Abdomen ARDMS mock exam Flashcards

Question

Which of the following correctly describes the preferred patient position for a renal biopsy? a. decubitus with knees drawn to chest b. supine with a pillow under the back to accentuate the normal curvature of the spine c. prone with a pillow under the abdomen to accentuate the normal curvature of the spine d. posterior oblique with ipsilateral arm extended over the head

Answer 1

C The preferred position for the patient undergoing a renal biopsy is prone with a pillow under the abdomen to accentuate the normal curvature of the spine. This approach allows the needle to travel the shortest distance through other tissues before reaching the kidney. It also prevents puncture of bowel and other organs. An anterior approach is least preferable due to the bowel, liver, spleen and vessels that could be punctured in the procedure.

Answer 2

B Bilateral hydronephrosis and hydroureter with increased serum levels of BUN and creatinine and an empty bladder most likely indicates acute renal failure. Acute renal failure caused by a bilateral ureteral obstruction can be treated by removing the obstructions. They parenchyma can be saved if the patient gets immediate treatment. A neurogenic bladder will not empty properly, causing increased bladder volumes pre- and post-void. Antibiotics are used to treat infections, not obstructions.

Answer 3

B The output control will increase/decrease the voltage applied to the transducer which affects the intensity of the beam accordingly. Harmonic imaging is a frequency compounding technique used to improve image resolution of the displayed information. The TGC and overall gain controls are used to amplify the reflected signal.

Answer 4

B | The Valsalva maneuver will not usually affect the evaluation of the pancreas.

Answer 5

A 11mm CBD is too large and abnormal. The pancreas head should be evaluated for a reason that the CBD is dilated if the duct is clear.

Answer 6

C The needle used for the FNA is usually much smaller than the biopsy needle. Core needle biopsies are more commonly performed to assess parenchymal disease than for liver mass evaluation. FNA procedures are less traumatic to the tissues than needle biopsy procedures.

Answer 7

D A patient with Alzheimer's disease cannot sign the informed consent for the procedure and may be uncooperative. Contraindications for sonography guided procedures: 1. coagulopathy- use of blood thinners 2. unsafe biopsy route- must avoid large vessels, bowel, trachea and adjacent organs. 3. Uncooperative patient- uncontrolled movement during the procedure can result in laceration or hemorrhage.

Answer 8

C Capsular artery courses along the testicle periphery and produces branches called centripetal arteries which course through the parenchyma. The deferential artery supplies the vas deferens and epididymis with blood. The cremasteric supplies the scrotal sac with blood.

Answer 9

A Increased levels of AST with normal ALT is associated with myocardial infarction, CHF, CNS disease and other non-hepatic disorders. Some patients that experience a myocardial infarction describe the radiating pain as heart burn or intense indigestion.

Answer 10

D | A right renal mass will cause medial displacement of the IVC.

Answer 11

A Reducing overall exam time will reduce patient exposure. Adhering to ALARA principle will also reduce exposure by limiting power output increases and using TGC contrast controls instead.

Answer 12

A Immediately wash the affected area with soap and water. Notify your supervisor and immediately report to occupational health to file an exposure report.

Answer 13

B Harmonic imaging does not affect the beam intensity so there is no restriction of its use. The process is performed by the machine processing more reflections to improve contrast resolution.

Answer 14

A | CT scan can detect the high fat composition of the mass.

Answer 15

B | Cavernous transformation causes the formation of varices that can rupture and cause significant hemorrhage, even death.

Answer 16

C Gel is not used as a coupling agent when scanning intraoperatively. Surface moisture is usually enough to allow sound transmission into the body but sterile saline can be used.

Answer 17

A Increased levels of ADH and low urine output indicates the patient is dehydrated. The recent PE indicates there is potential thrombus formation in the IVC or its branches.

Answer 18

C Amylase usually increases within the first 3-6 hours of the onset while lipase usually increases within 48 hours of the onset of acute pancreatitis.

Answer 19

D If the celiac artery is occluded, the splenic artery will receive no blood because it is distal to the celiac origin. The lack of blood to the celiac artery will cause a significantly low pressure within the vessel that will allow collateral flow to occur. As the blood enters the empty splenic artery from a point distal to its origin from the celiac, it will flow back to the origin to the point of obstruction. Severe portal HTN could cause increased resistance and flow reversal in the splenic artery but mild portal HTN will have little effect on the splenic artery flow.

Answer 20

B | In a normal fasting adult, blood sugar should not exceed 100mg/100ml of blood.

Answer 21

D | Prostatitis is usually a diffuse process that affects the entire gland.

Answer 22

A Increased frame rate will increase temporal resolution that may reduce any visible delay in displayed information. Smaller sample sizes will increase frame rates. Color threshold determines the limit of when color is displayed over the 2D image. Increasing the threshold allows for more color to be displayed.

Answer 23

C The gut signature (sonographically): superficial mucosa- epithelial lining (and lumen); echogenic deep mucosa- consists of loose connective tissue and muscularis mucosa; hypoechoic submucosa- echogenic muscularis propria- inner circular fibers and outer longitudinal fibers; hypoechoic serosa or adventitia- echogenic

Answer 24

D Post-processing is the only control that will adjust the brightness of the image AFTER the data is stored in the digital memory.

Answer 25

A | The major branches of the celiac axis are the left gastric, splenic, common hepatic arteries.

