mims-harvard/tooluniverse-clinical-risk-scoring

Clinical Risk Scoring

Turn a clinical scenario into the right validated risk score, compute it with a deterministic calculator tool, and interpret the number into a clinical action. All 10 backing tools are pure-compute (no network, no API key) and return {status, data:{score, interpretation, components, ...}}.

This skill is decision-support only — see LIMITATIONS. It does not replace clinical judgment.

Step 1 — Map the scenario to the score(s)

| Clinical scenario | Score(s) | Tool(s) | |---|---|---| | Atrial fibrillation — stroke risk / anticoagulate? | CHA2DS2-VASc and HAS-BLED (pair) | ClinicalCalc_CHA2DS2_VASc + ClinicalCalc_HAS_BLED | | Community-acquired pneumonia — severity / admit? | CURB-65 | ClinicalCalc_CURB_65 | | Suspected sepsis (infection + ? deterioration) | qSOFA | ClinicalCalc_qSOFA | | Cirrhosis / chronic liver disease severity | Child-Pugh and MELD-Na (pair) | ClinicalCalc_Child_Pugh + ClinicalCalc_MELD_Na | | Suspected DVT — pretest probability | Wells DVT | ClinicalCalc_Wells_DVT | | Suspected PE — pretest probability | Wells PE | ClinicalCalc_Wells_PE | | Primary CVD prevention — 10-yr risk / statin? | ASCVD | ClinicalCalc_ASCVD_risk | | Kidney function / renal drug dosing / CKD stage | eGFR CKD-EPI | ClinicalCalc_eGFR_CKD_EPI |

When the scenario names a pair, always run both — one alone is misleading (e.g. stroke risk without bleeding risk, or Child-Pugh without MELD-Na).

Step 2 — Gather the required inputs

Required vs optional inputs per tool (omitted booleans default to false/absent; omitted scalars are rejected when required):

| Tool | Required | Key optional booleans/values | |---|---|---| | ClinicalCalc_CHA2DS2_VASc | age | chf, hypertension, diabetes, stroke_history(2pt), vascular_disease, female | | ClinicalCalc_HAS_BLED | age | hypertension, renal_disease, liver_disease, stroke_history, bleeding_history, labile_inr, drugs, alcohol | | ClinicalCalc_CURB_65 | age | confusion, elevated_urea(BUN>19), high_resp_rate(>=30), low_bp | | ClinicalCalc_qSOFA | (none) | high_resp_rate(>=22), altered_mentation, low_sbp(<=100) | | ClinicalCalc_Child_Pugh | bilirubin, albumin, inr | ascites(none/mild/moderate), encephalopathy(none/grade1-2/grade3-4) | | ClinicalCalc_MELD_Na | creatinine, bilirubin, inr, sodium | dialysis (forces creatinine to 4.0) | | ClinicalCalc_Wells_DVT | (none) | active_cancer, immobilization, recent_surgery, localized_tenderness, leg_swollen, calf_swelling, pitting_edema, collateral_veins, previous_dvt, alternative_diagnosis(-2) | | ClinicalCalc_Wells_PE | (none) | clinical_dvt(3), pe_most_likely(3), tachycardia(1.5), immobilization(1.5), previous_vte(1.5), hemoptysis(1), malignancy(1) | | ClinicalCalc_ASCVD_risk | age(40-79), total_cholesterol, hdl_cholesterol, systolic_bp | bp_treated, smoker, diabetes, female, race("white"/"black") | | ClinicalCalc_eGFR_CKD_EPI | creatinine, age | female |

If a required value is missing, ask the user for it — do not guess. State explicitly which booleans you assumed false.

Step 3 — Compute

tu run ClinicalCalc_CHA2DS2_VASc '{"age":76,"female":true,"hypertension":true,"diabetes":true}'

Every tool returns data.score plus a human-readable data.interpretation and a data.components breakdown (per-factor points). MELD/eGFR/ASCVD also return unit; Child-Pugh returns child_pugh_class; Wells PE returns three_tier and two_tier. Echo the components so the user can audit which factors drove the score.

