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HS/APR 2008/MRD543

UNIVERSITI TEKNOLOGI MARA FINAL EXAMINATION

COURSE COURSE CODE EXAMINATION TIME

: : : :

CLINICAL APPLICATIONS IN ULTRASONOGRAPHY MRD543 APRIL 2008 2 HOURS

INSTRUCTIONS TO CANDIDATES 1. 2. 3. 4. This question paper consists of sixty (60) questions. Answer ALL questions in the OMR Multiple True/False Answer Sheet. Do not bring any material into the examination room unless permission is given by the invigilator. Please check to make sure that this examination pack consists of: i) ii) the Question Paper an OMR Multiple True/False Answer Sheet - provided by the Faculty

DO NOT TURN THIS PAGE UNTIL YOU ARE TOLD TO DO SO

This examination paper consists of 15 printed pages Hak Cipta Universiti Teknologi MARA CONFIDENTIAL

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Answer ALL questions.

(100 marks)

For each statement answer TRUE or FALSE in the OMR Multiple True/False Answer Sheet given.

1. The term "best window" refers to the A. covering of the transducer face. B. area on the patient that the transducer may be angled to record the majority of the abdominal landmarks without interference from ribs, bowel, stomach or lungs. C. correct overall gain setting. D. piezoelectric effect. E. correct time gain compensation.

2. Regarding patient preparation for the ultrasound examination: A. The ultrasound examination is most effective if the patient has been NPO for at least six hours. B. Intestinal gas does not interfere with the transmission of sound. C. Water may be given to improve visualization of the pancreas. D. For ultrasound of the aorta, you may need to avoid eating for 8-12 hours before the test. E. The kidneys are best imaged when the patient is not well hydrated.

3. The ultrasound transducer depends on several factors: A. B. C. D. E. Size of the patient. Muscle composition of the patient. Fat composition of the patient. Height of the patient. Age of the patient.

4. The sonographer is able to electronically amplify the echo in a certain area so the sound will be stronger and produce a brighter echo return by changing the A. B. C. D. E. time gain compensation. overall gain. lowering the reject. increasing the depth. changing the focal zone.

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5. Several factors are important to understand the cause of the acute abdomen; these may include A. B. C. D. E. age. laboratory findings. number of pregnancies. past and present history. prolonged fasting.

6. The caudate lobe has several identifying factors that include A. B. C. D. E. the ligamentum venosum is the anterior border. the main portal vein is inferior to the caudate lobe. the inferior vena cava is inferior to the caudate lobe. the aorta is the superior border. the superior mesenteric artery is posterior to the caudate lobe.

7. Regarding the transducer: A. Abdominal ultrasound in an adult patient should be examined using transducer with resonant frequency of 3-5 Hz. B. Superficial structures are best examined using the curvilinear probe. C. The scrotum is best examined using transducer with resonant frequency of 7.5MHz. D. Doppler study must be performed using the curvilinear probe. E. Curvilinear probe has higher frequency than linear probe.

8. Elevation of the following laboratory values may indicate renal failure: A. B. C. D. E. Protein. Creatinine. Blood urea nitrogen (BUN). All of the above. None of the above.

9. Regarding ultrasonographic features: A. B. C. D. E. Bile- 'anechoic'. Benign cystic liver lesion - 'through transmission'. Gall stone - 'hypoechoic'. Wall of Common Bile Duct - 'echogenic'. Angiomyolipoma - 'acoustic shadows'.

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10. Mandatory areas to be explored in ultrasound examination of the liver include A. B. C. D. E. the the the the the subphrenic area. porta hepatis. suprarenal area. hepatorenal angle. subdiapragmatic region.

