Ultrasonography managed by internists: The stethoscope of 21st century?

Beltrán, L.M.; García-Casasola, G.

doi:10.1016/j.rceng.2014.01.005

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Se observa la cortical ósea de cabeza humeral por debajo (H) y el músculo deltoides por encima (DE). C y D) Ecografía articular del paciente: Proyecciones longitudinal (C) y transversal (D) del tendón largo del músculo bíceps del enfermo donde se observa engrosamiento y disrupción de las fibras con aumento del líquido en la vaina sinovial (cabezas de flecha)." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "L.M. Beltrán, G. García-Casasola" "autores" => array:3 [ 0 => array:2 [ "nombre" => "L.M." "apellidos" => "Beltrán" ] 1 => array:2 [ "nombre" => "G." 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"apellidos" => "Sopeña" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0014256513003846" "doi" => "10.1016/j.rce.2013.11.014" "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/S0014256513003846?idApp=WRCEE" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887414000113?idApp=WRCEE" "url" => "/22548874/0000021400000003/v1_201404111208/S2254887414000113/v1_201404111208/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "Special article" "titulo" => "Ultrasonography managed by internists: The stethoscope of 21st century?" 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"apellidos" => "García-Casasola" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 2 => array:1 [ "colaborador" => "members of the Group of Clinical Ultrasound of the Spanish Society of Internal Medicine" ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Unidad Metabólico-Vascular, Servicio de Medicina Interna, Hospital Universitario La Paz, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital Universitario Infanta Cristina, Parla, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "La ecografía en manos del internista: ¿el estetoscopio del siglo xxi?" ] ] "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" => 587 "Ancho" => 1584 "Tamanyo" => 76477 ] ] "descripcion" => array:1 [ "en" => "(A) Normal carotid echocardiography: common carotid artery (CCA), carotid bulb (CB) and internal carotid artery (ICA) in a healthy individual. Regular intima–media with normal intima–media thickness in the posterior wall post of the CCA (arrowhead), the standard location for measurement. (B) Patient's carotid echocardiography: common carotid artery with increased intima–media thickness in the anterior wall (arrowhead). Calcified plaques affecting the bulb and origin of the internal right carotid artery (arrows)." ] ] ] "textoCompleto" => "BackgroundIn recent years, ultrasonography has been shown to be a tool of considerable usefulness in the everyday clinical practice of many internists. The development of portable and transportable equipment and its increased accessibility has enabled the use of point-of-care ultrasonography. General practitioners who traditionally depended on specialized ultrasound examinations have begun to use this technique as a tool that is complementary to the medical history and physical examinations to rule out or confirm a diagnostic suspicion without performing focused ultrasonography. This gives rise to the concept of basic clinical ultrasound as a complementary examination that responds, quickly and at the location where the patient is being treated, to specific clinical questions that have dichotomous responses, such as “Is there hydronephrosis?” or “Is there systolic dysfunction of the left ventricle?” Basic clinical ultrasound enhances the clinicians’ senses to improve the sensitivity of their physical examination and enable diagnoses in the same medical act. <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the possible indications of basic clinical ultrasound in the hands of medical internists.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>The objective of this article is to show the usefulness of clinical ultrasonography in the internal medicine setting. We present several case studies that illustrate this concept.Clinical casesCase 1This case concerned a 25-year-old woman with no relevant history of disease and no known cardiovascular risk factors who was in the 36th week of her first pregnancy. She had undergone the standard gynecological controls, with no problems detected. She complained of progressive edema in the lower limbs and dyspnea on minor exertion for the past week. She presented a blood pressure (BP) of 120/85mmHg, a heart rate of 110 beats per minute, a respiratory frequency of 30 respirations per minute and 92% baseline oxygen saturation (OS). The gynecologist requested an urgent assessment from the internist who observed rhythmic tones and a systolic murmur at the apex and in the bilateral basal crackles in the pulmonary auscultation. Chest radiography and blood tests were not available. Basic clinical ultrasonography (portable equipment Esaote MyLab25 Gold®) was performed, which detected left ventricular dilation with severe systolic dysfunction (left ventricle ejection fraction of 25%) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) and moderate mitral regurgitation. Lung ultrasonography revealed B lines in both lung fields and bilateral pleural effusion suggestive of acute pulmonary edema. The patient was admitted to the intensive care unit for stabilization and subsequent induction of labor.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>This case illustrates the enormous usefulness of ultrasonography in the assessment of a patient with dyspnea. In less than 5min, we can assess ventricular function and other potential heart lesions (right ventricular dysfunction, pericardial effusion, severe valvular heart disease) and detect lung disease (pleural effusion, signs of interstitial edema, pneumothorax).Case 2This case concerned a 74-year-old woman with isolated systolic hypertension (HT) and dyslipidemia. She was undergoing treatment with irbesartan, amlodipine and simvastatin. In the 24-h outpatient monitoring, her mean BP (mBP) was 143/54mmHg, with a significant white coat effect (mBP in the doctor's office was 164/56mmHg). Her total cholesterol, LDL-c and HDL-c levels were 205mg/dL, 126mg/dL and 70mg/dL, respectively. According to Systematic Coronary Risk Evaluation (SCORE) scale, her overall cardiovascular risk was estimated as moderate (3%); however, this scale has not been validated in patients older than 65 years and could underestimate the actual risk. Based on the risk stratification tables of the European Society of Hypertension,<a class="elsevierStyleCrossRef" href="#bib0005">1</a> the patient presented high risk. A carotid ultrasound was performed to detect subclinical arteriosclerosis and improve the risk stratification (portable equipment Esaote MyLab25 Gold®). The ultrasound detected increased intima–media thickness in the anterior wall of the common carotid artery (by consensus, the thickness is typically measured in the posterior wall 1cm proximal to the carotid bifurcation)<a class="elsevierStyleCrossRef" href="#bib0010">2</a> and 2 calcified plaques, which affected the bulb and origin of the internal right carotid artery, occupying a large part of the lumen (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). These unexpected findings entailed significant changes in the treatment. According to current recommendations,<a class="elsevierStyleCrossRefs" href="#bib0015">3,4</a> antiplatelet therapy was initiated with acetyl-salicylic acid, and the lipid-lowering treatment was intensified to reduce the LDL-c levels below 70mg/dL.