Section II: Patient Interview Grade: 5

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1 Only written competency completed with this EXACT form will be accepted for grading. No modifications to the LAYOUT of the form will be accepted for a written competency. Failure to comply will result in a zero for the written competency. It is highly recommended that students save a copy of this exact form to a computer for future use Student Name: Lindsey Simon Date student submitted Written Comp: Comp Performed: Renal Artery Doppler Date student scanned Final Comp: Clinical Site: BMH- Collierville Exam Ordered on Request: US Abdominal Doppler Sonographer Providing Scan Comp Grade: Leah Townsend Patient MRN: Each section is worth points. Section I: Room and Patient Prep Grade: In summary format, describe what you did before beginning the sonographic examination in regards to practicing good hand hygiene, identifying the patient, determining allergies, explanation of examination, and patient set up. Examination preparation Practiced good hand hygiene Exam room set up and why Patient identification Determined allergies Explanation of exam to patient Patient set up and why Explanation I used sanitizer before the exam, wore gloves during the exam, and washed my hands after the exam. I had the scan area dim lit to reduce glare on the screen to see the images easier. I put a clean sheet on the stretcher for the patient. I made sure the probe was clean for sanitation purposes and I got a towel ready and warm gel put on the machine. I checked the patient s armband and matched the name and MRN to the request form. I also had the patient verify his date of birth. The patient request form stated the patient did not have any allergies and I confirmed that he was not allergic to latex before beginning the exam. I told the patient I would be checking the arteries in his kidneys and the connection of the renal arteries at the aorta. I told him the exam may take up to an hour and I would be having him take in deep breaths and holding his breath periodically throughout the exam. I had the patient start out supine so I could image the right kidney and the aorta. I then had the patient lie in the RLD position to image the left kidney. I raised the stretcher up so that I could easily reach the patient without having too much arm abduction. Section II: Patient Interview Grade: In summary format discuss what you learned about your patient from the chart, examination order, and from the patient as it pertains to the sonographic examination ordered. Things to be included but not limited to are: sex, age, weight, race, current clinical symptoms, questions asked to the patient including

2 answers given, chart findings, previous test and results, admitting diagnosis, and reason for exam to be ordered. Required Elements- If no chart available, indicate where appropriate Age, Race, Sex and Weight (if any unknown, give best guess) Reason for exam ordered (request form or scheduling sheet) Is this different from admitting diagnosis if this is an inpatient? If yes, identify admitting diagnosis Previous examinations and results from chart, PACS, and patient interview Additional Patient History from chart and interview (surgeries, previous hospital admissions, etc) Current clinical symptoms and pertinent information from chart and interview. Questions asked (or should have been asked) to the patient including answers given Discussion 61 year old Caucasian male weighing approximately 17 pounds Ordering diagnosis: elevated hypertension This was an outpatient so there was not an admitting diagnosis No previous No previous When was the last time you had anything to eat or drink? Last night around midnight. How long have you had high blood pressure? Not very long at all. I noticed I had a hernia so I went to my doctor and they decided they were going to do surgery on it. They were doing the pre-surgery physical and my blood pressure was 188/98. I have never had high blood pressure before so I thought it was from anxiety about surgery. They took my blood pressure again before I left the doctor s office and it was still high. Have you been having any other problems associated with the high blood pressure, such as, dizziness, headaches, etc? Yes, the day after the doctors appointment I woke up feeling very dizzy so I went back to the doctor. Are you on any blood pressure medication? The doctor gave me some when I went back for being dizzy and it brought my blood pressure back down to normal and I haven t had a problem since. Do you have a family history or high blood pressure? Yes, both my parents had it. Identify the significance of the information gathered as it relates to the exam you performed. This includes what clinical questions your exam will answer for the patient and how did the information prepare your thought process going into the exam Information significant for this examination Explanation Knowing that the patient has hypertension makes me think that there may be a chance of the patient have pathology of the renal arteries, such as renal artery disease or renal artery stenosis.