Answer 26

C Increased pressure in the liver and portal system causes them to engorge with blood. In some cases, this pressure is great enough to recanalize the umbilical vein outward to the umbilicus, as blood backs up in the system. The umbilical vein is a remnant of fetal circulation that used to connect the portal system of the liver to the placenta.

Answer 27

D In order to balance resolution and penetration a 5-7MHz transducer should work best for liver surface evaluation in an average size patient. The linear array works best due to its large near field and rectangular field of view.

Answer 28

A | The fever and increased WBC's indicate an infection. Cholangitis is common in Asian countries.

Answer 29

D Centripetal arteries course through the parenchyma to deliver blood to the testicular tissues. These arteries sampled with doppler in a standard US evaluation.

Answer 30

A A lymphocele is a collection of lymphatic fluid that is usually associated with trauma or surgery. The fluid commonly contains debris and septations. A hematoma will form quickly after the procedure due to the constant blood flow from the heart, while a lymphocele or seroma will usually present after several days, or even weeks, post-biopsy.

Answer 31

D A transverse view can demonstrate a transverse image of both great vessels on the same image. A coronal view can demonstrate a sagittal view of both great vessels on the same image.

Answer 32

C | Both hepatic adenoma and Budd Chiari syndrome have been associated with oral contraceptive use.

Answer 33

A | Deep abdominal imaging is best performed with a low frequency, curvilinear phased array transducer.

Answer 34

B MCKD is a congenital malformation of the kidney with formation of multiple cysts and decreased function. In most cases it causes the unilateral formation of multiple large cysts that consume the parenchyma. Medullary sponge kidney and nephrocalcinosis lead to enlarged kidneys. Medical renal disease leads to decreased renal function and size bilaterally.

Answer 35

C Color priority- adjusts the threshold setting; determines if a pixel is displayed as a shade of gray, black or white, or as a color; lower threshold settings reduce the display of color (lower color priority); higher threshold settings display more color (higher color priority); necessary to minimize color ghosting and improper placement of color on vessel walls.

Answer 36

C | If the GB is the only part of the biliary system that is dilated, the blockage must be isolated to the cystic duct.

Answer 37

B | Liver metastasis is the most common liver malignancy.

Answer 38

B As the pancreas begins to produce the mucous substance, the gland becomes fibrotic. These changes lead to an increase in echogenicity and decrease in size.

Answer 39

B | The RI is calculated using the peak and end diastolic velocities measured on a Doppler tracing. PSV-EDV/PSV.

Answer 40

A The left intersegmental fissure divides the left lobe into medial and lateral lobes. The falciform ligament, ligamentum teres and left hepatic vein course within this fissure.

Answer 41

D Oncocytoma would normally present as a hypoechoic renal mass, acute pyelonephritis does not cause mass formation but will present as loss of corticomedullary definition. The other choices will appear as a hyperechoic mass.

Answer 42

B The nephrons are located within the parenchyma. Bowmann’s capsule and the vascular supply of the nephron are located in the cortex layer. The nephron tubules to and from the capsule dive between the pyramids within the medulla area of the parenchyma to connect to the loop of Henle.

Answer 43

A | Seminomas make up to 40-50% of all germ cell tumors identified in the testicle.

Answer 44

D | The flow in the hepatic veins is normally triphasic due to right atrial contraction and relaxation.

Answer 45

D | The IVC and SVC empty their blood into the right atrium

Answer 46

D The liver filters blood from many abdominal organs, such as the stomach and the colon. This function of the liver makes if more susceptible to metastasis.

Answer 47

B | A pancreatic adenoma is composed of beta cells.

Answer 48

C | The suffix -itis refers to an infection. A, B and D refer to tumor formation.

Answer 49

A | Pancreatic divisum is difficult to detect sonographically.

Answer 50

B The main lobar fissure courses through the right lobe between the neck of the GB and the IVC fossa. Sonographically, the main lobar fissure appears to connect the GB neck and junction of the right and left portal veins. Ligamentum teres courses through the left lobe and contains the collapsed umbilical vein. Ligamentum venosum separates the left lobe from the caudate lobe. The right and left segmental fissures separates the left and right lobes in 2 portions.

Answer 51

B The IMV drains blood from the distal colon. The SMV drains the blood from the proximal colon and some small bowel portions. The IMV meets the splenic vein near the portal confluence.

Answer 52

A | Acute pyelonephritis is most commonly diagnosed clinically with lab testing and is treated with antibiotics.

Answer 53

D Perirenal space holds kidneys, perinephric fat, prox ureter, adrenal glands. Renal infection can lead to fluid, abscess or gas within the space which will distort renal fascia.

Answer 54

A CHF indicates poor cardiac function. There will be a back log if blood tries to enter the heart from the IVC causing it to dilate. Bilateral pedal edema is a common sign of CHF.

Answer 55

B | The portal triad contains the portal vein, proper hepatic artery and CBD(/CHD?)

Answer 56

A | The CBD usually courses anterior to the main portal vein when it exits the liver.

Answer 57

D The aorta tapers in size as it courses inferiorly through the abdomen. The celiac axis is the most superior branch of the aorta therefore the aorta diameter is greatest at the level of its origin.

Answer 58

B | The most common primary malignancy to metastasize to the spleen is melanoma.

