Kristen Cherry Liver Comp Final

Liver Written Competency
Student Name: Kristen Cherry
Date Written Comp submitted: 11/05/13
Directions:
Students are required to complete each area 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.
Answer formatting:
Reflective writing: describes what you did during the examination
Technical writing: describes what can be found in the literature
Bullet format is preferred for most sections (complete sentences are not required)
Narrative format is identified for specific sections. The narrative should be written in a
format that is easy to follow and understand.
Clinical Site:
Sonographer
Providing Scan
Comp Grade:
Identify the
Sonographers
Credentials:
1st Attempt
BMH New
Albany
Tana
Henderson
2nd Attempt
RDMS (AB) &

RVT (VT)
Patient MRN:
1st Attempt
000130312
Exam Ordered on
Request:
US
GALLBLADDER
Performance date
of Final Scan
Competency
10/18/13
2nd Attempt
Section I: Patient Care, Patient Identification, and Universal Precautions

Complete the table below by providing a self-reflection of each component as it relates to the patient
examination you performed.
Some components contain several elements. For maximum score each element must
be answered.
Reflective writing will be used for this section.
Answers should be written in a narrative form
Examination preparation
Describe the patient set up and
include reasoning for set up used
Explanation
I had the patient lay supine on stretcher for this exam so that
her abdomen was accessible for scanning.
I then had the patient pull her shirt up to expose her
abdomen, and tucked a towel under the edge of her bra as to
not get gel on her clothing.
I had her raise her right arm above her head while performing
Describe how the patient was

identified
Identify how patient allergies were

determined (chart and patient
interview)
Describe how you educated the

patient about the examination you
performed (must include specifics
about organs involved in the
competency performed)
Describe universal precautions

utilized at the beginning and end
of exam regarding handwashing
and transducer cleaning as well as
other applicable techniques
the exam.
o I utilized this technique, because it increases the
width of the intercostal spaces for less rib shadowing
and better windows to visualize liver.
o I did not use LLD and RLD for the liver images.
GB images were taken by sonographer.
I asked the patient to state her full name and date of birth.
o I then verified this information by checking it against
the request form.
I checked the patients outpatient wristband for her full name
and date of birth as well.
o I verified this information by checking it against
request form.
I asked the patient if she had any kind of allergies.
This patient was an outpatient, so there was no chart to
check for allergies.
I read over the allergies that were listed on the request form.
I introduced myself to the patient and informed her that I am
a student sonographer, and would be performing part of the
exam.
I informed the patient that the physician ordered an
ultrasound of the gallbladder, and that the liver, pancreas,
and right kidney would also be scanned for the exam.
I explained to the patient that I would apply warm gel to her
abdomen and use a transducer to take images so that the
physician could examine the previously stated organs.
I told the patient the exam would take around 20-30 minutes.
I asked the patient if she had any questions for me before
beginning the exam.
I also informed the patient I would be using some of the
images for a grade at school, and made sure she understood
and was alright with my doing so.
I cleaned the transducer with the proper disinfectant wipes
after the last exam was performed.
I applied the proper disinfecting hand rub and completely
rubbed it in for approximately 20 seconds.
I donned new gloves.
After the exam, I again used the proper disinfecting wipes to
clean the transducer.
I properly removed my soiled gloves and placed them in the
proper trash container.
Finally, I washed my hands with soap and warm water,
utilizing the proper had rub technique for approximately 40

