Liver Written Comp

Student Name: Shelby Rhoda Date Submitted: 10/14/15

 Students are required to complete each area based on the scan comp completed to
receive maximum points.
 There are 10 sections; each section is worth a maximum of 5 points. Answers
provided must relate to specific information requested. Additional information
including non-applicable information will result in point deduction

Before the exam: Patient Interview, Chart Review, Possible Pathology, Patient Set
Up, and Preparation

Section 1:
Identify the patient’s age, sex, ethnicity, current symptoms and pertinent history relevant to
the exam.
 Age: 61
 Sex: Male
 Ethnicity: white
 Current Symptoms: asymptomatic
 History: metastatic esophageal cancer, elevated liver enzymes

Identify the patient’s labs relevant to the exam (as high, low, or normal) and explain what
the patient’s lab values indicate.
If the patient had no labs, identify the labs relevant to the exam (with normal values) and
explain what deviations in these lab values indicate.
 Elevated total Bilirubin indicating biliary obstruction, jaundice, or liver damage
 Elevated AST indicating cirrhosis, hepatitis, liver damage, or MI
 Elevated ALT indicating hepatitis or jaundice
 Elevated ALP indicating abscess or biliary obstruction

Identify the patient’s previous exams and results relevant to this exam.
If the patient had no previous exams, identify one other imaging modality that could be used
to evaluate your patient’s symptoms. Explain why this modality would be used in
conjunction with sonography.
 A previous CT of the abdomen and pelvis was done on 9/25/15 showing the liver,
spleen, pancreas, and gallbladder normal.
Liver Written Comp

Grade for
Section 1

Section 2:
Based on the patient’s clinical history, labs, and previous exams and results, what did you
expect to find during this exam and why?
 Based on the labs I expected to possibly find some sort of biliary obstruction because
of the bilirubin elevation and based on patient history possibly something that had
metastasized from the esophageal cancer even though the liver appeared normal in
the previous CT scan. This could be a tumor in the liver compressing a duct or an
actual tumor within the biliary ductal system.

Grade for
Section 2

Section 3:
Describe how you identified the patient and educated the patient on the exam being
performed. Identify the patient set up and exam preparation.
 I greeted the patient by his last name and verified with his wristband. Once I got the
patient into the exam room I explained to him that I was going to be taking a look at
his liver, gallbladder, and pancreas with ultrasound and asked him if he had any
questions. I then got a towel and a bottle of gel from the warmer and asked him to
pull his gown up to his chest. I verified if birthdate and name again on the exam on
the machine. Once I had the exam verified and the towel over his gown, I proceeded
with the test.

Grade for
Section 3

During the Exam: Sonographic findings of structures, pathologies,
measurements, and instrumentation
Section 4:
Identify the sonographic features of the liver in its entirety, as well as the pancreas,
gallbladder, and common bile duct.
 The liver appeared homogeneous, medium shades of gray.
 The pancreas was not visualized due to overlying bowel gas.
Liver Written Comp

 The gallbladder appear anechoic with a lumen containing echogenic, mobile, material
representing sludge with an echogenic wall within the normal measurements
 The common bile duct was dilated at 12 mm and appeared anechoic with echogenic

Grade for
Section 4

Section 5:
Identify all protocol measurements obtained and identify if each measurement is normal or
abnormal. If abnormal, what is indicated?
 Liver length: 15.41 cm (normal)
 Gallbladder wall: 0.23 cm (normal)

 CBD: 1.18 cm (dilated which can indicate biliary obstruction)

Grade for
Section 5

Section 6:
Identify the pathology documented during the exam including location, size, vascularity, and
sonographic features.
If no pathology is seen, identify a common pathology seen with this exam and how you
would need to modify your protocol to document this pathology.
 Intrahepatic and extrahepatic dilatation was documented with specific measurement
of the common bile duct at 12 mm which were seen as anechoic vessels within the
liver tissue and outside of the porta hepatis
 Mobile, echogenic material seen in the gallbladder lumen documented as sludge with
echogenic foci within the sludge

