Protocols

B. anywhere along the digestive tract *Bezoars are intraluminal masses of undigested material Concretions - inorganic substances; medications, bubble gum Trichobezoar - hairball Phytobezoar - undigestible plant or vegetable materials (cellulose) Lactobezoar - milk materials; seen in infants

A mother presents with her 3mo old infant due to excessive vomiting and crying for 3 days. The referring physician suspects a lactobezoar may be the problem. Where will you look for this abnormality? A. gallbladder B. anywhere along the digestive tract C. urinary bladder D. the appendix

C. Left inguinal canal *Cryptorchidism refers to an undescended testicle. The testicles originate in the pelvis and normally descend along the inguinal canal into the scrotum.

A patient is referred to rule out cryptorchidism. You evaluate the scrotal sac with US and demonstrate the presence of a right testicle only. Where will you look first for the left testicle? A. Right inguinal canal B. Left paracolic gutter C. Left inguinal canal D. Right paracolic gutter

A. Evaluate the surrounding areas for lymphadenopathy. *The portal confluence is posterior to the pancreatic head, so an anterior mass would not correlate with portal thrombosis. Acute pancreatitis is a diffuse enlargement of the organ with overall decreased echogenicity. A mass in the head of the pancreas is highly suspicious for carcinoma and lymphadenopathy should also be suspected.

A patient presents for an abdominal ultrasound due to loss of appetite, weight loss and epigastric pain. A hypoechoic mass is identified in the anterior aspect of the head of the pancreas. Which of the following best describes the next step in evaluating this patient? A. Evaluate the surrounding areas for lymphadenopathy. B. Apply color Doppler to the area to determine if the hypoechoic area is a possible portal thrombosis. C. Review the patient chart to view the pancreatic enzyme levels related to acute pancreatitis. D. Evaluate the gallbladder for stones.

B. in the IVC just below the level of the renal veins *Greenfield Filter is used to prevent emboli from reaching the lungs (Does NOT prevent thrombus formation). It is inserted via catheter into the IVC in patients with a history of deep vein thrombosis in the pelvis and lower extremities. Normal location is in the IVC lumen just below the level of the renal veins. It appears as an echogenic "umbrella" in the lumen of the IVC.

A patient presents for an abdominal ultrasound due to suspected displacement of the Greenfield filter. Where should you look to find the filter in the normal position? A. in the renal artery at the renal hilum B. in the IVC just below the level of the renal veins C. in the renal vein at the renal hilum D. in the IVC just below the level of the hepatic veins

E. All of the above

A patient presents for an abdominal ultrasound with a prior history of hepatocellular carcinoma. Multiple hypoechoic masses are identified in the liver parenchyma. Which of the following should be a part of this patient's exam? A. Evaluate the porta hepatis for lymphadenopathy. B. Evaluate the biliary tree for areas of dilatation. C. Use color Doppler to assess the portal system for tumor invasion. D. Evaluate the retroperitoneum for lymphadenopathy. E. All of the above

D. Ask the patient to hold a 5lb weight and reassess the thickness of the tendon *Rocking the transducer will ensure the transducer face is perpendicular to the tendon and anisotropy artifact is eliminated. Comparison views are always helpful in MSK evaluations. Inflammation of the tendon can demonstrate increased vascularity on color Doppler evaluation. Variation in the arm position is helpful in tendon evaluation but the use of weights is not part of the protocol.

A patient presents for an extremity ultrasound to evaluate the bicep tendon for tendonitis. The following image was obtained on the symptomatic left arm. Which of the following is least likely to assist in the tendon evaluation? A. Rock the transducer back and forth to ensure the transducer face is perpendicular to the tendon B. The right bicep tendon should be evaluated to provide comparison views. C. Color Doppler should be applied to assess any increased vascularity associated with inflammation. D. Ask the patient to hold a 5lb weight and reassess the thickness of the tendon

B. Use color Doppler to assess the structure for internal flow. *The left hepatic artery courses adjacent to the left portal vein. The cystic structure could be a biopsy complication such as, urinoma, seroma or pseudoaneurysm. Applying color Doppler is the most logical next step in evaluating the patient.

A patient presents with a history of a left lobe liver mass that was biopsied 1 week ago. The patient complains of increasing pain midline area. A new anechoic round mass is identified in the left lobe adjacent to the left portal vein. What is the most likely next step in characterizing this finding? A. Rescan the patient in the decubitus position. B. Use color Doppler to assess the structure for internal flow. C. The patient will most likely go to CT for mass characterization. D. Paracentesis will be performed to remove the fluid accumulation. E. Follow up exam in two weeks after the patient completes antibiotic therapy.

B. locate the right portal vein and the main lobar fissure, trace the fissure to the gallbladder neck *The main lobar fissure appears to connect the right portal vein to the neck of the gall bladder on ultrasound evaluation. Once you locate the echogenic tissue at the right portal vein, follow it to the opposing end to find the gall bladder neck.

