cases/bank.py

"""
Nursing Case Study Bank
10 detailed patient scenarios covering major body systems.
For educational purposes only.
"""

CASE_BANK = [

    # ── 1. CARDIOVASCULAR — STEMI ──────────────────────────────────────────
    {
        "id": "case_001",
        "title": "Crushing Chest Pain: STEMI",
        "category": "Cardiovascular",
        "difficulty": "Intermediate",
        "tags": ["MI", "STEMI", "chest pain", "cardiovascular", "emergency"],
        "learning_objectives": [
            "Recognise clinical presentation of STEMI",
            "Prioritise immediate nursing interventions (MONA)",
            "Understand reperfusion therapy urgency (door-to-balloon < 90 min)",
            "Monitor for complications: arrhythmias, cardiogenic shock",
            "Provide appropriate patient and family education",
        ],
        "patient": {
            "name": "Mr. Robert Chen",
            "age": 64,
            "gender": "Male",
            "weight_kg": 92,
            "height_cm": 176,
            "allergies": ["Penicillin (rash)"],
            "pmhx": ["Hypertension (10 years)", "Type 2 Diabetes Mellitus", "Hyperlipidaemia", "Ex-smoker"],
            "medications": [
                "Metformin 1000 mg BD",
                "Atorvastatin 40 mg nocte",
                "Amlodipine 5 mg daily",
                "Aspirin 100 mg daily",
            ],
            "social": "Retired teacher. Lives with wife. Smoked 20/day for 30 years, quit 5 years ago. Occasional alcohol.",
            "family_hx": "Father died of MI at age 58. Mother has T2DM.",
        },
        "presentation": (
            "Mr. Chen is brought to ED by ambulance at 14:30. He describes sudden onset crushing "
            "central chest pain radiating to his left arm and jaw, rated 9/10, starting 90 minutes ago "
            "while mowing the lawn. He is diaphoretic, pale, and nauseated. Wife confirms he took one "
            "GTN tablet at home with no relief."
        ),
        "vitals": {
            "BP": "158/96 mmHg",
            "HR": "104 bpm (irregular)",
            "RR": "22 breaths/min",
            "SpO2": "93% on room air",
            "Temp": "36.8°C",
            "Pain": "9/10",
            "GCS": "15",
            "BSL": "14.2 mmol/L",
        },
        "physical_exam": (
            "Patient appears anxious and diaphoretic. Skin pale and clammy. "
            "Heart sounds: S1, S2 present; no murmurs. Crackles at lung bases bilaterally. "
            "JVP mildly elevated. Peripheral pulses present. No peripheral oedema."
        ),
        "investigations": {
            "ECG": "ST elevation in leads II, III, aVF (inferior STEMI). Reciprocal ST depression in I, aVL.",
            "Troponin I": "3.8 ng/mL (↑↑ normal < 0.04)",
            "CK-MB": "68 U/L (↑ normal < 25)",
            "BNP": "420 pg/mL (↑)",
            "FBC": "Hb 138 g/L, WCC 11.2 × 10⁹/L",
            "UEC": "Na 138, K 4.1, Cr 102 μmol/L",
            "Glucose": "14.2 mmol/L",
            "Lipids": "Total cholesterol 6.8 mmol/L, LDL 4.2 mmol/L",
            "CXR": "Mild cardiomegaly. Early pulmonary oedema.",
        },
        "medical_diagnosis": "Inferior ST-Elevation Myocardial Infarction (STEMI)",
        "nursing_priorities": [
            "Immediate 12-lead ECG and cardiac monitoring",
            "Establish IV access × 2 large-bore",
            "Administer O₂ if SpO₂ < 94% — target 94–98%",
            "Administer MONA: Morphine, Oxygen, Nitrates, Aspirin (per protocol)",
            "Prepare for urgent PCI (door-to-balloon < 90 minutes)",
            "Continuous cardiac monitoring — watch for arrhythmias",
            "Maintain patient rest — reduce myocardial O₂ demand",
            "Monitor haemodynamic status — watch for cardiogenic shock",
        ],
        "nursing_diagnoses": [
            {
                "diagnosis": "Acute Pain related to myocardial ischaemia",
                "evidence": "Patient reports 9/10 crushing chest pain, diaphoresis, facial grimacing",
                "goal": "Patient reports pain ≤ 3/10 within 30 minutes of intervention",
                "interventions": [
                    "Administer GTN SL (if SBP > 90 mmHg) per protocol",
                    "Administer IV morphine titrated to pain per medical order",
                    "Position patient in semi-Fowler's to reduce preload",
                    "Reassess pain score every 15 minutes",
                    "Provide calm reassurance to reduce anxiety-induced sympathetic stimulation",
                ],
            },
            {
                "diagnosis": "Decreased Cardiac Output related to myocardial injury",
                "evidence": "Tachycardia 104 bpm, SpO₂ 93%, elevated BNP, pulmonary oedema on CXR",
                "goal": "Haemodynamic stability: MAP > 65 mmHg, HR 60–100 bpm, SpO₂ ≥ 94%",
                "interventions": [
                    "Continuous cardiac monitoring — 12-lead ECG on admission",
                    "Monitor vital signs every 15 minutes",
                    "Apply O₂ to target SpO₂ 94–98%",
                    "Ensure IV access — prepare for urgent PCI",
                    "Monitor for signs of cardiogenic shock: ↓ BP, ↓ UO, altered LOC",
                    "Restrict fluids if signs of pulmonary oedema",
                ],
            },
            {
                "diagnosis": "Anxiety related to acute illness and fear of death",
                "evidence": "Patient appears anxious; high-acuity cardiac event",
                "goal": "Patient verbalises reduced anxiety and understands planned treatment",
                "interventions": [
                    "Explain all procedures clearly and calmly",
                    "Allow family member to stay if appropriate",
                    "Administer anxiolytic per protocol if needed",
                    "Reassure patient that team is taking immediate action",
                ],
            },
        ],
        "adpie": {
            "assessment": (
                "Subjective: 9/10 crushing chest pain to left arm and jaw, nausea, diaphoresis. "
                "Objective: HR 104 irregular, BP 158/96, SpO₂ 93%, ECG showing inferior ST elevation, "
                "Troponin I 3.8 ng/mL (markedly elevated), crackles at lung bases."
            ),
            "diagnosis": (
                "1. Acute Pain r/t myocardial ischaemia AEB 9/10 pain, diaphoresis.\n"
                "2. Decreased Cardiac Output r/t myocardial injury AEB tachycardia, low SpO₂.\n"
                "3. Anxiety r/t acute illness AEB restlessness and verbalised fear."
            ),
            "planning": (
                "Short-term: Pain ≤ 3/10 within 30 min; SpO₂ ≥ 94%; HR < 100 bpm.\n"
                "Long-term: Patient undergoes successful PCI; understands cardiac rehab; "
                "modifies risk factors (diet, exercise, medication adherence)."
            ),
            "implementation": (
                "• Applied O₂ via Hudson mask at 6 L/min — SpO₂ improved to 96%.\n"
                "• IV access × 2 established — bloods taken, fluids connected.\n"
                "• GTN 400 mcg SL given — partial relief; morphine 2.5 mg IV titrated to pain 4/10.\n"
                "• Aspirin 300 mg PO loading dose given per protocol.\n"
                "• Continuous cardiac monitoring applied — telemetry for PVCs noted.\n"
                "• Catheterisation lab notified — door-to-balloon time tracking initiated.\n"
                "• Family updated; patient's anxiety visibly reduced after explanation."
            ),
            "evaluation": (
                "Pain reduced to 4/10 within 20 minutes. SpO₂ 96% on O₂. HR 98 bpm, BP 142/88. "
                "Patient transferred to catheterisation lab at 15:08 — door-to-balloon time 38 minutes. "
                "PCI performed successfully. Post-procedure: haemodynamically stable, pain free."
            ),
        },
    },