seconds.
Grade:
Section II: Patient History
Complete the table below by providing a self-reflection of each component as it relates to the patient
examination you performed
Some components contain several elements. For maximum score each element must
be answered correctly.
Answers written in a bullet format are preferred
Patient interview includes questions asked of the patient regarding including answers
given
Required
Discussion
(Must include specifics regarding exam ordered and the liver
protocol)
Identify the patients age, race, sex and
25 years
weight
White
Female
Outpatientno chart, weight not on request
Identify why the examination ordered
RUQ abdomen pain
(see request form or scheduling sheet for
Vomiting
reason exam was ordered) If this different
Diarrhea
from admitting diagnosis for an inpatient,
explain?
Identify previous imaging examinations
Outpatientno chart
and exam results the patient had that are
PACS
related to the competency as discovered
o CT ABD AND PELVIS
in patient chart, PACS, and patient
08/23/13
interview.
25x15x11 cm multiseptated cystic
lesion arising from the pelvic
region into the abdomen
Liver, spleen, pancreas, adrenal
glands and kidneys unremarkable
09/21/13
After interval removal of
abdominopelvic mass
o Liver, spleen, kidneys,
pancreas, and adrenal
glands unremarkable
o Gallbladder
unremarkable
Identify pertinent lab tests and lab results

that are relevant to the competency made
available in patient chart and from patient
interview. (If none are identified in chart or
from interview, note none were available and
identify lab tests should be reviewed and
why)
Identify medical history that is relevant to

the competency or reason for exam. This
history was gathered from the patient
chart and patient interview. (Include
previous surgery, hospital admission,
previous history of similar condition, known
disease, and other applicable historical
information)
Identify the patients presenting clinical

symptoms from chart and patient
interview. This includes questions asked
of the patient regarding presenting
symptoms
(This reflects only current information)
Patient interview
o I asked the patient if she had any recent imaging
exams done and for the results of those exams.
The patient stated that she had a CT
done on her abdomen and pelvis, but did
not mention, or was not aware of any
specific results relating to the liver.
No lab tests available in patient chartoutpatient
I asked the patient if she had any lab work done recently,
since she had started experiencing the present symptoms.
o Patient stated that she did not have any other
tests done, blood drawn, urine sample, etc., and
was not aware of any labs that were recently
done.
Alkaline Phosphate (ALP)
o Increase indicates metastases, obstruction,
lesions, and/or jaundice
AST
o Increase indicates hepatitis, liver injury, jaundice,
cholestasis, myocardial infarction, muscle
disease, cirrhosis, metastases, fatty liver, and/or
lymphoma
ALT
o Increase indicates jaundice and/or hepatitis
Bilirubin
o Increase indicates jaundice, liver damage, and/or
obstruction
AFP
o Increase could indicate cancer
No previous surgery, hospital admission, previous history
of similar condition, known disease, or other applicable
historical information in patient chartoutpatient
I asked the patient if she had any previous surgeries,
hospital admissions, previous history of similar condition,
known disease, etc.
o The patient told me of previous hospital stays and
a previous surgery, but nothing that was pertinent
to this exam.
Per patient requestRUQ abdomen pain, vomiting,
diarrhea
I asked the patient what kind of symptoms she had been
having that brought her to the hospital.
o The patient stated that she had been having pain
in the upper outer part of her abdomen, and had
Grade:
also been experiencing nausea, vomiting and

diarrhea.
I asked the patient what kind of problems she had been
having since her surgery.
o The patient stated that she had been having pain
in the upper outer portion of her abdomen.
I asked the patient how long the pain had been occurring.
o The patient stated that the pain had been present
for about a week.
o She also stated that she recently had a mass
removed from her abdomen.
This was causing pain in the lower
abdomen/pelvis area at incision site.
I asked the patient if the pain in her upper abdomen was
worse at any particular time, like after she ate.
o The patient stated that the pain was not worse at
any particular time.
I asked the patient if the area of pain was tender to the
touch or when pressure was applied.
o The patient said that the area did not hurt any
worse when she pressed on it or bent over.
Section III: Analyze Patient Information