A patient presents with a long history of digestive issues and RUQ pain that comes and goes after a few days. The doctor suspects chronic cholecystitis. You are having trouble locating the gallbladder on his ultrasound exam. Which of the following describes a technique that could be used to locate this patient's gallbladder? A. have the patient perform the valsalva maneuver to force bile into the gallbladder for improved visualization B. locate the right portal vein and the main lobar fissure, trace the fissure to the gallbladder neck C. use color Doppler to identify the associated hypervascularity seen with wall inflammation D. locate the umbilical vein and trace it to the ligamentum teres to locate the gallbladder neck just medial to the proximal ligamentum

D. all of the above *Lymphadenopathy can be found in the following locations in the abdomen: para-aortic, at the splenic hilum, at the renal hilum, and at the porta hepatis.

A patient presents with multiple metastatic lesions in the liver. Where in the abdomen should you look to find associated lymphadenopathy with ultrasound? A. around the IVC and aorta B. porta hepatis C. splenic hilum D. all of the above

A. Evaluate flow in both internal iliac arteries. *Normally the common iliac arteries are evaluated because they are the direct branches of the affected vessel (aorta).

All of the following are a required part of a AAA evaluation with ultrasound, except? A. Evaluate flow in both internal iliac arteries. B. Evaluate the length of the affected segment. C. Assess location in relationship to the renal arteries. D. Evaluate the AP and Width measurements of the true and false lumen if thrombus is present.

B. Prone *Due to the anatomical position of the gallbladder and the limited imaging windows from the patient's back, the prone position will not provide additional imaging views of the GB.

All of the following are patient positioning techniques that can assist in viewing the gallbladder, except: A. Erect B. Prone C. Left lateral decubitus D. Supine

A. Drink water *Drinking water is not considered a patient position but a supplemental technique or maneuver.

All of the following are patient positioning techniques used to better visualize the pancreas, except A. Drink water B. Semi-erect position C. Decub positions D. Upright position

D. Decrease blood sugar for better pancreas visualization *Blood sugar levels do not affect the sonographic visualization of the abdominal organs.

All of the following are reasons for a patient to be NPO prior to an abdominal ultrasound, except: A. Decrease peristalsis in GI tract B. Allow gallbladder to fill with bile for better visualization C. Decrease gas in GI tract D. Decrease blood sugar for better pancreas visualization

D. Apply graded transducer compression to the area of interest. *Graded compression should demonstrate pliable loops of bowel with normal peristalsis. Rebound pain should not be present when the compression of a normal bowel segment is released.

An average sized patient presents with a fever, acute RLQ pain and vomiting. The ER physician wants to rule out appendicitis in this patient. Which of the following techniques would be used in the US exam? A. Ask the patient to perform the valsalva maneuver while scanning. B. Use a stand-off pad to better visualize the superficial bowel loops. C. Drink 32oz of water and fill the bladder prior to the exam. D. Apply graded transducer compression to the area of interest.

C. Trendelenburg position *The majority of the GB does not adhere to the liver or adjacent structures. It is connected to the biliary tree by the cystic duct. The free floating ability of the GB allows us to use additional decub and erect positions for better visualization. The trendelenburg position refers to tilting the table to an angle with the feet lower than the head. This position would not normally cause a significant change in GB position.

For a complete GB evaluation, it may be necessary to examine the patient in all of the following positions, except: A. Erect B. Supine C. Trendelenburg position D. Decubitus

B. Renal Veins *Anytime a solid renal mass is identified, renal cell carcinoma should be a part of the differential diagnosis. These tumors are highly aggressive and tend to invade the surrounding draining vessels (renal vein, IVC)

If a solid renal mass is seen in the kidney on an US exam, the following additional areas should also be closely evaluated: A. Portal Veins B. Renal Veins C. Hepatic Veins D. Renal Arteries

B. supraspinatus, subscapularis *Internal rotation of the arm is preferred for evaluation of the supraspinatus, while external rotation of the arm is preferred for evaluation of subscapularis.

Internal rotation of the arm is preferred for evaluation of the _____________, while external rotation of the arm is preferred for evaluation of _______________. A. flexor tendon, biceps tendon B. supraspinatus, subscapularis C. long bicep tendon, short bicep tendon D. subscapularis, supraspinatus

A. Nothing by mouth *NPO comes from the Latin terms, Non Per Os which translates to nothing by mouth.

NPO means: A. Nothing by mouth B. No liquids C. Liquids only D. Nothing to eat after midnight

B. end diastolic velocity *The velocities used to calculate the RI are measured by placing the cursor at the true peak systolic velocity and the end diastolic velocity. RI = PSV - EDV / PSV

Note the Doppler measurement on the image. What other Doppler measurement should be taken to calculate the resistive index? A. end systolic velocity B. end diastolic velocity C. peak diastolic velocity D. peak systolic velocity

E. Have the patient drink 16-24oz of water and rescan in 30 minutes. *Emptying the bladder can eliminate a false positive diagnosis of hydronephrosis. Color Doppler can help identify the vascular structures at the hilum. If the hydronephrosis is truly present, the option of adding more fluid into the system should not be considered.

