Point-of-Care Ultrasound (POCUS) is integral to the care we provide at our center in rural Guatemala. We incorporate POCUS as an extension of our physical exam and utilize sonography in assessing and treating our patients every day. The confluence of a high volume of scans coupled with a patient population that not infrequently presents with interesting pathology (typically untreated and advanced in its clinical course) has afforded us a library of interesting ultrasound images and cases.
I have a personal interest in echocardiography (i.e. ultrasound of the heart). I find echo to be both fascinating as well as extremely high yield in arriving at an accurate diagnosis and guiding therapy.
The combination of the above two facts (loads of cool ultrasound images + a personal interest in echo) lead us to the current post. I hope this will be the first entry of a somewhat regular blog series highlighting cardiac images of some of our patients' "Broken Hearts."
Case 1: The Unexpected Goombah
A male patient in his forties presented with complaints of shortness of breath, abdominal bloating, and lower extremity swelling. In taking his history, it was revealed that he consumed alcohol on a regular basis. Alcoholic liver disease and its sequelae moved towards the top of my working differential diagnosis.
As part of this patient's evaluation, I scanned his belly and noted a small amount of ascites (free fluid in the abdomen). I began to anchor on my suspicion that his symptoms were related to his proclivity for cerveza.
For completeness, I took a look at his heart. What I saw on the screen immediately untethered my anchoring bias.
There was a goombah (a term in medical lingo which is employed when describing a large unidentified mass) occupying nearly his entire left atrium! This intracardiac mass was obstructing flow of blood through his mitral valve, essentially causing heart failure, and leading to hypervolemia.
Echocardiography dramatically and unequivocally changed our treatment plan. Diuresis would still be part of our management of symptoms. Decreasing alcohol consumption remained a reasonable recommendation. But, neither intervention would adequately address the etiology of the patient's symptoms. Definitive management would entail surgery to excise the mass residing in his "Broken Heart."
Photo by Kelly Sikkema on Unsplash