Grade for
Section 6

Section 7:
Identify the ultrasound preset, transducer, and frequency utilized to provide diagnostic
images and explain why the specific instrumentation was correct.
Liver Written Comp

 Ultrasound preset: Abdomen
 Transducer: curvilinear probe
 Frequency: 4 MHz
 The preset abdomen was used because this is what has been set on the machine for
the best imaging presets when beginning an abdomen scan and the curvilinear probe
at 4 MHz was used for best penetration for deep structures within the abdomen and
being able to penetrate completely through the liver tissue with the lower frequency.

For your sagittal liver image with left lobe, caudate lobe, and IVC , identify the depth and
focal zone(s) used and explain why they were correct.
 Depth at 12 cm
 Focal zones at 6 cm and 8 cm
 These are correct because this was the depth needed to see the entire part of the
liver that was of concern and the focal zones were placed near the bottom of the
image to allow for the best resolution along all of the liver tissue.

For your transverse superior liver image, identify the depth and focal zone(s) used and
explain why they were correct.
 Depth at 14 cm
 Focal zones at 8cm and 11 cm
 This depth was needed to see all of the sampled liver tissue and the space beyond
the diaphragm to check for ascites or possible masses that could be hanging off of
the liver and the focal zones allowed for best resolution along the entirety of the liver

Grade for
Section 7

Exam Findings: Student’s Preliminary Report and Physician’s Interpretation
Liver Written Comp

Section 8:
What did you report to the sonographer and/or physician regarding the exam? Describe
your interaction.
 I reported to the sonographer that the CBD was dilated and the gallbladder contained
sludge and possible stones within the sludge. The sonographer complimented my
images and gave me some advice on increasing my depth on a few of my liver
pictures to see that there were no possible masses hanging off of the edge of the
liver surface. I also learned that using harmonics helps when imaging the common
bile duct and the gallbladder. I think more could have been done to show possible
stones within the sludge in the gallbladder so I took away that just slowing down and
spending a little more time would have given clearer images of that pathology.

Grade for
Section 8

Section 9:
What was the physician’s interpretation of the exam?
 The distal proximal CBD was dilated at 12 mm possibly due to infiltration of known
metastatic disease.
 Gallbladder sludge and that intermixed, small, nonshadowing, gallstones could not be

Grade for
Section 9

Section 10:
Do you agree or disagree with the physician’s interpretation of the exam? Why or why not?
(This must be supported by current literature)
 I agree with the physician’s interpretation.
 I agree that the common bile duct is dilated because the normal measurements are
less than 7-8 mm and I imaged and measured the common bile duct while scanning.
 I also agree that the gallbladder has sludge in it because it appeared echogenic,
smooth, and moved when I rolled the patient LLD and I also saw multiple focal
objects within the sludge possibly being gallstones but they were hard to view
because of the sludge.
Liver Written Comp

Grade for
Section 10

Clinical Site: BMH Desoto
Sonographer with credentials Kelsey Locke, RDMS (AB)
and specialties:
Patient MRN: 150783764
Exam order on request: US Liver
Performance date of final scan 10/7/15
Is this a second attempt written No

Points Description
5  No errors were identified
4  One error was identified
3  Errors identified In less than the ½ of the components required
2  Errors identified In up to ¾’s of the components required

1  Immediate action required
 errors identified in more than ¾’s of the components required
 evidence of an unsafe event (unsafe events may result in
failure of the competency)
 required image not included

Point Value Conversion Chart
50=100 49=98 48=97 47=96 46=95 45=93 44=92 43=91 42=90 41=89
40=88 39=86 38=85 37=84 36=82 35=80 34=79 33=78 32=77 31=76
30=75 29=74 28=73 27=72 26=71 25=70 24=68 23=66 22=64 21=61
20=60 19=57 18=55 17=45 16=40 15=45 14=35 13=30 12=25 11=20
10 or less = 0

Section Points Received
Liver Written Comp

Total/Final score