Answer 59

C Focal nodular hyperplasia is a benign liver tumor. An adenoma is a benign liver tumor commonly associated with oral contraceptives. A hemangioma is an abnormal accumulation of vascular tissues that forms as a benign liver mass. A hepatoma is a primary malignant tumor of the liver.

Answer 60

A A thyroglossal duct cyst is identified on the midline neck, superior to the thyroid gland. A brachial cleft cyst is located near the angle of the mandible.

Answer 61

B | Courvesier GB refers to an enlarged, non-tender GB caused by a distal obstruction.

Answer 62

C | The renal arteries branch just below the SMA.

Answer 63

D When the BP drops, the GFR drops. The kidneys release renin to prompt the release of angiotensin which constricts flow in the arterioles. This increases BP and GFR.

Answer 64

C Splenomegaly is an acquired condition. Common causes include infection and portal HTN. Agenesis is a congenital absence of the spleen. An ectopic spleen forms in a different location than in the LUQ adjacent to the left kidney. A splecunculi is an accessory spleen or mass of normal splenic tissue not attached to the main gland.

Answer 65

E ALT, AST, bilirubin and alkaline phosphatase levels will all increase with cirrhosis. Alpha fetoprotein levels increase with malignancy and pregnancy. If HCC develops with cirrhosis, then AFP levels will rise.

Answer 66

D Hepatization of the GB refers to a GB filled with sludge that is isoechoic to the liver. This makes the GB difficult to identify on US. Try to identify the GB wall in these cases.

Answer 67

D Echinococcal cysts are also called hydatid cysts and demonstrate a cyst with another cyst inside. They form due to parasitic infection of the liver.

Answer 68

D | The splenic vein is a part of the portal venous system. It joins with the SMV at the portal confluence.

Answer 69

A Most tumors with round smooth borders are benign. Most pancreatic tumors located in the head are malignant. Masses found in the tail are usually benign. Because of the proximity of the pancreatic tail to the splenic hilum, tail masses can look like splenic pathology.

Answer 70

C | The ejaculatory duct is formed at the junction of the vas deferens and seminal vesicles.

Answer 71

C | The GDA is demonstrated as a small circular anechoic structure at the anterior portion of the pancreas head.

Answer 72

C FNH and liver adenomas have a similar sonographic appearance and biopsy is usually required to determine the mass origin.

Answer 73

A A pleural effusion will be located above the diaphragm. A subcapsular hematoma will be located between the splenic tissue and the splenic capsule. A pericardial effusion refers to fluid in the pericardial sac around the heart. Sub- means under and -phrenic means diaphragm. The subphrenic abscess will be located under the diaphragm adjacent to the splenic capsule.

Answer 74

D | The anterior fibromuscular zone is composed of mostly smooth muscle and occupies 1/3 of the gland.

Answer 75

E | Leukocytes are WBCs. They are produced in the splenic tissue.

Answer 76

D Retroperitoneal fibrosis usually occurs at the level of the aortic bifurcation. It refers to idiopathic overgrowth of fibrous tissue. It can be related to drugs, infection, malignancy or cancer therapy. The overgrowth of tissue may lead to ureteral obstruction, causing hydronephrosis.

Answer 77

D | Adenocarcinoma is the most common malignant neoplasm found in the prostate.

Answer 78

C The hepatic veins course between the liver segments (intersegmental). The portal veins and hepatic arteries course into the mid portion of each segment and branch toward the edge (intrasegmental).

Answer 79

A | Acute cholecystitis is associated with GB wall thickening >3mm.

Answer 80

A The renal pyramids are wedge-shaped spaces located in the medulla portion of the renal parenchyma. The base of the triangle is adjacent to the cortex of the parenchyma. The urine is funneled to the papilla, or tip of the wedge, that is connected to the calyce of the renal sinus.

Answer 81

B Morrison’s pouch is located between the liver and the right kidney. The pancreatic tail, fundus of the stomach and lesser sac are anterior/medial to the spleen

Answer 82

C Calcitonin is produced by in the thyroid in the parafollicular cells. These cells are located in the tissues between the thyroid follicles.

Answer 83

B Papillary carcinoma is the most common type of thyroid cancer. It is commonly associated with enlarged cervical lymph nodes but is highly curable. Sonographic characteristics include a hypoechoic mass with calcifications.

Answer 84

C The pancreas is isoechoic as a child and increases in echogenicity as the pt reaches adulthood. Cystic fibrosis causes an increase in echogenicity of the gland.

Answer 85

C | Sclerosing cholangitis is an acquired inflammatory disorder of the biliary tree

Answer 86

A In most pts the proper hepatic artery bifurcates into the right and left hepatic arteries. In about 10% of pts the right hepatic artery originates from the SMA and the left originates from the left gastric artery.

Answer 87

E Increasing diffuse fatty replacement will cause the liver tissues to increase in echogenicity and the mass will become more isoechoic or even hypoechoic to the liver tissues

Answer 88

A | The seminiferous tubules empty into the efferent ductules that connect to the epi.

Answer 89

B | Beckwith-Weidemann syndrome is associated with hepatoblastoma

Answer 90

A As kidney function decreases the organ atrophies. The cortex thins and becomes increasingly dense leading to an increase in cortical echogenicity

Answer 91

A The resistive index should normally be below 0.7 in a renal allograft. If the RI reaches 0.8-1.0 transplant failure is suspected.

Answer 92

C | Insulin is a hormone produced by the pancreas (endocrine).

