Lower Extremity Arterial Written Comp

Student Name: Jennifer Pittman

Date Submitted: 8/10/2014

Directions:

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 patients age, sex, ethnicity, current symptoms and pertinent history relevant to
the exam.
Answer:

Age: 54 years old

Sex: Female

Ethnicity: Caucasian

Current symptoms: The patient states she has constant pain in both legs that has
been occurring for several months. She says the pain cannot be relieved by rest, and
does not get worse with walking.

Pertinent history: This was an outpatient so there was no chart available; all
information was gathered during the patient interview. She had a previous arterial
exam performed that showed abnormal ABIs, but we are unable to gain access to
this exam in PACS. The patient is a daily smoker. She admitted to having high blood
pressure, but was unsure of the name of the medication she takes to control it. She is
not overweight and denies having diabetes. She does not have a history of
hyperlipidemia, coronary artery disease, or end stage renal disease.

Identify the patients labs relevant to the exam (as high, low, or normal) and explain what
the patients 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.
Answer:

The patient did not have any labs drawn prior to receiving this ultrasound.

Labs that could be relevant to this exam include:

o

Hematocrit. A decreased hematocrit level could possibly indicate rupture or

bleed. A decreased level would be less than 40%.

Cholesterol. An increased cholesterol lab value could lead to atherosclerosis or

heart disease. An increased cholesterol level would be greater than 200
mg/dL.

Identify the patients previous exams and results relevant to this exam.

Lower Extremity Arterial Written Comp

If the patient had no previous exams, identify one other imaging modality that could be used
to evaluate your patients symptoms. Explain why this modality would be used in
conjunction with sonography.
Answer:

The patient had a previous ABI performed without an ultrasound; however, it was not
found in PACS.

Another image modality that could be used in conjunction with ultrasound is contrast
arteriography. It has been used as the gold standard imaging tool to evaluate the
peripheral arterial system. Contrast arteriography is a radiologic imaging technique
using ionizing radiation to provide detailed arterial system configuration and
pathology information. It is a very well-known and useful modality.
Grade for
Section 1

Section 2:
Based on the patients clinical history, labs, and previous exams and results, what did you
expect to find during this exam and why?
Answer:

Based on the information gathered about the patient I expected to find a stenosis in
either or both of the legs. The patient presented with constant pain in both of her legs
which is a symptom associated with a stenosis. The patient also admitted to smoking
and having high blood pressure; which are also findings associated with a stenosis. A
stenosis would appear sonographically with wall thickening, heterogeneous plaque of
mixed echogenicity, and calcifications with the use of gray scale imaging. With color
Doppler there would be focal areas of aliasing with distal turbulence. In the use of
spectral Doppler, a focal increase in PSV would be noted with poststenotic turbulence
and a velocity ratio > 2.0. The waveforms would appear monophasic distally with no
reverse flow and continuous flow in diastole.
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.
Answer:

Before bringing the patient into the exam room I checked her armband to be sure it
matched the name on the request. I looked at the name, date of birth, and MRN
number. I even asked the patient if they knew what exam they were having. When in
the exam room I asked her to verify her full name and date of birth. I matched this
information to the information provided on the machine.

Before beginning the exam I informed the patient that I was a student that would be
scanning the arteries in her left and right leg and would be using a different machine
with blood pressure cuffs afterwards. I informed her that the sonographer would
come behind me to make sure no abnormalities were overlooked. I told her the exam

Lower Extremity Arterial Written Comp

would not be painful, and the only thing that may hurt would be slight pressure. I
showed her the transducer and explained that the test did not involve radiation, only
warm gel and sound waves that would create an image for the radiologist to review.

After explaining the test and checking the patient identifiers I told the patient that
she would need to take off her pants and cover up with the sheet provided so that I
could access the arteries in both legs. I stepped out of the room for a moment to give
her some privacy while changing. In the exam room I made sure the patient was in
the supine position with the right leg rotated slightly outward; the left leg would be
rotated outward after scanning the right. I raised the bed to the best height to avoid
any MSK injury and discomfort. I dimmed the lights in order to better view the
compare and contrasts of the gray scale images. I put on gloves and tucked a towel
into the sheet and the bottom of her underwear to avoid spreading the gel. I kept the
opposite leg covered for patient privacy while I was not scanning it. I applied warm
gel, for the patients comfort, on the patients groin where the exam would be
started. A fair amount of gel will aid in making it easier to get a clear image.
Grade for
Section 3

During the Exam: Sonographic findings of structures, pathologies,

measurements, and instrumentation
Section 4:
Identify the gray scale, color, and spectral Doppler sonographic features of the lower
extremity arteries included in this protocol.
Answer:

Right and Left EIA:

o

Color Doppler: Color filed in lumen completely without aliasing.

