Why I prefer LOOKING at hearts

Seriously, if you haven’t yet learned how to LOOK at hearts with bedside ultrasound you are doing your patients a disservice.  The amount of critical information you are likely missing with auscultation is scary.

I saw a 48 year old female currently receiving chemotherapy via portacath for metastatic colon CA.  Presents in the middle of the night with a few very brief episodes of chest pain.  Not pleuritic.  No fever.  No cough.  Not dyspneic.  Completely symptom-free during ED stay.  Ex-smoker.  Normal physical exam.  No cardiac murmurs or rubs.  Chest absolutely clear.

ECG normal.  CXR shows nondescript mildly prominent interstitial markings.  Bloodwork unremarkable.

Bedside echo shows this:

I was quite surprised since the patient looked and felt fine.  Arranged stat echo and CT of the chest while starting anticoagulation.

Large right atrial thrombus confirmed on formal echo and CT demonstrated multiple small pulmonary emboli.

The internist thanks me for the referral.  “You saved us having to do a consult on someone near dead in a week.”

Thus my threshold for doing bedside echo has dropped even further.  I wonder why I even bother breaking out the stethoscope on anyone with risk factors or a good story for clinical badness.