An Academic Family Physician’s Point-of-Care Ultrasound (POCUS) Experience

Identification of a Soft Tissue Mass: A male patient presents with a left posterior back mass for 1 year. The soft, rubbery mass is estimated to be 4 cm in diameter, likely lipoma. Despite the examination and explanation of findings, the patient is adamant to pursue imaging and removal. POCUS allowed for accurate, quick, non-ionizing confirmation of the size and identification of a soft tissue mass. In addition, this can aid in pre-procedural planning prior to soft tissue mass removal. Based on the large size of 6 cm confirmed by POCUS, the patient was preferentially referred to dermatology, rather than in-office removal. Research in primary care has shown notable differences in size estimation between physical exams and POCUS, impacting medical decision-making² (Figure 1).

Reassurance and Patient Education: In an abdominal wall abscess case, POCUS allowed the clinician to communicate findings clearly and allow the patient to visualize the pathology, showing a highly anxious patient the exact location of the cavity. POCUS is 94.6% sensitive, and 85.4% specific for identifying abscesses.⁵ Over subsequent visits, the clinician demonstrated how the cavity was shrinking. This immediate feedback was invaluable and not easily achievable with traditional radiology, improving patient education and safety by serving as evidence to avoid unnecessary repeat procedures. There is evidence that POCUS is well received by patients, providing reassurance and improved patient understanding and patient satisfaction^6,7 (Figure 2).

Foreign Body: For a patient accidentally stepping on glass, POCUS revealed evidence of a foreign body, and guided removal. Pooled sensitivity and specificity for foreign body identification were 72% and 92% respectively⁸ (Figure 3).

Joint Effusions: POCUS helped assess joint effusions in patients with equivocal physical exams. By checking for joint effusions before performing arthrocentesis, unnecessary procedures have been avoided (Figure 4).

Posterior Knee Pain: An elderly patient presented with painful posterior left knee symptoms had a suspected Baker’s cyst. POCUS guided the needle to the cyst without risking injury to the popliteal vasculature and simultaneously ruled out a popliteal Deep Vein Thrombosis (DVT) (Figure 5).

Carpal Tunnel: For a patient with pain and numbness in the median nerve distribution, POCUS was beneficial to visualize and measure the median nerve, accurately directed the injectate to the proper location hydro-dissecting the nerve, resulting in effective pain relief (Figure 6).

Achilles Tear: An elderly male playing pickleball experienced an audible pop and swelling in the posterior ankle. POCUS showed a full thickness Achilles tear, expediting workup with orthopedics for follow up (Figure 7).

Achilles Pain and Magnetic Resonance Imaging (MRI) Deferral: Another patient expressed concern about their Achilles pain and requested an MRI. While the exam noted tenderness at the distal Achilles insertion, Thompson test was negative. Utilizing POCUS, the patient was reassured that the Achilles fibers were intact, suggesting tendinopathy rather than a tear. The patient left feeling assured and ready for physical therapy without an MRI (Figure 8).

Full-Thickness Muscle Tear: A patient presented after an Emergency Department (ED) evaluation for a traumatic left medial knee pain following a motorcycle accident. An X-ray was negative, but due to medial knee swelling and warmth, the provider suspected an abscess or hematoma. A bedside Ultrasound (US) revealed a near-complete medial vastus medialis tear, confirmed by MRI, leading to a more accurate treatment plan (Figure 9).

Positive DVT: A male with a history of DVT presented with left calf pain and discoloration after recent international travel. POCUS enabled rapid treatment with initiation of Eliquis by the end of the appointment. Another case involved a male with history of cancer, initially suspected to have a calf strain but identified on POCUS to have extensive femoral and popliteal DVT, who had prompt initiation of anticoagulation treatment all in the same office visit.

Negative DVT: Numerous DVT rule-outs were conducted for low-risk patients per Wells Criteria, effectively eliminating the need for ED referrals, particularly before weekends when outpatient radiology services are unavailable. POCUS sensitivity and specificity with DVT diagnosis is 88% and 95% overall.⁹ In primary care, DVT POCUS has the potential to significantly change clinical management and curtail low-risk DVT related ED visits.

Ruling Out Pneumonia: During winter, pediatric patients frequently present with upper respiratory infection (URI) symptoms lasting 3-4 weeks. Utilizing lung US, patients and parents were reassured that no significant pneumonia was visible, deferring the need for a chest X-ray and avoiding unnecessary radiation exposure in a low-risk scenario. For diagnosing pneumonia in children, the sensitivity was 96% and specificity 93%.¹⁰

POCUS as a Complement to Physical Exam: An elderly female with abdominal pain and fever exhibited rebound tenderness in the right lower quadrant, raising suspicion for appendicitis or diverticulitis. The specificity for diagnosing appendicitis is 97%,¹¹ and diagnosing diverticulitis is 90%.¹² POCUS increased the diagnostic confidence, revealing signs of colon inflammation, eventually leading to a Computed tomography (CT) confirming complicated cecal diverticulitis and hospitalization for IV antibiotics. (Figure 10).

Ruling in Urinary Retention: An elderly gentleman presented with lower urinary tract symptoms and inability to void. POCUS revealed over one liter of post-void residual urine, prompting appropriate referral for foley placement and urology consultation.

Ruling in Gallstones: A middle-aged female with suspected biliary colic needed a US but faced scheduling delays. POCUS for gallstones have shown high sensitivity and specificity of 94% and 93%, respectively.¹³ For detection of cholecystitis, sensitivity and specificity was 73% and 93%, respectively.¹³ Within moments of scanning, POCUS identified a large gallstone in the gallbladder neck, allowing the clinician to promptly counsel the patient on elective cholecystectomy and an expedited surgical referral (Figure 11).

Ruling in Hernia: An elderly female was evaluated in the ED for colicky right lower quadrant abdominal pain. A CT abdomen did not show any acute findings. On follow up, due to her colicky pain, POCUS revealed a fat-containing partially reducible inguinal hernia, suspecting this is a possible reason for her discomfort. This was not seen or commented on the CT report. Ultrasound can diagnosis inguinal hernias with a sensitivity of 86%, and a specificity of 77%,¹⁴ and has a role in stratifying clinically evolving hernias.¹⁵ A radiology ultrasound confirmed these findings. She was scheduled for an elective hernia repair (Figure 12).

Ruling in Intrauterine Pregnancy: For a patient with a positive pregnancy test and missed menstrual period, POCUS provided an immediate diagnosis allowing for immediate counseling for next steps. Specificity is 92-100% confirming an intrauterine pregnancy when gestational sac and yolk sac or fetal pole are seen.¹⁶

Ectopic Pregnancy: A female patient followed up in primary care after leaving the emergency room against medical advice for vaginal bleeding. A positive urine pregnancy test prompted a POCUS which showed a gestational sac with fetal heart tones seen outside the uterus, which suggested an ectopic pregnancy. This expedited a referral to emergency and OBGYN specialists for an urgent left salpingectomy.

Pericardial Effusion: In a challenging case of a pericardial effusion of unclear etiology, POCUS allowed the clinician to assess whether the effusion was worsening throughout multiple return clinic visits. Diagnosing pericardial effusions have a sensitivity of 96%, and a specificity of 98%.¹⁷ This occurred while coordinating care with specialists, including cardiologists and rheumatologists. This approach reduced patient anxiety without requiring repeated radiation. The patient was eventually diagnosed with lupus. (Figure 13).