Cases that changed me - connecting the dots (8 Jun 2026)

This transcript has not been edited for accuracy.

Transcripts are available on popular podcast platforms.

Dr Heather Kennedy (HK): Hello and welcome to this episode of Clinical Conversations, brought to you by the Trainees and Members Committee of the Royal College of Physicians of Edinburgh. This episode forms part of our miniseries called Cases that Changed Me. I am Doctor Heather Kennedy and I'm a member of the Trainees and Members Committee. Today I'm delighted to be joined by Doctor Neil Watson, who is a sd7 in neurology, stroke and internal medicine at the Royal Infirmary of Edinburgh. Welcome, Neil, and thank you so much for joining me today.

Dr Neil Watson (NW): Thank you very much for inviting me to take part in this after the conference. It's a real pleasure and I'm really happy to do so. So, thank you.

HK: Great. So, this miniseries focuses on clinical cases that have changed how a senior clinician thinks or approaches practice. And today we're going to discuss a case that Neil, as you mentioned, presented at our recent medical trainees’ conference in February 2026. This presentation was titled Connecting the Dots and featured a case that was challenging but rewarding for Neil. Myself and other attendees found the talk highly engaging and with interesting learning points that are also relevant to the wider audience of our podcast listeners. So, the case we're discussing today highlights multisystem disease, and that as physicians, we're not ever looking only at one organ. Neil, before we discuss your case, can you explain the changes to your training program in recent years and what being a higher specialty trainee in neurology looks like?

NW: Absolutely. That's a good thing to open with. So, I began neurology training in 2021, which was the first year of a new program in which we integrated with general internal medicine, as well as taking a much bigger role in stroke. So historically, stroke was a specialty that a subset of neurologists chose to pursue as a sub interest, but many of the people providing stroke medicine services around the UK would come from medicine, the elderly pathways or acute medicine aligned pathways, and it was less common, perhaps, for neurologist to accredit in that as a subspecialty, unless they wished to. It became a core part of our competencies as well. So really, we now triple CCG in neurology, stroke and general internal medicine. So, I was the first of a generation to do so for a while. It was quite novel. You'd be in the acute medical unit, and everyone was quite surprised to see a year old just hanging around. It's actually become a lot more normal now, and I think people are getting used to it. And I had a really interesting experience with it and quite enjoyed it and hopefully been useful in some regards doing it as a neurologist and medic. So, this case really, I think, ties in nicely with that.

HK: Yeah. Like you say, this case really highlights the context of that training that you're going through. I think for me, that was what really struck through hearing it before. So, the case we're discussing, your patient was admitted to the acute medical unit in a tertiary centre where you were conducting the post-take specialty consult round for neurology. Can you talk us through the symptoms of her acute presentation at that time?

NW: Absolutely. We were seeing her, of course, on the morning of an acute presentation to hospital. But before I go and see people, I always have a browse of their records that are available to just to get a sense of who is this and what's been happening lately and what immediately stood out, which we'll come back to, is that this acute presentation came on the back of quite a number of strange things happening to someone who before this had been very well and clearly in the last few months, had a lot of medical encounters for seemingly unrelated problems, which made me think, is there something that unifies all this? The acute symptoms, though, were quite focused. So, there were three things that had happened the day before. I was seeing the patients. They'd come in the night before. The first was that out of the blue and without any real precipitant to this, the patient had developed sudden onset of double vision through binocular double vision. So, closing one eye. It would become one image but opening it. It would be two again. And this came on out of the blue, associated with a mild dizzy feeling that was a vertigo feeling. So, a sense of things in motion, but certainly not a violent room spinning type dizziness. And it wasn't debilitating. Mainly the double vision was the strange bit, and this seemed to last about half an hour. It didn't really fluctuate or change. It was just there. She sat it out, it passed, and then she was back to normal again. But a bit surprised by this. Then a little bit later on in the same afternoon, had a spontaneous onset of a chest pain that sounded very much like a cardiac chest pain. So central, heavy, tight, radiating down the left arm without any precipitant. And again, that lasted about twenty thirty minutes and seemed to go away. So, two completely disconnected symptoms there that were transient and came to hospital with this. The third wasn't really a symptom because the patient had no awareness, but it was witnessed by the triage staff in the A&E, in which she mid-conversation blanked out and essentially was staring into space with some lip smacking for about 30s and didn't respond to her name. And then there seemed to stop, and she was just back to normal and had no insight into the fact that this just happened to read things separated over time, all quite different. And they'd led to this person coming into the hospital.

