It was odd – me, fully dressed in suit and tie and Parsons, colleague and head of my PCT, sitting in front of me almost naked. The thought of examining him didn't trouble me. It was the thought of what I might find that gave me pause.

Difficult as it was, I was prepared to treat him as any other patient. It was one of the big changes I'd had to make from my surgical practice in London. There, I knew almost none my patients. Here, I knew almost all of them so, in that respect, treating Parsons was not all that unusual.

What was rare was for me to be examining a colleague. In London, most of my patients were elderly and it was unusual for my fellow physicians to consult me on a surgical matter involving their own health. In Portwenn, it was virtually unheard of. Occasionally, Samuels, the Wadebridge GP, would seek me out. And there was the unfortunate recent episode with Dr. Dibbs. But other than that, I hadn't examined a fellow doctor in years.

It didn't matter. Parsons was just another patient – except that he wasn't. He was, I had to admit, a friend.

I deferred taking vital signs until the vascular workup and started with a basic neuro exam, as a neurological issue remained the most likely explanation for the symptoms Parsons had experienced. Given his expressed issues with blurred vision and aphasia, I first checked the cranial nerves, focusing on CNs II, III, and XII.

"Look at my nose and don't move your eyes."

He nonetheless rolled his eyes at me. "Mart, I know how it's done."

"Uh-huh." I had Parsons follow my finger through various movements and then carefully examined both the optic discs and the vessels of his eyes. I asked him to show his teeth, shrug, cough, and wrinkle his forehead, all to test neurological responses.

"I feel like an idiot," he said as, at my command, he stuck out his tongue and moved it from side to side.

I didn't even smile. "Neuro exams can have that effect."

My exam wasn't as rigorous as a neurologist would have performed, but his responses were all within normal limits and I was reasonably certain that his ischemic episodes didn't have a neurological origin. And nothing in his history suggested a recent viral problem. Which made it more likely that Parsons' problem was vascular. Time to move on.

His ears, nose and throat were all normal as was my palpation of his neck. I returned the ophthalmoscope to my desk and placed the tips of my stethoscope in my ears.

"Are you always this quiet?" Parsons asked.

"I'm conducting a medical examination not auditioning for a reality show."

"Some casual conversation might help put your patients at ease."

"I don't engage in casual conversation."

He sighed and gave me a limp smile. "No, I suppose you don't."

I had him breathe in and out while I listened to his lungs, which were clear, and his heart, which was without murmur or other abnormality.

"Mart, I must say that, bedside manner aside, you make a damn good GP."

I shrugged. "I'm only doing a basic exam. It's not difficult."

"What do you find difficult?" he asked.

"Having casual conversations with patients. Lie back."

He paused halfway there. "Everything check out so far?"

This time I rolled my eyes. "Yes."

"You'll tell me if you find something that troubles you?"

"Your symptoms trouble me," I replied. When he furrowed his brow at my response, I relented. "Yes, I'll tell you. Now lie back."

As I probed his abdomen, the tension beneath my hands told me that, despite Parsons' light banter, he was quite nervous. Unfortunately, it was making my examination more difficult.

"Relax," I said, switching my gaze to his face.

He grimaced. "Sorry. I'm trying."

I bit back a "try harder," and instead said, "Take some deep breaths."

He did as instructed, and I continued my exam, finding his abdomen soft and non-tender, with no palpable masses. I stepped over to my rolling cart and grabbed a pair of gloves. "Slip off your pants and stand next to the table."

Parsons propped himself on his elbows and frowned. "Come on, Mart. That's not necessary."

I didn't even pause in pulling on the gloves. "I'm your doctor. I'll decide what's necessary."

"Is this how you talk to all your patients?" he grumbled.

"Yes." I seated myself on the rolling stool. "You know these exams are important. You should be visiting your doctor on a regular basis."

"Mart, you sound like a GP."

I looked up briefly. "I am a GP."

"Not for much longer."

True. It was something I should be thinking about constantly – my return to surgery. What I'd desired for so many years, what I'd worked so hard to achieve, was about to become a reality. In but a few weeks, I'd be back in London, at Imperial Hospital, in the operating theatre. And yet, since my aborted departure from Portwenn and the birth of my son, I rarely found myself thinking about my future.

