4 months ago she started more neck pain, electric current like feeling in whole body, headache, body pain, nausea, vertigo, vomiting, fever (random) breathlessness and loss of sensation in little finger and ring finger and so she had even started taking baclofen twice a day. She was unable to stand/walk we had to admit her in hospital, and got suggestion for problem in spine, referred to another hospital for surgery, to cut bone, Then before surgery they said of low blood cells, and also next day, blood cells were low so surgery was cancelled and she was referred back till blood cells become normal, and same time also found ulcer due to infection in stomach. Then we took her to another hospital after 7 days and she was admitted to ICU and before admitting we also found that she had got bed sores on back. They did many test and gave her blood after 2 days and albumin. She became better, Then we took her home and she was still having tube in her mouth to give her food. We gave her food by tube for 5 days, and packet juice using same tube and feeding injection, a person used to come and do dressing for her bed sores which had improved, but on around 8th day she got diarrhoea, 4-5 times 1st day and it became fine after 3 days without giving any medicine for diarrhea. She was only on already prescribed medication. Her stool was water like, no blood and and blackish so we stopped giving her pomegranate juice.
Case link: https://classworkdecjan.blogspot.com/2016/12/60f-with-coma-e-coli-sepsis-and-upper.html
Take the case history above and return it broken into clearly defined history points, with each point tagged against every VibeRounds module prompt (by Module–Step number) that can plausibly be applied at that specific point in the case. For each tagged prompt, state why it applies there — what in that history point gives the prompt something concrete to work with, not just that the module exists in general.
Source case: Family/advocate-reported longitudinal history — neurological, haematological, infective, and nutritional course over ~4 months, including ICU admission and home tube-feeding.
How to read this file: The case is broken into sequential history points. Each point carries the original text unchanged, followed by a table of every prompt (by Module–Step number) that can plausibly be run at that point in the case, with a one-line reason tied to what is actually present in that point. A prompt is listed only where the history point gives it something concrete to work with — not just because the module exists. Some prompts (session-setup / contract-setting prompts) are listed once, at the first point where that mode of working would sensibly begin.
4 months ago she started more neck pain, electric current like feeling in whole body, headache, body pain, nausea, vertigo, vomiting, fever (random) breathlessness and loss of sensation in little finger and ring finger and so she had even started taking baclofen twice a day.
| Prompt | Why it applies here |
|---|---|
| 2.0 (Case Opening & Advocate Onboarding) | This is the natural start of a case record — an advocate first describing the main symptom cluster that prompted documentation. Step 2.0 is designed to open exactly this kind of entry. |
| 2.1 (Symptom & Classifier Capture) | A dense list of symptoms (neck pain, paraesthesia-like “electric current” sensation, headache, body pain, nausea, vertigo, vomiting, random fever, breathlessness, ulnar-distribution sensory loss) is exactly the narrative material this prompt is built to capture and structure into a symptom/classifier list. |
| 17.0 / 17.1 (Problem Representation — Session Setup / Raw Case to Qualifier Summary) | This raw, ordinary-language symptom dump is the ideal input for compressing into semantic qualifiers (e.g. “subacute, polyfocal, neuro-systemic with sensory deficit”) before any diagnosis is attempted — exactly the compression step Module 17 trains. |
| 15.1 (Enabling-Conditions-Only Script Trigger) | The symptom cluster (electric-current sensation + neck pain + ulnar-distribution sensory loss) is a classic illness-script trigger for a cervical cord/root process (e.g. Lhermitte’s-type phenomenon, cervical myelopathy/radiculopathy) — useful for script-based pattern recognition once enabling conditions are added. |
| 18.0 / 18.1 (Network Reasoning — Session Setup / Sequential Finding Reweighting) | Several findings here plausibly belong to different problems (a neuro-axis process vs. a systemic/infective process vs. a vestibular process) — this is a good point to start reasoning about whether “random fever” changes the weight given to the neurological cluster, or whether they are two separate networks. |
