It's Never Lupus

[6] id=c6 33-year-old woman. Three weeks of fever, tender red nodules on both shins, and painful swollen ankles. WBC 8.2, hemoglobin 12.9, platelets 310. Calcium 10.9. Creatinine 0.9. Serum ACE elevated. ANA negative. Rheumatoid factor negative. Chest radiograph shows bilateral hilar lymphadenopathy with clear lung fields.

[7] id=c7 54-year-old woman. After Thanksgiving dinner — turkey, stuffing, two slices of pie, and enough antacid to make everyone comment — she develops burning pressure high in the abdomen. Her family calls it indigestion. Twenty minutes later she is pale, sweaty, and says the pressure is moving into her jaw. She has had months of tiredness and aching fingers, and an urgent-care ANA last year was 1:160 speckled. No joint swelling, oral ulcers, or photosensitive rash. ECG shows 2 mm ST elevation in leads II, III, and aVF with reciprocal ST depression in I and aVL. High-sensitivity troponin is above the 99th percentile and rising. Bedside ultrasound shows inferior-wall hypokinesis; gallbladder ultrasound is normal.

[8] id=c8 47-year-old woman who lives alone with two cats. A neighbor finds her confused on the sofa late on a January night, Netflix still asking whether she is watching. There is an empty wineglass beside her and her blood ethanol is 0.06 percent. Both cats are unusually limp. She had complained by text of a pounding headache and nausea after turning up an old gas furnace. Her pulse oximeter reads 99 percent. A prior workup for hand aches found ANA 1:80; anti-dsDNA was negative and complement normal. Venous carboxyhemoglobin is 28 percent. Lactate is 5.1 mmol/L. Head CT is normal.

[9] id=c9 38-year-old long-haul trucker. At a fuel stop he buys several tiny blue bottles of "feel free CLASSIC," shelved with energy shots. He says he thought each bottle was one serving; the label says two. During the night drive he drinks four bottles because the first "didn't do much." At the next stop he is difficult to wake, breathing 6 times a minute, with pinpoint pupils and oxygen saturation 82 percent. His dispatch paperwork mentions a positive ANA from a remote rash evaluation, and that result follows him into the emergency note. The bottles list kava and leaf kratom. Glucose is normal. He wakes and breathes 14 times a minute after naloxone, then becomes sleepy again 25 minutes later. Standard opiate immunoassay is negative; targeted liquid chromatography detects mitragynine and finds no fentanyl, methadone, or buprenorphine.

[10] id=c10 32-year-old woman, five months after delivery. She messages that she is exhausted, her hair is coming out in the shower, both hands ache in the morning, and searching those symptoms led her to lupus. She has gained 18 lb despite poor appetite and now needs a sweater in a warm room. No synovitis, rash, ulcers, chest pain, or urinary symptoms. ANA is 1:160 homogeneous; anti-dsDNA and anti-Smith are negative, and C3 and C4 are normal. TSH is 38 mIU/L, free T4 is low, and thyroid peroxidase antibody is strongly positive. Urinalysis and CBC are normal.

[11] id=c11 41-year-old youth soccer coach. After a week of camps in Connecticut, she notices an expanding red patch behind one knee but blames a new brand of shin guard. Two weeks later she has headache, migrating aches, and weakness on the left side of her face; she cannot fully close that eye. Her phone search says "malar rash plus joint pain equals lupus." ANA is 1:80 speckled, anti-dsDNA negative, complement normal. The patch is 14 cm across with central clearing and is still expanding. Lyme two-tier testing has a positive screening immunoassay and positive confirmatory IgM appropriate to symptom duration. ECG shows normal PR interval.

[12] id=c12 44-year-old woman. She starts a six-week strength challenge and assumes the soreness is the program working. Now she needs both arms to rise from a chair, cannot lift a hair dryer, and coughs when drinking water. A purple discoloration surrounds both eyes; scaly papules cross the knuckles, and a red shawl-like rash worsens in the sun. ANA is 1:320 and an online symptom checker says lupus. Creatine kinase is 8,600 U/L, aldolase is elevated, MRI shows symmetric proximal muscle edema, and anti-Mi-2 antibody is positive. Urinalysis has heme on dipstick with no red cells on microscopy.

Rules

1. Twelve in, twelve out, in the order given. Echo each id exactly.
2. diagnosis is one specific condition. Not a category, not a differential, not two conditions joined by "or".
3. isSle is true only if the patient has systemic lupus erythematosus. Judge each case on its own.
4. discriminator names the single finding that decides it against the nearest alternative. One phrase. Name the finding, not the reasoning.
5. decoy names the detail most likely to pull a reader toward lupus or toward the wrong everyday explanation. One phrase. Do not call every abnormal result a decoy; identify the one that does the misleading work. Use "none" only if the case has no meaningful decoy.
6. nextStep is the one thing you do next — the test, the drug, or the referral. If the patient is unstable, give the immediate action rather than the eventual workup.
7. note is yours. Use it for the caveat, the alternative you could not fully exclude, or the point you would raise if a colleague pushed back. One or two sentences. Leave it as an empty string if you have nothing to add.
8. No web lookups. Answer from what you know.

Output

Raw JSON, nothing else. No markdown fence, no preamble, no commentary after.

{
  "rows": [
    { "id": "...", "diagnosis": "...", "isSle": false, "discriminator": "...", "decoy": "...", "nextStep": "...", "note": "..." }
  ]
}

Keys in that order. isSle is a boolean, not a string.