Using information gathered from section II complete the table below to determine an applicable
pathology that should be considered when performing the examination.
In order determine the applicable pathology, consider the following:
What was the pathology you were prompted to rule out first?
Having trouble identifying priority pathology to rule out first?
Do the current clinical symptoms including labs help you identify an aorta
pathology to consider?
Are the clinical symptoms too vague, if so what other clinical/medical
history (previous surgery, test results, etc.) help you identify an abdominal
pathology to consider?
If you unable to determine a pathology, contact grading instructor for
assistance.
Reflective and technical writing will be used in this section
Reflective writing is use for the section labeled reason for selecting the pathology
All other sections will require technical writing and bullet format is preferred.
Pathology (Must relate to the liver competency)
Describe the reason for selecting

pathology (use information from
section 2)
Identify the name of a pathology to
be considered and list applicable
synonym(s)
Provide a definition of the pathology
Identify common clinical findings
associated with the pathology
(symptoms, labs, occurrence,
associations, etc.)
I am selecting this pathology because the patient has

symptoms that are commonly associated with this disease:
nausea, vomiting, and abdomen pain.
Viral hepatitis
No applicable synonyms available
Liver inflammation caused by a virus that is transmitted
parenterally or by oral ingestion
Symptoms
Loss of appetite, nausea, vomiting, fever, weakness,
tiredness, abdomen pain, jaundice, & dark urine
Labs
Increased AST
Increased ALT
Increased bilirubin during jaundice phase
Increased PT in severe cases
Occurrence
Common and occurs world-wide
Around 700 million people affected
Third world countries, IV drug users, people
with unsafe sex habits
Six distinct hepatitis viruses
Hepatitis A-E and G
Types A, B, & C most common
Identify main sonographic

appearance of the pathology
(use of proper terminology is required)
Identify one additional area to be
evaluated and explain why it would
be evaluated
(other organ/systems could be involved
or affected- scan through of the organ
involved is not acceptable)
Identify and explain one pitfall that
should be considered (why the
diagnosis of the pathology may be
incorrect. The pitfall may relate to a
differential or technique (scan through
is not acceptable)
Grade:
Spread through fecal to oral route,

parenterally, sexual contact, & at birth
Associated with drug and alcohol use and/or toxicity,
hepatic failure and worsening jaundice, coagulopathy, portal
hypertension, cirrhosis, hepatocellular carcinoma and hepatic
encephalopathy
Diffusely decreased echogenicity of liver parenchyma
Attenuated brightness of portal triads (periportal cuffing)
Hepatomegaly
Coarsened, heterogeneous echotexture when cirrhosis
develops
Gallbladder
Thickening of gallbladder wall is associated
A pitfall might be having the gain too high on the images.

If the image is too bright, the liver may be mistaken for
the correct echogenicity
Cause the pathology to be overlooked
Section IV: Diagnostic Image Quality- Acquired Images
Complete the table below by providing a self-reflection of each component as it relates to the images
taken in the patient examination you performed
Students are required to image each structure of the required competency, if a
situation occurs that this cannot be completed due to clinical site instructions, contact
the clinical coordinator immediately.
If additional images are taken of structures required for the competency, you may add
additional rows below the last image identified.
Answers written in a bullet format are preferred (complete sentences not required)
Structure
Liver
Scan
Plane
Sagittal
Label
LIVER
SAG
Landmarks
(Key structures required for the
image according to protocol)
Left lobe with inferior tip
Sonographic Features
(Identify and describe the
sonographic appearance of
each structure seen in the
image)
Left lobe
homogeneous, midlevel gray
Liver
Sagittal
LIVER
SAG
Left lobe
Caudate lobe
IVC
Liver
Sagittal
LIVER
SAG
Right lobe
Diaphragm
Liver
Sagittal
LIVER
SAG
SUP
Right lobe superior

Right hemidiaphragm
Right pleural space
Aorta, splenic artery,

& splenic vein
anechoic lumen with
echogenic walls
Pancreas
homogeneous to
liver, echogenicity
varies
Spinehighly
echogenic with
posterior shadowing
Diaphragmthin,
highly echogenic line
Left lobe & caudate
lobehomogeneous,
mid-level gray
IVC, portal vein,
hepatic vein, &
splenic vein
anechoic lumen with
echogenic walls
Diaphragm &
ligamentum venosum
thin, highly
echogenic line
Right lobe
Main lobar fissure &
diaphragmthin,
MPV, hepatic veins, &
gallbladder
anechoic lumen with
echogenic walls
Right kidney: ISO to
hypoechoic
compared to liver,
mid-level gray,
echogenic sinus
Right lobe
Hepatic veins
anechoic lumen with
Liver
Sagittal
LIVER
SAG
MPV
Right lobe mid

