A medical student is looking for inferior vena cava in a nephrology clinic patient and finds something ‘weird’ adjacent to the IVC.  He/she calls the nephrology fellow for help. Here are the images and corresponding scan positions. 1. What are those numerous anechoic structures? 2. Did the student identify IVC accurately? Interestingly, the student did not know the patient’s medical history.

Now the nephrology fellow obtains more views and demonstrates bilateral polycystic kidneys in this patient with known ADPKD. So, those weird things are renal cysts. Yes, the student did identify the IVC correctly – note that it is entering into the heart (beating anechoic structure on the left) and the hepatic vein is draining into it.

Take home points: 1. Know the patient’s history (& have focused questions on mind) before performing POCUS: you are a clinician first 2. When you find something abnormal, try and obtain more views, trace the structures that you know.

A sonographer once told me “when you don’t know what you are looking at, go home” – it means, everybody has a ‘comfort scan zone’ (home) and better understanding of the surrounding anatomy. For nephrologists, it is the kidney. So, go scan the kidneys first and try to figure out the surrounding abnormal things.