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Emergency Medicine Attending (Consultant) PGY20. History, Physical, #POCUS!
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25 Nov
Thread, 1/n - Male 75. Acute dyspnea since 1 hour, can't talk, wheezy. SPO2 75%. No previous record. "All that wheezes is not asthma". #POCUS leaves no doubt about pulmonary edema, Dx while patient is being attached to monitor.BP 180/110 mmHg.
2/n CPAP 10 mmHg, IV infusion of nitrate being prepared. Pectus excavatum, parasternal long axis impossible from usual 3/4 ICS. But Apical 4 chamber suggests mild LV systolic dysfunction
3/n As I was about to bolus nitrate 500 mcg - BP drops from 180/110 to 120/70 mmHg. Patient improving with CPAP. So I hold the bolus and try to get more cardiac views. Patient upright plus pectus excavatum, thus not the best quality, but aortic valve appears calcific.
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11 Dec 20
1/n #POCUS is more sensitive than CXR for subtle consolidation detection. M/40, fever, right sided chest pain. Had cough 3 d ago, now resolved.WCC 13k, CRP 230. Normal physical exam.
2/n #POCUS showed bilateral small basal consolidations, B-lines at right base with sub pleural consolidations. Right posterior basal region sub pleural consolidation -
3/n B-lines right base
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8 Nov 20
1/n #POCUS findings of effusive constrictive pericarditis. Patient presented with 2 months progressive pedal edema and ascites. Pericardial effusion, funny bounce of IVS
2/n A4C septal bounce
3/n Plethoric IVC
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26 Oct 20
1/n #POCUS as a part of ED evaluation for first episode of atrial fibrillation (this demographic has significant prevalence of rheumatic heart disease) - appears grossly normal - moving on to other views...
2/n Apical 4C also grossly normal....
2/n but as probe swept caudally from A4C .. what’s that in RA?
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5 Oct 20
1/n #POCUS M/68, vomiting since 6 hours, back pain since 1 h. Says no to chest pain /abd pain / dyspnea. Diaphoretic, vomiting, HR 90, RR 24, BP 128/70, SpO2 91% (air). Reduced BS left side, Abd distended, nontender. ECG normal. Is it acute aortic? Tried to get PLAX heart -
2/n - scanning right parasternal area - found the heart - hyperdynamic, but nothing grossly wrong there.
3/n #POCUS Another look at left hemithorax anteriorly (parasaggital plane, mid-clavicular line, 4th. ICS)
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30 Sep 20
Thread 1/4 - #POCUS Case - MPA+bilateral PE. HR 110, BP 94/68, Sats 98% room air. Subjectively, patient feels well, no dyspnea/pain. Warm skin. Shifted to EM Resus. Lytic or not? Young pt, no known co-morbids / provocation.
2/4 #POCUS - RV does not seem dilated
3/4 #POCUS - IVC seems collapsed
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4 Jul 20
#POCUS case - F/80. Known mesenteric stenosis (celiac origin, and SMA). Has upper abdominal pain off and on - ? mesenteric angina. Now presents with severe upper abdominal pain. Tender+++ epigastrium, no peritonism. Normal GB ultrasound and lipase. Lactate 0.4. Previous CT:
Epigastric tenderness and normal lactate argue against acute mesenteric occlusion. #POCUS - SMA origin
#POCUS Color doppler SMA
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27 Jun 20
Thread 1/n. #POCUS findings in a M/31, leg swelling and abdomen distention progressive since 1/12. Starting with right IJV (high gain setting)
Abdomen RUQ Image
Abdomen LUQ
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22 Sep 19
Thread - (1/n) #POCUS findings in Left Main coronary occlusion.. this is not a STEMI - its WORSE ! M/50, 12 h intermittent chest pain. 2 hours of constant chest pain. Normal BP, no rales... but.. ECG horrible.
