Transcription - 20251119T 20-21.mp3

Georgina neil 35 year old lady 966270 this is walter she's not telling me of the she was okay she has growth scan today accelerated growth velocity fetal work within normal limits fetal size measurements normal said I don't think she's still worried about it community midwife's suspicion of small for gestational age and reduced fetal movements however in the thyroid movements fine today investigation crp 1 hemoglobin a 113 from a 115 potassium and sodium and urea all normal white blood count white blood cells count normal observations heart rate a 110 initially at 06:00 but improving to 88 on ecg prior to review temperature 36.7 respiratory rate 20 blood pressure a 130 over 86 saturation is 98% and this is compare ecg sinus rhythm rate 88 no ecg changes associated with pulmonary embolism p mitrale seen in lead 1 he's had a cabg 8 weeks ago and 2 you don't think it's he's he's related to k if I can find the line switch alright you want to be how's it all going yeah okay yeah it's a long stop isn't it it's okay yeah it was okay I am okay I think they're just extra precaution just doing because I have a a bit of a high heart rate mhmm but is that something that's affected you before in pregnancy or is it no I can't remember that's I I had it in my little guy 4 years ago I never seem to remember things like that mhmm I know I went in a few times it was either heart rate or blood pressure mhmm that was raised but then it was fine it treatment for it no no nothing no nothing and it's only on the slight it's on the edge isn't it a 100 a 105 I think exactly but I have been fine with yeah exactly I have been fine with it I think they tested me on monday for gestational diabetes okay because some of the symptoms I don't know if that's all linked to what are the symptoms tiredness mhmm like waves of tiredness which can be normal for my yeah we attribute everything to pregnancy though don't we any symptom you've got but I think pregnancy it's hard no no was gonna do yeah accelerated growth as well which I just had a scan today yeah you saw that is only slightly but because it keeps going sort of that and what was the other symptoms you go for a wee a lot or anything like that yeah sorry of course yeah it's a long day sorry yeah yeah so what's the other symptoms mean which again I haven't raised it because I thought oh it's quite normal cause the baby's pushing my bladder so yeah drinking it and yeah so hopefully fingers crossed it'll be good I was like I'm maybe there like 3 and a half weeks so I don't wanna yeah exactly but this is where all the the annoying problems start isn't it yeah exactly yeah just because I mentioned shortness of breath I think they were concerned I mean it hasn't it's only ever so often I think it's as I was talking to midwife she thinks it was because I was leaning on like it's positional like you don't feel it as I'm walking around fine or like fine stairs yeah yeah fine well yeah yeah slowly slowly but you could do it and you wouldn't feel puffed out no no it depends on the stairs I was saying the maternity stairs a 100% I would be yeah that's true because I'm unfit as well but that's a lot yeah little ones a lot yeah for carrying extra weight but of course like since I've been here my chest has been fine mean I just need to just lie back a little bit but he is quite high up yeah of course on my diaphragm they said so I think did they say did they say that's where he was lying yeah yeah and you're having a little boy I'm guessing yeah yeah yeah that's nice it's just because there's a little and then so they just because they because the heart rate wasn't coming down kicking you in the ribs yes yeah yeah which is makes sense that when she says is it when I'm like leaning forward a little bit and I'm like actually yeah so I'm just like that when I do feel like that and I feel okay after that so but yeah that's why cough or cold or anything like that no I mean I have coughed a little bit today but I don't know if there's bring anything up no no no nothing no it's not like a bad fro or sniffy nose or nothing like that no nothing like that today okay well not for a little while haven't had a cold really no I feel fine apart from the normal pregnancy and it's just because I would if you wouldn't know about the heart rate unless it was being tested yeah mhmm do you get palpitations or pain in the chest or anything like that no no pain in the chest I thought at 1. I did have a palpitation palpitation which I brought up to the midwife this morning just because I I came over like a wave of tiredness and palp and that's when I felt my pulse and first felt it was a 100 mhmm but then that went so mhmm it was then I haven't had that yeah of course don't blame me it's ready yeah but and ready for sleepless nights if you're happy that the heart rate yeah so we don't yeah your heart rate's got better now yeah you had the ecg yeah I'm sure everyone's explained to you what we worry about is a clot on the lungs mhmm when you're pregnant your risk is 4 to 5 times higher than an average person yeah because you've got baby in there your blood's a bit thicker you're a bit dehydrated and you're at more risk of getting clots in the hand glots are rare in pregnancy they they happen in less than 1 in 10000 really pregnancies they are rare objectively rare yeah and people that we investigate we only find it in about 2% of cases where we investigate it we see this a lot in our acute medical unit is that all over or just the lungs in clots in the lungs or the lungs oh okay yeah yeah lungs or legs the 2 places that we mostly look for in the lungs so we'll find it in about 3 4 7 people when we go looking you don't have any of the worrying changes on your electrocardiograms your ecgs you'd see them great we usually would yeah yeah in about half the people we'd see some changes on the ecg and we don't see that on serial testing of your ecg just see anything about which is good but we don't have a good test for it in terms of blood test some people we can do a non invasive blood test and they'll tell us but when you're pregnant that blood test will be raised anyway so we're in a difficult situation where if we want to exclude it a clot on your lungs then we need