First Steps with POCUS: High-Yield Applications that Every Primary Care and Urgent Care Provider Should Know

Point-of-care ultrasound (POCUS) is becoming a vital tool for urgent care and primary care providers. The ability to perform diagnostic imaging at the bedside not only enhances patient outcomes but also streamlines care delivery, saves costs, and improves patient experience. More on this in our prior post. This article highlights the five essential POCUS applications that are simple to learn and perform for a novice POCUS user in urgent care and primary care settings. These are “low-hanging fruit” applications! Here we cover what they are, brief evidence, the indications, and use cases.

1. Lung Ultrasound

Lung ultrasound has emerged as a critical tool in assessing patients with respiratory complaints. POCUS is especially important in clinics that are seeing radiology tech shortages and have inconsistent access to X-ray.

Moreover, lung ultrasound has been shown to have consistently better performance in detecting the below conditions as compared to chest X-ray. [1-3]  For example, the 2024 meta-analysis found that lung ultrasound sensitivity for pleural effusion was 95% compared to 68% with chest X-ray. [2]

Indications for outpatient lung ultrasound:

• Dyspnea;

• CHF;

• Pleuritic chest pain.

High-yield diagnoses that a novice POCUS user can evaluate for:

• Pneumothorax;

• Pulmonary edema;

• Pleural effusion.

Lung ultrasound is also highly sensitive for diagnosis of pneumonia, but this application requires a higher skill level. If diagnosing a pneumothorax is a low-hanging fruit, then you’ve got to reach on your tippy toes to diagnose pneumonia.

Examples of patient scenarios where lung POCUS could make a difference:

• A young patient with pleuritic chest pain in whom there is a concern for a pneumothorax.

• A patient with a history of congestive heart failure (CHF) complains of mild dyspnea and/or leg swelling and has normal O2 sat and no tachypnea. You are wondering if they have mild CHF exacerbation and should be diuresed.

2. Lower Extremity Vascular Ultrasound

Deep vein thrombosis (DVT) is a condition that demands prompt diagnosis and treatment to prevent potentially life-threatening complications. POCUS enables primary care and urgent care providers to perform a compression ultrasound of the proximal deep veins of the lower extremities. This tool is especially important when high-sensitivity D-dimer and formal radiology scans are not readily available.

Metanalysis done on emergency physicians performing compression ultrasound reported 96% sensitivity and specificity.[4] A study done on hospitalists showed 100% sensitivity and 95.8% specificity when using formal radiology vascular scan as the gold standard. [5]

Indications for proximal leg compression ultrasound:

• Lower extremity pain;

• Lower extremity swelling.

High-yield diagnoses that a novice POCUS user can evaluate for:

• DVT;

• Baker’s cyst;

• Hematoma.

Examples of patient scenarios where lower extremity POCUS could make a difference:

• Low-risk patients with unilateral leg pain or swelling for whom D-dimer is not readily available.

• Moderate or severe-risk patients for whom urgent imaging is indicated.

Check out our previous blog in which we dive deep into the DVT workup in outpatient settings and propose a sample clinical pathway.

3. Soft Tissue Ultrasound

Musculoskeletal injuries and soft tissue infections are common presentations in outpatient settings.  POCUS is particularly effective in differentiating between cellulitis and abscesses, guiding procedures such as abscess drainage, and identifying foreign bodies embedded in soft tissues.

POCUS changed management in 56% of the cases when emergency physicians used it to determine if incision and drainage were indicated. [6]

 Indications for soft tissue or musculoskeletal ultrasound:

• Focal soft tissue swelling or pain;

• Soft tissue foreign body.

High-yield diagnoses that a novice POCUS user can evaluate for:

• Abscess;

• Foreign body in soft tissue.

Examples of patient scenarios where soft tissue POCUS could make a difference:

• A patient with groin pain and swelling in whom you are not certain if there is an abscess that requires drainage versus a reactive lymph node.

• A patient who stepped on a wooden splinter, and you are not able to visualize it.

4. Musculoskeletal Ultrasound

For musculoskeletal injuries, ultrasound can assess fractures, dislocations, and joint effusions with a sensitivity and specificity comparable to, and sometimes surpassing, traditional radiography. The use of POCUS in these scenarios not only improves diagnostic accuracy but also facilitates immediate treatment.

POCUS has shown 97% sensitivity and 94% specificity in diagnosing rib fractures that are notoriously hard to see on an X-ray. [7]

 Indications for soft tissue or musculoskeletal ultrasound:

• Joint swelling or pain;

• Tendon injury;

• Dislocation or fracture.

