Hydropic Research Articles

Co-presentation of diabetic ketoacidosis and hepatitis an infection with anasarca: a case report

Diabetic ketoacidosis is the common initial presentation of Type 1 Diabetes Mellitus in paediatric practice. Hepatitis A infection is a common cause of jaundice in children with varied constitutional symptoms. However, co-presentation of diabetic ketoacidosis and hepatitis A infection with anasarca is rare. One four-year-ten-month-old male child presented to the emergency department of our hospital with diabetic ketoacidosis with new-onset Type 1 diabetes mellitus. At the time of presentation, the blood sugar level was in the diabetic range, 677 mg% laboratory value and was suggestive of diabetes mellitus. The HbA1c level was 14.47% at that time; however, there was no history of the classical triad of polyuria, polydipsia and polyphagia in the child. The child presented with mild acidosis (pH 7.3) and responded to the Milwaukee regimen of DKA management. During the course of the management, the child developed clinical jaundice on the 5th day of hospital admission and was investigated and diagnosed as having viral hepatitis A. On the 7th day of illness, the child developed anasarca in the form of moderate pleural effusion and gross ascites, leading to respiratory distress along with pedal edema and scrotal edema. The anasarca responded to symptomatic treatment and the clinical improvement of Hepatitis A occurred after 15 days. The stressful event of brewing hepatitis A, precipitating DKA in a relatively asymptomatic child of type 1 diabetes mellitus, is more likely in our case. The chance association of both the conditions in an underweight child with a history of 3rd degree consanguinity is noted in our child. The child also developed anasarca, which is uncommon in viral hepatitis A or diabetic ketoacidosis alone.

The Effect of Wearing Elastic Compression Stockings on Leg Edema in Pregnant Women in Late Pregnancy as Determined by Measuring the Deep Venous Velocity and Flow

The Effect of Wearing Elastic Compression Stockings on Leg Edema in Pregnant Women in Late Pregnancy as Determined by Measuring the Deep Venous Velocity and Flow

A treatable cause of bilateral leg edema and pleural effusion: yellow nail syndrome with IgG4-related disease.

A treatable cause of bilateral leg edema and pleural effusion: yellow nail syndrome with IgG4-related disease.

Clinical and Hematological Manifestation of Dengue Patients in 2022 Outbreak: A Tertiary Care Hospital-Based Cross-Sectional Study.

Dengue is a mosquito-borne viral disease that frequently causes seasonal outbreaks in Bangladesh, particularly during the monsoon months from June to September. Recent outbreaks have shown significant shifts in clinical manifestations, including changes in the timeframe and serotype mixing. This study focused on the clinical and hematological profiles of patients during the 2022 outbreak, which was notably severe. This quantitative cross-sectional study at Dhaka Medical College and Hospital classified 67 dengue-positive patients as having dengue fever (DF), dengue fever with warning signs (DFWS), and severe dengue (SD). Fisher's exact test, Pearson's chi-squared test, and Wilcoxon rank-sum test were conducted for statistical analysis using the R software (version 4.2), with significance established at p < 0.05. Predominantly male patients (76%) aged 21-40 (63%) and middle-class patients from Dhaka (57%) formed the majority. Most patients (45%) lacked a regular drainage system. Laboratory tests showed 63% NS1 antigen (nonspecific antigen 1) positivity, and 16% tested positive for both NS1 and IgM (Immunoglobulin M). Symptoms included headache (84%), retroorbital pain (51%), joint pain (75%), myalgia (72%), vomiting (75%), abdominal pain (69%), diarrhea (39%), and shock (48%). Thrombocytopenia was present in 61% of patients, with 79% showing elevated hematocrit (HCT) levels. Pedal edema, pleural effusion, and ascites were observed in DF and DFWS cases, while SD cases exhibited distinct HCT level variations. Accurate clinical and laboratory assessments are vital for the treatment and prediction of dengue outcomes in Bangladesh, given the severe manifestations of dengue shock syndrome (DSS). It is characterized by headache, muscle pain, thrombocytopenia, anemia, leukopenia, and potential neurological complications or mortality. Severe cases involve critical plasma leakage, leading to DSS with fluid accumulation, respiratory distress, and potential multiorgan involvement. Enhancing physician awareness regarding dengue case detection and management, along with routine dengue testing, are recommended for early diagnosis and improved patient outcomes.

Prediction of deep vein thrombosis in pregnant women by platelet indices: A retrospective case-control study.