Mid-portal vein
Liver
Liver
Sagittal
Transverse
LIVER
SAG
INF
LIVER
TX
Right lobe inferior

o Demonstrating
largest superior to
inferior area
o Measure liver
length from
superior to inferior
Right kidney
Left lobe
Caudate lobe
IVC
Liver
Transverse
LIVER
TX
Right lobe
Left lobe
Right hepatic vein
Left hepatic vein
Middle hepatic vein
echogenic walls
DiaphragmThin,
Pleural space
homogeneous
dark/black with dirty
shadowing from the
lung
Right lobe
MPVanechoic
lumen with echogenic
walls
Diaphragmthin,
Right lobe
Diaphragmthin,
Right kidneyiso to
hypoechoic
compared to liver,
mid-level gray,
echogenic sinus
Left lobe & caudate
lobehomogeneous,
mid-level gray
IVC & aorta
anechoic lumen with
echogenic walls
Ligamentum
venosum &
diaphragmthin,
Spinehighly
echogenic with
posterior shadowing
Right lobe
IVC, right hepatic
vein, middle hepatic
vein, & left hepatic
Liver
Liver
Transverse
Transverse
LIVER
TX
LIVER
TX
SUP
Right lobe-most anterior

portion
Diaphragm
Right lobe superior

Right hemidiaphragm
Right pleural space
Liver
Transverse
LIVER
TX
MPV
Right lobe mid

Portal vein
Liver
Transverse
LIVER
TX
MPV
Right lobe mid

Portal vein with color and
spectral Doppler
o Slight phasic flow
toward the liver
Liver
Transverse
LIVER
Right lobe-inferior
veinanechoic
walls
Diaphragmthin,
Right lobe
Diaphragmthin,
Right lobe
Diaphragmthin,
Pleural space
homogeneous
dark/black with dirty
shadowing from the
lung
Right lobe
MPV, IVC, hepatic
veinanechoic
walls
Diaphragmthin,
Right lobe
MPV, IVC, hepatic
veinanechoic
walls
MPV with Doppler
vessel completely
filled in with color and
showed hepatopetal
flow according to the
velocity scale
Diaphragmthin,
Right lobe

TX INF
Right kidney

Right kidneyiso to
hypoechoic
compared to liver,
homogeneous, midlevel gray, echogenic
sinus
Grade:
Section V: Diagnostic Image Quality- Measurements/Calculations
Complete the table below by providing a self-reflection of each component as it relates to the
patient examination you performed
Note-explanation of why the measurement is normal or abnormal is related to technical
writing
Reflective writing is used for measurement recorded and description of caliper placement.
Technical writing is used for normal or abnormal and explanation of why measurement is
considered normal or abnormal
Required
Measurements
Liver sag right lobe
Measurement
Recorded
15.7 cm
Normal
or
Abnormal
Normal
Describe
caliper
placements
used in
measurements
Placed calipers
from the
superior dome
of the right lobe
to the inferior tip
in the sagittal
scan plane
Explain why the

measurement is
normal or abnormal
Measurement is
normal, because liver
size ranges from 15-17
cm compared to the
size of the patient. This
patient was small,
which is why the liver
measured on the
smaller end of the size
range.
Grade:
Section VI: Diagnostic Image Quality- Instrumentation
Complete the table below by provided information as it applies to sonographic principles and
instrumentation as it relates to the images taken in the patient examination you performed

Reflective writing is used for the column labeled what was used
Reflective writing with the support of technical writing is used for the column labeled Why
its correct
Required Elements
What was used

Must be specific
Identify the transducer

C5-2 curved probe
selected for the examination
robe
Identify the frequency(s)

used during examination
3.0 MHz
Depth and focal zone for

Liver SAG right lobe &
diaphragm image
Depth19 cm
Focal zone15 cm
Why its correct