On a transverse 2D view of the right kidney hilum, a prominent tubular anechoic structure is identified that extends into the kidney. Which of the following is least likely to provide more information to better evaluate this finding? A. Scan the bladder to see if the tubular structure enters the pelvis and connects to the bladder. B. Apply color Doppler. C. Have the patient empty their bladder and rescan the kidney. D. Rescan the patient in the left lateral decubitus position. E. Have the patient drink 16-24oz of water and rescan in 30 minutes.

D. Common Iliac arteries *The distal aorta and bifurcation are bordered anteriorly by the bowel. Placing the patient in the decubitus position displaces the anterior abdominal contents slightly and may allow a better view of the aorta bifurcation into the common iliac arteries.

Scanning a patient's aorta while they are in the oblique position may aid in visualization of what branches of the vessel? A. Common iliac veins B. Suprarenal arteries C. Hepatic Artery D. Common Iliac arteries

B. kidneys and pancreas *Simple cysts identified in the liver before age 50 are usually related to polycystic disease and cysts in the kidneys, pancreas and ovaries are also identified. Male patients do not have ovaries so the best answer is kidneys and pancreas.

Several simple cysts are identified in the liver of a 38yr old male patient. What structures should also be evaluated in the abdomen for related findings? A. kidneys and thyroid B. kidneys and pancreas C. abdominal aorta and renal arteries D. kidneys, pancreas and ovaries

B. Evaluate the right groin for an undescended testicle. *The testicles form in the lower pelvic region and migrate to the scrotal sac after 36 weeks of gestational age. When the scrotal sac is found to contain only one testicle, the undescended teste is most commonly found along the inguinal canal of the affected side.

The following image is obtained on a 12yr old boy with a non-palpable right testicle. What should be your next step as the sonographer performing this exam? A. Evaluate the left groin for an undescended testicle. B. Evaluate the right groin for an undescended testicle. C. Evaluate the paraumbilical area for an undescended testicle. D. Evaluate the perineal area for an undescended testicle.

B. c *Alpha angle is measured between line 1 (yellow) and 2 (red). It refers to the angle that is formed by the acetabular roof to the vertical cortex of the iliac bone. The normal value is greater than or equal to 60 degrees. Less than 60 degrees suggests dysplasia, subluxation or dislocation

The image displayed is an infant hip ultrasound with measurements added. Which letter indicates where the alpha angle is measured? A. b B. c C. d D. none of the above

D. d *Beta angle is measured between line 1 (yellow) and 3 (blue). It refers to the angle formed between the vertical cortex of the iliac bone and the triangular labral fibrocartilage (echogenic triangle). It is not universally used to assess dysplasia.

The image displayed is an infant hip ultrasound with measurements added. Which letter indicates where the beta angle is measured? A. a B. b C. c D. d

C. the superior inferior dimension *The superior-inferior dimension of the liver is used to assess liver size. It is measured in the sagittal view of the midclavicular plane.

The liver measurement normally used to assess liver size is: A. measured from the transverse view at the midclavicular plane B. the medial to lateral dimension C. the superior inferior dimension D. overall volume (l x w x h x 0.5)

B. hepatic artery *Hepatic artery patency is most important to evaluate because it is the only way oxygenated blood is supplied to the biliary tree. If the biliary tree is cut off from oxygenated blood, biliary tissue death will occur. The portal vein also carries oxygenated blood to the liver tissues but NOT the biliary tree.

The most important structure to evaluate with a liver transplant is: A. hepatic vein B. hepatic artery C. biliary anastomosis D. portal vein

D. More than one of the above

The radiologist requests that a patient return for a repeat scan of the left kidney. The original scan performed 2 days prior demonstrated the presence of the cyst that appears hemorrhagic. The radiologist requests that you provide better images to distinguish a possible simple cyst from a hemorrhagic cyst. How will you accomplish this request? A. Use different patient positions to evaluate the kidney. B. Scan the patient using multiple windows. C. Adjust the gain settings throughout the exam. D. More than one of the above

A. evaluate the organs for carcinoma *Portal lymphadenopathy is present. The abdomen should be evaluated for signs of a primary carcinoma or metastasis.

This image is the first sagittal image of an abdominal US exam you are performing. What should you be sure to do during the rest of the exam for this patient? A. evaluate the organs for carcinoma B. evaluate the aorta for thrombus accumulation and source of embolus C. evaluate the organs for parasitic infection D. evaluate the abdomen for fluid collections and/or active bleeding

C. Width *In both the transverse and longitudinal views, the top of the image is anterior and the bottom of the image is posterior. In the longitudinal view, the left side of the image is the head and the right side of the image is the feet of the patient. In the transverse view the left side of the image is the right side of the patient and the right side of the image is the left side of the patient.

