chronic-condition-monitor

name: chronic-condition-monitor description: "Monitors multiple chronic disease indicators (BP, glucose, HbA1c, lipids, uric acid, creatinine, eGFR, liver function) against Chinese clinical guidelines. Detects abnormal trends, metabolic syndrome, and generates visit summaries. Use when the user tracks lab results or manages multiple chronic conditions." version: 1.0.0 user-invocable: false allowed-tools: Read, Grep, Glob, Write, Edit metadata: {"openclaw":{"emoji":"🏥","category":"health"}}

Chronic Condition Monitor

Record and track multiple chronic disease indicators, detect abnormal trends, perform cross-indicator analysis, assess severity, and generate visit summaries.

Capabilities

1. Multi-Indicator Recording

Track the following chronic disease indicators:

Blood Pressure: SBP / DBP (mmHg), pulse (bpm)

Blood Glucose: Fasting plasma glucose FPG (mmol/L), 2-hour postprandial glucose 2hPG (mmol/L), HbA1c (%)

Weight & BMI: Weight (kg), height (cm), BMI = weight(kg) / height(m)^2, waist circumference (cm)

Uric Acid: umol/L

Kidney Function: Serum creatinine Scr (umol/L), eGFR (mL/min/1.73m^2) via CKD-EPI 2021

Lipid Panel: Total cholesterol TC, triglycerides TG, LDL-C, HDL-C (all mmol/L)

Liver Function: ALT, AST (U/L)

2. Reference Ranges and Classification

For complete reference ranges and classification thresholds, see references/ranges.md

Classification logic:

• Within normal range -> Normal
• Within caution range -> Elevated/Low, needs attention
• Reaches critical value -> Immediate alert, advise medical attention

3. Abnormal Trend Detection

Consecutive Out-of-Range:

• Check last N readings for each indicator
• 3+ consecutive readings above upper normal limit -> "Persistent elevation" alert
• 3+ consecutive readings below lower normal limit -> "Persistent low" alert

Progressive Worsening:

• Check whether last 3 readings show progressive deterioration
• Worsening = each reading worse than the previous (for rising-type indicators: each higher; for falling-type like HDL-C, eGFR: each lower)
• Progressive worsening -> "Progressive deterioration" alert

Rate of Change:

• Calculate change rate between last two readings
• Single change exceeding 20% of normal range -> "Rapid change" alert

Detection Steps:

1. Glob memory/health/items/ to read indicator files
2. Extract last 5-10 records from ## History table
3. Apply all three detection algorithms per indicator
4. Aggregate all alerts

4. Cross-Indicator Analysis

Metabolic Syndrome Detection

Diagnose metabolic syndrome when 3 of 5 criteria are met:

Check each criterion against the most recent reading. >= 3 triggers metabolic syndrome warning.

Diabetes + Hypertension Comorbidity Alert

Trigger when both are met:

• FPG >= 7.0 mmol/L or HbA1c >= 6.5% (diabetes diagnostic criteria)
• SBP >= 140 or DBP >= 90 mmHg (hypertension diagnostic criteria)

Alert content:

• Diabetes combined with hypertension significantly increases cardiovascular risk
• Recommend stricter BP target: < 130/80 mmHg
• Recommend ACEI/ARB class antihypertensives (renal protective benefit)

CKD Progression Markers

Trigger CKD progression alert on any of:

• eGFR drops to a new CKD stage (e.g., G2 to G3a)
• eGFR annual decline rate > 5 mL/min/1.73m^2
• Creatinine rising for 3 consecutive readings

CKD staging reference (see kidney-function-tracker):

• G1: >= 90, G2: 60-89, G3a: 45-59, G3b: 30-44, G4: 15-29, G5: < 15

Hepatorenal Combined Abnormality

When ALT or AST is elevated AND creatinine is elevated or eGFR is decreased:

• Suggest possible drug-induced hepatorenal injury
• Recommend medication review
• Recommend prompt medical evaluation

5. Severity Grading

Level 1 (Mild):

• Only 1 indicator mildly out of range (within caution range)
• No progressive worsening trend
• Recommendation: Continue monitoring, lifestyle adjustments

Level 2 (Moderate):

• 2+ indicators out of normal range
• OR 1 indicator significantly elevated (beyond caution but below critical)
• OR progressive worsening trend detected
• Recommendation: Increase monitoring frequency, consider medical consultation

Level 3 (Severe):

• Any indicator reaches critical value
• OR 3+ indicators simultaneously out of range
• OR rapid change detected (single change > 20%)
• OR metabolic syndrome detected
• Recommendation: Seek immediate medical attention, bring monitoring records

6. Visit Summary Generation

Generate a structured visit summary covering the last 3-6 months.