Explain in detail why each element was
used in the examination
Curved probe used for exams
when depth and penetration are
needed with the highest resolution
possible
o Decreased resolution
Low frequency
ranges use longer
wavelengths,
which are worse
for detail and
resolution than
short
wavelengths
The curved field of view allows a
wider area to be visualized within
the abdomen
Used a low frequency for depth
and penetration with deep organs
Lowest frequency (2 MHz) was
not used, because higher
frequencies have better resolution
Depth is correct because it goes
just beyond the bottom of the liver,
as to not cut off any pathology
Focal zone was placed at 15 cm
o This was an incorrect
focal zone placement for
this image
o Focal zone should be at
least down to 18-19 cm as
well to clear up the bottom
of the image and not miss
a pathology
o Attenuation caused the
bottom of the image to
Depth and focal zone for

Liver TX right & left lobe
with hepatic veins image
Depth22 cm
Focal zone17 cm
Color and spectral Doppler

for Liver TX MPV image
Color Doppler
o Gain- 36
o Velocity
scale- 18
Spectral Doppler
o Gain- 50
o Velocity
scale- 18
o Sample
volume- 3.5
appear dark and with

decreased resolution
when the focal zone was
placed at 15 cm
Correct
placement of the
focal zone would
have helped with
lateral resolution
at the bottom of
the image
Depth could have been brought
up a littlea little far past the liver
parenchyma
Focal zone placement is correct
because it is placed at the very
bottom of any liver parenchyma in
the image
o This placement of focal
zone establishes good
lateral resolution through
the entire organ in the
image
Color Doppler
I chose this gain setting
because it was adequate
for filling the vessel, but
not too much that the
color would extend over
the vessel borders.
I chose this velocity scale
because it did not exceed
the Nyquist limit and
therefore did not alias.
Spectral Doppler
I chose this gain setting
because I felt it was a
proper brightness and
volume for the waveform.
I chose this velocity scale
because it did not exceed
the Nyquist limit and
therefore did not alias.
Sample Volume
I used the preset for the
Additional Technique
(describe techniques utilized beyond
those listed in the required elements
to provide diagnostic images listed
above or other images associated
with this comp (focal zone,
harmonics, patient position, 3D/4D,
filter, etc.)
Had patient hold

her breath
sample volume on this

exam.
This sample volume is
correct, because the gate
is fairly small.
I wanted the gate
to be small
because this will
take the highest
velocities when
placed in the
directly in the
middle of the
vessel.
I utilized this technique to prevent
movement of the portal vein when
acquiring the spectral waveform
image.
o Respiratory motion can
cause an irregular
waveform
Grade
Section VII: Diagnostic Image Quality- Pathology Documentation
Complete the following table by describing the sonographic features of pathologies associated with
examination you performed
Technical writing is used for the column labeled proper name
For the column labeled Sonographic features, technical writing if pathology is not seen,
reflective writing if pathology seen
Reflective writing is used for the column labeled identify or rule out pathology
Structure
Describe all
pathologies seen
or
If no pathology was seen,
describe 2 pathologies
that could be ruled out
Liver
Identify the proper

name of the
pathology seen or
excluded
(Indicate if the
pathology was seen
or excluded)
Viral hepatitis
excluded
Sonographic Features
(If a pathology was seen
include measurements
taken of the pathology as
well as the sonographic
features. If no pathology,
identify main
sonographic features of
pathology you ruled out)
Diffusely
decreased
echogenicity of liver
parenchyma
Attenuated
brightness of portal
triads (periportal
cuffing)
Hepatomegaly
Coarsened,
heterogeneous
echotexture when
cirrhosis develops
Sonographic techniques used to

