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1. ▌
   nhs-genomic-test-finder · dromlakhani bundle

   Look up NHS England genomic tests for rare and inherited diseases. Use this skill whenever a clinician asks what genetic test to order for a condition, which genes are covered for a specific diagnosis, what commissioning category a genomic test falls under (Core, Specialised, or Highly Specialised), or which tests belong to a specialty group (Neurology, Cardiology, Endocrinology, etc.). Also trigger for questions like what panel is used for a condition, whether there is an NHS test for something, what the R number is for a condition, or whether anything has changed in the genomic test directory. Source: NHS England National Genomic Test Directory for Rare and Inherited Disease v9.0 (April 2026).
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2. ▌
   mirago-prescribing-guide · dromlakhani

   Complete bedside prescribing reference for Mirago (mirabegron, beta-3 adrenoceptor agonist) for overactive bladder — covering contraindications, safety screening, drug interactions, dose selection in special populations, titration, and administration. Use when a clinician asks how to start mirabegron, what dose to use in renal or hepatic impairment, is mirabegron safe in this patient, mirabegron drug interactions, or Mirago for OAB.
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3. ▌
   endo-sdm-aed · dromlakhani

   This skill guides clinicians in sharing decision‑making when selecting an antiepileptic drug (AED) by providing quantitative estimates of each drug’s expected weight effect. It is triggered when a clinician asks how to discuss weight‑change risks when choosing an AED or what information to provide on weight effects of specific agents such as valproate versus lamotrigine.
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4. ▌
   esa-pa-test-fhi · dromlakhani

   Determines when to pursue genetic testing for glucocorticoid-remediable aldosteronism (FH-I/GRA) in patients with confirmed primary aldosteronism (PA). Indicated when PA onset is before age 20 or there is a family history of PA or stroke before age 40.
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5. ▌
   ata-di-workup · dromlakhani

   This skill guides the simultaneous measurement of serum and urine osmolarity to evaluate polyuria for central diabetes insipidus. It is triggered when a patient presents with polyuria exceeding 50 mL/kg/24 hours or 3.5 L/day in a 70‑kg individual.
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6. ▌
   nd-t2d-oad-selector · dromlakhani

   Select oral and injectable glucose-lowering agents for a newly diagnosed patient with type 2 diabetes using a compelling-indication hierarchy (heart failure → ASCVD → DKD → obesity) followed by glucose-pattern matching. Incorporates modern GLP-1 receptor agonists — Ozempic (semaglutide SC, T2D), Mounjaro (tirzepatide), and Wegovy/Noveltreat (semaglutide 2.4 mg, obesity). Use when a clinician asks "what drug to start for newly diagnosed T2D", "which OAD to use", "first-line diabetes medication", "SGLT2i vs GLP-1 in new T2D", or presents a newly diagnosed T2D patient needing a personalised medication plan.
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7. ▌
   esa-pa-test-kcnj5 · dromlakhani

   Determines when to test for germline KCNJ5 mutations indicating familial hyperaldosteronism type III in very young patients with primary aldosteronism. Triggered by severe early-onset hypertension with hypokalemia in infants or young children (<20 years) with confirmed PA.
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8. ▌
   endo-doc-offlabel · dromlakhani bundle

   We need to output a SKILL.md file with the specified format.
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9. ▌
   esa-pa-gra-add-mra · dromlakhani

   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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10. ▌
    endo-efficacy-5pct · dromlakhani

    This skill guides clinicians to assess whether a patient has achieved ≥5% weight loss at 3 months while on a weight‑loss medication and to determine continuation versus discontinuation based on efficacy and safety. It is triggered when a clinician asks, 'Has this patient lost enough weight at 3 months to continue lorcaserin?' or 'Should I stop phentermine/topiramate because the patient lost only 3% of body weight?'.
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11. ▌
    ata-gh-titration · dromlakhani

    Titrates GH replacement dose to keep IGF-1 below the upper limit of normal and reduces dose when side effects appear. Use when monitoring GH replacement therapy; triggers include patient on GH replacement needing dose adjustment.
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12. ▌
    ata-preop-ch-lt4 · dromlakhani

    This skill guides perioperative levothyroxine management for adults with preoperative central hypothyroidism undergoing non-emergency surgery. Trigger phrases include "preoperative central hypothyroidism patient requiring non-emergency surgery" and "use when managing preoperative CH patient".
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13. ▌
    ata-gh-bmi-cutoff · dromlakhani