HK: Yeah. So that was three quite unusual and different symptoms that she presented with acutely. And you mentioned this was on the background of months of some more chronic, unexplained issues. What else had been happening for her and what investigations had happened prior to your acute encounter?

NW: So, I was meeting her about eight months into a chain of seemingly unconnected, strange events. The first had been eight months before something quite similar happened, actually, to that dizziness and double vision episode lasting about an hour or so. And that had gone away, and the patient hadn't actually sought any medical attention for that. I just thought it was one of these unusual things. Maybe I'm tired. Viral illness. The usual things people sometimes assume. And then later had some, I think, routine blood tests, if I remember right with the GP that had shown quite a high platelet count, which was new for this person. And actually, at this stage, eight or seven months before we met, the platelet count was over one thousand. It was one thousand four hundred. And this was discussed with the haematology team, who met with the patient and really found her very asymptomatic and did quite a thorough assessment and didn't really find anything that would suggest any blood disorder, for example, anything suggestive of a myeloproliferative disease which had quite a number of tests, including a bone marrow analysis and a Jak2, and nothing really was found. And without any intervention, the platelets seemed to be falling within normalised, but they seemed to come down to seven fifty and then five hundred and the patient was kept just under follow up to review without any specific diagnosis. But just thinking, well, this seems to have peaked and gone away. We haven't done anything. Let's just keep this person under review. So that was the first issue was unexplained high platelets. And of course, before that transient dizzy thing. Then about three months before we met, had then developed this new set of skin lesions, which were in the digits in the fingers and the soles of the feet, and also the palms, the hands and feet, unpleasant and a bit burning and a bit painful, not associated with any joint swelling or cracked skin or any other broader symptoms, but just these peripheral features and have been seen in an ambulatory care unit and at that stage had a bit of an inflammatory response. I think the CRP was somewhere between fifty and seventy. Maybe the white cell count was slightly raised, but afebrile there weren't any obvious systemic symptoms to point to anything. I think the rest of the general examination was unremarkable. The person did a very thorough review. The impression was maybe this is something like a viral illness. Could it be sort of hand, foot and mouth disease type thing. The way it was managed was essentially some bloods were sent off, including a vasculitis screen and a urine analysis, and they were normal. There wasn't any evidence of vasculitis, for example. Connective tissue diseases on the connective tissue screen. I thought maybe this was a viral illness. They called the patient a few days later, and actually she seemed to think the hand symptoms were getting better. So again, spontaneously waxing and waning and at this stage was discharged with a plan that could be referred back if things are changing or depending what happens to another service, if there's something more localising, for example. And then lastly, I know there's a lot of detail where there was a lot to process since May, it transpired, from speaking to the partner of the patient that the blank spells were the lip smacking had been going on for about three months, and they were very stereotyped and they were very brief, and they were always the same. And she'd have no awareness or responsiveness during them, would come around after and be okay, but just not have any instinct that this has happened, but a partner had noticed it quite a lot. Unfortunately, she wasn't a driver. I should add at this point, really, in terms of other things, I did a bit of a screen for systemic symptoms. I didn't find anything else of note, so she'd not had fevers. I've mentioned already the lack of joint pains and things. There weren't any obvious respiratory or cardiac symptoms lately. There had been some angina detected a few months before this, but that seemed to have settled with some GTN. She'd lost a little weight, but that was on purpose. So really nothing pointing to someone who's got symptoms of multi-system disease. But we've got these blank spells. We've got this digital rash; we've got these unexplained high platelets. We've got a grumbling, inflammatory response. So, there's a few things kind of going on here in this person who is normally fit and well and doesn't see the doctor about anything.