Identify
or
Rule out Pathology
Liver
Cavernous
hemangioma-excluded
Typically well
defined,
homogeneous,
& hyperechoic
< 3 cm in
diameter
May have
nonhomogeneo
us central area
containing
granular,
hypoechoic
portions
May have an
echogenic
border (thin or
thick)
Tendency to
Obtained patient history while

scanning through the liver
Used intercostal spaces to
obtain lateral liver images
Used deep breath technique to
bring liver and landmarks
down from ribs
Used dig and angle technique
for anterior liver images
Ensured gain was correctly set
as to not cause liver to look
like a pathology was present
o Hepatitis causes loss
of echogenicity of
liver parenchyma
Made sure the color flow in the
portal vein was above the
baseline
o Indicates hepatopetal
flow
Obtained patient history while
scanning through the liver
Scanned through carefully and
thoroughly to ensure no
difference in parenchyma
echogenicity indicating a mass
Used intercostal spaces to
obtain lateral liver images
Used deep breath technique to
bring liver and landmarks
down from ribs
Used dig and angle technique
for anterior liver images

scalloping of the
margin
>3 cm tend to
be
heterogeneous
with central
hypoechoic foci
corresponding
to fibrous
collagen scars
Grade:
Section VIII: Interpretation of Exam Findings
Complete the following table as it relates to information given to the reviewing sonographer and the
physician for the examination you completed.
This section will require both technical writing and reflective writing
Technical writing is used for the column labeled description of findings to physician
Reflective writing is used for column labeled description of findings to sonographer and
all components in the self-reflection column.
The Self Reflection column must:
Describe the interaction you had with the sonographer and physician. At a minimum
include at least one of the following:
Sonographer:
Did the sonographer retake any of your images? How were they different?
Provide a detail summary
Did the sonographer take additional images? Provide a detail summary.
Would you have liked the interaction with the sonographer to be different?
Why? Provide a detail summary
Describe in detail if the sonographer taught you something new, ask you
to clarify an image or challenged your images or patient history.
Physician:
o If you were not allowed to write on the jot pad/report page or disagreed
with what was written. Explain what you would have done differently and
why.
o Would you have liked the interaction different with the physician? Why?
(must be detailed and specific)
o Describe in detail if the physician taught you something new, ask you to
clarify an image or challenged your images or patient history.

Person of Interest
Sonographer
(Describe at a
minimum sonographic
features and
measurements
reported to the
sonographer)
Description of Findings
Reported
Physician
(Identify exactly what
is written on the jot
pad, report and/or
verbally)
Method used
Self-Reflection
to Report
(See details in instructions for this
Findings
section)
(Identify :
verbal, jot
pad, report
page, etc.)
I verbally
After the exam, I
After the exam, the
reported
reported back to the
sonographer retook all
findings of
sonographer that the
images for the exam:
the
exam
to
liver appeared
pancreas, liver,
the
homogeneous with no
gallbladder, and CBD
sonographer
internal anechoic,
o The particular
echogenic or hypoechoic
sonographer that
areas that should not be
came to follow
there.
behind me on
this patient
I said that the diaphragm
always retakes
appeared thin and
images for the
smooth on the edge of
entire exam.
the liver as it should.
Some
of
the
I reported to the
sonographers liver
sonographer that the
images were slightly
liver measured 15.7 cm
brighter than the liver
from the superior end to
images I took
the inferior tip in the
o They did not
sagittal scan plane.
differ much
I told the sonographer
o
I think both the
that the portal and
sonographers
hepatic veins did not look
images and my
dilated, and the MPV
own were an
demonstrated slight
accurate
phasic flow toward the
representation of
liver as it should.
the liver
I finished up by telling
echogenicity.
the sonographer that the
They were both
right kidney looked
within the correct
homogeneous to the liver
range of midand did not appear to be
level gray.
too large or too small
compared to it.
I did not
After the sonographer
I would have liked my
report
any
scanned behind me, she
interaction with the
findings to
filled out an abdomen
physician to have been
the
physician
complete worksheet.
different
on the jot
o Liver 16.5 cm
o I was able to
pad, report,

