Lower Extremity Arterial Written Comp

Student Name: Nicole Wolcott

Date Submitted: October 13, 2015

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:
A 72 year-old Caucasian female presented to the hospital as an outpatient with current symptoms of leg pain and
claudication within both lower extremities. Upon interviewing the patient, it was discovered that she had diabetes.
The patient denied ever smoking. The patient explained that she could not stand or walk for more than five
minutes before her legs and feet began to hurt.

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 was an outpatient so she did not have labs taken the day of the exam. The most recent labs the patient
had taken was a little over a month prior to when this examination was completed. Her most recent lab panel
indicated that the patients hematocrit and hemoglobin were both within normal limits. Since this patients labs
were normal, no pathology was indicated.

Identify the patients 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
patients symptoms. Explain why this modality would be used in conjunction with sonography.
Answer:
The patient did not have any previous exams that were relevant to the exam discussed in this competency.
Another imaging modality that could be used in conjunction with sonography to evaluate the lower extremity
arteries is vascular angiography. Angiography is the gold standard for evaluation of arterial disease. This modality
serves to observe blood flow patterns in vessels. Along with providing information about the anatomy of the
vessels, angiography can also help to gauge the hemodynamic severity of a lesion more accurately than
ultrasound, however it is a more invasive and expensive alternative to ultrasound.
Grade for Section 1
Section 2:

Lower Extremity Arterial Written Comp

Based on the patients clinical history, labs, and previous exams and results, what did you expect to find during this
exam and why?
Answer:
Though the patients labs were normal, since the patient described severe episodes of claudication that occurred
frequently, along with the fact that she had diabetes, I expected to find at least a mild form of peripheral arterial
disease.
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:
I identified the patient by having her state her full name and date of birth as I checked for accuracy on the patients
chart, wristband, and the ultrasound machine.
I explained to the patient that I would be performing an ultrasound of the arteries in both of her legs. I let her
know that I would simply be putting some warm jelly on her right leg first and would be scanning all the way down
her leg, starting high up in her groin, scanning down the inside of her thigh, behind her knee, on the inside of her
calf, and then on the top of her foot with my probe and would be taking some images for the radiologist to review.
I told her that once I was done with the right side, I would do the exact same thing on her left leg. I let her know
that she could feel free to relax during the exam. I asked the patient if she had any questions then began the exam.
To prepare for the exam I checked the patients history and made sure I had the correct transducer, a warm bottle
of gel, gloves, and two wash cloths.
The patient was lying supine on the bed and the bed was raised to a comfortable scanning position. The patient
had removed her pants and had a sheet lying on top of her legs. I uncovered the patients right leg and had her
bend her right knee slightly and lie her leg out to the side like a frog leg. I tucked a towel up high in her right groin
to prevent any gel from getting on her underwear or shirt. When scanning the left side, I had the patient do the
same maneuver and placed the towel the same way just on her left side this time.
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:
No gray scale images were acquired, however, in real time, the external iliac, common femoral, superficial femoral,
popliteal, posterior tibial, and dorsalis pedis arteries all appeared to have anechoic lumens with echogenic walls
bilaterally.
Bilaterally the external iliac, common femoral, superficial femoral, popliteal, posterior tibial, and dorsalis pedis
vessels all completely filled in with color when color Doppler was applied to them and no area of aliasing was
noted throughout the entirety of the lower extremity arteries.