HK: Okay, so we've got our history from speaking with the patient and from your research. Looking through the notes. So, she's just to summarise got binocular horizontal diplopia chest pain with radiation into the left arm and a brief blank spell with lip smacking. And this is on the background of previous episodes of dizziness and double vision. A rash, multiple similar blank spells, and persistently elevated platelets. So, moving on from the history to examining, what did you find examining her on that day?

NW: I actually found very little and I did my best. I had a good look. I didn't just do a cursory neurologist going down to Amu and ignoring all the systemic bits. I did try and think about what could explain this, and actually I found very little. So, the observations were normal. She looked well, she was alert and orientated. I didn't see any of those blank spells with lip smacking during our review, and neurologically she was completely intact. There was nothing suggestive of any double vision, for example, or signs of something like myasthenia, for instance, checked and nothing really fluctuated. The cardiac exam was normal as well. I had a good listen to check. There weren't any murmurs or anything, couldn't find anything abnormal there. The only thing that was abnormal were these skin lesions in the palms and some of the fingers, and also in the soles of the feet bilaterally, which were pretty painless and red-ish. And some were a bit raised and she'd had them for a little while, and maybe they were fading a little bit, since she'd been seen in the ambulatory care unit two or three months earlier. But those were really the only things I found me. Describing them might be difficult for listeners, but essentially just little, like I say, reddish bumps, quite small, and the palms around the fingertips and the soles of the feet. And that was the only abnormality I could detect on examination.

HK: Okay. And so, she was being seen by herself in a post-take round. And what initial investigations had she had for her work up before you met her?

NW: The key thing with this, of course, is that she'd had quite an array of symptoms, I suppose two neurological Ones and one more cardiac. So, first focus had been on the chest pain. So, she'd had the sort of acute coronary syndrome work up and had a normal ECG, a baseline troponin several hours after the event was normal. So, I don't think serials were done. She was pain free. She had a chest X-ray was normal. She'd had some routine bloods, including inflammatory markers. And yet again, she still had the platelet count that was going back up a bit. It was now back up to about seven hundred and forty. Her albumin was twenty-nine. So potentially indicative of something consumptive really. We know from certainly before that that proteinuria sort I think it was a leak issue unless she had a new one of course, but maybe suggestive of something inflammatory. Her CRP was now one hundred and ten. It had been in the seventies when last checked a month or so ago. White cell sixteen. So, some inflammatory response and thrombocytosis, but no other real investigations of note that were pointed to a specific cause for this.

HK: Okay, so I'm sure our listeners will have some ideas running through their minds after what we've discussed so far. But what were your initial thoughts and differential diagnoses?

