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Clinical ultrasonography in the decision-making process in medicine
Ecografía clínica en el proceso de toma de decisiones en medicina
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El punto más importante es la adquisición de la información que se basa en la historia clínica (anamnesis y exploración física clásica). Posteriormente el clínico decide si es necesario solicitar pruebas complementarias adicionales para confirmar las sospechas diagnósticas, interpreta toda la información obtenida e idea un plan de acción (tratamiento). Finalmente valora los resultados. La ecografía puede apoyar al médico en todo el proceso ya que complementa la exploración física, es en sí una prueba complementaria y facilita la monitorización y el seguimiento del enfermo.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "G. García de Casasola, I. Casado López, J. Torres-Macho" "autores" => array:3 [ 0 => array:2 [ "nombre" => "G." "apellidos" => "García de Casasola" ] 1 => array:2 [ "nombre" => "I." "apellidos" => "Casado López" ] 2 => array:2 [ "nombre" => "J." 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Modified from Monnier et al.<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">3</span></a></p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "P.J. Pinés Corrales, V. Bellido Castañeda, F.J. Ampudia-Blasco" "autores" => array:3 [ 0 => array:2 [ "nombre" => "P.J." "apellidos" => "Pinés Corrales" ] 1 => array:2 [ "nombre" => "V." "apellidos" => "Bellido Castañeda" ] 2 => array:2 [ "nombre" => "F.J." "apellidos" => "Ampudia-Blasco" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0014256518302558" "doi" => "10.1016/j.rce.2018.06.015" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0014256518302558?idApp=WRCEE" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887418301966?idApp=WRCEE" "url" => "/22548874/0000022000000001/v1_202002130124/S2254887418301966/v1_202002130124/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2254887419302152" "issn" => "22548874" "doi" => "10.1016/j.rceng.2019.06.010" "estado" => "S300" "fechaPublicacion" => "2020-01-01" "aid" => "1735" "copyright" => "Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI)" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Rev Clin Esp. 2020;220:43-8" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Special article</span>" "titulo" => "Iron and heart failure" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "43" "paginaFinal" => "48" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Hierro e insuficiencia cardiaca" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1782 "Ancho" => 2167 "Tamanyo" => 167018 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Selection and identification of patients who would benefit the most from intravenous iron according to the meta-analysis by Anker et al.<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">36</span></a> Results related to readmissions for cardiovascular cause and mortality of patients with irony deficiency treated with intravenous iron.</p> <p id="spar0045" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>: Ferrit, ferritin (expressed in ng/mL); TSAT, transferrin saturation.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M.Á. de las Nieves López" "autores" => array:1 [ 0 => array:2 [ "nombre" => "M.Á." 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García de Casasola, I. Casado López, J. Torres-Macho" "autores" => array:3 [ 0 => array:4 [ "nombre" => "G." "apellidos" => "García de Casasola" "email" => array:1 [ 0 => "ggcasasolaster@gmail.com" ] "referencia" => array:4 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 3 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "I." "apellidos" => "Casado López" "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 2 => array:3 [ "nombre" => "J." "apellidos" => "Torres-Macho" "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital Universitario Infanta Cristina, Parla, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Grupo de Trabajo de Ecografía Clínica, Sociedad Española de Medicina Interna, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Ecografía clínica en el proceso de toma de decisiones en medicina" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2255 "Ancho" => 2500 "Tamanyo" => 228742 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Pulmonary ultrasonography. The technique is simple: posterior, anterior and lateral face sweeps of both lungs. 1. Normal lung: characterized by the presence of A-lines. 2. Interstitial pattern: characterized by the presence of B-lines. 3. Pulmonary condensation (pneumonia). 4. Pleural effusion.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Background</span><p id="par0005" class="elsevierStylePara elsevierViewall">Significant technological advances in recent years have led to the development of high-quality, relatively affordable ultrasound systems, many of which are portable, thereby enabling their widespread use. Ultrasonography has therefore become an important imaging test in numerous medical specialties (anesthesia, intensive care, dermatology, rheumatology, pediatrics, nephrology, neurology, pneumology, trauma, urology, etc.).<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In the field of internal medicine and primary care, the incorporation of ultrasonography in clinical practice is likely the most significant technological advance in the past century.