11. Regarding the liver segments: A. The falciform ligament is seen as an echogenic line projecting between segments II and III anteriorly. B. The left portal vein divides the left lobe into the medial and lateral segments. C. Segment I is also called the quadrate lobe. D. Segment V is also called the caudate lobe. E. The 8 liver segments are called Couneids segments. 12. Regarding ultrasonographic features of abdominal structures: A. B. C. D. E. The The The The The normal normal normal normal normal liver span is not exceeding 17 cm. Common Bile Duct diameter measures 5 cm in diameter. splenic span ranges from 9 to 12 cm. bipolar length of the kidneys should be more than 9.0 cm. intrahepatic ducts should appear like "starry nite' pattern.

13. In ultrasonography assessment of the gall bladder: A. B. C. D. The normal wall is 'pencil line' thickness. The patient need to be fasting for at least 4 hours. An echogenic focus within the gall bladder is always an indication of calculi. In an adequately fasted patient, the gall bladder can be examined only in transverse plane. E. Murphy's sign is an important sign.

14. Regarding splenic evaluation in ultrasonography: A. B. C. D. E. The liver is a little less hypoechoic than the spleen. The echogenicity of the left kidney should be compared with the splenic echotexture. The normal size of the splenic bipolar length should not be less than 12 cm. The spleen is best examined in prone position. A hematoma in the spleen could represent as a splenic cyst.

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15. Regarding renal evaluation in ultrasonography: A. The renal cortex is normally hypoechoic relative to hepatic or splenic parenchyma. B. Renal pyramids are hyperchoic relative to the cortex. C. Corticomedullary junction is demarcated by the arcuate vessels, which are seen as small echogenicfoci. D. Central echogenic complex is the most echogenic part of the kidney consisting of collecting system, vessels and connective tissues. E. Echogenicity of central echogenic complex increases with emaciated patients and decreases in neonates. 16. Sonographic findings in a patient with hepatitis include: A. B. C. D. E. Uniform increased echogenicity with good sound attenuation. Diffuse focal lesions throughout the hepatic parenchyma. Increased visualization of the portal triad. Overall decreased echogenicity of the hepatic parenchyma. Increased vascularity noted.

17. The three branches of the celiac artery are A. B. C. D. E. common hepatic, left gastric, splenic. common hepatic, right gastric, splenic. common hepatic, gastroduodenal, splenic. pancreatic, left gastric, splenic. pancreatic, right gastric, splenic.

18. Ultrasonographic findings suggestive of the diagnosis of liver cirrhosis include: A. B. C. D. E. The diameter of portal vein less than 3 cm. Presence of collateral vessels. Span of the spleen more than 13 cm. Fluid in the Morrison's pouch. Small shrunken liver.

19. Pitfalls in abdominal scanning: A. Placing the patient in the erect or Tredelenburg will differentiate ascites from abscess or hematoma. B. Give the patient water enema or fluids by mouth, or doing real-time examination to ascertain bowels or abscess. C. Apparent fluid collections in the pelvis behind the bladder are due to grating lobe artifacts. D. Acoustic shadowing can be enhanced by using a low-frequency transducer. E. Increasing the overall gain produces an artifact-free gallbladder.

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20. Regarding ultrasound examination of the abdomen: A. The isthmus of a horse-shoe kidney can resemble the pancreatic head. B. The posterior wall of the stomach can be mistaken for the pancreatic duct. C. Decreasing the gain differentiates between the echopenic psoas muscle from a hydroureter. D. Cystic structures near the pancreas are always pseudocysts. E. The right kidney often has a hump on its lateral aspect known as a dromedary hump.

21. A forty-six year old female has been brought to the emergency room by her husband following an acute onset of right upper quadrant pain during a weight watchers meeting. She complains of excruciating pain radiating to the right shoulder. When you place the transducer on the abdomen for a quick survey she screams in pain. You are most likely to find A. B. C. D. E. hemorrhagic pancreatitis. leaking abdominal aneurysm. acute cholecystitis with pericholecystic fluid. adenomyomatosis. acute pyelonephritis.

