Physician's Assistant

Clerking (130 days ago 19:40)

Clerking Thu 27 November 2025 19:40

Last Modified: 130 days ago

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Medical ST4 Miller Clerking

Presenting Complaint:
Tachycardia and shortness of breath in pregnancy

History of Presenting Complaint:
Georgina is a 35-year-old lady at 35+4 weeks gestation (G2P1) presenting with tachycardia and shortness of breath. She had a growth scan today showing accelerated fetal growth velocity but fetal measurements within normal limits. Community midwife had concerns regarding small for gestational age and reduced fetal movements, however fetal movements were normal today. Patient reports waves of tiredness and increased urinary frequency, currently being investigated for gestational diabetes. Shortness of breath is positional, occurring when leaning forward, with baby lying high against diaphragm. No shortness of breath when walking or climbing stairs normally. Experienced one episode of palpitations this morning associated with tiredness, pulse felt at 100bpm but subsequently resolved. No chest pain, cough productive of sputum, or signs of upper respiratory tract infection. Has planned caesarean section. Previous pregnancy 4 years ago had similar issues with raised heart rate or blood pressure but no ongoing treatment required.

Past Medical History:
• Previous pregnancy with raised heart rate/blood pressure (no treatment required)
• Planned caesarean section this pregnancy

Medication History:
Pregnancy vitamins

Allergic History:
Not mentioned

Social History:
Lives with husband who was present today. Mobilising normally.

On Examination:
Heart rate initially 110bpm at 06:00, improved to 88bpm. Temperature 36.7°C, respiratory rate 20, BP 130/86, oxygen saturation 98%. Heart sounds normal. Chest clear but with quiet bases bilaterally. Abdomen distended consistent with 35+4 weeks gestation. No calf pain or swelling. ECG shows sinus rhythm rate 88bpm, no changes associated with pulmonary embolism, P mitrale seen in lead I.

Investigations:
CRP 1, Hb 113 (previously 115), potassium, sodium and urea all normal, white cell count normal. ECG: sinus rhythm rate 88, no PE-associated changes, P mitrale in lead I. Growth scan today: accelerated growth velocity but fetal measurements normal.

Impression:
Very unlikely pulmonary embolism. Tachycardia resolved. Mild anaemia of pregnancy. No ECG changes associated with PE.

Plan:
1. Discharge home with strong safety-netting advice [_]
2. Return immediately if persistent tachycardia, worsening shortness of breath, or syncope [_]
3. Consider iron supplementation for mild anaemia [_]
4. Routine obstetric follow-up as planned [_]

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Rapidreview (130 days ago 19:45)

Rapidreview Thu 27 November 2025 19:45

Last Modified: 130 days ago

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ACUTE MEDICAL ASSESSMENT

Date: 27/11/2025
Patient: Georgina Neil
MRN: 966270
Age: 35 years
Gestation: 35+4 weeks, G2P1

PRESENTING COMPLAINT:
Tachycardia and shortness of breath in pregnancy. Community midwife concern regarding small for gestational age and reduced fetal movements.

HISTORY OF PRESENTING COMPLAINT:
Patient presented with heart rate initially 110 bpm at 06:00, improving to 88 bpm on review. Experienced episodes of tiredness, palpitations, and positional shortness of breath. Symptoms appear related to fetal position high on diaphragm. No chest pain. Shortness of breath occurs mainly when leaning forward, resolves when lying back. Patient reports similar issues in previous pregnancy 4 years ago with heart rate and blood pressure fluctuations which resolved without treatment.

Symptoms potentially related to gestational diabetes screening (tested Monday) include fatigue, polyuria, and polydipsia, though patient attributes these to normal pregnancy symptoms.

