A Young Adult with Worsening Cough: Using Lung POCUS to Diagnose Early Pneumonia
This article also appears in the Southern Medical Association News at this link.
Case Presentation:
A 24-year-old man presents to a primary care clinic with seven days of respiratory symptoms. He initially developed cough, fever, sore throat, and fatigue. His symptoms improved on days 4 and 5, but then worsened in the past 48 hours with recurrent fever and productive green sputum.
Patient’s past medical history is notable for asthma, well-controlled with an as-needed inhaler. COVID-19 and influenza testing are negative. On exam, he is febrile but otherwise well appearing, with normal oxygen saturation. Lung auscultation reveals faint crackles at the right lower lung base without wheezing. Given concern for a post-viral bacterial pneumonia, the clinician performs a point-of-care ultrasound (POCUS) of the lungs. Representative clips of the right and left lungs are shown below.
What do you see, and what’s the diagnosis?
Clip 1 – Right Lung
Ultrasound clip of the right posterior lung showing pleural sliding and pathological B-lines.
Clip 2 – Left Lung
Ultrasound clip of the left posterior lung showing pleural sliding and normal A-lines.
POCUS Findings:
Lung ultrasound of the right posterior-axillary chest (Clip 1) reveals focal pathological B-lines arising from the pleural line, while the remainder of the right lung and the entire left lung demonstrate normal lung patterns. There is no visible consolidation or pleural effusion.
Focal B-lines are abnormal vertical, hyperechoic artifacts that extend from the pleura to the bottom of the screen and move with lung sliding. Pathologic B-lines erase A-lines, occur as three or more per intercostal space over a short (≈3-second) clip, and extend at least 10 cm from the pleura. When they are localized to a single lung region, they suggest a focal interstitial process, such as an early pneumonia or scarring.
In this case, the focal nature of the B-lines, combined with fever and purulent sputum, supports the diagnosis of early bacterial pneumonia, even before a consolidation has formed.
What a Normal POCUS Should Show
A normal lung ultrasound (Clip 2) shows:
A smooth, sliding pleural line
Horizontal reverberation artifacts known as A-lines
Absence of pathological B-lines
Mirror Image artifact and lack of spine sign at the base of the lung
In a healthy lung, these findings indicate aerated lung tissue without interstitial fluid, inflammation, or infection.
What other POCUS findings can be seen with pneumonia?
Subpleural consolidation, pleural irregularity, & shred sign.
Hepatization of the lung. The lung looks consolidated, just like the liver.
Dynamic air bronchograms – pathognomonic for pneumonia!
When pneumonia involves the lung base, the normal mirror image artifact is lost, and a spine sign appears, because consolidated lung conducts ultrasound, allowing visualization of structures that are normally obscured by air.
Evidence:
Lung ultrasound has been shown to be highly sensitive for the diagnosis of pneumonia, often outperforming chest X-ray, particularly in early disease. Multiple studies demonstrate sensitivities ranging from 85–95% for lung ultrasound in detecting pneumonia, compared with lower sensitivity for chest radiography, especially in early or subtle cases.
Training in lung point-of-care ultrasound can be accomplished through structured didactic education and supervised hands-on practice. Multiple studies have demonstrated high diagnostic accuracy for pneumonia when lung ultrasound is performed by non-radiologist clinicians after brief training, supporting its feasibility and reliability in primary care settings.
Case Resolution:
Based on the focal right-sided B-lines seen on POCUS, the clinician diagnoses early bacterial pneumonia and initiates oral antibiotics during the visit. The patient is given strict return precautions and close follow-up. Over the next several days, his fever resolves and respiratory symptoms improve, confirming the clinical diagnosis without the need for immediate chest X-ray or emergency department referral.
Impact of POCUS:
In this case, POCUS:
Identified pneumonia, and thus reduced diagnostic uncertainty
Distinguished focal pathology from diffuse processes such as asthma exacerbation or viral illness
Enabled timely initiation of antibiotics
Avoided delayed imaging and radiation exposure
For patients, this means faster answers and earlier treatment. For clinicians, it means greater confidence when the physical exam and symptoms do not align.
In addition to its clinical value, POCUS can generate modest direct revenue when billed appropriately. Limited lung ultrasound may be billed using CPT code 76604, with reimbursement of approximately $60 based on the 2025 national CMS Physician Fee Schedule, helping offset equipment and training costs. Practice-level financial impact varies by utilization and payer mix and can be explored using the Hello Sono POCUS ROI Calculators.
More importantly, timely diagnosis in the clinic can prevent unnecessary emergency department referrals and, in selected cases, avoid hospital admission for pneumonia. While a single ED visit for respiratory complaints may cost approximately $1,500–$2,500, inpatient admission for pneumonia typically costs $15,000–$25,000, with substantially higher costs when complications or ICU care are required.
Conclusion:
Pneumonia does not always present with classic exam findings or radiographic consolidation, particularly early in the disease course. As this case demonstrates, early bacterial pneumonia may appear on lung ultrasound as focal interstitial changes before consolidation develops. In this context, POCUS provides objective information that directly guides management.
When integrated into primary care, lung POCUS reduces diagnostic uncertainty, supports timely treatment, and helps avoid unnecessary downstream testing, referrals, and costs.
Ready to take the next step with POCUS? Hello Sono helps practices roll out high-quality, compliant, and profitable POCUS programs.
References:
Baid H, Vempalli N, Kumar S, et al. Point of care ultrasound as initial diagnostic tool in acute dyspnea patients in the emergency department of a tertiary care center: diagnostic accuracy study. Int J Emerg Med. 2022;15(1):27. Published 2022 Jun 13. doi:10.1186/s12245-022-00430-8
Padrao EMH, Caldeira Antonio B, Gardner TA, et al. Lung Ultrasound Findings and Algorithms to Detect Pneumonia: A Systematic Review and Diagnostic Testing Meta-Analysis. Crit Care Med. 2025;53(11):e2271-e2281. doi:10.1097/CCM.0000000000006818
Ye X, Xiao H, Chen B, Zhang S. Accuracy of Lung Ultrasonography versus Chest Radiography for the Diagnosis of Adult Community-Acquired Pneumonia: Review of the Literature and Meta-Analysis. PLoS One. 2015;10(6):e0130066. Published 2015 Jun 24. doi:10.1371/journal.pone.0130066
Rodríguez-Contreras FJ, Calvo-Cebrián A, Díaz-Lázaro J, et al. Lung Ultrasound Performed by Primary Care Physicians for Clinically Suspected Community-Acquired Pneumonia: A Multicenter Prospective Study. Ann Fam Med. 2022;20(3):227-236. doi:10.1370/afm.2796
Shitrit IB, Shmueli M, Ilan K, et al. Continuing professional development for primary care physicians: a pre-post study on lung point-of-care ultrasound curriculum. BMC Med Educ. 2024;24(1):983. Published 2024 Sep 10. doi:10.1186/s12909-024-05985-z
Centers for Medicare & Medicaid Services (CMS). Physician Fee Schedule Search Tool. Baltimore (MD): CMS; [cited 2026 Jan 2]. Available from: https://www.cms.gov/medicare/physician-fee-schedule/search
Divino V, Schranz J, Early M, Shah H, Jiang M, DeKoven M. The annual economic burden among patients hospitalized for community-acquired pneumonia (CAP): a retrospective US cohort study. Curr Med Res Opin. 2020;36(1):151-160. doi:10.1080/03007995.2019.1675149