Follow the clues to test your diagnostic sleuthing skills. (And if you want some clues, and more information about all symptoms you encounter in general practice, try our new site Pulse Reference)

The Case

Mrs C, aged 83.

Past history: hypertension, ischaemic heart disease, diabetes, osteoarthritis of knees, hips, hands and neck.

Medication: amlodipine 5mg/day, aspirin 75mg/day, lansoprazole 15mg/day, bisoprolol 2.5mg/day, atorvastatin 20mg/day, metformin 500mg bd, co-codamol 8/500mg 2 qds PRN.

First clue

‘…and I’m feeling tired all the time, and another thing doctor. My rheumatism is playing up terribly. I know I’m riddled with arthritis but this seems worse. I’ve been reading the leaflets that come with my pills and I’m wondering if it might be them? If not, can I have some stronger painkillers?’

Can you have a snap guess at the diagnosis?

Bad luck! Keep trying. Have another clue.

You decide to check a full blood count, LFT, U&E and creatine kinase and advise her to try without her statin to see if that makes any difference. The bloods show Hb 10.4 (one year ago 12.8) with normal MCV and MCH. The CK is normal. Via a subsequent brief telephone consultation, she tells you that stopping the statin did not help at all and the pain is worse. ‘I’m sure it’s the old wear and tear in my neck, doctor, but it seems to be spreading – can I have a stronger painkiller?’ You prescribe some co-codamol and arrange further bloods.

What is your best diagnostic guess now?

Bad luck! Keep trying. Have another clue.

Her CRP is markedly elevated at 86. You give her an urgent call for review. ‘It’s worse if anything, doctor. The painkillers aren’t helping. I’m going to need some help at home at this rate. I can barely brush my hair or get dressed in the morning’. You arrange urgent review with rheumatology.

What would be your diagnosis at this point?

Bad luck! Keep trying. This is your last clue.

Before she is seen by the rheumatologist, she phones again on the day you are duty doctor. ‘I’ve got something else now,’ she says. I’ve developed terrible headaches at the side of my head. And I called now because this morning my vision went all funny.’

This is your last diagnostic chance: what do you make of it now?

It looks like you are a diagnostic genius

It looks like you are a diagnostic genius!

Diagnosis: Polymyalgia (Leading to temporal Arteritis)

Clinical moral:

Polymyalgia can be a tricky diagnosis to make. It occurs in the elderly and can produce a variety of vague aches and pains easily attributed by the patient – and doctor – to pre-existing osteoarthritis. These patients often suffer multimorbidity and polypharmacy, so it is easy for polymyalgia to be overlooked among all the other issues and symptoms raised. Clues are a significant change, and symptoms focused around the neck and shoulders, markedly worse first thing in the morning. Inflammatory markers are usually elevated and there may be a mild normochromic, normocytic anaemia. Treatment with steroids give a characteristically rapid and dramatic response – and, of course, protects against the associated temporal arteritis.

It looks like you are a diagnostic wizard

It looks like you are a diagnostic wizard!

Diagnosis: Polymyalgia (Leading to temporal arteritis)

Clinical moral:

You are diagnostically spot on

Diagnosis: Polymyalgia (Leading to temporal arteritis)

Clinical moral:

You are diagnostically dogged

You are diagnostically dogged – you got there in the end!

Diagnosis: Polymyalgia (Leading to temporal arteritis)

Clinical moral:

Sorry, it looks like you are a diagnostic dunderhead!

Diagnosis: Polymyalgia (Leading to temporal arteritis)

Clinical moral:

Stuck on how to proceed with a patient’s presenting symptoms? Help is at hand with Pulse’s fantastic and GP-written new resource: Pulse Reference. It covers all the symptoms which GPs commonly see, giving information on likely diagnoses, pointers to relevant investigations, plus handy tips and red flag warnings. There’s something for everyone, whether you’re feeling a diagnostic genius or dunderhead.

Visit the site now by going to https://pulsereference.com

Would you like to see all the clues?Yes please

Clue 1

Clue 2

You decide to check a full blood count, LFT, U&E and creatine kinase and advise her to try without her statin to see if that makes any difference. The bloods show Hb 10.4 (one year ago 12.8) with normal MCV and MCH. The CK is normal. Via a subsequent brief telephone consultation, she tells you that stopping the statin did not help at all and the pain is worse. ‘I’m sure it’s the old wear and tear in my neck, doctor but it seems to be spreading – can I have a stronger painkiller?’ You prescribe some co-codamol and arrange further bloods.

Clue 3

Clue 4

YHer CRP is markedly elevated at 86. You give her an urgent call for review. ‘It’s worse if anything, doctor. The painkillers aren’t helping. I’m going to need some help at home at this rate. I can barely brush my hair or get dressed in the morning’. You arrange urgent review with rheumatology.

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Visit the site now by going to https://pulsereference.com