3 Section III: Analyze Patient Information Grade: After reviewing your patient interview information, identify and define a common sonographic pathology you would possibly encounter. Include in your answer the specific information used to determine the pathologies selected. Pathology should be determined in the following order: 1st. Current clinical symptoms as it relates to the examination ordered 2nd. If clinical symptoms are vague, use clinical history (previous surgery, previous test, results, etc) 3rd. If unable to determine pathology, contact clinical instructor for assistance. Describe the pathologies sonographic features and pertinent information Name and synonyms for pathology Definition Clinical Findings (Symptoms, lab values, etc.) Why this pathology was chosen Sonographic Features (main findings) Where else to look Pitfalls Pathology Renal artery stenosis Occlusion or narrowing of a main renla artery or an accessory artery. The patient will present with hypertension and symptoms that correspond to increased blood pressure, such as headache, dizziness, and vision problems. This patient had hypertension and dizziness. This pathology was chosen because the patient presented with hypertension and renal artery stenosis is the most common correctable cause of hypertension. Narrow lumen, increased arterial velocities, Color Doppler aliasing, post-stenotic turbulence, damped waveforms distal to the stenosis It is important to check the main renal artery from the origin at the aorta into the kidney and then the arteries branching within the kidney to document where the stenosis starts and where it ends. Renal arteries are often hard to image and Doppler due to patient body habitus and bowel gas present. This makes the exam long and tedious for the sonographer. Sometimes, no matter how hard the sonographer tries, the images may not be clear, therefore, making it hard to diagnose renal artery stenosis. Section IV: Diagnostic Image Quality- Acquired Images Grade: Complete images identified below in the order you imaged them (images relate to required protocol) o If additional images are taken of structures required for the competency. Add additional rows to the bottom of the table. Describe the land marks and sonographic features associated with the structure Organ Image Scan Plane/ Location Not seen Sonographic Features Techniques attempted to see structure if needed Aorta SAG at level of RA N/A The aorta appeared as a long, tubular, anechoic structure with smooth, echogenic walls. The vessel completely filled in with Color.

4 Rt Main RA Lt Main RA Rt & Lt Main RA TRV at origin (Color & Spectral) TRV at origin (Color & Spectral) TRV at origin (Color only) N/A N/A N/A The aorta appeared anechoic with smooth walls. The renal artery appeared anechoic with smooth walls as well. The vessel The aorta appeared anechoic with smooth walls. The renal artery appeared anechoic with smooth walls as well. The vessel The aorta appeared anechoic with smooth walls. The renal arteries appeared anechoic with smooth walls as well. The vessel Rt Kid SAG Mid N/A appeared echogenic. Rt Kid Rt Seg RA Rt Seg RA Rt Seg RA Rt Main RA Rt RV SAG Mid w/measurement SAG Sup (Color & Spectral) SAG Mid (Color & Spectral) SAG Inf (Color & Spectral) TRV at hilum (Color & Spectral) TRV at hilum (Color & Spectral) appeared echogenic. Calipers were placed on the outer border of the superior pole to the outer border on the inferior pole through the mid portion of the kidney. I did not have to use an additional technique for this image. Rt Main RA TRV Mid Not seen

5 Lt Kid SAG Mid N/A appeared echogenic. Lt Kid Lt Seg RA Lt Seg RA Lt Seg RA Lt Main RA Lt RV SAG Mid w/measurement SAG Sup (Color & Spectral) SAG Mid (Color & Spectral) SAG Inf (Color & Spectral) TRV at hilum (Color & Spectral) TRV at hilum (Color & Spectral) N/A appeared echogenic. Calipers were placed on the outer border of the superior pole to the outer border on the inferior pole through the mid portion of the kidney. hold it, but that did not help. I also tried rolling the patient, but that did not help either due to bowel gas. Lt Main RA TRV Mid Not seen RLD position but that did not help due to bowel gas.

