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 D, aged 60.

Past history: hypertension, diabetes, longstanding GORD.

Medication: perindopril 4mg/day, metformin 500mg tds, lansoprazole 30mg/day.

Smoker (20/day long term); previous alcohol excess but none for last five years.

First Clue

‘I keep getting this pain in my belly for the last few months, mainly when I eat. It can’t be my tablets because I’ve been on them for years. My bowels are fine. But it’s just getting worse. It doesn’t feel like my reflux but maybe I need something stronger than the lansoprazole?’

Can you have a snap guess at the diagnosis?

Bad luck! Keep trying. Have another clue.

Physical examination is unremarkable, so you arrange urgent bloods, OGD and ultrasound of her abdomen. You review her on receipt of the tests, all of which are normal. She is unimpressed by this news. ‘Well, I know something’s wrong, doctor, because I’m starting to lose weight and I feel sick sometimes, too.’

What is your best diagnostic guess now?

Bad luck! Keep trying. Have another clue.

You refer her on the two-week pathway to gastroenterology. She has a ‘straight to test’ CT scan of chest, abdomen and pelvis, all of which is normal, and is discharged back to the GP. She volunteers that she is getting depressed with the symptoms. Her psychological state is not helped by the fact that she has, in the interim, seen another doctor about leg pains. ‘He thinks I’ve got circulation problems,’ she says, tearfully.

What would be your diagnosis at this point?

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

You give her a trial with antidepressants. On review six weeks later, she feels no better. ‘I’m worse if anything, doctor. I’m definitely losing weight, feeling sick and the pain is so bad that I’m afraid to eat.’

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

It looks like you are a diagnostic genius

You are a diagnostic genius!

DIAGNOSIS IS MESENTERIC ISCHAEMIA

Clinical moral:

Mesenteric ischaemia is a rare cause of recurrent abdominal pain. It is very easy to overlook, and not just because of its obscurity. The diagnostic approach tends to be heavily weighted towards detecting structural lesions visible on scans, scopes and so on. And the hands-off, fast-turnover, narrow-focus approach in some secondary care departments can leave GPs either with a false sense of security (that there is nothing wrong) or with a feeling of clinical confusion (that there is something wrong but that it is difficult to know where to go with it). So it’s always worth bearing in mind that ‘no significant abnormality’ on hospital tests should not always be the end of the story, that there are some obscure but important causes of abdominal pain and that ‘being afraid to eat’ is a red flag.

It looks like you are a diagnostic wizard

You are a diagnostic wizard!

DIAGNOSIS IS MESENTERIC ISCHAEMIA

Clinical moral:

You are diagnostically spot on

DIAGNOSIS IS MESENTERIC ISCHAEMIA

Clinical moral:

You are diagnostically dogged

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

DIAGNOSIS IS MESENTERIC ISCHAEMIA

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 MESENTERIC ISCHAEMIA

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

Physical examination is unremarkable, so you arrange urgent bloods, OGD and ultrasound of her abdomen. You review her on receipt of the tests, all of which are normal. She is unimpressed by this news. ‘Well I know something’s wrong, doctor, because I’m starting to lose weight and I feel sick sometimes, too.’

Clue 3

You refer her on the two week pathway to gastroenterology. She has a ‘straight to test’ CT scan of chest, abdomen and pelvis, all of which is normal, and is discharged back to the GP. She volunteers that she is getting depressed with the symptoms. Her psychological state is not helped by the fact that she has, in the interim, seen another doctor about leg pains. ‘He thinks I’ve got circulation problems,’ she says, tearfully.