ANSWER: A) Simple Large Pleural Effusion

The images shown display an anechoic (black) area deep to the pleural line, with extension up to the axilla (R3 lung zone) and depth of roughly 8cm. This is consistent with a large pleural effusion. The lack of septations or floating debris suggest the effusion to be simple.

ANSWER: C) Ascites

An anechoic space is visualized beneath the abdominal wall tissues in both clips consistent with fluid. The free flowing nature is consistent with ascites – note that ascites fluid fills irregular spaces and is NOT encapsulated.

ANSWER: C) Severely depressed EF, severe TR, presence of RV overload

Visually there is severely depressed LV ejection fraction, which is supported by an increased EPSS at 13.4mm. Colour Doppler in the Apical 4 Chamber view reveals a large TR jet reaching the back of the right atrium consistent with severe Tricuspid Regurgitation. The Parasternal Short view shows bowing of the septum, consistent with elevated RVSP. Traditional teaching is that septal flattening predominantly in diastole is more in keeping with RV volume overload; whereas flattening in systole is in keeping with RV pressure overload.

ANSWER: D) Severe venous congestion

The IVC views show a large and circular Inferior Vena Cava, which indicate an elevated CVP. This is the starting point for venous congestion.

The VEXUS (Venous Excess UltraSound) exam is a collection of ultrasound applications designed to identify deleterious venous congestion at an organ level. Each of the hepatic, portal, and intra-renal veins can be interrogated with spectral Doppler; each has a predictable waveform under normal physiologic conditions, which changes predictably with increasing venous congestion. For more about VEXUS, see the linked screencast on the ”All UBC IM POCUS” video tutorials page.

 Here, hepatic vein doppler shows severe abnormality with reversal of systolic flow (consistent with the known severe TR). Portal vein doppler shows reversal of flow below the baseline, again supporting severe congestion. The intra-renal vein doppler is somewhat suboptimal (likely too much baseline noise), but appears to to have diastole-only monophasic flow – again, supportive of severe venous congestion and right-sided overload.

Answer: A) Analysis is consistent with a transudate.

None of Light’s criteria are met, suggesting this fluid is transudative in nature.

ANSWER: True

The SAAG is 20, consistent with ascites from portal hypertension. The total protein on ascitic fluid analysis is 26, suggesting the cause is from congestive heart failure as opposed to cirrhosis. A high ascites protein count (typically > 25) is supportive of a cardiogenic origin of ascites.