38 Year-old Male with Cough and Shortness of Breath
Author: Chris Rowley, MD PGY-3
Peer Reviewers: Lee LaRavia, DO; Dan Kaminstein, MD
Learning Objectives:
Discuss differential diagnosis
Discuss use of US in the workup of dyspnea
Discuss the US characteristics/findings associated with cardiopulmonary disease
Review any recent literature
Case Presentation
38-year-old male recently immigrated from India with no reported PMH who has been
having 2 weeks of progressively worsened dyspnea, orthopnea, and early satiety.
Denies CP, syncope, palpitations, or peropheral edema. No hx of MI, DVT/PE, heart
failure.
HE and his wife had URI illness 2-3 weeks ago. He has progressively declined since
then. He used to sleep flat but naow has to sleep upright.
T: 37.1 °C HR: 92 RR: 20 BP: 120/90 SpO2: 100% WT: 82 kg
Normal heart sounds. Clear lungs. Soft/nontender abdomen. Trace bilateral LE edema.
Troponin negative, no leukocytosis, normal H&H, normal UA, mild transaminitis, mild
elevation in T. bili, BNP 899
Apical: place probe at PMI habe patient lie on L shoulder.
Subcostal: scan through the liver for better image quality. Don't mash the xiphoid.
Diagnosis and Case Disposition
Ultrasound was used at initial patient encounter. While the initial differential was
broad, prompt usage of POCUS echocardiography paired with history made the diagnosis
of new congestive heart failure, likely post-viral.
Case specific POCUS findings helped narrow likely cause:
Global LV dilation without focal wll motion abnormalities - less likely to be ischemic.
RV is not significantly dilated - less likely to be chronic LV failure.
Trace pericardial effusion - less likely Tb or cancer
Easy POCUS Findings for Dyspnea
Diagnosis and Case Disposition
Patient wanted to leave AMA due to new immigration status and financial concerns.
POCUS was helpful for prompt cardiology consultation who convinced the patient to
be admitted.
Admitted to CVICU. TTE w/ EF<15%. Pt declined ischemic work-up due to cost. Started
on GDMT and patient left AMA on day 2 of hospitalization.
At patien't last cardiology visit, a few weeks ago, his EF 46%. NYHA Class I on GDMT.
Literature Review
POCUS results in faster time to diagnosis (24 vs 186 minutes) for ED patients presenting
with dyspnea.1
POCUS ECHO + IVC + lung ultrasound nears 100% sensitivity and specificity for diagnosing
heart failure.2
98% diagnostic agreement between initial ED POCUS and formal diagnosis of acute decompensated
heart failure.3
POCUS leads to faster “disease-specific” treatments for dyspnea in the ED.4
POCUS outperforms the stethoscope in diagnosis of heart failure and pneumonia.5
Take Away Points
Incorporating POCUS into your work-up for dyspnea will likely lead to faster and more
accurate diagnosis of dyspnea.
Decreased cardiac function can be assessed visually without need of advanced echocardiography
measurements.
Know the correct “windows” for POCUS Echocardiography for best assessment of cardiac
function and other cardiopulmonary disease.
Even with sub-optimal views obtained in a hallway chair, POCUS is sensitive enough
for focused decision making.
References
1) Zanobetti M, Scorpiniti M, Gigli C, Nazerian P, Vanni S, Innocenti F, Stefanone
VT, Savinelli C, Coppa A, Bigiarini S, Caldi F, Tassinari I, Conti A, Grifoni S, Pini
R. Point-of-Care Ultrasonography for Evaluation of Acute Dyspnea in the ED. Chest.
2017 Jun;151(6):1295-1301. doi: 10.1016/j.chest.2017.02.003. Epub 2017 Feb 16. PMID:
28212836.
2) Yampolsky S, Kwan A, Cheng S, Kedan I. Point of Care Ultrasound for Diagnosis and
Management in Heart Failure: A Targeted Literature Review. POCUS J. 2024 Apr 22;9(1):117-130.
doi: 10.24908/pocus.v9i1.16795. PMID: 38681155; PMCID: PMC11044942.
3) Núñez-Ramos JA, Duarte-Misol D, Petro MAB, Pérez KJS, Echeverry VPG, Malagón SV.
Agreement of point of care ultrasound and final clinical diagnosis in patients with
acute heart failure, acute coronary syndrome, and shock: POCUS not missing the target.
Intern Emerg Med. 2024 Jun 12. doi: 10.1007/s11739-024-03639-y. Epub ahead of print.
PMID: 38864971.
4) Nakao S, Vaillancourt C, Taljaard M, Nemnom MJ, Woo MY, Stiell IG. Evaluating the
impact of point-of-care ultrasonography on patients with suspected acute heart failure
or chronic obstructive pulmonary disease exacerbation in the emergency department:
A prospective observational study. CJEM. 2020 May;22(3):342-349. doi: 10.1017/cem.2019.499.
PMID: 32106899.
5) Özkan B, Ünlüer EE, Akyol PY, Karagöz A, Bayata MS, Akoğlu H, Oyar O, Dalli A,
Topal FE. Stethoscope versus point-of-care ultrasound in the differential diagnosis
of dyspnea: a randomized trial. Eur J Emerg Med. 2015 Dec;22(6):440-3. doi: 10.1097/MEJ.0000000000000258.
PMID: 25715019.