Spectral Doppler: High-resistive and triphasic with a sharp systolic upstroke, a

rapid deceleration, retrograde flow below the baseline, and brief antegrade
flow in diastole.

Right and Left CFA:

o

Color Doppler: Color filled in lumen completely without aliasing.

Spectral Doppler: High-resistive and triphasic with a sharp systolic upstroke, a

rapid deceleration, retrograde flow below the baseline, and brief antegrade
flow in diastole.

Right and Left SFA PROX:

o

Color Doppler: Color filled in lumen completely without aliasing.

Spectral Doppler: High-resistive and triphasic with a sharp systolic upstroke, a

rapid deceleration, retrograde flow below the baseline, and brief antegrade
flow in diastole.

Right and Left DFA:

o

Color Doppler: Color filled in lumen completely without aliasing.

Spectral Doppler: High-resistive and biphasic with a sharp systolic upstroke

followed by a period of diastolic flow reversal.

Lower Extremity Arterial Written Comp

Right and Left SFA MID:

o

Color Doppler: Color filled lumen in completely without aliasing.

Spectral Doppler: High-resistive and triphasic with a sharp systolic upstroke, a

rapid deceleration, retrograde flow below the baseline, and brief antegrade
flow in diastole.

Right and Left SFA DIST:

o

Color Doppler: Color filled in lumen completely without aliasing.

Spectral Doppler: High-resistive and triphasic with a sharp systolic upstroke, a

rapid deceleration, retrograde flow below the baseline, and brief antegrade
flow in diastole.

Right and Left POP ART:

o

Color Doppler: Color filled in lumen completely without aliasing.

Spectral Doppler: High-resistive and triphasic with a sharp systolic upstroke, a

rapid deceleration, retrograde flow below the baseline, and brief antegrade
flow in diastole.

Right and Left PTA:

o

Color Doppler: Color filled in lumen completely without aliasing.

Spectral Doppler: High-resistive and triphasic with a sharp systolic upstroke, a

rapid deceleration, retrograde flow below the baseline, and brief antegrade
flow in diastole.

Right and Left DPA:

o

Color Doppler: Color filled in lumen completely without aliasing.

Spectral Doppler: High-resistive and biphasic with a sharp systolic upstroke

followed by a period of diastolic flow reversal.
Grade for
Section 4

Section 5:
Identify all peak systolic velocity measurements obtained and identify if each measurement
is normal or abnormal. If abnormal, what is indicated?
Identify the ABIs and identify if they are normal or abnormal. If abnormal, what is indicated?
Answer:

Right EIA: 96.9 cm/s. This is in the normal range of 119 cm/s + or 22 cm/s.

Right CFA: 50.5 cm/s. This is abnormal because it is decreased. The difference is
greater than 20 cm/s between segments. The normal range is 114 cm/s + or 25
cm/s.

Right DFA: 63.7 cm/s. This is abnormal because it is slightly decreased. It could be
due to the medication the patient is taking for her blood pressure.

Right SFA PROX: 83.7 cm/s. This is normal because it is in the range of 91 cm/s + or
14 cm/s.

Lower Extremity Arterial Written Comp

Right SFA MID: 72.7 cm/s. This is abnormal because it is slightly decreased from the
normal range of 91 m/s + or 14 cm/s. It could be due to the medication the patient
is taking for her blood pressure.

Right SFA DIST: 67.5 cm/s. This is abnormal because it is slightly decreased from the
normal range of 94 cm/s + or 14 cm/s. This could be due to the medication the
patient is taking for her blood pressure.

Right POP ART: 60.6 cm/s. This is in the normal range of 69 cm/s + or 14 cm/s.

Right PTA: 48.0 cm/s. This is a normal range because there isnt a difference greater
than 20 cm/s between segments.

Right DPA: 30.1 cm/s. This is a normal range because there isnt a difference greater
than 20 cm/s between segments.

Left EIA: 89.4 cm/s. This is abnormal because it is slightly decreased from the normal
range of 119 cm/s + or 22 cm/s. The decrease could be due to the medication the
patient is taking for her blood pressure.

Left CFA: 82.3 cm/s. This is abnormal because it is slightly decreased from the normal
range of 114 cm/s + or 25 cm/s. The decrease could be due to the patients blood
pressure medication.