| 1.0 (Socratic Session Setup) | If this case is to be used for active teaching/reasoning practice (rather than documentation), this is the natural point to set the Socratic contract before working through the differential for the symptom cluster. |
| 12.0 / 12.1 (Devil’s Advocate Setup / Working Diagnosis Attack) | Once a working diagnosis is formed from this cluster (e.g. “cervical disc disease”), this point is where the adversarial stress-test would begin — attacking that diagnosis using exactly these case features. |
| 2.3 (Prescription Transcription & Dosage Capture) | Baclofen (twice daily) is introduced here — the first medication in the record, and the natural point to begin structured medication capture (drug name, dose, frequency, route, indication). |
| 13.0 / 13.1 (Medication Reconciliation — Session Setup / Build the Medication Table) | This is the first drug in what becomes a multi-medication course; starting the medication table here (even with one entry) sets up later reconciliation once more drugs are added (antibiotics, albumin, tube-feed formula, etc.). |
| 9.1 (N-of-1 Protocol — Stage 1: Index Case Structuring) | If this case is being run through the full N-of-1 research protocol, Point 1 supplies the first diagnosis-related and intervention-related terms (symptom list; baclofen) for the two clean term lists Stage 1 extracts. |
| 19.0 / 19.1 (Social History Framing / Structured Social History Elicitation) | A new symptomatic presentation is the right place to begin eliciting social context (occupation, household role, access to care) that will later explain referral, transport, and caregiving decisions seen further down the case. |
She was unable to stand/walk we had to admit her in hospital, and got suggestion for problem in spine, referred to another hospital for surgery, to cut bone,
| Prompt | Why it applies here |
|---|---|
| 3.4 (Critical Alert & Red-Flag Triage) | Sudden inability to stand/walk is a textbook red-flag deterioration in a patient already being monitored — this is precisely the kind of real-time symptom change Step 3.4 is built to scan and flag urgently. |
| 20.0 / 20.1 / 20.2 (Recognition-Primed Decision — Setup / Pattern Recognition Under Time Pressure / Single-Plan Generation) | “Unable to stand/walk” reported acutely is a compressed, urgent piece of information of exactly the kind RPD training uses — recognise the pattern (cord compression until proven otherwise), commit to one immediate plan (urgent admission/imaging), and forward-simulate it. |
| 4.4 (Night Shift Stat Call Triage) | If this deterioration were being relayed as a sudden overnight/on-call event, this is the structured “sudden deterioration” triage prompt that fits — bedside checks, immediate interventions, escalation threshold. |
| 15.4 (Atypical Presentation — Script Mismatch Recognition) | A spinal/bony surgical suggestion is offered for a presentation that began with diffuse, multi-system symptoms (fever, vomiting, vertigo) — this is a good point to test whether the “spinal surgical” script actually fits all the data or whether something doesn’t match. |
| 12.2 / 12.4 (Alternative Differential Generation / Zebra Test) | A surgical referral for a spine problem, on top of systemic features (fever, vomiting) that don’t obviously fit a purely structural spinal diagnosis, is exactly the moment to adversarially generate competing diagnoses and check for a missed alternative (e.g. infective, neoplastic, or inflammatory cause of the spinal finding) before committing to surgery. |
| 4.2 (Ward Admission & Pre-Op Checklist) | Admission with a plan referred onward “for surgery, to cut bone” is the natural point to build a pre-admission/pre-op checklist (monitoring, clearances, blood banking) — directly anticipating the cancelled surgery in Point 3. |
| 14.0 / 14.2 (Resource-Ceiling Declaration / Ceiling-Aware Differential) | Being referred to “another hospital for surgery” signals a resource/capability gap at the first hospital — a natural point to declare what was and wasn’t available locally and reason about the differential within that ceiling. |
| 2.5 (Data Completeness Audit) | At the point of admission and referral, this is a sensible checkpoint to audit what case-record fields (vitals, exam, imaging) are still missing before the case moves to a second institution. |
Then before surgery they said of low blood cells, and also next day, blood cells were low so surgery was cancelled and she was referred back till blood cells become normal, and same time also found ulcer due to infection in stomach.