Answer 93

D | Seminomatous tumors are comprised of seminomatous cells.

Answer 94

A | Corpora amylacea refers to calcifications commonly seen in the inner gland.

Answer 95

A Cavernous transformation of the vessels at the porta hepatis refers to the formation of varices from the increased portal pressure with portal HTN. Accessory veins dilate at the porta hepatis due to the backlog of blood flow. These vessels are small and tortuous. Splenomegaly is another sign of portal HTN and a backlog of blood flow in the porta hepatis.

Answer 96

C Fusiform aneurysms usually occur in the distal abdominal aorta while dissecting aneurysms usually occur in the aortic arch.

Answer 97

C | Hutch diverticula are congenital outpouchings of the bladder wall near the urethral opening.

Answer 98

A Esophageal diverticulum refers to the outpouching of a weak spot in the esophageal wall. Killian-Jameison diverticulum- protrudes from anterolateral wall of the cervical esophagus. Zenker’s diverticulum- located at the back of the throat, protrudes posterior or midline. They can be mistaken for a thyroid mass.

Answer 99

A No intrarenal arterial flow will be detected in the kidney with an acute renal arterial occlusion. Acute tubular necrosis, acute renal failure and renal vein thrombosis reflect the kidneys that cannot properly filter blood and cortical tissue resistance is increased.

Answer 100

C Tardus parvus waveform- absence of early systolic peak and prolonged acceleration time. If identified in the native arcuate arteries, significant stenosis is present.

Answer 101

D A splenic hamartoma is a rare, benign vascular proliferation that is often found incidentally. A hemangioma is another type of benign vascular malformation. A granuloma forms after infection. Lymphoma is a primary malignancy of the spleen related to the lymphatic tissues.

Answer 102

C | The lack of opening of the biliary tree will cause persistent jaundice after birth.

Answer 103

D | The most common BILATERAL malignancy of the testes is lymphoma.

Answer 104

D | Unilateral, bilateral

Answer 105

A Carpal tunnel syndrome refers to compression of the median nerve by the carpal sheath causing numbness, weakness and pain in the wrist/hand.

Answer 106

B | Chronic cholecystitis can lead to calcium formation within the wall of the GB.

Answer 107

D Hepatomegaly is diagnosed when the length of the liver exceeds 15.5cm. the AP measurement will also increase but the length is most accurate.

Answer 108

C FAST evaluation- Focused Assessment with Sonography in Trauma; used to evaluate the abdomen for fluid or blood in trauma pts; check the 4 quadrants, midline and Morrison’s pouch

Answer 109

A | Serosa, muscularis, submucosa, deep mucosa, superficial mucosa/lumen.

Answer 110

B Thyroid volume increases normally with age and body weight. Iodine deficiency, acute hepatitis and chronic renal failure can also cause increased gland volume. Chronic hepatitis, thyroxine treatment and radioactive iodine treatment can cause decreased gland volume.

Answer 111

B Percutaneous ethanol injection is used to cause tumor necrosis in thyroid adenomas and cysts, parathyroid adenomas, HCC and liver metastasis. Acetic acid is another type of injectable used for liver tumor treatment. Radiofrequency ablation of liver tumors induces thermal injury to the target tissues. Thrombin is used in the treatment of pseudoaneurysms.

Answer 112

D Sterile field: All items and personnel in a sterile field must be sterile Sterile packages or fields are opened or created as close as possible to the time of actual use. Moist areas are not considered sterile. Contaminated items must be removed immediately from the sterile field. Gowns are considered sterile only in the front, from chest to waste and from the hands to slightly above the elbow. Personnel with colds should avoid working while ill or apply a double mask. Edges of sterile areas are not considered sterile.

Answer 113

B Thoracentesis is performed for removal of fluid from the pleural space in the thoracic cavity. It is performed for diagnostic or therapeutic purposes. A chest x-ray is performed before and after the procedure to evaluate fluid removal and for the presence of a potential pneumothorax caused by the procedure. Most pts are placed in the semi-erect position and leaning forward over a table.

Answer 114

A | Jaundice is caused by an increase in bilirubin in the blood. This can be due to ductal obstruction or liver malfunction.

Answer 115

A The depth of the mass can affect the length of needle required for the procedure. Normally only one biopsy device is opened and used for the procedure.

Answer 116

A The mechanical index should be low, 1.0 or less, to decrease cavitation and decrease the potential to burst the microbubbles. Harmonics will assist in visualizing the contrast in the microvascularity. The focal zone should always be placed at or just below the area of interest.

Answer 117

C Superficial imaging is best performed with linear transducers. The large near field and rectangular FOV provide improved imaging of superficial structures. Higher frequencies also provide the best resolution.

Answer 118

A Due to the anatomic position of the GB anf the limited imaging windows from the pt’s back, the prone position will not provide additional imaging views of the GB.

Answer 119

B | An enlarged prostate can cause urine retention in the bladder and associated hydronephrosis.

Answer 120

D As log compression increases, the dynamic range decreases. The lower the dynamic range, the smaller number of shades of gray that are displayed on the image. Overall gain would adjust the brightness of all shades on the screen and will not affect contrast.

Answer 121

B Wound-skin precautions- AKA contact precautions; used to protect others from germs in pt’s wounds or any other heavily contaminated areas; require gown and gloves for any type of pt contact; MRSA, scabies, VRE, Impetigo.