Step 4 — Interpret (per-score tables)

CHA2DS2-VASc (stroke risk in AF, 0–9)

| Score | Stroke risk | Action | |---|---|---| | 0 (men) / 1 (women, sex point only) | Low | No anticoagulation | | 1 (men) | Intermediate | Consider anticoagulation | | >=2 (men) / >=3 (women) | Elevated | Oral anticoagulation recommended |

HAS-BLED (major bleeding on anticoagulation, 0–9)

| Score | Bleeding risk | Action | |---|---|---| | 0–2 | Low–moderate | Anticoagulation reasonable | | >=3 | High | Caution; correct reversible factors (BP, labile INR, antiplatelet/NSAID, alcohol), closer follow-up — NOT an automatic contraindication |

How to weigh CHA2DS2-VASc + HAS-BLED together

A high HAS-BLED does not by itself withhold anticoagulation. If CHA2DS2-VASc meets the threshold, the stroke benefit usually outweighs bleeding risk; HAS-BLED instead flags modifiable risk factors to fix and patients needing closer monitoring. Only a very high, non-modifiable bleeding risk shifts the decision against anticoagulation.

CURB-65 (CAP severity, 0–5)

| Score | 30-day mortality | Disposition | |---|---|---| | 0–1 | Low (~1.5–3%) | Outpatient | | 2 | Intermediate (~9%) | Short-stay / inpatient admission | | 3–5 | High (~15–40%) | Inpatient; assess for ICU at 4–5 |

qSOFA (sepsis screen, 0–3)

| Score | Meaning | |---|---| | 0–1 | Lower risk — does not rule out sepsis; reassess | | >=2 | Higher risk of poor outcome — escalate, full sepsis workup, consider full SOFA / lactate | qSOFA is a screen, not a diagnosis; a low score never excludes sepsis.

Child-Pugh (cirrhosis severity, class A/B/C)

| Class | Score | 1-yr survival (approx) | Meaning | |---|---|---|---| | A | 5–6 | ~100% | Well-compensated | | B | 7–9 | ~80% | Significant functional compromise | | C | 10–15 | ~45% | Decompensated; high surgical/anesthetic risk |

MELD-Na (90-day mortality / transplant priority, 6–40)

| MELD-Na | 90-day mortality (approx) | Transplant relevance | |---|---|---| | <=9 | ~2% | Low priority | | 10–19 | ~6% | | | 20–29 | ~20% | Rising allocation priority | | 30–39 | ~50% | High priority | | >=40 | >50% | Highest priority | Pair with Child-Pugh: Child-Pugh class anchors chronic severity / surgical risk; MELD-Na drives short-term mortality and transplant listing.

Wells DVT (pretest probability)

| Score | Probability | Workup | |---|---|---| | <2 (esp. <=0) | DVT unlikely | D-dimer; if negative, DVT excluded | | >=2 | DVT likely | Proceed to compression ultrasound |

Wells PE (pretest probability)

| Two-tier | Three-tier | Workup | |---|---|---| | PE unlikely (<=4) | low (0–1) / moderate (2–6) | D-dimer; if negative, PE excluded (consider PERC if very low) | | PE likely (>4) | high (>6) | CT pulmonary angiography (D-dimer not sufficient to exclude) |

ASCVD 10-year risk (%)

| Risk % | Category | Statin guidance (with shared decision-making) | |---|---|---| | <5% | Low | Lifestyle | | 5–7.4% | Borderline | Consider if risk-enhancers present | | 7.5–19.9% | Intermediate | Moderate-intensity statin reasonable | | >=20% | High | High-intensity statin |

eGFR CKD-EPI (mL/min/1.73m^2) → CKD stage

| eGFR | Stage | Note | |---|---|---| | >=90 | G1 | Normal (CKD only if other markers of damage) | | 60–89 | G2 | Mildly decreased | | 45–59 | G3a | Mild–moderate | | 30–44 | G3b | Moderate–severe | | 15–29 | G4 | Severe — nephrology referral | | <15 | G5 | Kidney failure | Use eGFR for renal drug dosing and CKD staging; a single value is an estimate — confirm with a repeat/eGFR trend for staging.

