GUSI E-newsletters

Case #1: Outpatient 

A 72-year-old male, overweight chef with a history of smoking, hypertension, and COPD sees his PCP for shortness of breath. His normal inhalers aren’t working.  

Physical exam without POCUS…

With a stethoscope, the PCP hears decreased breath sounds at the lung bases and is unsure if S3 is present. She notes trace ankle edema. To gather more information, she orders a chest x-ray and prescribes five days of steroids and antibiotics. Unfortunately, the patient’s symptoms worsen and he presents to the ER before the imaging results arrive.

Physical exam with POCUS…

The PCP incorporates ultrasound into the bedside exam to visualize the heart and lungs. She sees:

Depressed Ejection Fraction and Dilated Left Atrium

Dilated IVC with <50% Respiratory Variation

Bilateral B Lines at the Bases, Suggestive of Pulmonary Edema

The combination of these POCUS findings is strongly suggestive of new onset acute congestive heart failure (citation). The patient is admitted to the hospital the same day. 

Case #2: Inpatient 

An attending physician is called to the bedside of a 58-year-old obese woman who has chest pain, shortness of breath, and a new oxygen requirement. The patient had been admitted for hip surgery, and has a history of hypertension and congestive heart failure. The physician has two differentials: an exacerbation of underlying heart failure or a postoperative pulmonary embolism. But which is it?

Physical exam without POCUS…

The physician identifies tachycardia and accessory respiratory muscle use. There is no cardiac murmur, wheezing, or rales. He decides to order a chest x-ray first, and will later consider a CT scan to evaluate for a pulmonary embolism. 

Physical exam with POCUS…

The physician uses ultrasound at the bedside to diagnose acute right heart strain and evaluate EF, IVC size, and IVC collapsibility. He is able to definitively rule out the presence of a pericardial effusion, pulmonary edema, pneumothorax, or pleural effusion.

The POCUS finding of acute right heart strain is strongly indicative of a pulmonary embolism (citation). The physician knows he must order a CT scan immediately.