To D-dimer, or Not to D-dimer? That is the Question

0:00Hello and welcome to a new episode of Home of Medicine, podcasted in association with the RCP, Edinburgh. My name is Ben Lovell, I'm one of your hosts today and my co-host is my friend Amy. Hi Amy. Hey, hi, I'm Amy Barabage and I'm a consultant in acute and general medicine. Amy, I've got a case for you this time. All right. Another busy day in acute medicine, another busy day on the take and we are asked to see by a local GP, a 26-year-old woman. She is 14 weeks pregnant and she's been sent in with left-sided pleuritic chest pain. Now, if you're anything like me, your brain starts going into diagnosis mode. The second you start getting the first sentences of referral. So, without even knowing anything else,

1:02my brain has already thrown up. It could be A, it could be B, maybe it's a bit of C, and then I keep listening. But are you the same? And if so, what's your initial reaction to that? Yes. So, first of all, 26-year-old female, my first question is she's pregnant or proven otherwise, but then you tell me she was pregnant. So, okay, we've got that diagnosis. And then you said she had some left pleuritic chest pain. Now, she's pregnant. So, although she's quite early in the pregnancy, she will be hypercoagulable. So, I'd think pulmonary embolism. Puritic, I would like, I think, about could this be an pneumonia? Has she had pleuricy, has she had a recent viral infection? And number three, I think, could this be an atopic pregnancy? So, that's where my thought process is at the moment. Or could it just be some a bit of chest pain? A twinge, one of light twinges. One of five twinges, which we all get, absolutely. Yeah. So, exactly the same as me. Someone says, oh, please, can you see a 26-year-old lady? 14 weeks

2:03pregnant pleuritic chest pain. My brain immediately goes, oh, she's got a PE. But I keep listening, and I keep my mind open. And as you say, PE may be pneumonia. So, I'm listening out for short and so breath and cough and sweetened reduction. Maybe musculoskeletal, as we say, a twinge. 14 weeks, but maybe still quite small. So, shouldn't be straining at the ligaments and all the carton side and sort of impressing itself upon the internal ribs yet. So, we shouldn't be seeing that sort of pain at this stage in the pregnancy. But there were my initial thoughts. So, time to go and meet the patient herself. Now, to give you a bit of a timeline, I actually met the patient a little bit later in her journey. And the initial assessment was done by a different doctor on the acute medical tape. And they saw the patient, and they elicited the history. It's her first pregnancy. So far, so good. No complications. She's had three days of constant, started out as left a procondromed pain, but then quickly migrated to the lateral ribs,

3:04like her stitch. Really difficult to take a deep breath in or to cough. So, very classic for pleuracy. Occasionally, she's feeling some pain in her left shoulder and the shoulder tip as well. It's waking her up at night. She's struggling to take deep breaths. But she has not got a cough. She's not produced any flim, and she doesn't feel particularly short of breath, albeit deep respiration is limited by the pain. Her past medical history is completely normal. She's never had any kind of venous thromboembolism before. And the only medication that she was taking is folic acid as part of a healthy pregnancy plan and has no allergies. She's a never-smoker. She works in an accounting firm and does not drink alcohol and lives with her husband. And I don't normally do a deep dive into family history when I'm taking a history, but at this point she's that we asked and there was no family history of venous thromboembolism either.

4:06Because when you're making a sort of judgment in your head about risk factors, it's something that you ask for, inherited hyper-curregulable states. So, that's the history so far. A little pause there. Have you moved towards or away from any particular diagnosis based on that information? So, she's had three days of left upper quadrant pain. So, then I start to think about what organs do we have in the left upper quadrant? So, we have got the basis of the lungs, which we've said, but also we've got the spleen. So, could this be something splenic? That's quite usual. You've also got, I mean, kidneys, but they're a lot lower down. Doesn't normally cause upper quadrant pain. Could it be stomach, something gastro, potentially? But the pain has moved to the left shoulder and the shoulder tip. So, when I think of shoulder tip pain, I think of diaphragmatic irritation, which you can get from within the abdomen. So, maybe an abdominal, something abdominal going on, either. I mean, I did say ectopic pregnancy, but it's a bit late in the pregnancy