Left DFA: 76.0 cm/s. This is abnormal because it is slightly decreased. It could be due
to the medication the patient is taking for her blood pressure.

Left SFA PROX: 79.7 cm/s. This is abnormal because it is slightly decreased from the
normal range of 91 cm/s + or 14 cm/s. The slight decrease could be due to the
medication the patient is taking for her blood pressure.

Left SFA MID: 67.5 cm/s. This is abnormal because it is slightly decreased from the
normal range of 91 cm/s + or 14 cm/s. The slight decrease could be due to the
medication the patient is taking for her blood pressure.

Left SFA DIST: 79.5 cm/s. This is a normal PSV. It would be rounded up to 80 cm/s
making it in the normal range of 94 cm/s + or 14 cm/s.

Left POP ART: 62.2 cm/s. This is in the normal range of 69 cm/s + or 14 cm/s.

Left PTA: 46.5 cm/s. This is a normal range because there isnt a difference greater
than 20 cm/s between segments.

Left DPA: 30.5 cm/s. This is a normal range because there isnt a difference greater
than 20 cm/s between segments.

ABIs: The ratio for the right side was 1.01 and the ratio for the left was 1.02. This is a
normal ABI ratio because it is in the normal range of 0.90 1.30.
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.

Lower Extremity Arterial Written Comp

Answer:

No pathology was seen during this exam.

A common pathology that would have been visualized is a stenosis, in both or one
leg. If a stenosis was visualized the protocol would need to be altered. Gray scale
images would need to be taken in the transverse and sagittal plane without adjusting
the TGCs. Color Doppler would need to be utilized to demonstrate blood flow around
the plaque and to demonstrate the mosaic of color. Spectral Doppler would then be
used to evaluate the highest velocity in the stenotic area. The velocities in the
highest PSV and in the normal area of the vessel, approximately 2 cm prestenotic and
postenotic, would need to be recorded. A significant stenosis is considered when the
flow in the designated stenotic area is twice the velocity of the area just previous to
it.
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.
Answer:

Preset: The Vascular preset was chosen with LEA. This is correct because this is the
type of exam I was performing. The preset properly adjusts the settings for the
specific exam.

Transducer: A 9 linear array transducer was used for this exam because it allowed for
adequate penetration and the axial resolution necessary. Linear array transducers are
helpful in vascular studies because of the ability to angle the color box to provide
better angles. There is more accurate velocity information and color fill in.

Frequency: A frequency of 9 MHz was used during the entire exam. A high frequency
will provide high resolution although some depth is lost. With a higher resolution
more detail is provided. These vessels are mostly superficial in the leg so a high
frequency is the best choice.

For your external iliac artery color and spectral image, identify the color and spectral
Doppler settings used and explain why they were correct.
Answer:

Right and Left EIA:

o

Color PRF: Set at 10.7 m/s for the right EIA and 8.5 m/s for the left EIA. Color
PRF was adjusted at an appropriate level to allow for even color hues without
aliasing. This PRF setting allowed detection of the presence of blood flow in
the EIA.

Color Gain: Set at 20 dB for the right EIA and 15.5 dB for the left EIA. It was set
at this level so that the lumen filled in completely with color without bleeding
outside of the walls.

Spectral PRF: Set at 8.3 m/s for the right EIA and 7.2 m/s for the left EIA.
Spectral PRF was adjusted to accurately display the waveform without
aliasing. Increasing the PRF too high will extend passed the Nyquist limit

Lower Extremity Arterial Written Comp

causing aliasing.
o

Spectral Gain: Set at 22 dB for the right EIA and the left EIA. It was set at an
appropriate level so that no background noises or echoes were visualized.

Baseline: 1/3 below the baseline and 2/3 above the baseline. The baseline was
set to allow for the complete arterial waveform to be visualized above and in
the case of reversal flow there was room for it to be seen below.

Sample Volume: Set at 2 for the right and left EIA. The PW sample volume
defines the three-dimensional region evaluated in Doppler. The sample gate is
placed in the middle of the vessel in order to sample the flow of the EIA and a
wide range of blood cells.

Angle Correct: 30 degrees for the right EIA and 37 degrees for the left EIA.
Angle correct must always be below 60 degrees. The angle correct is set to be
parallel with the vessel walls in order to get an accurate reading.

For your popliteal artery color and spectral image, identify the color and spectral Doppler
settings used and explain why they were correct.
Answer:

Right and Left POP ART:

o

Color PRF: Set at 4.1 m/s for the right POP ART and 3.8 m/s for the left POP
ART. Color PRF was adjusted at an appropriate level to allow for even color
hues without aliasing. This PRF setting allowed detection of the presence of
blood flow in the POP ART.