<elsevierMultimedia ident="fig0010"></elsevierMultimedia>Case 3This case concerned a 73-year-old man with multiple cardiovascular risk factors (poorly controlled obesity, AHT and type 2 diabetes mellitus [hemoglobin A1c, 10.3%], active smoker [cumulative consumption of approximately 50packs/year] and hypercholesterolemia). He was assessed in the emergency department for exertional dyspnea that progressed to resting dyspnea in the last 5 days. He presented no chest pain or paroxysmal nocturnal dyspnea. The physical examination revealed a systolic murmur in the aortic area, which radiated to the carotid arteries. At the time, his blood pressure was normal and his baseline SaO2 was 92%. The hemogram and basic biochemistry revealed a glucose level of 249mg/dL and a creatinine level of 1.4mg/dL. The results of the electrocardiogram were normal, with no signs of ventricular hypertrophy, but the chest radiography showed discreet cardiomegaly and vascular redistribution. The patient was hospitalized with the diagnosis of heart failure and suspected aortic stenosis. The day after his admission to the hospital ward, a basic clinical ultrasound (portable equipment Esaote MyLab25 Gold®) was performed, revealing significant left ventricular hypertrophy with normal ejection fraction, with a calcified aortic valve and a reduced opening. Surprisingly, an aneurysm of the abdominal aorta measuring more than 10cm in maximum diameter was detected (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). Focused ultrasonography confirmed the mild to moderate aortic stenosis. The patient improved rapidly after diuretic treatment, and a week later successfully underwent surgery for the abdominal aortic aneurysm. The screening for abdominal aortic aneurysms is especially indicated (class 1B level of evidence)<a class="elsevierStyleCrossRefs" href="#bib0025">5,6</a> in men aged 65–75years with cardiovascular risk factors and especially if they are or have been smokers.<elsevierMultimedia ident="fig0015"></elsevierMultimedia>Case 4This case concerned a 52-year-old man, a cook by profession, with AHT diagnosed 10 years ago, controlled with olmesartan and amlodipine. He complained of pain on abduction of the right shoulder starting at 60°, which intensified when resistance was applied. He had no restrictions to passive mobilization. A basic clinical ultrasound of the joint was performed (portable equipment Esaote MyLab25 Gold®), which revealed thickening and abnormalities in the fibrillar structure of the supraspinatus tendon compatible with tendonitis. Additionally, we observed a disruption of the fibers of the long tendon of the biceps and increased fluid in the synovial sheath (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>). The patient was diagnosed with tendonitis of the supraspinatus tendon and tendonitis with a partial tear of the long bicep tendon. The ultrasound enabled, in one visit, the confirmation of the suspected diagnosis after the physical examination (supraspinatus tendonitis) and provided additional information by adding an initially unsuspected diagnosis (tendonitis with partial tearing of the long bicep tendon).<elsevierMultimedia ident="fig0020"></elsevierMultimedia>Case 5This case concerned a 78-year-old man with a history of type 2 diabetes mellitus, long-standing AHT and stable but chronic ischemic heart disease (he underwent surgical revascularization 9 years ago). The patient presented postphlebitic syndrome of the right lower limb secondary to deep vein thrombosis, which he experienced 7 years ago. Two years ago, chronic atrial fibrillation was detected and treated with oral anticoagulants (initially with acenocoumarol and in recent months with dabigatran under irregular control). The patient complained of pain in the right lower leg when starting to walk after a few hours of relative immobility (conduction). The pain was reproduced with ambulation. The patient presented no signs of external inflammation or fever, and the Homans’ sign was negative. The basic clinical ultrasound (portable equipment Esaote MyLab25 Gold®) revealed adequate pressure of the femoral and popliteal veins and in the lower leg a collection of 10cm×2.1cm below the soleus aponeurosis, with irregular echoes in its interior (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>). The clinical judgment was spontaneous hematoma of the soleus. As an adjuvant factor, the patient presented a serum creatine level of 1.2–1.6mg/dL. The evolution was favorable with conservative treatment.<elsevierMultimedia ident="fig0025"></elsevierMultimedia>This patient illustrates the usefulness of clinical ultrasound in the differential diagnosis of acute pain in the popliteal and lower leg regions. Among the possible diagnoses, we should consider deep vein thrombosis, a complicated Baker's cyst, a pseudoaneurysm of the popliteal artery, a fibrillar muscle tear and, as happened in this case, a spontaneous hematoma. All of these diagnoses can be quickly identified during the same visit or at the bedside with ultrasound.DiscussionWe have presented several cases in which clinical ultrasound provided relevant information for an appropriate diagnosis and treatment. Clinicians from various medical specialties, such as intensivists, internists and family doctors have started using ultrasound in their standard practice with excellent results. It can take months or even years to become skilled at the multiple procedures and techniques within ultrasonography. In the field of internal medicine, it is essential to select specific aspects within ultrasonography that allow us to approach specific medical problems where the diagnostic cost-effectiveness is high and in which, in general, long learning curves are unnecessary. Multiple studies have demonstrated a good relationship between examinations conducted by general practitioners after a limited training period and specialized ultrasonography in the assessment of various parameters of clinical interest. Basic clinical echocardiography has probably been the most studied modality, with good accuracy in the detection of pericardial effusion and systolic and diastolic dysfunction of the left ventricle.<a class="elsevierStyleCrossRefs" href="#bib0035">7–11</a> Clinical abdominal and vascular ultrasonography is a reliable method for detecting cholelithiasis and cholecystitis,<a class="elsevierStyleCrossRefs" href="#bib0060">12–14</a> deep vein thrombosis,<a class="elsevierStyleCrossRef" href="#bib0075">15</a> hydronephrosis<a class="elsevierStyleCrossRef" href="#bib0080">16</a> and abdominal aorta disease.<a class="elsevierStyleCrossRefs" href="#bib0085">17,18</a> Recently, a study in which members of the Clinical Ultrasound Group of the Spanish Society of Internal Medicine participated, several emergency department physicians (after a short training period in ultrasonography) showed adequate skills (92.6% sensitivity and 89% specificity) in the diagnosis of cholecystitis, hydronephrosis, deep vein thrombosis and various cardiovascular problems.