    # ── 2. RESPIRATORY — ACUTE ASTHMA ─────────────────────────────────────
    {
        "id": "case_002",
        "title": "Acute Severe Asthma Exacerbation",
        "category": "Respiratory",
        "difficulty": "Intermediate",
        "tags": ["asthma", "respiratory", "bronchospasm", "wheeze", "emergency"],
        "learning_objectives": [
            "Assess severity of asthma using PEFR and clinical signs",
            "Administer stepwise bronchodilator therapy",
            "Recognise life-threatening asthma (silent chest, cyanosis)",
            "Monitor response to treatment and escalate appropriately",
            "Provide asthma action plan education",
        ],
        "patient": {
            "name": "Ms. Aisha Patel",
            "age": 28,
            "gender": "Female",
            "weight_kg": 62,
            "height_cm": 163,
            "allergies": ["NSAIDs (bronchospasm)", "Cats"],
            "pmhx": ["Asthma since childhood", "Eczema", "Allergic rhinitis"],
            "medications": [
                "Salbutamol 100 mcg puffer PRN",
                "Fluticasone/salmeterol 250/25 mcg 1 puff BD",
                "Cetirizine 10 mg nocte",
            ],
            "social": "Schoolteacher. Non-smoker. Lives in apartment with cat. Recently started new cleaning products at work.",
            "family_hx": "Mother has asthma. Father has hay fever.",
        },
        "presentation": (
            "Ms. Patel presents to ED at 22:15 unable to complete sentences. She has been wheezing "
            "for 4 hours, progressively worsening since visiting a friend's home who has two cats. "
            "Used salbutamol puffer 8 times in the last 2 hours with minimal relief. Appears frightened "
            "and is leaning forward in tripod position."
        ),
        "vitals": {
            "BP": "138/82 mmHg",
            "HR": "118 bpm",
            "RR": "28 breaths/min",
            "SpO2": "89% on room air",
            "Temp": "37.0°C",
            "Pain": "0/10 (dyspnoea 8/10)",
            "GCS": "15",
            "PEFR": "38% of predicted",
        },
        "physical_exam": (
            "Patient in obvious respiratory distress. Using accessory muscles (sternocleidomastoid, intercostals). "
            "Tripod position. Unable to complete full sentences. Widespread bilateral expiratory and inspiratory wheeze. "
            "Prolonged expiratory phase. No cyanosis. No stridor."
        ),
        "investigations": {
            "PEFR": "38% of predicted (severe: < 50%)",
            "ABG": "pH 7.48, pCO₂ 32 mmHg, pO₂ 58 mmHg, HCO₃ 24 — respiratory alkalosis + hypoxaemia",
            "FBC": "WCC 13.2 × 10⁹/L (stress response), Eosinophils 0.8",
            "CXR": "Hyperinflated lungs. No consolidation. No pneumothorax.",
            "ECG": "Sinus tachycardia 118 bpm",
            "Theophylline level": "Not applicable (not on theophylline)",
        },
        "medical_diagnosis": "Acute Severe Asthma Exacerbation",
        "nursing_priorities": [
            "High-flow O₂ immediately — target SpO₂ 93–95%",
            "Back-to-back salbutamol nebulisers (2.5–5 mg) every 20 min × 3",
            "Ipratropium bromide nebuliser added for severe exacerbation",
            "Oral/IV prednisolone (or hydrocortisone IV) per protocol",
            "Continuous SpO₂ monitoring and frequent PEFR reassessment",
            "Keep patient upright (sitting forward) — optimise respiratory mechanics",
            "Prepare for escalation: IV magnesium sulphate, HDU/ICU if no improvement",
            "Reassess every 15–20 minutes",
        ],
        "nursing_diagnoses": [
            {
                "diagnosis": "Impaired Gas Exchange related to bronchospasm and mucus plugging",
                "evidence": "SpO₂ 89%, RR 28, ABG shows hypoxaemia, widespread wheeze",
                "goal": "SpO₂ ≥ 93%, RR < 20, PEFR > 50% predicted within 1 hour",
                "interventions": [
                    "Apply O₂ 6–8 L/min via face mask — titrate to SpO₂ 93–95%",
                    "Administer salbutamol 5 mg + ipratropium 0.5 mg via nebuliser",
                    "Position: high Fowler's or forward-leaning (tripod)",
                    "Monitor SpO₂ continuously, PEFR every 20 minutes",
                    "Prepare IV magnesium sulphate 2 g over 20 min if no improvement",
                ],
            },
            {
                "diagnosis": "Ineffective Breathing Pattern related to airway obstruction",
                "evidence": "Accessory muscle use, prolonged expiratory phase, RR 28, PEFR 38%",
                "goal": "RR 12–20, accessory muscle use reduced, patient able to speak in sentences",
                "interventions": [
                    "Coach pursed-lip breathing to prolong exhalation",
                    "Ensure calm, quiet environment to reduce anxiety and O₂ demand",
                    "Administer corticosteroids (prednisolone 50 mg PO / hydrocortisone 200 mg IV)",
                    "Repeat PEFR 15–20 minutes post-bronchodilator",
                ],
            },
        ],
        "adpie": {
            "assessment": (
                "Subjective: 4-hour history of worsening wheeze, dyspnoea 8/10, unable to finish sentences, "
                "8 × salbutamol puffs with no relief. Objective: SpO₂ 89%, RR 28, HR 118, "
                "PEFR 38%, accessory muscles, bilateral wheeze."
            ),
            "diagnosis": (
                "1. Impaired Gas Exchange r/t bronchospasm AEB SpO₂ 89%, ABG hypoxaemia.\n"
                "2. Ineffective Breathing Pattern r/t airway obstruction AEB accessory muscles, RR 28.\n"
                "3. Anxiety r/t breathing difficulty AEB frightened appearance."
            ),
            "planning": (
                "SpO₂ ≥ 93% within 30 min; PEFR > 50% within 60 min; "
                "RR < 20; patient able to speak in full sentences."
            ),
            "implementation": (
                "• O₂ 8 L/min via face mask applied — SpO₂ improved to 94%.\n"
                "• Salbutamol 5 mg + ipratropium 0.5 mg nebulised — 3 doses 20 min apart.\n"
                "• Prednisolone 50 mg PO given.\n"
                "• Reassurance provided, calm environment maintained.\n"
                "• PEFR measured at 20 min intervals: 38% → 52% → 61%."
            ),
            "evaluation": (
                "After 60 minutes: SpO₂ 96% on 4 L O₂, PEFR 61%, RR 18, HR 96. "
                "Speaking in full sentences. Wheeze reduced. Admitted to ward for observation. "
                "Asthma action plan discussed before discharge."
            ),
        },
    },

    # ── 3. ENDOCRINE — DKA ────────────────────────────────────────────────
    {
        "id": "case_003",
        "title": "Diabetic Ketoacidosis (DKA)",
        "category": "Endocrine",
        "difficulty": "Advanced",
        "tags": ["DKA", "diabetes", "endocrine", "ketoacidosis", "insulin"],
        "learning_objectives": [
            "Identify DKA diagnostic criteria (BSL, ketones, pH)",
            "Manage IV fluid resuscitation protocol",
            "Administer insulin infusion safely — monitor potassium closely",
            "Monitor for DKA complications: cerebral oedema, hypokalaemia",
            "Identify and address precipitating factors",
        ],
        "patient": {
            "name": "Ms. Emily Thornton",
            "age": 19,
            "gender": "Female",
            "weight_kg": 58,
            "height_cm": 168,
            "allergies": ["NKDA"],
            "pmhx": ["Type 1 Diabetes Mellitus (since age 9)"],
            "medications": [
                "Insulin glargine 20 units nocte",
                "Insulin aspart sliding scale with meals",
            ],
            "social": "First-year university student. Lives in student accommodation. Recently had gastroenteritis — unable to eat for 2 days. Forgot to take insulin.",
            "family_hx": "Nil relevant.",
        },
        "presentation": (
            "Emily is brought to ED by her roommate at 03:00. She has been vomiting for 36 hours "
            "and is confused and lethargic. Her roommate reports she has been breathing strangely "
            "('like she can't catch her breath') and there is a fruity smell on her breath. "
            "She omitted her insulin for 2 days as she wasn't eating."
        ),
        "vitals": {
            "BP": "98/62 mmHg (lying)",
            "HR": "124 bpm",
            "RR": "28 breaths/min (Kussmaul)",
            "SpO2": "97% on room air",
            "Temp": "37.4°C",
            "Pain": "5/10 (abdominal)",
            "GCS": "13 (E3 V4 M6)",
            "BSL": "28.4 mmol/L",
        },
        "physical_exam": (
            "Patient is drowsy and confused. Dry mucous membranes, sunken eyes, poor skin turgor — "
            "estimated 10% dehydration. Tachycardic. Kussmaul respirations (deep and rapid). "
            "Fruity/acetone breath. Diffuse abdominal tenderness. No peritonism."
        ),
        "investigations": {
            "BSL": "28.4 mmol/L",
            "Blood ketones": "5.8 mmol/L (↑↑ normal < 0.6)",
            "ABG": "pH 7.18, pCO₂ 18 mmHg, pO₂ 98 mmHg, HCO₃ 8 mmol/L — severe metabolic acidosis",
            "Anion Gap": "30 (↑ normal 8–12)",
            "UEC": "Na 132, K 5.8 (↑ — due to acidosis shift), Cr 118 μmol/L",
            "Urine ketones": "4+ (strongly positive)",
            "FBC": "WCC 18.4 (stress leucocytosis), Hb 132",
            "HbA1c": "11.2% (↑↑ poor glycaemic control)",
            "Lipase": "Normal",
            "ECG": "Sinus tachycardia. Peaked T waves (hyperkalaemia).",
        },
        "medical_diagnosis": "Diabetic Ketoacidosis (DKA) — severe (pH < 7.2)",
        "nursing_priorities": [
            "URGENT IV fluid resuscitation: 0.9% NaCl 1 L over 1 hour",
            "Commence insulin infusion — DO NOT start until K⁺ ≥ 3.5 mmol/L",
            "Hourly potassium monitoring — replace aggressively as insulin drives K⁺ into cells",
            "Strict fluid balance — IDC for accurate urine output monitoring",
            "Hourly BSL, 2-hourly blood ketones and ABG",
            "Continuous cardiac monitoring — hyperkalaemia/hypokalaemia arrhythmia risk",
            "Neurological observations — watch for cerebral oedema (↓GCS, headache, vomiting)",
            "NG tube if GCS < 13 (airway protection, vomiting)",
        ],
        "nursing_diagnoses": [
            {
                "diagnosis": "Deficient Fluid Volume related to osmotic diuresis and vomiting",
                "evidence": "BP 98/62, HR 124, dry mucous membranes, estimated 10% dehydration",
                "goal": "BP > 100/60, HR < 100, urine output ≥ 0.5 mL/kg/hr within 2 hours",
                "interventions": [
                    "Administer 0.9% NaCl 1 L stat, then 1 L/hr × 2 hours per DKA protocol",
                    "Insert IDC — monitor hourly urine output",
                    "Monitor vital signs every 30 minutes",
                    "Accurate intake/output chart",
                    "Assess skin turgor, mucous membranes hourly",
                ],
            },
            {
                "diagnosis": "Imbalanced Nutrition / Risk for Electrolyte Imbalance",
                "evidence": "K⁺ 5.8 (acidosis shift — will drop rapidly with insulin), HCO₃ 8",
                "goal": "K⁺ maintained 3.5–5.5 mmol/L; pH > 7.3 within 12 hours",
                "interventions": [
                    "DO NOT start insulin until K⁺ ≥ 3.5 — risk of fatal hypokalaemia",
                    "Commence KCl replacement as per DKA protocol once insulin started",
                    "Hourly potassium levels while on insulin infusion",
                    "Continuous ECG monitoring for arrhythmias",
                    "Administer sodium bicarbonate only if pH < 7.0 per protocol",
                ],
            },
            {
                "diagnosis": "Acute Confusion related to cerebral effects of acidosis and dehydration",
                "evidence": "GCS 13, confused, lethargic",
                "goal": "GCS returns to 15 within 6 hours as metabolic derangement corrects",
                "interventions": [
                    "Neurological observations hourly (GCS, pupils)",
                    "Reorient patient frequently",
                    "Raise bed rails — fall prevention",
                    "Alert medical team immediately if GCS drops ≥ 2 points — cerebral oedema risk",
                    "Avoid rapid fluid correction (risk of cerebral oedema)",
                ],
            },
        ],
        "adpie": {
            "assessment": (
                "Subjective: 36-hour vomiting, omitted insulin 2 days, abdominal pain. "
                "Objective: BSL 28.4, ketones 5.8, pH 7.18, BP 98/62, HR 124, GCS 13, "
                "Kussmaul respirations, fruity breath, 10% dehydration."
            ),
            "diagnosis": (
                "1. Deficient Fluid Volume r/t osmotic diuresis AEB hypotension, tachycardia, dry mucous membranes.\n"
                "2. Risk for Electrolyte Imbalance r/t insulin-potassium shift AEB K⁺ 5.8 (will drop with insulin).\n"
                "3. Acute Confusion r/t acidosis and dehydration AEB GCS 13."
            ),
            "planning": (
                "Fluid resuscitation to restore haemodynamic stability within 2 hours. "
                "Safe insulin infusion with hourly K⁺ monitoring. "
                "Ketones < 0.5, pH > 7.3 within 12 hours. GCS 15 within 6 hours."
            ),
            "implementation": (
                "• IV 0.9% NaCl 1 L over 1 hour commenced — BP improved to 108/70 after 1 hour.\n"
                "• Insulin infusion commenced at 0.1 units/kg/hr after K⁺ confirmed ≥ 3.5.\n"
                "• KCl replacement added to IV fluids as per DKA sliding scale.\n"
                "• IDC inserted — urine output 40 mL/hr after fluid resuscitation.\n"
                "• Hourly BSL, 2-hourly ketones, continuous ECG monitoring.\n"
                "• Family updated; patient reoriented regularly."
            ),
            "evaluation": (
                "At 6 hours: BSL 14.2 mmol/L, ketones 1.8 mmol/L, pH 7.28, K⁺ 3.9, BP 118/76, "
                "HR 98, GCS 15. At 12 hours: ketones cleared, pH 7.36, patient eating. "
                "Diabetes educator consulted. Sick-day management plan provided."
            ),
        },
    },

