"A\" / \"ay\") — consolidation, sometimes top of an effusion",
              "Whispered pectoriloquy positive (whisper clearly audible) — consolidation"
            ]
          }
        ]
      },
      "cv": {
        "overview": "Systematic cardiovascular exam: inspection → palpation → auscultation at the five classic points → peripheral vascular exam. Always palpate the apex BEFORE auscultating — knowing where the apex lies tells you where to put the stethoscope and flags cardiomegaly immediately.",
        "components": [
          {
            "name": "Inspection",
            "significance": "Detects obvious precordial activity, chest-wall signs of congenital heart disease, and systemic markers (cyanosis, clubbing, dysmorphic features).",
            "pearl": "Clubbing + central cyanosis in a well-appearing adolescent = cyanotic congenital heart disease until proven otherwise. Inspect the fingernails before reaching for the stethoscope.",
            "steps": [
              {
                "label": "General appearance",
                "method": "Observe body habitus, features suggesting syndromic CHD (Turner, Down, Marfan, Williams).",
                "normal": "No dysmorphic features, appropriate growth"
              },
              {
                "label": "Central cyanosis",
                "method": "Inspect lips, tongue, and oral mucosa for bluish discoloration.",
                "normal": "Pink oral mucosa, no cyanosis"
              },
              {
                "label": "Peripheral cyanosis / clubbing",
                "method": "Inspect nail beds; do Schamroth's window (oppose nails of 4th fingers — normally forms a diamond-shaped window).",
                "normal": "Pink nail beds, Schamroth window present"
              },
              {
                "label": "Precordial bulge",
                "method": "Inspect anterior chest wall tangentially for asymmetric prominence over the heart.",
                "normal": "Symmetric chest, no bulge"
              },
              {
                "label": "Visible apex beat",
                "method": "Inspect for a visible cardiac impulse at the 5th ICS mid-clavicular line.",
                "normal": "Apex may be visible in thin patients; should not be displaced"
              },
              {
                "label": "Neck veins (JVP)",
                "method": "Patient reclined 45°, head turned slightly left. Observe the right internal jugular pulsation; measure vertical height above the sternal angle.",
                "normal": "≤ 4 cm above sternal angle (≤ 9 cm H₂O from right atrium)"
              }
            ],
            "abnormalHints": [
              "Central cyanosis — right-to-left shunt, severe hypoxemia",
              "Clubbing — cyanotic CHD, chronic hypoxemia",
              "Precordial bulge — long-standing cardiomegaly (grew during skeletal growth)",
              "Visible apex displaced lateral/inferior — cardiomegaly",
              "Elevated JVP — right-heart failure, fluid overload, cardiac tamponade"
            ]
          },
          {
            "name": "Palpation",
            "significance": "Localises the apex (confirms cardiac size), detects thrills (loud murmurs), and identifies a parasternal heave (RV hypertrophy).",
            "pearl": "If you feel a thrill, the murmur is at least grade 4/6 — grade your murmur as ≥4 even if it sounds less impressive. Thrill = loud, palpable turbulence.",
            "steps": [
              {
                "label": "Apex beat — localise",
                "method": "Feel with the tips of the fingers at the 5th ICS mid-clavicular line. If not found, roll the patient to the left lateral decubitus position.",
                "normal": "Located at 5th ICS, mid-clavicular line, less than 2 cm in diameter"
              },
              {
                "label": "Apex character",
                "method": "Describe: tapping (normal), heaving (pressure overload, e.g. AS/HTN), thrusting (volume overload, e.g. AR/MR), dyskinetic (MI/aneurysm).",
                "normal": "Brief tapping quality"
              },
              {
                "label": "Parasternal heave",
                "method": "Place the heel of the hand along the left sternal border. Sustained outward movement with each systole = heave.",
                "normal": "No heave"
              },
              {
                "label": "Thrills",
                "method": "Use the palmar aspect of the hand at each of the 5 auscultation areas (A, P, E, T, M). A thrill = palpable turbulence.",
                "normal": "No thrills"
              },
              {
                "label": "Peripheral pulses — upper",
                "method": "Palpate radial pulses bilaterally, then brachial. Note rate, rhythm, volume, and symmetry.",
                "normal": "Symmetric 2+ pulses, regular rhythm, age-appropriate rate"
