Ultrasound
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Dx: Normal aorta, but what about the liver?

The patient’s aorta (labeled “A”) appears normal in both the transverse and longitudinal views next to the inferior vena cava (IVC). The diameter is less than 3 cm and there is no evidence of any intraluminal clot or dissection flap. Careful review of the ultrasound images demonstrates some abnormalities in the glimpses we get of the surrounding organs. A small piece of the liver can be visualized on both scans just near-field to (below) the aorta. Within the parenchyma of the liver, there is a well-defined lesion seen on both images.

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Before your medical student can ask any questions or make any statements in front of the patient that may put everyone in an uncomfortable situation, your senior resident tells the patient that he’s going to order a comprehensive abdominal ultrasound to evaluate some things he visualized on the scan. He explains that the machines in the radiology department have better resolution and imaging capabilities so often times they can clarify subtle things we see on our bedside scans.

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The patient is wheeled away for her comprehensive abdominal ultrasound in the radiology department, which leaves ample time to review all of her labs and urinalysis ordered from the ED. Her UA is normal, and her CBC and CMP are only notable for a hemoglobin of 9.0 along with a scattering of anisocytosis, microcytes, hypochromia, ovalocytes, target cells and tear drop cells. As the patient’s comprehensive ultrasound images begin uploading on the PACS machine, you can’t help but gasp at what they show (bottom). What do you see on the scans?

The patient has multiple metastatic lesions seen throughout her entire liver. Your senior resident delivers the news with both empathy and kindness and arranges for the patient to be admitted for a comprehensive oncology evaluation as an inpatient.

You take a moment to provide some teaching pearls to your residents and the medical students who are on service. You remind them that although most things in medicine are not “black and white” there are a few rules that are pretty well accepted:

  1. Never overlook or ignore questionable or abnormal findings.
  2. Don’t anchor into a diagnosis and potentially ignore other etiologies on your differential diagnosis. The three most common decision-making heuristics are anchoring, availability and attribution. Try your hardest to avoid these pitfalls:
  • Anchoring: refers to the tendency to seize on the first symptom, physical exam finding, or laboratory abnormality and anchor one’s mind onto an answer prematurely.
  • Availability: refers to the tendency to assume that an easily remembered prior experience explains the new situation you are facing.
  • Attribution: refers to the tendency to invoke stereotypes in our minds and attribute symptoms and findings to those stereotypes.

You are your patient’s best advocate. Be comprehensive and fight for what’s right for them.

 

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