Lower Extremity Arterial Written Comp

On the spectral waveform, the right external iliac, common femoral, superficial femoral and popliteal arteries all
presented with triphasic flow while the right posterior tibial and dorsalis pedis arteries presented with biphasic
flow.
On the spectral waveform, the left external iliac, common femoral, superficial femoral, and popliteal arteries all
presented with triphasic flow while the left posterior tibial and dorsalis pedis arteries presented with biphasic flow.
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 81.3 cm/s normal
Right CFA 79.4 cm/s normal
Right Prox SFA 89.8 cm/s normal
Right Mid SFA 63.8 cm/s normal
Right Dist SFA 72.8 cm/s normal
Right Pop A 57.9 cm/s normal
Right PTA 32.8 cm/s normal
Right DPA 108.1 cm/s - If a peak systolic velocity was taken in the ATA and the velocities between the ATA and
DPA doubled, there would be an indication of stenosis; however, the ATA was not examined and when the
sonographer scanned behind, she agreed that the velocity in the DPA was correct and that there was no stenosis
seen. No plaque or area of aliasing was examined within the right DPA.
Left EIA 84.9 cm/s normal
Left CFA 80.3 cm/s normal
Left Prox SFA 101.2 cm/s normal
Left Mid SFA 84.0 cm/s normal
Left Dist SFA 63.8 cm/s normal
Left Pop A 71.6 cm/s normal
Left PTA 59.3 cm/s normal
Left DPA 51.7 cm/s normal
ABIs were not performed during this examination.
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 specific pathology was documented during this exam.
A common pathology seen when scanning lower extremity arterial exams is a stenosis. To document this pathology
you would take an image of the stenotic area with color Doppler to demonstrate the area of aliasing and to have
an idea of where to place your spectral gate. If no flow is seen using color Doppler, power Doppler can be utilized
to further evaluate the area of stenosis for any slow flow that color Doppler may not have picked up. Waveforms
should then be obtained using a spectral Doppler gate placed 2 cm prior to, at the sight of, and 2 cm after the area
of stenosis.
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:
A 9L transducer at 9 Mhz frequency with a lower extremity arterial preset was utilized during the entirety of this
exam. This probe was utilized because it is in the sonographers best interest to use the highest frequency probe
possible to be able to get the best quality image possible, however the probe should not have too high of a
frequency that it is unable to penetrate the legs adequately to produce diagnostic images; the frequency of this
probe met the needs of this exam. The probe that was utilized is unable to penetrate as well as other lower
frequency probes; however, the resolution and image quality of this probe made it suitable for this type of
examination. The lower extremity arterial preset was chosen to attain the best possible images since the computer
has preconfigured settings (such as power, depth, gain, etc.) that improve the visualization of the lower extremity
arteries and surrounding structures. The frequency was set at 9 MHz during the entire exam which was a good
frequency to choose because it was able to penetrate adequately while still yielding the best quality image.
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
CF:
Frq

3.6

Gn

14.5

PRF

8.2

WF

596

AO% 100
PW:
Frq

3.1

Gn

33

PRF 6.0
WF

60

Lower Extremity Arterial Written Comp

SV

SVD 4.9
AO% 100

LEFT
CF:
Frq

3.6

Gn

15.5

PRF 7.7
WF

558

AO% 100
PW:
Frq

3.1

Gn

33

PRF 6.0
WF

60

SV

SVD 5.6
AO% 00
All of these settings were correct because they displayed the color and spectral Doppler flow without aliasing while
still proving that the vessels completely filled in. The spectral waveform showed a clear spectral window further
proving the lack of turbulent flow within the vessel.
For your popliteal artery color and spectral image, identify the color and spectral Doppler settings used and explain
why they were correct.
Answer:
RIGHT
CF:
Frq

5.0

Gn

24.5

PRF

7.8

WF

623

AO% 100
PW:
Frq

3.1

Gn

33

Lower Extremity Arterial Written Comp

PRF

2.9

WF

62

SV

SVD 2.4
AO% 100

LEFT
CF:
Frq

5.0

Gn

21.5

PRF 10.4
WF

554

AO% 100
PW:
Frq

3.1

Gn

33

PRF

3.4

WF

60

SV

SVD 2.6
AO% 100
All of these settings were correct because they displayed the color and spectral Doppler flow without aliasing while
still proving that the vessels completely filled in. The spectral waveform showed a clear spectral window further
proving the lack of turbulent flow within the vessel.
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:
I reported to the sonographer that I was unable to find any significant stenosis, however, I let her know that the
right DPA had a higher velocity than in any other portion of the arteries in either leg and that it was higher than the
contralateral DPA. The sonographer watched as I scanned through both legs again and rechecked the right DPA to

Lower Extremity Arterial Written Comp

see if she was able to get another high velocity similar to the one I documented. The sonographer was able to
obtain a similar velocity and agreed with my findings and that there was no stenosis visualized.
Grade for Section 8
Section 9:
What was the physicians interpretation of the exam?
Answer:
There is triphasic flow in the right external iliac, common femoral, femoral and popliteal arteries with biphasic
flow in the posterior tibial and dorsalis pedis arteries on the right.
There is triphasic flow in the left external iliac, common femoral, femoral and popliteal arteries with biphasic flow
in the left posterior tibial and dorsalis pedis arteries.
No significant stenosis is identified on either side.
Impression.
There is no significant stenosis in either lower extremity.
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 physician that there was no significant stenosis found in either lower extremity.
According to the BCHS protocol, plaque that would be the cause of a stenosis would make the walls of the artery it
was affecting to appear thick and the calcification from the plaque would produce acoustic shadowing. The
protocol also describes the appearance of a stenotic area as showing aliasing when color Doppler is placed on the
area of interest. The arteries in this exam did not present with any of these sonographic appearances of a stenosis
as described in the BCHS protocol.
Grade for Section 10

Clinical Site:
Sonographer with credentials and
specialties:
Patient MRN:
Exam order on request:
Performance date of final scan comp:
Is this a second attempt written comp?
Points

*****
Sarah Craig
RDMS (NE); RVT (VT)
*****
US US Arterial Lower Extremity Bilateral
*****
No
Description

Lower Extremity Arterial Written Comp

5

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