NW: The interesting thing about a case like this, you could take any one of the bits of the presentation and there's a whole differential for that alone. So, you know, haematology had already gone to town on the platelets. People had thought about some of the other aspects of this, like the digital changes as well. You could talk about what gives you transient double vision. There's all sorts of bits. I didn't so much go into the what are each of these things? Definitely. But I thought more about systematically what would explain someone getting all these things at once. And really, I thought, well, we've got a multi-system disease firstly, and it's got inflammatory components to it. So, you're into that kind of triad of infective inflammatory and neoplastic things being the big three that cause a sort of grumbling inflammatory illness. Connective tissue diseases, etc. And then I thought, well, what are the actual pieces of this? There was a chest pain of some kind that sounded cardiac, although it doesn't seem to have been a myocardial ischemia presentation, certainly, but it sounded like a cardiac chest pain rather than a noncardiac one. The dizziness and double vision thing was a bit concerning for a brain stem. Tia so someone having a bit of vertigo and binocular diplopia, that sudden onset and lasts half an hour and then goes away is a bit alarming for something like an ischemic insult that was paroxysmal. So, brainstem Tia crossed my mind. And then you've got these attacks in which she glazes over and has lip smacking and has no awareness. And they sound very much like focal seizures and probably particularly temporal lobe seizures. She's had them for two or three months. They're very stereotyped. So that sounded like an epileptic phenomenon. So, there's some brain involvement. There's maybe some heart involvement. Maybe there's multi-system inflammation. And then the big kicker was the fingertips, the palms and the soles. And I thought, well, what gives people an inflammatory response? Cardiac and brain symptoms and funny skin lesions on your hands and feet with endocarditis, right? Because you have that and it can be quite subacute. Could go on for months, potentially depending on the organism involved in it. Some are more fulminant; others are more subacute. Certainly, that could present in this fashion. The other thing that crossed my mind, just because it is a condition that's getting commoner and commoner for various reasons with syphilis, and that classically gives you a rash on your palms and soles. It's one of the things in the list of causes of that. And again, you can get meningovascular syphilis, giving you strokes and tias due to vasculitis. You can also get seizures as well. People can get seizures due to meningeal irritation or parenchymal brain damage, etc. too. So, I thought, you know, worth testing for that in parallel. HIV is another thing that can cause multi-system disease and co-occurs with it. So, I suppose what I could segue onto there is what did I actually suggest? Bear in mind, I was coming down as a neurologist, seeing this person who was on our board of eight people to see that morning. I said the above. I said, you know, here's my formulation of all these pieces. I are something multisystem going on. I suggested we do a few things. Some blood cultures, in case you've got endocarditis, HIV, bloodborne, viruses and syphilis. And we got that run the same day, which was extremely helpful. It was all negative. An LDH just because it's non-specific because sometimes lymphomas and things can present in a multisystem way. I went for an MRI brain as well, because I was looking to see if there was any evidence of recent embolic phenomena, which can sometimes show up on the scan with diffusion weighted changes. I thought about an EEG, but I thought I'd be lucky if I caught one of these attacks in the act because they're so brief and we might not get one, so we can shelve that for now. And I also thought it's probably worth speaking to cardiology as well. And just saying, is it possible to test? I can't hear a murmur, but I'm probably not the definitive opinion on who doesn't have a murmur in this hospital. So maybe someone more expert could have a think about that too.

HK: Okay, so we're keeping in mind your time differentials being endocarditis and syphilis but maintaining more of a broad list of possibilities. And you've mentioned those investigations that you planned. So, what did those tests show and what happened next?