Worked example A — Atrial fibrillation, weigh anticoagulation (paired)

76-year-old woman with AF, hypertension, type 2 diabetes; on an NSAID; no prior stroke/bleed, BP controlled, stable INR.

tu run ClinicalCalc_CHA2DS2_VASc '{"age":76,"female":true,"hypertension":true,"diabetes":true}'
# -> score 5: "Elevated risk (5) — oral anticoagulation recommended"
#    components: Age>=75 2, Hypertension 1, Diabetes 1, Female 1

tu run ClinicalCalc_HAS_BLED '{"age":76,"hypertension":true,"drugs":true}'
# -> score 3: "High bleeding risk (3) — caution, review reversible factors"
#    components: Hypertension_uncontrolled 1, Elderly_>65 1, Drugs_antiplatelet_NSAID 1

Interpretation. CHA2DS2-VASc 5 (>=3 for a woman) → anticoagulation recommended. HAS-BLED 3 is high but driven by modifiable factors: stop the NSAID and control BP and 2 of the 3 points disappear, lowering bleeding risk. The high HAS-BLED does not cancel anticoagulation — it directs you to fix reversible risks and monitor more closely.

Worked example B — Cirrhosis severity and transplant priority (paired)

Cirrhotic patient: bilirubin 3.5 mg/dL, albumin 2.5 g/dL, INR 2.4, moderate ascites, grade 1–2 encephalopathy; creatinine 2.0, sodium 128, not on dialysis.

tu run ClinicalCalc_Child_Pugh '{"bilirubin":3.5,"albumin":2.5,"inr":2.4,"ascites":"moderate","encephalopathy":"grade1-2"}'
# -> score 14, child_pugh_class "C": "Class C (score 14): decompensated disease"

tu run ClinicalCalc_MELD_Na '{"creatinine":2.0,"bilirubin":5.0,"inr":2.0,"sodium":128,"dialysis":false}'
# -> score 31: "MELD-Na 31: very high ... 90-day mortality risk"

Interpretation. Child-Pugh class C (14) = decompensated cirrhosis, very high surgical/anesthetic risk — avoid elective surgery. MELD-Na 31 implies roughly a third-or-higher 90-day mortality and a high transplant-allocation priority. Together they justify urgent hepatology / transplant evaluation. (Note MELD uses bilirubin 5.0 and INR 2.0 from this patient's labs; lower bounds of 1.0 are applied internally.)

Completeness checklist

• [ ] Picked the score(s) that match the scenario — ran both members of a pair (CHA2DS2-VASc+HAS-BLED, Child-Pugh+MELD-Na)
• [ ] Confirmed all required inputs; asked for missing ones rather than guessing
• [ ] Stated which optional booleans were assumed false
• [ ] Reported score, interpretation, and the components breakdown
• [ ] Mapped the score to a clinical action using the interpretation table
• [ ] For pairs, explained how to weigh the two scores together
• [ ] Stated the LIMITATIONS caveat (decision-support, validated population, ASCVD age 40–79)

LIMITATIONS

• Decision-support only. These scores inform, but do not replace, clinical judgment and the full clinical picture. Do not present output as a treatment directive.
• Validated populations. Each score was derived/validated in specific cohorts and may not transfer to children, pregnancy, valvular AF (CHA2DS2-VASc is for non-valvular AF), or other excluded groups.
• ASCVD Pooled Cohort Equations are validated only for ages 40–79 and the White / African-American coefficient sets; they can mis-estimate for other ancestries and are for primary prevention (no prior ASCVD event).
• eGFR CKD-EPI assumes stable kidney function (steady-state creatinine); it is unreliable in acute kidney injury, extremes of muscle mass, or amputees, and a single value does not stage CKD on its own.
• qSOFA / CURB-65 / Wells are screening / pretest-probability tools — a reassuring score does not exclude the diagnosis; combine with clinical gestalt and confirmatory testing.
• MELD-Na / Child-Pugh apply to chronic liver disease; they do not capture acute liver failure or hepatocellular-carcinoma exception points.
• Inputs are taken at face value — garbage in, garbage out. Verify lab units (mg/dL vs mmol/L, BUN vs urea) before entry.
• Not a substitute for institutional protocols, guideline updates, or specialist consultation.