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Concept of clinical ultrasonography</span><p id="par0015" class="elsevierStylePara elsevierViewall">Clinical ultrasonography can be defined as an ultrasound examination performed by the physician directly responsible for the patient, in other words, by the physician who reviewed the medical history and who is most responsible for the patient's diagnostic and therapeutic process. This situation represents an added value in terms of regulated examinations performed in the central departments (e.g., radiology, cardiology) in which clinical information on the patient is limited.</p><p id="par0020" class="elsevierStylePara elsevierViewall">In clinical ultrasonography, it is essential that the examination be performed at the patient's bedside (“point-of-care ultrasound”), thereby avoiding displacing the patient to locations where the ultrasound is located, as happens in the central departments. This ability is an advantage for the patient, especially if they are unstable. Another relevant characteristic of clinical ultrasonography is that it can be repeated as often as the physician considers it necessary. They can thereby monitor disease progression in numerous scenarios (e.g., pulmonary congestion and pleural effusion in heart failure or in patients with volume overload, ascites, pericardial effusion, pneumonic condensation, etc.).</p><p id="par0025" class="elsevierStylePara elsevierViewall">Lastly, one of the key elements of clinical ultrasonography is the selection, within the complex world of ultrasonography, of simple procedures and examinations that have high clinical cost-effectiveness (utility). Thus, given the difficulties of assessing the abdomen with ultrasonography, the characterization and diagnosis of hepatic and renal tumors can be truly complex and should be reserved for regulated ultrasonography in the central departments. However, detecting free fluid within the abdomen and diagnosing acute urine retention are easy procedures and are with the reach of any clinician with basic ultrasound training.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Decision-making process in medicine</span><p id="par0030" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> shows a schematic of the diagnostic and decision-making process in medicine, which is performed sequentially. The first step is the most important and consists of collecting information regarding the patient. To this end, clinicians perform the anamnesis and physical examination. Depending on the information obtained, a number of diagnostic possibilities (differential diagnosis) are established and the likelihood of each (pretest probability) is mentally assigned. In the second step, the necessary complementary tests (blood tests, imaging studies, endoscopies, etc.) are chosen to confirm the suspected diagnosis. The cost-effectiveness of complementary tests is directly linked to the diagnostic probability before performing the tests. It is therefore essential to perform the first step (collecting information regarding the patient) as best as possible.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">After learning the results of the complementary tests, clinicians interpret the available data, establish the diagnosis and plan the most appropriate treatment. They then monitor and follow-up the patient.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Unfortunately, errors are often made during this process. A number of studies have shown that 14% of medical errors are related to incorrect diagnoses or the omission of the diagnosis, generally due to an incomplete or deficient anamnesis and physical examination. Obviously, this type of error is potentially avoidable. In the United States, it is estimated that approximately 35,000 patients die every year due to errors or omissions in the diagnosis.<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">2,3</span></a></p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">The classical physical examination and its limitations</span><p id="par0045" class="elsevierStylePara elsevierViewall">The classical physical examination, based on the inspection, palpation, percussion and auscultation of various organs, can be considered a diagnostic test whose accuracy varies significantly depending on the physician's ability and the patient's characteristics. However, due to enormous technological advances in recent decades, practitioners’ interest and expertise in performing physical examinations have declined substantially.</p><p id="par0050" class="elsevierStylePara elsevierViewall">A hundred years ago, most diseases were diagnosed based on the detection of certain signs and symptoms without any type of complementary test. Currently, the diagnosis of numerous processes rests mainly on laboratory and imaging tests. Due to the increased availability and accessibility of these tests, the physical examination has for many physicians been relegated to a secondary level. Nevertheless, there are many diseases (cellulitis, psoriasis, amyotrophic lateral sclerosis, Parkinson's disease, Bell's palsy, etc.) whose diagnosis is based exclusively on the classical physical examination.