Answer: D

The anechoic space in the R4 zone represents a large pleural effusion with compressive atelectasis seen in the far field.

The pattern of cardiogenic pulmonary edema is diffuse B-line pattern with thin and smooth pleural line, whereas, the predominant pattern in the anterior lung zones in our patient are that of A-lines.

Lung ultrasound cannot confirm the presence of pulmonary embolism. Subpleural consolidations could represent pulmonary infarcts but the differential also includes other causes such as infection or malignancy.

The findings in our patient of unilateral B-lines and subpleural consolidation could suggest an infection, but the addition of clinical data such fevers, sputum production, and/or hemoptysis are required for corroboration.

Answer: A

Also known as D-sign, evidence of septal flattening during diastole indicates volume overload. Septal flattening during systole indicates pressure overload.

Answer: E

Her RV size is greater than LV size (indicating severely dilated RV), and her TAPSE is < 1.7 cm (indicating reduced RV function)

A mildly dilated RV is an RV size (measured at the tricuspid annulus) greater than two thirds of the size of the LV (measured at the mitral annulus)

Answer: C

Her IVC measured > 2.5 cm (dilated) and there is < 50% respiratory variation.

Answer: D

Severe TR on qualitative assessment as evidenced by a very large central jet that occupies >50% of the RA and hits the back wall with colour doppler. Severe TR can also be graded quantitatively by measuring the vena contracta width (>7mm)

Severe MR on qualitative assessment due to presence of eccentric MR jet that is anteriorly directed.

Answer: C

As venous congestion progressively worsens, or in the presence of severe tricuspid regurgitation, the S wave on hepatic vein tracing begins to move towards the baseline and eventually reverses to above the baseline. Spectral doppler of the portal vein shows increasing pulsatility in the face of venous congestion. By definition a pulsatility index of greater than 50% of the portal vein is consistent with severe venous congestion. In very severe cases, such as here, there is actual reversal of flow.

Answer: D

Continue diuresis with vasopressor support

There is severe RV enlargement with volume overload causing reduced LV filling due to ventricular interdependence. Diuresis will help with offloading the RV.

Additional IV fluids will worsen RV failure by increasing RV volume overload which further worsens RV systolic function (RV spiral of death).

Nitroglycerin is a non-selective vasodilator which in this case would worsen the hypotension; selective pulmonary vasodilators such as epoprostenol or nitric oxide could be considered.