| Prompt | Why it applies here |
|---|---|
| 18.3 (Explaining Away — Competing Causes) | Two findings now compete to explain the clinical picture (low blood cells; a stomach ulcer “due to infection”). This is the precise scenario Step 18.3 trains: does the infective ulcer explain the low counts, or does confirming one cause reduce — without ruling out — consideration of the other (e.g. marrow suppression, malignancy, drug effect)? |
| 18.4 (Network Reasoning Under a Surprising Negative) | If surgery proceeding was the expected path and was instead halted by an unexpected lab finding, this is a good point to ask what else in the case network should now be reweighted because of the unexpected cytopenia. |
| 12.1 / 12.5 (Working Diagnosis Attack / Evidence Sufficiency Challenge) | A cancelled surgery on the basis of two low blood counts is a high-stakes pivot — adversarially testing whether “low blood cells” alone (vs. confirmed cause) is sufficient evidence to defer a planned spinal procedure is exactly Step 12.5’s A/B/C evidence-sufficiency framing. |
| 13.3 (Drug-Disease Conflict) | Baclofen and any other agents already on board should now be checked against the new finding of low blood counts and a gastric ulcer — whether any current medication could be contributing to either (e.g. marrow suppression, gastric irritation) is a direct drug-disease conflict question. |
| 13.6 (Prescribing Cascade Detection) | A stomach ulcer “due to infection” appearing alongside ongoing medication is the right point to check whether any prescribed drug could be producing or worsening a gastric problem that is then being treated as a new, separate diagnosis. |
| 14.5 (Referral Threshold & Transport-Reality Check) | “Referred back till blood cells become normal” is an explicit referral/timing decision — a natural point to reason through whether deferring surgery and sending the patient back was the safer course versus the risk of delay. |
| 9.1a (Stage 1 Completeness Check) | Two new diagnosis-relevant terms appear here (cytopenia/low blood cells; gastric ulcer, infective) — if running the N-of-1 protocol, this is where the Stage 1 term lists need a second pass to make sure both are captured, including the “ruled-out/deferred” surgical plan. |
| 5.8 (Data Anomaly Flagging) | “Low blood cells” reported on two consecutive days without a stated value is exactly the kind of vague or unquantified data point Step 5.8 is designed to flag for follow-up (what counts, what threshold, what trend). |
Then we took her to another hospital after 7 days and she was admitted to ICU and before admitting we also found that she had got bed sores on back.
| Prompt | Why it applies here |
|---|---|
| 3.4 (Critical Alert & Red-Flag Triage) | ICU admission itself is the clearest possible red-flag escalation point in this longitudinal record — this is where an active monitoring companion would have generated an ALERT block in real time. |
| 20.3 (Plan Rejection and Re-Recognition) | A second hospital and an ICU-level admission, 7 days after the first plan (surgery deferred for blood counts) was halted, is a clean example of needing to ask: does this new information (deterioration severe enough for ICU) require abandoning the original “spinal surgical” read of the situation entirely, or just adjusting the plan within the same read? |
| 19.5 (Health System and Access Barriers) | A 7-day gap before reaching definitive ICU-level care, with an inter-hospital transfer in between, is the natural point to examine whether distance, cost, or transport access shaped the timeline — and whether the “achievable” plan diverged from the “ideal” one during that week. |
| 14.5 (Referral Threshold & Transport-Reality Check) | The 7-day interval between being referred back and reaching the second hospital is exactly the kind of transport/referral-reality gap this prompt is built to interrogate — was the delay itself a risk, separate from the underlying diagnosis. |
| 18.5 (Build the Case Network) | By this point the case has several major findings (neuro symptoms, cytopenia, gastric ulcer, now bed sores and ICU-level illness) — this is a sensible point to build a simple network map of the 4–6 most clinically important findings and how they interact. |
| 13.4 (High-Risk Drug Class Spotlight) | ICU admission is the natural point to re-screen the medication list (baclofen and anything added) against the five high-risk classes, since ICU-level care often adds new drug classes (sedatives, anticoagulant prophylaxis) that interact with what is already on board. |
| 4.0 / 4.3 (Study Partner Context Load / Cross-System Complication & Polypharmacy Screen) | A multi-system ICU patient (neurological + haematological + gastrointestinal + now integumentary, with bed sores) is exactly the complex multi-system case this peer-level cross-system screening prompt is designed for. |
| 17.3 (Same Findings, Different Representation) | The case could honestly be represented as “subacute, multifocal, neuro-systemic with secondary haematological and integumentary complications” vs. “acute-on-chronic critical illness with pressure injury” — useful to test which representation better matches the actual unfolding timeline. |
They did many test and gave her blood after 2 days and albumin. She became better,
| Prompt | Why it applies here |
|---|---|
| 5.1 (Drug Interaction & Prescription Audit) | Blood transfusion and albumin infusion, added on top of existing medication (baclofen), is the right point to audit the combined regimen for interactions or timing concerns. |
| 13.1 / 13.2 (Build the Medication Table / Drug-Drug Interaction Hunt) | Two new interventions (packed cells, albumin) need to be added to the running medication/intervention table and screened against existing drugs as part of the ongoing reconciliation work. |