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Despite the importance of the physical examination, we need to be aware of its limitations. Although the distance between the border of the liver and the costal margin can be palpated and measured, this assessment has a poor correlation with increased liver size. This situation is similar with the spleen. It is relatively easy to palpate very large spleens (>20<span class="elsevierStyleHsp" style=""></span>cm), but the sensitivity for detecting splenomegalies of 13–18<span class="elsevierStyleHsp" style=""></span>cm is very low (clearly <50% in numerous series).<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">4–6</span></a> In terms of aorta abdominal aneurysms, if their size is >5<span class="elsevierStyleHsp" style=""></span>cm, the sensitivity for detecting the aneurysm using palpation can reach 80%; however, if its size is between 3 and 5<span class="elsevierStyleHsp" style=""></span>cm and especially if the patient has excess weight, the effectiveness drops significantly.<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">7</span></a> The bladder can only be detected (through percussion or palpation) when it contains more than 500<span class="elsevierStyleHsp" style=""></span>mL of urine.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">4</span></a> When the ascites is <1000<span class="elsevierStyleHsp" style=""></span>mL, it is virtually impossible to detect it through the physical examination. The sensitivity will significantly increase only if it exceeds 2000<span class="elsevierStyleHsp" style=""></span>mL.<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">8</span></a> Estimating the central venous pressure by inspecting the jugular vein, one of the paradigms of the cardiovascular physical examination, is difficult to perform accurately in many patients, even for expert clinicians, for numerous reasons (obesity, short neck, lack of cooperation, etc.).<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">9</span></a> With regard to cardiac auscultation, expert cardiologists can correctly identify 60% of systolic murmurs but only 16% of diastolic murmurs.<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">10</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Clinical ultrasonography as a supplement to physical examinations</span><p id="par0060" class="elsevierStylePara elsevierViewall">Numerous studies have irrefutably shown that clinical ultrasonography improves the diagnostic yield of physical examinations, Which is especially apparent in cardiovascular physical examinations.<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">10,11</span></a> In addition, a long training period is not required for certain objectives. Even medical students with basic ultrasonography training can substantially improve their diagnostic capacity compared with the physical examinations conducted by expert physicians.<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">10,12</span></a> Specifically, ultrasonography has noteworthy reliability in diagnosing cardiac valve lesions, estimating central venous pressure, detecting pleural and pericardial effusion and free abdominal fluid and diagnosing splenomegaly and acute urine retention, to name just a few examples.<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">13,14</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Clinical ultrasonography does not replace the classical physical examination but rather complements it. For example, pulmonary ultrasonography is an excellent tool for detecting interstitial lesions (cardiogenic and noncardiogenic pulmonary edema, pulmonary fibrosis), alveolar consolidations (pneumonia), pneumothorax and pleural effusion.<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">15–17</span></a> However, pulmonary ultrasonography is unable to detect the presence of rhonchi and wheezing in a patient with asthma or chronic obstructive pulmonary disease. In expert hands, pulmonary ultrasonography can provide a diagnostic yield greater than even chest radiography for diagnosing pneumonia<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">18</span></a>; however, an extensive swept of the lung fields needs to be performed to achieve this yield. A prior pulmonary auscultation can direct clinicians toward choosing lung areas where the pulmonary consolidation is most likely to be detected and thus where to place the ultrasound probe. In contrast, an abnormal pulmonary auscultation, as happens with the bases of many elderly patients, can lead to the suspicion of underlying lung disease, and pulmonary ultrasonography can help rule it out.</p><p id="par0070" class="elsevierStylePara elsevierViewall">It is apparent that echocardiography is clearly superior to cardiac auscultation for detecting cardiac valve lesions. Nevertheless, when middle to low-end portable scanners are employed or when the patient's window is deficient, it can be difficult to observe significant valvular heart disease. In contrast, cardiac auscultation has more than acceptable sensitivity for detecting an aortic stricture or significant mitral regurgitation (systolic murmurs).<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">11</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">In short, classical cardiac and pulmonary physical examinations are still of considerable usefulness even when ultrasonography equipment is available, and when we have adequate training to use them properly. Clinical ultrasonography (insonation) can help implement a more effective form of physical examination.