Answer 122

A Blood that collects between the renal capsule and the cortex is an intracapsular hemorrhage. Blood that collects outside the capsule. Between the capsule and the liver tissue is an extracapsular hemorrhage. An intracapsular hemorrhage will distort the renal cortex while an extra capsular hemorrhage will not.

Answer 123

A The recent history of an MVA and acute presentation of the complex masses should lead to a diagnosis of a hematoma. Fibrosis would appear as dense formations within the muscular tissues. A sebaceous cyst would present in a much more superficial location as they are related to the oil glands of the skin. Lipomas are composed of fatty tissue and usually present as a round or oval homogeneous, hyperechoic mass related to the surrounding muscle tissue.

Answer 124

A | Sickle cell anemia causes the spleen to enlarge early in life and then atrophy later.

Answer 125

C | If the image is too bright, always decrease the output power first to decrease pt exposure. Remember, ALARA.

Answer 126

E The endocrine system includes the pancreas, pituitary gland, hypothalamus gland, pineal gland, thyroid, parathyroid, adrenal glands, ovaries and testes.

Answer 127

A Reverse protective isolation- AKA protective environment precautions; protects pts from the germs of others; it is used with pts who have extremely impaired immune systems or recent organ transplant.

Answer 128

A Increased gain settings can cause fill in anechoic structures. Small cysts may demonstrate artifactual echoes from surrounding tissues. A very superficial cyst can demonstrate range resolution artifact in the anterior cyst. Increased attenuation of the sound beam would actually help to remove artifactual echoes because it will lead to a decreased amount of reflections that reach the probe.

Answer 129

A Respiratory isolation- AKA droplets; used to protect others from germs In the pt’s nose, mouth, throat and lungs. It is used for diseases that are airborne.

Answer 130

C Thompson test- pt placed in the prone position and the calf muscle is squeezed. If the foot flexes in response to the squeeze the tendon is not completely torn. If the foot is non-reactive to the squeeze, the tendon is completely torn.

Answer 131

A | If there is a small bleed in the AA or the GI, anemia can be an indicator for these problems.

Answer 132

A Increasing the area to be scanned will require an increase in time to process the increased # of reflections for display causing a decreased frame rate.

Answer 133

C Pheochromocytoma cause increased secretion of dopamine, epinephrine and norepinephrine. This leads to symptoms that include HTN, anxiety, headache, nausea, vomiting, sweating and tachycardia. Tumors originate in medulla tissue and grow to average size of 5-6cm.

Answer 134

B A left lateral approach is commonly used to obtain a longitudinal image of the spleen. This coronal view is used to assess the length of the spleen.

Answer 135

B When the arterial supply to the kidney is obstructed, the kidney atrophies and does not perform the proper filtration of the blood. This leads to increased serum levels of BUN and creatinine.

Answer 136

D Pulsed wave Doppler demonstrates the range of peak flow velocities and flow direction of the blood vessel. Color Doppler demonstrates the average flow velocity of the blood in a vessel and flow direction. Power Doppler usually does not demonstrate flow direction but does demonstrate the presence/absence of flow.

Answer 137

D Cystic structures related to Caroli’s disease and choledochal cysts will communicate with the biliary tree. Cysts that form with PCLD do not.

Answer 138

A | Most cases of pancreatic adenocarcinoma will demonstrate normal enzyme levels.

Answer 139

A Renal vein thrombosis will demonstrate increased kidney size, hypoechoic renal cortex, decreased corticomedullary differentiation, mottled echogenicity, dilated renal vein and no intrarenal venous flow and increased resistance in renal arteries.

Answer 140

D A hydrocele is the accumulation of serous fluid between the two layers of the tunica vaginalis. They most commonly occur in newborns but are also seen in adults associated with infection/inflammation.

Answer 141

B | The majority of angiomyolipomas form in the right kidney.

Answer 142

C An acute hematoma will be anechoic or mildly hypoechoic to surrounding tissues. The linea alba stops the blood from crossing the midline, above the level of the arcuate line. Blood is not confined within the sheath below the arcuate line which allows the blood to extend into the pelvis.

Answer 143

D In the average sized pt, 5-7MHz linear probe will usually provide the appropriate level of penetration for the exam. The linear array is preferred for its footprint and large near field.

Answer 144

A Gleason score is used to classify prostate cancer; 1-10 with 10 as the most aggressive. A score of 8 indicates a moderately aggressive prostate tumor. The pelvis should be evaluated for lymphadenopathy and metastasis related to prostate cancer.

Answer 145

C | The right adrenal gland is posterior to the IVC. Tumor invasion can displace the IVC more anteriorly.

Answer 146

C | Lithotripsy is used to shatter kidney stones into “manageable” sized pieces to allow the pts to pass them normally.

Answer 147

C A low hematocrit means the percentage of RBC’s is below the lower limits of normal. Causes include internal bleeding (varices), RBC destruction (anemia) and malnutrition.

Answer 148

C The caudate enlarges as the larger right and left lobes shut down due to cirrhosis. A caudate to right lobe ratio >0.65 is said to be related to cirrhotic atrophy. The caudate lobe os drained by the emissary veins which drain into the IVC.

Answer 149

C | The hepatic veins divide the liver longitudinally into the superior right and left lobe segments.