| 5.2 (Recent Interventions Recap) | “Many tests… gave her blood after 2 days and albumin… She became better” is a clean, bounded set of recent interventions with a stated outcome — ideal material for a recap of the 5 most recent interventions and what response was expected from each. |
| 18.1 (Sequential Finding Reweighting) | Improvement following transfusion and albumin is new information that should reweight earlier findings — does the response to blood/albumin make the earlier “low blood cells” and gastric ulcer more specifically explained (e.g. blood loss/anaemia from the ulcer) or does it leave the original cause still open? |
| 9.7 (N-of-1 Protocol — Stage 7: Convergence to Fixed Outputs) | “She became better” is a clinically meaningful symptom-response data point for the intervention–symptom correlation table the protocol’s fixed output package requires (transfusion/albumin → improvement, patient-reported/clinician-observed). |
| 15.2 (Full-Script Articulation) | This is a good point to ask for the full illness script (enabling conditions, fault, consequences) behind why low blood counts plus low albumin plus a bleeding/infective gastric source would predict exactly this transfusion-and-albumin response. |
Then we took her home and she was still having tube in her mouth to give her food. We gave her food by tube for 5 days, and packet juice using same tube and feeding injection, a person used to come and do dressing for her bed sores which had improved,
| Prompt | Why it applies here |
|---|---|
| 3.0 (Baseline Domain Snapshot) | Discharge home with ongoing tube feeding and wound care is exactly the moment to set a longitudinal monitoring baseline across lifestyle/physical status, mood/coping, medication adherence, and red-flag risk before home monitoring begins. |
| 3.1 (Lifestyle Monitoring) | Tube feeding, “packet juice,” and feeding via syringe/injection technique are dietary-intake and fluid-compliance details that fall directly under this prompt’s scope — analysing routine details for dietary intake, fluid compliance, and practical recommendations. |
| 2.2 (Clinical Examination Guidance) | Ongoing bed-sore dressing by a visiting carer is a hands-on observational task — this prompt’s plain-language guidance on what physical findings to observe and relay (wound appearance, healing, signs of infection) applies directly here. |
| 3.3 (Medication Monitoring & Adherence) | “Feeding injection” and continued baclofen at home should be tracked in a current-medication table as part of ongoing adherence monitoring once the patient transitions to home care. |
| 19.3 (Adherence and Non-Adherence Through a Social Lens) | A family managing tube feeding, packaged supplements, and a visiting dressing carer at home is a scenario where structural factors (carer availability, cost of supplies, household capacity) — not motivation — would explain any gaps in care, making this the right point to apply a social, non-blaming lens if any step is later missed. |
| 13.5 (Practical Safety — What the Patient Actually Experiences) | Tube feeding with multiple inputs (food, juice, “feeding injection,” plus baclofen) raises real practical-safety questions — timing relative to feeds, number of administrations per day, and what happens if a feed/dose is missed — exactly what this prompt probes. |
| 2.7 (Advocate Handover Brief) | A patient discharged home with an NG tube and an external wound-care provider is precisely the situation that benefits from a short, plain-language handover brief the family could read aloud to a new provider if anything changes. |
but on around 8th day she got diarrhoea, 4-5 times 1st day and it became fine after 3 days without giving any medicine for diarrhea. She was only on already prescribed medication.
| Prompt | Why it applies here |
|---|---|
| 3.4 (Critical Alert & Red-Flag Triage) | A new symptom (diarrhoea, 4–5 episodes on day 1) arising in a recently-discharged, tube-fed, recently-ICU patient is exactly the kind of real-time symptom change this prompt is designed to triage for red-flag features (dehydration risk in particular). |
| 18.2 (Causal vs. Correlational Discrimination) | Diarrhoea here could be causally linked to the feeding regimen (osmotic/intolerance to packet juice or feed rate) or merely co-occurring (e.g. self-limiting viral/infective cause unrelated to feeding) — this is the direct causal-vs-correlational discrimination drill. |
| 13.6 (Prescribing Cascade Detection) | “She was only on already prescribed medication” is the advocate’s own statement ruling out a new drug cause — but this is still the right point to check whether any already-prescribed medication (or the feed/juice itself) could be producing this as a known effect, rather than treating it as an unrelated new illness. |
| 5.8 (Data Anomaly Flagging) | A self-resolving diarrhoeal episode lasting 3 days, with no medication given, in a patient with a recent stomach ulcer and ongoing tube feeding, is a good candidate to scan for anomalies or undocumented detail (was a stool sample sent, was a temperature recorded) before assuming it is benign. |
| 19.2 (Social Determinant to Clinical Pathway) | If feed preparation, water source, or hygiene during home tube feeding played any role, this is the point to trace a social/practical pathway (e.g. feed hygiene, supply storage) to the clinical event, rather than assuming a purely biological cause. |
| 15.4 (Atypical Presentation — Script Mismatch Recognition) | A self-resolving, non-bloody, watery diarrhoea with no treatment needed is a relatively reassuring pattern — useful to explicitly test whether it fits a benign/self-limiting script or whether something (recent ICU stay, recent antibiotics if any were given, immunosuppression from critical illness) makes it atypical enough to warrant a different script. |
Her stool was water like, no blood and and blackish so we stopped giving her pomegranate juice.