Thread - (2/n) #POCUS findings in Left Main coronary occlusion
Thread - (3/n) #POCUS findings in Left Main coronary occlusion: Cardiology fellow seeing patients .. they (and I) can't appreciate any rales.. but this is how lungs appear all over anteriorly
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16 Sep 19
#POCUS guided above elbow radial nerve block thread (1/n) Identification or radial nerve
#POCUS guided radial nerve block thread (2/n): Actual block administration
#POCUS guided radial nerve block thread (3/n): This patient's abscess was eminently suitable for this block: M/50, diabetic, throbbing pain, temp 39.5
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16 Jul 19
Patient referred for arthrocentesis, suspected septic arthritis. #POCUS shows triceps abscess, NO effusion. Aspiration attempt could have contaminated the joint & CAUSED septic arthritis. Consider scanning before sticking any needles. Image
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26 Jun 19
#POCUS diagnosis of epididymitis (thread) n/1 - scanning at root of scrotum - sweeping from spermatic cord downwards to find epididymis - which is enlarged and has complex appearance.
n/2 inflamed epididymis - complex appearance, increased vascular flow
n/3 sweeping from epididymis (inflamed) to testis (which is normal)
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4 Jun 19
ED visit for unrelated issue, incidentally I found a murmur which the patient was unaware of...#POCUS
These high pressure muscular VSD’s have no hemodynamic consequence but can cause endocarditis Image
Modified Short Axis view
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24 May 19
#POCUS image (transverse probe orientation in suprapubic region) in a 20 year old lady (language barrier++) with history of lower abdominal pain and recurrent vomiting since 20 days. Pregnancy test negative. Exam - fullness in lower abdomen, tenderness, no peritonism.
Saggital suprapubic #POCUS image
All sorts of differentials pass through - including obstetric fistula.... but patient has just passed urine - so repeat scan after full bladder.. with CT images 5 h later.
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17 May 19
#POCUS appearance of pneumoperitoneum (thread) - appreciate how normally abdominal wall, peritoneal line and intraperitoneal structures can be appreciated Image
Pneumoperitoneum causes peritoneal line to be enhanced, and gas scatter beneath means intraperitoneal structures can't be seen. Instead, reverberation artefacts from peritoneal line - similar to pleural A-lines - can be seen. Image
#POCUS at borderzone of pneumoperitoneum can show "peritoneal point" (cf. lung point in pneumothorax)
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10 Feb 19
#POCUS in cardiac arrest - keep probe on prior to pulse check pause - avoid delays searching for window - to minimize duration - and record a 3 sec loop which can be analyzed later. (thread)
(continued) this is what image looked like at pulse check - Dilated RV with septum bowing towards LV - should we give fibrinolytic for possible pulmonary embolism?
#POCUS is just a data point - in overall clinical context - additional data - this was a out of hospital VF arrest. With PE - we would expect a PEA arrest. Moreover, no risk factor for PE - and in fact, patient is on long term warfarin for AF - a "negative risk factor" for VTE?
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15 Dec 18
#POCUS in a gentleman with LUQ tenderness after blunt abdominal trauma 1 week ago. What is seen caudal to the spleen?
Perisplenic hematoma was suspected - and CT was performed
This is a normal anatomical variant of elongated left liver lobe - so called "Beaver tail liver"
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7 Dec 18
#POCUS appearance of acute epididymitis with funiculitis (inflamed spermatic cord)
Comparison of normal and abnormal epididymis Image
Testes appear symmetrical in echotexture Image
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8 Nov 18
What does #POCUS show in this 30 year old male with gradually progressive exertional dyspnea since 1 year? Exam - Loud systolic murmur.
ECG - Image
CXR Image
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22 Oct 18
Male/37. Fever 39 with cough and runny nose. Wheezy, HR 124, RR 30, sat 88% on air. Comments? ( the "season" has started! ) #POCUS
"Figure 8: Transverse thin-section CT scan at the level of the bronchus intermedius in a patient with influenza A virus shows ill-defined centrilobular nodules (arrows). Peripheral subpleural consolidation in the apical segment of left lower lobe"
Absence of consolidation (“hepatization” with air bronchograms) with #POCUS showing sub pleural consolidation supports diagnosis of viral pneumonia
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