22. Ultrasonographic features to differentiate between aerobilia and intraductal stones include A. B. C. D. E. pockets of acoustic shadowing that change in location with patient's position. air tends to prefer the right branch of ducts. "starry-nite" appearance "dirty shadowing" that contains echoes tortous appearance with acoustic enhancement.

23. Ultrasonographic features of a liver lesion that are suggestive of malignancy include A. B. C. D. E. well defined delineated margin. increased vascularity peripherally or within the tumour. posterior acoustic shadows. heterogenous appearance. "Bull's eye" appearance of lesion.

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24. Regarding the abdominal structures: A. The left renal vein runs posterior to the body of pancreas between the superior mesenteric artery and the aorta. B. Hemangioma is the most common primary tumour of the spleen. C. The common bile duct runs anterior to the head of the pancreas. D. In acute hepatitis the portal vein borders appear more prominent than usual. E. The crus of the diaphragm is anterior to the inferior vena cava.

25. Regarding ultrasonographic appearances of the abdominal structures: A. Echopenic subcapsular hematomas surrounding the liver can be mistaken for ascites. B. To differentiate from hypoechoic liver metastases, focal fatty sparing usually have smooth borders and vessels run through them undistorted . C. Hypertrophied Column of Bertin can be mistaken for a duplex pelvicalyceal system or a pseudomass. D. Calcification in the arcuate arteries do not mimic renal calculi. E. Increasing the overall gain helps to differentiate small calculi within the central echo complex.

26. Ultrasonographic features that are used as criteria to strictly diagnose cholelithiasis include A. B. C. D. E. mobile echogenic lesion(s) . presence of acoustic shadow. posterior enhancement. positive Murphy's sign. pericholecystic fluid.

27. Regarding testicular sonography: A. In chronic epididymitis the epididymis becomes thickened and focally hypoechoic and may contain calcification. B. In focal orchitis, the testicle is less echogenic in the involved area. C. Infarction of the testis appears hyperechoic. D. In acute torsion vascularity is maintained in the center. E. Varicocoeles are always longer on the left than the right.

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28. Points to remember when scanning the gallbladder include: A. To reduce artifacts due to partial volume effect or reverberation, increase the overall gain. B. Acoustic shadowing can be enhanced by using a high frequency transducer. C. Scattered echoes adjacent to the posterior wall of the gallbladder may be due to reverberation. D. Refractive shadowing can mimic stones. E. A sonolucent space lateral to the gallbladder can be caused by portal vein collaterals.

29. Regarding ultrasound examination of the hepatobiliary system: A. The pancreas is retroperitoneal. B. The ligamentum teres is a remnant of the fetal umbilical vein. C. In chronic pancreatitis the pancreatic outline is irregular and the pancreatic duct is 4mm. D. In advanced cirrhosis the liver appears less echogenic than the renal parenchyma. E. Thickening of the gallbladder wall can be due to hyperalbuminemia.

30. Factors that can interfere with an ultrasound examination and accuracy of the results include: A. B. C. D. E. Stool, air or barium in the stomach or intestines. Extreme obesity. A crying and uncooperative infant. Having a large plaster or bandage near the area of interest. Having an open wound in the area being viewed.

31. In chronic pancreatitis the pancreas is usually noted to be A. B. C. D. E. less echogenic than the liver. more echogenic than the liver enlarged. free floating. filled with small cluster of dense echoes with acoustic shadowing.

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32. In sonographic evaluation of the gall bladder and biliary tree: A. Sludge balls are often hypoechoic. B. the right lateral decubitus position is most helpful if there are bowels obstructing the view to visualized the CBD. C. dilated ducts are commonly seen in normal young healthy individuals due to air swallowing. D. Rokitansky-Aschoff sinuses can cause mild recurrent right upper quadrant pain. E. Diffuse wall thickening can be seen in patients with acute cholangitis, uraemia and portal hypertension.

33. In sonographic evaluation of the kidneys, A. B. C. D. E. the kidneys are routinely evaluated in longitudinal plane only. fasting is mandatory. evaluation of residual urine volume is important in patient with urinary incontinence. the prostate diameter is taken as widest dimension of the gland during post voiding. normal renal central echogenic complex exclude presence of obstructive uropathy.