<a class="elsevierStyleCrossRef" href="#bib0095">19</a>Overall patient assessment is inherent to the specialty of internal medicine and ultrasonography, applied in a wide range of settings, and can be a tool of considerable usefulness. Thus, osteoarticular ultrasonography of soft and thyroid tissue can provide relevant information for the assessment of various common consultation issues in our clinical practice, such as shoulder pain, arthritis, soft tissue infection and thyroid nodules. Additionally, ultrasound provides direct and real-time visualization of deep structures, facilitating and improving the safety of invasive procedures such as thoracentesis,<a class="elsevierStyleCrossRefs" href="#bib0100">20,21</a> paracentesis,<a class="elsevierStyleCrossRefs" href="#bib0105">21,22</a> and central or peripheral venous access cannulation<a class="elsevierStyleCrossRefs" href="#bib0115">23–25</a> in patients with difficult-to-find superficial veins (obese patients, patients with significant edema, users of parenterally administered drugs).<a class="elsevierStyleCrossRefs" href="#bib0130">26,27</a>Basic clinical ultrasonography has the added value of resolving or driving the solution to the patient's problem in the same clinical act. It is the patient's doctor who performs the examination, which is highly appreciated by patients,<a class="elsevierStyleCrossRef" href="#bib0140">28</a> which reinforces the doctor-patient relationship and provides considerable personal satisfaction for the physician.It is important to indicate the limitations of basic clinical ultrasonography, which, depending on the physician's level of training, provides limited information; other undetected pathological conditions can exist and should therefore not be excluded. The procedure also requires additional examination time, specific training resources and equipment availability. Lastly, we have to take into account the inherent limitations of the equipment with which we perform the examination. In the internal medicine department setting, we often have access to only portable (easy to move) or transportable (can be moved but are heavier and often require support) equipment that can entail significant technical limitations: lack of or less sensitive Doppler, lower quality images, lack of specific probes for exploring certain structures, etc. It is therefore very important to know the technical characteristics of our equipment and take into account their limitations to avoid diagnostic errors.Ultrasound in the hands of internists is a supplement to their traditional clinical activities, provides relevant information in numerous scenarios and increases their capacity for resolving their patients’ problems. We should emphasize that this is a complementary test to the comprehensive physical examination; it provides additional information but should never substitute it.In recent years, ultrasound training has also been implemented in undergraduate programs. This technique facilitates learning of anatomy, helps in understanding the physiology and pathophysiology of numerous organs and systems (especially the cardiovascular) and, of course, improves the performance and reliability of physical examinations by the students. For some teachers of medicine, ultrasound will change the method of teaching and practicing medicine for the coming decade. In our teaching, we as internists should lead or participate in the teaching of ultrasonography in undergraduate programs.<a class="elsevierStyleCrossRefs" href="#bib0145">29,30</a>The interest in ultrasonography is growing at a breakneck pace among Spanish internists. Proof of this interest is the creation and growth of the Clinical Ultrasound Workgroup of the Spanish Society of Internal Medicine. There is a long road ahead in achieving widespread implementation of ultrasound as a standard tool in the practice of internal medicine. It will require a definition of competencies, the design of training plans, and the acquisition of ultrasound scanners in the various departments, among other tasks. However, the usefulness of ultrasound and the interest it has raised indicates that this process will be successful in the short to medium term and will represent an irreversible change in improving the clinical practice of internal medicine.Conflicts of interestThe authors declare that they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:2 [ "identificador" => "xres329542" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec311425" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres329541" "titulo" => "Resumen" ] 3 => array:2 [ "identificador" => "xpalclavsec311426" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Background" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Clinical cases" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Case 1" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Case 2" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Case 3" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Case 4" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "Case 5" ] ] ] 6 => array:2 [ "identificador" => "sec0040" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflicts of interest" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-11-01" "fechaAceptado" => "2014-01-08" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec311425" "palabras" => array:3 [ 0 => "Internal medicine" 1 => "Ultrasonography" 2 => "Diagnostic imaging" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec311426" "palabras" => array:3 [ 0 => "Medicina interna" 1 => "Ultrasonografía" 2 => "Diagnóstico por imagen" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Ultrasonography in the hands of the internist can answer important clinical questions quickly at the point of patient care. This technique “enhances” the senses of the physicians and improves their ability to solve the problems of the patient. Point of care ultrasonography performed by clinicians has shown good accuracy in the diagnosis of diverse cardiac, abdominal and vascular pathologic conditions. It may also be useful for evaluation of thyroid, osteoarticular and soft tissue diseases. Furthermore, the use of ultrasound to guide invasive procedures (placement of venous catheters, thoracentesis, paracentesis) reduces the risk of complications. We present 5 cases to illustrate the usefulness of this technique in clinical practice: (i) peripartum cardiomyopathy; (ii) subclinical carotid artery atherosclerosis; (iii) asymptomatic abdominal aortic aneurysm; (iv) tendinitis of long head of biceps brachii and supraspinatus, and (v) spontaneous soleus muscle hematoma." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "La ecografía en manos del internista permite responder preguntas clínicas concretas de forma rápida en el lugar de atención al paciente. Esta técnica «potencia» los sentidos del clínico y mejora su capacidad para resolver los problemas del enfermo. La ecografía clínica ha mostrado una buena precisión en el diagnóstico de diversas patologías cardíacas, abdominales y vasculares. También es útil para la evaluación de la patología tiroidea, osteoarticular y de partes blandas. Además, el uso de la ecografía para guiar procedimientos invasivos (accesos venosos, toracocentesis, paracentesis) reduce el riesgo de complicaciones. Presentamos 5 casos para ilustrar la utilidad de esta técnica en la práctica clínica habitual del médico internista: a) miocardiopatía periparto; b) ateromatosis carotídea subclínica; c) aneurisma de aorta abdominal asintomático; d) tendinitis de los tendones largo del bíceps braquial y supraespinoso, y e) hematoma espontáneo en sóleo." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Beltrán LM, García-Casasola G, members of the Group of Clinical Ultrasound of the Spanish Society of Internal Medicine. La ecografía en manos del internista: ¿el estetoscopio del siglo xxi? Rev Clin Esp. 2014;214:155–160." ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1713 "Ancho" => 1658 "Tamanyo" => 137552 ] ] "descripcion" => array:1 [ "en" => "Echocardiogram: (A) parasternal long-axis plane. Increased telediastolic diameter of the left ventricle (LV); normal right ventricle (RV), left atrium (LA) and aortic root (AR). (B) M-mode section. Represents the insonated structures in a parasternal long-axis section and how they evolve during the cardiac cycle. Lack of physiological systolic thickening of the interventricular septum (IS) and posterior wall (PW) of the left ventricle. Observe that the thickness of the lines corresponding to the interventricular septum and posterior wall remains constant over time. Pulmonary ultrasound: (C) B lines (arrows), suggestive of pulmonary edema." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 587 "Ancho" => 1584 "Tamanyo" => 76477 ] ] "descripcion" => array:1 [ "en" => "(A) Normal carotid echocardiography: common carotid artery (CCA), carotid bulb (CB) and internal carotid artery (ICA) in a healthy individual. Regular intima–media with normal intima–media thickness in the posterior wall post of the CCA (arrowhead), the standard location for measurement. (B) Patient's carotid echocardiography: common carotid artery with increased intima–media thickness in the anterior wall (arrowhead). Calcified plaques affecting the bulb and origin of the internal right carotid artery (arrows)." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 789 "Ancho" => 1650 "Tamanyo" => 77716 ] ] "descripcion" => array:1 [ "en" => "(A) Cross section of abdominal ultrasound that reveals a large aneurysm in the abdominal aorta (arterial lumen [Ao], thrombus wall [Tr]). (B) Abdominal computed axial tomography of the same patient." ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1771 "Ancho" => 1626 "Tamanyo" => 189182 ] ] "descripcion" => array:1 [ "en" => "Normal joint ultrasound: longitudinal (A) and cross-sectional (B) projections of the long bicep tendon (T). The cortical bone of the humeral head can be observed below (H), and the deltoid muscle can be seen above (DE). Patient's joint ultrasound: longitudinal (C) and transversal (D) projections of the patient's long biceps tendon that reveals thickening and disruption of the fibers with increased fluid in the synovial sheath (arrowheads)." ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 979 "Ancho" => 1651 "Tamanyo" => 98251 ] ] "descripcion" => array:1 [ "en" => "(A) Ultrasound of normal calf muscle mass: the gastrocnemius muscle (G) can be observed. The soleus muscle (S) is located beneath the gastrocnemius muscle and is separated by the muscular fascia (F). (B) Longitudinal projection of the patient's left lower leg: fluid collection (HEM) can be seen below the aponeurosis of the soleus muscle, with hypoechoic areas at the edges (arrowheads) and some “floating” echoes, compatible with evolving hematoma." ] ] 5 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cardiac \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Determining systolic function of the left ventricle \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Quantification of left ventricular hypertrophy and left atrium dimensions \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Detection of pericardial effusion \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Initial evaluation of patients with heart murmurs \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Assessment of intravascular volume (inferior vena cava index) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Vascular \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Detection of subclinical carotid and femoral arteriosclerosis (atheromatous plaques, intima–media thickening) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Measurement of the diameter of the abdominal aorta. Diagnosis of abdominal aortic aneurysm \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Diagnosis of proximal deep vein thrombosis in the lower limbs \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Abdominal \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Diagnosis of cholelithiasis and cholecystitis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Detection of free intraabdominal fluid \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Diagnosis of hydronephrosis and acute urine retention \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Data assessment of chronic liver disease and portal hypertension \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Measurement of liver and spleen size \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Determination of hepatic steatosis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Osteoarticular \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Detection of joint effusion \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Assessment of bone erosion \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Diagnosis of tendonitis and fasciitis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Miscellaneous \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Thoracic ultrasonography (pleural effusion, interstitial edema, pneumothorax, pneumonia) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Initial assessment of thyroid nodules \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Visualization of collections in soft tissue (abscesses, hematomas) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Guiding invasive procedures (thoracentesis, paracentesis, arthrocentesis, cannulation of central and peripheral venous accesses) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab483105.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Indications for clinical ultrasonography in internal medicine." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:30 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "2013 ESH/ESC Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC)" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "G. 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Collet" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/eurheartj/ehr211" "Revista" => array:6 [ "tituloSerie" => "Eur Heart J" "fecha" => "2011" "volumen" => "32" "paginaInicial" => "2851" "paginaFinal" => "2906" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21873417" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "ESC/EAS Guidelines for the management of dyslipidaemias. The Task Force for the management of dyslipidaemias of the European Society of Cardiology (ESC) and the European Atherosclerosis Society (EAS)" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A.L. Catapano" 1 => "Z. Reiner" 2 => "G. de Backer" 3 => "I. Graham" 4 => "M.R. Taskinen" 5 => "O. 