What dimension of the mass is being measured on the image? A. Length B. AP C. Width

C. AP *In both the transverse and longitudinal views, the top of the image is anterior and the bottom of the image is posterior. In the longitudinal view, the left side of the image is the head and the right side of the image is the feet of the patient. In the transverse view the left side of the image is the right side of the patient and the right side of the image is the left side of the patient.

What dimension of the mass is being measured on the image? A. Width B. Length C. AP

B. Patient not NPO *The gallbladder contracts after eating. A very common reason for nonvisualization of the gallbladder is normal contraction after eating. It is very important that the patient be NPO for the exam to ensure a normal gallbladder will be distended

What is a common cause for non-visualization of the GB? A. Acute cholecystitis B. Patient not NPO C. Biliary sludge D. Polyps

A. peak systolic velocity

What is being measured on the Doppler tracing? A. peak systolic velocity B. resistive index C. end diastolic velocity D. peak diastolic velocity

D. erect *If the patients stands while being scanned, the increase in hydrostatic pressure will cause the vessels of the varicocele to dilate.

When evaluating a suspected testicular varicocele, what patient position will better demonstrate the abnormality? A. decubitus left B. supine C. decubitus right D. erect

B. erect *If the patients stands while being scanned, the increase in hydrostatic pressure will cause the vessels of the varicocele to dilate.

When evaluating a suspected testicular varicocele, what patient position will better demonstrate the abnormality? A. supine B. erect C. decubitus left D. decubitus right

D. right lateral decubitus *When evaluating an infant for pyloric stenosis, the infant should be placed in the right lateral decubitus position for better visualization of the pylorus.

When evaluating an infant for pyloric stenosis, the infant should be placed in the _______________ position for better visualization of the pylorus. A. prone B. semi-erect C. left lateral decubitus D. right lateral decubitus

D. Scan the patient in the decubitus position *The decubitus position allows for transducer placement closer to the kidney than from an anterior approach. Coronal and posterior probe placement can aid in better visualization of the kidneys, especially in obese patients.

When scanning a large habitus patient, a possible renal cyst is identified. Which of the following is a technique that would most likely be used to better visualize the finding? A. Use a standoff pad B. Drink water and rescan in 20-30 minutes C. Switch to a higher frequency probe D. Scan the patient in the decubitus position

E. All of the above

When scanning a large habitus patient, a possible renal mass is identified. Which of the following is a technique that would most likely be used to better visualize the finding? A. Switch to a lower frequency probe B. Apply color Doppler to assess flow within the mass C. Evaluate the renal vasculature at the hilum for tumor extension D. Scan the patient in the decubitus position E. All of the above

E. All of the above

When scanning a large habitus patient, an irregular renal mass is identified. Which of the following is a technique that would most likely be used to better characterize the finding? A. Apply color Doppler to assess flow within the mass B. Evaluate the renal vasculature at the hilum for tumor extension C. Evaluate the retroperitoneum for lymphadenopathy D. Evaluate the liver for metastasis E. All of the above

C. ask patient to perform the valsalva maneuver *The valsalva maneuver will not usually affect the evaluation of the pancreas.

When scanning the pancreas, which of the following techniques will not assist in reducing the gas artifact around the pancreas? A. water ingestion B. deep inspiration C. ask patient to perform the valsalva maneuver D. NPO 8-12 hrs prior to exam

A. kidneys for hydronephrosis *An enlarged prostate can cause urine retention in the bladder and associated hydronephrosis.

When the prostate is enlarged, what other structures should be evaluated for related findings? A. kidneys for hydronephrosis B. portal vein for thrombosis C. renal arteries for thrombosis D. renal veins for Nutcracker syndrome

C. Cephalad *The celiac axis originates from the anterior aorta superior to the origin of the SMA.

When the superior mesenteric artery is in view in a transverse plane, the probe must be angled __________ to see the celiac axis. A. Caudal B. Oblique C. Cephalad D. Ventral

B. green *The end diastolic velocity is measured just before the start of systolic flow begins on the next cardiac cycle.

Which arrow indicates where the end diastolic velocity should be measured? A. blue B. green C. yellow D. orange

B. orange *It is important to measure all organs/structures according to their axis in the body. The cyst is sitting in an oblique position in the liver. The length and width should be measured with calipers placed perpendicular to the appropriate axis of the structure.

Which line indicates the correct AP measurement of the liver cyst? A. purple B. orange C. blue D. green

B. blue *It is important to measure all organs/structures according to their axis in the body. The cyst is sitting in an oblique position in the liver. The length and width should be measured with calipers placed perpendicular to the appropriate axis of the structure.

Which line indicates the correct length measurement of the liver cyst? A. green B. blue C. orange D. purple

C. length *The image is a sagittal view which means the calipers are measuring the superior to inferior dimension AKA length.

