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Your next ED patient is a 47 year old male with a history of diabetes,
hypertension, coronary arterial disease and CHF who presents with 2
weeks of gradually worsening leg swelling, abdominal swelling, and
trouble sleeping due to orthopnea. He states that he has had the leg
swelling and trouble breathing in the past from his CHF, but he has
never had a “jelly belly” before. He denies any change in his
medications or dietary indiscretion. He has not had any chest pain,
abdominal pain other than feeling “fat and bloated” or any vomiting,
diarrhea or fever. His main concern seems to be his abdomen and his
request is simple. “Doc, can you fix me?”
On physical exam, he is in no acute distress but is a bit hypertensive and tachypneic. His temperature is 96.8°F with a respiratory rate of 24 and a pulse ox of 96% on room air. His pulse and blood pressure are 68 and 179/96, respectively. His head and neck appear normal except for his eyes, which have just the slightest tint of yellow. His lungs are clear, but he has decreased breath sounds bilaterally. His heart is regular, without murmur or gallop. His abdomen is quite distended, but non-tender, and he has a positive fluid wave. His extremities have symmetric 2+ edema, without redness or tenderness.
You order some basic tests and none of the results surprise you much. His EKG and chest X-ray show nothing acute, just poor inspiration. His potassium is a bit low and his bicarb a bit high from the Lasix he is taking, but otherwise his metabolic panel looks good. His CBC is fine except for low platelets at 111,000. His troponin is normal, but his BNP and LFT’s are all slightly out of whack.
You call his internist to admit him for a mild CHF exacerbation with new onset ascites, likely due to a combination of the CHF and previously undiagnosed liver disease. His internist agrees, but wants you to tap his abdomen first – conditions, conditions.
“This guy is breathing fine,” you think to yourself. “He doesn’t really need the tap done now, and the ED is pretty busy. I don’t really want to give myself more work, but it is Saturday evening, and if I don’t do it, it probably won’t be done till midday on Monday.”
You tell the internist, “sure,” then, after getting off the phone, you ask one of your trusty ED techs to set you up for a paracentesis. As an afterthought you add, “Better get the ultrasound machine in there as well.” You might as well confirm 100% that there is actually fluid in there, that there is enough to tap, and where the safest puncture location is.
When the time is ripe, you turn on your ultrasound machine, add a small dab of gel to the curvilinear probe and take the following image (below) in the right lower quadrant.
What do you see? Is there ascites?
If so, how much? Does this look like a promising location or should you look elsewhere?
Would repositioning your patient help?