Not Parkinson’s — the referral that argues back

Progressive supranuclear palsy announces itself to anyone who examines rather than reads: the MDS criteria name the vertical supranuclear gaze palsy, the early falls, the axial predominance and the dopamine resistance, and this man carries all four. The physiotherapy implication is not despair but timetable — falls arrive earlier and hit harder than in PD, downgaze compensation and stair strategy become core skills, the swallow needs watching, and equipment planning starts now. What you do with it: name the pattern to the neurologist, build the plan for PSP’s arc, and leave the standard PD programme on the shelf where it belongs.

• Choking episodes or weight loss — swallowing assessment now, not at the next review
• Falls with head strike — same-day medical review; his backward falls do not telegraph
• Rapid functional decline — the timeline for equipment and care planning shortens with it

• The backward faller — the pull test and the next fallTier 2
• H&Y V — maintenance is not giving upTier 4

This page carries the case’s first decision. The full sequence — every decision, the examination by domain, and the debrief that grades you — is in the drill, and the library is included with membership.