PAST MEDICAL HISTORY:
Previous pregnancy with similar heart rate/BP issues - resolved spontaneously
Planned caesarean section for current pregnancy

OBSTETRIC HISTORY:
G2P1, 35+4 weeks gestation
Growth scan today showing accelerated growth velocity but fetal measurements within normal limits
Planned caesarean section

INVESTIGATIONS:
Bloods: CRP 1, Hb 113 g/L (previously 115), K+/Na+/Urea normal, WCC normal
ECG: Sinus rhythm, rate 88 bpm, no changes associated with PE, P mitrale seen in lead I
Vital signs: HR 88 bpm (improved from 110), T 36.7°C, RR 20, BP 130/86, SaO2 98%
Gestational diabetes screening: Results pending

EXAMINATION:
General: Well-appearing pregnant female, comfortable at rest
Cardiovascular: Heart sounds normal, no murmurs
Respiratory: Chest clear but quiet bases bilaterally, consistent with pregnancy
Abdomen: Distended in keeping with 35+4 weeks gestation
Lower limbs: No calf pain, swelling, or redness. Patient monitoring for signs of DVT

IMPRESSION:
Very unlikely pulmonary embolism. Tachycardia now resolved. No ECG changes associated with PE. Mild anaemia (Hb 113). Positional shortness of breath likely due to fetal position and diaphragmatic compression.

PLAN:
1. Discharge home with safety netting
2. Strong advice to return if persistent tachycardia, worsening shortness of breath, syncope, or chest pain
3. Iron supplementation for mild anaemia - continue pregnancy vitamins
4. Follow up gestational diabetes screening results
5. Routine obstetric follow-up continues
6. Patient advised regarding increased VTE risk in pregnancy and post-partum period

Patient declined further investigation (CT-PA) which is reasonable given clinical picture and resolved tachycardia.

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Rapidreview (130 days ago 19:50)

Rapidreview Thu 27 November 2025 19:50

Last Modified: 130 days ago

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35-year-old lady, G2P1 at 35+4 weeks gestation, presenting with tachycardia and concerns regarding fetal growth.

History of Presenting Complaint:
Patient attended for growth scan today showing accelerated growth velocity, though fetal measurements remained within normal limits. Community midwife had previous concerns regarding small for gestational age and reduced fetal movements, however fetal movements were reported as normal today.

Patient reports episodes of tachycardia with heart rate initially 110 bpm at 06:00, improving to 88 bpm. Describes positional shortness of breath, particularly when leaning forward, which resolves when lying back. Attributes symptoms to baby lying high on diaphragm. One episode of palpitations this morning associated with wave of tiredness. Denies chest pain, productive cough, or symptoms of URTI. Reports increased urinary frequency and tiredness - tested for gestational diabetes on Monday (results pending).

Past Medical History:
Similar episodes of raised heart rate and blood pressure in previous pregnancy 4 years ago, no treatment required. Planning caesarean section.

Observations:
HR: 110 bpm initially, improved to 88 bpm
BP: 130/86 mmHg
Temp: 36.7°C
RR: 20/min
SaO2: 98%

Investigations:
ECG: Sinus rhythm, rate 88 bpm. No ECG changes associated with pulmonary embolism. P mitrale seen in lead I.
FBC: Hb 113 g/L (previously 115 g/L) - mild anaemia
U&Es: Potassium, sodium and urea all normal
WCC: Normal
CRP: 1

On Examination:
Heart sounds normal. Chest clear but with quiet bases bilaterally. Abdomen distended in keeping with gravidity. No calf tenderness or swelling.

Assessment:
G2P1 at 35+4 weeks with resolved tachycardia. Very unlikely pulmonary embolism given normal ECG, positional nature of breathlessness, and clinical picture. Mild anaemia contributing to symptoms.

Plan:
1. Discharge home with strong safety-netting advice
2. Return immediately if persistent tachycardia, worsening shortness of breath, syncope, or any concerns
3. Consider iron supplementation for mild anaemia
4. Routine antenatal follow-up
5. Patient declined further investigations for PE which appears reasonable given clinical picture

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Rapidreview (130 days ago 19:52)

Rapidreview Thu 27 November 2025 19:52

Last Modified: 130 days ago

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Content:

35-year-old lady, G2P1, currently 35+4 weeks gestation, presented with tachycardia and shortness of breath.

History of Presenting Complaint:
Patient attended for routine growth scan today which showed accelerated fetal growth velocity but fetal measurements within normal limits. Community midwife had concerns regarding small for gestational age and reduced fetal movements, though patient reports fetal movements are fine today.

Patient experienced episodes of tachycardia with heart rate initially 110 bpm at 06:00, improving to 88 bpm. Reports occasional shortness of breath which appears positional, particularly when leaning forward. Describes waves of tiredness and increased urinary frequency. Had one episode of palpitations this morning associated with fatigue. Recently tested for gestational diabetes due to symptoms. Previous pregnancy 4 years ago had similar issues with raised heart rate or blood pressure but no treatment required.