<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">19</span></a></p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Multiorgan clinical ultrasonography</span><p id="par0080" class="elsevierStylePara elsevierViewall">The Focused Assessment with Sonography in Trauma (FAST) protocol is a basic examination within the emergency ultrasonography setting and might have been the inspiration for clinical ultrasonography (point-of-care ultrasound) as it is currently understood.</p><p id="par0085" class="elsevierStylePara elsevierViewall">The objective of the FAST protocol is to detect free fluid in the abdominal cavity in the context of abdominal trauma and has replaced diagnostic peritoneal flushing as the alternative method for abdominal computed tomography. Since the 1970s, several teams of surgeons in Germany and Japan have reported the ultrasound findings of patients with free peritoneal fluid. In the mid 1990s, the technique was protocolized and its use extended thanks to the availability of portable systems. Shortly thereafter, the subxiphoid plane was added to the 3 basic abdominal layers of the FAST protocol to visual the heart. Slices in the posterior-inferior region of the chest were also added to rule out hemopericardium and hemothorax. This addition led to the so-called extended FAST protocol (eFAST). The eFAST protocol is a form of multiorgan clinical ultrasonography because it assesses the heart, lungs and abdomen, although highly concisely and with highly specific objectives.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Both in emergency departments and intensive care units, clinical ultrasonography should be performed quickly and limiting the examination to basic layers that help establish a diagnostic approach to specific medical problems, especially when assessing gravely ill or unstable patients. To diagnose certain symptoms and signs, such as hypotension-shock and dyspnea, ultrasonography needs to be performed on several organs and systems in a structured manner. In recent years, numerous protocols have been proposed (RUSH, RUSH-VTI, SHoC, BLUE, FALLS, FEEL, FEER, SEARCH 8Es, LuCUS, LCI, FATE, etc.).<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">20–30</span></a> Most of these protocols are based on performing basic planes at the pulmonary, cardiac and, occasionally, abdominal level (especially when assessing the inferior vena cava and abdominal aorta). Thanks to studies based on these protocols, the use of multiorgan clinical ultrasonography has been widespread and popularized.</p><p id="par0095" class="elsevierStylePara elsevierViewall">Interestingly, multiorgan ultrasonography is an aspect of ultrasound that has no “owner” because it is outside the sphere of regulated ultrasounds that are performed in the central departments such as radiology and cardiology. Pulmonary ultrasonography, a fundamental technique in a number of the protocols mentioned earlier, is not generally employed currently by a significant percentage of radiologists and cardiologists. Multiorgan ultrasonography is a tool that is almost exclusively employed by physicians who require a comprehensive patient assessment (internists, family physicians, intensivists, emergency physicians, geriatricians, pediatricians, nephrologists, etc.).</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Systemization of multiorgan clinical ultrasonography in internal medicine</span><p id="par0100" class="elsevierStylePara elsevierViewall">One of the objectives of clinical ultrasonography is to supplement the classical physical examination to improve its cost-effectiveness. Just as physical examinations are suitably regulated and standardized and should be performed systematically to assess all patients, so should clinical ultrasonography.</p><p id="par0105" class="elsevierStylePara elsevierViewall">There is currently no consensus specifying how systematic ultrasound examinations should be performed to supplement the classical physical examination. Studies have very recently begun to assess the usefulness of standardized multiorgan clinical ultrasonography for patients who are not critically ill (hemodynamically stable), regardless of the reason for the consultation.<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">31,32</span></a> For patients with chest pain and fever, a pulmonary ultrasound can be very useful (after conducting an anamnesis and physical examination) for determining whether there is a consolidation and the possibility of associated pleural effusion. However, it might be more efficient to complete the lung-focused ultrasonography with ultrasonography of other organs (heart, abdomen) to detect other abnormalities (significant heart disease, abdominal aortic aneurysm, acute urine retention, etc.), which can also be clinically important.</p><p id="par0110" class="elsevierStylePara elsevierViewall">We propose a multiorgan ultrasound examination with selected basic planes of the lungs, heart and abdomen, which should be performed at the same time as the anamnesis and physical examination. The diagnostic yield of selected ultrasound images has been demonstrated in numerous studies.