5:11at 14 weeks to be ectopic. So, that sort of, I would expect that early in the pregnancy. So, has she ruptured a viscous within the abdomen? I mean, I'm really stretching things now. No cough, no shortness of breath, you said. Although it's pain on deep inspiration. I still don't know that this patient doesn't have a PE. And you haven't told me anything that would say that she definitely doesn't have one, to be honest. Although she's not a short of breath, it doesn't necessarily mean she hasn't got one. I think my differential diagnosis is still very broad. Thinking of the organs in that area, I've got the lungs, I've got the spleen, some abdominal organs, some retroperitoneal organs. So, that's what I'm sort of thinking about at the moment, but I'm still unsure. I want to look at a legs. What are a legs like, a calf? Oh, I'll tell you about examination. So, on examination, she was clearly uncomfortable with this left-sided

6:16pleuritic pain, really digging into the left ribs now. But on examination, her chest was clear to oscultation. With the caveat that she really couldn't take the deep breaths that we like, because she was really in a bit of pain when she took a deep breath with the pleuricy. Electronormal. No clinical DVT noted. No legs swelling noted. That's important, as you say. And the abdominal exam was normal. Cardiovascular exam was normal. Her observations revealed her stats were actually 100% on remote. Her respiratory rate was 1818. Her high. Okay, well, really? What's your cutoff for the speech? Well, I guess I, 12 to 14 to 16. I think 18 is still within the normal limits, doesn't it? But it's at the higher end of normal. It is the upper limit of normal. It's your pulse. Yeah. I love how we stick to even numbers, though, don't we? It's not weird. I know. But the volume on your TV's got to be a new number. How rate was 69? What's plus, say about us.

7:20And blood pressure. 69. I'm grateful. Yep. Blood pressure 117 over 59. Okay. And her temperature was 36.8. So they were a bicell science for her. Has that colored, you're thinking at all? Oh, I'm reassured that her legs have got a not a softened on tender. I did write new mithorax when for some bizarre reason, because I'm thinking about sort of hormone-lingucine mithorax, but a chest was clear. And I wouldn't expect necessarily 100% on room air and normal respite with a new mithorax, but something in my mind, maybe. The heart rate's reassuring, the blood pressure temperature, they're all reassuring, actually. That's a normal set of observations. Yeah. What I would like to do at this point, actually, is probably do an ultrasound scan of the lungs. And ultrasound, why? Because two weeks ago, Ben, I got my famous accreditation.

8:25Which is cannot be the only reason to do it, you get scared. So everybody gets one. It's taken me so long to get this accreditation. Look, because I thought I was too old to learn a new skill. But what I'd be able to do in this situation is I could use the little handheld scanner that I now love carrying around with me. And I could identify straight away whether there was a new mithorax, whether there was a collection without exposing her to radiation. So that could be why. So you would look for new mithorax. Yeah. And you could see fluid, plural, yeah, I could do it. I could solidation. Yeah. Absolutely. You can see consolidation. Yeah. Okay. Oh, we didn't have a pocus capable person there, unfortunately. So she didn't get that. Would you like some blood test results? I would love some blood tests, please. Full blood count normal across the board. Léonemia, renal function, using these normal, clotting normal,

9:29CRP 81. And that's the only abnormality we're looking at here. And she had an ECG, which showed normal sinus rhythm and nothing pathological on that. And she had a chest x-ray. And the chest x-ray revealed a small amount of left lower zone consolidation with a small rim of fluid. Okay. Watch your diagnosis and watch your plan. So just say that again. The chest x-ray showed a small, it showed left lower zone consolidation. Okay. And with a small rim of plural fluid around. And then fluid as well. So, okay. So a tiny, plural effusion with consolidation. So what could this be? Okay. So it could be inflammatory. So it could be infection potentially. You could get this in a PE. You can get consolidation and a little bit of plural effusion in a PE.

10:33So that could still be an option, to be honest. How do you get consolidation in a PE? So if you get infarcted tissue within the long due to a large PE, you can get an inflammatory response. And you can get white cells, macrophages, neutrophils, cytokase, rush to the area. And cause some localized inflammatory response. And you can get consolidation like that. Okay. It's not common. Okay. I want to give us some pain relief because she's in pain, this will show you. That's a good thought actually. And that's actually her main concern. It's a pain. I can't take a deep breath in here. And I always worry about someone who, I mean, she's got clinical, some radiological signs of pneumonia. She's got a CRP of 80, well, she's got a consolidation. And she's not going to be able to expect to rate and clear and ventilate that area if she can't take a deep breath in. So you've got to break the pain cycle. And sometimes that does get forgotten. And she'd already been saying, and she'd been taking

11:34paracetamol at home and it did nothing. So what are you going to give her? She's pregnant. So I am therefore limited by the options, but you can give co-dealing pregnancy, and you can give more feeling pregnancy. So I think we often get scared of giving pain relief in pregnancy, but having had three pregnancies and been in pain, you know, I think, you know, opioids are safe if you are in pain because it takes the pain away. So I would go for either paracetamol codeine. If it's really bad, you can consider oramore for something. So I'd work at the pain ladder, avoid non-steroidals. Very good. And just to be clear, we avoid non-steroidals because. Because they do something to the blood flow within the placenta. Enough said. They do something unpleasant to the blood, they blood flow across a placenta, yes. Something to do the afferent and efferent constriction of the blood vessels of the placenta, to the blood flow to the, maybe, am I right? Yeah, as far as I'm concerned. Okay.