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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Background</span><p id="par0005" class="elsevierStylePara elsevierViewall">In recent years&#44; ultrasonography has been shown to be a tool of considerable usefulness in the everyday clinical practice of many internists&#46; The development of portable and transportable equipment and its increased accessibility has enabled the use of point-of-care ultrasonography&#46; General practitioners who traditionally depended on specialized ultrasound examinations have begun to use this technique as a tool that is complementary to the medical history and physical examinations to rule out or confirm a diagnostic suspicion without performing focused ultrasonography&#46; This gives rise to the concept of basic clinical ultrasound as a complementary examination that responds&#44; quickly and at the location where the patient is being treated&#44; to specific clinical questions that have dichotomous responses&#44; such as &#8220;Is there hydronephrosis&#63;&#8221; or &#8220;Is there systolic dysfunction of the left ventricle&#63;&#8221; Basic clinical ultrasound enhances the clinicians&#8217; senses to improve the sensitivity of their physical examination and enable diagnoses in the same medical act&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the possible indications of basic clinical ultrasound in the hands of medical internists&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">The objective of this article is to show the usefulness of clinical ultrasonography in the internal medicine setting&#46; We present several case studies that illustrate this concept&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical cases</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Case 1</span><p id="par0015" class="elsevierStylePara elsevierViewall">This case concerned a 25-year-old woman with no relevant history of disease and no known cardiovascular risk factors who was in the 36th week of her first pregnancy&#46; She had undergone the standard gynecological controls&#44; with no problems detected&#46; She complained of progressive edema in the lower limbs and dyspnea on minor exertion for the past week&#46; She presented a blood pressure &#40;BP&#41; of 120&#47;85<span class="elsevierStyleHsp" style=""></span>mmHg&#44; a heart rate of 110 beats per minute&#44; a respiratory frequency of 30 respirations per minute and 92&#37; baseline oxygen saturation &#40;OS&#41;&#46; The gynecologist requested an urgent assessment from the internist who observed rhythmic tones and a systolic murmur at the apex and in the bilateral basal crackles in the pulmonary auscultation&#46; Chest radiography and blood tests were not available&#46; Basic clinical ultrasonography &#40;portable equipment Esaote MyLab25 Gold<span class="elsevierStyleSup">&#174;</span>&#41; was performed&#44; which detected left ventricular dilation with severe systolic dysfunction &#40;left ventricle ejection fraction of 25&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; and moderate mitral regurgitation&#46; Lung ultrasonography revealed B lines in both lung fields and bilateral pleural effusion suggestive of acute pulmonary edema&#46; The patient was admitted to the intensive care unit for stabilization and subsequent induction of labor&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">This case illustrates the enormous usefulness of ultrasonography in the assessment of a patient with dyspnea&#46; In less than 5<span class="elsevierStyleHsp" style=""></span>min&#44; we can assess ventricular function and other potential heart lesions &#40;right ventricular dysfunction&#44; pericardial effusion&#44; severe valvular heart disease&#41; and detect lung disease &#40;pleural effusion&#44; signs of interstitial edema&#44; pneumothorax&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Case 2</span><p id="par0025" class="elsevierStylePara elsevierViewall">This case concerned a 74-year-old woman with isolated systolic hypertension &#40;HT&#41; and dyslipidemia&#46; She was undergoing treatment with irbesartan&#44; amlodipine and simvastatin&#46; In the 24-h outpatient monitoring&#44; her mean BP &#40;mBP&#41; was 143&#47;54<span class="elsevierStyleHsp" style=""></span>mmHg&#44; with a significant white coat effect &#40;mBP in the doctor&#39;s office was 164&#47;56<span class="elsevierStyleHsp" style=""></span>mmHg&#41;&#46; Her total cholesterol&#44; LDL-c and HDL-c levels were 205<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#44; 126<span class="elsevierStyleHsp" style=""></span>mg&#47;dL and 70<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#44; respectively&#46; According to Systematic Coronary Risk Evaluation &#40;SCORE&#41; scale&#44; her overall cardiovascular risk was estimated as moderate &#40;3&#37;&#41;&#59; however&#44; this scale has not been validated in patients older than 65 years and could underestimate the actual risk&#46; Based on the risk stratification tables of the European Society of Hypertension&#44;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> the patient presented high risk&#46; A carotid ultrasound was performed to detect subclinical arteriosclerosis and improve the risk stratification &#40;portable equipment Esaote MyLab25 Gold<span class="elsevierStyleSup">&#174;</span>&#41;&#46; The ultrasound detected increased intima&#8211;media thickness in the anterior wall of the common carotid artery &#40;by consensus&#44; the thickness is typically measured in the posterior wall 1<span class="elsevierStyleHsp" style=""></span>cm proximal to the carotid bifurcation&#41;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> and 2 calcified plaques&#44; which affected the bulb and origin of the internal right carotid artery&#44; occupying a large part of the lumen &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; These unexpected findings entailed significant changes in the treatment&#46; According to current recommendations&#44;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a> antiplatelet therapy was initiated with acetyl-salicylic acid&#44; and the lipid-lowering treatment was intensified to reduce the LDL-c levels below 70<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Case 3</span><p id="par0030" class="elsevierStylePara elsevierViewall">This case concerned a 73-year-old man with multiple cardiovascular risk factors &#40;poorly controlled obesity&#44; AHT and type 2 diabetes mellitus &#91;hemoglobin A1c&#44; 10&#46;3&#37;&#93;&#44; active smoker &#91;cumulative consumption of approximately 50<span class="elsevierStyleHsp" style=""></span>packs&#47;year&#93; and hypercholesterolemia&#41;&#46; He was assessed in the emergency department for exertional dyspnea that progressed to resting dyspnea in the last 5 days&#46; He presented no chest pain or paroxysmal nocturnal dyspnea&#46; The physical examination revealed a systolic murmur in the aortic area&#44; which radiated to the carotid arteries&#46; At the time&#44; his blood pressure was normal and his baseline SaO<span class="elsevierStyleInf">2</span> was 92&#37;&#46; The hemogram and basic biochemistry revealed a glucose level of 249<span class="elsevierStyleHsp" style=""></span>mg&#47;dL and a creatinine level of 1&#46;4<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#46; The results of the electrocardiogram were normal&#44; with no signs of ventricular hypertrophy&#44; but the chest radiography showed discreet cardiomegaly and vascular redistribution&#46; The patient was hospitalized with the diagnosis of heart failure and suspected aortic stenosis&#46; The day after his admission to the hospital ward&#44; a basic clinical ultrasound &#40;portable