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This skill outlines monitoring glucocorticoid replacement in children with primary adrenal insufficiency (PAI) using clinical assessment of growth velocity, weight, blood pressure, and energy levels. Trigger when evaluating a child with PAI for adequacy of glucocorticoid therapy during routine follow-up.

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Recommends equipping every patient with primary adrenal insufficiency (PAI) with a glucocorticoid injection kit for emergency self‑administration and providing training on its use. Trigger when preparing a PAI patient for stress dosing, adrenal crisis prevention, or when prescribing glucocorticoid replacement and needing to ensure emergency preparedness.

日本語の概要は準備中です。原文の説明を表示しています。

Determines whether to add a mineralocorticoid receptor antagonist (e.g., spironolactone or eplerenone) to glucocorticoid therapy in glucocorticoid-remediable aldosteronism when blood pressure fails to normalize with glucocorticoid alone. Triggered by persistent hypertension or inadequate BP control despite optimized glucocorticoid dosing in GRA patients.

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This skill outlines monitoring of mineralocorticoid replacement in primary adrenal insufficiency, focusing on clinical assessment of salt craving, postural hypotension, or edema alongside serum electrolyte measurements. It is initiated when evaluating patients on fludrocortisone therapy to ensure adequate dosing and avoid over- or under-replacement.

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Recommends hydrocortisone replacement dosing of 15–20 mg total daily, administered as a single dose or divided doses with the highest dose given in the morning upon awakening and the second dose in the afternoon (two-dose regimen) or second and third doses at lunch and late afternoon (three-dose regimen). Use when initiating glucocorticoid replacement for adrenal insufficiency; triggers include diagnosing adrenal insufficiency requiring glucocorticoid replacement.

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Decide when to order coronary artery calcium (CAC) scoring in a primary-prevention patient and interpret the result per the 2026 ACC/AHA multisociety dyslipidaemia guideline. Covers the Class 1 indication (men ≥40 / women ≥45, borderline / intermediate PREVENT-ASCVD risk, uncertainty about LLT), CAC score interpretation (0, 1–99, 100–299, ≥300, ≥1000), how CAC modifies LDL and non-HDL goals, when to repeat CAC, and pitfalls (incidental CAC on non-cardiac CT, radiation, cost). Use when a clinician asks should I order a CAC score, CAC indications, what does CAC 150 mean, treatment goals with CAC score, repeat CAC frequency, CAC in a smoker, CAC vs CCTA, is CAC useful in intermediate risk. Grounded in the 2026 ACC/AHA multisociety dyslipidaemia guideline.

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Suggests using hydrocortisone 15–25 mg or cortisone acetate 20–35 mg daily in two or three divided oral doses for adult primary adrenal insufficiency (PAI) patients initiating glucocorticoid replacement. The highest dose is given upon awakening, with the second dose either early afternoon (≈2 h after lunch) or split into lunch and afternoon doses; consider total daily dose calculation based on chosen formulation and frequency.

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Recommends using the lowest tolerable hydrocortisone dose to potentially decrease risks of metabolic and cardiovascular disease in central adrenal insufficiency. Triggers include managing a patient with central adrenal insufficiency requiring glucocorticoid replacement.

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The Endocrine Society guideline recommends against routine hormonal monitoring of glucocorticoid replacement in primary adrenal insufficiency and advises adjusting therapy solely based on clinical response. Use when evaluating glucocorticoid dose adequacy, such as when patients report fatigue, weight loss, hypotension, or signs of Cushingoid over-replacement.

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Recommends measuring serum cortisol levels at 8–9 AM as the first-line test for diagnosing central adrenal insufficiency. Use when starting diagnostic workup for suspected adrenal insufficiency; triggers include suspected adrenal insufficiency requiring initial cortisol testing.

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Guides individualised HbA1c target-setting and identifies the correct intensification trigger for adults with type 2 diabetes using the NICE NG28 (2026) framework, covering standard targets, hypoglycaemia-risk adjustment, indications for target relaxation, and appropriate monitoring frequency.

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Performs corticotropin stimulation test to diagnose adrenal insufficiency when morning cortisol is indeterminate (3-15 µg/dL). Triggers include morning cortisol 3-15 µg/dL requiring further AI testing.

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In patients with adrenal insufficiency receiving dexamethasone replacement, the guideline suggests increasing the dexamethasone dose when enzyme-inducing antiepileptic drugs are co-administered. Trigger phrases include "AI patient on dexamethasone starts enzyme-inducing antiepileptic drug" or "AI patient on dexamethasone requiring enzyme-inducing AED".

