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COW #1: I can't lie flat

This is classic case of a new diagnosis of systolic heart failure resulting in a CHF exacerbation with pulmonary edema and R pleural effusion

This is a very common presentation for new CHF. Often times in the real world, body habitus and other factors make your physical exam inadequate. As we've mentioned before, auscultation is a very poor screening tool for pulmonary edema. Without using POCUS on this patient, the differential would be very broad - combining basically all common cardiac and pulmonary disease. With a 5 minute heart and lung exam, we come to our answer.

Diffuse B lines consistent with pulmonary edema

Looking 3cm deep, you can see the bright, shimering pleural line with spotlight projections beaming down. These are B-lines and 3 or more in multiple lung fields are highly sensitive for pulmonary edema.

If you are able, you can zoom in on the pleural line using the vascular probe to assess its characteristics. A smooth pleural line with B-lines provides even more evidence for pulmonary edema as the cause.


It is very important to look at both lungs and multiple lung fields. Any focal lung pathology can also cause B-line pattern but it would not be diffuse. In the case of pneumonia or pulmonary fibrosis, there can b-lines the pleural line is often jagged.

Right Pleural Effusion

As you scan down the R lung, we find a pleural effusion. This image has multiple classic pleural effusion signs.


Spine sign - you know this is fluid and not air because the distal image is hyperechoic indicating the ultrasound waves are penetrating to the spine. 

Curtain sign - with each inhale, you can see the lung expand and cover the view of the effusion

Jellyfish sign - The compressed, atelectatic lung can be seen the the left of the image

Cardiac Parasternal long view

Due to this patient's anatomy, we were unable to get all the cardiac views. However with parasternal long, you can get most of the information you need to make the diagnosis. As we have discussed, to make a qualitative EF assessment, you look at the overall squeeze of the heart (fractional shortening) and the motion of the anterior mitral valve leaflet (anterior mitral valve leaflet excursion).

In this patient, the LV is hardly contracting and the anterior leaflet of the mitral valve is > 1cm away from the septum during end diastole. 

These findings are consistent with a severely reduced EF.

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