    Uses BMI-specific cutoffs to interpret peak GH values during stimulation testing. Use when interpreting GH stimulation test results; triggers include GH stimulation test requiring BMI-adjusted interpretation.
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14. ▌
    ata-gh-dosing-age · dromlakhani

    Calculates the initial growth hormone (GH) replacement dose based on patient age for adults with proven growth hormone deficiency (GHD). Triggers include initiating GH replacement in patients with proven GHD requiring GH replacement.
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15. ▌
    ata-lt4-dosing-ch · dromlakhani

    Determines levothyroxine dosing for central hypothyroidism to achieve serum free T4 in the mid to upper half of the reference range. Triggers include confirmed central hypothyroidism requiring thyroid hormone replacement when initiating L‑4 therapy.
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16. ▌
    mapi-score-calculator · dromlakhani

    Calculate the Maryland Aggregate Pathology Index (MAPI) on a deceased donor procurement kidney biopsy to predict graft survival and decide single vs dual vs discard allocation. Trigger when a clinician asks "what's the MAPI score", "interpret donor kidney biopsy", "should I use this marginal kidney", "MAPI cutoff for transplant", "procurement biopsy scoring", or has histology results from a deceased donor kidney and needs an objective grading.
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17. ▌
    ata-aed-ai-education · dromlakhani

    Clinicians educate adrenal insufficiency patients taking nondexamethasone glucocorticoids who initiate enzyme-inducing antiepileptic drugs about early signs of adrenal insufficiency. Trigger when an AI patient on nondexamethasone GC starts an enzyme-inducing AED such as phenytoin, carbamazepine, or oxcarbazepine.
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18. ▌
    esa-pa-interpret-avs · dromlakhani

    Determines unilateral vs bilateral aldosterone excess based on cortisol-corrected aldosterone ratios from adrenal venous sampling, with ratio >4:1 indicating unilateral excess, ratio 3:1 suggestive of bilateral hypersecretion, and interpretation dependent on cosyntropin stimulation protocol used during sampling. Use when analyzing AVS results to guide surgical vs medical treatment decisions; triggers include 'AVS lateralization ratio', 'cosyntropin-stimulated AVS', 'aldosterone-to-cortisol ratio >4:1', and 'ratio 3:1 suggestive of bilateral disease'.
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19. ▌
    esa-pa-interpret-cct · dromlakhani

    Evaluates likelihood of primary aldosteronism by measuring plasma aldosterone suppression after oral captopril; normal suppression ≥30% makes PA unlikely, while lack of suppression with persistently suppressed plasma renin activity suggests PA. Use when assessing captopril challenge test (CCT) results for PA diagnosis in patients with positive aldosterone-to-renin ratio.
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20. ▌
    esa-pa-interpret-fst · dromlakhani

    Determines if primary aldosteronism is confirmed based on upright plasma aldosterone ≤6 ng/dL (170 nmol/L) on day 4 at 10 AM of fludrocortisone suppression test, provided plasma renin activity ≥1 ng/mL/h and plasma cortisol concentration lower than the 7 AM value to exclude ACTH confounding. Use when reviewing FST results to diagnose PA; triggers include "FST", "upright aldosterone ≤6 ng/dL", "PRA ≥1 ng/mL/h", and "cortisol drop".
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21. ▌
    esa-pa-interpret-sit · dromlakhani

    Interprets the saline infusion test (SIT) to assess the probability of primary aldosteronism when a patient has a positive aldosterone-to-renin ratio (ARR) and requires confirmatory testing. Triggers include evaluating post‑infusion plasma aldosterone concentration (PAC) after a positive ARR, hypertension work‑up, or when deciding whether to proceed to adrenal venous sampling (AVS).
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22. ▌
    jes-pa-mra-selection · dromlakhani

    Guides choice among spironolactone, eplerenone, and esaxerenone for primary aldosteronism based on comparative efficacy, safety, and patient-specific factors. Triggers include when initiating MRA therapy and asking 'Which MRA should I prescribe?' or considering switching agents due to adverse effects, cost, or need for potassium supplementation.
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23. ▌
    endo-ace-arb-ccb-htn · dromlakhani

    Recommends ACE inhibitors, ARBs, or calcium channel blockers as first-line hypertension therapy rather than β‑adrenergic blockers in obese patients with type 2 diabetes. Triggers include when a clinician asks, 'What antihypertensive should I start for this obese patient with T2DM to avoid weight gain?' or 'Should I avoid β‑blockers in this patient with diabetes and hypertension?'
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24. ▌
    endo-dose-escalation · dromlakhani