This study aimed to investigate the predictive value of the platelet indices for the diagnosis of acute deep vein thrombosis (DVT) in pregnant women. Pregnant women aged 20-45 years who presented to the emergency room with leg pain and edema and underwent bilateral lower extremity venous Doppler examination for DVT were included in the study. Platelet large cell ratio (P-LCR), platelet distribution width (PDW) and mean platelet volume (MPV) values, which provide information on current platelet activity in the hemogram parameters recorded at first presentation in the emergency department, were analyzed between the two groups. Pregnant women with a history of venous thromboembolism, anticoagulant medication, heart disease, cancer, essential thrombocytopenia, gestational thrombocytopenia, pulmonary embolism, and multiple pregnancies were excluded. A total of 125 participants were included in the study. Acute DVT was diagnosed in 37 participants using venous Doppler of the lower extremities. In the remaining 88 patients, the diagnosis of DVT was excluded. There was no significant difference between the groups in terms of age, body mass index, parity, and gestational age at diagnosis. Although platelet counts were similar between groups, P-LCR, PDW, and MPV values, which provide information on platelet shape and volume, were statistically significantly lower in Group DVT (p < 0.05). According to this study, low MPV, PDW and P-LCR values in pregnant women can be evaluated as independent markers in the diagnosis of acute DVT or these markers can be included in the DVT scoring system for pregnant women.

Benefits of an Adjustable Compression Garment System for the Reduction of Chronic Leg Oedema (ACROE Study)

Benefits of an Adjustable Compression Garment System for the Reduction of Chronic Leg Oedema (ACROE Study)

Clinical And Socio-Demographic Profile Of Chidren Aged 6-59 Month With Severe Acute Malnutrition Presenting In A Tertiary Care Hospital In Nuh, Haryana

Background: Malnutrition adversely affects achievement of all the milestones namely motor, sensory, cognitive and social. Methods: The records of 150 patients with severe acute malnutrition over a period of one year (July 2022-July 2023) were reviewed, and a statistical comparison of various variables were made. Results: As per study, mean weight(kg) 7.48 ± 2.02, mostly i.e.78.67% were having weight &lt;-3 SD. Mean height or length(cm) was 77.5 ± 11.14 ,majority was in between 2SD to -3SD i.e. 48.00%, MUAC was &lt; 11.5 among 123 (82%), 11.6-12.5 among 10 (6.67%), 12.6-13.5 among 17 (11.33%).There were 41.33% males and 58.67% females.Of study population, Birth order was 1st among 9 (6.0%), 2nd among 11 (7.33%), 3rd among 38 (25.33%) and 4th and above among 92 (61.34%) subjects with a mean of 4.05± 1.52.Among my study most of children were mixed Feeding 53.34%,while only 13.33% were Exclusive breast feed while 33.33% were Top feed .Immunization was Complete among 10.67%, Incomplete among 62.67% and Unimmunized among 26.67% subjects. Pedal Edema was present among 44 (29.33%) subjects and absent in 106(70.67%).The presenting complaint reported were anemia (38.67%), pneumonia (26.67%), acute gastroenteritis (12.67%), hypoglycemia (10.00%), Dehydration (8.0%) and UTI (4.00%) and most common presenting complication wasanemia (80%), followed by pneumonia (52%), acute gastroenteritis (34.00%), dehydration (29.67%), Lethargy/hypoglycaemia (30%), meningitis (8.00%), tuberculosis(5.33%)and UTI (4.00%)As per my study, complication are more severe unvaccinated children, however effect is statistically insignificant (p&gt; 0.05) Conclusion: SAM was most common in 13-24 months age group and with increasing age, a lesser proportion of children were affected with SAM. There was a strong correlation between adverse outcomes and dietary risk factors such as the length of time spent nursing exclusively, using a bottle, and delaying the introduction of supplementary foods. Most common co-morbidities were anaemia and pneumonia.

