Case study 1. 41 yo female presents with 2/52 history of mild neck soreness, bilateral arm pain to elbow, and bilateral vague ‘wooly feeling' in feet. Previously diagnosed elsewhere – via telehealth - with ‘stress related neck pain, and sensitised nerves’. No neuro exam. 1/

Examination. Good neck range. Normal upper limb neural tension tests. Hyperreflexia upper and lower limb. Reduced sensation below C7, maximally in feet. Slightly unsteady gait. Minimal palpatory tenderness through Cx spine. 2/

Differential Diagnosis: 1. Demyelinating condition such as GBS. 2. Cx disc with cord compression...note: stress related neck pain didn’t quite make the list. Referred to A&E with covering letter requesting urgent investigation with neuro team. 3/

Assessed by A&E doc. Nil investigations. Nil neuro exam. Diagnosed with non specific neck pain and referred to a physio friend of the doctor. I am not kidding. This was a barn door neuro presentation, and no neuro was performed. Letter reportedly went unread. 4/

Patient calls. Anxious, symptoms worsening. Now difficulty rising from chair. Arrange consult with private neuro colleague, and she is seen urgently. MRI confirms large prolapse and cervical cord compression. Immediate surgery arranged. Patient recovering well 6/52 post 5/

Insights: 1. Be an advocate for patients. Safety net them. Particularly those who are falling through cracks or incompetencies in the system. I give my number to patients I’m concerned about. They don’t tend to use it unless they need to. But it’s an invaluable saftey net. 6/

2. When we're busy or unsure of the diagnosis, don’t jump for the non-structural/non specific label too quickly. When a presentation just doesn’t feel right, trust your intuition. 7/

3. Neurological symptoms require a neurological exam.
4. Telehealth consults have their limitations. End.