    Guides dose escalation for obesity pharmacotherapy based on efficacy and tolerability while staying within approved upper dose limits. Triggers include clinician questions like "How should I titrate naltrexone/bupropion if the starting dose is tolerated?" or "What is the maximum liraglutide dose I can use?"
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25. ▌
    obesity-meal-planner · dromlakhani

    Step-by-step meal planning for a patient with obesity — from diet recall to calorie prescription to macronutrient targets. Use when a clinician asks "how do I plan a diet for my obese patient", "what calorie target for weight loss", "how many calories should I prescribe", "meal plan for obesity", "diet plan for overweight patient", or needs to build an individualised dietary prescription at the clinic.
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26. ▌
    ata-hc-dosing-regimen · dromlakhani

    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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27. ▌
    endo-pa-mra-over-enac · dromlakhani

    Recommends using mineralocorticoid receptor antagonists rather than epithelial sodium-channel inhibitors for medical treatment of primary aldosteronism. Use when a clinician asks whether to use an MRA or ENaC inhibitor for medical treatment of PA.
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28. ▌
    esa-pa-decide-avs-use · dromlakhani

    Determines whether to perform adrenal venous sampling (AVS) to lateralize aldosterone excess in patients with confirmed primary aldosteronism (PA) who are being evaluated for surgical treatment. Indicated when surgery is feasible and desired by the patient, or when subtype workup is planned for a surgical candidate, especially in those younger than 35 years with spontaneous hypokalemia, marked aldosterone excess, and unilateral adrenal lesions on CT.
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29. ▌
    jes-pa-avs-indication · dromlakhani

    Determines when adrenal venous sampling (AVS) is indicated for functional subtyping of primary aldosteronism (PA) when surgical treatment is feasible and desired by the patient. Triggered when a clinician confirms PA diagnosis and asks 'Do I need AVS for subtyping?' or evaluates surgical candidacy.
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30. ▌
    endo-hsd-t-trial · dromlakhani

    Suggests a 3- to 6‑month trial of testosterone dosing to achieve a mid‑normal premenopausal value in a reference assay for postmenopausal women with properly diagnosed HSDD and no contraindications. Triggered when a postmenopausal woman requests therapy for low sexual desire after appropriate HSDD workup and exclusion of contraindications.
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31. ▌
    endo-weightloss-maint · dromlakhani

    This skill suggests using approved weight‑loss medication over no pharmacological therapy to ameliorate comorbidities and improve physical activity in adults with BMI ≥30 kg/m² or BMI ≥27 kg/m² with at least one comorbid condition. It is triggered when a clinician asks, for example, 'Should I add medication to help maintain weight loss in this patient with BMI 31 and diabetes?' or 'Is pharmacotherapy appropriate for long‑term weight control in a patient with BMI 28 and hypertension?'.
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32. ▌
    ata-di-emergency-id · dromlakhani

    Recommends that all diabetes insipidus patients wear an emergency bracelet or necklace to alert clinicians to their condition if incapacitated. Use when establishing care for a diabetes insipidus patient; triggers include diabetes insipidus diagnosis.
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33. ▌
    ata-aed-lt4-monitoring · dromlakhani

    Monitor free T4 and adjust levothyroxine after starting antiepileptic drugs in central hypothyroidism
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34. ▌
    esa-pa-interpret-18ohb · dromlakhani

    Differentiates aldosterone-producing adenoma from idiopathic adrenal hyperplasia based on 18-hydroxycorticosterone levels, with APA patients generally having levels >100 ng/dL at 8:00 a.m. and IAH patients usually having levels <100 ng/dL. Use when reviewing 18-OHB test results to help subtype PA; triggers include 18-OHB >100 ng/dL (suggesting APA) or <100 ng/dL (suggesting IAH).
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35. ▌
    esa-pa-interpret-18oxo · dromlakhani

    Helps distinguish unilateral from bilateral adrenal disease based on 18-oxocortisol levels, which are typically higher in aldosterone-producing adenoma than idiopathic adrenal hyperplasia. Use when evaluating 18-oxocortisol results during PA workup to guide subtype classification after a positive ARR.
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36. ▌
    jes-pa-initial-imaging · dromlakhani

    This skill recommends computed tomography (CT) as the initial imaging modality for primary aldosteronism (PA) evaluation in Japan, citing its accessibility and comparable performance to MRI. It is triggered when a clinician orders imaging for suspected PA and asks 'What imaging should I start with?' or seeks a cost-effective initial evaluation.
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37. ▌
    icsm-avoid-tt-bcr · dromlakhani

