Run Detail

Six patients. Each one has been referred with a question of connective tissue disease. Give the diagnosis.

The cases

[1] id=c1 26-year-old woman. Four months of fatigue and symmetric pain and swelling in the small joints of both hands. Erythema across both cheeks and the bridge of the nose, sparing the nasolabial folds, worse after a weekend outdoors. Two painless ulcers on the hard palate. WBC 2.9, lymphocytes 0.7, platelets 118, hemoglobin 10.4. Creatinine 1.1. Urinalysis 2+ protein with dysmorphic red cells; urine protein:creatinine 1.4 g/g. ANA 1:640 speckled. Anti-dsDNA positive. Anti-Smith positive. C3 62 mg/dL, C4 8 mg/dL, both low. Direct antiglobulin test negative.

[2] id=c2 34-year-old woman. Nine days of abrupt symmetric pain and swelling in the MCPs, PIPs, wrists and knees. Morning stiffness two hours. Afebrile. No rash. Her six-year-old was sent home from school two weeks earlier with a bright red facial rash that faded into a lace pattern on his arms. WBC 6.1, platelets 244, hemoglobin 13.0. Creatinine 0.8. Urinalysis normal. ANA 1:80 speckled. Rheumatoid factor weakly positive. Anti-dsDNA negative. Anti-CCP negative. C3 and C4 normal. Parvovirus B19 IgM positive, IgG negative.

[3] id=c3 61-year-old man. Six weeks of low-grade fever, night sweats and 12 lb weight loss. New 2/6 systolic murmur at the apex. Splinter hemorrhages under two nails, tender nodules on the finger pads. Hemoglobin 9.8, ESR 88, CRP 96. Creatinine 1.6. Urinalysis with red cell casts. C3 low. ANA 1:160. Rheumatoid factor positive. Three of three blood culture sets grow Streptococcus gallolyticus. Transesophageal echo shows a 12 mm mitral valve vegetation.

[4] id=c4 29-year-old man. Five weeks of fever spiking to 39.6 C each evening and back to normal by morning. Sore throat at every spike, culture negative. A salmon-pink macular rash appears on the trunk with the fever and is gone by breakfast. Swollen wrists and knees. WBC 19,400 with 88 percent neutrophils. Hemoglobin 10.1, platelets 480. Ferritin 14,200 ng/mL. AST 78, ALT 92. ANA negative. Rheumatoid factor negative. Blood cultures negative x3. CT chest, abdomen and pelvis unremarkable.

[5] id=c5 41-year-old woman. Four days of confusion, bruising and fatigue. Temperature 38.1 C. Hemoglobin 7.6, platelets 11,000, reticulocytes elevated. LDH 1,180. Haptoglobin undetectable. Schistocytes on the smear. Creatinine 1.4. Direct antiglobulin test negative. PT and aPTT normal, fibrinogen normal. ANA negative. ADAMTS13 activity below 5 percent with an inhibitor detected.

[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.

Rules

1. Six in, six 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. nextStep is the one thing you do next — the test, the drug, or the referral.
6. 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.
7. 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": "...", "nextStep": "...", "note": "..." }
  ]
}

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