Answer 150

C TCC forms in the transitional cells that line the renal pelvis, ureters and bladder. It is the most common bladder neoplasm. The most common symptom is painless macroscopic hematuria. Mass or focal wall thickening of the bladder wall are strong indicators of TCC. Sonographic characteristics include solitary or multiple hypoechoic mass formation with potential invasion into surrounding tissues. Unilateral hydronephrosis can be present with single ureter involvement, bilateral hydro seen with bilateral ureter involvement.

Answer 151

D The sonographic appearance of the normal testes is an oval structure filled with homogeneous, uniform, medium level echoes. The mediastinum testis (AKA rete testes) is seen as a linear echogenic band within the testicle. The tunica albuginea is not normally visualized sonographically. The epididymis is normally isoechoic or mildly hyperechoic to the testicle. Doppler waveforms demonstrate high levels of antegrade, monophasic flow.

Answer 152

C Papillary necrosis refers to ischemia of the medullary pyramids. Sloughed papilla are identified in the urine and can cause urinary obstruction. The most common cause is analgesic abuse. Sonographic characteristics include swollen pyramids, clubbed calix, echogenic material and calcifications with shadowing within the collecting system and triangular cystic areas in the cortex.

Answer 153

B The head of the pancreas is usually anterior to the IVC, while the aorta is posterior to the neck. The celiac axis is a branch of the aorta that originates superior to the neck of the pancreas.

Answer 154

D The jaundice indicates chronic liver malfunction. Hep-C is associated with liver dysfunction and cirrhosis. Chronically decreased liver function usually leads to ascites formation in the abdomen.

Answer 155

D Aldosterone secreted by the adrenal cortex increases the rate of sodium resorption and potassium excretion in the kidneys; adjusts urine output to increase or decrease blood volume.

Answer 156

C Left adrenal gland- medial to the spleen, posterior to the pancreas tail and stomach, lateral to the aorta and left diaphragmatic crura.

Answer 157

D The pyramids and loops of Henle are located in the medulla portion of the parenchyma of the kidney. The calyces are a part of the collecting system in the renal sinus. Bowman’s capsules are located in the cortex portion of the parenchyma and are responsible for blood filtration.

Answer 158

B A cyst and a hematoma are not considered solid masses. A goiter is a diffuse condition. The adenoma is the most common solid, benign thyroid mass.

Answer 159

C | The other 3 choices are malignancies.

Answer 160

C | Estrogen replacement therapy and pregnancy can cause a hemangioma to increase in size.

Answer 161

B | Because the liver is in contact with the diaphragm in the bare area, fluid con not accumulate there.

Answer 162

B Most malignancies are constantly growing and “invading” so this requires constant flow throughout the cardia cycle. Doppler will demonstrate increased diastolic flow consistent with a low resistance vascular bed.

Answer 163

D Asplenia is a type of heterotaxia that causes double right-sidedness. It involves absence of the spleen, right-sided aorta, left sided IVC, midline liver and GB, horseshoe kidneys and congenital heart defects are common.

Answer 164

C The Kasai procedure is performed to treat biliary atresia. A segment of the ductal system is directly connected to a portion of the GI tract. Biliary tree dilation should reduce and the expected homogeneous liver appearance should return to normal.

Answer 165

D | All other options are related to the liver a urinoma is not.

Answer 166

D The ampulla of vater connects to the duodenum and is formed by the junction of the CBD and the pancreatic duct. A mass in this location will lead to dilated biliary tree and pancreatic ducts.

Answer 167

D | There are usually 2 on each side of the trachea. One set is usually more superior than the other.

Answer 168

C | The key words are non-shadowing and mobile.

Answer 169

B | McBurney’s point is the most common location of the appendix.

Answer 170

A Micronodular cirrhosis- multiple nodule <1cm; usually associate with alcoholism Macronodular cirrhosis- multiple nodules usually 1-5cm in size; usually associated with chronic viral hepatitis.

Answer 171

B Normal lymph nodes are ovoid is shape. They do not demonstrate posterior enhancement. As they enlarge they become rounded in shape.

Answer 172

A | Both will demonstrate normal renal size with a focal, indistinct, hypoechoic wedge shaped segment of parenchyma.

Answer 173

A Capsular courses along the testicle periphery and produces branches called centripetal arteries which course through the parenchyma. The deferential supplies epi and vas deferens. The cremasteric supplies scrotal sac.

Answer 174

A Sickle cell anemia is determined by abnormally shaped RBC’s that carry abnormal forms of hemoglobin. These abnormal cells can cause pooling of the blood in the spleen. The spleen will become enlarged and painful from the increase in blood volume early in life. After repeated episodes of splenic sequestration, the spleen becomes scarred and permanently damaged causing atrophy.

Answer 175

D Leukemia, lymphoma, myelofibrosis= severe splenomegaly AIDS, portal HTN, infection= mild-moderate splenomegaly

Answer 176

D Epidermoid cysts have fibrous walls that may calcify. They are described as having an onion-like appearance due to alternating rings of hyper and hypoechoic tissues. These cysts contain thick keratin and are avascular.

Answer 177

B | 95% of BPH occurs in the transitional zone.

Answer 178

C A pseudocyst forms as an accumulation of digestive enzymes form and the body attempts to wall off the accumulation of the enzymes by forming a reservoir. In most cases, only one pseudocystic area forms as the fluid builds up.

Answer 179

A Midgut malrotation refers to any variation in the normal rotation and fixation of the GI tract during development. It is usually associated with malposition of the SMA and SMV.