Color Gain: Set at 28.5 dB for the right POP ART and 20 dB for the left POP ART.
It was set at this level so that the lumen filled in completely with color without
bleeding outside of the walls.

Spectral PRF: Set at 4.2 m/s for the right POP ART and 3.9 m/s for the left POP
ART. Spectral PRF was adjusted to accurately display the waveform without
aliasing. Increasing the PRF too high will extend passed the Nyquist limit
causing aliasing.

Spectral Gain: Set at 33 dB for the right POP ART and 31 dB for the left POP
ART. It was set at an appropriate level so that no background noises or echoes
were visualized.

Baseline: 1/3 below the baseline and 2/3 above the baseline. The baseline was
set to allow for the complete arterial waveform to be visualized above and in
the case of reversal flow there was room for it to be seen below.

Sample Volume: Set at 2 for the right and left POP ART. The PW sample volume
defines the three-dimensional region evaluated in Doppler. The sample gate is
placed in the middle of the vessel in order to sample the flow of the POP ART
and a wide range of blood cells.

Angle Correct: 49 degrees for the right POP ART and 60 degrees for the left
POP ART. Angle correct must always be below 60 degrees. The angle correct is
set to be parallel with the vessel walls in order to get an accurate reading.

Lower Extremity Arterial Written Comp

Grade for
Section 7

Exam Findings: Students Preliminary Report and Physicians Interpretation

Section 8:
What did you report to the sonographer and/or physician regarding the exam? Describe
your interaction.
Answer:

After I finished the ultrasound and the ABIs I spoke with the sonographer. I informed
her that all of the vessels filled in completely with color with the use of color Doppler.
I stated that with spectral Doppler the waveforms appeared normal with normal PSV
ranges bilaterally. Bilaterally all the arteries documented besides the DFA and DPA
appeared high-resistive and triphasic with a sharp systolic upstroke, a rapid
deceleration, retrograde flow below the baseline, and brief antegrade flow in diastole.
Bilaterally the DFA and DPA appeared high-resistive and biphasic with a sharp systolic
upstroke followed by a period of diastolic flow reversal. There were no signs of a
significant stenosis. I informed her that when the ABI machine was utilized the ratios
of both sides were within the normal range of 0.90 1.30. I felt the interaction with
the sonographer went well. She agreed with my findings and allowed me to write the
jot pad. She said that my images looked good and that I made good use of my time.
Grade for
Section 8

Section 9:
What was the physicians interpretation of the exam?
Answer:

The radiologists impression of this exam was that it was normal. In his findings he
wrote the ABI ratios of 1.01 on the right side and 1.02 on the left. He stated that the
waveforms appeared triphasic and biphasic throughout the arterial system bilaterally,
without any evidence of any significant stenosis in either the right or left leg.
Grade for
Section 9

Section 10:
Do you agree or disagree with the physicians interpretation of the exam? Why or why not?
(This must be supported by current literature)
Answer:

I agree with the radiologists interpretation of the exam; the ultrasound was normal.
The ABI ratios of both sides were in the normal range of 0.90 1.30. All of the vessels
filled in completely with color with the use of color Doppler. With spectral Doppler the

Lower Extremity Arterial Written Comp

waveforms appeared normal with normal PSV ranges bilaterally. Bilaterally all the
arteries documented other than the DFA and DPA appeared high-resistive and
triphasic with a sharp systolic upstroke, a rapid deceleration, retrograde flow below
the baseline, and brief antegrade flow in diastole. Bilaterally the DFA and DPA
appeared high-resistive and biphasic with a sharp systolic upstroke followed by a
period of diastolic flow reversal. There were no signs of a significant stenosis.
Grade for
Section 10
Clinical Site:

BMH-Tipton

Sonographer with credentials

and specialties:

Sonographer present: Kellie Naumann- AB

(2014)

Graded by: Heather McCain RDMS,AB

(2008),NE (2008),OB/GYN (2014); RVT,VT
(2012)

Patient MRN:

T0000061116

Exam order on request:

US ART DOPP LEG BILATERAL

Performance date of final scan

comp:

08/05/2014

Is this a second attempt written

comp?

No

Points

Description

No errors were identified

One error was identified

Errors identified In less than the of the components required

Errors identified In up to s of the components required

Immediate action required

errors identified in more than s of the components required

evidence of an unsafe event (unsafe events may result in

failure of the competency)

required image not included