Pain all over…

I want to talk about a case that I picked up in the rapid assessment area of my emergency department where geography, as it turned out, was not destiny. It was not as glamourous as a challenging airway or as exciting as a pediatric resuscitation and yet it is one that has stuck with me years later. The patient was old. The patient was weak. The patient was dizzy. It was the end of my shift.

She had been seen at another hospital in recent days, sent home each time with no answer for why she was steadily becoming less able to walk. The patient was frustrated. The family present at the bedside upset and annoyed. In short, the perfect case for POCUS….

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Is it a thrombus?

It is not uncommon to get all excited when seeing shadows of foreign body in the chambers of the heart. Common causes are usually thrombus and vegetations but is it always true?

We present a case of a 70 years of gentleman who presents with generalised weakness for 2 to 3 days and hypotension. He presented with symptoms of urinary and cough symptoms with significant loss of appetite of 10lbs in the last few months.

Physical examination revealed hypotension but he was afebrile with no tachycardia. He is clinically dry with no abnormal neurological, heart, lung or abdomen findings.

An apical 4 chamber U/S of the heart was performed.

A mobile, elongated mass can be seen floating in the right atrium and a thrombus-in-transit or endocarditis was considered. However, this does not tie in with the presentation of the patient. The patient received fluids and antibiotics for a working diagnosis of a sepsis with dehydration.

Patient undergone a formal 2D echo and the masses were determined to be eustachian valves. The eustachian valve is a remnant of the embryonic valve of the IVC. It is found at the posterior margin of the IVC shaped like a crescent. It is hemodynamically insignificant in adults.

So the next time when you see a mass in the RA which does not tie in with the clinical presentation of the patient. Consider the mimics of thrombus in the heart and don’t jump into conclusion too quickly!

A PoCUS Year in Review – Part 2

Here’s the final section of a 2-part series on some PoCUS pearls learned along my 1 year fellowship.

5. Trust the gut.

This year, I’ve seen multiple presentations of cholecystitis. Let’s take a look at a slam dunk diagnosis. The following is a patient who presented with RUQ pain, vomiting, fever:

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