NW: So, in brief, the cultures, of course, don't come back until a bit later on. We'll come back to those. The blood borne virus and HIV tests and syphilis tests were negative. That was helpful. Then the MRI really was the other idea that I had. And that indeed showed a very cardioembolic looking pattern of infarctions on the diffusion weighted scan. What you see is in both sides of the brain and in different territories, anterior and posterior circulations, you could see evidence of recent infarctions. So bilateral back and front of the brain. In other words, proximal source usually cardiac although they can be occasionally aortic pathology can do this too. But usually cardiac. And something has just sent a volley of clots up into the circulation and hit various bits of it. So probably that kind of brain stem, Tia was one of those clinically manifest. The other ones seemed to be more asymptomatic. But it was conceivable that if this had been going on for some time, one of them might have caused some damage that led to those seizures as well. Maybe one of them hit the temporal lobe in the recent weeks, triggered that as well as a sort of post-stroke phenomenon. So that came back about, I think it was about four o'clock and it was a Friday. And Fridays are always difficult because your arsenal of tests and personnel things can sometimes be a bit different from what it is on a Monday morning. And but that came back and I went back to see her. And I really at this point thought, oh, surely, she's got not just missed it. Let's have another listen. And I did my best. I dusted off all my pastry skills. I still could not hear a man that I couldn't hear anything abnormal. The patient actually didn't even want to stay in the hospital. She felt well and she had commitments she wanted to get away for. But I had to say to her, quite frankly, I'm very worried. There's something serious going on. I've been going on for some time. I think you've got this far. We're close, maybe to getting an answer now. Would you mind staying on? And we could just get a few more people involved in this and really try and nail this down. I'm worried you've got a heart infection, and if you've got that, it's extremely dangerous. And I think, you know, that was enough to convince her to cancel what she was planning to do and stick around in her best interest. But obviously it's never nice to have to cancel plans. So, what happened next was I spoke with a cardiology colleague, and the medical team also referred to infectious disease, who advised, yet you've sent cultures off. Let's wait for those. Don't start antibiotics with no evidence of infective just yet but agree there's a lot of suspicion. Cardiology. We're going to come and see her. In terms of things that I did therapeutically well, I gave aspirin on the basis that she seems to have had lots of infarcts. Maybe it'll help, although there's a debate around whether it makes a difference in some of the endocarditis where it's not really thrombotic. Well, it is, but from infection and heart problems rather than atheroma, etc. So, to what extent actually makes a difference is something to debate. But we gave aspirin and we gave her an anti-seizure drug. In this case, I spoke with my consultant. We used one called Lacosamide, which for focal epilepsy can be quite useful. It has various advantages. We just went with that. That's a whole topic of why we chose that. We're all going to. So, cardiology then came down. I had left the building at this point, but the cardiologist actually contacted me because I think both of us were quite amazed at actually what was going on. So, he also couldn't hear a murmur. That's my first statement. So, I was vindicated. It wasn't just me, but he did a bedside echo, and what was visible on that echo was that there was actually a large mass tethered to the atrium. And during atrial contraction, that was essentially, I think, flopping forward through the mitral valve towards the ventricle. And the appearances looked suggestive of a very large atrial myxoma. So, my colleague phoned me and let me know this information. And at this point I was thinking, well, you know, I've never seen this. I know of it. It's one of these things you learn off. I'm surprised that we could do all of these things. It seems a bit of a stretch. It was just a sort of blob of inert tissue flopping around. You get everything this person has had. Maybe the emboli. Sure. But I don't know about all the platelets and CRP. And actually, what I also didn't really know, just because it's not something I've spent time thinking about is this is something that you operate on as soon as you can, because one of the issues associated with sudden death, it can obstruct outflow from the heart and lead to a cardiac arrest. So, this was something that actually it was all go, go, go. And despite feeling really well, this patient was kept in admitted and underwent emergency heart surgery the next morning to respect the lesion. And sure enough, the pathology came back showing an atrial myxoma with typical pathological features and there was no evidence of secondary infection. And the blood cultures were all sterile.

HK: So yeah, that was really interesting. I've never encountered a patient with an atrial myxoma, and I don't think it would have been going through my mind as a possibility for this patient. And is this how it would typically present?

