Clinical Case 140: Rapid POCUS Diagnosis

A quick case from the Broome vault…

This case really shows how we can use bedside POCUS to make really important diagnoses in rapid time.  Sometimes the fact that “traditional tests” are not available forces me to use POCUS as a “Substitute” which works out really well!

If you are a POCUS junky or want to get involved in a really cool free-POCUS project then please check out thepocusatlas.com  – online atlas launching soon!! Thanks to Dr Michael Macias for making this happen

Our patient today is a 45 yo chap who has presented to ED with 2 days of non-productive cough and some vague posterior chest pain which seems to be worse when he tries to lay down at night.  He has no significant previous medical history.  He denies any fever, recent URTI or prodromal symptoms.  On specific questioning he has noticed some exertional dyspnoea in the last few weeks which he had attributed to being “outta shape”.  He does recall that his older brother has had a heart problem and had to have a “pacemaker” at age 48 for some “heart issues”.

Obs:  HR = 85 SR,   BP 160/100,  SpO2 = 96% RA,  RR = 20,  Afebrile

Our trusty local medical student has had a listen and think that there may be some bibasal crackles, maybe some decreased air entry.  He isn’t sure if he heard a murmur or not…

So that is pretty much where the clinical data stops.  It is Saturday, there are no labs or radiology available for at least 48 hours…. so let’s look at the chest and see what is going on.

Here are the posterior lung views looking at the bases:

RIGHT LUNG BASE                     LEFT LUNG  BASE

We see symmetrical bibasal, anechoic pleural effusions.  As we scanned up above these effusions we saw symmetrical, dependent B-lines which continued all the way up to the upper lungs.  So the most likely diagnosis here is pulmonary oedema with bilateral effusions.

So, now we must look at the heart – that is where the problem is most likely to be.

Here is a rough and ready subcostal view (long axis):  SUBCOSTAL LONG AXIS   {click for vid clip}

If you would like a little colour Doppler to help: SUBCOSTAL LONG + COLOUR {click for clip}

Tech tip: Some patients just do not have good windows, so you need to be creative and use any window that gives you the data that you need to make a call.  Generally you can get either parasternal OR subcostal views on most patients, so keep looking, don’t quit if your first window is tough.

A few still images to help bring it all together…

So this is how I put it all together. We have a man who was “well” until recently.

He has dilated cardiomyopathy with pretty poor global LV function (guessing his EF is 20 – 30 %).

He also probably has some degree of mitral regurgitation, which is probably functional due to the dilated LV, rather than a primary valve lesion.

Put together with the family history – we may be looking at a genetic lesion? Maybe something environmental?

The power of POCUS in this case was that it allowed us to diagnose all of that within a few minutes of triage.  Without POCUS and with no conventional tests available on the weekend this chap would have lingered, undiagnosed.

POCUS makes our jobs much more satisfying and can really accelerate the delivery of excellent care in “resource poor” hospitals.

I have been talking at the EMUGs sessions in Australia recently about POCUS in Under Resourced Environments (PURE).  However, I think this is the wrong way around.  For me, POCUS, is about getting the most out of the resources that are available.  Moving the care forward,  doing smarter care with the resources that we have at our dispopsal.

So if you have a great POCUS case to share – go over to thePOCUSatlas.com and share your images with the world.  We can learn together to deliver great care.

Casey