 High-yield diagnoses that a novice POCUS user can evaluate for:

• Achille’s tendon tear;

• Long bone fracture;

• Shoulder dislocation.

Examples of patient scenarios where musculoskeletal POCUS could make a difference:

• A patient with shoulder deformity in whom you suspect a dislocation, but you don’t have an  X-ray to confirm.

• A patient who stepped on a wooden splinter, and you are not able to visualize it. 

5. Bladder Ultrasound

Bladder ultrasound is an essential tool for evaluating patients with urinary difficulties. It allows clinicians to measure bladder volume and confirm adequate Foley catheter placement, ensuring that interventions are appropriately guided by real-time imaging.

Indications for post-void bladder ultrasound:

• Suprapubic pain;

• Decreased urination;

• Bladder distention;

• Foley catheter placement confirmation.

High-yield diagnoses for novice POCUS users:

• Urinary retention.

Examples of patient scenarios where lung POCUS could make a difference:

• A patient with suprapubic pain and decreased urination in whom you are wondering if a urinary catheter should be placed.

• A patient with an indwelling Foley catheter that has decreased output.

Conclusion

POCUS is transforming urgent care by offering a powerful, versatile, and immediate diagnostic tool that meets the demands of modern healthcare. By integrating these five essential POCUS applications, urgent care providers can improve diagnostic accuracy, enhance patient outcomes, and achieve greater operational efficiency. As healthcare continues to advance, embracing POCUS is not just an option—it’s a necessity.

For more information on how to implement POCUS in your urgent care practice, or to learn about upcoming training opportunities, visit Hello Sono. Let’s advance patient care together!

Authored by Tatiana Havryliuk, MD

References 

1.     Maw AM, Hassanin A, Ho PM, McInnes MDF, Moss A, Juarez-Colunga E, Soni NJ, Miglioranza MH, Platz E, DeSanto K, Sertich AP, Salame G, Daugherty SL. Diagnostic Accuracy of Point-of-Care Lung Ultrasonography and Chest Radiography in Adults With Symptoms Suggestive of Acute Decompensated Heart Failure: A Systematic Review and Meta-analysis. JAMA Netw Open. 2019 Mar 1;2(3):e190703. doi: 10.1001/jamanetworkopen.2019.0703. PMID: 30874784; PMCID: PMC6484641.

2.    Zaki HA, Albaroudi B, Shaban EE, Shaban A, Elgassim M, Almarri ND, Basharat K, Azad AM. Advancement in pleura effusion diagnosis: a systematic review and meta-analysis of point-of-care ultrasound versus radiographic thoracic imaging. Ultrasound J. 2024 Jan 23;16(1):3. doi: 10.1186/s13089-023-00356-z. PMID: 38261109; PMCID: PMC10805747.

3.     Blaivas M, Lyon M, Duggal S. A prospective comparison of supine chest radiography and bedside ultrasound for the diagnosis of traumatic pneumothorax. Acad Emerg Med. 2005 Sep;12(9):844-9. doi: 10.1197/j.aem.2005.05.005. PMID: 16141018.

4.    Pomero F, Dentali F, Borretta V, Bonzini M, Melchio R, Douketis JD, Fenoglio LM. Accuracy of emergency physician-performed ultrasonography in the diagnosis of deep-vein thrombosis: a systematic review and meta-analysis. Thromb Haemost. 2013 Jan;109(1):137-45. doi: 10.1160/TH12-07-0473.

5.     Fischer EA, Kinnear B, Sall D, Kelleher M, Sanchez O, Mathews B, Schnobrich D, Olson APJ. Hospitalist-Operated Compression Ultrasonography: a Point-of-Care Ultrasound Study (HOCUS-POCUS). J Gen Intern Med. 2019 Oct;34(10):2062-2067. doi: 10.1007/s11606-019-05120-5.

6.    Tayal VS, Hasan N, Norton HJ, Tomaszewski CA. The effect of soft-tissue ultrasound on the management of cellulitis in the emergency department. Acad Emerg Med. 2006;13(4):384-388. doi:10.1197/j.aem.2005.11.074

7.    Yousefifard M, Baikpour M, Ghelichkhani P, Asady H, Darafarin A, Amini Esfahani MR, Hosseini M, Yaseri M, Safari S. Comparison of Ultrasonography and Radiography in Detection of Thoracic Bone Fractures; a Systematic Review and Meta-Analysis. Emerg (Tehran). 2016 Spring;4(2):55-64. PMID: 27274514; PMCID: PMC4893752.