An innovative multicomponent compression system in a single bandage for venous leg ulcer and/or oedema treatment: a real-life study in 343 patients

Objective: This study aimed to evaluate the performance of an innovative multicomponent compression system in a single bandage (UrgoK1, Laboratoires Urgo, France) in the treatment of patients with venous leg ulcers (VLUs) and/or lower limb oedema in everyday practice. Method: A prospective, observational, clinical study with the evaluated compression system was conducted in 39 centres in Germany between March 2022 and July 2023. Main outcomes included a description of the treated patients, changes in wound healing and oedema progression, local tolerance and acceptability of the compression system. Results: In total, 343 patients were treated with the evaluated compression system for a mean period of 48±30 days; 196 had a VLU and 275 had oedema, mostly of venous origin. By the final visit, 49% of VLUs healed (75% in absence of oedema and 61% in VLUs of ≤1 month's duration). Oedema was completely resolved or greatly improved in 87% of patients, with significant reduction in calf and ankle circumferences. Improvement in pruritus, pain, age-related ankle mobility and skin changes were also reported in patients who experienced them at baseline. The system was judged ‘very easy’ to apply (median: 108 seconds, three times a week), ‘extremely useful’ and ‘very well accepted’ by most patients who reported an improvement in comfort compared with previous systems. Similar results were observed when patients and/or their relatives were involved in the bandage application between the study visits. During the study, three cases of local intolerance related to the system and five early terminations (unrelated to the system) were reported. Conclusion: These results are consistent with the previous clinical evidence available on this new compression system and further support its good efficacy, tolerability, acceptability and usefulness in the treatment of patients with VLUs and/or oedema. Declaration of interest: This study was supported by a grant from Laboratoires Urgo, France. EH, UM and LT are employees of Laboratoires Urgo. CS, TB, WK, MS and JD provide advisory and speaking services to pharmaceutical and other healthcare organisations including, but not limited to, Laboratoires Urgo. Data management and statistical analyses were conducted independently by INPADS GmbH, Germany.

Molecular insights into Wnt3a and Wnt5a gene expression in venous insufficiency.

Chronic venous insufficiency (CVI) manifests as morphological and functional abnormalities in the venous system, primarily affecting the lower extremities and presenting as leg heaviness, oedema, and varicose veins. CVI is a common vascular disorder characterised by impaired blood flow in the veins, often leading to various clinical manifestations. To better understand the additional underlying mechanisms of CVI, it is essential to explore the role of Wnt proteins, which play a crucial role in regulating signalling processes. This study aimed to investigate the expression levels of the Wnt3a and Wnt5a genes using real-time PCR in patients with venous insufficiency compared to acontrol group. 68 participants were included, comprising 29 controls and 39 patients with venous insufficiency from Near East University Hospital. Real-time PCR was utilised for gene expression analysis on a segment of the great saphenous vein biopsy, encompassing all vascular layers, from each participant in both groups. With a significance threshold of p < 0.05, the analysis revealed a significant difference in Wnt3a gene expression (p ₌ 0.0007) and a nonsignificant difference in Wnt5a expression levels (p ₌ 0.5726) between patients with venous insufficiency and the healthy control group. This study indicates fluctuations in the Wnt genes in varicose vein biopsies compared to healthy veins. Consequently, further research is essential to elucidate whether the dysregulation of the Wnt pathway induces venous insufficiency or vice versa. This may facilitate targeted interventions addressing its fundamental molecular aberrations.

Heart Failure Caused by Incidentally Discovered Right Atrial Myxoma: A Rare Case Report

Primary cardiac tumors, though uncommon, play a significant role in medical practice. Cardiac myxoma is the most common benign cardiac tumor, characterized by varying symptoms depending on the location and size of the tumor. We report the case of a 44-year-old woman with complaints of shortness of breath, upper abdominal pain, and leg oedema. Right atrial myxoma was incidentally found after an echocardiography examination, which is an essential tool for detecting and diagnosing cardiac tumors. The patient exhibited clinical improvement with inotropic therapy and antibiotics and was referred for surgical removal of the tumor. Cardiac myxoma surgical procedures generally have a favorable prognosis with a high survival rate. However, postoperative complications such as arrhythmias and infections require close monitoring. Thus, early diagnosis and appropriate management are essential in addressing cardiac myxoma.

Undiagnosed mirror syndrome with maternal hypoxemia onset during an emergency cesarean section: A case report.

Mirror syndrome is a rare pregnancy condition in which maternal edema is associated with fetal hydrops. Because of its rarity and overlapping symptoms, this condition is often misdiagnosed as another pregnancy complication. A 28-year-old pregnant Japanese woman presented with sudden 7.5-kg weight gain, leg edema, and increased d-dimer level. Ultrasound revealed polyhydramnios and fetal hydrops, and findings of maternal edema and blood test results were suggestive of Miller syndrome. Although, the patient was initially misdiagnosed due to a lack of information and the rarity of this disease. An emergency cesarean section was performed under spinal anesthesia at 36 weeks and 2 days of- pregnancy. We could not diagnose mirror syndrome. The newborn's Apgar scores were 2 and 5 at 1 and 5 minutes after delivery, respectively. The patient's SpO2 suddenly decreased to 86% during cesarean section and persisted for 2 days. Chest computed tomography revealed pleural effusion and pulmonary edema. The pleural effusions and lung edema spontaneously resolved after the cesarean section. This case reports on Miller syndrome with maternal hypoxemia onset during an emergency cesarean section and highlights the potential for better perioperative management and improvement in maternal mortality through prompt diagnosis and appropriate treatment shared not only among obstetricians and pediatricians but also among anesthesiologists.