o
o
o
o
o
o
GB r/o obvious
internal echoes,
negative
Murphys sign,
fold noted
Gallbladder wall:
2.61 cm
CBD 1.89 cm
Pancreas WNL
Hepatic veins
patent
Portal vein
patent
hepatopetal
or verbally
discuss the
findings with the
sonographer and
go over the
findings she
wrote on the
worksheet, but it
was after I had
clocked out that
the radiologist
was available to
verbally discuss
the findings with
the sonographer.
Grade:
Section IX: Physicians Report
Complete one of the following tables with information gathered from the final report of the examination
you performed
This section will require both technical writing and reflective writing
Technical writing used for description of sections labeled overall impression of the report
and in the structures and measurements components as applicable
Reflective writing and technical writing are both used for describing components in the
self-reflection column.
Self-reflection Component:
The summary must include why you agree or disagree with the findings normal or
abnormal findings. For why, be sure to demonstrate your knowledge of the structure
compared to the impression of the physician. Your critique needs to be accurate to the
examination findings and clinical history.
Overall Impression
on the Report
(Exact wording found
on report)
If the report is attached, Complete the Following

The gallbladder demonstrates no echogenic shadowing stones or mobile
gallbladder sludge. There is no gallbladder wall thickening or pericholecystic
fluid. Negative sonographic Murphys sign. The common bile duct is normal
measuring 2 mm. The liver size and contour is normal. Normal hepatic echo
texture. No intrahepatic biliary dilatation or specific demonstrated focal hepatic
abnormality. Visualized portions of the pancreas are normal. The right kidney is
not obstructed.
Self-Reflection
(refer to instructions
above)
Unremarkable ultrasound of the right upper quadrant. Negative for gallstones.

I agree with the findings on the radiologists report. The liver appeared
medium gray and homogeneous. It measured within the normal measurement
range. The portal vein demonstrated good color fill and hepatopetal flow.
Grade:
If no report attached: Complete Table and Provide and Overall Impression below the table
Structure
All Measurements
Reported
Normal vs Abnormal (If abnormal, describe

the abnormal findings)
Overall Impression
on report
(Exact wording found
on report)
Self Reflection
(refer to instructions
above)
Grade:
Section X: Pathology Diagnosed or Pathology Ruled Out
Using information gathered from physicians examination reports complete the table below to determine
an applicable pathology that should be considered when performing the examination.
Reflective writing is use for the section labeled reason for selecting the pathology
All other sections require technical writing
Selecting the pathology: The report may indicate a possible diagnosis at the conclusion of the report.
In some reports more than one possible diagnosis is listed (differential diagnosis), for this section you
will be required to identify the diagnosis and 1 differential diagnosis. Your answer must be based on:
The pathology identified in the impression/findings made by the physician in the first table
and 1 differential diagnosis for the pathology identified in the 2 nd table.
In the event 2 or more pathologies are seen, complete the chart for 2 pathologies and no
differentials
In the event of a normal report, identify and define 2 sonographic Liver pathologies that
should be considered.
Pathology

pathology (see instructions)
synonym(s)
associations, etc.)
I am selecting this pathology because the patient has

symptoms that are commonly associated with this disease:
nausea, vomiting, and abdomen pain.
Viral hepatitis
No applicable synonyms available
Liver inflammation caused by a virus that is transmitted
parenterally or by oral ingestion
Symptoms
Loss of appetite, nausea, vomiting, fever, weakness,
tiredness, abdomen pain, jaundice, & dark urine
Labs
Increased AST
Increased ALT
Increased bilirubin during jaundice phase
Increased PT in severe cases
Occurrence
Common and occurs world-wide
Around 700 million people affected
Third world countries, IV drug users, people
with unsafe sex habits
Six distinct hepatitis viruses
Hepatitis A-E and G
Types A, B, & C most common
Spread through fecal to oral route,
parenterally, sexual contact, & at birth
Associated with drug and alcohol use and/or toxicity,
hepatic failure and worsening jaundice, coagulopathy, portal
hypertension, cirrhosis, hepatocellular carcinoma and hepatic
encephalopathy
Diffusely decreased echogenicity of liver parenchyma

be evaluated
is not acceptable)
Grade:
Attenuated brightness of portal triads (periportal cuffing)

Hepatomegaly
Coarsened, heterogeneous echotexture when cirrhosis
develops
Gallbladder
Thickening of gallbladder wall is associated
A pitfall might be having the gain too high on the images.

