During my recent on-call, a 33 year-old-lady was admitted with a 2 hour history of sudden onset central chest pain started while she was in bed. No shortness of breath and no other respiratory symptoms. No palpitation. It was revealed that she had been easy to get tired in last 4 weeks. She gave 10/28 rather heavy menstrual history. Not investigated for that before.

She is a normally fit and well beauty therapist. Apart from previous ectopic pregnancy, nil significant medical issues in the past. She is not on any medication and no know drug allergy.

She is a mother of a son. Life long non-smoker and she drinks a couple of glasses of wine in the weekends. Family history was nil significant.

On examination, she looked well. Mildly pale. Apyrexia, normotensive. Pulse was 78. Cardiovascular, respiratory, abdominal examinations were unremarkable. No calf muscle swelling. No pedal oedema.

CXR:NAD, ECG NSR.
Admission blood tests showed Hb7. Low MCV and MCH. Otherwise, normal U&E and LFT.

My impression:

1.    Chest pain secondary to anaemia
2.    Hypochromic microcytic anaemia secondary to menorrhagia

So my initial management was

•    Iron study
•    Blood film
•    12 hr Trop to rule out ACS
•    Not for blood transfusion for the time being
•    If iron low, for iron replacement
•    If iron normal, Hb electrophoresis and haematology referral
•    Gynae referral for menorrhagia

My time was over and I went home.

2 days later,  I found her on the hospital push chair and the porter was bringing her to the CT department. That made me surprised.
So I did check her note when I had time.

I found out that she was discharged later on the day of admission with iron tablet. But someone checked repeat Hb which was 6.5 (Admission Hb 7). So she was called back for blood transfusion. In view of on-going chest pain even after discharge, CT PA was requested, which came back bilateral PE. What are the risk factors? I can not find it. Maybe a coagulation disorder.

Gynae team also reviewed her and requested USS Pelvis which showed fibroid in the uterus, explaining the cause of menorrhagia.
She had been on loading dose of Warfarin and therapeutic Clexane while waiting for target INR.

Anyway, I am happy she looked comfortable. She has been in right direction. But clearly, we still need to find out the cause of PE. I wish she does have nasty malignant disease.