to do another test yeah which would be a scan exactly sure there's no concern for me as to- I think from what you tell me I don't think there is but we know that it's a significant risk you're at risk of it and it's a significant factor in terms of maternal morbidity and maternal mortality having clots so on your if you are getting palpitations more regularly you're feeling more yes definitely I'll keep an eye before pregnancy and then I'll keep an eye after pregnancy as well yeah exactly because you're on a slightly increased risk after still as well yeah for the last 2 weeks after you're at a slightly increased risk I mean I am yeah because I do remember I'm having a c section as well so I do remember having some yeah you have the injections as well to stop that yeah the socks and stuff because you're moving around so much because you're sort of tonny no okay I'll make sure I'll do all that yeah so the the you might say what's this what's the problem just do a scan the problem is that we expose you in terms of your sensitive breast tissue at this moment because it's developing food for your baby and your baby to radiation the baby radiation isn't really a problem doesn't really cause much trouble but the risk of breast cancer is increased by quite significantly maybe by 13 or so% although your relative risk is small yeah it does increase the risk you know small% of that happening and you finding a clot exactly so we end up investigating a lot we don't find it very often but we should be vigilant about it and we should worry about it yeah you don't seem worried no no it's only if if I was feeling like really out of breath yeah then most of the time and blah blah blah then I'm feeling comfortable like I've got yeah then I would but then it's just yeah it makes sense just the the the positional yeah on my diaphragm yeah and then yeah so if that wasn't the case yeah like lying back here it was fine so yeah so no I think it's positional and if we thought it was a clot what we would do is give you an injection of some blood thinning medicine like the stuff you have after a c section the same stuff and then send you home and bring you back tomorrow to do a scan so what we could do is a nice middle ground and say we'll give you any blood thinning medicine if you don't think it is but if you go home overnight and feel crap just come back and see us come back and see us at 02:00 in morning don't mind or come back to see us tomorrow morning and we can do a scan and give you the blood thinners and any breathing issues then come you're like your heart's still going fast and you don't have a reason why then please do come in and see us and we we can just do the scan tomorrow no trouble giving the blood thinner okay perfect yeah does that sound like a good yeah that does sound like a net for you like we're here and we're happy to see you yeah exactly yeah yeah sound sounds good your blood test show you're slightly anemic lots of people who are pregnant are slightly anemic yeah so I was yeah I was expecting it to be that's what I thought was gonna be the case just because of the that came back when yeah I mean a little bit lower yeah it is a little low you know that can make people feel slightly short of breath okay maybe not massively short of breath it could contribute and certainly could contribute to tightness but not enough wearing isn't he well you know I think it we just accept those levels we're bad because when we see people are pregnant we're like oh that's alright yeah but probably being not anemic will make you feel good and some people go on iron tablets for those have you have you tried that before no I mean I knew it would help if I took pregnancy vitamins yeah as well vitamins initially a little bit in there and see how you're yeah yeah fantastic it's better than nothing isn't it and then eat eat a little bit better yeah yeah yeah definitely better that sound good yes sounds good examine you quickly just take your chest as well okay yeah just just make sure it has some you don't to take anything off I'll just be okay knocked on the lights but we'll be giving off alright yeah I'm just just holding is that enough you don't have palpitations no no no it's fine just gonna sit you off that was a good listen to your back big breaths whenever you're ready k yeah bottom of your lungs don't sound like they're inflating very much as you say with baby pushing oh god so that that's quite normal isn't it yeah yeah are you in yeah a position any pain in your calf no no like at night problems when I did because I had to lie on my side mhmm that's the only thing I have my legs do hurt sometimes I for a while I was getting things and needles and that was for a while that's improved okay but it's just because I have to lower my size and gain extra weight hurts of course it hurts and then it goes when I walk around when I get off so good fine but no I have been checking for any swelling or redness and things like like that great looking for the signs and you've got someone with you tonight yeah yeah your husband's at home yeah so so you can keep an eye on your feet yeah you're really really funny yeah exactly and it come and if you're feeling poorly just come straight back and we'll and we can sort everything out sounds good sound good yeah great sounds good great thank you so much any questions or anything I forgot not that that I think of goodbye thank you so much real pleasure to meet you thank you sort of a message to you if you need to get a good night oh perfect thanks a lot see you the face now on examination heart sounds normal chest clear but with quiet basis bilaterally abdomen distended in keeping with gravidity and she's gravidity 2 para 1 and she's 35 weeks and 4 days 35 + 4 having a c section for impression very unlikely pulmonary embolism tachycardia resolved no ecg changes associated with pe patient not keen for further investigations which I think sounds reasonable plan number 1 discharge number 2 strong safety netting advice to return if persistent tachycardia or worsening shortness of breath syncope etcetera

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

Summary

Investigations

Plans

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.

Summary

Investigations

Plans