Emergency Department presentation
Age: 45 years old
Chief Complaint: Chest pain, shortness of breath
History: Panic disorder (diagnosed 2 years ago)
Clinician: Dr. Chen (Emergency Medicine)
Dr. Chen seeks clinical decision support
Patient has chest pain radiating to left arm, diaphoresis, but normal ECG. History of panic disorder. How should I approach the differential diagnosis? I'm concerned about missing a cardiac event but also don't want to over-investigate if this is anxiety.
Dr Bot selects SAGE for complex differential diagnosis
Deep reasoning for complex cases
Rapid triage decisions
Ethical review & oversight
Exploring 27 diagnostic pathways (3³ = 27)
Ahimsa (non-harm) prevents premature diagnostic closure
Cannot rule out cardiac cause with normal ECG alone. Normal ECG does not exclude NSTEMI or unstable angina in first 6-12 hours.
SAGE's evidence-based recommendations
Recommended Approach:
Do not diagnose panic attack until cardiac causes are definitively ruled out. The patient's history of panic disorder increases cognitive bias risk toward premature psychiatric diagnosis.
Dr Bot's constitutional safety check saved a life
Dr. Chen follows recommendation:
Final Diagnosis: Non-ST elevation myocardial infarction (NSTEMI)
Action Taken: Patient transferred to cardiology, started on dual antiplatelet therapy, scheduled for cardiac catheterization
Outcome: 95% LAD stenosis identified and stented. Full recovery.
Popper-Feynman: Generate hypotheses, then try to kill them
Acute Coronary Syndrome (NSTEMI)
Left arm radiation + diaphoresis consistent with cardiac ischemia. Normal ECG does NOT exclude — 30% of NSTEMIs present with normal ECG in first 6 hours.
Falsification test: Serial troponins at 0, 3, 6 hours. If all negative → hypothesis weakened.
Panic Attack with Somatic Features
Known panic disorder history. Chest pain + dyspnea common in panic. BUT: Cannot diagnose panic until cardiac causes EXCLUDED.
Falsification test: Negative serial troponins + low HEART score → hypothesis strengthened.
Pulmonary Embolism
Chest pain + dyspnea atypical presentation. Wells score needed.
Falsification test: D-dimer + CT angiogram if Wells score elevated.
Constitutional requirement: Every recommendation must cite evidence
Every decision cryptographically signed and auditable
Powerful compute. No governance layer. No audit trail. No constitutional constraints. The AI gives advice — but who checks the advice?
Same compute + governance provenance. Every decision scored, every recommendation cited, every session auditable. The AI gives advice AND proves why it's safe.
Anthropic = Compute. Axiom = Trust.
Dr Bot's constitutional safety check (Ahimsa) prevented a potentially fatal diagnostic error. Every decision is hypothesis-framed, evidence-cited, and cryptographically auditable — governance that raw AI cannot provide.
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