Handheld ultrasound: accurate diagnosis at a lower cost?

C ardiovascular physical examination has changed little since the 19th century, but medical practice, in the meantime, has changed substantially. The diseases we treat, the circumstances of patient evaluation, the ages and comorbidities of patients, the availability of diagnostic testing, and the implications of missed diagnoses in an era of effective therapy all pose challenges. The traditional bedside diagnostic method is a subjective process that is strongly operator dependent, has both low interobserver and test-retest consistency, and can be hard-copied, stored, and transmitted to others only incompletely and with difficulty (1). In addition to its fundamental limitations, the process is often performed poorly, with a high error rate (2). In contrast, diagnostic imaging has marched on with a strong evidence base that is subjected to repeated scrutiny and testing; we can detect the pathophysiologic analogs of jugular venous distention, gallops, pulmonary crackles, and pericardial function rubs, all bastions of the physical examination that could not be obtained from testing in a former era. In addition, imaging provides other information that physical examinations cannot, and this incremental information has important therapeutic implications. Although limited to 2-dimensional and color Doppler imaging, handheld ultrasound (HHU) devices provide high image quality, and previous work has shown the diagnostic content of studies performed with these systems is analogous to that of high-end ultrasound systems (3,4). Previous studies have documented the ability of medical students, medical residents,