| Prompt | Why it applies here |
|---|---|
| 18.4 (Network Reasoning Under a Surprising Negative) | “No blood” is a reassuring negative finding in the context of a recent gastric ulcer — this is precisely the prompt that trains asking whether this negative effectively lowers concern for active GI bleeding, or whether it is not specific enough to fully exclude it, and what else in the network should be reweighted as a result. |
| 18.2 (Causal vs. Correlational Discrimination) | The black stool colour is correctly attributed by the family to pomegranate juice rather than melaena — this is a direct, well-resolved example of distinguishing a causal GI-bleed explanation from a simple dietary/correlational one, useful to discuss explicitly as a discrimination exercise. |
| 17.1 (Raw Case to Qualifier Summary) | “Water-like, no blood, blackish stool, resolving over 3 days without treatment” is exactly the kind of raw descriptive detail that should be compressed into qualifiers (e.g. “self-limiting, non-haemorrhagic, dietary-explained”) before any further diagnostic reasoning is layered on. |
| 11.1 / 11.6 (Patient’s Inner Question List / Lifestyle, Diet & Daily Living Questions) | A family independently noticing and correcting a dietary cause of stool discolouration is a strong example of patient/advocate-level health literacy in action — a good point to surface what further diet-and-daily-living questions the family might still have about tube feeding and bowel changes going forward. |
| 2.1 (Symptom & Classifier Capture) | The stool description and the resulting dietary change are new classifier-level detail that should be added to the structured case record as the diarrhoeal episode is closed out. |
These prompts apply to the case as a complete unit rather than to a single point above, and would naturally be run once the full history (Points 1–8) has been documented.
| Prompt | Why it applies here |
|---|---|
| 9.1 → 9.7 (N-of-1 Protocol, full sequence) | This is a genuinely complex, multi-system, multi-institution n-of-1 case (neurological onset → spinal surgical referral → cytopenia → gastric ulcer → ICU → transfusion/albumin → home tube feeding → self-limited diarrhoea) — exactly the kind of case the seven-stage protocol exists to structure end-to-end, from term extraction through to a severity/priority rating, condensed timeline, and intervention–symptom correlation table. |
| 2.4 / 2.6 (SOAP Note Generation / Case Record Sign-Off Checklist) | Once the full narrative above is captured, this is the point to generate a plain-language SOAP note and a closing sign-off summary (working impression, current medications, outstanding investigations, next review trigger) for the family’s records. |
| 2.5 (Data Completeness Audit) | Across the whole case there are several unquantified or missing data points (actual blood count values, ulcer biopsy/culture result if any, ICU day count, current feed volumes) — a full completeness audit is appropriate once the narrative is assembled. |
| 18.5 (Build the Case Network) | With 4 months of interlocking findings now available, this is the point to build the full case network — neuro symptoms, cytopenia, gastric ulcer, ICU course, bed sores, transfusion response, and the diarrhoeal episode — and identify the single most load-bearing finding. |
| 12.0–12.8 (Devil’s Advocate, full sequence) | Once a working diagnosis for the original spinal/neurological presentation is stated, the complete case (including the alternative explanations raised by the cytopenia and gastric ulcer) is rich enough to support a full adversarial stress-test culminating in a Diagnostic Confidence Score and an unresolved-vulnerability list. |
| 1.7 / 1.10 (End-of-Case Teaching Summary / Critical Awareness Debrief) | If this case is being used for teaching, the full narrative supports a closing summary of reasoning strengths, clinical pearls, and a critical-awareness debrief (biases, generalisability risk, unresolved uncertainty) across the whole course. |
| 19.8 (Case-to-Community Closing Synthesis) | The inter-hospital delays, referral pattern, and home-based caregiving load across this case support a closing synthesis of which social/system factor most changed management, and what it suggests at a community level. |
| 13.7 / 13.8 (Socratic Integration Round / Personal Learning Summary) | With baclofen, transfusion, albumin, and tube-feed additives all now on the record across months, a full cross-finding medication reasoning round and a student-authored learning summary are appropriate closing steps. |