34. Regarding structures of the abdomen: A. B. C. D. E. The 1 st part of the duodenum is retroperitoneal. The common bile duct joins the pancreatic duct at the ampulla of Vater. Hartmann's pouch is posterior to the uterus. Normal adult kidneys measure 8 - 10 cm in length. Caroli's disease appears as solid areas in the liver.

35. Ultrasonography findings on renal transplant that are evidence of rejection include: A. B. C. D. E. Resistive index less than 0.75 on Doppler evaluation. The kidney is decreased in size. Small central echogenic complex. Medullary pyramids more prominent and sonolucent than usual. Normal in size and hypoechoic renal parenchyma.

36. Increased serum bilirubin is suggestive of A. pancreatitis. B. haemoptysis. C. gangrenous disease. D. hepatocellular disease. E. congestive heart disease.

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37. The ultrasonographic features that could be suggestive of chronic renal failure include A. B. C. D. E. echogenic kidneys. bipolar length 9.5 cm. cortico-medullary differentiation preserved. cortical thickness 0.8 cm. all of the above.

38. While performing an ultrasound examination of the kidney on a patient, you could not locate the left kidney in the renal fossa. How do you handle this problem? A. B. C. D. E. You will ask your patient to turn to right decubitus position. Your patient may have congenital absent left kidney. You may want to ask your patient important questions. Look for scar on the abdominal wall. All the above.

39. When you cannot demonstrate the normal gall bladder in your patient, you would like to A. B. C. D. E. reassure that the patient has been fasting for at least past 4 hours. conclude that there is possibility of acute cholecystitis. conclude the presence of porcelain gall bladder. look for any evidence of scar. none of the above.

40. Regarding ultrasound examination of the hepatobiliary system: A. The caudate lobe is separated from the left lobe by the ligamentum teres. B. A hydatid cyst is usually related to tapeworms. C. The head of pancreas is posterior to the inferior vena cava. D. Glisson's capsule contains the portal vein, hepatic artery and the bile duct. E. In advanced cirrhosis, the liver appears less echogenic than the renal parenchyma.

41. The pancreas produces A. B. C. D. E. lipase. insulin. glucagon. amylase. all of the above.

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42. Regarding the abdomen: A. Ectopic pregnancy means pregnancy in the abdomen. B. The clinical symptoms of acute appendicitis may include epigastric pain with extension to the left iliac fossa. C. The etiology of acute abdominal pain may arise from trauma, metabolic, vascular, congenital and acquired. D. The most frequent organs to be injured in an automobile accident include spleen, gallbladder and pancreas. E. The etiology of acute appendicitis may include familial disposition and neoplasm.

43. The division between the right and left lobes of the liver is A. B. C. D. E. ligamentum teres. main lobar fissure. middle hepatic vein. left hepatic vein. left portal vein.

44. Portal vein flow is usually from the A. B. C. D. E. IVC spleen omentum intestines splenic vein

to the liver

45. Regarding ultrasonography evaluation of Deep Venous Thrombosis of the lower limbs: A. Absence of echogenic clots in the deep system exclude the diagnosis of thrombosis. B. In case where there is deep vein thrombosis, the vein is incompressible. C. Small veins of the calf can be evaluated by asking the patient to perform the Valsalva's maneuver. D. Presence of lateral vein along side the deep system indicates Acute Deep Vein Thrombosis. E. If clots are seen in the femoral veins, the iliac veins also need thorough assessment as the clot may propagate.

46. False diagnosis of hydronephrosis can occur due to A. B. C. D. E. distended bladder. venous hypertension. prostate enlargement. a large ovarian tumour. none of the above.
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47. A near term patient tells the sonographer that she feels faint. The spnographer should A. B. C. D. E. call 999. let her sit up. turn her on her side. turn her on her stomach. none of the above.

