Panelysis archive
Every past blood-results puzzle, with the patient story, diagnosis and teaching point. Newest first.
11 past puzzles, up to Thursday 5 November 2026. Today’s and future puzzles are never shown here.
November 2026
#11 · Thursday 5 November 2026 Medium
Patient: Mele, 66, female
Type 2 diabetes. Woke with nausea, jaw ache and breathlessness. No chest pain, and she thinks it's reflux. ECG shows no ST elevation.
Key results: hs-Troponin T (0 h) 38 ng/L (H), ref <14; hs-Troponin T (3 h) 214 ng/L (H), ref <14
Diagnosis: NSTEMI (heart attack)
Why: A troponin climbing from 38 to 214 ng/L in three hours means acute heart muscle injury. With this story, that's a heart attack until proven otherwise, and without ST elevation it's an NSTEMI. Unstable angina, by definition, has no troponin rise. Normal kidney function, D-dimer and lipase make kidney-related troponin, PE and pancreatitis unlikely.
Teaching point: Women, older people and people with diabetes are more likely to have heart attacks without classic chest pain: nausea, jaw or back ache, breathlessness or exhaustion. Women's heart attacks are still more likely to be missed or treated late.
Play this puzzle#10 · Wednesday 4 November 2026 Medium
Patient: Liam, 48, male
Aching knuckles (index and middle fingers), tired, and a low libido. Has two beers most nights. His dad had 'liver trouble'.
Key results: Transferrin saturation 86 % (H), ref 15–45; Ferritin 1480 µg/L (H), ref 30–500; ALT 74 U/L (H), ref <40
Diagnosis: Hereditary haemochromatosis
Why: Ferritin rises in lots of conditions (inflammation, alcohol, fatty liver). The tell is transferrin saturation: at 86% the iron transport protein is overloaded, the hallmark of true iron overload. With arthritis in the index and middle knuckles, abnormal liver tests, a creeping fasting glucose, low libido and a family history, hereditary haemochromatosis (usually HFE C282Y) leads the list. Two beers a night doesn't push saturation to 86%, and the CRP is normal.
Teaching point: Haemochromatosis is one of the commonest genetic conditions in people of northern European ancestry. Men tend to show it earlier than women, as periods and pregnancy offload iron. Found early, complications like cirrhosis are largely preventable.
Play this puzzle#9 · Tuesday 3 November 2026 Easy
Patient: Grace, 41, female
Ran her first marathon yesterday. Drank at every water station ‘to be safe’ and kept drinking afterwards. Now headache, nausea and puffy fingers, and she weighs 1.5 kg more than before the race.
Key results: Sodium 124 mmol/L (L), ref 135–145; Osmolality 258 mOsm/kg (L), ref 275–295
Diagnosis: Exercise-associated hyponatraemia
Why: A sodium of 124 with a low measured osmolality is true, dilutional hyponatraemia. Gaining weight over a race means she took in more water than she sweated and passed, and race-day stress hormones (ADH) stop the kidneys clearing the excess. Dehydration would push sodium and urea up, and pseudohyponatraemia has a normal osmolality. A CK of 620 is typical after a marathon, nowhere near rhabdomyolysis territory.
Teaching point: Exercise-associated hyponatraemia is mostly about drinking too much, not losing salt, and slower runners who stop at every water station are most at risk. Sports medicine consensus statements now say to drink to thirst. Confusion or a seizure after a race is an emergency.
Play this puzzle#8 · Monday 2 November 2026 Easy
Patient: Siobhan, 19, female
A week of severe sore throat, fevers and exhaustion, with swollen glands in her neck. Just started uni.
Key results: Lymphocytes 9.2 ×10⁹/L (H), ref 1.0–4.0; Blood film Many atypical (reactive) lymphocytes (!); Heterophile antibody (Monospot) Positive (!), ref Negative
Diagnosis: Glandular fever (EBV)
Why: Lots of lymphocytes, many of them atypical (reactive), mildly raised liver enzymes and a positive heterophile antibody test, in a young adult with fever, sore throat and big neck glands. That's glandular fever (infectious mononucleosis), caused by Epstein–Barr virus. Bacterial tonsillitis usually raises neutrophils, not lymphocytes.
