Case of the Week — Case #1: "I Can't Breathe!"

An 80 year old lady presents to the ED with complaints of shortness of breath gradually increasing over the course of a week. She denies cough, fever or chest pain. She admits to dyspnea on exertion, orthopnea and PND severe enough to keep her sleeping upright. Her PMH is significant for hypertension only. Physical exam demonstrates decreased breath sounds on the left, without crackles or wheezing. She appears in mild respiratory distress and her POx is 95% on 3L NC O2. Her CXR demonstrates complete white-out of the left side. How can you determine if this is caused by atelectasis versus effusion? Ultrasound can be used to interrogate the pleural cavity as part of the Extended FAST exam (E-FAST). The probe is placed in the coronal position in the upper quadrant (side depends on the affected area) with the probe indicator to the patient's head. Any time you see black on the cranial side of the diaphragm (no mirror artifact visible) then there is fluid in the pleural cavity. Notice the diaphragm at the right side of the screen and the lung fluttering within a large pleural effusion every time she breathes.