So it's a clocking for fiona peachy foxtrot 303065 36 year old lady 25 weeks pregnant presenting complaint chest pain 3 weeks past medical history migraine low vitamin d previous pregnancy 2022 psychotic disorder suicidal thoughts emotionally unstable personality disorder serotonin syndrome irritable bowel syndrome celiac disease lutarone fibroids previous sexual abuse medications list perazine 1 taken up to 3 times per day for nausea stexoril d 3 1000 unit tablets per day for vitamin d ferrous fumarate 210 mg 1 to be taken twice a day tranexamic acid 1000 mg to be taken 3 times a day for the maximum of 4 days during periods investigations crp 16 lft is normal troponin less than 2 neutral 6.9 with white cells 9.7 hemoglobin 100 with low red cell counts venous blood gas normal recent ultrasound abdomen and pelvis for lower abdominal pain no abdominal pathology demonstrated no uterine fibroid visualized looks alright it's well stuck down yeah so like said I'm rob I'm 1 of the medical doctors hello I've read all about what happened in amy last night yeah and you've been having some chest discomfort for 3 weeks yeah when you're breathing or all the time like when I'm breathing mhmm it's like coming off so mhmm so when will it affect you it just comes off nothing no clear trigger fine short of breath along with it yeah any cough literally k and what are ringing up nothing I taste blood but I'm not actually bringing anything no you're not bringing blood up yeah you're just coughing along fine okay and any fevers or anything like that no no fine okay so and and did did they explain to you what they might be worried about in a and e or anything well they mhmm yeah so your risk is increased 3 to 4 fold during pregnancy of a clot on the lungs which is a pe have you had scans to look for a pe before you've had that investigated in my last pregnancy in last pregnancy 2022 was it yeah yeah mhmm fine and how did that all go the pregnancy fine good yeah fine no trouble you didn't have a pe at that time no no okay great fine so does this feel similar to your last pregnancy what happened last time no no feels different it was literally was at fine completely oh completely different that time yeah and the test then didn't show you had a pe no any blood clots in the family or anything like that okay good any sore legs nope nope great fine there's a clot ramps okay test only show that your electrolytes are depleted or you're dehydrated or anything like that rest of require you're a bit anemic but it looks like someone's already started you on iron no fine you're on you've got iron on your repeat prescriptions ferrous sulfate so I was on it before I was mhmm got that so it's safe in pregnancy to have iron it's probably good to have normal hemoglobin in pregnancy it'll probably make it feel better make your baby grow better so you can take that if you want about that 1 the ferrous sulfate is called you're taking 200 and I saw in your okay I think have ferrous it might be fumarate both of them are safe in pregnancy yeah I thought it was sulfate but was mainly fumarate so it's folic acid then folic acid helps your red blood cells be created in your bone marrow so you need folate to make cells basically and make dna to also make but you need iron to make hemoglobin for red cells so you need folic acid in pregnancy you're making your baby is lots of cells being yeah exactly it's a different thing that can be low you can be anaemic because of low folate as well we recommend all pregnant women have folic acid from even when you're trying to conceive up to delivery we recommend everyone has folic acid like in pregnant care and things like that like a folic acid supplement and then we for you because you're anaemic iron would be good as well question will be what we do to investigate the potential of a clot oh they're done so no you you've had some blood tests which are fine there's high markers of red white blood cells what we know that goes along with being pregnant so and it doesn't look like you've got a big raging chest infection on your blood test to explain chest stuff had a urine infection I wasn't at the doctor had some tummy pain you had an ultrasound still got the tummy pain mhmm okay well we can have a look today dip your urine and see whether there's any protein in it or any infection in it do have she says I have protein in there just in case of weight did she start your antibiotics no no okay no have you is this similar to utis you've had before it's just it's stinging down there yeah yeah unfortunately that swab isn't back yet I haven't got the result of that oh it should off yes okay fine yeah so I don't have that if you do go for a wee while you're here it'd be great to get a sample of your urine to see so in terms of investigating for a pulmonary embolism similar to last time when you had a ct scan there's a risk benefit sort of discussion about investigating pe pregnancy there's in terms of radiation risk to the baby a scan is negligible in terms of there's no risk that it causes loss of the baby or damage to the baby in uterus there's a very tiny increased risk of childhood cancer it's so tiny and it's probably overestimated the main risk is to you and to your breast tissue which is sensitive when you're pregnant to radiation you've already been scanned before during pregnancy which further increases your risk so the increased risk is 13.6% of an increased risk so your absolute risk for a woman is naught naught 1% so it increases that risk by 13.6% so your risk is naught naught naught 1 1 3 6% does that make sense and then another scan will increase your risk further by another 13.6% my. Being 13.6% sounds like a scary number I'm not saying that 13.6% of people in your case will get breast cancer I'm saying that your risk is increased by that by having another scan what we'll try and do is do a scan called a vq scan so it's not a ct scan but it has less radiation risk for your breasts but it hopefully will answer the same question for us it's a nuclear medicine scan which sounds scary but it's when you breathe in some slightly radioactive material and we see how it's excreted dust it's complicated but it's a better scan for you in terms of risk to your breast tissue than a