    # ── 4. NEUROLOGICAL — STROKE (CVA) ────────────────────────────────────
    {
        "id": "case_004",
        "title": "Acute Ischaemic Stroke",
        "category": "Neurological",
        "difficulty": "Advanced",
        "tags": ["stroke", "CVA", "neurological", "tPA", "FAST", "thrombolysis"],
        "learning_objectives": [
            "Apply FAST/BE-FAST stroke recognition tool",
            "Understand time-critical thrombolysis window (< 4.5 hours)",
            "Perform accurate neurological assessment (NIH Stroke Scale)",
            "Monitor for post-tPA haemorrhagic transformation",
            "Prevent aspiration — nil by mouth until formal swallow assessment",
        ],
        "patient": {
            "name": "Mrs. Joan McAllister",
            "age": 72,
            "gender": "Female",
            "weight_kg": 74,
            "height_cm": 161,
            "allergies": ["Sulfonamides"],
            "pmhx": ["Atrial Fibrillation", "Hypertension", "Hyperlipidaemia", "Previous TIA 3 years ago"],
            "medications": [
                "Apixaban 5 mg BD",
                "Perindopril 4 mg daily",
                "Rosuvastatin 20 mg nocte",
            ],
            "social": "Retired nurse. Widowed. Lives alone. Independent ADLs. Last seen well 1.5 hours ago by neighbour.",
            "family_hx": "Sister had stroke at age 68.",
        },
        "presentation": (
            "Mrs. McAllister is brought to ED by ambulance at 09:45. Her neighbour found her on the "
            "kitchen floor at 09:30. She has right-sided facial droop, right arm weakness (cannot raise "
            "arm above shoulder), and slurred speech. She appears confused about the date but knows her name. "
            "Last known well: 08:15 (spoke to neighbour on phone)."
        ),
        "vitals": {
            "BP": "186/104 mmHg",
            "HR": "88 bpm (irregular — AF)",
            "RR": "18 breaths/min",
            "SpO2": "96% on room air",
            "Temp": "37.1°C",
            "Pain": "0/10 (headache 3/10)",
            "GCS": "13 (E4 V3 M6)",
            "BSL": "8.6 mmol/L",
        },
        "physical_exam": (
            "Right facial droop (lower face). Right arm drift positive — arm falls within 10 seconds. "
            "Right leg mild weakness. Speech dysarthric. No aphasia — comprehension intact. "
            "NIHSS score: 8 (moderate stroke). Pupils equal and reactive. No neck stiffness. "
            "Irregular rhythm on auscultation (AF)."
        ),
        "investigations": {
            "CT Brain (non-contrast)": "No haemorrhage. Early ischaemic changes in left MCA territory.",
            "CT Angiography": "Partial occlusion left middle cerebral artery (MCA)",
            "NIHSS": "8 — moderate stroke",
            "ECG": "Atrial fibrillation. Rate 88 bpm.",
            "FBC": "Hb 128 g/L, Platelets 224 × 10⁹/L",
            "Coagulation": "INR 1.1 (apixaban — anti-Xa not routinely measured)",
            "UEC": "Na 139, K 4.0, Cr 88 μmol/L",
            "BSL": "8.6 mmol/L",
            "Lipids": "LDL 3.4 mmol/L",
        },
        "medical_diagnosis": "Acute Ischaemic Stroke — Left MCA territory (NIHSS 8)",
        "nursing_priorities": [
            "TIME CRITICAL — establish onset-to-door time, activate stroke pathway",
            "NIL BY MOUTH until formal swallow screen completed",
            "Maintain BP 140–180 mmHg (do NOT lower aggressively pre-tPA)",
            "Position: HOB 0° (flat) initially to maximise cerebral perfusion",
            "Continuous neurological observations — NIHSS, GCS, pupils every 15 min",
            "IV access × 2 — bloods per stroke protocol",
            "BSL monitoring — target 4–11 mmol/L (hypo/hyperglycaemia worsen outcomes)",
            "Prepare for thrombolysis (tPA) or endovascular thrombectomy — if eligible",
        ],
        "nursing_diagnoses": [
            {
                "diagnosis": "Ineffective Cerebral Tissue Perfusion related to MCA occlusion",
                "evidence": "NIHSS 8, right-sided weakness, facial droop, dysarthria, BP 186/104",
                "goal": "No neurological deterioration; NIHSS improves or stabilises within 24 hours",
                "interventions": [
                    "HOB flat (0°) to maintain cerebral perfusion pressure",
                    "Do NOT lower BP aggressively unless > 220 mmHg (or > 185 if tPA candidate)",
                    "15-minutely neuro obs: GCS, NIHSS, pupillary response",
                    "Monitor for signs of haemorrhagic transformation post-tPA: ↓GCS, new headache, vomiting",
                    "Maintain BSL 4–11 mmol/L",
                ],
            },
            {
                "diagnosis": "Risk for Aspiration related to dysphagia secondary to stroke",
                "evidence": "Dysarthria, reduced GCS, neurological deficits — high aspiration risk",
                "goal": "No aspiration event; formal swallow screen completed before any oral intake",
                "interventions": [
                    "NIL BY MOUTH until speech pathology swallow assessment",
                    "Position: lateral/semi-prone if vomiting risk",
                    "NG tube for medications and hydration if swallow impaired",
                    "Oral suctioning available at bedside",
                    "Head of bed 30° once haemodynamic goals met",
                ],
            },
            {
                "diagnosis": "Impaired Physical Mobility related to right-sided hemiparesis",
                "evidence": "Right arm weakness, right leg weakness, right facial droop",
                "goal": "No skin breakdown; commence physiotherapy within 24 hours",
                "interventions": [
                    "Pressure injury prevention: 2-hourly repositioning",
                    "Heel protectors applied",
                    "Limb positioning to prevent contractures",
                    "VTE prophylaxis per protocol",
                    "Early physiotherapy and occupational therapy referral",
                ],
            },
        ],
        "adpie": {
            "assessment": (
                "Subjective: Headache 3/10, confusion (knows name, not date). "
                "Objective: Right facial droop, right arm/leg weakness, dysarthria, NIHSS 8, "
                "BP 186/104, AF on ECG, CT — left MCA ischaemia, last known well 1.5 hours ago."
            ),
            "diagnosis": (
                "1. Ineffective Cerebral Tissue Perfusion r/t MCA occlusion AEB NIHSS 8, hemiparesis.\n"
                "2. Risk for Aspiration r/t dysphagia AEB dysarthria, reduced GCS.\n"
                "3. Impaired Physical Mobility r/t hemiparesis AEB arm/leg weakness."
            ),
            "planning": (
                "Activate stroke pathway — tPA within 4.5 hours of onset. "
                "Prevent aspiration until swallow screen. "
                "NIHSS monitoring every 15 min. Commence rehab within 24 hours."
            ),
            "implementation": (
                "• Stroke pathway activated — neurology notified at 09:48.\n"
                "• CT Brain completed at 10:02 — no haemorrhage confirmed.\n"
                "• tPA (alteplase) administered at 10:18 — door-to-needle time 33 minutes.\n"
                "• BP managed: avoided antihypertensives while tPA infusing.\n"
                "• Nil by mouth — NG tube inserted for medications.\n"
                "• Neurological observations every 15 minutes.\n"
                "• Speech pathology, physiotherapy, OT referrals placed."
            ),
            "evaluation": (
                "At 24 hours: NIHSS improved to 4. Right arm strength improving. "
                "Speech clearer. Swallow screen passed (modified diet). "
                "No haemorrhagic transformation on repeat CT. Transferred to stroke unit."
            ),
        },
    },

