Answer: B) Bilateral diffuse B-lines, smooth pleural line, and bilateral pleural effusions, suggestive of pulmonary edema
The images here are classic for the ultrasound appearance of pulmonary edema. There are diffuse, symmetrical B-lines present bilaterally. Furthermore, these B-lines are associated with a smooth pleural line, which supports cardiogenic pulmonary edema as an underlying cause. In contrast, B-lines associated with a ragged pleural line suggest an underlying inflammtory or infectious cause – things like pneumonia, ARDS, inflammatory lung disease, etc. We also see bilateral simple pleural effusions here, again consistent with volume overload as an underlying etiology.

Answer: D) Echogenic kidneys consistent with chronic medical renal disease

The kidneys here appear echogenic, which is seen in chronic medical renal disease of many etiologies. There are a few renal cysts noted, but the burden is not such that PCKD is the suspected etiology of his renal failure.

His cardiac POCUS views are shown below.

Answer: C) Markedly decreased LVEF with global hypokinesis; normal RV function

Cardiac ultrasound, surprisingly, revealed markedly decreased LVEF with LV dilation and global hypokinesis. We can assess LV function from a POCUS perspective with three tools: myocardial excursion (qualitative); myocardial thickening (qualitative); and EPSS, or E-point septal separation, which can be assessed qualitatively or quantitatively, as was measured in his case. A normal EPSS is 0.7cm or less; 0.7-1.7cm is mildly abnormal, and >1.7cm is very abnormal. Here, qualitative visual assessment and measured EPSS both point to a severely decreased LVEF.

Other findings from this cardiac point include normal RV function; mild to moderate MR, and a small pericardial effusion that is not hemodynamically significant.

For the true cardiac POCUS nerds, below is his VTI measured at the LVOT. (For more on this, see the Advanced Cardiac tutorials page).

Answer: B) Decreased

This still image, showing pulsed-wave Doppler (PW) placed in the left ventricular outflow tract (LVOT), reveals a velocity-time integral (VTI) of 12.6, which is low. Normal LVOT VTI is 18-22cm. This low VTI corresponds to a low stroke volume, consistent with his decreased LVEF. Note that, for this particular patient, cardiac output was maintained due to a compensatory increase in heart rate (patient was tachycardiac at 110). For more on stroke volume and cardiac output calculations, see the tutorial from WesternSono on our hemodynamics page.