Obese elderly Mid 70s pt on tri-weekly dialysis presents with three days of worsening SOB. No infective symptoms. Some new mild abdominal bloating.
Appears uncomfortable lying flat, finding it hard to breathe.
On long term 1.2L fluid restriction – which pt states he is compliant to.
Crackles heard to both bases. Normotensive. Oedematous to thighs.
CXR as follows:
Impression: Fluid overload in setting of renal failure.
However, his dry weight is 64kg, and he is only 62kg today with all clothes on.
He seems reasonable, and you believe that he has been compliant and strict with his fluid balance. He’s dry as a chip, with a coated tongue, and refuses ice chips because he knows he’s approaching his 1L daily limit.
POCUS Lung
No pathological B lines seen anteriorly on both L and R (L shown above).
Borderline pathological B lines (extending > 15cm, over 3x per rib space) seen to R base. It was difficult to capture the B lines seen above – they were not floridly present posterolaterally.
Something is amiss. There may be something else making him SOB.
Use The Force
On thorough clinical examination, it is determined that he has shifting dullness to percussion of his abdomen, indicative of ascites as an aetiology of his SOB/SOBOE.
… not. Seriously it is impossible to assess shifting dullness in an obese person.
Further US reveals:
Sitting up, morrison’s pouch appears clear. However, there is clearly fluid below the tip of the liver.
Gross ascites seen on the left.
Even sitting upright, pt’s diaphragm was way up in his chest from all this abdominal free fluid.
Result: Patient was transferred to his home/base hospital, where he received dialysis and was considered for a ascitic tap – on further history, he has had an ascitic tap in the past for symptomatic relief. “Have you ever had fluid build up in your belly” “Um, yes.. they put a tube in once to drain it”. A quick SC TTE showed no pericardial effusion (as uremic patients tend to get).
Learning: Always be vigilant, especially when something from hx or ex doesnt quite fit the clinical picture. This man was obese, and it is impossible to assess for shifting dullness (not that it is a reliable examination, btw). Score 1 for POCUS.
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