6 Section V: Diagnostic Image Quality- Measurements/Calculations Grade: List all findings for the examination not just what was required for the competency. (add or delete rows as needed) Identify if finding is normal verses abnormal Describe how the measurements, calculations, etc. were documented as required by protocol. Describe the indications of any abnormal findings, measurements, calculations, etc.. Image Location Velocity Normal vs. Abnorma l RT SEG RA SUP PS: 32.8 cm/s Normal ED: 13.9 cm/s RI: 0.8 AT: 0.0 s RT SEG RA MID PS: 32.6 cm/s Normal ED: 1.3 cm/s RI: 0.3 AT: 0.06 s RT SEG RA INF PS: 48.3 cm/s Normal ED: 20.4 cm/s RI: 0.8 AT: 0.06 s RT MAIN RA AT HILUM PS: 42.6 cm/s Normal ED: 20.3 cm/s RI: 0.2 AT: 0.07 s RT MAIN RA ORIGIN PS: cm/s Normal ED: 37.1 cm/s RI: 0.7 AT: 0.08 s AORTA AT LEVEL OF RA LT SEG RA SUP LT SEG RA MID LT SEG RA INF PS: 99.7 cm/s ED: 8.2 cm/s RI: 0.92 PS: 2.7 cm/s ED: 10.7 cm/s RI: 0.60 AT: 0.0 s PS: 16.9 cm/s ED: 8.1 cm/s RI: 0.2 AT: 0.04 s PS: 17.7 cm/s ED: 9.0 cm/s RI: 0.49 AT: 0.0 s Normal Normal Normal Normal LT MAIN RA AT HILUM PS: 3 cm/s Normal How findings are documented I made sure my angle was 60 degrees or less. I placed my Doppler gate in the center of the vessel to document the highest velocity of blood flow through center of the vessel. I measured peak systolic (PS), end diastolic (ED), and acceleration time (AT). For PS I placed the caliper at the highest velocity of each peak of the waveform. For ED I placed the caliper at the waveform at the end of diastole. For AT I placed the caliper at the notch right before the waveform stated to accelerate and peak. Abnormal Indications No pathology seen

7 LT MAIN RA ORIGIN ED: 22.8 cm/s RI: 0.7 AT: 0.0 PS: cm/s ED: 33.0 cm/s RI: 0.71 AT: 0.09 s Normal Section VI: Diagnostic Image Quality- Instrumentation Grade: Identify the probe, frequency, preset, and specific techniques utilized during the exam. Summarize why the settings selected were correct. Required Elements What was used Why it s correct Probe Name(s) 4C This is a curved probe, which is the appropriate probe used for abdomen scans. Curved probes are used for these scans because they have a lower frequency, which allows for more depth. When doing this type of scan depth is needed because the abdominal organs are deeper in the body therefore it is key to use a low frequency probe. Curved probes also display a larger field of view in the far field on the screen and this is needed for abdominal scans because organs are larger and deeper so the field of view needs to be as large as possible. Frequency(s) used during examination 4 MHz This is a low frequency, which is what is used on abdominal exams. This is used because low frequencies allow more depth and penetration for the exam. Since the abdominal organs are in fact deeper in the body it is important for the sonographer to have enough depth to get an optimal image of the organs being scanned. This frequency also worked well with the patient s body habitus. Preset Renal Since the order was for a renal artery Doppler, then it is correct to have the preset on renal. When a specific preset is chosen it automatically puts the settings that are most frequently used and operates in accordance with certain parameters. Some of the functions that are automatically set when a preset is chosen are overall gain, number and position of focal zones, depth, contrast ratio, scan lines, and the text for labeling. Depth 10-1 cm I set my depth to the bottom of the structure to include all the structure being imaged, but I did not have extra depth below what was being imaged. Focal Zones 2 The focal zones were placed at the bottom of the structure being imaged. This is done because the transmit focal zone allows the maximum intensity of