equipment Esaote MyLab25 Gold<span class="elsevierStyleSup">&#174;</span>&#41; was performed&#44; revealing significant left ventricular hypertrophy with normal ejection fraction&#44; with a calcified aortic valve and a reduced opening&#46; Surprisingly&#44; an aneurysm of the abdominal aorta measuring more than 10<span class="elsevierStyleHsp" style=""></span>cm in maximum diameter was detected &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; Focused ultrasonography confirmed the mild to moderate aortic stenosis&#46; The patient improved rapidly after diuretic treatment&#44; and a week later successfully underwent surgery for the abdominal aortic aneurysm&#46; The screening for abdominal aortic aneurysms is especially indicated &#40;class 1B level of evidence&#41;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a> in men aged 65&#8211;75<span class="elsevierStyleHsp" style=""></span>years with cardiovascular risk factors and especially if they are or have been smokers&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Case 4</span><p id="par0035" class="elsevierStylePara elsevierViewall">This case concerned a 52-year-old man&#44; a cook by profession&#44; with AHT diagnosed 10 years ago&#44; controlled with olmesartan and amlodipine&#46; He complained of pain on abduction of the right shoulder starting at 60&#176;&#44; which intensified when resistance was applied&#46; He had no restrictions to passive mobilization&#46; A basic clinical ultrasound of the joint was performed &#40;portable equipment Esaote MyLab25 Gold<span class="elsevierStyleSup">&#174;</span>&#41;&#44; which revealed thickening and abnormalities in the fibrillar structure of the supraspinatus tendon compatible with tendonitis&#46; Additionally&#44; we observed a disruption of the fibers of the long tendon of the biceps and increased fluid in the synovial sheath &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; The patient was diagnosed with tendonitis of the supraspinatus tendon and tendonitis with a partial tear of the long bicep tendon&#46; The ultrasound enabled&#44; in one visit&#44; the confirmation of the suspected diagnosis after the physical examination &#40;supraspinatus tendonitis&#41; and provided additional information by adding an initially unsuspected diagnosis &#40;tendonitis with partial tearing of the long bicep tendon&#41;&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Case 5</span><p id="par0040" class="elsevierStylePara elsevierViewall">This case concerned a 78-year-old man with a history of type 2 diabetes mellitus&#44; long-standing AHT and stable but chronic ischemic heart disease &#40;he underwent surgical revascularization 9 years ago&#41;&#46; The patient presented postphlebitic syndrome of the right lower limb secondary to deep vein thrombosis&#44; which he experienced 7 years ago&#46; Two years ago&#44; chronic atrial fibrillation was detected and treated with oral anticoagulants &#40;initially with acenocoumarol and in recent months with dabigatran under irregular control&#41;&#46; The patient complained of pain in the right lower leg when starting to walk after a few hours of relative immobility &#40;conduction&#41;&#46; The pain was reproduced with ambulation&#46; The patient presented no signs of external inflammation or fever&#44; and the Homans&#8217; sign was negative&#46; The basic clinical ultrasound &#40;portable equipment Esaote MyLab25 Gold<span class="elsevierStyleSup">&#174;</span>&#41; revealed adequate pressure of the femoral and popliteal veins and in the lower leg a collection of 10<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>2&#46;1<span class="elsevierStyleHsp" style=""></span>cm below the soleus aponeurosis&#44; with irregular echoes in its interior &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46; The clinical judgment was spontaneous hematoma of the soleus&#46; As an adjuvant factor&#44; the patient presented a serum creatine level of 1&#46;2&#8211;1&#46;6<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#46; The evolution was favorable with conservative treatment&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">This patient illustrates the usefulness of clinical ultrasound in the differential diagnosis of acute pain in the popliteal and lower leg regions&#46; Among the possible diagnoses&#44; we should consider deep vein thrombosis&#44; a complicated Baker&#39;s cyst&#44; a pseudoaneurysm of the popliteal artery&#44; a fibrillar muscle tear and&#44; as happened in this case&#44; a spontaneous hematoma&#46; All of these diagnoses can be quickly identified during the same visit or at the bedside with ultrasound&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Discussion</span><p id="par0050" class="elsevierStylePara elsevierViewall">We have presented several cases in which clinical ultrasound provided relevant information for an appropriate diagnosis and treatment&#46; Clinicians from various medical specialties&#44; such as intensivists&#44; internists and family doctors have started using ultrasound in their standard practice with excellent results&#46; It can take months or even years to become skilled at the multiple procedures and techniques within ultrasonography&#46; In the field of internal medicine&#44; it is essential to select specific aspects within ultrasonography that allow us to approach specific medical problems where the diagnostic cost-effectiveness is high and in which&#44; in general&#44; long learning curves are unnecessary&#46; Multiple studies have demonstrated a good relationship between examinations conducted by general practitioners after a limited training period and specialized ultrasonography in the assessment of various parameters of clinical interest&#46; Basic clinical echocardiography has probably been the most studied modality&#44; with good accuracy in the detection of pericardial effusion and systolic and diastolic dysfunction of the left ventricle&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#8211;11</span></a> Clinical abdominal and vascular ultrasonography is a reliable method for detecting cholelithiasis and cholecystitis&#44;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#8211;14</span></a> deep vein thrombosis&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> hydronephrosis<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> and abdominal aorta disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;18</span></a> Recently&#44; a study in which members of the Clinical Ultrasound Group of the Spanish Society of Internal Medicine participated&#44; several emergency department physicians &#40;after a short training period in ultrasonography&#41; showed adequate skills &#40;92&#46;6&#37; sensitivity and 89&#37; specificity&#41; in the diagnosis of cholecystitis&#44; hydronephrosis&#44; deep vein thrombosis and various cardiovascular problems&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Overall patient assessment is inherent to the specialty of internal medicine and ultrasonography&#44; applied in a wide range of settings&#44; and can be a tool of considerable usefulness&#46; Thus&#44; osteoarticular ultrasonography of soft and thyroid tissue can provide relevant information for the assessment of various common consultation issues in our clinical practice&#44; such as shoulder pain&#44; arthritis&#44; soft tissue infection and thyroid nodules&#46; Additionally&#44; ultrasound