12:35Yes, you can cause renal problems in fetus, and it can affect blood flow across a placenta. Yep. And it can do something to the heart as well, can't it, I think, potentially. Why are you, why are you exposing my lack of non-steroid, yeah? But no, you're right. But it's something that we avoid. Yeah, absolutely. Okay. So you're going to give pain relief, yeah. Oh, so I'm going to give some antibiotics because I've got a CIP, I've got consolidation, and I've got some fluid. So there's definitely some inflammation there. Now the question is, given her pain and the fluid, do I need to roll out a PE? Um, okay. First things first, which antibiotic are you going to give her? Okay. So again, we're limited in pregnancy for antibiotics we can give, but I know that a moxacillin is safe in pregnancy. So I'd probably go for, because I'm treating a community quite pneumonia at a moxacillin, 500 ml, EDS.

13:36So your plan is analgesia, a moxacillin orally. Yeah. And then you're going to scratch your head a little bit about whether or not we stop in terms of investigating and thinking whether we have our diagnosis. Yeah. Okay. And where do you sit with that? What would you do? What would you've done? Uh, this is a really difficult one because I think I'm overthinking it now. To talk me through what you're thinking puts on what's going on. Why is struggling? So I'm struggling because you said the very first sentence you said was 14 weeks pregnant left proolerotic chest pain. This is a pulmonary embolism until proven otherwise. Have I now gathered enough information that's proven me otherwise? Or have I fallen prey to anchoring bias and anchored onto that first piece of information that you've given me and then completely gone down that pee route, which is, I guess,

14:37potentially stopped me from thinking of anything else, but also I'm very conscious that I can't miss a pee as well. Yes. So just to be clear, pee is the leading cause of maternal. Absolutely. We cannot afford to get this wrong. On the other hand, you've made a diagnosis which satisfies the presentation and that clinical picture. And you've made it based on more than one modality. You've seen it on imaging. You've seen the inflammatory response on the blood test. It would explain the pit of pleural fluid. There's a bit of parietus there. You have actually made a diagnosis. The only thing that's a bit weird is the normal blood tests. So apart from the CRP of 81, which you can get potentially in pregnancy, everything else is normal. Now if somebody's got a pneumonia, I would have thought that there would be some pyrexia and some inflammatory response. So would the some white cell talent, some neutral failure, which we don't have? Oh, flu. Have we done a flu flu flu flu flu?

15:41Oh, that's a really good thought. That was part of the post-itwardrun plan, flu swab and COVID swab, and they both came back negative. A good thought. I mean, given my new famous skills, I could almost put in, I could put a probe on and see what's, I don't know. This is what I'm going to do. I'm going to discharge or am I going to crunch time. Do you know what I could do? This is crazy. With my new facial ultrasound skills, I can actually do DVT scans now. So I could have a look for any DVTs in the lower legs. Okay, her legs are not swollen, but you want to have a look anyway. Okay. Just because it's a new skill and it's like when you have a new toy, I feel like I need to yeah, okay. Do you know what Ben? I'm, I'm going to do what we're going to do. I'm going to send a home. Yes. I'm going to go, I'm going to a safety netter, but I'm only going to send a home

16:44when she can breathe normally because the amount of pain that she's in, I want to make sure that her pain is controlled properly. And how are you in a safety netter? So safety net wise, if the pain gets worse, if you become short of breath, if you start any cough, any, you feel like you've got palpitations, any coughing blood, please come back to hospital straight away. Okay. So the red flags are going to give her, I sounded like with signs of pneumonia and respiratory distress. Yes. Yeah. And I guess I'm thinking about a pee as well. So if she becomes more short of breath, the pain gets worse, she feels dizzy. So when she starts to exercise or walk on exertion, does she become more short of breath? So decreased exercise tolerance. Okay. So worsening breathlessness. Yeah. Now, what's really interesting is your plan is identical to the letter of the plan made by the clinician sore on that day, which was we have a