During the day, I plodded through the routine of being the Portwenn GP, diagnosing and treating the mundane ailments of the village idiots. And at night . . . at night, I was with Louisa and the baby and my only thoughts were of the small number of nights the three of us had left together as a family in Portwenn. Even though we weren't a family—

"Mart?"

Blast it! I blinked with the realization that Parsons had been standing there while I reflected on . . . "Sorry," I said with a sigh, mentally shaking off my thoughts and refocusing my attention on my patient.

The urological and prostate exams were unremarkable. I binned my gloves and had Parsons put his pants back on while I washed my hands.

"Everything's normal thus far," I reported. "I'll do the vascular workup now."

It was Parsons' turn to sigh. "Right."

Although it had been several years since I'd last performed a detailed vascular exam, the instant I started it was as if I'd never been away. Given Parsons' symptoms and the lack of findings on physical exam thus far, my major concern was the carotid, but I didn't want to make a premature diagnosis without a complete examination.

"Give me your hands." I carefully examined his arms and legs and checked his reflexes. There was no swelling or other sign of peripheral artery disease. "Now your right arm."

I continued with bilateral BPs, finding them equivalent although slightly above normal. "Your BP's 160 over 86," I told him with a frown.

Parsons shrugged. "White coat syndrome."

"I don't wear a white coat," I pointed out but, ironically, he was probably correct. As I'd already seen this morning, even a doctor had some fear of what an examination might reveal – and especially a doctor with symptoms he knew could be serious. I'd take his BP again at the end of the consultation – if it remained high, I'd consider adjusting his medications.

"Lie back again." A check of peripheral pulses in the carotids, wrists, femoral arteries, and ankles was unremarkable. Yeah, it was almost certainly the carotid.

"Martin, when is this going to end?"

"When I'm finished."

I pressed my stethoscope to his neck, listening carefully to the blood flow through first the right carotid artery and then the left. As I did so, Parsons lay quietly, worried eyes fixated on mine.

"Do you hear a bruit?" he asked anxiously.

I raised my free hand. "Shush."

He scowled but remained silent.

I was surprised Parsons had used the technical term for the sound made by blood rushing past an arterial obstruction. Either he had a good memory from medical school or he'd done some brushing up. When I'd finished my examination, I pulled the stethoscope from my ears and stepped away from the table.

"Get dressed. I'll take some blood and I'll need a urine sample. And I want to take your blood pressure again before you leave."

"So?" he asked, pulling on his trousers.

I sat down at my desk and faced him squarely. "In answer to your question, there is a bruit on the left side. However, that's not always indicative of vascular disease."

"Oh, come on Mart. The TIAs, the bruit . . ."

What I'd said was true. Most people who came to diagnostic conclusions from watching medical shows on TV or from reading articles on the Internet would conclude that a bruit – the "rush" – in one of the carotid arteries – was the primary mechanism for diagnosing carotid artery stenosis. Although certainly one indication, it was insufficient to make the diagnosis and could be present even in the absence of vascular disease. As a physician, Parsons should know that. But, as I'd come to realize, he was thinking like a patient instead of a doctor.

"The repeated ischemic attacks are more worrisome than my findings on exam," I said, adding to his patient notes. "I'll organize an immediate carotid duplex and MRA, which should be determinative."

"Yeah," Parsons said in resignation, buttoning his shirt.

"You know they're not painful."

"It's not the scans I'm worried about. It's the results. Tell me the truth, Mart, what do you think?"

I shook my head. "Chris, the H and P only give me so much information. I can't make a definitive diagnosis without further investigation."

"But," he said meaningfully as he finished tying his shoes and then seated himself across the desk from me, leaning forward in the chair. "Come on, Mart. I came to you because you're the vascular expert. What does all that experience tell you?"

Given Parsons' symptoms, his history of hypertension and elevated cholesterol, and the results of my neuro and vascular exams, I was reasonably certain of the diagnosis even without the confirmatory scans.

I sighed. "That you have carotid stenosis."

Parsons blew out a long breath. "Damn."