8 the beam to be focused in that specific area of the structure. By doing this, lateral resolution is maximized. 2 focal zones were brought up in the present and I placed them so one was right above and one was right below the structure I was imaging. Gain Around 2 My B Mode gain was set around 2 throughout the exam. This helped the kidneys appear isoechoic to the liver. This also helped when imaging the aorta. TGC I used my TGC s to make my near field and far field match as close as possible. Color settings Gain: PRF: adjusted throughout Spectral settings Gain: PRF: KHz I adjusted my TCG s to make the near field and the far field look as close as possible. I also adjusted my TGC s as fine tuning to help clear of the aorta and renal arteries to make more anechoic by getting rid of artifacts. My TGC s were used to help compensate for attenuation in the images. The color gain was set so that the vessel filled into the wall of the vessel, but did not bleed out over the vessel walls. The PRF was set so that the aorta and renal arteries did not alias, but in fact it had a solid red color, without alias. I adjusted these settings several times throughout the exam, especially when going from images of aorta and the renal arteries at the origin to the segmental arteries within the kidney. The velocity of the aorta and renal arteries at the origin are higher than the segmental artery so I had to increase my PRF. I adjusted the spectral settings quite often throughout the exam. The PRF was set high enough for the waveform to be bright and recognizable, but low enough that spectral noise was not present in the background. I adjusted this several times throughout the exam, especially between the aorta and segmental renal arteries. Identify and describe additional techniques utilized or should have been utilized to provide diagnostic images listed above or other images associated with this comp (harmonics, patient position, 3D/4D, filter, etc.) The description should include why the technique was used and what additional diagnostic information or resulted changes were evident from the utilization of the technique. Must list at least 2 additional techniques Area of Interest Technique Used Resulted Changes Bilateral Kidneys and Deep Inspiration aorta This helped bring the kidneys down out of the ribs and it helped stop the organ from moving when using Doppler so the Spectral could be easily picked up. Left Kidney RLD position This helped me be able to scan more posterior to get a better window for the kidney. Sweep speed Renal arteries This was set to allow 2 large waveforms to be documented on Spectral Doppler. This will allow the waveform to appear very large and with great detail.

9 Section VII: Diagnostic Image Quality- Pathology Documentation Grade: Describe the sonographic features of all pathology(s) seen in the examination and technique utilized to document pathology. If no pathology was seen, describe 2 pathologies that could be ruled out as it relates to the comp. Be specific with use of the probe and landmarks used to evaluate the structure. Pathology Seen or Excluded (example plaque, etc.) Renal Artery Aneurysm-Excluded Renal Vein Thrombosis- Excluded Sonographic Features of Pathology or Excluded Pathology including measurements Dilatation of the aorta at the level of the renal arteries Clot seen within the lumen obstructing the flow through the vein Technique Used to Identify or Rule out Pathology I scanned through the aorta at the level of the renal arteries and used color to document the renal arteries at the origin of the aorta I imaged the renal vein at the hilum and used color and spectral Doppler. Section VIII: Preliminary Findings to Physician Grade: Describe specifically the sonographic findings of the examination given to the reviewing sonographer and the physician, and how the information was relayed. Describe the interaction you had with the sonographer or physician (did you learn how to better your image or use a new technique from the sonographer regarding images or reporting information, etc.) (did the physician teach you a new idea, compliment, need clarification or challenge your images or patient history, etc.). Person of Interest Sonographer Physician Description of Findings Reported I told the sonographer that all waveforms appeared low resistive and they appeared within the normal velocity range. I told her I could not see the mid portion of the main renal arteries on the right or left. I typed that the patient had a history of elevated hypertension as stated on the request form. I put the findings as: all waveforms appeared within the normal velocity range and the mid region of the renal arteries was not visualized bilaterally due to bowel gas. Method used to Report Findings The sonographer stayed in the room while I scanned the patient and the sonographer scanned through after I finished and verified that the mid portion of the right and left renal arteries could not be visualized. Jot Pad Self Reflection The sonographer verified that the mid portion of the main renal arteries could not be visualized due to bowel gas. The radiologist did not have any questions about my images or the information I provided him.