Steps:

1. Glob memory/health/items/*.md for all indicator files
2. Read each file, extract ## History table data
3. Filter records from the last 3-6 months
4. Per indicator: compute latest, average, max, min, trend
5. Run trend detection and cross-indicator analysis
6. Read memory/health/_health-profile.md for baseline health info
7. Read memory/health/items/medications.md for current medications
8. Compile visit summary report

eGFR Calculation (CKD-EPI 2021, Race-Free)

Auto-calculate eGFR when creatinine is recorded.

Female:

• Scr <= 0.7 mg/dL: eGFR = 142 * (Scr/0.7)^(-0.241) * 0.9938^age
• Scr > 0.7 mg/dL: eGFR = 142 * (Scr/0.7)^(-1.200) * 0.9938^age

Male:

• Scr <= 0.9 mg/dL: eGFR = 142 * (Scr/0.9)^(-0.302) * 0.9938^age
• Scr > 0.9 mg/dL: eGFR = 142 * (Scr/0.9)^(-1.200) * 0.9938^age

Unit conversion: Chinese labs report creatinine in umol/L. Convert first:

• Scr (mg/dL) = Scr (umol/L) / 88.4

Input Format

User provides indicator values in natural language. Parse and match to known indicators. Examples:

• "BP 135/88, fasting glucose 6.8, uric acid 398"
• "Lab results: creatinine 95, TC 5.5, TG 1.9, LDL 3.6, HDL 1.15, ALT 35, AST 28"
• "Generate visit summary"
• "Show 3-month glucose trend"

Output Format

Indicator Dashboard

# Chronic Condition Monitoring Report

## Date
YYYY-MM-DD

## Indicator Dashboard

| Indicator | Latest | Reference | Status | Trend |
|-----------|--------|-----------|--------|-------|
| Blood Pressure | 135/88 mmHg | < 120/80 | Elevated | Stable |
| Fasting Glucose | 6.8 mmol/L | 3.9-6.1 | Elevated | Rising |
| ... | ... | ... | ... | ... |

## Trend Alerts

### Persistent Elevation
- Fasting glucose: last 4 readings all above normal (6.5, 6.6, 6.7, 6.8)

### Progressive Deterioration
- Fasting glucose: 4 consecutive increases

### Rapid Change
- None

## Cross-Indicator Analysis

### Metabolic Syndrome Assessment
- [criteria evaluation, count met/5]
- **Result: meets N/5 criteria, [diagnosis or not]**

### Comorbidity Alerts
- [if applicable]

## Severity Assessment

**Overall Level: Level N (Mild/Moderate/Severe)**
- Abnormal indicators: N items
- Worsening trends: [details]
- Combined abnormalities: [details]
- **Recommendation: [action]**

Visit Summary

# Visit Summary

## Generated
YYYY-MM-DD (covering YYYY-MM-DD to YYYY-MM-DD)

## Basic Information
- Sex, Age, Height, Weight, BMI

## Current Medications
- [medication list with doses]

## Indicator Summary
### Blood Pressure (N readings)
| Stat | SBP | DBP |
|------|-----|-----|
| Latest / Average / Max / Min / Trend / Target rate |

### [Other indicators with similar tables]

## Issues Requiring Attention
1. [prioritized list]

## Suggested Discussion Topics
1. [for physician consultation]

Data Persistence

Follow health-memory write protocol:

1. Update daily file: Insert/replace section ## Chronic Indicators [chronic-condition-monitor · HH:MM]
2. Update items files: Update ## Recent Status, prepend row to ## History table, trim rows older than 90 days

Daily section format:

## Chronic Indicators [chronic-condition-monitor · 09:30]
- Blood Pressure: 135/88 mmHg, pulse 75 -> Elevated
- Fasting Glucose: 6.8 mmol/L -> Impaired fasting glucose
- Severity: Level 2 (Moderate)
- Alerts: Progressive FPG increase, Metabolic syndrome risk

Data files:

• Daily logs: memory/health/daily/YYYY-MM-DD.md
• Indicator files: memory/health/items/blood-pressure.md, blood-sugar.md, weight.md, uric-acid.md, kidney-function.md, blood-lipids.md, liver-function.md
• Health profile: memory/health/_health-profile.md

Alerts and Safety

Critical Value Thresholds

Emit immediate emergency alert when any of the following are detected:

• SBP >= 180 mmHg or DBP >= 110 mmHg (hypertensive crisis)
• Blood glucose >= 16.7 mmol/L or <= 2.8 mmol/L
• eGFR < 15 mL/min/1.73m^2
• ALT or AST > 200 U/L

Alert message: Seek immediate medical attention or call emergency services. This skill cannot replace emergency medical care.

Consult a Physician When

• Any indicator is abnormal for the first time
• An indicator shows persistent worsening
• Multiple indicators are simultaneously abnormal
• Metabolic syndrome screening is positive
• Medication adjustment is needed

Medical Disclaimer

This skill is for health monitoring reference only. It does not constitute medical diagnosis or treatment advice. It does not diagnose diseases, formulate treatment plans, recommend medications, or replace physician consultations.