Which measurement of the hydrocele is being assessed on the image? A. AP B. width C. length

C. peak systolic velocity and end diastolic velocity *The resistive index = PSV - EDV / PSV

Which of the following Doppler information is necessary to calculate the resistive index? A. peak systolic velocity and peak diastolic velocity B. peak systolic velocity, average flow velocity and end diastolic velocity C. peak systolic velocity and end diastolic velocity D. peak systolic velocity only

D. adenocarcinoma of the descending colon *A water enema can be helpful to evaluate lumen characteristics of the colon. It may assist in identifying an intraluminal defect or tumor formation.

Which of the following abnormalities would benefit the most from the administration of a water enema during the ultrasound evaluation? A. distal abdominal aorta B. gastric sarcoma C. pancreatic adenocarcinoma (head) D. adenocarcinoma of the descending colon

D. Supine with neck extended *Some patients lying supine may require a pillow to be placed under their shoulders to hyperextend the neck for proper thyroid evaluation.

Which of the following best describes the patient position for a thyroid ultrasound? A. Semi-erect with chin angled toward the side not being scanned B. Posterior oblique with neck extended C. Prone with the neck extended D. Supine with neck extended

A. The technologist uses ultrasound to guide the probe placement during compression therapy applied in 10 minute intervals. *Treatment of a pseudoaneurysm is performed by applying compression over the stalk. Compression is performed in 10 minute intervals with a re-evaluation of flow within the pseudo after each compression interval. Thrombin can be injected into the body of the pseudoaneurysm under ultrasound guidance. Lovenox is used to treat DVT.

Which of the following correctly describes how ultrasound is used to guide treatment of a pseudoaneurysm of the external iliac artery? A. The technologist uses ultrasound to guide the probe placement during compression therapy applied in 10 minute intervals. B. The physician uses ultrasound guidance during the injection of Lovenox into the stalk of the pseudoaneurysm. C. The technologist uses ultrasound to guide the probe placement during compression therapy applied in 30 minute intervals. D. The physician uses ultrasound guidance during the injection of Lovenox into the body of the pseudoaneurysm.

C. With the ultrasound beam as perpendicular to the gallbladder wall as possible, measure the AP thickness of the anterior wall *With the ultrasound beam as perpendicular to the gallbladder wall as possible, measure the AP thickness of the anterior wall. Be sure that you are not slicing obliquely through the organ when assessing wall thickness.

Which of the following correctly describes the method used to measure the wall thickness of the gallbladder? A. With the ultrasound beam as parallel to the gallbladder wall as possible, measure the AP thickness of the anterior wall B. With the ultrasound beam as parallel to the gallbladder wall as possible, measure the AP thickness of the posterior wall C. With the ultrasound beam as perpendicular to the gallbladder wall as possible, measure the AP thickness of the anterior wall D. With the ultrasound beam as perpendicular to the gallbladder wall as possible, measure the AP thickness of the posterior wall

B. length X width X height / 27 = SVI *length X width X height / 27 = SVI; no unit because it is an index, 8-35 normal

Which of the following correctly lists the equation for the splenic volume index? A. length X width X height X 3.14 = SVI B. length X width X height / 27 = SVI C. length X width X height X 2 = SVI D. (length X width X height)2= SVI

D. Roll the patient into the left lateral decubitus position. *Rolling the patient will cause the stones to roll to a new position in the lumen while a polyp will remain in the same location as when the patient was supine.

Which of the following describes the best technique to differentiate a polyp in the gallbladder wall from a stone within the lumen? A. Ask the patient to perform the Valsalva maneuver. B. Have the patient drink water and rescan the GB. C. Apply color Doppler. D. Roll the patient into the left lateral decubitus position.

B. Left lateral decubitus or lithotomy position *Transrectal ultrasound or the prostate is performed with the patient in the left lateral decubitus or lithotomy position.

Which of the following describes the patient position for a transrectal prostate ultrasound? A. Lithotomy or prone B. Left lateral decubitus or lithotomy position C. Prone or Fowler D. Trendelenburg or supine

A. Aligned with iliac bone and extends through femoral head *Infant Hip Alpha/Beta Angle Assessment Line 1 - Aligned with iliac bone extends through femoral head Line 2- Extends from the iliac bone along the labrum on the medial aspect of the femoral head Line 3 - Extends from the bony edge of the acetabulum to the lateral aspect of the femoral head

Which of the following describes the placement for the first line for measurement of the alpha angle during an infant hip evaluation? A. Aligned with iliac bone and extends through femoral head B. Extends from the bony edge of the acetabulum to the lateral aspect of the femoral head C. Extends from the bony edge of the acetabulum to the medial aspect of the femoral head D. Extends from the iliac bone along the labrum

C. Extends from the iliac bone, along the labrum, and the medial aspect of the femoral head *Infant Hip Alpha/Beta Angle Assessment Line 1 - Aligned with iliac bone extends through femoral head Line 2- Extends from the iliac bone along the labrum on the medial aspect of the femoral head Line 3 - Extends from the bony edge of the acetabulum to the lateral aspect of the femoral head

Which of the following describes the placement for the second line for measurement of the alpha angle during an infant hip evaluation? A. Aligned with iliac bone and extends through the center of the femoral head B. Extends from the bony edge of the acetabulum to the lateral aspect of the femoral head C. Extends from the iliac bone, along the labrum, and the medial aspect of the femoral head D. Extends from the iliac bone, along the labrum, and the lateral aspect of the femoral head

A. Scanning with the US beam as perpendicular to the tendon as possible to improve visualization. *Dynamic imaging is also helpful to assess tendons. Scanning with the US beam as perpendicular to the tendon as possible to improve visualization and eliminate anisotropy artifact.