              },
              {
                "label": "Peripheral pulses — lower",
                "method": "Palpate femoral pulses. Compare to brachial — radio-femoral or brachio-femoral delay suggests coarctation of the aorta.",
                "normal": "Femoral pulses 2+ symmetric, no delay relative to radial"
              }
            ],
            "abnormalHints": [
              "Apex displaced laterally/inferiorly — cardiomegaly",
              "Heaving apex — pressure overload (AS, HTN)",
              "Thrusting apex — volume overload (AR, MR)",
              "Thrill over precordium — always pathological; at least grade 4/6 murmur",
              "Parasternal heave — RV hypertrophy (pulmonary HTN, pulmonary stenosis, VSD with Eisenmenger)",
              "Radio-femoral delay — coarctation of the aorta (always check in a hypertensive adolescent)"
            ]
          },
          {
            "name": "Auscultation — approach",
            "significance": "Systematic technique ensures every relevant finding is detected. Listen at all 5 points, with both diaphragm and bell, in supine/sitting/left-lateral positions as needed.",
            "pearl": "Time every murmur by simultaneously palpating the carotid pulse with the fingers of your free hand. Pulse = systole. Murmur heard during the pulse = systolic; in between pulses = diastolic.",
            "steps": [
              {
                "label": "Positioning",
                "method": "Patient supine, head of bed at 30°. Exam room quiet, patient relaxed. Warm the stethoscope first.",
                "normal": "N/A — technique"
              },
              {
                "label": "Diaphragm technique",
                "method": "Firm contact with skin. Detects HIGH-pitched sounds: S1, S2, systolic ejection murmurs, AR, MR.",
                "normal": "N/A — technique"
              },
              {
                "label": "Bell technique",
                "method": "Very light contact — enough to make a seal but not stretch the skin. Detects LOW-pitched sounds: S3, S4, mitral stenosis rumble.",
                "normal": "N/A — technique"
              },
              {
                "label": "Listen at each of the 5 points",
                "method": "A → P → E → T → M in order, each with diaphragm then bell. Spend a full cycle at each zone.",
                "normal": "S1 crisp, S2 clear (splits physiologically on inspiration at P), no added sounds, no murmur"
              },
              {
                "label": "Left lateral decubitus position",
                "method": "If apex murmur suspected. Roll patient to left side. Listen at the apex with the BELL for mitral stenosis rumble or S3/S4.",
                "normal": "No added sounds, no diastolic rumble"
              },
              {
                "label": "Sitting forward, held expiration",
                "method": "Patient leans forward, exhales fully, holds. Listen at left lower sternal border and Erb's point with the DIAPHRAGM for aortic regurgitation (soft early diastolic decrescendo).",
                "normal": "No early-diastolic murmur"
              }
            ],
            "abnormalHints": [
              "Fixed split S2 (no change with respiration) — ASD",
              "Loud S2 at pulmonic area — pulmonary HTN",
              "S3 — volume overload, CHF (can be normal in young athletes)",
              "S4 — stiff ventricle (HTN, HCM, ischemia)",
              "Audible opening snap — mitral stenosis (rare in children)"
            ]
          },
          {
            "name": "Auscultation — heart sounds and murmurs",
            "significance": "Characterising a murmur by timing, location, radiation, pitch, quality, and dynamic maneuvers narrows the differential.",
            "pearl": "Innocent murmurs in children share 7 \"S\" features: Soft (≤ grade 2), Systolic, Short, Single (no added S3/S4), Small (localised, non-radiating), Sweet (musical), Sensitive to position/respiration (louder supine, softer standing). Anything breaking this pattern deserves workup.",
            "steps": [
              {
                "label": "S1",
                "method": "Listen at the apex (mitral). Coincides with the carotid pulse upstroke. Mitral + tricuspid closure.",
                "normal": "Single, crisp, single-component sound"
              },
              {
                "label": "S2",
                "method": "Listen at the pulmonic area in HELD INSPIRATION and HELD EXPIRATION. Note whether S2 splits physiologically (wider in inspiration, narrower/absent in expiration).",
                "normal": "Physiologic split (widens on inspiration, narrows on expiration)"
              },
              {
                "label": "S3 / S4 gallops",
                "method": "Bell at the apex in left lateral decubitus. S3 = early diastole (after S2), low-pitched. S4 = late diastole (just before S1).",
