1/ #Nephrology #POCUS case study:
Dr. X is rounding on an ESRD pt who initially presented with dyspnea after missing a dialysis (HD) session; underwent dialysis in the hospital. Pt asymptomatic at the time of exam and lung #ultrasound revealed https://abs.twimg.com/emoji/v2/... draggable="false" alt="👇" title="Rückhand Zeigefinger nach unten" aria-label="Emoji: Rückhand Zeigefinger nach unten"> Further story in thread #MedEd
2/ Based on the 2-zone lung #POCUS, Dr. X orders for another session of HD. Notably, pt says he is at his & #39;dry weight& #39; and HD nurse says they could only get 1.5L off during first session. Dr. X doesn& #39;t change his/her mind.
Info on various lung scan zoneshttps://abs.twimg.com/emoji/v2/... draggable="false" alt="👇" title="Rückhand Zeigefinger nach unten" aria-label="Emoji: Rückhand Zeigefinger nach unten"> https://youtu.be/o9Syl0F3AuY ">https://youtu.be/o9Syl0F3A...
3/ Patient becomes hypotensive during HD and only ~500cc fluid could be removed.
Why can& #39;t we get more fluid out of a hypervolemic patient? Dr. X is perplexed and decides to more #POCUS Here is the IVC
4/ Looks like the tank is empty....no wonder pt didn& #39;t tolerate ultrafiltration.
#VExUS is not needed if IVC is small but just to make sure, hepatic and portal vein Doppler obtained - look normal!
5/ Time to scan the lungs again....
This time Dr. X does 8-zone #POCUS scan and finds similar images.
6/ Why are the lungs still congested? patient is asymptomatic. May be heart is the culprit https://abs.twimg.com/emoji/v2/... draggable="false" alt="🤔" title="Denkendes Gesicht" aria-label="Emoji: Denkendes Gesicht">
Pump function? diastolic dysfunction? bad mitral regurgitation?
Cardiac #POCUS performed. Not great windows but here is what Dr. X managed to get. Subcostalhttps://abs.twimg.com/emoji/v2/... draggable="false" alt="👇" title="Rückhand Zeigefinger nach unten" aria-label="Emoji: Rückhand Zeigefinger nach unten">
7/ No pericardial effusion, LV systolic function grossly seems OK.
Little bit of maneuvering shows some aortic valve calcification. Aortic stenosis? gradient not measured but seems to be opening, LV doesn& #39;t look obviously big/thick. Pt is 60+, kidney disease.
8/ Moving on to apical window #POCUS. Grey scale looks OK, may be some mitral annular calcification (note shadowing), which is also not unexpected in patients with kidney disease.
9/ Color: May not be optimal but doesn& #39;t look like there is horrible mitral regurgitation. May be a little aortic regurgitation https://abs.twimg.com/emoji/v2/... draggable="false" alt="🤔" title="Denkendes Gesicht" aria-label="Emoji: Denkendes Gesicht">
10/ Another color
11/ Mitral inflow Doppler #POCUS
Impaired relaxation (A>E) but not unexpected in older people. Shouldn& #39;t fill the lung with B-lines. Tissue Doppler not performed.
Need a refresher on diastology? Refer to @Pocus101 & #39;s guide https://www.pocus101.com/how-to-measure-and-grade-diastolic-dysfunction-using-echocardiography/">https://www.pocus101.com/how-to-me...
12/ Lung #POCUS performed again. Dr. X noted something unusual about the pleural line. Takes a closer look with linear probe (high resolution - lower depth)
Left lung imageshttps://abs.twimg.com/emoji/v2/... draggable="false" alt="👇" title="Rückhand Zeigefinger nach unten" aria-label="Emoji: Rückhand Zeigefinger nach unten">
13/ Right lung #POCUS
Irregular pleural line suggestive of underlying lung disease (COVID negative, no symptoms). A CT chest was ordered.
14/ CT demonstrated interlobular septal thickening more pronounced at bases and linear scarring more pronounced in the upper lobes. Pt chronic smoker.
Verdict: B-lines on lung #POCUS were likely not due to water. Pt referred to Pulmonologist.
15/ B-lines can be seen in lung fibrosis, contusion, pneumonia etc. in addition to congestion/edema.
In these cases, pleural line is irregular, show subpleural consolidations, may be thickened and some areas are spared.
Diffuse involvement as in this Pt can create confusion.
16/ What if this patient really has pulmonary edema? How can lung #POCUS help in the outpatient #dialysis unit?
Any input @kyliebaker888 @siddharth_dugar @msiuba https://abs.twimg.com/emoji/v2/... draggable="false" alt="🧐" title="Gesicht mit Monokel" aria-label="Emoji: Gesicht mit Monokel">
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