10 Section IX: Impression/Findings Grade: Attach the final report or summarize the impression/findings of the examination (dictated report). If you mark yes that a final report is attached, you do not have to complete the summary chart Self Reflection- Summarize a critique of the findings/report. The summary must include if you agree or disagree with the findings and why. 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 Final Report Attached (Circle one) Yes or No Summary- Complete Table and Provide an Overall Impression Structure Measurement (If applicable) Normal vs. Abnormal (If abnormal, describe the abnormal findings) Right Kidney 9.1 cm Normal Left Kidney 9.6 cm Normal Overall Impression: Ultrasound is negative for renal artery stenosis. Self Reflection. I agree that the findings were normal because the waveforms appeared to have velocities within the normal range and no increased velocities were noted to suspect renal artery stenosis. Section X: Diagnosis and Differential Diagnosis Grade: Physician examination reports will 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 and define the diagnosis and 1 differential diagnosis. Your answer must be based on: The impression/findings made by the physician, identify and define the report diagnosis and 1 differential diagnosis. In the event of a normal report, identify and define 2 sonographic pathologies that should be considered as based on this competency! (these 2 cannot be the same one used in section 3) Describe the sonographic features, pertinent information and techniques used to document the diagnosis and differential(s). Name and synonyms for pathology Definition Clinical Findings (Symptoms, lab values, etc.) Why this pathology was chosen Sonographic Features (main findings) Where else to look Pitfalls Pathology 1 or Differential Diagnosis 1 Renal Fibromuscular dysplasia (FMD) Fibrous thickening of the intima, media, or adventitia Hypertension and most common in women. This was chosen since my patient had hypertension, even though it was a male. Thickened layer of the arteries, can occur at any location, may involve multiple branches. This pathology is very common in the mid to distal ICA as well. This usually occurs in the mid to distal segments of the renal arteries and depending on the patient s body habitus and ability to cooperate during the exam, this may be hard to

11 image and diagnose. Name and synonyms for pathology Definition Clinical Findings (Symptoms, lab values, etc.) Why this pathology was chosen Sonographic Features (main findings) Where else to look Pitfalls Pathology 2 or Differential Diagnosis 2 Renal artery disease Disease caused by atherosclerosis in the renal arteries due to buildup of fatty substances. If the plaque is severe, it may cause a stenosis, therefore causing hypertension. This pathology was chosen because the patient presented with hypertension. Echogenic material along the walls of the renal arteries. It may cause a narrowing of the lumen. If a person has plaque in one area of the body, it is very likely they have it throughout other areas as well, such as the carotids, legs, and heart. The renal arteries are often hard to visualize, especially in a larger patient. Since the arteries are so small and hard to visualize in some normal patients, it may be hard to see the vessel if plaque is present because it may appear smaller. Points Description No errors were identified 4 One error was identified 3 Errors identified In less than the ½ of the components required 2 Errors identified In up to ¾ s of the components required 1 Immediate action required- errors identified in more than ¾ s of the components required or evidence of an unsafe event (unsafe events may result in failure of the competency) Point Value Conversion Chart 0=100 49=98 48=97 47=96 46=9 4=93 44=92 43=91 42=90 41=89 40=88 39=86 38=8 37=84 36=82 3=80 34=79 33=78 32=77 31=76 30=7 29=74 28=73 27=72 26=71 2=70 24=68 23=66 22=64 21=61 20=60 19=7 18= 17=4 16=40 1=4 14=3 13=30 12=2 11=20 10 or less = 0 Section Points Received

12 Total Points and Final Grade: 0=100 Instructor: Connie Willis Comments: