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

Mr A, aged 77.

Past history: osteoarthritis and hypertension

Medication paracetamol as needed and amlodipine 5mg/day.

First Clue

‘I’m worried about my husband – he doesn’t like to bother you. I can’t put my finger on what’s wrong. He’s aged so much in the last year or so. He’s just not the man he used to be.’

No particular further symptoms are volunteered, and his weight is steady.

Can you have a snap guess at the diagnosis?

Answers 1DementiaDepressionIron deficiency anaemiaB12 deficiencyParkinson’s diseaseMyasthenia gravisAddison’s diseaseType 2 diabetesHypothyroidismChronic fatigue syndrome

Bad luck! Keep trying. Have another clue.

You organise an array of blood tests: FBC, CRP, U&E, LFT, TFT, calcium, vitamin D and HbA1c. All are normal. You arrange a video call with the patient. He looks very down to you but he – and his wife – deny that he is depressed, other than being fed up about how he feels.

What is your best diagnostic guess now?

Answers 2DementiaDepressionIron deficiency anaemiaB12 deficiencyParkinson’s diseaseMyasthenia gravisAddison’s diseaseType 2 diabetesHypothyroidismChronic fatigue syndrome

Bad luck! Keep trying. Have another clue.

A few weeks later, his wife brings him up for a face-to-face appointment. He does look much older than when you last saw him and seems very flat. His wife mentions that he’s had a couple of falls in the last few months.

What would be your diagnosis at this point?

Answers 3DementiaDepressionIron deficiency anaemiaB12 deficiencyParkinson’s diseaseMyasthenia gravisAddison’s diseaseType 2 diabetesHypothyroidismChronic fatigue syndrome

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

You remain puzzled and decide to refer him to the department of elderly medicine for further assessment and falls prevention. You help him and his wife out of the door and watch him shuffling down the corridor.

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

Answers 4DementiaDepressionIron deficiency anaemiaB12 deficiencyParkinson’s diseaseMyasthenia gravisAddison’s diseaseType 2 diabetesHypothyroidismChronic fatigue syndrome

It looks like you are a diagnostic genius

You are a diagnostic genius!

DIAGNOSIS IS PARKINSON’S DISEASE

Clinical moral:

Parkinson’s is a very easy disease to miss. Rather than having text-book symptoms, patients may present with vague issues such as tiredness, unsteadiness or slowing up. The tell-tale tremor may be subtle or absent, bloods, of course, are normal, and unless the diagnosis is actively considered, the relevant signs may not be elicited, or confused with depression or dementia.

It looks like you are a diagnostic wizard

You are a diagnostic wizard!

DIAGNOSIS IS PARKINSON’S DISEASE

Clinical moral:

You are diagnostically spot on

DIAGNOSIS IS PARKINSON’S DISEASE

Clinical moral:

You are diagnostically dogged

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

DIAGNOSIS IS PARKINSON’S DISEASE

Clinical moral:

Sorry, it looks like you are a diagnostic dunderhead!

You are a diagnostic dunderhead. But only on this occasion and, hey, we all have bad days!

DIAGNOSIS IS PARKINSON’S DISEASE

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

‘I’m worried about my husband – he doesn’t like to bother you. I can’t put my finger on what’s wrong. He’s aged so much in the last year or so. He’s just not the man he used to be.’

No particular further symptoms are volunteered and is weight is steady.