Which of the following describes the proper technique for visualization of the bicep tendon? A. Scanning with the US beam as perpendicular to the tendon as possible to improve visualization. B. Oblique probe position with the notch turned 60 degrees medially; placed on the anterior upper arm, just proximal to the elbow joint C. Longitudinal probe position on the posterior upper arm, just proximal to the elbow joint D. Oblique probe position with the notch turned 30 degrees medially; placed on the posterior upper arm, just proximal to the elbow joint

D. RUQ ultrasound for possible cholecystitis *In order to assess thickening of the gallbladder wall, the patient must be NPO. A false positive diagnosis of cholecystitis is possible due to normal GB wall contraction and thickening with eating. All abdominal ultrasound exams should be performed with the patient NPO 6-8hrs prior to the exam. The other exams listed could still be performed for the abnormality specified, even if the patient recently ate.

Which of the following ultrasound exams requires the patient to be NPO, even if they are ordered STAT? A. Abdominal ultrasound for possible rectus sheath hematoma B. Abdominal ultrasound for possible Crohn's disease C. RUQ ultrasound for possible hepatoma D. RUQ ultrasound for possible cholecystitis

C. Apply color Doppler to the portal vein *Apply color Doppler to differentiate tumor invasion from thrombus formation. Tumor invasion should demonstrate internal blood flow while thrombus will not demonstrate internal arterial flow.

Which of the following will help to differentiate hepatocellular carcinoma invasion of the portal vein from portal thrombosis on ultrasound examination? A. Measure the portal vein diameter on before and after a fatty meal B. Measure the portal vein diameter on inspiration and expiration C. Apply color Doppler to the portal vein D. Cannot differentiate thrombus from tumor in the portal vein by ultrasound, requires CT exam

D. Stand-off Pad *A stand-off pad eliminates the dead zone on the image. This is helpful for very superficial structures like the thyroid isthmus.

Which of the following would improve the visualization of the thyroid isthmus? A. Compound Imaging B. Color Doppler C. Extended Field of View D. Stand-off Pad

C. Oblique subcostal approach with the transducer rotated slightly with the notch side of the transducer angled more superiorly than the side of the probe without the notch. *In most patients, an oblique subcostal approach with the transducer rotated slightly with the notch side of the transducer angled more superiorly than the side of the probe without the notch should demonstrate the length of the portal vein as it enters the liver.

Which probe position is used to demonstrate a longitudinal view of the main portal vein entering the liver? A. Sagittal subcostal position just to the right of midline B. Sagittal subcostal position just to the left of midline C. Oblique subcostal approach with the transducer rotated slightly with the notch side of the transducer angled more superiorly than the side of the probe without the notch. D. Oblique subcostal approach with the transducer rotated slightly with the notch side of the transducer angled more inferiorly than the side of the probe without the notch.

B. Oblique subcostal approach angled superior toward the right shoulder *In most patients, an oblique subcostal approach angled superior toward the right shoulder should demonstrate all three hepatic veins within the liver.

Which probe position is used to demonstrate all three hepatic veins entering the IVC? A. Sagittal subcostal position just to the left of midline B. Oblique subcostal approach angled superior toward the right shoulder C. Sagittal subcostal position just to the right of midline D. Oblique intercostal approach angled superior toward the left shoulder

B. Request that the patient swallow to better evaluate the area. *The esophagus is demonstrated posterior to the left thyroid lobe.

While performing a thyroid ultrasound, you notice the area indicated by the blue arrow. Which of the following statements is true regarding completing this patient's exam? A. Color Doppler must be applied to assess the tumor vascularity. B. Request that the patient swallow to better evaluate the area. C. The radiologist will need all lab values related to the parathyroid hormones and calcium levels in the blood to aid in confirming the diagnosis of the mass. D. The arrow indicates the normal longus colli muscle.

D. Roll the patient into an oblique or decubitus position and rescan the aorta. *By rolling the patient into an oblique position and scanning from a more lateral approach, you can angle the beam posterior to the bowel to view the aorta.

While performing an ultrasound of the abdominal aorta, the mid and distal portions of the vessel are partially obscured by bowel gas. Which of the following techniques can be used to improve your visualization of the aorta? A. Scan the patient in the semi-erect position. B. Have the patient drink water and rescan the aorta. C. Give the patient a laxative and rescan after 60 minutes. D. Roll the patient into an oblique or decubitus position and rescan the aorta.