    Advises against testosterone therapy in men with biochemical recurrence after prostate cancer treatment due to very limited data and potential risk of progression. Consider when a patient has a rising PSA after definitive therapy and the clinician evaluates testosterone for hypogonadism, questioning whether TTh is safe in BCR.
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38. ▌
    endo-sdm-antipsychotic · dromlakhani

    Recommends using weight‑neutral antipsychotic alternatives when possible and employing shared decision‑making that provides quantitative estimates of expected weight effect to guide drug choice. Triggered when a clinician asks, “How do I involve this patient in choosing an antipsychotic with minimal weight gain?” or “What resources show weight‑change projections for risperidone vs aripiprazole?”.
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39. ▌
    ata-gh-ch-monitoring · dromlakhani

    Monitors euthyroid adults with growth hormone deficiency (GHD) who are initiating GH replacement therapy for the development of central hypothyroidism (CH). Initiates levothyroxine (L-T4) if free thyroxine (fT4) falls below the laboratory reference range; triggers include GHD patient starting GH replacement.
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40. ▌
    ata-lowest-tolerable-hc · dromlakhani

    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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41. ▌
    ata-preop-stress-dosing · dromlakhani

    Recommends administering stress-dose glucocorticoids before surgery and tapering after surgery in patients with adrenal insufficiency before repeat testing. Triggers include preoperative planning for surgery in a patient with known or suspected adrenal insufficiency.
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42. ▌
    esa-pa-gra-gluco-dosing · dromlakhani

    Calculates the lowest effective glucocorticoid dose (dexamethasone or prednisone) to normalize blood pressure and serum potassium in glucocorticoid-remediable aldosteronism (GRA/FH-I) by titrating to biochemical and clinical targets. Indicated when initiating medical treatment for confirmed GRA, triggered by findings such as early-onset hypertension, family history of stroke before age 40, spontaneous hypokalemia, or suppressed plasma renin activity with elevated aldosterone.
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43. ▌
    jes-pa-mra-normotensive · dromlakhani

    Recommends mineralocorticoid receptor antagonists for all primary aldosteronism patients to prevent target organ damage, irrespective of blood pressure control or serum potassium levels. Triggered when a clinician encounters a PA patient with well‑controlled BP and normal K and wonders, 'Do I still need to treat with MRA?' or considers stopping therapy.
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44. ▌
    icsm-dre-before-tt · dromlakhani

    Perform digital rectal examination (DRE) in all men before initiating testosterone therapy to exclude prostate abnormalities or support suspicion of hypogonadism when prostate volume is reduced. Triggered when a clinician considers starting testosterone and questions whether a prostate exam is needed first or whether to check the prostate before prescribing TTh.
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45. ▌
    endo-prefer-nsaid-dmard · dromlakhani

    Recommends using NSAIDs or DMARDs instead of glucocorticoids for chronic inflammatory disease (e.g., rheumatoid arthritis) to limit weight gain. Triggered when clinicians ask, “What anti‑inflammatory should I choose for this RA patient to avoid weight gain?” or “Should I avoid steroids in this obese patient with RA?”
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46. ▌
    endo-sdm-antidepressant · dromlakhani

    Recommends a shared decision‑making process that provides patients with quantitative estimates of the expected weight effect of antidepressants to inform drug choice, also considering expected treatment length. Triggers include clinician questions such as ‘How should I discuss weight‑change risks with this patient starting an antidepressant?’ or ‘What tool can I use to show expected weight impact of sertraline vs bupropion?’.
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47. ▌
    endo-weightneutral-t2dm · dromlakhani

    Recommends weight‑losing and weight‑neutral medications as first‑ and second‑line agents for managing overweight/obese patients with type 2 diabetes. Triggers include when a clinician asks, 'Which diabetes medications will not worsen weight in this obese patient?' or 'Should I avoid sulfonylureas in this patient with T2DM and obesity due to weight gain risk?'
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48. ▌
    ata-ch-before-gh-stim · dromlakhani

    Recommends treating central hypothyroidism before performing GH stimulation testing because CH may impair accurate diagnosis of GHD. Use when preparing for GH stimulation testing; triggers include patient requiring GH stimulation test with possible CH.
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49. ▌
    endo-postdiag-imaging · dromlakhani

