Lloyd’s Corner: Unusual Lung POCUS

Here is another cool case from Dr Lloyd Gordon of Humber in Toronto…

A 25 year-old man from the Caribbean had one month history of cough, low grade fevers and chest pain. He was seen 2 weeks prior with right-sided chest pain. A POCUS done at the time showed normal lung sliding. He presented via ambulance for the 2nd visit. Paramedics found a pulse of 109 and O2 Sat. of 96%. His BP was normal. His pulse settled to 90 with an O2 Sat. of 100% while in our ED. He had no particular risk factors for infectious diseases, no recent travel and was very physically active. Upon questioning he had used testosterone injections at the gym with clean equipment. Blood tests included a VBG which showed a mild respiratory acidosis, probably from splinting.

I thought he may have some sort of odd pneumonia, maybe TB? The exam was normal except that he was experiencing left lateral chest pain with movement and breathing. Two weeks ago it was on the right side. POCUS is of course better than a  CXR in diagnosing pneumonia.

The pleura and lung POCUS was mostly normal.

The exception was some abnormal areas near the heart, liver and spleen. The really abnormal area was on the left lateral lower chest where he had the pain. [Ed note: that can make the scan more efficient. Place the probe where the pain is located. The yield will be higher.]

[Ed note: The last image points out that you can look for B lines and other abnormalities in the far field, in that wedge-shaped 6 to 9 o’clock area that is your area of interest on Pleural Effusion EDE (see red arrow)]

The IVC was normal. There was no evidence of RV strain.

I took a closer look at the left, lateral area with the linear probe.

Note the irregular pleura and areas of pleural effusion invaginating into the lung. This is typical of a Hampton’s Hump on POCUS.

Here’s the CXR which the radiologist said might be early consolidation.

Here’s the CT…

…showing extensive bilateral proximal emboli.

An echo 2 days later showed mild RV dilatation (after low-molecular weight heparin).

It is likely that the parenteral androgen was the major risk factor for the PE. For more on that topic, click here.

So now you can diagnose PE at the bedside with lung POCUS. Click here for an article.