provides direct and real-time visualization of deep structures&#44; facilitating and improving the safety of invasive procedures such as thoracentesis&#44;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20&#44;21</span></a> paracentesis&#44;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;22</span></a> and central or peripheral venous access cannulation<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23&#8211;25</span></a> in patients with difficult-to-find superficial veins &#40;obese patients&#44; patients with significant edema&#44; users of parenterally administered drugs&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">26&#44;27</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Basic clinical ultrasonography has the added value of resolving or driving the solution to the patient&#39;s problem in the same clinical act&#46; It is the patient&#39;s doctor who performs the examination&#44; which is highly appreciated by patients&#44;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> which reinforces the doctor-patient relationship and provides considerable personal satisfaction for the physician&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">It is important to indicate the limitations of basic clinical ultrasonography&#44; which&#44; depending on the physician&#39;s level of training&#44; provides limited information&#59; other undetected pathological conditions can exist and should therefore not be excluded&#46; The procedure also requires additional examination time&#44; specific training resources and equipment availability&#46; Lastly&#44; we have to take into account the inherent limitations of the equipment with which we perform the examination&#46; In the internal medicine department setting&#44; we often have access to only portable &#40;easy to move&#41; or transportable &#40;can be moved but are heavier and often require support&#41; equipment that can entail significant technical limitations&#58; lack of or less sensitive Doppler&#44; lower quality images&#44; lack of specific probes for exploring certain structures&#44; etc&#46; It is therefore very important to know the technical characteristics of our equipment and take into account their limitations to avoid diagnostic errors&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Ultrasound in the hands of internists is a supplement to their traditional clinical activities&#44; provides relevant information in numerous scenarios and increases their capacity for resolving their patients&#8217; problems&#46; We should emphasize that this is a complementary test to the comprehensive physical examination&#59; it provides additional information but should never substitute it&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">In recent years&#44; ultrasound training has also been implemented in undergraduate programs&#46; This technique facilitates learning of anatomy&#44; helps in understanding the physiology and pathophysiology of numerous organs and systems &#40;especially the cardiovascular&#41; and&#44; of course&#44; improves the performance and reliability of physical examinations by the students&#46; For some teachers of medicine&#44; ultrasound will change the method of teaching and practicing medicine for the coming decade&#46; In our teaching&#44; we as internists should lead or participate in the teaching of ultrasonography in undergraduate programs&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">29&#44;30</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">The interest in ultrasonography is growing at a breakneck pace among Spanish internists&#46; Proof of this interest is the creation and growth of the <span class="elsevierStyleItalic">Clinical Ultrasound Workgroup of the Spanish Society of Internal Medicine</span>&#46; There is a long road ahead in achieving widespread implementation of ultrasound as a standard tool in the practice of internal medicine&#46; It will require a definition of competencies&#44; the design of training plans&#44; and the acquisition of ultrasound scanners in the various departments&#44; among other tasks&#46; However&#44; the usefulness of ultrasound and the interest it has raised indicates that this process will be successful in the short to medium term and will represent an irreversible change in improving the clinical practice of internal medicine&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conflicts of interest</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
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        0 => array:2 [
          "identificador" => "xres329542"
          "titulo" => "Abstract"
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        1 => array:2 [
          "identificador" => "xpalclavsec311425"
          "titulo" => "Keywords"
        ]
        2 => array:2 [
          "identificador" => "xres329541"
          "titulo" => "Resumen"
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        3 => array:2 [
          "identificador" => "xpalclavsec311426"
          "titulo" => "Palabras clave"
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        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Background"
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        5 => array:3 [
          "identificador" => "sec0010"
          "titulo" => "Clinical cases"
          "secciones" => array:5 [
            0 => array:2 [
              "identificador" => "sec0015"
              "titulo" => "Case 1"
            ]
            1 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Case 2"
            ]
            2 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Case 3"
            ]
            3 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Case 4"
            ]
            4 => array:2 [
              "identificador" => "sec0035"
              "titulo" => "Case 5"
            ]
          ]
        ]
        6 => array:2 [
          "identificador" => "sec0040"
          "titulo" => "Discussion"
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        7 => array:2 [
          "identificador" => "sec0045"
          "titulo" => "Conflicts of interest"
        ]
        8 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2013-11-01"
    "fechaAceptado" => "2014-01-08"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec311425"
          "palabras" => array:3 [
            0 => "Internal medicine"
            1 => "Ultrasonography"
            2 => "Diagnostic imaging"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec311426"
          "palabras" => array:3 [
            0 => "Medicina interna"
            1 => "Ultrasonograf&#237;a"
            2 => "Diagn&#243;stico por imagen"
          ]
        ]
      ]
