Public Science Insights: Point of Care Ultrasound: Changing the Physical Exam

Posted Thu, Jul, 14,2016

As medical students we spent our first year learning the art of the physical exam. We admired the masters of the physical exam, usually gray-haired and seasoned veterans of the hospital wards. They could differentiate subtle murmurs and tell us the different lung sounds they heard on each patient. We then followed and hoped that we were hearing the same thing. Today things are different and point of care ultrasound is leading the way. It should be clearly noted that point of care ultrasound is not meant to replace radiology exams and full cardiac echo studies. It is meant as an extension of the physical exam to make minute to minute decisions regarding patient care.

Lung ultrasound allows us to differentiate a consolidation pattern that is likely from pneumonia versus fluid overload leading to diffuse B line pattern. It allows us to see normal aeration pattern that gives us a lot of information about the lungs both volume status and infection. It is also easily repeatable multiple times as the patient is volume resuscitated to follow the volume status of the lungs.

Point of care cardiac exam allows us to determine the etiology of shock state quickly. Using the 5 view exam you can evaluate left ventricular function to determine if the shock state is secondary to cardiogenic shock, you can see if there is fluid around the heart to determine if the shock state is from obstructive shock secondary to tamponade physiology. You can determine if the left ventricle is hyper dynamic from hypovolemic shock or if the right ventricle is enlarged and the shock state may be from acute right heart failure from pulmonary embolism. Gross valvular abnormalities such a flail leaflet or severe aortic stenosis.

There is also a role for vascular diagnostic screening studies and the limited abdominal exam to evaluate for hydronephrosis and bladder obstruction, abdominal aortic aneurysm and in the evaluation of ascites. Its role for vascular interventions, central lines, peripheral lines, arterial lines is well established and for some of the above it is considered to be standard of care.

The power of point of care ultrasound lies in the user. The user has to be the clinician that knows the patient, the same person that has done the history and the physical exam. They know what the patient is presenting with and what the clinical state is at the time of the point of care exam. There is no time dissociation while waiting for the technician to come do the echo, and there is no physical dissociation with the patient. Ultrasound brings us back to our patients; we speak to them, touch them and spend time with them. It is much more specific, and much less subjective than physical diagnosis. It is also verifiable by others looking at the screen. The real limitation is training. This can be overcome by national level training courses for physicians, nurse practitioners, physician's assistants, fellows and residents. Medical schools are teaching point of care ultrasound starting in the first year of medical school. The learner must identify champions or mentors at their home institutions to continue their training on a daily basis at their home institutions. Point of care ultrasound is becoming an essential part of the way that intensivists and hospitalists evaluate their patients.

Dr Mangala Narasimhan is an author of the recently published paper Ultrasound for the Pulmonary Consultant, available for download now in Clinical Medicine Insights: Circulatory, Respiratory and Pulmonary Medicine.

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