    This skill recommends performing an imaging study to assess tumor size, appearance, and parasellar extent once biochemical diagnosis of acromegaly is confirmed. Trigger when IGF-1 is elevated and GH fails to suppress to <0.4 µg/L during an oral glucose tolerance test.
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50. ▌
    ata-rai-decision · dromlakhani

    ATA RAI Remnant Ablation / Adjuvant Therapy Decision Tool
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51. ▌
    glp1-endoscopy-pre-procedure · dromlakhani bundle

    Guide pre-endoscopy management decisions for patients on GLP-1 receptor agonists (semaglutide, tirzepatide, liraglutide etc.), deciding whether to proceed, delay, or modify the approach based on GI symptoms, fasting status, and indication. Trigger when a clinician asks about GLP-1 RA and endoscopy, semaglutide before colonoscopy, Ozempic before procedure, or whether to hold a GLP-1 agonist before endoscopy.
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52. ▌
    bemdec-prescribing-guide · dromlakhani

    Bedside prescribing reference for Bemdec (bempedoic acid / NEXLETOL) — indication check, dose, statin co-prescribing safety caps, monitoring plan, warnings for hyperuricemia and tendon rupture, and special population guidance. Use when a clinician asks "can I start bempedoic acid", "Bemdec indication", "is bempedoic acid safe with my statin", "patient on Nexletol has joint pain or high uric acid", "bempedoic acid in CKD or liver disease or pregnancy", or any prescribing or monitoring question about bempedoic acid.
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53. ▌
    esa-pa-avs-skip-criteria · dromlakhani

    Determines when adrenal venous sampling may be skipped in primary aldosteronism. Applies to patients <35 years with spontaneous hypokalemia, marked aldosterone excess, and unilateral adrenal lesions suggestive of cortical adenoma on CT.
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54. ▌
    jes-pa-screening-arr-arc · dromlakhani

    Interprets the aldosterone-to-renin ratio using active renin concentration (ARC) to screen for primary aldosteronism. Triggered when a clinician has PAC and ARC results and asks 'How do I interpret this ARR using active renin concentration?'
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55. ▌
    jes-pa-screening-arr-pra · dromlakhani

    Determines if PAC/PRA ratio and PAC levels indicate positive or provisionally positive screening for primary aldosteronism. Triggered when a clinician has PAC and PRA results and asks “Is this screening test positive for PA?” or needs to interpret borderline results.
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56. ▌
    endo-followup-assessment · dromlakhani

    Advises assessing efficacy and safety at least monthly for the first 3 months, then at least every 3 months for all patients prescribed weight‑loss medications. Triggers include clinician questions such as “How often should I check progress after starting orlistat?” or “What is the follow‑up schedule for a patient on liraglutide?”.
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57. ▌
    endo-lifestyle-mod-bmi25 · dromlakhani

    Recommends that diet, exercise, and behavioral modification be included in all obesity management approaches for patients with a BMI of 25 kg/m2 or higher. Triggered when clinicians ask, 'What foundational non-pharmacologic therapy should I start for this overweight patient?' or 'Should I initiate lifestyle changes for a patient with BMI 26?'.
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58. ▌
    ata-acromegaly-gh-dose · dromlakhani

    Recommends low-dose GH replacement in patients with cured acromegaly and documented GHD in the absence of known contraindications. Triggers include managing a cured acromegaly patient with documented growth hormone deficiency.
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59. ▌
    ata-mild-ch-management · dromlakhani

    Manages suspected mild central hypothyroidism in patients with pituitary disease and low-normal free thyroxine (fT4). Initiates levothyroxine (L-T4) when suggestive symptoms are present or when serial fT4 shows a decrease of 20% or more.
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60. ▌
    ata-post-acth-tumor-gc · dromlakhani

    Recommend continuing glucocorticoid replacement until hypothalamic-pituitary-adrenal (HPA) axis recovery after surgical resection of ACTH-secreting pituitary tumors. Use when managing postoperative patients following ACTH-secreting tumor surgery to prevent adrenal insufficiency during HPA axis recovery.
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61. ▌
    es-ghd-igfi-limitation · dromlakhani

    This skill determines whether serum insulin-like growth factor-1 (IGF-I) levels alone can be used to diagnose growth hormone deficiency (GHD) in childhood cancer survivors exposed to hypothalamic-pituitary axis radiotherapy. Triggers include questions such as “Can I rely on IGF-I alone to diagnose GHD after cranial radiation?” or “Is IGF-I sufficient for GHD assessment post-HP RT?”
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62. ▌
    mm-mrd-assessment · dromlakhani