Clinical Presentation of Patients with Hepatocellular Carcinoma in Tertiary level Hospital of Bangladesh

Hepatocellular carcinoma (HCC) is the most common type of primary liver cancer, accounting for 75% - 86% of all cases. Men are affected approximately two to three times more than women. It is considered as the fifth most common cancer in men and the ninth in women. The prognosis for liver cancer is very poor which has made it globally the second most common cause of death from cancer. The highest liver cancer rates are found in East and Southeast Asia and in Middle and Western Africa. Western world is complaining of rising HCC prevalence as a result of migration from HBV-endemic regions, hepatitis C virus (HCV) infection, alcoholic cirrhosis, and non-alcoholic steatohepatitis associated with the obesity epidemics. The accurate diagnosis of HCC dependent on clinical presentation, biochemical, imaging, cytological and/ or histopathological examination. This was a descriptive study of hepatocellular carcinoma patients those attended Dhaka Medical College Hospital and Shaheed Suhrawardy Medical College Hospital, Dhaka, Bangladesh from September 2006 to march 2008. Thirty (30) consecutive biopsy proven hepatocellular carcinoma patients were enrolled in this study. This study collected data by reviewing Medical records (prescriptions and diagnostic reports) and interviewing patients for various present symptoms/ signs, past complaints (symptoms/ signs) they experienced in different duration and for confirmation of HCC. Among the symptoms almost all 29(96.66%) of the patients had experienced loss of appetite and most of the patients were experienced generalized weakness 28(93.33%) followed by weight loss 24(80%). More than two-third of the patients had complained abdominal pain 22(73.33%), abdominal fullness 21(70%), abdominal mass 20(66.66%) and nausea and vomiting 20(66.66%). Various signs of HCC were found in examination during interview and from their past experience/ reviewing medical record of illness; where most of them 27(90%) had hepatomegaly and half of them 15(50%) had splenomegaly and ascites. Among the others sign of HCC, one-third (33.33%) of them had yellow discolouration of eyes, yellowish urine, jaundice and fever. Several signs were also observed like Leg swelling 9(30%), cough 8(26.66%), alteration of bowel habit 6(20%). Signs like blood vomiting 1(3.33%) and leg oedema 4(13.33%) were also observed. Information regarding clinical presentation from this study may be utilized as indicator for referral, case definition in research works and probable diagnosis of HCC. This clinical presentation may be a strong tool for symptomatic surveillance of HCC and prevention of HCC including chronic hepatitis B and chronic hepatitis C virus infection. Bangladesh Med J. 2023 Sept; 52(3): 8-13

Management of Chronic Kidney Disease through Ayurvedic Shodhana and Shamana Chikitsa: A Case Report

Chronic Kidney Disease (CKD) has become a major public health issue affecting both younger and older individuals. The prevalence of CKD is on the rise, primarily driven by conditions such as hypertension and type 2 diabetes mellitus. CKD is characterised by progressive and irreversible damage to the kidneys, often presenting asymptomatically in its early stages. As the disease advances, patients may experience symptoms such as pedal oedema, decreased appetite, nausea, reduced urine output, frothy urine and fatigue. Laboratory tests typically show increased levels of creatinine and serum urea, indicating poor renal function. Traditional treatments, including dialysis and renal transplantation, remain mainstream approaches for managing CKD. However, these interventions are often financially prohibitive for many individuals in India, underscoring the urgent need for more affordable and accessible alternatives. In response to these challenges, Ayurvedic medicine offers promising alternative treatments. Hereby, the authors present a case of a 30-year-old male suffering from CKD; despite being recommended for dialysis, the patient opted for Ayurvedic treatment. Ayurvedic Shodhana chikitsa (purification and rejuvenating therapy) through Basti (therapeutic enema) combined with oral herbomineral formulations has demonstrated renoprotective effects and potential benefits in improving haematological parameters in CKD cases. The present case report highlights the importance of traditional Ayurvedic approaches as alternatives to prevent dialysis for CKD patients, particularly in low-income populations.

