In the most recent issue of WestJEM, a very interesting ultrasound case by Drs. Wendler, Schoenberger, Mailhot and Perera was published illustrating that if you dont look, you won’t get the diagnosis! How bedside ultrasound solved the case! Below is only the beginning of the case:
“A 57-year-old Hispanic male presented with a 1-day history of altered mental status. He had a past medical history significant for alcohol abuse, hepatitis C and Child-Pugh Class B cirrhosis. He had undergone TIPS placement an unknown number of years before presentation to the ED. Additionally, he had been previously hospitalized for hepatic encephalopathy due to noncompliance with his medical regimen.
On physical examination, the patient appeared comfortable and calm. He was alert, but oriented to name only. Vitals signs were temperature 98.1°F pulse 78 beats/ min, respiratory rate 16 breaths/min and blood pressure 130/89 mmHg. The patient was noted to have scleral icterus, and his abdominal exam revealed moderate ascites without tenderness, rebound, or guarding. Unexpectedly, on cardiac auscultation, the patient was noted to have a 2/6 systolic and a 2/6 diastolic murmur with ectopy. A 12-lead electrocardiogram (ECG) was obtained in addition to standard laboratory studies to elucidate the cause of the patient’s altered mental status.
The serum white blood cell count was 6,500/mm3 without neutrophilic predominance, hemoglobin of 10 g/dL, BUN of 10 mg/dL and a creatinine of 0.6 mg/dL. The patient was noted to have an elevated ammonia level at138 umol/L. The 12-lead ECG showed normal sinus rhythm with multiple premature atrial contractions. To further assess cardiac function, a bedside EUS was performed…..” (see below)
Oh, but there’s more! The case isnt over, nor the discussion – read more!