17:47diagnosis of an infection and pneumonia process. I don't think we have enough reason to justify proceeding to cross-section imaging at this point. I don't think the risk benefit ratio favors that direction. I think home with a moxacillin and a bit of oramorph. That's weird. Same plan. And if your symptoms were to worsen, here is how you access our safety net, safety net phone number that we have, you can ring on a daily basis. Okay. So you've just been discharged or you can come back to ambulatory care part of an essay exactly the same plan. How interesting. And I think that's an extremely reasonable plan. But we don't want to go over diagnosing people. End of episode. Bye. Thank you for listening. Of course, there's a little post script. Two days later, she represents to ambulatory care where I met her for the first time. Or rather, one of the registrars I was working with met her, but I was sick and so on sitting in that day. And she went and saw her. And the reason this woman

18:50came back to ambulatory care, she was adherent with all the medications we gave her. But this paritic pain is a nightmare. It's getting so bad. I'm like clutching my chair, I'm holding a hot water bottle on it, but it's like the worst stitch I've ever had and I can't get comfortable. It is so painful. Breathing was okay, actually. And there was no other clinical change in any of the status she had leg didn't swell up. She didn't become hypoptical breathless. It was just the pain. It was just the pain. And the registrar came and spoke to me and said, look, well, what do you think about this? We're still in the early doors, 40 hours of treatment. We could intensify the antibiotic treatment. She's still a febrile. We have got a working diagnosis here. Or do we do something else? And what would you do if your registrar came to you with that with that question? I'd go into the patient. Okay. Primarily because pregnant women, I always get a little bit twitchy because it's not my area of expertise or confidence. So

19:54and obviously known that they are high risk of clotting and sepsis and that they are the leading killers of maternal causes of maternal death. So second presentation with the pain, I want to know what is causing the pain. So, I did some observations again just to make sure the rocks turn levels are okay. Would I repeat the bloods? Probably not because the bloods were only done two days ago and I'm not sure it's going to change my management plan. I want to scan this lady's laws. Usually what modality? My laugh drive obviously did my famous ultrasound scanner. Oh, so you've got two options. She's had a chest X-ray and then we need to think about are we're going to do a VQ scan or we're going to do a CTA? Now I can't do a VQ scan because she has because we've already got changes on the chest X-ray. So, so therefore a VQ scan is pointless because there's always going to be VQ mismatch. Exactly. So, the only modalities are CTA.

20:58Now, if you follow the green tub guide lines from the opposite gyne, then you must do first of all, bilateral droplets of the legs because if you do bilateral droplets of the legs and it shows a clot, then you don't have to do a CTA. If you do bilateral droplets and there's no clot, but you still think there's a clot in the lungs, then you do a CTA. So, just to be clear, what would your what's your plan now? I want to do scan both of the legs. So, I could do that, but I can only rule one in. So, if I find a clot, when I do that, that's great, but if I don't find one, I'd have to send a four-her-departmental ultrasound of both legs. Okay, would you get that same day? Yeah, potentially. Yeah, absolutely. Also, now I'm starting to think about, because I'm thinking clot, do I need to actually start treatment?

21:59Which with HEPRIN, because at low molecular weight HEPRIN, because obviously we can't use a dogucking pregnancy. So, I'm going to use 1 milligram per kilogram BD of an oxopowerin, and I'm going to do it according to her booking weight. And what your booking weight is, is the weight that you are when you are eight or nine weeks pregnant when you first see the midwife. So, it's not your weight at the time when you have the presentation. Yeah. And if these droplets were negative, yeah. Then what? Would I see TPA or not? Yeah, I guess. To see TPA or not to see TPA? I'm going to do a CTPA, Ben. Okay, thank you. Now, I'm glad I'm in this episode. I've got a little bit of CPD for you. The green top guidelines have changed. The Royal College now no longer recommends bilateral droplets in the absence of clinical signs of DVT. Oh my. I do not know,

23:03it changed within my consultant career, because I remember when I was only qualified consultant in 2017, bilateral droplets were considered the first line tests, where they diagnosed these days, there were no ionizing radiation. But now they say, and if they have no signs of DVT in the leg, then you don't do it because the yield is microscopically low. And it doesn't prevent ionizing tests later on in the patient's journey. So that's actually out the window now. So I'll say that. There you go. Fact of the day. So I spoke to the registrar and I said, look, I think we do have a diagnosis here. Why don't you speak to the patient about a CTPA? See what she thinks. I'm very happy to support a CTPA for them. We can get it done in an hour here in a stake. Wow. And then we know the risks are very, very, very, very low. And I think sometimes we get a bit more worried than we need to be about ionizing radiation. But what we have to hang on to is the fact that you need a healthy mother to have a healthy baby. We can't look at mum and baby as two separate entities and say, well, I think I'll protect babies. So let's

