A 70-year-old patient was admitted to the department of internal medicine for worsening dyspnea and weight gain.

A history of dilated cardiomyopathy, chronic renal insufficiency and malignant obesity (BMI around 60).

Examination revealed fine inspiratory crackles dorsobasally, symmetric swelling of both lower limbs reminding of lymphedema and stiff swelling of the abdominal wall in the left iliac region. Chest X-ray revealed no pathology and BNP level was around 4000 pg/ml. She has been receiving forced diuresis therapy for the last four days, without response. A drop in diuresis and elevation of creatinine (from 240 to 360 umol/l) was observed. Blood gas analysis revealed neither significant metabolic acidosis nor hyperkalemia. An attempt of restoration of diuresis by careful volume therapy was without any effect. She was admitted to the ICU for dialysis.

 At this time, the patient was well oriented to time and space during admission, rest dyspnea, atrial fibrillation and no fever. Invasive blood pressure monitoring was established with values around 100/60 mmHg. Auscultation revealed clear breathing bilaterally. A higher position of the diaphragm was suspected. Because of morbid obesity, the abdomen could not be examined by palpation. The patient was able to lie in bed only on her left side and only for a short time. “Challenging patient”.


Lung ultrasonography (LUS), the patient was in the sitting position:

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