</p><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Pulmonary ultrasonography</span><p id="par0115" class="elsevierStylePara elsevierViewall">Pulmonary ultrasonography is a simple technique and can be performed with any type of probe, both high and low frequency. As with the stethoscope in auscultation, a sweep with the transducer should be performed on both lungs (anterior, lateral and posterior faces). If the patient's clinical condition permits, the examination should ideally be performed in the sitting position.<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">33</span></a> Pulmonary ultrasonography is excellent for diagnosing pleural effusion, condensation (pneumonia, tumors),<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">18</span></a> pneumothorax<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">34</span></a> and interstitial disease (heart failure, pulmonary fibrosis) (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">35</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">For patients with diffuse interstitial disease, a full pulmonary sweep is often not required. A craniocaudal examination of the posterior regions of both lungs might be sufficient.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Abdominal ultrasound</span><p id="par0125" class="elsevierStylePara elsevierViewall">Performing 6 essential planes is sufficient for basic abdominal ultrasonography. The right and left coronal planes at the last costal arches and a transverse and a longitudinal slice of the pelvis constitute the layers of the FAST protocol. The longitudinal slice in the epigastric region and transverse slice in the mesogastric region serve to visualize the inferior vena cava and aorta. The right subcostal plane helps visualize the hepatic parenchyma, gallbladder and bile duct. <a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a> shows these abdominal planes, the structures that are visualized and their clinical utility.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Cardiac ultrasonography</span><p id="par0130" class="elsevierStylePara elsevierViewall">To perform echocardiography, we employ 4 basic planes: subxiphoid, parasternal long and short axes and apical 4 chamber. The subxiphoid plane can be performed perfectly with the convex probe and can therefore be added to the abdomen slices. <a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a> shows these layers, the structures that are visualized and their clinical utility.</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0135" class="elsevierStylePara elsevierViewall">In selected patients, the ultrasound examination of other structures might need to be completed. Thus, for example, for a patient with suspected thromboembolism, ultrasonography of the deep venous system of the legs is essential. Carotid ultrasonography might also be necessary to assess the cardiovascular risk.</p><p id="par0140" class="elsevierStylePara elsevierViewall">With certain experience, routine multiorgan pulmonary, abdominal and cardiac ultrasonography can be performed in less than 15<span class="elsevierStyleHsp" style=""></span>min. Supplementing the physical examination with ultrasonography can help improve the physician-patient relationship and generate increased patient and practitioner satisfaction.<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">14</span></a> After the initial ultrasound study, ultrasonography would only need to be repeated if abnormalities were detected that need monitoring (e.g., pleural effusion, ascites, pulmonary condensation).</p><p id="par0145" class="elsevierStylePara elsevierViewall">Multiorgan ultrasonography performed systematically on patients assessed in emergency departments has been shown to help diagnose significant medical problems in up to a third of patients.<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">31</span></a></p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Conclusions</span><p id="par0150" class="elsevierStylePara elsevierViewall">Clinical ultrasonography supplements but does not replace the classical physical examination and serves to improve the cost-effectiveness and reliability of physical examinations. Ultrasonography can help recover and redefine the physical examination in a more complete and effective manner than the classical approach.</p><p id="par0155" class="elsevierStylePara elsevierViewall">Clinical ultrasonography should be routinely integrated into the decision-making process in medicine, given that, in addition to supplementing the physical examination, ultrasonography facilitates the diagnosis, prognostic stratification, monitoring and follow-up of patients.</p><p id="par0160" class="elsevierStylePara elsevierViewall">As with the standardized manner in which physical examinations are performed, ultrasound studies should also be systematized as a supplement to the physical examination. We propose a protocol that includes the multiorgan ultrasonography of the lungs, heart and abdomen with selected basic layers whose diagnostic yield is widely demonstrated.