24:07not scan mum. That logic doesn't really stand up. If mum has a diagnosis that is going to cause morbidity and mortality, because of course, baby is there with her. So I said, see what she was using. And she came back to look, I spoke into the mum. She's really sensible. We're going to do the CTPA. So we did the CTPA results came back in an hour later. Bilateral pulmonary embolite to the lower lobes, burden higher on the left than the right. There's consolidation at the left base, which is likely a pulmonary infarct with a surrounding effusion, just like Dr. Burgers said at the top of the episode. So there we go. So this is a woman who presented with Bilateral thromboembolic disease, a mask rating, because you're I get as a chest infection and was initially treated still so reasonably, I think, with antibiotics and all geyser based on what was going on the front door. But then came back because safety netting worked. Yeah. And she yeah, and she and she got a scan and she got a diagnosis. And so the plan changed dramatically. So of course,

25:08as you say, low molecular heparin, she needs that for a whole pregnancy now. And six weeks after. She's a planned C section on a certain date, they can plan it around her empty regulation doses. She needs to take low molecular heparin and every subsequent pregnancy for the rest of her life, because she's now high risk. She needs an echo to look for pulmonary hypertension right heart strain. So and follow up in the obstetric physician clinic, which we have here. So a big big change in plan from go home with antibiotics. Now, to me, when she came back and told me that result, that was too close. That was too close for comfort for me, because I could have sent her home. I nearly did. And I don't know what that would have happened. And it was just an example of a bullet whistling past your ear, just missing you. And a nice symbol of sitting with risk. And how sitting with risk is really the consultant's core. And it's what we have to do a lot.

26:16We can't diagnose everybody with everything. We can't see TPA every pregnant woman who comes in with a twitch, as you said at the beginning, because that would be an absolute misuse of resources and would expose the population to harm and would actually overdiagnose things that never needed to be known about. But we cannot miss PEs and pregnant women because it's the leading cause of maternal death. And we have to do something about this. So that's my case. And to be fair, right at the top of the episode, you were talking about PEs. And you talked about looking for consolidation and how that could still be a PE lurking underneath it. And remind me, Amy, how many diagnoses are patients allowed to have? They can have as many diseases as they down well pleases. Thank you. So, of course, she can have a chest infect recipe if she likes. But this case, I think, was a really big example for me about sort of the sliding doors moment in medicine,

27:17where in another reality, we said, look, to keep going down to biotics, stating it again, let's just see how you get on. She might not have come to any harm. But the case is that like there's these near misses, they do make my blood run cold a little bit. Yeah. But what I'm paid to do after my 20 years of experience of being a doctor is, is be able to analyze risk and sit with risk and explain risk, explain it to myself, explain it to a patient and explain it in the notes to anybody who cares to read it thereafter. So they can understand my thought process at a time. And it's a skill which is a lifelong learning event. Would this change your practice? So if a patient came to you tomorrow with exactly the same symptoms, would you do a CTA on admission? I've got to be completely honest. Yes. It has lowered my threshold. Yeah. I did a bit of reading after this. And I was like, am I being a bit silly about CTPAs?

28:19And I did a bit of reading. And actually, the radiation involved in a CTP and a VQ scan is well below the threshold that are associated with any kind of fetal or maternal harm, but because the radiations there, that's why we have to have these conversations and be careful. But there are actually any hard studies which have shown increased short-term risk of breast cancer per CTPA in mothers or in congenital malformations in children. But because of theoretical risk, we feel beholden that we should be talking to patients about it. But I think sometimes we're a bit eye, then own it. I am a bit fearful of radiation. You know, I see all these signs up in the X-ray saying, if you are pregnant, do not come in and tell a member of staff immediately. That probably affects me as some liminal. And we're taking consent from patients. We're asking you consent to a scan. So it is a big deal in my mind. And of course, historically, you had to argue for a scan. It ring up radiology and they say, but they're pregnant. You had to really state

