Start from the patient

The echo approach to 28 presenting complaints, step by step.

• Chest pain — Four killers first — ACS, aortic dissection, PE, tamponade — then the structural causes.
• Palpitations — Document the rhythm, then use echo to find the substrate that changes prognosis and therapy.
• Syncope & transient loss of consciousness — Separate reflex syncope from cardiac syncope — echo finds the obstructive and arrhythmic substrates.
• Dizziness & presyncope — Most dizziness is not cardiac — echo is useful when the story, ECG or examination point to the heart.
• Nausea & vomiting — A classic disguise of inferior MI, heart failure congestion and takotsubo — check the heart when the abdomen is quiet.
• New murmur — Innocent flow murmur or structural disease — echo answers definitively.
• Dyspnoea (breathlessness) — Heart or lung? Echo defines the HF phenotype, filling pressure, valves, pulmonary pressure and pericardium.
• Acute respiratory distress & tachypnoea — Heart plus lung ultrasound at the bedside: pulmonary oedema, PE, pneumothorax, pneumonia or tamponade.
• Hypoxaemia (low SpO₂) — Oedema, PE or shunt — the saline bubble study and its timing separate intracardiac from intrapulmonary shunts.
• Haemoptysis — Cardiac causes are few but important: mitral stenosis, pulmonary oedema, PE with infarction and pulmonary hypertension.
• Hypotension & shock — Pump, tank, pipes: find the obstructive cause first, then phenotype and measure flow.
• Cardiac arrest — Echo only during the pulse check, never longer than 10 seconds — looking for the reversible causes.
• Respiratory arrest & peri-intubation — Before and after positive pressure: find the RV, tamponade and volume problems that turn intubation into arrest.
• Severe hypertension & hypertensive emergency — Acute organ damage (oedema, ACS, dissection) now; LV hypertrophy, the aorta and secondary causes later.
• Pulse deficit & inter-arm BP difference — Acute: dissection until proved otherwise. Chronic: subclavian stenosis, coarctation or aortitis.
• Lower-limb oedema — Is venous pressure raised? The IVC and RV answer in one view — then find why.
• Ascites — Cardiac ascites, cirrhosis or both? Constriction, severe TR and RV failure hide as 'liver disease'.
• Abdominal pain (cardiovascular causes) — Inferior MI, aortic catastrophe, mesenteric embolism and congestive hepatopathy — all visible from the subcostal window.
• Bradycardia & conduction disease — Structural disease behind the block (amyloid, sarcoid, ischaemia, abscess) and LVEF for choosing the device.
• Ventricular tachycardia (acute or history) — Structurally normal heart or scar? LVEF, scar pattern and cardiomyopathy type decide ablation and ICD.
• Family history of sudden cardiac death — Screen first-degree relatives for cardiomyopathies and aortopathies; the ECG finds the channelopathies echo cannot.
• Stroke, TIA & peripheral embolism — Find the cardioembolic source: AF and the LA appendage, LV thrombus, vegetations, tumours, PFO and the aortic arch.
• Kidney failure & dialysis — Volume, LV hypertrophy, pericardium, calcific valves, pulmonary pressure and the fistula — best studied at dry weight.
• Liver failure & cirrhosis — Cirrhotic cardiomyopathy, portopulmonary hypertension, hepatopulmonary syndrome — and the heart that caused the liver disease.
• Hypothyroidism & thyroid disease — Slow heart, stiff heart, pericardial effusion — or high output, AF and heart failure in thyrotoxicosis.
• Sepsis & septic shock — Septic cardiomyopathy, fluid responsiveness and tolerance, the endocarditis source — echo guides every hour.
• Fever with bacteraemia (suspected endocarditis) — Who needs echo, who needs TOE, and when to repeat it — the Duke-ISCVID imaging criteria.
• Patient with a prosthetic valve (by type) — Know the valve, have a baseline, then separate stenosis, patient–prosthesis mismatch, high flow, thrombus and pannus.