Ultrasound Quiz 5: More Than Just Subxiphoid

Question 1:

Your patient in the ICU is in shock. You want to perform an echo of the heart but you were unable to elicit an ultrasound from the thorax. So you decide to perform a transesophageal ultrasound. What can you see?

We cannot see the heart since it is being obscured by bowel gas There are no abnormalities seen here. We can see the blood on ultrasound because of the interaction between RBCs and plasma proteins in low sheer conditions. Woah thrombi moving in the heart! That's the ultrasound of a washing machine

Yes! Those are emboli!

We can see here some thrombi moving in the heart.
If we were to see gas, we wouldn't see anything at all, since gas disperses ultrasound waves. Rather, we see here echogenic (white) substances moving around in the heart. Those echogenic substances are thrombi. It does look like a washing machine though!

Question 2:

A 60 year old patient is referred from his family physician because they heard an abnormal heart sound. The patient presents dyspneic and his ankles are swollen. He has a history of some form of heart disease. An ultrasound of the heart from the parasternal view is performed and you are able to diagnose:

Yes great job! You were able to identify the hockey stick formation which is indicative of rheumatic mitral stenosis.

The patient has rheumatic mitral stenosis. Although this is a more advanced view, in some of your courses you may have studied the classic "hockey stick formation". We can see this sign when the mitral valve is going straight up and bends straight down, like a hockey stick. This is indicative of rheumatic mitral valve stenosis. This is mitral stenosis caused by rheumatic heart disease.

Question 3:

You are the resident on call at the ER. A 54 year old female is brought in for chest pain that has lasted a few days. She had a fever a few days prior to coming in the ER and her coworkers had flu-like symptoms. She is able to localize her pain and it feels sharp. You are suspecting pericarditis. After, the medical student performed an ultrasound and told you that she has no abnormalities. How do you respond?

You agree with the student about the ultrasound, but still perform a pericardiocentesis because she has pericarditis You agree with the students and decide to send the patient home. The ultrasound is inconclusive, redo the ultrasound. The patient has some type of stenosis because of calcifications on her valves and needs further investigation. The patient needs antibiotics for endocarditis.

Great job! Remember, unless you sweep the entire heart with the "lucky 7" in view, the scan remains inconclusive and you cannot exclude a pericardial effusion. You could have a minor effusion hiding somewhere!

This ultrasound is inconclusive.
Remember, unless you sweep the entire heart with the "lucky 7" in view, the scan remains inconclusive and you cannot exclude a pericardial effusion. You could have a minor effusion hiding somewhere!
You need to keep sweeping until the heart disappears entirely, and then sweep in the opposite direction until it disappears again.
Otherwise, there are no abnormalities seen on this ultrasound.