    Decide when and how to assess minimal residual disease (MRD) in multiple myeloma — bone marrow MRD by next-generation flow (NGF) or sequencing (NGS), plus imaging MRD by PET-CT — and how to act on the result. Trigger when a clinician asks "how to assess MRD in myeloma", "MRD-negative complete response", "PET-CT for MRD", "is bone marrow MRD enough", "when to test for MRD", "next-generation flow for myeloma", or "myeloma sustained MRD negativity". Based on EHA-ESMO 2021.
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63. ▌
    dizziness-type-classifier · dromlakhani

    Classifies a patient's dizziness into one of four categories — vestibular/vertigo, presyncope, disequilibrium, or nonspecific — using history, timing, triggers, and associated symptoms. Use when a patient presents with dizziness, giddiness, lightheadedness, feeling off-balance, spinning, or nearly blacking out and you need to determine the type before further workup.
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64. ▌
    monogenic-obesity-diagnosis · dromlakhani

    Diagnose monogenic and syndromic obesity in children and adolescents using a structured step-by-step algorithm. Use this skill whenever a clinician suspects a genetic cause of obesity, asks about leptin deficiency, MC4R mutation, POMC deficiency, PCSK1 deficiency, leptin receptor deficiency, Bardet-Biedl syndrome, Prader-Willi syndrome, Alström syndrome, or any case of early-onset severe obesity with hyperphagia. Also trigger for questions about targeted pharmacotherapy including setmelanotide or metreleptin, or when to order a genomic obesity panel. Cross-references the NHS Genomic Test Finder skill to surface the relevant R-code once a diagnosis is reached.
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65. ▌
    ata-stress-dose-education · dromlakhani

    Teaches AI patients about stress-dosing and emergency glucocorticoid administration; instructs to obtain emergency card/bracelet/necklace and kit with injectable high-dose GC. Triggers when counseling any patient with adrenal insufficiency (e.g., "Use when counseling patient with adrenal insufficiency...").
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66. ▌
    enda-acth-measurement-pai · dromlakhani

    Recommends measurement of plasma ACTH to establish primary adrenal insufficiency (PAI) diagnosis in patients with confirmed cortisol deficiency; a plasma ACTH concentration ≥2-fold the upper limit of the reference range supports PAI. Use when evaluating plasma ACTH in a patient with low morning cortisol or abnormal corticotropin stimulation test.
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67. ▌
    enda-dhea-six-month-trial · dromlakhani

    Initiates a 6‑month trial of DHEA replacement in women with primary adrenal insufficiency (PAI) who have persistent low libido, depressive symptoms, or low energy despite otherwise optimized glucocorticoid and mineralocorticoid therapy. If the patient does not report a sustained beneficial effect after 6 months, discontinue DHEA.
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68. ▌
    enda-stress-dose-hc-labor · dromlakhani

    Administer Hydrocortisone Stress Dosing During Active Phase of Labor
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69. ▌
    endo-pa-mra-titrate-renin · dromlakhani

    In patients with primary aldosteronism receiving mineralocorticoid receptor antagonist therapy, the guideline recommends titrating the MRA dose upward to raise renin when blood pressure remains uncontrolled and renin is suppressed. Consider this step when hypertension is not at goal despite MRA therapy and plasma renin activity (or direct renin concentration) is low.
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70. ▌
    jes-pa-dexamethasone-test · dromlakhani

    Identifies patients with adrenal tumors on CT who should undergo dexamethasone suppression test to evaluate for autonomous cortisol co-secretion. Triggers include when a clinician finds an adrenal tumor on CT and asks 'Should I test for cortisol co-secretion?' or is planning AVS for a tumor >3.0 cm.
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71. ▌
    jes-pa-screening-sampling · dromlakhani

    Provides guidance on acceptable blood sampling conditions for primary aldosteronism screening when ideal early‑morning supine fasting conditions cannot be met. Triggers include when a clinician says “The patient wasn’t fasting/supine” or questions whether non‑ideal sampling affects screening validity.
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72. ▌
    endo-pharmaco-eligibility · dromlakhani

    Assess pharmacotherapy eligibility based on BMI/comorbidity
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73. ▌
    ata-ch-ai-screening-lt4 · dromlakhani

    Evaluates central hypothyroidism (CH) patients for adrenal insufficiency (AI) prior to initiating levothyroxine (L‑T4) replacement. Triggers include consideration of L‑T4 start in central hypothyroidism needing thyroid replacement.
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74. ▌
    ata-ddavp-di-management · dromlakhani