If the image is too bright, the liver may be mistaken for
the correct echogenicity
Cause the pathology to be overlooked
Pathology or Differential
pathology (see instructions)
synonym(s)
associations, etc.)

Patient experiencing RUQ pain, nausea, & vomiting
Cavernous hemangioma
Cavernoma
Cavernous malformation
A benign tumor composed of a large network of vascular
endothelium-lined spaces filled with red blood cells
Symptoms
Usually asymptomatic
Labs
Abnormal LFTs
Occurrence
Most common benign liver lesion
Approximately 4% of the population
Occur in all age groups, more common in adults
Primarily women with a female/male ratio of 5:1
Usually small & asymptomatic
Associations
Thrombocytopenia/ Kasabach-Merritt Syndrome
Usually < 3 cm in diameter
Usually found in the right lobe
Well defined, homogeneous, and hyperechoic
Sometimes have a nonhomogeneous central area containing
hypoechoic portions
May appear uniformly granular

be evaluated
is not acceptable)
Grade:
Can have a thick or thin echogenic border

Larger lesions tend to be heterogeneous with central
hypoechoic foci corresponding to fibrous collagen scars
Vascular spaces may contain thrombi
Calcifications are possible, but rare
Extremely slow flow
Will not routinely be picked up by color or duplex Doppler
May show a low to midrange kilohertz shift from both
peripheral and central blood vessels
Power Doppler is controversial
Gallbladder
Thickening of wall
A pitfall would be a diagnosis of cavernous hemangioma that

is later proven to be hepatocellular carcinoma.
Grading
Points
5
4
3
2
1
50=100 49=98
40=88
39=86
30=75
29=74
20=60
19=57
10 or less = 0
Description
48=97
38=85
28=73
18=55
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
47=96
37=84
27=72
17=45
Point Value Conversion Chart

46=95 45=93 44=92
36=82 35=80 34=79
26=71 25=70 24=68
16=40 15=45 14=35
43=91
33=78
23=66
13=30
42=90
32=77
22=64
12=25
41=89
31=76
21=61
11=20
Section
1
2
3
4
5
6
7
8
9
10
Total/Final score
Instructor:
Comments:
Points Received

Kristen Cherry Liver Comp Final

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Liver Written Competency

Student Name: Kristen Cherry

Date Written Comp submitted: 11/05/13

RDMS (AB) &

Section I: Patient Care, Patient Identification, and Universal Precautions

Liver Written Competency

Describe how the patient was

Identify how patient allergies were

Describe how you educated the

Describe universal precautions

Liver Written Competency

Section II: Patient History

Liver Written Competency

Identify pertinent lab tests and lab results

Identify medical history that is relevant to

Identify the patients presenting clinical

Liver Written Competency

also been experiencing nausea, vomiting and

Liver Written Competency

Section III: Analyze Patient Information

Describe the reason for selecting

I am selecting this pathology because the patient has

Liver Written Competency

Identify main sonographic

Spread through fecal to oral route,

A pitfall might be having the gain too high on the images.

Section IV: Diagnostic Image Quality- Acquired Images

Left lobe with inferior tip

Liver Written Competency

Right lobe superior

Aorta, splenic artery,

Liver Written Competency

Right lobe mid

Right lobe inferior

Liver Written Competency

Right lobe-most anterior

Right lobe superior

Right lobe mid

Right lobe mid

Liver Written Competency

homogeneous, midlevel gray

Liver sag right lobe

Explain why the

Liver Written Competency

Reflective and technical writing will be used in this section

What was used

Identify the transducer

Identify the frequency(s)

Depth and focal zone for

Why its correct

Liver Written Competency

Depth and focal zone for

Color and spectral Doppler

appear dark and with

Liver Written Competency

Had patient hold

sample volume on this

Section VII: Diagnostic Image Quality- Pathology Documentation

Liver Written Competency

Identify the proper

Sonographic techniques used to

Obtained patient history while