C. LUQ to locate the spleen *Asplenia is a group of congenital defects termed double right sidedness. Associated findings include absence of the spleen, right sided aorta, duplicated IVC, midline liver location, horseshoe kidneys/adrenals

While scanning a patient's RUQ you identify the aorta on the right side of the spine, duplicated IVC and a horseshoe kidney along the midline. Where should you look next for an associated abnormality? A. RUQ for ectopic liver tissue B. Midline to identify a patent azygous vein C. LUQ to locate the spleen D. LLQ for an ectopic kidney

B. Apply color Doppler *The gastroduodenal artery appears as a small circular structure at the anterior pancreas head. The vessel has a superior to inferior course in the body and the length of the vessel is best demonstrated in the longitudinal plane.

While scanning in the transverse plane of the abdomen, you notice a round anechoic structure just anterior to pancreatic head. Which of the following should be the next step in evaluating this finding? A. Have the patient drink water B. Apply color Doppler C. Evaluate the kidneys for cysts D. Scan the patient in the decubitus position

D. Evaluate the liver for portal HTN. *Portal HTN causes a backlog of blood trying to enter the liver. The splenic vein empties into the portal vein and will dilate when portal HTN is present.

While scanning the LUQ you identify multiple dilated vessels at the hilum of the spleen. What is the next step in evaluating this patient? A. Check the splenic artery for stenosis. B. Check the aorta for an aneurysm. C. Evaluate the porta hepatis for lymphadenopathy. D. Evaluate the liver for portal HTN.

D. Change the patient position and rescan *If there is any finding inside the gallbladder lumen, additional images with the patient in the left lateral decubitus position should be obtained to assess mobility of the findings.

You are scanning the gallbladder and you obtain images of several echogenic foci within the lumen. Which of the following best describes the next step in evaluating these findings? A. Apply color Doppler B. Have the patient drink water and rescan C. Ask the patient to perform the Valsalva maneuver D. Change the patient position and rescan

A. Give the patient cholecystokinin. *Cholecystokinin is administered to cause the gallbladder contraction. Giving the patient a drink of water, asking the patient to take in a deep breath and using graded compression can help displace bowel gas.

You are trying to scan the liver from a midline window but there is excessive gas in the GI tract. All of the following techniques can aid in better visualization of the liver, except? A. Give the patient cholecystokinin. B. Give the patient water and rescan. C. Use graded compression to displace bowel gas. D. Ask the patient to take a deep breath and hold it.

D. pancreas for mass in the head *11mm CBD is too large and abnormal. The pancreas head should be evaluated for a reason that the CBD is dilated if the duct is clear.

A 50yr old patient presents with acute RUQ pain and elevated alkaline phosphatase and bilirubin. The gall bladder appears normal and the CBD measures 11mm at the porta hepatis. What should be evaluated next for this patient's exam? A. pancreas for mass in the tail B. liver for metastasis C. spleen for varices D. pancreas for mass in the head

B. hepatic veins *Budd Chiari syndrome refers to the chronic obstruction of the hepatic veins and/or the IVC. It can be related to thrombus formation, extrinsic compression by a mass or cardiac disease.

A 55yr old male presents with a history of Budd-Chiari syndrome. What vessels should be evaluated with Doppler on this exam? A. aorta B. hepatic veins C. hepatic arteries D. renal veins

A. right lobe, portal vein and caudate lobe *The caudate lobe is normally spared from the atrophy associated with cirrhosis. Comparing the size of the caudate lobe to the size of the right lobe aids in assessment of liver atrophy seen with cirrhosis. The portal vein will dilate as the cirrhosis progresses. A portal vein diameter greater than 13mm is abnormal.

A 56yr old male presents with a 4yr history of cirrhosis. When performing the ultrasound exam on this patient, the size of which of the following structures should be assessed to evaluate the effects of the cirrhosis? A. right lobe, portal vein and caudate lobe B. portal vein, hepatic vein, and hepatic artery C. caudate lobe and hepatic artery D. left lobe and caudate lobe

A. spleen *Epstein Barr infection is associated with mononucleosis. It leads to significant splenomegaly

A 6yr old is referred for an abdominal ultrasound due to a history of Epstein Barr infection. What organ should be closely evaluated for associated findings? A. spleen B. gallbladder C. kidneys D. liver

A. Transverse views are preferred for the most accurate diameter measurement *Evaluating the aorta for possible aneurysm: Identifying the celiac axis guarantees a complete evaluation of the proximal segment Identifying the aortic bifurcation guarantees a complete evaluation of the infrarenal segment Right lateral oblique position can be especially helpful for evaluating the distal aorta bifurcation into the common iliac arteries Goal of the exam is to find the location of the maximum diameter of the aorta Longitudinal images provide the best view for accurate measurements perpendicular to the axis of the vessel Measure true vessel size from outer edge of the wall to outer edge of the wall Enlarged vessel >3cm or >50% increase in diameter compared to adjacent segment Possible thrombus accumulation causes echogenic debris levels within the lumen Measure true lumen size, if thrombus accumulation present Turbulence seen with Color and PW Doppler evaluation