A Rare Case of Dilated Cardiomyopathy in Sjögren’s Syndrome

Dilated Cardiomyopathy (DCM) is a rare but significant complication in patients with primary Sjögren’s Syndrome (pSS), a systemic autoimmune disease that primarily affects the exocrine glands. Cardiac involvement in pSS is uncommon, making the recognition of DCM in these patients crucial for timely intervention. This is a case of a 44-year-old female with well-controlled hypertension who developed progressively worsening shortness of breath, chest pain and bilateral pedal oedema. She also had a two-month history of dry eyes and dry mouth, indicative of sicca symptoms. Clinical examination revealed signs of fluid overload, a pansystolic murmur and sicca features. Electrocardiogram (ECG) and echocardiography demonstrated severe left ventricular dysfunction with an ejection fraction of 15%, consistent with DCM. Laboratory investigations revealed elevated N-terminal pro b-type natriuretic peptide (NT-proBNP) levels and positive anti-Ro52 and anti-La antibodies, pointing to an autoimmune aetiology. Cardiac Magnetic Resonance (CMR) Imaging confirmed non ischaemic DCM, ruling out ischaemic causes. The patient was diagnosed with DCM secondary to pSS. She was treated with diuretics, Angiotensin Converting Enzyme (ACE) inhibitors and immunosuppressive therapy, including methylprednisolone and a tapering course of prednisolone over six months. Significant clinical improvement was observed on follow-up. This case highlights the importance of recognising autoimmune aetiologies, such as pSS, in patients presenting with unexplained cardiomyopathy. Early diagnosis and interdisciplinary management are essential in preventing severe cardiac complications and improving patient outcomes in rare presentations of Sjögren-associated cardiomyopathy

Rheumatological Diseases and Lower Extremity Edema: A Lymphoscintigram Study

“Lymphedema” is commonly used as a generic term to describe any form of leg swelling; 25% of patients referred to our center with “lymphedema” do not have the condition. The purpose of this study was to evaluate the lymphatic function of subjects with rheumatologic disease. Five individuals with a rheumatologic disease and leg edema underwent a lymphoscintigram. All individuals had normal lymphatic function. Patients presenting with lower extremity swelling and a rheumatologic condition do not have lymphedema. The etiology of their leg swelling is by mechanisms other than lymphatic dysfunction.

Ayurvedic Management of Stage V Chronic Kidney Disease

This study aims to evaluate the effectiveness of Ayurvedic therapies in managing chronic kidney disease (CKD) in a 46-year-old female patient with stage five CKD. The patient presented with polyarthralgia for three years and acute worsening of CKD over two months, along with symptoms of joint discomfort, bilateral pedal edema, constipation, facial swelling, dyspnea on exertion, and disrupted sleep. Despite being advised to undergo dialysis by her nephrologist, she opted for Ayurvedic treatment, including Panchakarma therapies, dietary and lifestyle modifications, and Ayurvedic medicines. Significant improvements were observed in clinical symptoms such as reduced edema, relief from joint pain and constipation, improved sleep, and reduced dyspnea, alongside better biochemical markers. These findings suggest that Ayurvedic therapies may effectively manage CKD and improve patient outcomes. However, further research is needed to substantiate these results and explore the potential of Ayurvedic treatments as an alternative or complementary approach to conventional CKD management.

Two- and Three-dimensional Imaging in Carcinoid Heart Disease

Abstract A 70-year-old male presented with a history of pedal edema, abdominal distension, and dyspnea on exertion New York Heart Association Class III for cardiology evaluation. He was a known case of a neuroendocrine tumor of the small intestine diagnosed 3 years back and was on octreotide injection monthly for 20 months, now presented with features of the right heart failure. Transthoracic echocardiography showed thickened shortened immobile tricuspid valve leaflet with severe tricuspid regurgitation, and transesophageal echocardiography also confirmed the same. Three-dimensional (3D) echocardiography showed a tricuspid valve thickened and retracted with restricted mobility called a club-shaped leaflet, and with this, a diagnosis of carcinoid heart disease was made. This case mainly aims at stressing the need for early echo in neuroendocrine patients, which helps with early diagnosis and intervention to improve their survival significantly, and the application of 3D echo which will provide detailed anatomical information, particularly if tricuspid and pulmonary valves are involved.