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    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Ultrasonography in the hands of the internist can answer important clinical questions quickly at the point of patient care&#46; This technique &#8220;enhances&#8221; the senses of the physicians and improves their ability to solve the problems of the patient&#46; Point of care ultrasonography performed by clinicians has shown good accuracy in the diagnosis of diverse cardiac&#44; abdominal and vascular pathologic conditions&#46; It may also be useful for evaluation of thyroid&#44; osteoarticular and soft tissue diseases&#46; Furthermore&#44; the use of ultrasound to guide invasive procedures &#40;placement of venous catheters&#44; thoracentesis&#44; paracentesis&#41; reduces the risk of complications&#46; We present 5 cases to illustrate the usefulness of this technique in clinical practice&#58; &#40;i&#41; peripartum cardiomyopathy&#59; &#40;ii&#41; subclinical carotid artery atherosclerosis&#59; &#40;iii&#41; asymptomatic abdominal aortic aneurysm&#59; &#40;iv&#41; tendinitis of long head of biceps brachii and supraspinatus&#44; and &#40;v&#41; spontaneous soleus muscle hematoma&#46;</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La ecograf&#237;a en manos del internista permite responder preguntas cl&#237;nicas concretas de forma r&#225;pida en el lugar de atenci&#243;n al paciente&#46; Esta t&#233;cnica &#171;potencia&#187; los sentidos del cl&#237;nico y mejora su capacidad para resolver los problemas del enfermo&#46; La ecograf&#237;a cl&#237;nica ha mostrado una buena precisi&#243;n en el diagn&#243;stico de diversas patolog&#237;as card&#237;acas&#44; abdominales y vasculares&#46; Tambi&#233;n es &#250;til para la evaluaci&#243;n de la patolog&#237;a tiroidea&#44; osteoarticular y de partes blandas&#46; Adem&#225;s&#44; el uso de la ecograf&#237;a para guiar procedimientos invasivos &#40;accesos venosos&#44; toracocentesis&#44; paracentesis&#41; reduce el riesgo de complicaciones&#46; Presentamos 5 casos para ilustrar la utilidad de esta t&#233;cnica en la pr&#225;ctica cl&#237;nica habitual del m&#233;dico internista&#58; a&#41; miocardiopat&#237;a periparto&#59; b&#41; ateromatosis carot&#237;dea subcl&#237;nica&#59; c&#41; aneurisma de aorta abdominal asintom&#225;tico&#59; d&#41; tendinitis de los tendones largo del b&#237;ceps braquial y supraespinoso&#44; y e&#41; hematoma espont&#225;neo en s&#243;leo&#46;</p>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Beltr&#225;n LM&#44; Garc&#237;a-Casasola G&#44; members of the Group of Clinical Ultrasound of the Spanish Society of Internal Medicine&#46; La ecograf&#237;a en manos del internista&#58; &#191;el estetoscopio del siglo <span class="elsevierStyleSmallCaps">xxi</span>&#63; Rev Clin Esp&#46; 2014&#59;214&#58;155&#8211;160&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Echocardiogram&#58; &#40;A&#41; parasternal long-axis plane&#46; Increased telediastolic diameter of the left ventricle &#40;LV&#41;&#59; normal right ventricle &#40;RV&#41;&#44; left atrium &#40;LA&#41; and aortic root &#40;AR&#41;&#46; &#40;B&#41; M-mode section&#46; Represents the insonated structures in a parasternal long-axis section and how they evolve during the cardiac cycle&#46; Lack of physiological systolic thickening of the interventricular septum &#40;IS&#41; and posterior wall &#40;PW&#41; of the left ventricle&#46; Observe that the thickness of the lines corresponding to the interventricular septum and posterior wall remains constant over time&#46; Pulmonary ultrasound&#58; &#40;C&#41; B lines &#40;arrows&#41;&#44; suggestive of pulmonary edema&#46;</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Normal carotid echocardiography&#58; common carotid artery &#40;CCA&#41;&#44; carotid bulb &#40;CB&#41; and internal carotid artery &#40;ICA&#41; in a healthy individual&#46; Regular intima&#8211;media with normal intima&#8211;media thickness in the posterior wall post of the CCA &#40;arrowhead&#41;&#44; the standard location for measurement&#46; &#40;B&#41; Patient&#39;s carotid echocardiography&#58; common carotid artery with increased intima&#8211;media thickness in the anterior wall &#40;arrowhead&#41;&#46; Calcified plaques affecting the bulb and origin of the internal right carotid artery &#40;arrows&#41;&#46;</p>"
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Cross section of abdominal ultrasound that reveals a large aneurysm in the abdominal aorta &#40;arterial lumen &#91;Ao&#93;&#44; thrombus wall &#91;Tr&#93;&#41;&#46; &#40;B&#41; Abdominal computed axial tomography of the same patient&#46;</p>"
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Normal joint ultrasound&#58; longitudinal &#40;A&#41; and cross-sectional &#40;B&#41; projections of the long bicep tendon &#40;T&#41;&#46; The cortical bone of the humeral head can be observed below &#40;H&#41;&#44; and the deltoid muscle can be seen above &#40;DE&#41;&#46; Patient&#39;s joint ultrasound&#58; longitudinal &#40;C&#41; and transversal &#40;D&#41; projections of the patient&#39;s long biceps tendon that reveals thickening and disruption of the fibers with increased fluid in the synovial sheath &#40;arrowheads&#41;&#46;</p>"
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Ultrasound of normal calf muscle mass&#58; the gastrocnemius muscle &#40;G&#41; can be observed&#46; The soleus muscle &#40;S&#41; is located beneath the gastrocnemius muscle and is separated by the muscular fascia &#40;F&#41;&#46; &#40;B&#41; Longitudinal projection of the patient&#39;s left lower leg&#58; fluid collection &#40;HEM&#41; can be seen below the aponeurosis of the soleus muscle&#44; with hypoechoic areas at the edges &#40;arrowheads&#41; and some &#8220;floating&#8221; echoes&#44; compatible with evolving hematoma&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Cardiac</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Determining systolic function of the left ventricle&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Quantification of left ventricular hypertrophy and left atrium dimensions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Detection of pericardial effusion&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Initial evaluation of patients with heart murmurs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Assessment of intravascular volume &#40;inferior vena cava index&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Vascular</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Detection of subclinical carotid and femoral arteriosclerosis &#40;atheromatous plaques&#44; intima&#8211;media thickening&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Measurement of the diameter of the abdominal aorta&#46; Diagnosis of abdominal aortic aneurysm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Diagnosis of proximal deep vein thrombosis in the lower limbs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Abdominal</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Diagnosis of cholelithiasis and cholecystitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Detection of free intraabdominal fluid&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Diagnosis of hydronephrosis and acute urine retention&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Data assessment of chronic liver disease and portal hypertension&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Measurement of liver and spleen size&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Determination of hepatic steatosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Osteoarticular</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Detection of joint effusion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Assessment of bone erosion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Diagnosis of tendonitis and fasciitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Miscellaneous</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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