    # ── 5. SEPSIS ─────────────────────────────────────────────────────────
    {
        "id": "case_005",
        "title": "Septic Shock — Urinary Source",
        "category": "Multi-system / Infectious",
        "difficulty": "Advanced",
        "tags": ["sepsis", "septic shock", "infection", "qSOFA", "Sepsis-3", "antibiotics"],
        "learning_objectives": [
            "Apply Sepsis-3 criteria and qSOFA screening tool",
            "Implement Sepsis 1-Hour Bundle (blood cultures, antibiotics, fluids)",
            "Monitor haemodynamic response to resuscitation",
            "Understand vasopressor use in septic shock",
            "Prevent secondary complications: AKI, ventilator-associated pneumonia",
        ],
        "patient": {
            "name": "Mr. Harold Stevens",
            "age": 78,
            "gender": "Male",
            "weight_kg": 68,
            "height_cm": 170,
            "allergies": ["Cephalosporins (anaphylaxis)"],
            "pmhx": ["Benign Prostatic Hyperplasia", "Chronic Kidney Disease (Stage 3)", "Hypertension", "Type 2 Diabetes"],
            "medications": [
                "Tamsulosin 0.4 mg nocte",
                "Metformin 500 mg BD (held — CKD)",
                "Ramipril 5 mg daily",
                "Insulin glargine 14 units nocte",
            ],
            "social": "Retired farmer. Lives with wife. IDC in situ (inserted 4 days ago at GP for urinary retention).",
            "family_hx": "Nil relevant.",
        },
        "presentation": (
            "Mr. Stevens is brought to ED by his wife at 16:20. She reports he has been 'not himself' "
            "for 24 hours — drowsy, confused, not eating. He developed rigors and fever this afternoon. "
            "Urine from his IDC is cloudy and malodorous. Wife says he was well last week."
        ),
        "vitals": {
            "BP": "82/50 mmHg",
            "HR": "118 bpm",
            "RR": "24 breaths/min",
            "SpO2": "94% on room air",
            "Temp": "39.4°C",
            "Pain": "3/10 (suprapubic)",
            "GCS": "12 (E3 V3 M6)",
            "BSL": "18.6 mmol/L",
            "UO": "20 mL over last 2 hours (oliguria)",
        },
        "physical_exam": (
            "Patient appears unwell, flushed and diaphoretic. Confused — knows name only. "
            "Warm, vasodilated peripheries. Capillary refill 3 seconds. Suprapubic tenderness. "
            "IDC in situ — bag contains 100 mL cloudy, dark urine. "
            "No crepitations. Abdomen soft. No rigidity."
        ),
        "investigations": {
            "qSOFA score": "3/3 (↓BP, ↑RR, altered mentation) — HIGH RISK SEPSIS",
            "SOFA score": "8 — organ dysfunction × 3 systems",
            "Lactate": "4.8 mmol/L (↑↑ — > 4 = septic shock)",
            "FBC": "WCC 24.6 × 10⁹/L, Neutrophils 22.1, Hb 106 g/L",
            "CRP": "348 mg/L (↑↑)",
            "Procalcitonin": "28.4 ng/mL (↑↑)",
            "UEC": "Na 134, K 5.2, Cr 248 μmol/L (↑ — baseline Cr 132), Urea 22.4",
            "LFTs": "ALT mildly elevated",
            "Coagulation": "PT 16.2 s, APTT 42 s, Fibrinogen 1.8 g/L (↓)",
            "Blood cultures × 2": "Pending (collected before antibiotics)",
            "MSU/catheter urine": "WCC > 10⁸, Gram-negative rods (presumed E. coli)",
            "CXR": "No consolidation. Mild cardiomegaly.",
        },
        "medical_diagnosis": "Septic Shock — catheter-associated urinary tract infection (CAUTI)",
        "nursing_priorities": [
            "SEPSIS PATHWAY — 1-HOUR BUNDLE",
            "Blood cultures × 2 sets BEFORE antibiotics",
            "IV fluid resuscitation: 30 mL/kg crystalloid (0.9% NaCl or Hartmann's) STAT",
            "IV antibiotics WITHIN 1 HOUR — per allergy/local protocol (avoid cephalosporins)",
            "Measure serial lactates — target < 2 mmol/L",
            "IDC output — strict hourly urine output (target ≥ 0.5 mL/kg/hr)",
            "Consider vasopressors (noradrenaline) if MAP < 65 mmHg despite fluids",
            "Continuous cardiac monitoring, ICU review",
        ],
        "nursing_diagnoses": [
            {
                "diagnosis": "Ineffective Tissue Perfusion (multi-organ) related to septic shock",
                "evidence": "BP 82/50, lactate 4.8, oliguria 10 mL/hr, GCS 12, Cr 248",
                "goal": "MAP ≥ 65 mmHg, lactate < 2, UO ≥ 0.5 mL/kg/hr within 3 hours",
                "interventions": [
                    "IV 0.9% NaCl 30 mL/kg (2040 mL) over 3 hours — reassess after each 500 mL",
                    "Noradrenaline infusion via central line if MAP < 65 after fluids",
                    "2-hourly lactate clearance measurement",
                    "Strict hourly urine output — target ≥ 34 mL/hr",
                    "Continuous cardiac monitoring",
                ],
            },
            {
                "diagnosis": "Hyperthermia related to systemic infection",
                "evidence": "Temp 39.4°C, rigors, WCC 24.6, CRP 348",
                "goal": "Temperature < 38.5°C within 2 hours",
                "interventions": [
                    "Administer paracetamol 1 g IV/PO per protocol",
                    "Cooling blanket or ice packs to axillae/groin",
                    "Ensure adequate hydration",
                    "Temperature monitoring every 1–2 hours",
                    "Remove IDC and replace with new IDC or suprapubic catheter",
                ],
            },
        ],
        "adpie": {
            "assessment": (
                "Subjective: 24-hour confusion, anorexia, rigors, 4-day IDC for urinary retention. "
                "Objective: BP 82/50, HR 118, Temp 39.4, GCS 12, lactate 4.8, qSOFA 3, "
                "WCC 24.6, Cr 248 (AKI), cloudy malodorous urine."
            ),
            "diagnosis": (
                "1. Ineffective Tissue Perfusion r/t septic shock AEB BP 82/50, lactate 4.8, oliguria.\n"
                "2. Hyperthermia r/t systemic infection AEB Temp 39.4, rigors, WCC 24.6.\n"
                "3. Acute Confusion r/t septic encephalopathy AEB GCS 12."
            ),
            "planning": (
                "1-hour sepsis bundle. MAP ≥ 65 within 3 hours. Lactate clearance ≥ 10%. "
                "Appropriate antibiotics within 1 hour. Source control (IDC review)."
            ),
            "implementation": (
                "• Blood cultures × 2 collected immediately.\n"
                "• Meropenem 1 g IV (avoiding cephalosporins per allergy) within 45 minutes.\n"
                "• IV 0.9% NaCl 2000 mL over 3 hours commenced.\n"
                "• Noradrenaline 0.05 mcg/kg/min commenced via central line — MAP improved to 68.\n"
                "• IDC removed; new IDC inserted; urine sent for C&S.\n"
                "• ICU team notified; patient transferred to ICU.\n"
                "• Family updated and support provided."
            ),
            "evaluation": (
                "At 3 hours: MAP 68, HR 102, lactate 2.8 (↓ — clearance 42%), UO 38 mL/hr. "
                "At 12 hours: lactate 1.4, UO improving, GCS 14. "
                "Blood cultures: E. coli — sensitive to meropenem. Antibiotics rationalised."
            ),
        },
    },