Vascular rescue–minimally invasive management of a post-spinal surgery fistulized ilio-iliac pseudoaneurysm: a case report

BackgroundAortoiliac injury after intervertebral disc surgery is an uncommon but potentially fatal complication. This case study emphasizes how crucial it is to identify this uncommon complication, which can manifest itself in a variety of ways, including leg oedema, heart failure, and deep vein thrombosis. This case is unique in that it presents with an uncommon post-spinal surgery complication of fistulized pseudoaneurysm of the common iliac artery and vein. This combination calls for an immediate diagnosis and careful care.Case presentationA 36-year-old female patient presented with progressively worsening orthopnea, accompanied by chest pain and palpitations. Her medical history revealed gradually increasing right lower limb swelling since three months, following a discectomy procedure for the management of lower back pain associated with a herniated lumbar disc at the L5-S1 level. Doppler ultrasonography demonstrated an arterialized flow within the right common iliac vein. Subsequent computed tomography angiography identified a pseudoaneurysm of the right common iliac artery, which had formed a fistulous connection to the right common iliac vein. This uncommon complication was likely attributable to prior disc surgery. The patient received endovascular intervention, which was executed in two primary stages: first, embolization of the right internal iliac artery was performed, followed by the exclusion of the arteriovenous fistula through the deployment of a covered stent graft within the right common iliac artery. The intervention successfully resolved both the pseudoaneurysm and the arteriovenous fistula.ConclusionsThis case report underscores the importance of considering vascular complications in patients presenting with unusual symptoms following intervertebral disc surgery, even after a significant time lapse. While both open surgical and endovascular approaches can yield good results in treating such complications, the endovascular method, as demonstrated in this case, is associated with minimal morbidity. This approach offers a less invasive alternative that can effectively manage complex vascular injuries resulting from disc surgery. Clinicians should be aware of this rare but serious complication to ensure timely diagnosis and appropriate management, potentially improving patient outcomes in similar cases.

Thyme oil and argan oil's effects on horse welfare

This study examines the effectiveness of thyme oil and argan oil as potential treatments for leg edema in horses. Swollen legs, often a result of infections, injuries, allergies, and underlying health conditions can significantly affect a horse's mobility and overall health. Traditional treatments may include antibiotics, anti-inflammatories, cold therapy, compression bandaging, and rest, but there is growing interest in natural remedies. For this purpose, argan and thyme oil were applied to 22 horses of various ages and different breeds at different times at Mersin Doğa Horse Farm. As a result of the study, some observations before and after the application of thyme and argan oil are listed. In addition, there was a significant association between oils and side effect from rash, itchiness, temperature increase, drinking too much, excessive urination (p

Dizziness, Light-Headedness or A Clot-In-Transit: Obtaining a History and Physical Examination is Both a Science and an Art.

Venous thromboembolism (VTE) rarely presents with dizziness as the primary complaint, which can delay diagnosis. We report a rare case of dizziness as the chief complaint for a clot-in-transit and extensive bilateral pulmonary emboli. A 70-year-old woman presented to the emergency room (ER) with dizziness and a fall, without reporting loss of consciousness. Her symptoms included positional dizziness, tinnitus and visual darkness, alongside prior exertional fatigue and dull chest pressure. Despite a history of left leg oedema and inconsistent use of medications for hypertension and diabetes, initial examinations suggested vestibular neuritis and decompensated heart failure, confirmed by echocardiogram findings and response to prednisone. While hospitalised, she experienced pre-syncope after showering, initially deemed vasovagal. However, exertional hypotension led to further investigation, revealing right heart strain. Ultrasound identified a left popliteal deep vein thrombosis, and a computed tomography (CT) angiogram confirmed extensive bilateral pulmonary emboli with right heart strain. Cardiology discovered large, mobile thrombi in transit in the heart, necessitating an urgent mechanical thrombectomy. Following treatment, her pulmonary pressure improved, and she was discharged on anticoagulation medicine. One month later, an echocardiogram showed normalised heart function. This case highlights the importance of differentiating dizziness from pre-syncope, as exertional pre-syncope can indicate an obstructive physiology such as VTE. Cognitive bias can obscure diagnosis in atypical presentations. A pulmonary embolism response team could improve management of these cases, where prompt diagnosis and treatment are essential for favourable outcomes. Cognitive bias should be consistently challenged while ruling out pulmonary emboli based on the absence of typical signs.It is essential to differentiate vertigo from light-headedness or pre-syncope in patients presenting with a complaint of dizziness.Pre-syncope can be an important presenting complaint of haemodynamically significant pulmonary emboli and clots in transit.