NW: So I've since read about this and the answer is yes, but I didn't know that I knew of it as one of these hidden bits of knowledge and that, you know, you can hear a tumour plop, apparently, although I didn't hear a tumour plop and neither did the cardiologist, but I just knew of it as one of these benign, rare but potentially dangerous lesions. But actually, this is certainly compatible with how they present. And so, from looking at the literature on this and finding review articles, you've really got a triad of things they do. And I suppose all three were here, although fortunately the third one didn't happen fully. And we'll come back to that. So embolic phenomena are the first point and a bit like endocarditis or having a metallic mitral valve or aortic valve or something. Central cardiac pathology can fire off emboli all around the body, and the brain is often the first hit, presumably because it takes up twenty five percent of the circulation. It's right next to the heart. It's very symptomatic when these things show up. So cardioembolic stroke and Tia would be one of the manifestations, but also embolic phenomena to the digits, which is presumably in this case was why she had those cutaneous lesions and extremities. You could potentially also have them to places like the spleen or the gut. The way you sometimes see with other cardiac diseases too. So embolic phenomena is the first point. And then constitutional symptoms is the second point, which I didn't know. Actually, these are, I think quite immunogenic and I'm not sure whether that's the immune system reacts against those or they actually secrete things. I think it's a bit of both. But certainly, I think they secrete interleukins and cytokines. And that can trigger things like fever in some cases. But weight loss, anaemia of chronic disease, high platelets, which this person did have and inflammatory markers to rise to. So, they have a bit of a cytokine phenomenon that maybe puts them in that ballpark of things like the connective tissue diseases and the chronic infections and the cancers that manifest with constitutional symptoms, malaise, weight loss, abnormal bloods, Markers and myxomas on that list somewhere. The third and final one that I do think she probably did have a degree of is obstructive symptoms in the heart. So, as I said, it can cause sudden cardiac death. And I'm pleased to say she didn't have that. She sailed through the operation and did really well and is still doing really well. But you can, I think, get things like chest pains in the context, maybe of flow abnormalities and perhaps some of the angina she'd been experiencing in the run up to this, including the day before. Maybe it was directly from that rather than coronary artery disease, although referred to cardiology colleagues to comment on that. So that triad rule is the way they present. And as I say, the treatment is essentially just operate on this as quickly as you can, given the problems that they can lead to. And as I say, she had a really good perioperative course. There weren't issues, I think had to come back at a later stage with some chest discomfort and had a degree of pericardial effusion that was thought maybe a reactive thing, almost as a sort of Dressler's-esque post-mi type phenomenon and was given some colchicine and ibuprofen tablet. And I think things settled down, but actually, other than that, did really well. The seizures also seem to be totally controlled on the medication too, actually, and there is no evidence she went on had any stroke. So, all in all, as good as it could have been and it could have been a lot worse.

HK: Well, that's really great to hear how she's done since then. And I think that's such an interesting and challenging case where the patient's presentation didn't clearly fit into one box or follow a pattern that we would all recognize. And after you've connected the dots in that multi-system puzzle, I wonder what were your main reflections on the case?

NW: Well, it ties in to how we started this podcast, actually, in the training that I've had, and to be clear, I don't necessarily think one has to have done dual training. That also involves general internal medicine to necessarily think in this fashion. You know, and I think there are other specialties that don't do that who also would still have that approach. But I do think maybe it's influenced me more. Or maybe I already was interested in internal medicine in broad sense anyway, so perhaps it's just the way that I maybe like to think about these kind of cases. But I'd say the reflection for me was thinking that whatever bit of medicine you work in as a physician, whether it's acute medicine or you're an organ focused specialist rather than a system type specialist, perhaps you're always going to deal with things that are multi system in terms of body systems. And there can in some ways, and maybe due to the way services are designed and the pressures on us, the temptation to stay in your lane a little bit and stay to your bit and kind of review from your own angle, but say, you know, general medicine to look into the other aspects of this case or consider consulting X, Y, and Z and keep to your island. And to be clear, this is not just an issue in medicine. This is an issue in neurology. So, people that I know have written about this in one of our journals about the danger of everyone living on our islands and, you know, your movement disorder neurologist. And oh, this person's also got neuromuscular issue refers to neuromuscular colleague for an opinion on that rather than staying generalist, but with areas of expertise. And I think as a person who's doing neurology, a lot of multisystem diseases affect the nervous system. Many of them do a lot of neurological diseases have multisystem components that you also think about. Two, you really do, in my opinion, have to be a doctor overall and a generalist, and not just keep a focus on the brain or the nerves or whichever bit you're dealing with at that point. And I think in this case, I was lucky to come into it. Eight months in, lots of other people had seen things at more preliminary stage. I don't expect anyone would have just unified all this on day one. It takes time to mature. And I maybe was seeing someone acutely, but on the back of months of puzzles, I had a different position, but I think my focus was trying to think, well, hang on a sec. These acute presentations are on the back of something that's been grumbling for a while and is unexplained. There must be something that explains at least most of this, and then clinically trying to make observations that put me on a path of thinking of an infective heart problem. I suppose the answer in the end was something I didn't think of, but hopefully I was localized to the right sort of ballpark and thinking on the right lines. So, I think it's mainly about thinking that you want to always try and be multi-system, focused and connecting dots whilst doing your bit and not just doing your bit and then leaving the rest to everyone else. Because that actually I think isn't the best thing for patients.