Teaching point: The spleen often swells in glandular fever, which is why contact sport is usually off for a few weeks. The Monospot can be negative early on and in young children; EBV serology helps then.
Play this puzzle#7 · Sunday 1 November 2026 Genius
Patient: Desmond, 70, male
Back pain for three months, tired, and his third chest infection this winter. The lab has flagged his sodium.
Key results: Osmolality 289 mOsm/kg, ref 275–295; Globulin 84 g/L (H), ref 25–45; Corrected calcium 2.94 mmol/L (H), ref 2.10–2.60
Diagnosis: Multiple myeloma (pseudohyponatraemia)
Why: A low sodium with a normal measured osmolality is pseudohyponatraemia: a huge load of protein takes up plasma volume, and many lab methods then under-read the sodium. The extra protein is globulin, 84 g/L. Add anaemia, high calcium, kidney impairment, bone pain, recurrent infections and an ESR over 100, and this is myeloma until proven otherwise. Sneaky bonus clue: the anion gap is only 6 (128 − 98 − 24), because positively charged paraprotein fills the gap.
Teaching point: CRAB: high Calcium, Renal impairment, Anaemia, Bone lesions. A big gap between total protein and albumin should prompt serum protein electrophoresis and free light chains.
Play this puzzle
October 2026
#6 · Saturday 31 October 2026 Hard
Patient: Yusuf, 24, male
Dark, cola-coloured urine and exhaustion, two days after a big feed of fresh broad beans (fava beans). Mild yellow tinge to his eyes.
Key results: Haptoglobin <0.1 g/L (L), ref 0.3–2.0; Direct antiglobulin test Negative , ref Negative; Blood film Bite and blister cells (!)
Diagnosis: G6PD deficiency
Why: Haemolysis everywhere: falling Hb, lots of young red cells (retics), unconjugated bilirubin and LDH up, and haptoglobin used up mopping free haemoglobin, which also darkens the urine. A negative DAT argues against autoimmune haemolysis, and the liver enzymes are normal. Bite and blister cells mean oxidative damage, and fava beans are the classic trigger in G6PD deficiency.
Teaching point: G6PD deficiency is X-linked and common in people with African, Mediterranean, Middle Eastern and Asian ancestry. The G6PD level can look falsely normal during an attack because the oldest, most deficient cells have already burst, so it's re-tested a few months later.
Play this puzzle#5 · Friday 30 October 2026 Hard
Patient: Helen, 58, female
Breast cancer treated six years ago. Two weeks of thirst, constipation and new back pain. Her family say she's 'foggy'.
Key results: Corrected calcium 3.48 mmol/L (H), ref 2.10–2.60; PTH 0.5 pmol/L (L), ref 1.6–6.9; ALP 236 U/L (H), ref 30–110
Diagnosis: Hypercalcaemia of malignancy
Why: Corrected calcium is 3.48 mmol/L, high enough to cause thirst, constipation, confusion and kidney injury. PTH is appropriately switched off, which rules out primary hyperparathyroidism (where PTH is high or inappropriately normal). With previous breast cancer, new back pain and a raised ALP from busy bone, the likely driver is cancer: bone metastases, PTH-related peptide, or both.
Teaching point: 'Stones, bones, abdominal groans and psychic moans.' The first question with any high calcium is: what's the PTH? High or normal points to the parathyroids. Suppressed sends you looking elsewhere, especially for cancer.
Play this puzzle#4 · Thursday 29 October 2026 Medium
Patient: Rangi, 61, male
Brief weakness of his right arm last week, fully resolved. Ruddy face, and itchy after hot showers. Never smoked.
