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A 63-year-old, undomiciled male, who has been out of care for many years presents with shortness of breath for the last 3 days. He has also had 3 days of constant, substernal chest tightness which is not pleuritic, positional or exertional. He has a chronic cough with some worsening yellow sputum production but no fevers. He denies leg swelling. He is an active smoker with a 40 pack-year history. He has a history of alcohol abuse and methamphetamine abuse. His EKG does not show any acute ischaemia.
Initial vital signs
BP 135/96, pulse 121, RR 28, temperature 36.3, oxygen saturation 95% on room air.
The patient is tachypnoeic. His heart sounds are notable for tachycardia without murmurs, gallop or rubs. His lung sounds are notable for both wheeze and rales at the bases. His abdomen is soft and non-distended and non-tender, and his extremities are warm and well perfused without any oedema.
Indications for ultrasound
In this patient, and the acutely dyspnoeic patient in general, the differential is broad, including but not limited to acute coronary syndrome, congestive heart failure, chronic obstructive pulmonary disease, pneumonia and pulmonary embolus. These various diagnoses have different diagnostic tests and treatments and ultrasound can assist with rapidly narrowing the differential to help immediately guide management.
For cardiac ultrasound, using the phased array probe, obtain four views including the parasternal long, parasternal short, four chamber apical view and subxiphoid view.
In the parasternal long view (figure 1, online supplementary video 1), the left ventricular ejection fraction (LVEF) can be estimated visually to obtain an overall assessment of cardiac squeeze. In this patient, the squeeze is diminished. Another proxy that can be used for LVEF is the E-point septal separation (EPSS) (figure 2).1
To calculate EPSS, the distance from the tip of the …
Contributors ML conceived of the article, obtained the images and wrote and edited the article while NA also wrote and edited the article.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent for publication Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.