48. Regarding the abdominal structures: A. In ultrasound examination, kidneys of a patient with systemic lupus erythematosus will appear hypoechoic. B. The most common cause of aortic aneurysm is atherosclerosis. C. Adenomyosis is a malignant invasion of endometrial tissue into the myometrium. D. The kidneys are retroperitoneal. E. The splenic vein runs anterior to the pancreatic body.

49. The echogenicity of a normal pancreas should be A. B. C. D. E. equal to less than not be compared to none of the above greater than

to the liver.

50. Regarding gynecological ultrasonography: A. Real-time or water enema allows the distinction between bowels or an abnormal adnexal mass. B. A retroverted uterus can give a misdiagnosis of a mass in the Morrison's Pouch. C. Corpus luteal cysts may form a fluid-fluid level or a clumplike pattern due to clot. D. Some features of ruptured ovarian cyst include an adnexal mass with an irregular shape and fluid in the cul-de-sac. E. Cysts in the ovary may be associated with torsion.

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51. A forty-four year old male presents to the emergency room with severe epigastric pain which radiates to the back. You immediately recognize him as a frequent visitor to the ultrasound department. His liver is shrunken and the texture is coarse. He flinches when you touch his epigastric area. Your area of concentration should include: A. B. C. D. E. the aorta to rule out a dissection. the pancreas to rule out pancreatitis. the gallbladder to rule out acute cholecystitis. the spleen to rule out a subcapsular hematoma. the right upper quadrant to look for a ruptured gallbladder.

52. Regarding ultrasound examination of the abdomen: A. B. C. D. E. The upper limit for normal post cholecystectomy common duct diameter is 8mm. The falciform ligament is a remnant of the fetal ductus venosus. The left gastric artery arises from the superior mesenteric artery. The spiral valve of Heister is in the fundus of the gallbladder. Fluid between the diaphragm and the spleen may represent a subphrenic abscess.

53. The pancreatic duct and the common bile duct join to enter the duodenum. A. B. C. D. E. first second third gastric fourth

portion of the

54. A high level of serum amylase is suggestive of A. B. C. D. E. acute pancreatitis. acute cholecystitis. acute hepatitis. acute pyelonephritis. none of the above.

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55. An unconscious young man was admitted to the emergency room for motor vehicle accident. The clinician is asking you to perform an ultrasonography examination of the abdomen. You will A. wait till the patient wakes up to perform the examination. B. only explore the abdomen where the organs are accessible to be viewed and make inconclusive remarks. C. get assistance to position the patient in areas not easily accessible. D. suggest another modality to examine the patient if you are not satisfied with the findings. E. decline to examine the patient.

56. Using gloves is mandatory in ultrasound examination of the A. B. C. D. E. testis. abdomen in a patient with positive HIV infection. breasts. carotid arteries. interventional ultrasound.

57. A ductal tumour at the bifurcation of the right and left hepatic ducts is known as a tumour. A. B. C. D. E. Katskil Klatskin Kaposi Kawasaki Klapskil

58. Regarding ultrasound examination of the hepatobiliary system: A. B. C. D. E. Porcelain gallbladder means decalcification of the gallbladder walls. Three hepatic veins empty into the superior vena cava. Aorta is a retroperitoneal structure. The head of pancreas is posterior to the portal vein. Shadowing from a gallstone is soft or "dirty".

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59. Regarding obstetric ultrasound: A. Femur length is used for the first trimester gestational age. B. The most sensitive finding in a patient with ectopic pregnancy is free fluid in the culde-sac. C. Nuchal thickening is not associated with Down's syndrome. D. Femur length measurement is most accurate from 20 - 30 weeks. E. Spalding's sign is double image of the fetal head.

60. Doppler interrogation should be performed at angle of cursor placed the vessel walls. A. B. C. D. E. 90, perpendicular 64, parallel < 60, parallel < 60, perpendicular >90, parallel

degrees, with the angle

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