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 B, aged 33.
Past history: Eczema, GORD.
Medication: As needed emollients and hydrocortisone 1% cream; occasional lansoprazole 30mg/day
Never-smoker

First clue

‘I’ve had this cough for months now. I feel like I’m getting a bit short of breath with it, too. One doctor said it might be asthma and gave me inhalers, but they didn’t help at all. Could it be stress? I’m an accountant and it’s been really tough at work – but I just had a long break away on holiday and did start to feel better towards the end of my break. But it’s all come back again now I’m back.’

Can you have a snap guess at the diagnosis?

Answers 1Carcinoma of the lungAsthmaExtrinsic allergic alveolitisGORDPost-viral coughBronchiectasisRhinitisHeart failureInhaled foreign bodyTB

Bad luck! Keep trying. Have another clue.

You arrange to see him face to face. Clarifying the history, you note he does suffer from nasal blockage and a runny nose; and he hasn’t been taking his GORD treatment lately. Examining his chest you find that there is no wheeze at all but you can hear some fine crepitations at both lung bases. You send him for a chest X-ray.

What is your best diagnostic guess now?

Answers 2AsthmaCarcinoma of the lungGORDPost-viral coughBronchiectasisRhinitisExtrinsic allergic alveolitisHeart failureInhaled foreign bodyTB

Bad luck! Keep trying. Have another clue.

You review him with the results of his chest X-ray. In the meantime he has been taking his lansoprazole regularly and has also tried a nasal steroid spray. Neither have helped. If anything, he says his breathlessness on exertion is worse. The X-ray states ‘possible slight ground glass shadowing in both lung fields’.

What would be your diagnosis at this point?

Answers 3Post-viral coughCarcinoma of the lungGORDAsthmaBronchiectasisExtrinsic allergic alveolitisRhinitisHeart failureInhaled foreign bodyTB

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

You tell him that you are going to discuss with the radiologist the possible significance of the X-ray findings. After contacting the radiologist, a few days later, you phone the patient back. It’s then that you hear a squawking in the background. ‘Sorry, that’s my parrot,’ says the patient.

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

Answers 4Post-viral coughCarcinoma of the lungAsthmaGORDBronchiectasisRhinitisExtrinsic allergic alveolitisTBHeart failureInhaled foreign body

It looks like you are a diagnostic genius

It looks like you are a diagnostic genius!

Diagnosis: Bird Fancier’s Lung (A form of Extrinsic Allergic Alveolitis)

Clinical moral:

Common things being common, and with cough being such a mundane presentation, we are bound to be lulled into a false sense of security, tending only to consider the ‘usual suspects’ as likely causes. This case illustrates the need to occasionally think outside the box when the diagnosis is particularly elusive or the assessment reveals unexpected findings. It also shows that, very occasionally, a remote consultation can provide more information than a face-to-face one!

It looks like you are a diagnostic wizard

It looks like you are a diagnostic wizard!

Diagnosis: Bird Fancier’s Lung (A form of Extrinsic Allergic Alveolitis)

Clinical moral:

You are diagnostically spot on

Diagnosis: Bird Fancier’s Lung (A form of Extrinsic Allergic Alveolitis)

Clinical moral:

You are diagnostically dogged

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

Diagnosis: Bird Fancier’s Lung (A form of Extrinsic Allergic Alveolitis)

Clinical moral:

Sorry, it looks like you are a diagnostic dunderhead!

Diagnosis: Bird Fancier’s Lung (A form of Extrinsic Allergic Alveolitis)

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

Clue 3

Clue 4

HTML

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READERS' COMMENTS [2]

Please note, only GPs are permitted to add comments to articles

Patrufini Duffy 2 November, 2022 9:43 pm

Yes, one would have asked about pets at the start, because of the dog epidemic and because it’s cute to hug tigers apparently online.

David Church 10 November, 2022 11:22 am

That’s not fair.
From clue 1, we know he had been able to take a long holiday away, which implies that he had no pets that needed care for the duration, or else he spent a long period away from work and spending more time at home, and improved.
By far the most likely cause is covid-induced lung damage with a bit of heart failure as a post-viral effect, as we are now seeing quite commonly.
Hopefully one day the Pandemic actuall will be ‘over’, and we will be able to look back on this period in our lives and reminisce on the differences in diagnoses and heatlh conditions during this period. And use it to teach the next generations of doctors (but not politicians, obviously) of the importance of a healthy population to a good economy.