    Manage diabetes insipidus with desmopressin
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75. ▌
    ata-lt4-target-range-ch · dromlakhani

    We need to output a SKILL.md file with the specified format.
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76. ▌
    es-ghd-provocative-test · dromlakhani

    This skill guides selection of an appropriate provocative test for growth hormone deficiency (GHD) diagnosis in childhood cancer survivors when clinicians ask, "What test should I use to diagnose GHD in this survivor?" or "Which provocative test is appropriate for GHD evaluation?" It recommends using the same testing modalities as in the noncancer population, tailored to patient-specific contraindications.
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77. ▌
    ata-hpa-axis-gh-monitoring · dromlakhani

    Suggests testing HPA axis functionality before and after starting GH replacement in patients not receiving glucocorticoid replacement with apparently normal pituitary-adrenal function. Triggers include initiating GH replacement in a GHD patient who is not on glucocorticoids and has normal adrenal function.
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78. ▌
    enda-confirm-pai-stim-test · dromlakhani

    Recommends confirmatory testing with corticotropin stimulation test in patients presenting with clinical symptoms or signs suggesting PAI (e.g., fatigue, hypotension, hyponatremia, hyperpigmentation) when the patient's condition permits safe testing. Use when a clinician identifies suggestive features and circumstances allow outpatient stimulation testing without imminent need for emergency glucocorticoids.
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79. ▌
    esa-pa-med-agent-bilateral · dromlakhani

    Selects spironolactone as first-line mineralocorticoid receptor antagonist for bilateral primary aldosteronism, with eplerenone as an alternative when spironolactone–related adverse effects are problematic. Trigger phrases include 'confirmed bilateral PA on AVS', 'idiopathic adrenal hyperplasia', 'bilateral adrenal hyperplasia', 'glucocorticoid-remediable aldosteronism', and 'initiating medical therapy for bilateral adrenal disease'.
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80. ▌
    esa-pa-pediatric-bp-target · dromlakhani

    Establishes age- and gender-specific blood pressure goals for pediatric patients with primary aldosteronism (PA) using published normative data to assess treatment adequacy and avoid over-treatment. Use when managing hypertension in children with PA to evaluate if BP is adequately controlled; triggers include pediatric PA hypertension, BP not normalized with glucocorticoid therapy, and need for age‑specific BP targets.
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81. ▌
    jes-pa-bypass-confirmatory · dromlakhani

    ---
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82. ▌
    jes-pa-treatment-selection · dromlakhani

    Determines whether to recommend adrenalectomy or mineralocorticoid receptor antagonists for primary aldosteronism based on PA subtype and patient/surgical factors. Triggered after subtype confirmation when clinicians ask “Should this patient have surgery or medical treatment?” or discuss treatment options with the patient.
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83. ▌
    endo-fha-bmd-pcos-fha · dromlakhani

    This skill recommends obtaining a baseline BMD measurement by DXA in adolescents or women with functional hypothalamic amenorrhea (FHA) and concurrent polycystic ovary syndrome (PCOS) who have six or more months of amenorrhea, and earlier if there is history or suspicion of severe nutritional deficiency, other energy deficit states, or skeletal fragility. Use when a clinician states, “She has PCOS and no periods for seven months—let’s get a DXA,” or similar triggers such as “Check BMD in PCOS+FHA after six months amenorrhea” or “Order DXA sooner due to low weight.”
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84. ▌
    endo-oc-vs-injectable · dromlakhani

    Suggests oral contraceptives over injectable contraceptives for women with BMI ≥27 kg/m2 with comorbidities or BMI ≥30 kg/m2 seeking contraception, provided they are well‑informed and oral contraceptives are not contraindicated. Triggers include clinician questions such as “Which contraceptive method is less likely to cause weight gain in this obese patient?” or “Should I recommend oral pills instead of depot injection for this patient with BMI 29 and hypertension?”.
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85. ▌
    endo-bariatric-eligibility · dromlakhani

    Assess bariatric surgery eligibility based on BMI/comorbidity
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86. ▌
    ata-adipsic-di-titration · dromlakhani

    Recommends careful DDAVP and fluid intake titration including frequent weighing and serum sodium level monitoring for adipsic diabetes insipidus. Use when managing adipsic DI requiring fluid balance management.
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87. ▌
    ata-aed-ddavp-monitoring · dromlakhani