    # ── 6. SURGICAL — POST-OP HIP FRACTURE ────────────────────────────────
    {
        "id": "case_006",
        "title": "Post-Operative Neck of Femur Fracture",
        "category": "Musculoskeletal / Surgical",
        "difficulty": "Beginner",
        "tags": ["hip fracture", "NOF", "orthopaedic", "post-op", "elderly", "falls"],
        "learning_objectives": [
            "Perform post-operative assessment using ABCDE approach",
            "Manage post-operative pain using multimodal analgesia",
            "Implement VTE prophylaxis and pressure injury prevention",
            "Promote early mobilisation — key to recovery",
            "Prevent delirium in elderly post-operative patients",
        ],
        "patient": {
            "name": "Mrs. Betty Kowalski",
            "age": 83,
            "gender": "Female",
            "weight_kg": 56,
            "height_cm": 154,
            "allergies": ["Codeine (nausea/vomiting)", "Latex"],
            "pmhx": ["Osteoporosis", "Hypertension", "Mild cognitive impairment", "Hypothyroidism", "Urinary incontinence"],
            "medications": [
                "Alendronate 70 mg weekly",
                "Calcium carbonate 600 mg BD",
                "Vitamin D 1000 IU daily",
                "Perindopril 5 mg daily",
                "Levothyroxine 50 mcg daily",
            ],
            "social": "Widow. Lives alone in home unit. Daughter visits daily. Independent with frame. 1 previous fall this year.",
            "family_hx": "Mother had hip fracture at age 85.",
        },
        "presentation": (
            "Mrs. Kowalski returned from theatre at 14:30 following right hemiarthroplasty (hip replacement) "
            "for a right neck of femur fracture sustained in a fall at home yesterday. "
            "The procedure was performed under spinal anaesthesia with sedation. She is now in the "
            "orthopaedic ward. She appears drowsy but rousable, and complaining of hip pain."
        ),
        "vitals": {
            "BP": "108/66 mmHg",
            "HR": "88 bpm",
            "RR": "16 breaths/min",
            "SpO2": "94% on room air",
            "Temp": "36.2°C",
            "Pain": "7/10 (right hip)",
            "GCS": "14 (drowsy but oriented to person and place)",
            "UO": "IDC in situ — 40 mL since returning from theatre (2 hours)",
        },
        "physical_exam": (
            "Patient drowsy but rousable — responds to voice. Right hip: dressing intact, "
            "wound drain in situ with 80 mL haemoserous drainage. Right leg warm, cap refill 2 sec. "
            "Pedal pulses present. No distal neurovascular deficit. "
            "Left leg: normal. Abdomen soft. Bowel sounds present."
        ),
        "investigations": {
            "Post-op FBC": "Hb 86 g/L (↓ from pre-op 112 g/L — surgical blood loss)",
            "UEC": "Na 138, K 3.8, Cr 92 μmol/L",
            "Coagulation": "INR 1.2",
            "CXR": "Clear. No consolidation.",
            "Right hip X-ray": "Right hemiarthroplasty in situ — satisfactory position",
        },
        "medical_diagnosis": "Post-operative Day 0 — Right hemiarthroplasty for right NOF fracture",
        "nursing_priorities": [
            "ABCDE post-operative assessment on return from theatre",
            "Multimodal pain management (paracetamol + NSAID + opioid PRN) — avoid codeine",
            "VTE prophylaxis: TEDS + enoxaparin (commence Day 1) + early mobilisation",
            "Pressure injury prevention: 2-hourly repositioning, heel protectors",
            "Delirium prevention: reorientation, familiar objects, glasses/hearing aids",
            "Wound drain monitoring — notify if > 200 mL/hour",
            "Neurovascular observations right leg every 2 hours × 12 hours",
            "IDC output — may remove IDC at 24–48 hours to reduce UTI risk",
        ],
        "nursing_diagnoses": [
            {
                "diagnosis": "Acute Pain related to surgical trauma (right hip)",
                "evidence": "Pain 7/10 right hip, facial grimacing, reluctance to move",
                "goal": "Pain ≤ 3/10 at rest and ≤ 5/10 with movement within 1 hour",
                "interventions": [
                    "Administer paracetamol 1 g QID (if not already given intra-op)",
                    "Administer opioid analgesia PRN per protocol (avoid codeine — allergy)",
                    "Position: supine with pillow between knees (hip precautions)",
                    "Apply ice pack wrapped in cloth to right hip",
                    "Reassess pain 30–60 minutes after analgesia",
                ],
            },
            {
                "diagnosis": "Risk for Perioperative Positioning Injury / Neurovascular Compromise",
                "evidence": "Post-surgical hip — at risk for dislocation, DVT, neurovascular compromise",
                "goal": "No distal neurovascular deficit; no signs of DVT throughout admission",
                "interventions": [
                    "Neurovascular observations (5 Ps) right leg every 2 hours",
                    "Maintain hip precautions: no hip flexion > 90°, no adduction, no internal rotation",
                    "TEDS stockings (check for latex allergy — use non-latex TEDs)",
                    "Enoxaparin per protocol starting Day 1",
                    "Early mobilisation with physiotherapy Day 1",
                ],
            },
            {
                "diagnosis": "Risk for Acute Confusion (Delirium) related to anaesthesia, pain, unfamiliar environment",
                "evidence": "Age 83, mild cognitive impairment, post-op drowsiness, pain",
                "goal": "No delirium episode; patient remains oriented × 3",
                "interventions": [
                    "Ensure glasses and hearing aids are available",
                    "Frequent reorientation — name, location, date, what happened",
                    "Maintain normal sleep-wake cycle — avoid unnecessary night interventions",
                    "Avoid benzodiazepines and anticholinergic medications",
                    "Encourage family presence",
                    "Adequate pain management — uncontrolled pain is a delirium trigger",
                ],
            },
        ],
        "adpie": {
            "assessment": (
                "Subjective: Pain 7/10 right hip. Drowsy post-op. "
                "Objective: BP 108/66, SpO₂ 94%, Hb 86 (↓), wound drain 80 mL, "
                "GCS 14, right hip dressing intact, no neurovascular deficit."
            ),
            "diagnosis": (
                "1. Acute Pain r/t surgical trauma AEB pain 7/10, facial grimacing.\n"
                "2. Risk for Neurovascular Compromise r/t post-op hip surgery.\n"
                "3. Risk for Delirium r/t age, cognitive impairment, anaesthesia."
            ),
            "planning": (
                "Pain ≤ 3/10 within 1 hour. No neurovascular compromise. "
                "Mobilise with physio Day 1. Delirium prevention strategy in place."
            ),
            "implementation": (
                "• O₂ 2 L/min via nasal prongs — SpO₂ improved to 97%.\n"
                "• Paracetamol 1 g IV given; oxycodone 2.5 mg PO given — pain 4/10 at 60 min.\n"
                "• Non-latex TEDS applied. Hip precautions explained.\n"
                "• Glasses and hearing aid retrieved from bedside. Family contacted.\n"
                "• Neurovascular obs every 2 hours — all normal.\n"
                "• Wound drain output charted hourly."
            ),
            "evaluation": (
                "Pain 4/10 at 1 hour, 3/10 at 2 hours. SpO₂ 97%. Neurovascular obs intact. "
                "No delirium at 12 hours — patient oriented × 3. "
                "Day 1: mobilised to chair with physio. Day 2: walking with frame."
            ),
        },
    },