I tapped my pen against my open palm. "If my diagnosis is confirmed, it's easily repaired surgically with endarterectomy. A routine procedure."

"You know what they say about routine surgery?"

I stared at him. "No I don't."

"It's surgery performed on someone else."

I rolled my eyes. Carotid stenosis was a serious condition but also a treatable one and certainly preferable to some of the diagnoses in my original differential.

"You should have your scans done in London," I told him, leaning back in my chair.

He blinked in surprise. "In London? Whatever for?"

"The ultrasound requires an experienced technician who performs the test frequently – someone whom I can assure you doesn't exist in Truro. More importantly, if you do need surgery, Leahy and Meadows are in London and they're not going to rely on testing done here. I wouldn't have. So, if you have the tests done in Truro, you'll need to have them redone in London."

"Martin, I'm head of the local PCT. How would it look if I went to London for tests that everyone else has to have done in Truro?"

"It would look like you had common sense."

He gave me an annoyed look. "I'll be fine having the tests here. Besides, I've no doubt you'll be looking over their shoulders every step of the way."

Of that he could be sure. If Parsons was going to let the local idiots run these critical scans, I would at least ensure they were performed properly.

"And if you do need surgery?" I challenged. The best surgeon in Truro was arguably Adrian Pitts and there was no way I was letting him operate on Chris Parsons. If Parsons needed surgery, I'd insist he go to London.

Parsons waived aside my objection. "Let's cross that bridge when – if – we come to it." He stood up.

"I'll book you in for the scans tomorrow."

"I can't tomorrow. I have—"

"Tomorrow," I said with finality.

"Martin . . ." he started ominously.

I raised myself to my full height and stared down at him. "Chris, you wanted my advice. With two TIAs in a fortnight, you're at increased risk for a massive CVA. I think we'd both prefer that didn't happen."

He raised his hands in mock surrender. "All right, all right. Tomorrow."

"Good."

After finishing the blood tests and rechecking his BP, which was now at least close to the normal range, I escorted him into the waiting room. Emily jumped to her feet the moment she saw us.

"Everything all right?" she asked hesitantly.

"Martin wants me to have some scans."

She frowned. "Scans? What's wrong?"

Parsons put his arm around her shoulder. "We'll talk about it on the drive home."

This only seemed to make Emily more nervous and her deep brown eyes flicked to mine, searching for answers. Unfortunately, it wasn't my place to discuss what I'd found. There was patient confidentiality but also, I thought to myself, some things that husbands – not doctors – needed to tell their wives.

"I'll see you tomorrow in Truro," I reminded him at the front door.

It was still raining outside, a situation that was unlikely to change all day. I checked my watch as I returned to the consulting room. I still needed to organize the scans. As I picked up the phone, I reminded myself that I was merely ensuring proper follow up for a patient. Just another patient.

Medical Glossary

Bruit – Unusual sound blood makes when rushing by an obstruction, such as one caused by plaque clogging an artery

Carotid artery stenosis/carotid stenosis – narrowing of the carotid artery due to atherosclerosis (plaque build up)

Carotid duplex – also called carotid doppler. A noninvasive, painless ultrasound screening used to view the carotid arteries looking for plaques and blood clots and to determine whether the arteries are narrowed or blocked.

CNs – cranial nerves. They are referred to by Roman numerals. CNs II and III relate to the optic nerves and control sight. CN XII is involved in speech articulation.

Endarterectomy - a surgical procedure to remove plaque or a blockage from an artery by separating the plaque from the arterial wall.

H&P – history and physical (medical history and physical exam)

Ischemic – refers to restriction in blood supply

Peripheral artery disease - obstruction of large arteries not within the heart, aorta or brain. Often refers to blockages found in the legs.

Peripheral pulse – pulse that can be felt in the extremities (arms, legs, etc.)

TIA – transient ischemic attack – often called a "mini-stroke." A passing episode of neurologic dysfunction caused by ischemia (loss of blood flow to the brain) without tissue death. A TIA may cause sudden loss of vision, aphasia, slurred speech, weakness, numbness and/or mental confusion as well paralysis on the opposite side of the body of the affected brain hemisphere. Unlike a stroke, the symptoms of a TIA can resolve within a minutes or hours.