rAn 85-year-old patient was admitted to the hospital for worsening of her health condition and weakness. She medicated 10 mg of prednisolone three times per day for ulcerative colitis. She presented neither with dyspnea nor with pain during admission. She was well-oriented to time and space. No fever was present. She was not able to walk due to weakness. Physical examination revealed anasarca of the dorsal part of trunk as well as of limbs diffusely. Peripheral parts of the limbs were cold due to vasoconstriction, and capillary refill time could not be assessed. Mottled skin in the region of both knees. Auscultation revealed inspiratory crackles basally on the left side. The patient could not cough out mucus. SpO2 96% with oxygen mask 6 l/min, 25 breaths per minute, mechanics of breathing was calm and symmetric. Atrial fibrillation with a rapid ventricular response, 150 bpm. Blood pressure 80/50 mmHg, noradrenalin 1.2 mg/h. The abdomen was soft, and palpation did not reveal any resistance. No pain occurred during palpation. Auscultation revealed peristalsis. Anuria. The patient was admitted to ICU. Central venous catheter was inserted, artery, blood samples were taken for blood cultures. CT of thorax and abdomen was performed. Infiltrations in both lower lobes and right upper lobe were found. Ultrasonography of the abdomen did not reveal any pathology. Lab tests revealed leucocytosis 21 000, 84% of neutrophils, CRP 217 mg/dl, procalcitonin 1.2 ng/ml.
The patient complained of dyspnea for one week. She could not sleep for one night due to burning chest pain which she ascribed to pyrosis. The pain withdrew without any intervention.
ECG: atrial fibrillation, iRBBB, without suspicion of ischemic changes.
Ultrasonography was performed at ICU. We started with lung ultrasonography:
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