Which of the following is incorrect regarding the evaluation of a patient with a suspected abdominal aortic aneurysm? A. Transverse views are preferred for the most accurate diameter measurement B. Identifying the celiac axis guarantees a complete evaluation of the proximal segment C. Identifying the aortic bifurcation guarantees a complete evaluation of the infrarenal segment D. Right lateral oblique position can be especially helpful for evaluating the distal aorta bifurcation into the common iliac arteries

C. have the patient fill their bladder and evaluate the scrotal sac for pocket of urine *Peristalsis of a bowel segment inside the scrotal sac is a definitive sign of a hernia. Color Doppler can be used to assess blood flow in the bowel segment. The strain and release from the Valsalva maneuver can stimulate peristalsis and accentuate the protrusion of bowel in the sac.

Which of the following is least likely to assist in diagnosing an inguinal hernia? A. record bowel peristalsis on a cine clip B. apply color Doppler to the suspected bowel protrusion into the scrotal sac C. have the patient fill their bladder and evaluate the scrotal sac for pocket of urine D. use dual screen imaging ,with and without Valsalva, over the suspected location of the hernia

B. evaluate the cortical thinning *Cortical thinning is related to chronic renal disease. ARF presents with acute reduction/elimination of urine production and the bladder will be mostly empty. Postrenal failure is caused by bilateral renal obstruction which leads to hydronephrosis. Intrinsic renal failure will demonstrate elevated resistance on Doppler evaluation of the arcuate arteries

Which of the following is least likely to assist in evaluating a patient with suspected acute renal failure? A. evaluate the kidneys for bilateral hydronephrosis B. evaluate the cortical thinning C. evaluate the resistive index of the arcuate arteries D. evaluate the bladder volume

A. Comparison views of the unaffected hip should always be obtained. *Use linear probe in an oblique plane on the anterior hip (parallel to the femoral neck); Normal hip capsule 2-5mm thick; should be symmetric between hips; Both hips should have should be evaluated for capsule comparison Transient Arthritis - Common cause of hip pain in children; May present with a history of recent respiratory infection, no fever at the onset of the hip pain; Treated with anti-inflammatory meds Septic Arthritis - Bacterial infection causes inflammation; Patient presents with fever, increased WBC count and hip pain; CONSIDERED A MEDICAL EMERGENCY to prevent long term joint damage; Requires US guided arthrocentesis for fluid evaluation; treated with IV antibiotics

Which of the following is true regarding the evaluation of a pediatric hip for suspected transient arthritis? A. Comparison views of the unaffected hip should always be obtained. B. The curved array is used for the best evaluation of the curved structures in the boney hip. C. Transient arthritis requires an immediate arthrocentesis for fluid evaluation. D. The normal hip capsule thickness is less than 1cm.

B. Valsalva *The image demonstrates an opening in the muscular fascia of the abdominal wall with a "mushroom cloud" of intestine extending anteriorly through the herniation. The valsalva maneuver is helpful in evaluating the presence/absence of bowel protruding through a herniation in the abdominal wall. The increase in intra-abdominal pressure should force the bowel through the opening and peristalsis should occur upon release.

Which of the following maneuvers is utilized to assist in the diagnosis of the abnormality displayed? A. Glisson B. Valsalva C. Murphy D. Homan

D. varicocele and inguinal hernia *The valsalva maneuver is used to demonstrate the increased vascular flow within a varicocele that forms outside the testicle. A hernia will demonstrate motion of tissues through the opening with the strain portion of the maneuver.

Which of the following scrotal abnormalities would be better displayed if the patient performed the Valsalva maneuver? A. varicocele only B. inguinal hernia only C. testicular torsion and inguinal hernia D. varicocele and inguinal hernia

D. color Doppler *Color Doppler can be used to evaluate the flow within the herniated bowel segment. The valsalva maneuver is not a sonographic technique but a patient action used to stimulate peristalsis and better visualize the contents of the hernia.

Which of the following sonographic techniques can be used to evaluate a possible inguinal hernia? A. valsalva maneuver B. PW Doppler C. tissue Doppler D. color Doppler

D. Placing the patient in the supine position best demonstrates this abnormality. *A varicocele is demonstrated on the image. The vessels will dilate and be easier to see if the patient is scanned while standing.

Which of the following statements is false regarding the abnormality on the image? A. It has been related to incompetent venous valves. B. It can be caused by Nutcracker syndrome. C. It is more commonly seen on the left side due to the relationship of the gonadal vascular anatomy to surrounding structures. D. Placing the patient in the supine position best demonstrates this abnormality.