1/
Resident presents a case of a 56 year old f w/ h/o COPD with 2 weeks of new bilateral leg swelling, high BNP and normal CXR. "I'm going to admit her for new onset CHF" he says. Sounds reasonable, but "new onset CHF" requires a #POCUS, so I go to the bedside.
PSLA view next:

2/ PSLA view shows normal LV systolic function which is the first clue to search for alternate causes. While this could be HFpEF, note that the interventricular septum looks flat...

3/ moving to the PSSA view confirms suspicion for RV strain. Note the flattened interventricular septum, known as the "D" sign.

4/ Moving to Apical 4 chamber, this view showed enlargement of the RV compared to the LV, further confirming elevated RV pressure.

5/ At this point, the thinking moves away from CHF and towards PE vs pulmonary htn given her history of COPD. How to differentiate the two?

6/ Utilize the 60/60 rule, measuring the RV systolic pressure and pulmonary acceleration time, with a nice infographic on this website by @UltrasoundJelly https://www.coreultrasound.com/uotw-71-answer/ 

7/ But on a very busy shift there may not be time, especially on a stable patient. Based on my brief #POCUS echo, I ordered dopplers and a CTA of the chest. She had a DVT.

8/
Lessons:
a) #POCUS all "new chf"
b) Even with a 2 minute #POCUS, ddx can completely change
c) Consider the 60/60 rule to further stratify acute vs chronic