Key results: Haematocrit 0.59 L/L (H), ref 0.40–0.54; Platelets 640 ×10⁹/L (H), ref 150–400; Erythropoietin 1.4 IU/L (L), ref 4.0–24.0
Diagnosis: Polycythaemia vera
Why: All three cell lines are up, the red cell mass is high and erythropoietin (EPO) is suppressed: the marrow is making red cells on its own, without being asked. That's a myeloproliferative neoplasm, and with this red cell picture it's polycythaemia vera. Low ferritin and small cells are common in PV because the expanding red cell mass soaks up the iron. Itch after hot water (aquagenic pruritus) is a classic clue.
Teaching point: Thick blood clots. Polycythaemia vera raises the risk of stroke, TIA and other clots, so a high haematocrit is worth noticing in anyone with a vascular event. Almost everyone with PV carries a JAK2 mutation, which helps confirm it.
Play this puzzle#3 · Wednesday 28 October 2026 Medium
Patient: Grace, 64, female
Pins and needles in both feet, unsteady in the dark, and a sore, smooth tongue. Has vitiligo.
Key results: MCV 114 fL (H), ref 80–100; Vitamin B12 92 pmol/L (L), ref 150–700; Intrinsic factor antibodies Positive (!), ref Negative
Diagnosis: Pernicious anaemia (B12 deficiency)
Why: Macrocytic anaemia with low white cells and platelets, a low B12 and a normal folate. Hypersegmented neutrophils mean megaloblastic change. The high LDH and bilirubin come from red cells dying in the marrow before they're released (ineffective erythropoiesis), not from true haemolysis. Intrinsic factor antibodies confirm pernicious anaemia, an autoimmune condition that loves company: vitiligo, thyroid disease, type 1 diabetes.
Teaching point: B12 deficiency can damage nerves before anaemia even appears, and the damage can become permanent if missed. Folate alone can fix the blood count while the nerve damage carries on, which is why B12 is always checked alongside it.
Play this puzzle#2 · Tuesday 27 October 2026 Easy
Patient: Leilani, 34, female
Has Down syndrome and lives in a shared house. Her occupational therapist notices her morning routine (showering, dressing, making breakfast) now takes twice as long. She feels the cold, is constipated and has gained weight.
Key results: TSH 38.5 mU/L (H), ref 0.40–4.00; Free T4 6.2 pmol/L (L), ref 10.0–20.0; Thyroid peroxidase antibodies 460 IU/mL (H), ref <35
Diagnosis: Primary hypothyroidism (Hashimoto's)
Why: TSH is sky-high because the pituitary is shouting at a thyroid that isn't answering, and free T4 is low. That's primary hypothyroidism. Positive thyroid peroxidase (TPO) antibodies point to Hashimoto's, the autoimmune cause. Raised cholesterol and a mildly raised CK are common knock-on effects that usually improve once thyroid levels are back to normal.
Teaching point: People with Down syndrome have a much higher risk of thyroid disease, so regular thyroid checks are recommended throughout life. A drop in everyday function shouldn't be put down to 'just Down syndrome': OTs and support workers are often first to notice the change.
Play this puzzle#1 · Monday 26 October 2026 Easy
Patient: Amara, 31, female
Tired for months and puffed on the stairs. Her periods have been heavy since she stopped the pill.
Key results: MCV 72 fL (L), ref 80–100; Ferritin 6 µg/L (L), ref 30–200; Transferrin saturation 4 % (L), ref 15–45
Diagnosis: Iron deficiency anaemia
Why: Small, pale red cells (microcytic, hypochromic) with a rock-bottom ferritin. A ferritin this low means the iron stores are empty, and nothing else does that. Transferrin rises as the body goes hunting for iron, while saturation falls. A raised RDW (mixed cell sizes) and a mildly high platelet count are classic sidekicks.
Teaching point: Heavy periods are the commonest cause of iron deficiency in premenopausal women, but diet, coeliac disease and gut blood loss are always worth considering. In men and post-menopausal women, iron deficiency means looking for a gut cause.
Play this puzzle