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Recommends adjusting glucocorticoid doses on the day of surgery based on illness severity and magnitude of surgical stress. Triggers when managing a patient requiring surgery needing perioperative glucocorticoid management, such as "patient on HC for central AI undergoing major abdominal surgery" or "patient with hypopituitarism scheduled for minor procedure".

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Suggests periodic screening for autoimmune diseases known to be more prevalent in PAI patients in whom autoimmune origin of PAI has not been excluded; optimal frequency unknown but can be done annually. Use when determining screening schedule for PAI patient with uncertain autoimmune origin.

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Triage an incoming request — pick the workflow entry phase (intake / spec / tdd / chore) and record the workflow statefile that the Track Guard reads.

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Report the health of the central system spec at `docs/system/` across seven checks — coverage gaps, stale elements, dangling anchors, duplicate anchors, orphan shards, unillustrated elements, and shards missing their kind annotation. Report-first and read-only: it repairs nothing until a human confirms a specific item. Use when the corpus has drifted, after a merge that touched `docs/system/`, or from `/archive` Step 5.5 in report-only mode. Requires `memory.architecture_map.enabled`.

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Propose the next dependency-ready sprint from the ALREADY-DECOMPOSED roadmap — standup's active sibling. Reads docs/roadmap-execution-plan.md + the memory backlog, computes per-task readiness from the roadmap's machine-readable status, orders with roadmap-planner's graph engine, and emits a proposed task-set (sprint-plan manifest shape) with per-feature done-criteria, excluding unready tasks and naming their unmet prerequisite. PROPOSES ONLY — the human confirms/edits before /triage routes it (typically to the `power` track). Distinct from `sprint-plan`, which decomposes a fresh vision.

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Cross-consistency review of a drafted spec's diagrams. Verifies that C4 components appear in the dependency graph, class-diagram changes have matching DDL, every AC resolves to a concrete sequence, and the dependency graph is acyclic. Read-only. Run after `/spec-lint` passes and before implementation.

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Draft a Workflow Phase 1 intake document capturing a new request — the problem, the desired outcome, constraints, and testable acceptance criteria. Use when a user brings a new feature, change, or investigation that doesn't yet have a spec. The output lives at `docs/intake/<slug>.md` and feeds `/scout`, `/research`, and `/spec` downstream.

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Cycle-end retrospective converting recurring judgment failures into durable enforcement. Reviews the cycle's friction — repeated user corrections, guard trips, RCA themes, integrate failures — and turns each recurring one into a landmines.md entry, then proposes graduation candidates up the enforcement funnel (landmine → advisory hook → hard gate). Pairs with standup: standup says what shipped and what's next; retrospective says what kept going wrong and how to stop it structurally. Writes only memory entries and a report — graduation proposals are advisory and require the normal seed.md amendment path to become enforcement. Invoke at the end of a release cycle, an epic, or any stretch of work with repeated friction.

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Workflow track for tasks that need no TDD — documentation edits, governance count bumps, vendored-skill content updates, configuration tweaks, formatting, typo fixes, dependency bumps where no project code changes. Skips `/scenario` and `/implement` (no failing test to drive) and runs the work directly. `archive`, `memory-sync`, `/grant-commit`, and `/commit` remain mandatory. `verify`, `simplify`, `integrate`, and `document` are conditional — required when the diff hits one of the listed triggers, optional otherwise. `verify` is skipped only when the diff is pure-docs/prose AND `project.json → test.kind` is `behavior` (absent/invalid `test.kind` → `structural` → verify runs). Chore is a stripped-down pipeline, not a bypass; never silently skip a conditional phase whose triggers apply.

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Capture what someone actually said without contaminating it with your own inference. Invoke when eliciting intent in conversation (design discussion, requirement interview, decision surfacing) and when turning a conversation into a durable record (ADR, decision node, memory entry, spec `## Decisions` row). Enforces quote-before-critique, keeps illustration separate from commitment, and holds interpretation subordinate to verbatim. Prevents the failure where unspecified space is filled by the recorder and then evaluated as if the speaker had specified it.

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Workflow Phase 11 — Commit Preparation and Execution. Stages and commits the work. Requires `/grant-commit` first (Git Commit Guard enforces a 15-min ad-hoc consent window; inside a workflow the grant is slug-scoped and one grant covers the whole landing).

日本語の概要は準備中です。原文の説明を表示しています。