Answer 180

B | Chronic renal disease leads to renal atrophy and a decrease in overall size.

Answer 181

B The pancreas is isoechoic to the liver as a child and increases in echogenicity as the pt reaches adulthood. Cystic fibrosis causes an increase in echogenicity of the gland with mucus production and gland fibrosis. The mucus can cause meconium ileus.

Answer 182

C The central portion of an abscess is fluid and debris with no vascularity. The surrounding tissues are inflamed which leads to increased flow.

Answer 183

B Nephroblastom (AKA Wilm’s tumor) is the most common renal malignancy in children. TCC is malignancy of the transitional cells of the ureters, bladder and renal pelvis.

Answer 184

D The lab indicates biliary obstruction. The presence of dilated INTRAhepatic ducts in both lobes indicates that the right and left hepatic ducts are obstructed=CHD.

Answer 185

C | The biliary anastomosis site is not vascular therefore there is no need or even ability to use PW Doppler at this site.

Answer 186

D Ureteroceles are thin membranes that cover the junction of the ureter and bladder. Posterior urethral valves are abnormal structures in the urethral tube causing a backlog pf urine starting in the bladder and extending to the kidneys.

Answer 187

A Surgical clips are highly echogenic and cause posterior shadowing which can cause a false positive diagnosis of a ductal stone. Rejection removes low level echoes from the image. If this setting is too high, the image will be overly grainy. This could remove reflections from small stones leading to a false negative. Decreased gain could also remove important information from reflectors in the GB leading to a false negative for stones.

Answer 188

B | A scrotal pearl refers to an extratesticular calcification.

Answer 189

C | Elevated serum copper level is indicative of Wilson disease.

Answer 190

B The celiac axis can be compressed by the median arcuate ligament near the diaphragm. Symptoms may be intermittent with respiration. Symptoms appear with expiration and resolve with inspiration.

Answer 191

B Advantages of US guided biopsy: #1 advantage is real time visualization of the needle massing through the area of interest to confirm an accurate sample is taken. Accurate diagnosis in 95% of cases. If you can see it on US you can biopsy it by US guidance. Minimally invasive. No radiation. Cost effective. Prevents surgical removal of tissue for analysis. Allows for multiple pt positions and approaches.

Answer 192

D The lower the probe frequency, the better the penetration of the beam. The longer the focus, the better the resolution of deeper structures.

Answer 193

D The recent history and the cystic structure with debris indicate a possible hematoma. A hemangioma is a benign formation of vascular tissues. A hydatid cyst is a parasitic infection that leads to cyst formation most commonly in the liver. Carcinoma formation usually presents as a solid, irregular mass.

Answer 194

A | A stand off pad eliminates the dead zone on the image. This is helpful for very superficial structures.

Answer 195

C Increased serum levels of ALP usually provide the first indication of an extrahepatic biliary obstruction. The levels elevate quickly and usually to a level that is 3 or more times the normal value.

Answer 196

D Excessive production of adrenocorticotropic hormone (ACTH) by the pituitary gland will cause the adrenal gland to produce excessive cortisol.

Answer 197

B | The main lobar fissure connects the GB neck to the right portal vein.

Answer 198

C Comparison of the AST and ALT levels is used to diagnose the associated liver abnormality. Significant increases in AST with mild increase in ALT indicates cirrhosis or metastatic disease is present. Significant increase in ALT with mild increase in AST indicates acute hepatitis or a benign hepatic obstruction is present.

Answer 199

D The caudate lobe is normally sparred from the atrophy associated with cirrhosis. Comparing the size of the caudate lobe to the size of the right lobe aids in assessment of liver atrophy seen with cirrhosis. The portal vein will dilate as the cirrhosis progresses. A portal vein diameter of >13mm is abnormal.

Answer 200

B Cavernous transformation refers to the dilation of the portal system varices at the entrance of the liver. Commonly caused by portal HTN.

Answer 201

A Tissue harmonic imaging reduces noise and clutter by improving signal to noise ratio and resolution. As an US wave propagates through the media, a change occurs in the shape and frequency of the transmitted signal. The change is due to the normal resistance of tissues/particles to propagate sound energy. This resistance and the resulting signal change is called harmonic oscillation. The input frequency doubles the output frequency in harmonic frequency. EX: transmit frequency of 4MHz for maximum penetration with a return frequency of 8MHz for improved resolution. The returning higher frequency signal has to only travel one direction to the probe. The advantages of high frequency imaging and the one-way travel effects are decreased reverberation, beam aberration, and side lobes, as well as increased resolution.

Answer 202

C A nephroblastoma is a primary renal malignancy. Adrenal tumors are commonly seen with cushing’s syndrome and conn’s disease. A pheochromocytoma primarily presents as a benign tumor of the adrenal gland that causes symptoms similar to anxiety.

Answer 203

A The right and left hepatic ducts join together inside the liver, near the porta hepatis. The cystic duct joins the CHD at the porta hepatis to form the CBD as it exits the liver.

Answer 204

D Emphysematous cholecystitis is an acute complication caused by a bacterial infection of the GB. It is a critical finding that should be reported to the radiologist immediately. Porcelain GB may develop after chronic infection of the wall. The other 2 choices are chronic conditions that affect the GB.

Answer 205

A FNC aspirates a smaller but more concentrated sample of cells than FNA. Both procedures use local anesthetic to numb the area around the puncture site. FNC and FNA procedures are used to collect cells from a mass.