    This skill recommends monitoring desmopressin (DDAVP) doses and adjusting them as needed in patients who have recently started antiepileptic drugs (AEDs). It is triggered when a patient initiates AED therapy and requires DDAVP management for diabetes insipidus.
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88. ▌
    ata-gnrh-testing-against · dromlakhani

    Recommends against performing dynamic GnRH stimulation testing in the evaluation of hypogonadism, as it provides no additional diagnostic information beyond baseline gonadotropins and sex steroids. Consider this recommendation when evaluating hypogonadism and contemplating GnRH testing.
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89. ▌
    es-ghd-retest-indication · dromlakhani

    This skill identifies adult childhood cancer survivors with isolated growth hormone deficiency and prior hypothalamic‑pituitary axis radiation exposure who require retesting to confirm persistence of GHD. Triggers include clinician questions such as “Should I retest for GHD in this adult survivor with childhood GHD and radiation history?” or “Is repeat GHD evaluation indicated in this patient?”
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90. ▌
    es-tshd-diagnostic-avoid · dromlakhani

    Avoid specific tests for TSHD diagnosis
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91. ▌
    t2dm-comorbidity-medicine-selector · dromlakhani bundle

    Guides comorbidity-stratified selection of initial and further glucose-lowering medicines for adults with type 2 diabetes using the NICE NG28 (2026) framework, covering six clinical profiles: no relevant comorbidity, heart failure, atherosclerotic cardiovascular disease, early onset, obesity, chronic kidney disease, and frailty.
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92. ▌
    mm-asct-eligibility · dromlakhani

    Decide whether a newly-diagnosed multiple myeloma (NDMM) patient is eligible for high-dose melphalan + autologous stem cell transplantation (ASCT) as part of front-line therapy, using the EHA-ESMO 2021 criteria. Trigger when a clinician asks "is this myeloma patient fit for transplant", "ASCT eligibility for myeloma", "transplant-eligible NDMM", "should I refer for stem cell transplant", "high-dose melphalan candidate", or any decision about whether a newly-diagnosed myeloma patient should go to upfront ASCT.
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93. ▌
    bppv-differential-diagnosis · dromlakhani

    BPPV Differential Diagnosis Checker
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94. ▌
    dizziness-red-flag-screener · dromlakhani

    Dizziness Red Flag Screener
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95. ▌
    ata-major-stress-hc-regimen · dromlakhani

    Administers 100-mg hydrocortisone IV bolus followed by continuous IV infusion of 200 mg HC per 24 hours (alternatively 50 mg IV every 6 hours) for patients undergoing major surgical stress. Use when managing patient with major surgical stress; triggers include patient undergoing major surgery.
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96. ▌
    endo-pa-screen-hypertension · dromlakhani

    Determines whether to screen a patient with hypertension for primary aldosteronism based solely on the presence of hypertension. Use when a clinician asks whether to screen a hypertensive patient for PA, triggered by phrases such as "should we screen for aldosteronism" or "evaluate for secondary hypertension".
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97. ▌
    esa-pa-pediatric-gluco-dose · dromlakhani

    Determines age- and body weight-appropriate glucocorticoid dosage for pediatric patients with primary aldosteronism, particularly glucocorticoid-remediable aldosteronism (GRA), to avoid over-treatment. Use when prescribing glucocorticoids to children with confirmed or suspected PA; triggers include pediatric PA, GRA, or need to dose glucocorticoid based on age and weight.
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98. ▌
    esa-pa-treatment-unilateral · dromlakhani

    Determines whether to recommend unilateral laparoscopic adrenalectomy or medical therapy with a mineralocorticoid receptor antagonist for patients with confirmed unilateral PA (aldosterone-producing adenoma or unilateral adrenal hyperplasia). Triggered when discussing treatment options after confirming unilateral PA in a hypertensive patient with hypokalemia or resistant hypertension.
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99. ▌
    jes-pa-avs-acth-stimulation · dromlakhani

    Recommends ACTH stimulation during AVS to improve success rate of bilateral selective catheterization, acknowledging unclear impact on diagnostic accuracy for laterality. Triggers include when setting up AVS and asking 'Should I administer ACTH?' or considering procedural optimization.
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100. ▌
     jes-pa-avs-bypass-bilateral · dromlakhani

     Identifies patients with normokalemia and no adrenal tumors on CT who likely have bilateral PA and may proceed directly to medical therapy without AVS. Triggers include when a clinician notes normokalemia and clean adrenal CT and asks 'Is AVS necessary if I suspect bilateral disease?'
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