Past Medical History:
G2P1, planning caesarean section
Previous pregnancy with similar tachycardia/hypertension issues

Examination:
Observations: HR 88 bpm (improved from 110), BP 130/86, Temperature 36.7°C, RR 20, Sats 98%
ECG: Sinus rhythm, rate 88, no changes associated with pulmonary embolism, P mitrale seen in lead I
Cardiovascular: Heart sounds normal, no chest pain
Respiratory: Chest clear but with quiet bases bilaterally, reduced lung expansion due to gravid uterus
Abdomen: Distended in keeping with 35+4 weeks gestation
No calf tenderness or swelling

Investigations:
CRP 1
Haemoglobin 113 g/L (previously 115) - mild anaemia
U&E normal (potassium, sodium, urea)
FBC: Normal white cell count
ECG: As above

Impression:
Very unlikely pulmonary embolism
Tachycardia now resolved
Mild anaemia of pregnancy
Positional shortness of breath secondary to gravid uterus

Plan:
1. Discharge home
2. Strong safety netting advice to return if persistent tachycardia, worsening shortness of breath, syncope or other concerning symptoms
3. Consider iron supplementation for mild anaemia
4. Patient declined further investigations which is reasonable given clinical picture
5. Routine obstetric follow-up

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Sdec (138 days ago 21:03)

Sdec Wed 19 November 2025 21:03

Last Modified: 138 days ago

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Content:

Presenting Complaint:
Tachycardia and shortness of breath in pregnancy

Past Medical History
• F+W

Diagnosis:
Very unlikely pulmonary embolism. Tachycardia resolved, no SOB.

I had the pleasure of meeting Georgina Neale in Same Day Emergency Care today.

Georgina is a 35-year-old lady, gravida 2 para 1, currently 35+4 weeks pregnant, who presented with tachycardia and shortness of breath. She had a growth scan today which showed accelerated growth velocity but fetal measurements were within normal limits. Her community midwife was concerned about her tachycardia and so she was assessed in the AMU.

Georgina reported episodes of tiredness and palpitations, with one episode this morning where she felt her pulse was around 100 bpm but this resolved. She describes paroxysmal positional shortness of breath, particularly when leaning forward, which she attributes to the baby being positioned high up against her diaphragm. She is still able to climb a flight of stairs and has not reduced exercise tolerance. She denies chest pain, cough, or signs of respiratory tract infection. She is being investigated for gestational diabetes due to symptoms of tiredness and polyuria. She recalls similar episodes of raised heart rate in her previous pregnancy 4 years ago but required no treatment.

On examination, heart sounds were normal, chest was clear but with quiet bases bilaterally. Abdomen was distended in keeping with gravidity. No calf pain or swelling noted.

Her initial heart rate was 110 bpm but improved to 88 bpm on subsequent ECG. Temperature 36.7°C, respiratory rate 20, blood pressure 130/86 mmHg, oxygen saturations 98%. ECG showed sinus rhythm rate 88 with no changes associated with pulmonary embolism. Very mild P mitrale was noted in leads I and II.

I explained today that there isn't any evidence of pulmonary embolism currently, but that we should be vigilant for this as she is at increased risk due to her pregnancy. Unfortunately, we can't use the blood test for clots in pregnancy and rely on scans. She would be very keen to avoid radiation.

Investigations:
CRP: 1
Haemoglobin: 113 g/L (previously 115)
Electrolytes: Normal (potassium, sodium, urea)
ECG: Sinus rhythm, rate 88, no tachycardia, S1Q3T3 or T wave changes
Growth scan: Accelerated growth velocity, fetal measurements normal

Plan:
1. Discharge home
2. Safety-netting advice to return if persistent tachycardia or worsening shortness of breath, syncope etc.
3. Return immediately if concerned about symptoms

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Clerking Thu 27 November 2025 19:40

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Rapidreview Thu 27 November 2025 19:45

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Rapidreview Thu 27 November 2025 19:50

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Rapidreview Thu 27 November 2025 19:52

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Sdec Wed 19 November 2025 21:03

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