29:22your case for the judge and say, look, I know it. I will take the risk of this, but I think in this case, the woman needs a scan. And because you argue it and they were pushing back, yeah, you take, you hold some of the risks with you. Do you think that she was 14 weeks pregnant, which is quite early in pregnancy? Do you think that we can say that the cause of the MRI was due to pregnancy or do you think this woman's investigation postpartum to look for the causes of hyperquagulability? That's a really good question. Did she have a chest infection to start with? And that plus the pregnancy led to a PE because we do know that pregnancy makes you five to 10 times more likely to have a VTE because hyperquagulable state. Or did she have the PE which then led to a low inflammation and maybe a secondary infection or maybe there was no infection at all? But the answer to your question, she will be followed up now by hematology. She goes to the appropriate investigations for inherited from buffiliers as see if there's any

30:27risk of a recurrence. So that will happen anyway. And because this was her first pregnancy, she had no previous pregnancies. I guess that sort of puts antiphospholipic syndrome as a cause a bit a bit lower down. The cause due factors because antiphospholipic syndrome, one of the problems women have with that is sort of multiple miscarriages within early pregnancy because of the form in the placenta. So actually, I guess it sort of doesn't rule it out but makes it sort of less likely. But it's certainly something that she's going to have then is postpartum, isn't it? Okay. Yeah. Really interesting case. Ben, I was doing some reading as well. Have you ever heard of the year's criteria? You know, I have heard of the year's criteria. I had not. Do you feel that you know well enough to talk about it now? No, it's a criteria that we utilise in pregnant women and it's all to do with our favourite test in the world. The D-Dimer. So do you want to elaborate on the year's criteria?

31:32It's something that I hadn't really come across before. Of course, when we were doing risk stratification for VTE in the general population, we talked about well's criteria. And well's criteria gives you a score and then you can guide you whether or not D-Dimer might be useful or whether you need to go to imaging. And the tricky thing with pregnancy is the world score gets really muddied up by some of the physiological changes of pregnancy. For example, they may be in elevated heart rate, pregnant women may get swollen legs, which are getting 9 million points on the world score or the respiratory might be up a little bit. So actually, the world score becomes less useful in pregnancy. And D-Dimer, I've always been taught, is useless in pregnancy because D-Dimer goes up in pregnancy. However, the year's criteria, which was actually published in the New England Journal in 2019, says that there are some criteria you can use to risk stratified pregnant women. And it's three clinical findings plus your D-Dimer. And the clinical findings are number one, signs of a DVT. Number two, hemoptosis.

32:39So far so good. And then number three, oh, this is where I was struck up with the world's criteria. Number three, PE is felt to be the most likely diagnosis. Oh, these subjective criteria, I really struggle with these and I'm using your criteria because I don't know. So I do struggle, but it says those are the three criteria you look at. And then you combine that with the pregnancy adjusted D-Dimer threshold. And then you can, it gives you a score, which calculates whether or not your pregnant patient is, I like to have a PE or not. I haven't used it before. It's something I'm going to think about now going forward. Because the, it was, and it was ratified actually in 2023 by the European Society of Cardiologists who said this should be our bread and butter now and actually avoid unnecessary scans and pregnant women. So I said, I'm going to try to use going forward years. That's just in Y-E-A-R-S criteria. And the other thing, yeah, as I mentioned before, is that Doppler's are now fully extremely limited in without any signs of a DVT. The number

33:41needed to scan to find a clot is 43. And it does now catch, doesn't catch clots really. Which is interesting because I'm in the learning that that was your first line test. And it was up DVT. Yeah, yeah, yeah. Never got to do any scans because you just treat the DVT and any PE that might be there as well. So I thought that was super interesting as well. Yeah, thank you. Really good case. Highlighted my lack of up-to-date knowledge on the green top guidelines. No, that's why I'm here for. Yeah, so I will read that. I read about years, years ago. So I will have a look at that. I think that's really helpful. Yeah, interesting case. Very thought-provoking. And I think I'm going to go away and reflect, do a lot of reflection on this. And how, I mean, I stick tomorrow, which is ambulator care. And I wonder if if this a patient submitted this comes in tomorrow. What would I do? Would I do this? Okay. Food for thought. Thank you so much for listening. Play along with me Amy. And thank you

34:44anyone for playing along at home. I hope you're enjoying these clinical cases and trying to work it out as we do as we go along. Maybe say a few things out loud, if you feel brave enough. And maybe these little stories will help cement knowledge in your brain because it just makes it a bit more real. And that's all we hope for here. Please do leave us a rating or a comment wherever you're listening to this. I tune Spotify or wherever. And tune in for further episodes of Home of Medicine Podcasts. Thank you for listening and goodbye. Goodbye.