PD case summary

This was a young patient on PD with SOB. 

The differential diagnosis is

- Viral infection +/- consolidation

- Acute PE 

- inadequate dialysis and fluid overload

- CCF due to cardiomyopathy

Bedside US helps differentiate between these differentials. 

The lung US shows B lines bibasally consistent with the examination findings of bibasal crackles. B lines are the vertical laser like lines extending down the screen from the pleura. They erase A lines. 

 Bilateral anechoic effusions are also consistent with fluid overload. The hyperechoic lung floating in the fluid is typical of collapsed lung rather than consolidation. 

Fluid overload in this case could be due to CCF, renal failure, cirrhosis and hypoalbuminaemia. 

Her echo images show a dilated LV with poor contractility. The anterior mitral leaflet is definitely >5mm from the anterior septum and the LV cavity only changes by 10-20% with each contraction (normally 30-50%).

Note that the LA is also dilated indicating increased end diastolic pressure +/- MR --> pulmonary oedema. LA should be 1:1:1 with RV and aorta.

The RV is dilated as well, but is smaller than the LV and you can see in the A4C that the IV septum bows into the RV. Thus, there is probably no severe RV pressure over load ie acute PE.  

In conclusion, this patient had a viral cardiomyopathy which caused SOB due to poor LV contractility and pulmonary oedema, Bedside echo expedited her management considerably.