HK: Yeah, I think that's really interesting to hear your perspective and reflections and how it's changed your thoughts going forward in your practice. And our listeners there at many different stages of their training career, but common to us all is that we're encountering patients either in acute and general medicine or in specialty environments that have more than one symptom or more than one issue. And what advice do you have for our listeners if they encounter a patient presenting with similar complex and escalating symptoms.

NW: It can be difficult and you may not be in the best position in the time pressures that you're under with in the key position, for example, to do that. But you certainly obviously have to stabilise and address the acute bit. That's your job and that's why they've come. But it can be rewarding, I think, in cases like this, to step back a bit and try and think a bit more broadly and actually put on your MRCP/PACES hat and think about it in a broader sense in terms of what might tie all this together. That doesn't have to be solving a medical puzzle, that can also be looking at the bigger picture of just this person's in and they've got a, I don't know, a infective exacerbation of a chronic condition. Okay, we'll deal with that and do these things. But also, actually, they've had several of them in the last five years and they're getting, they're losing all this weight and they're, you know, getting deconditioned. What's the bigger picture of this? And I think as I went through my training and got the hang maybe of the more basic stuff, I then had to learn more to think on those lines. And I'm on a general medicine rotation just now. It's something I've been trying to do today, for example, with some people I've seen. I think that bigger picture thinking takes time to cultivate, but I think it's actually rewarding because whether it's diagnostic or it's just thinking about where something is going on an overall sense and zooming out a bit, even when you're under acute pressure, I think is a rewarding thing to do. So I think as you progress in your physician path and whatever line of specializing or not, that you may go down, start to think of that as you progress along the line, that bigger picture look, as well as doing a huge part, looking at the bigger picture in terms of what's the overall context of this, and how can you kind of synthesize it all together? And I think for me, that was a rewarding thing to start trying to think about as I progressed.

HK: That's great. And thank you so much for sharing this case with us and your reflections on it. And I think your neurology focus, paired with your commitment to pursuing broader lines of inquiry that must have been quite time consuming, really paid off and made all the difference for this patient. And I think to summarize, what I've learned is that whatever specialty we choose to go into, like you say, we should keep our eyes and our minds open to the other organs that we might associate with other specialties, to stop and consider that there might be a multi-system disease at play. If a patient preferences between specialties or keeps coming back to the EMU. And like you say, just remember that everything is connected and step back and take that broader view. That's been really helpful. Thank you.

NW: Well, thanks very much for having me do this. And I'm really grateful for the time to speak to you about this case. And I learned a lot from it. And I'm especially grateful to the patient who, having gone through all this and being quite surprised that she's been harbouring this disease that she'd never heard of, and thankfully, having a good outcome was really supportive to us talking about her case, writing it up, presenting it so we wouldn't be doing this if not for her. So, I'm really grateful to her for that gift. I hope other people find it as educational as I have. Thank you.

HK: I think that's a great final thought to finish on that. You know, we're educators, but actually this patient has helped educate everyone as well. And we're really grateful for that. And so, for our listeners, if you are a medical student, foundation doctor or a collegiate associate member of any of the three UK royal colleges, keep an eye out for our next medical trainees conference next year. And if you encounter an interesting clinical case that's relevant to a general medicine audience like Neil's case, we'll be inviting submissions for our clinical lesson’s session nearer the time. Thank you for listening today and check out our other podcast episodes from both our Clinical Conversations and Career Conversation series. Thank you so much, Neil.

NW: Thank you. Thanks so much.