    # ── 7. MATERNAL — PREECLAMPSIA ─────────────────────────────────────────
    {
        "id": "case_007",
        "title": "Severe Preeclampsia",
        "category": "Maternal / Obstetric",
        "difficulty": "Advanced",
        "tags": ["preeclampsia", "obstetric", "maternal", "eclampsia", "magnesium", "hypertension"],
        "learning_objectives": [
            "Distinguish preeclampsia from gestational hypertension",
            "Recognise severe features: BP > 160/110, proteinuria, headache",
            "Administer magnesium sulphate safely for seizure prophylaxis",
            "Monitor fetal wellbeing: CTG interpretation basics",
            "Know antihypertensive options in pregnancy (labetalol, hydralazine)",
        ],
        "patient": {
            "name": "Ms. Yara Okafor",
            "age": 32,
            "gender": "Female",
            "weight_kg": 82,
            "height_cm": 167,
            "allergies": ["NKDA"],
            "pmhx": ["Primigravida", "No previous hypertension", "No pre-existing medical conditions"],
            "medications": ["Folic acid 500 mcg daily (ceased at 12/40)", "Iron supplements"],
            "social": "32-year-old G1P0, 36 weeks gestation. Works as a nurse. Lives with partner.",
            "family_hx": "Mother had preeclampsia in both pregnancies.",
        },
        "presentation": (
            "Ms. Okafor presents to the maternity assessment unit at 11:00 with a frontal headache "
            "rated 7/10, visual disturbances ('flashing lights'), and epigastric pain since this morning. "
            "She is 36+2 weeks gestation. Her midwife took her BP at home and it was 170/110. "
            "Her ankles have been very swollen for the past week."
        ),
        "vitals": {
            "BP": "172/114 mmHg (severe range — repeated × 2, 15 min apart)",
            "HR": "96 bpm",
            "RR": "18 breaths/min",
            "SpO2": "98% on room air",
            "Temp": "37.0°C",
            "Pain": "7/10 (frontal headache + epigastric)",
            "Reflexes": "Hyperreflexia 3+ bilaterally, clonus present (3 beats)",
        },
        "physical_exam": (
            "Alert and distressed. Generalised oedema — face, hands, ankles. "
            "Hyperreflexia with 3-beat clonus — eclampsia risk. "
            "Epigastric tenderness on palpation. "
            "Uterine fundus at 36 cm. Fetal heart rate: 148 bpm, reactive."
        ),
        "investigations": {
            "Urine dipstick": "Protein 3+ (significant proteinuria)",
            "Spot PCR": "450 mg/mmol (↑↑ severe, normal < 30)",
            "BP trend": "Two readings ≥ 160/110, 15 min apart — SEVERE range",
            "FBC": "Hb 112 g/L, Platelets 98 × 10⁹/L (↓ — HELLP concern)",
            "LFTs": "ALT 68 U/L (↑), AST 74 U/L (↑), LDH 420 U/L (↑)",
            "UEC": "Cr 98 μmol/L, Uric acid elevated",
            "Coagulation": "PT/APTT normal, fibrinogen 3.2 g/L",
            "CTG": "Reactive — fetal wellbeing reassuring at this time",
            "Ultrasound": "Fetus 36/40, estimated fetal weight 2.8 kg, reduced amniotic fluid",
        },
        "medical_diagnosis": "Severe Preeclampsia with severe features (36+2 weeks) ± evolving HELLP",
        "nursing_priorities": [
            "URGENT — notify obstetric registrar/MO immediately",
            "Continuous BP monitoring every 5–15 minutes",
            "IV antihypertensives: labetalol IV or hydralazine IV to bring BP < 160/110",
            "Magnesium sulphate: 4 g loading dose IV over 15–20 min — eclampsia prophylaxis",
            "Strict fluid balance — IDC for hourly urine output",
            "Continuous CTG monitoring",
            "Magnesium toxicity monitoring: urine output, RR, reflexes",
            "Prepare for delivery — discuss timing with obstetric team",
        ],
        "nursing_diagnoses": [
            {
                "diagnosis": "Risk for Maternal Injury (Seizure/Stroke) related to severe preeclampsia",
                "evidence": "BP 172/114, hyperreflexia, clonus, headache, visual disturbances",
                "goal": "No eclamptic seizure; BP < 160/110 within 1 hour",
                "interventions": [
                    "Administer magnesium sulphate 4 g IV over 15–20 min loading dose",
                    "Maintain maintenance MgSO₄ infusion 1–2 g/hr",
                    "Antihypertensives: labetalol IV per protocol (SBP target < 160, DBP target < 110)",
                    "Seizure precautions: cot sides up, suction at bedside, IV access confirmed",
                    "Dark quiet room — minimise stimulation",
                    "Monitor: RR ≥ 12, UO ≥ 25 mL/hr, reflexes — before each MgSO₄ dose",
                ],
            },
            {
                "diagnosis": "Risk for Fetal Distress related to placental insufficiency",
                "evidence": "Hypertension affecting uteroplacental blood flow, oligohydramnios",
                "goal": "Reassuring CTG; plan for delivery within 24–48 hours",
                "interventions": [
                    "Continuous CTG monitoring",
                    "Left lateral position — maximises placental perfusion",
                    "Report any late decelerations, reduced variability, or prolonged bradycardia immediately",
                    "Prepare for emergency LSCS if fetal compromise",
                    "Notify neonatal team — preterm delivery expected",
                ],
            },
        ],
        "adpie": {
            "assessment": (
                "Subjective: Frontal headache 7/10, visual disturbances, epigastric pain, facial swelling. "
                "Objective: BP 172/114 (×2), proteinuria 3+, platelets 98, LFTs elevated (HELLP), "
                "hyperreflexia, clonus, 36+2 weeks gestation."
            ),
            "diagnosis": (
                "1. Risk for Maternal Injury r/t severe preeclampsia AEB hypertension, hyperreflexia, clonus.\n"
                "2. Risk for Fetal Distress r/t placental insufficiency AEB oligohydramnios.\n"
                "3. Anxiety r/t acute illness and pregnancy AEB distress and fear for baby."
            ),
            "planning": (
                "BP < 160/110 within 1 hour. No seizure. "
                "Continuous CTG monitoring. Delivery planning with obstetric team."
            ),
            "implementation": (
                "• Obstetric registrar notified at 11:05 — reviewed at 11:10.\n"
                "• Labetalol 20 mg IV — BP 158/105 at 20 min. Repeat dose → BP 148/98.\n"
                "• MgSO₄ 4 g IV over 20 min loading dose; maintenance 2 g/hr.\n"
                "• IDC inserted — UO 35 mL/hr. Continuous CTG — reactive.\n"
                "• Neonatal team notified. Betamethasone for fetal lung maturity given.\n"
                "• Partner informed; birth plan discussed."
            ),
            "evaluation": (
                "BP stabilised 148/96 over next 2 hours. No seizure. CTG remained reactive. "
                "Decision for induction of labour at 37+0 weeks (4 days later after monitoring). "
                "Delivered healthy 2.9 kg boy via vaginal delivery with epidural. "
                "MgSO₄ continued 24 hours post-partum."
            ),
        },
    },

    # ── 8. PAEDIATRIC — FEBRILE SEIZURE ───────────────────────────────────
    {
        "id": "case_008",
        "title": "Paediatric Febrile Convulsion",
        "category": "Paediatric",
        "difficulty": "Beginner",
        "tags": ["paediatric", "febrile seizure", "child", "fever", "convulsion", "airway"],
        "learning_objectives": [
            "Differentiate simple vs complex febrile seizure",
            "Manage acute seizure: DRSABCD, airway positioning, benzodiazepines",
            "Identify and treat the underlying febrile illness",
            "Provide parent education and seizure first-aid teaching",
            "Understand when to investigate for meningitis",
        ],
        "patient": {
            "name": "Liam Nguyen",
            "age": 2,
            "gender": "Male",
            "weight_kg": 12,
            "height_cm": 88,
            "allergies": ["NKDA"],
            "pmhx": ["Nil significant", "No previous seizures", "Normal development"],
            "medications": ["Nil regular"],
            "social": "Lives with both parents and older sister. Fully vaccinated. Attends childcare 3 days/week.",
            "family_hx": "Father had two febrile convulsions as a toddler.",
        },
        "presentation": (
            "Liam's parents call an ambulance after witnessing a 2-minute tonic-clonic seizure at home. "
            "He has had a runny nose and fever for 24 hours — temperature was 39.2°C at home. "
            "The seizure was generalised and has now stopped. Liam is in the post-ictal phase — "
            "drowsy but breathing. Parents are very distressed."
        ),
        "vitals": {
            "BP": "Not measured initially (crying/post-ictal)",
            "HR": "148 bpm",
            "RR": "32 breaths/min",
            "SpO2": "95% (improving — was 90% immediately post-seizure)",
            "Temp": "39.8°C (axillary)",
            "Pain": "Unable to assess (post-ictal)",
            "GCS": "11 (E3 V3 M5 — improving)",
            "Weight": "12 kg",
        },
        "physical_exam": (
            "Post-ictal 2-year-old. Drowsy but gradually becoming more alert over 20 minutes. "
            "Red, inflamed tympanic membranes bilaterally. Rhinorrhoea. Clear chest. "
            "No rash. No petechiae. No neck stiffness. Anterior fontanelle normal. "
            "Pupils equal and reactive. No focal neurological deficit once fully recovered."
        ),
        "investigations": {
            "Temp": "39.8°C",
            "BSL": "6.2 mmol/L (normal)",
            "FBC": "WCC 16.8 (↑ — likely viral), Hb 112 g/L",
            "CRP": "22 mg/L (mildly elevated)",
            "UEC": "Normal",
            "LP (lumbar puncture)": "NOT indicated — simple febrile seizure in child > 12 months, no meningism",
            "EEG": "NOT indicated for first simple febrile seizure",
            "CT Brain": "NOT indicated — no focal deficit, simple febrile seizure",
        },
        "medical_diagnosis": "Simple Febrile Convulsion secondary to bilateral otitis media",
        "nursing_priorities": [
            "DURING SEIZURE: DRSABCD — DO NOT restrain",
            "Position: lateral/recovery position — airway protection",
            "Timing: note seizure start time (if > 5 min — IV midazolam or diazepam)",
            "Post-ictal: airway positioning, O₂ if SpO₂ < 94%, monitoring",
            "Treat fever: paracetamol 15 mg/kg PO/PR",
            "Identify fever source (bilateral OM — amoxicillin if bacterial)",
            "Parent education: seizure first aid, 999 criteria, recurrence risk",
            "Discharge planning: written information, follow-up",
        ],
        "nursing_diagnoses": [
            {
                "diagnosis": "Risk for Aspiration related to seizure and reduced consciousness",
                "evidence": "Post-ictal GCS 11, SpO₂ 95%, seizure just ceased",
                "goal": "Maintain patent airway; SpO₂ ≥ 95%; full recovery of consciousness within 30 min",
                "interventions": [
                    "Position: lateral/recovery position — maintains airway",
                    "Suction available at bedside",
                    "O₂ via face mask if SpO₂ < 94%",
                    "Nil by mouth until fully alert (GCS 15)",
                    "Monitor SpO₂ continuously for 30 minutes",
                ],
            },
            {
                "diagnosis": "Hyperthermia related to bilateral otitis media (infection)",
                "evidence": "Temp 39.8°C, inflamed tympanic membranes, rhinorrhoea, WCC 16.8",
                "goal": "Temperature < 38.5°C within 1 hour",
                "interventions": [
                    "Paracetamol 15 mg/kg = 180 mg PO/PR",
                    "Remove excess clothing, fan",
                    "Tepid sponging (not cold water — may cause shivering, increase temp)",
                    "Adequate hydration — oral fluids when fully alert",
                    "Amoxicillin if bacterial OM suspected per medical order",
                ],
            },
            {
                "diagnosis": "Parental Anxiety related to witnessed seizure in child",
                "evidence": "Parents visibly distressed, asking 'will it happen again?'",
                "goal": "Parents verbalise understanding of febrile seizures and first aid actions",
                "interventions": [
                    "Explain febrile seizures in simple, calm language",
                    "Teach seizure first aid: recovery position, timing, when to call 000",
                    "Reassure: simple febrile seizures do not cause brain damage",
                    "Provide written information leaflet",
                    "Discuss recurrence risk (~30%) and that fever does not need to be treated aggressively to prevent seizures",
                ],
            },
        ],
        "adpie": {
            "assessment": (
                "Subjective (parents): 2-min tonic-clonic seizure at home, 24-hr fever, runny nose. "
                "Father had childhood febrile seizures. "
                "Objective: Temp 39.8°C, GCS 11 (post-ictal, improving), bilateral OM, "
                "SpO₂ 95%, WCC 16.8, simple febrile seizure (< 15 min, generalised, single)."
            ),
            "diagnosis": (
                "1. Risk for Aspiration r/t post-ictal reduced consciousness.\n"
                "2. Hyperthermia r/t bilateral otitis media AEB Temp 39.8°C.\n"
                "3. Parental Anxiety r/t witnessed seizure."
            ),
            "planning": (
                "Airway safety maintained. Temperature < 38.5°C within 1 hour. "
                "Full neurological recovery within 30 min. Parents confident in first aid before discharge."
            ),
            "implementation": (
                "• Liam positioned in lateral recovery position on arrival.\n"
                "• SpO₂ improved to 98% without O₂ within 5 minutes.\n"
                "• Paracetamol 180 mg PR given — temp 38.6°C at 1 hour.\n"
                "• GP called — amoxicillin prescribed for bilateral OM.\n"
                "• GCS 15 within 25 minutes post-ictal — Liam smiling and sitting up.\n"
                "• Parents taught seizure first aid; written information provided."
            ),
            "evaluation": (
                "Liam fully alert at 30 minutes. Temp 38.4°C at 1 hour. SpO₂ 99%. "
                "Discharged home after 4 hours observation. "
                "Parents demonstrated correct seizure first aid. Follow-up with GP in 2 days."
            ),
        },
    },

