UOTW #98

A 28 yo male presents to your emergency department with increasing dyspnea over the past 6 days.  The patient reports receiving negative results for a COVID test that was performed yesterday, and due to his persistent symptoms he presents to your ED for a second opinion.   The patient denies any relevant past medical or surgical history.  He denies smoking and drug use and admits to occasional moderate alcohol consumption.

On exam, his vital signs are as follows: HR 95, RR 26, T 38.0ºC, BP 118/77, SpO2 95% R/A. On auscultation, you hear occasional scattered mild wheezing. You physical exam is otherwise unremarkable

You perform a bedside ultrasound of the lungs and obtain the following clip in the right axillary area.

What do the clips show? What is the diagnosis? (Click the button for the answer!)

Answer

Right Middle Lobe Pneumonia

An x-ray was subsequently obtained and demonstrated the following:

Right middle lobe pneumonia

    • Pneumonia is the third leading cause of hospital admission, and is the leading cause of sepsis and death from infection in the US.1
    • The physical exam and history by themselves are inadequate to rule in and rule out pneumonia.2
    • In one study in patients with shortness of breath (n = 285), CXR was found to have a +LR = 6.43, -LR = 0.4 for the diagnosis of pneumonia. Discharge diagnosis and/or CT scan results were used as the gold standard.3
    • In that same study, lung ultrasound (LUS) was found to have a  +LR = 35.8, -LR = 0.09 for pneumonia.3
    • There are multiple ultrasound findings that have been associated with pneumonia, including consolidations, air bronchograms and focal b-lines.3

  • In our patient, a large consolidation with static air bronchograms was seen in the right middle lobe.

  • Refer to the following video for a tutorial on how to diagnose pneumonia using your bedside ultrasound:

Authors: Jacob Avila, MD

Peer Reviewed by Ben Smith, MD

References

  1. Rider AC, Frazee BW. Community-Acquired Pneumonia. Emerg Med Clin North Am. 2018 Nov;36(4):665-683. doi: 10.1016/j.emc.2018.07.001. Epub 2018 Sep 6. PMID: 30296998; PMCID: PMC7126690.
  2. Grief SN, Loza JK. Guidelines for the Evaluation and Treatment of Pneumonia. Prim Care. 2018 Sep;45(3):485-503. doi: 10.1016/j.pop.2018.04.001. PMID: 30115336; PMCID: PMC7112285.
  3. Nazerian P, Volpicelli G, Vanni S, Gigli C, Betti L, Bartolucci M, Zanobetti M, Ermini FR, Iannello C, Grifoni S. Accuracy of lung ultrasound for the diagnosis of consolidations when compared to chest computed tomography. Am J Emerg Med. 2015 May;33(5):620-5. doi: 10.1016/j.ajem.2015.01.035. Epub 2015 Jan 28. PMID: 25758182.
  4. Liu XL, Lian R, Tao YK, Gu CD, Zhang GQ. Lung ultrasonography: an effective way to diagnose community-acquired pneumonia. Emerg Med J. 2015 Jun;32(6):433-8. doi: 10.1136/emermed-2013-203039. Epub 2014 Aug 20. PMID: 25142033.


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