ct scan especially since you've already had a ct scan before so I don't want to get breast cancer in the future the chest x-ray doesn't help no it it it make I you haven't got a pneumonia I can tell you that which is good well we had a chest x-ray today exactly exactly so if the ct so if the chest x-ray showed pneumonia and we were still worried about a pe then I'd say have a ct scan oh and we still wouldn't because you your previous ct scan in theory the guidelines would say to do a ct scan because that tells that shows us whether you've got a big pneumonia as well as whether you've got a clot in your lungs okay does that make sense the vq scan which is the nuclear medicine scan I'm talking about doesn't tell you if you have a pneumonia or not it just rules out pulmonary embolism okay but that's a safer scan for you and your breast tissue so I would recommend that from reviewing everything because I think that's I'll request that for you if that's okay it'll happen sometime today there's a fat waiting around with all these things in hospital sorry it is not the 1 that they yeah so yeah ct scan is the 1 where you get the dye but this is not that scan this scan I'm allergic to the dye oh you fine another reason to not have a ct scan what happens when you have the dye well I what happened just came out with massive rash right so another reason there's no dye in this 1 there's a radioactive material that you breathe in if we need to do that usually the first scan the first part of the test without any radioactive breathing in can exclude okay brilliant can I have a quick look at you if you mind yeah I'm just gonna see if you can great perfect done okay and this is done okay what do you do for a living I'm a carer I'm like out at the area I've got a couple of people who've seen me right yeah that's not just need to the family know you've got someone who can step in for you mhmm okay congrats whenever you're ready had anything to drink no yeah good you just a bit water your heart's been quite fast you might be a little bit dehydrated I don't know if you feel dehydrated dehydrated it's it's like all along things like that the paramedics come on and it's been raining quite a yeah fine good have you had a tracing of your heart yes fine I haven't seen it I'm not gonna look for it it's on a bit of paper somewhere that they've lost ah yes clearly you have I don't think I've done it I believe it if I that's fine you can take them off if you've had a tracing before then I can see that you can take them off it's fine yeah great so I'll look at the tracing of your heart I'll pick you that ct that vq scan not a ct scan good the nuclear medicine will go and do that now they should be able to give me a slot for when it will happen oh okay we've already given you the injection of the blood thinning haven't we yeah so you're safe it's the most important thing so even if this is delayed you're you're in a safe place and you're safe having had the medicine even if they can't do it today we could in theory send you home bring you back tomorrow for the scan and keep you on the blood thinning medicine okay sound good yeah thank you and this is your second pregnancy no fifth pregnancy I'm not sure when he's seen sorry just because your gp record only has 1 previous pregnancy code I've had like 4 so this is my fifth this is your fifth pregnancy yeah okay and you've got 4 kids yeah and last say again this is my last 1 5 okay and how many and you're 24 weeks 25 25 26 25 + what week on friday well 26 on monday you're 25 5 okay yeah well it's due to see the midwife today phone or in person in person because I've helped your mom oh from your friend from your friend yeah mhmm so I don't I think that's worth chatting to the midwife about and it's worth making sure you haven't got a urine infection as a cause of that isn't it yeah so if you're able to give us some urine whenever you get a chance that'd be great yeah I will call do you know the the name of the midwife you're seeing in the cumberland abby abby mhmm alright is she she she always see you yeah that's fine she's your named midwife she's seeing me every 2 to 3 0 what time is she so I'm not gonna you to oh o'clock o'clock should I give her a call and see maybe she might wanna catch up with you on the phone or even maybe come off yeah my signal's rubbish okay but I don't know if my partner's gonna do want me to leave you in here for a moment you can take your top off and take all of the things off I've got I've taken them all off cool yeah they look a bit red where they've been I'm sorry they're horrid things aren't they and sometimes people have very sensitive skin to look oh I do yeah can I get you anything in the meantime anything to make you feel better do want some paracetamol for your tummy pain chest pain yeah well it does anything something in it do have a bit yeah easier on things so I'll call abby and tell her that you're here I'll book you the vq scan I'll find out when it'll be if it's today we'll get it today if it's tomorrow we'll send you home with the blood thinning medicines and get it tomorrow thank you and I'll be here all weekend alright oh sadly or bloody hell that day mother told me they wouldn't do any tests over the weekend reassuring I would have thought if you had a big pe you'd be much more unwell if you've had it for 3 weeks it's it's it's good after that yeah so but yeah mhmm I'll ask them to check your blood pressure when you sit down and stand up if that's alright so you've got your all right now you're alright now yeah yeah had a 24 hour mhmm but we only monitored your heart rate didn't monitor your blood pressure did it those 24 hour monitors a 24 hour blood pressure monitor yeah yeah it's a little pain there it is it must be yeah right sorry I will do you want a bit of time in here to sort of you sniff it out or just say you've got something I think I've got 1 okay I'll find out it's alright look if there's if we all scuffed or you need anything just grab the nurses that can grab me I'll come and speak to you and we'll see some questions great and and what have a glass of water or something I've got coffee okay or you get shopping yep I've coffee I've coffee now a perfect combination thank you bye bye you too