    # ── 9. MENTAL HEALTH — OVERDOSE ───────────────────────────────────────
    {
        "id": "case_009",
        "title": "Paracetamol Overdose — Deliberate Self-Harm",
        "category": "Mental Health / Toxicology",
        "difficulty": "Intermediate",
        "tags": ["overdose", "paracetamol", "mental health", "self-harm", "NAC", "toxicology"],
        "learning_objectives": [
            "Manage acute paracetamol overdose using the Rumack-Matthew nomogram",
            "Administer N-acetylcysteine (NAC) safely",
            "Perform a risk assessment for deliberate self-harm",
            "Demonstrate therapeutic communication with mental health patients",
            "Understand mandatory reporting and duty of care obligations",
        ],
        "patient": {
            "name": "Mx. Alex Kim",
            "age": 22,
            "gender": "Non-binary (they/them)",
            "weight_kg": 67,
            "height_cm": 172,
            "allergies": ["NKDA"],
            "pmhx": ["Major Depressive Disorder", "Previous overdose 18 months ago"],
            "medications": ["Sertraline 100 mg daily"],
            "social": "University student. Shares house with friends. Recently broke up with partner. Support worker engaged. Family not yet notified per patient request.",
            "family_hx": "Mother has depression.",
        },
        "presentation": (
            "Alex presents to ED at 02:30 brought by a friend who found an empty paracetamol packet "
            "(30 × 500 mg = 15 g) and a note. Alex is alert and cooperative. They report taking all "
            "the tablets approximately 3 hours ago with alcohol. They state 'I wanted to disappear'. "
            "Alex is tearful but not acutely agitated."
        ),
        "vitals": {
            "BP": "118/74 mmHg",
            "HR": "96 bpm",
            "RR": "16 breaths/min",
            "SpO2": "98% on room air",
            "Temp": "36.9°C",
            "Pain": "2/10 (mild nausea)",
            "GCS": "15",
        },
        "physical_exam": (
            "Alert and oriented × 3. Tearful, cooperative. No jaundice. Abdomen soft, mild "
            "right upper quadrant tenderness. No crepitations. Pupils equal and reactive. "
            "No needle marks. Alcohol on breath."
        ),
        "investigations": {
            "Paracetamol level (4h post-ingestion)": "185 mg/L — ABOVE treatment line on nomogram (treat)",
            "LFTs": "ALT 42 U/L (normal — too early for hepatotoxicity), Bili normal",
            "INR": "1.2 (normal — will rise if hepatotoxicity develops)",
            "UEC": "Na 139, K 4.0, Cr 82 μmol/L",
            "FBC": "Normal",
            "Blood alcohol": "0.08% (present — increases hepatotoxicity risk)",
            "BSL": "5.6 mmol/L",
            "Urine drug screen": "Positive: alcohol; negative for opioids, benzodiazepines",
        },
        "medical_diagnosis": "Paracetamol overdose (15 g, 3 hours ago) above treatment line — commence NAC",
        "nursing_priorities": [
            "Commence N-acetylcysteine (NAC) infusion per protocol — do not delay",
            "LFTs, INR, creatinine monitoring every 4–8 hours",
            "Safe room environment: remove sharps, ligature risks — 1:1 or enhanced observation",
            "Mental health risk assessment — psychiatric team referral",
            "Therapeutic communication — non-judgemental, trauma-informed approach",
            "Activated charcoal if < 1 hour post-ingestion (not applicable here — 3 hours)",
            "Social work involvement, safe discharge planning",
        ],
        "nursing_diagnoses": [
            {
                "diagnosis": "Risk for Liver Failure related to paracetamol hepatotoxicity",
                "evidence": "Paracetamol 185 mg/L above nomogram treatment line, co-ingestion with alcohol",
                "goal": "LFTs and INR remain normal; NAC infusion completed",
                "interventions": [
                    "Commence NAC: Bag 1 — 150 mg/kg in 200 mL over 60 min",
                    "Bag 2 — 50 mg/kg in 500 mL over 4 hours; Bag 3 — 100 mg/kg in 1000 mL over 16 hours",
                    "Monitor LFTs, INR, Cr every 4–8 hours",
                    "Monitor for NAC anaphylactoid reaction (first 15 min): rash, wheeze, flushing",
                    "Antiemetics for nausea",
                ],
            },
            {
                "diagnosis": "Risk for Self-Harm related to major depressive disorder",
                "evidence": "Deliberate overdose, previous overdose history, suicide note found",
                "goal": "Patient remains safe; psychiatric review completed within 4 hours",
                "interventions": [
                    "1:1 nursing observation — do not leave patient alone",
                    "Remove all potential means of self-harm from environment",
                    "Therapeutic communication: non-judgemental, empathetic, use they/them pronouns",
                    "Psychiatric/mental health team consulted immediately",
                    "Document risk assessment (CSSRS or institutional tool)",
                    "Respect patient's request regarding family notification (within duty of care limits)",
                ],
            },
        ],
        "adpie": {
            "assessment": (
                "Subjective: Intentional paracetamol 15 g ingestion 3 hours ago with alcohol, "
                "suicide note, previous overdose, MDD. Objective: GCS 15, haemodynamically stable, "
                "paracetamol level 185 mg/L above treatment line, mild RUQ tenderness."
            ),
            "diagnosis": (
                "1. Risk for Liver Failure r/t paracetamol hepatotoxicity AEB level above nomogram line.\n"
                "2. Risk for Self-Harm r/t MDD and suicidal intent AEB deliberate overdose."
            ),
            "planning": (
                "NAC infusion completed (21 hours). LFTs remain normal. "
                "Psychiatric review and safe discharge planning. "
                "Patient engaged with mental health team."
            ),
            "implementation": (
                "• NAC Bag 1 commenced at 03:15 — no anaphylactoid reaction.\n"
                "• 1:1 observation commenced. Environment cleared of hazards.\n"
                "• Mental health consult at 06:00.\n"
                "• Communicated using they/them pronouns throughout — patient acknowledged and appreciated.\n"
                "• Social worker contacted at 08:00.\n"
                "• LFTs and INR repeated at 8 and 16 hours — remained normal."
            ),
            "evaluation": (
                "NAC infusion completed at 00:15 (Day 2). LFTs, INR normal throughout. "
                "Psychiatric review at 06:00 — not for inpatient admission; community mental health follow-up arranged. "
                "Discharged with crisis plan, mental health team contact, and GP review within 48 hours."
            ),
        },
    },