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1306143" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1206269" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1306142" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1206268" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Background" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Concept of clinical ultrasonography" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Decision-making process in medicine" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "The classical physical examination and its limitations" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Clinical ultrasonography as a supplement to physical examinations" ] ] ] 7 => array:2 [ "identificador" => "sec0030" "titulo" => "Multiorgan clinical ultrasonography" ] 8 => array:3 [ "identificador" => "sec0035" "titulo" => "Systemization of multiorgan clinical ultrasonography in internal medicine" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0040" "titulo" => "Pulmonary ultrasonography" ] 1 => array:2 [ "identificador" => "sec0045" "titulo" => "Abdominal ultrasound" ] 2 => array:2 [ "identificador" => "sec0050" "titulo" => "Cardiac ultrasonography" ] ] ] 9 => array:2 [ "identificador" => "sec0055" "titulo" => "Conclusions" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-04-02" "fechaAceptado" => "2019-04-08" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1206269" "palabras" => array:4 [ 0 => "Clinical ultrasonography" 1 => "Echocardiography" 2 => "Differential diagnosis" 3 => "Prognosis" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1206268" "palabras" => array:4 [ 0 => "Ecografía clínica" 1 => "Ecocardioscopia" 2 => "Diagnóstico diferencial" 3 => "Pronóstico" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Clinical ultrasonography has undergone significant development in recent years due to its considerable usefulness and equipment miniaturization, which have enabled its use at the point of care. Clinical ultrasonography is a tool that supplements the classical anamnesis and physical examination, thereby increasing the practitioner's diagnostic power. This tool can be employed in numerous clinical scenarios and can be applied at all steps when making decisions about the patient. In the hands of the general practitioner, ultrasonography of the various areas of the body (multiorgan ultrasonography) optimizes not only the diagnostic capacity but also the prognostic stratification and monitoring of progress after treatment has been applied. As with the systematic nature of conventional physical examinations, we need to establish an ultrasound examination protocol that supplements the physical examination, thereby redefining and boosting the classic examination.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La ecografía clínica ha experimentado un importante desarrollo en los últimos años debido a su gran utilidad y a la miniaturización de los equipos que han permitido llegar a la cabecera del enfermo. Se trata de una herramienta que complementa la anamnesis y la exploración física tradicional aumentando la potencia diagnóstica del profesional que la emplea en numerosos escenarios clínicos y que puede ser aplicada en todos los pasos de la toma de decisiones sobre el paciente. En manos de los generalistas, la aplicación de los ultrasonidos en diferentes áreas del cuerpo (ecografía multiórgano) permite optimizar no solo la capacidad diagnóstica, sino la estratificación pronóstica y el seguimiento evolutivo tras la aplicación de un tratamiento. De la misma forma que existe una sistemática de exploración física convencional, se debe plantear el establecimiento de un protocolo de exploración ecográfica que complemente a la primera y de esta forma poder redefinir y potenciar la exploración clásica.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: García de Casasola G, Casado López I, Torres-Macho J. Ecografía clínica en el proceso de toma de decisiones en medicina. Rev Esp Clin. 2020;220:49–56.</p>" ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1150 "Ancho" => 2083 "Tamanyo" => 112749 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Decision-making process in medicine. The most important point is the acquisition of information based on the medical history (classical anamnesis and physical examination). The clinician then decides whether additional complementary tests need to be requested to confirm the suspected diagnosis, interpreting all information received and forming a plan of action (treatment). Lastly, the clinician assesses the results. Ultrasonography can support physicians throughout the process because the technique supplements the physical examination, is in itself a complementary test and facilitates patient monitoring and follow-up.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2255 "Ancho" => 2500 "Tamanyo" => 228742 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Pulmonary ultrasonography. The technique is simple: posterior, anterior and lateral face sweeps of both lungs. 1. Normal lung: characterized by the presence of A-lines. 2. Interstitial pattern: characterized by the presence of B-lines. 3. Pulmonary condensation (pneumonia). 4. Pleural effusion.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 2279 "Ancho" => 3126 "Tamanyo" => 435721 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Basic abdominal planes and their clinical usefulness.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 2212 "Ancho" => 2919 "Tamanyo" => 403246 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Basic cardiac planes and their clinical usefulness.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:35 [ 0 => array:3 [ "identificador" => "bib0180" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Point-of-care ultrasonography" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "C.L. 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