                "normal": "Absent in adults; S3 can be normal in young athletes under age 30"
              },
              {
                "label": "Identify murmur — timing",
                "method": "Time vs carotid pulse. Systolic (during pulse) vs diastolic (between pulses) vs continuous.",
                "normal": "No murmur, or only soft innocent flow murmur"
              },
              {
                "label": "Identify murmur — location + radiation",
                "method": "Where loudest? Does it radiate? AS → carotids. MR → axilla. Coarctation → back.",
                "normal": "N/A — characterise only if murmur present"
              },
              {
                "label": "Identify murmur — character",
                "method": "Crescendo-decrescendo (ejection) vs holosystolic (plateau) vs decrescendo early-diastolic (AR, PR) vs mid-diastolic rumble (MS, TS).",
                "normal": "N/A — characterise only if murmur present"
              },
              {
                "label": "Grade intensity",
                "method": "Levine 1–6 scale (see scales card above).",
                "normal": "No murmur, or grade ≤ 2 soft innocent flow murmur"
              },
              {
                "label": "Dynamic maneuvers",
                "method": "Standing: ↑HOCM, ↑MVP click (earlier). Squatting: opposite. Valsalva: ↑HOCM, most others decrease.",
                "normal": "No significant change with posture"
              }
            ],
            "abnormalHints": [
              "Holosystolic murmur at apex → axilla — mitral regurgitation",
              "Holosystolic at lower left sternal border (LLSB) — VSD, tricuspid regurgitation",
              "Systolic ejection at upper right sternal border → carotids — aortic stenosis",
              "Systolic ejection at upper left sternal border — pulmonary stenosis",
              "Continuous \"machinery\" below left clavicle — PDA",
              "Early diastolic at Erb's point, leaning forward — aortic regurgitation",
              "Diastolic rumble at apex, bell in left-lateral — mitral stenosis",
              "Fixed split S2 + systolic flow murmur — ASD"
            ]
          },
          {
            "name": "Peripheral vascular exam",
            "significance": "Coarctation of the aorta hides until BP and pulses are checked in all four extremities. Differential diagnosis of a hypertensive adolescent should include this in the first 60 seconds.",
            "pearl": "Four-limb BP measurement is mandatory in any adolescent with hypertension or a murmur. Upper-extremity BP > lower-extremity BP (or brachio-femoral delay) = coarctation until excluded.",
            "steps": [
              {
                "label": "Four-limb blood pressure",
                "method": "Measure BP in right arm, left arm, and at least one leg. Use appropriately sized cuff (bladder width 40% of limb circumference, length 80–100%).",
                "normal": "Arm BPs within 10 mmHg of each other; leg systolic within 20 mmHg of arm systolic (may be higher)"
              },
              {
                "label": "Radial pulses",
                "method": "Palpate both radials simultaneously — note any delay or asymmetry.",
                "normal": "Simultaneous, symmetric, 2+"
              },
              {
                "label": "Radio-femoral delay",
                "method": "Palpate radial and femoral simultaneously. Feel the femoral as clearly \"after\" the radial = delay.",
                "normal": "No delay"
              },
              {
                "label": "Femoral pulses",
                "method": "Palpate both femoral pulses at the mid-inguinal point. Compare amplitude to radials.",
                "normal": "Symmetric 2+ pulses, equal amplitude to radial"
              },
              {
                "label": "Dorsalis pedis + posterior tibialis",
                "method": "Palpate in both feet.",
                "normal": "2+ pulses bilaterally"
              },
              {
                "label": "Capillary refill",
                "method": "Press and release the nail bed; time to normal colour.",
                "normal": "< 2 sec"
              }
            ],
            "abnormalHints": [
              "Asymmetric upper-extremity BP (> 10 mmHg) — subclavian stenosis or coarctation at the origin",
              "Upper >> lower-extremity BP — coarctation of the aorta",
              "Diminished or absent femoral pulses with brachio-femoral delay — coarctation",
              "Bounding pulses with wide pulse pressure — AR, PDA, arteriovenous fistula, thyrotoxicosis, anemia",
              "Weak thready pulses — low output state (heart failure, shock, hypovolemia)",
              "Prolonged capillary refill — dehydration, shock, cold stress"
            ]
          }
        ]
      }
    }
  }
}