    # ── 10. RENAL — ACUTE KIDNEY INJURY ───────────────────────────────────
    {
        "id": "case_010",
        "title": "Acute Kidney Injury (AKI) — Prerenal",
        "category": "Renal",
        "difficulty": "Intermediate",
        "tags": ["AKI", "renal", "acute kidney injury", "fluid balance", "oliguria", "hypotension"],
        "learning_objectives": [
            "Classify AKI using KDIGO criteria (Stage 1, 2, 3)",
            "Differentiate prerenal, intrinsic, and postrenal AKI",
            "Manage fluid resuscitation in AKI",
            "Monitor for hyperkalaemia — most dangerous complication",
            "Avoid nephrotoxic medications and contrast in AKI",
        ],
        "patient": {
            "name": "Mr. Daniel Obi",
            "age": 55,
            "gender": "Male",
            "weight_kg": 78,
            "height_cm": 180,
            "allergies": ["Ibuprofen (worsens kidney function)"],
            "pmhx": ["Hypertension", "Type 2 Diabetes", "CKD Stage 2 (baseline Cr 110 μmol/L)"],
            "medications": [
                "Ramipril 10 mg daily",
                "Metformin 1000 mg BD",
                "Furosemide 40 mg daily",
                "Amlodipine 10 mg daily",
            ],
            "social": "Bank manager. Married, 2 children. Had gastroenteritis for 5 days — unable to eat or drink. Continued all medications including ramipril and furosemide.",
            "family_hx": "Father has T2DM and hypertension.",
        },
        "presentation": (
            "Mr. Obi is admitted by his GP with 5 days of gastroenteritis (vomiting and diarrhoea × 8/day), "
            "poor oral intake, and dizziness on standing. His GP found BP 88/54 lying, Cr 348 on bloods. "
            "He continued taking ramipril and furosemide throughout his illness. "
            "He has not passed urine for 12 hours."
        ),
        "vitals": {
            "BP": "88/54 mmHg (lying); 72/44 mmHg (standing — postural drop)",
            "HR": "108 bpm",
            "RR": "18 breaths/min",
            "SpO2": "97% on room air",
            "Temp": "37.3°C",
            "Pain": "4/10 (abdominal cramps)",
            "GCS": "15",
            "UO": "0 mL last 12 hours",
        },
        "physical_exam": (
            "Patient appears unwell and dehydrated. Dry mucous membranes, sunken eyes, reduced skin turgor. "
            "Postural hypotension confirmed. Capillary refill 3 seconds. "
            "Abdomen: mild diffuse tenderness, no guarding. No peripheral oedema. "
            "No signs of urinary retention on palpation."
        ),
        "investigations": {
            "Creatinine": "348 μmol/L (↑↑ from baseline 110 — Stage 3 AKI by KDIGO: × 3.17 baseline)",
            "Urea": "28.4 mmol/L (↑↑)",
            "eGFR": "16 mL/min/1.73m² (critically reduced)",
            "Potassium": "6.2 mmol/L (↑↑ — dangerous hyperkalaemia)",
            "Sodium": "128 mmol/L (↓ — hyponatraemia)",
            "Bicarbonate": "14 mmol/L (↓ — metabolic acidosis)",
            "FBC": "Hb 122 g/L, WCC 9.8",
            "Urine": "No casts (consistent with prerenal), Urine Na < 20 mmol/L",
            "Urine osmolality": "620 mOsm/kg (concentrated — prerenal physiology)",
            "ECG": "Peaked T waves (hyperkalaemia). HR 108.",
            "Renal ultrasound": "Normal kidney size. No obstruction. No hydronephrosis.",
        },
        "medical_diagnosis": "Stage 3 AKI — prerenal (dehydration + ACE inhibitor/diuretic in gastroenteritis)",
        "nursing_priorities": [
            "URGENT: Treat hyperkalaemia (K⁺ 6.2 + ECG changes) — calcium gluconate IV",
            "IV fluid resuscitation: 0.9% NaCl 500 mL over 1 hour × 2",
            "HOLD nephrotoxic medications: ramipril, furosemide, metformin, NSAIDs",
            "Strict fluid balance — IDC for hourly urine output",
            "Continuous cardiac monitoring — hyperkalaemia arrhythmia risk",
            "Serial K⁺ and creatinine every 2–4 hours",
            "Renal team review — consider dialysis if refractory (unlikely if prerenal)",
            "Dietary consult — low potassium, low phosphate diet",
        ],
        "nursing_diagnoses": [
            {
                "diagnosis": "Deficient Fluid Volume related to gastroenteritis and diuretic use",
                "evidence": "BP 88/54, postural hypotension, anuria × 12 hours, dry mucous membranes",
                "goal": "UO ≥ 0.5 mL/kg/hr (≥ 39 mL/hr) within 4 hours; BP > 100 systolic",
                "interventions": [
                    "IV 0.9% NaCl 500 mL over 1 hour × 2 — reassess after each bolus",
                    "IDC inserted — strict hourly UO",
                    "Hold ramipril and furosemide",
                    "Vital signs every 30–60 minutes",
                ],
            },
            {
                "diagnosis": "Risk for Cardiac Arrhythmia related to hyperkalaemia (K⁺ 6.2)",
                "evidence": "K⁺ 6.2 mmol/L, peaked T waves on ECG, AKI",
                "goal": "K⁺ < 5.5 mmol/L within 4 hours; no arrhythmia",
                "interventions": [
                    "Calcium gluconate 10 mL 10% IV over 10 min (cardioprotective — immediate effect)",
                    "Insulin 10 units actrapid + 50 mL 50% dextrose IV (shifts K into cells)",
                    "Salbutamol nebuliser 10–20 mg (adjunct K-lowering)",
                    "Sodium bicarbonate 100 mmol IV if pH < 7.2 (treats acidosis/K shift)",
                    "Resonium (kayexalate) PO/PR for K removal",
                    "Continuous ECG monitoring — treat arrhythmias immediately",
                    "Repeat K⁺ 2 hours after treatment",
                ],
            },
        ],
        "adpie": {
            "assessment": (
                "Subjective: 5-day gastroenteritis, unable to eat/drink, continued ramipril and furosemide, "
                "anuria × 12 hours. Objective: BP 88/54, K⁺ 6.2, Cr 348 (Stage 3 AKI), "
                "peaked T waves on ECG, dry mucous membranes, Urine Na < 20 (prerenal)."
            ),
            "diagnosis": (
                "1. Deficient Fluid Volume r/t dehydration AEB hypotension, anuria, poor skin turgor.\n"
                "2. Risk for Cardiac Arrhythmia r/t hyperkalaemia AEB K⁺ 6.2, peaked T waves."
            ),
            "planning": (
                "Fluid resuscitation to restore UO. Treat hyperkalaemia urgently. "
                "Hold nephrotoxic medications. Cr to trend downward within 24–48 hours."
            ),
            "implementation": (
                "• Calcium gluconate 10 mL 10% IV given at 10:30 — ECG improved (T waves less peaked).\n"
                "• Actrapid 10 units + 50 mL 50% dextrose IV given.\n"
                "• 0.9% NaCl 500 mL × 2 over 2 hours.\n"
                "• Ramipril, furosemide, metformin withheld — medications reviewed by team.\n"
                "• IDC inserted — UO 15 mL/hr at 2 hours, 38 mL/hr at 4 hours.\n"
                "• K⁺ repeat at 2 hours: 5.4 mmol/L (↓ from 6.2)."
            ),
            "evaluation": (
                "At 12 hours: BP 118/76, UO 44 mL/hr, K⁺ 4.8, Cr 244 (↓ from 348 — prerenal responding). "
                "At 48 hours: Cr 148 μmol/L (↓ improving). "
                "Ramipril and furosemide restarted at discharge with sick-day medication advice."
            ),
        },
    },

]


# ---------------------------------------------------------------------------
# Helper functions
# ---------------------------------------------------------------------------

def get_all_cases():
    return CASE_BANK


def get_categories():
    seen = []
    for c in CASE_BANK:
        if c["category"] not in seen:
            seen.append(c["category"])
    return seen


def get_difficulties():
    return ["Beginner", "Intermediate", "Advanced"]


def get_by_category(category: str):
    return [c for c in CASE_BANK if c["category"] == category]


def get_by_difficulty(difficulty: str):
    return [c for c in CASE_BANK if c["difficulty"] == difficulty]


def get_by_id(case_id: str):
    for c in CASE_BANK:
        if c["id"] == case_id:
            return c
    return None


def search_cases(query: str):
    q = query.lower()
    results = []
    for c in CASE_BANK:
        if (q in c["title"].lower()
                or q in c["category"].lower()
                or any(q in t for t in c["tags"])
                or q in c["patient"]["name"].lower()
                or q in c.get("medical_diagnosis", "").lower()):
            results.append(c)
    return results