American College of Physicians: Internal Medicine — Doctors for Adults ®

Wednesday, October 12, 2016

My week in ultrasound

After 5 years of doing bedside ultrasound, I'm still excited about it. Bedside, or point-of-care, ultrasound is using an ultrasound machine during the physical examination of a patient in order to make a diagnosis. I use a pretty tiny machine that fits in my pocket. As an internist who works in the hospital and in rural clinic outpatient settings, I get to use my ultrasound all the time, and it's still lots of fun. (For more on adventures in ultrasound see this or this or this.) Those of you who have read this blog for a while can skip the intro and go to the cool cases.

When I talk about it, most people who haven't already heard me wax eloquent say, “You mean you look at babies?” Ultrasound has been used as a bedside tool for looking at pregnant wombs for a very long time. It is extremely useful for that, since you can see if the baby is alive, about how old it is, whether there are 2, what position it is in, and a number of other useful things. I would never give up the chance to look at a baby if my patient were pregnant and willing, because they are so cute, but since I am not an obstetrician, I look mostly at other things. I can see whether the heart is failing, whether there is extra fluid in the lungs or belly, whether the kidneys are blocked, whether the bladder empties. I can see pneumonia and broken bones, tell whether a swelling is full of fluid and whether a lump is solid or a cyst. I can see disease in blood vessels and stones in gallbladders. Combined with talking to a patient and doing my usual physical exam, I can determine whether a patient is dehydrated or the opposite and can often be more accurate about diagnosing blood clots or sepsis. It's cool. Yes indeedy it is.

This week I worked as an outpatient doctor in clinic and also in the hospital, admitting and taking care of sick patients. I use the ultrasound nearly every time I examine a patient and it always helps, but there were some cases in which it was more spectacularly useful than in others.
1. A patient in clinic had pain in her head and cheek and teeth on the right side 3 weeks after getting a cold. She had a long history of allergies and sometimes used a nose spray or an antihistamine, but this was worse than usual. On exam there were polyps in the nose and maybe a little bit of tenderness in the right side of her face. It is possible to use the ultrasound on the sinus bones behind the cheek to see if there is fluid, because fluid transmits ultrasound and you can see the back wall of the sinus only if there is fluid in it. I could see the back wall on the right, the side with symptoms and not on the left. I diagnosed a sinus infection. She will try nasal steroid spray and washes to see if things can open up and drain, and if that doesn't work, she has a “pocket prescription” for an antibiotic which she can fill and take. I also looked at the teeth on the right with the ultrasound and found no evidence of an abscess, which was reassuring.
2. Another patient in clinic had stubbed his toe pretty hard. It had swollen and then swollen some more and he was concerned about an infection. The clinic does not have an X-ray machine and is a pretty long drive to the closest one. Beside the cost, it takes an hour of a patient's time to wait, fill out papers and then have an X-ray done, plus I will usually then wait another hour for results and the patient will then be difficult to contact. I was able to ultrasound the toe, find a non-displaced fracture at the point where he was tender and give an explanation plus an appropriate set of recommendations.
3. At the hospital I had a patient who had been admitted with low blood pressure and likely pneumonia along with blood enzyme tests suggesting a possible heart attack. He responded well to antibiotics and fluids and, due to having lots of chronic medical problems, wanted to avoid being transferred to a larger hospital to see a cardiologist. I knew from previous visits what his heart looked like with ultrasound and could tell him that it looked no worse, which meant that an emergent visit to the cardiologist was not necessary. I was able to use the ultrasound of the heart at the time of our conversation to help guide our shared decision-making about whether to get in a helicopter and head far away from family and friends.
4. Another patient had severe pancreatitis, an inflammation of one of the nastiest and most caustic organs in the digestive system. He was 80 years old and drank too much whiskey on a daily basis, which caused the pancreas to become angry. After a day or so he developed an acute alcohol withdrawal syndrome, trying to crawl out of bed, anxious and with an elevated heart rate. We treated him for the alcohol withdrawal, but his heart rate remained elevated. Was he dehydrated? None of the other labs gave me the information I needed, but ultrasound of the inferior vena cava showed that he had been adequately hydrated and that, as expected in severe pancreatitis, there was some fluid in the belly and at the base of the lungs, so more fluid would make things worse rather than better. I was able to repeat the ultrasound daily to determine how much intravenous fluid to give.
5. A young man with a history of longstanding intestinal inflammation and several operations in the past presented with abdominal pain. X-ray was pretty normal, but can be hugely misleading. A CT scan would have been helpful, but is associated with a high radiation dose. He had undergone many CT scans in his life and the possibility of his developing cancer on the basis of his radiation exposure was already significant. I was able to look for fluid in the belly or fluid filled loops of bowel which would suggest obstruction and feel pretty confident that a non-surgical approach to his problem was safe.

It was a good week. Nobody died. I felt competent. Patients were happy. Bedside ultrasound was terrific.

Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health Care So Expensive?, where this post originally appeared.

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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

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Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

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Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

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Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

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Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

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Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

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The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

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Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

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Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

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Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

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