Answer 206

D The speed of sound in fatty tissue is slower than in soft tissue. A large fatty tumor could lead to structures posterior to the mass being displayed deeper on the image than they actually are in the body.

Answer 207

C Graded compression should demonstrate pliable loops of bowel with normal peristalsis. Rebound pain is a strong indicator of appendicitis.

Answer 208

E Acute pain and swelling, not associated with trauma, are usually caused by infect. Scrotal infections can lead to hydrocele formation that will present as swelling. A testicular infarct would not be related to fever.

Answer 209

D An insulinoma causes an increase in insulin in the blood stream leading to hypoglycemia. An insulin pump is for those who do not produce enough insulin.

Answer 210

A Substances NOT normally found in the urine: sugar (glucose), RBCs, WBCs, protein and acid keytones. Creatinine is normally filtered from the blood and expelled in the urine.

Answer 211

D Malignant HTN is a significant increase in systemic BP that is unaffected by medication (AKA uncontrolled HTN). When the kidneys do not receive the necessary amount of blood, they activate the renin-angiotensin system. The hormones in this system cause the BP to rise until the kidneys are satisfied. If there is a stenosis in the renal artery, the BP will rise to a critical level and still not satisfy the kidney. Meds will not affect the BP due to the cause of the increase.

Answer 212

C Increasing the size of the field of view by steering the beam into a trapezoidal shape will lead to increased beam divergence. Lateral resolution is reduced by wider beams.

Answer 213

A Xanthogranulomatous pyelonephritis is most commonly a unilateral finding. Recurrent infections cause chronic obstruction to renal urine output. Stone formation is a commonly associated finding with most presenting with staghorn calculus formation. Females and diabetic pts have a higher risk of developing this abnormality.

Answer 214

B Dehydration will cause blood to thicken and the kidneys will slow their filtration of blood. These 2 factors can lead to thrombus formation in the renal vein.

Answer 215

A Most hemangiomas demonstrate some level of posterior enhancement. Flow within the hemangioma is usually very slow and color Doppler is not an effective evaluation tool.

Answer 216

C Angiomyolipomas are a hyperechoic mass found within the renal parenchyma or attached peripherally. They are most commonly associated with tuberous sclerosis. These masses can be found in the liver and spleen too but are much less common in these organs.

Answer 217

A Blood that collects between the renal capsule and the renal cortex is an intracapsular hemorrhage. Blood that collects outside the capsule, between the capsule and the liver tissue is as extacapsular hemorrhage. An intracapsular hemorrhage will distort the renal cortex while and extracapsular hemorrhage does not.

Answer 218

C Ducts of luschka: located in the GB wall, bile thickening occurs there, can result in the stasis of bile/debris which leads to inflammatory disease.

Answer 219

B Packet size refers to the number of lines of information used to create the color displayed on the image. The more lines of data used, the larger the packet size, the better the color display. Decreasing PRF or scale will assist in visualization of slower flow. Low PRF are used to examine low velocity flow. The longer interval between pulses allows the scanner a better chance of identifying slow flow.

Answer 220

``` B BUN (blood urea nitrogen) levels are a direct assessment of the filtration function of the kidneys. WBC levels are related to the presence of infection. ALT is a liver enzyme that is assessed for liver function. Lipase is an enzyme produced by the pancreas for digestion. ```

Answer 221

D Bowman’s capsule is part of the renal nephron. Morrison’s pouch is the right renal fossa, the area between the right kidney and liver. Gerota’s fascia covers the kidney like glisson’s capsule covers the liver.

Answer 222

D The pancreas lies across the abdomen with its long axis best demonstrated in a TRV plane. The tail lies slightly superior to the head and body which requires an oblique TRV probe position.

Answer 223

D | A linear probe provides the largest near field.

Answer 224

B Anisotropy artifact refers to falsely hypoechoic areas of a tendon. This occurs when the transducer is not completely parallel to the tendon. It can be reduced by rocking the transducer more parallel to the tendon. Curved tendons can be straightened by muscular contraction to make the tendon more parallel to the transducer.

Answer 225

A Adrenal myelolipomas are composed of fatty and bony elements that cause the mass to be echogenic an US. Fatty tissue causes increased attenuation. Diaphragm disruption due to propagation speed artifact may be seen. The decrease in the speed of sound in fatty tissue can cause the portion of the diaphragm that is posterior to the mass to be placed more posterior so the diaphragm looks ‘broken’. Comet tail artifacts are caused by repetitive reflections at a media boundary between very different tissues.

Answer 226

B Beam width, clutter and cross talk all involve the incorrect display of lower level Doppler shifts. Increasing the wall filter can reduce the appearance of the weaker Doppler shifts on the image.

Answer 227

D Non-seminomatous germ cell tumors commonly demonstrate multiple cystic area due to tumor necrosis. Seminomas normally remain solid yet heterogeneous.

Answer 228

D b-color is the colorize function on the 2D image. The different shades of a single color are used to display the reflected information on the image. Changing from gray scale to shades of color can change the contrast resolution.

Answer 229

C BPH causes increased levels of PSA in the blood. Carcinoma also causes increased PSA (>10ng/ml) but usually much more significantly that BPH

Answer 230

C Glycogen storage disease is an inherited disorder of glycogen metabolism. It usually affects either the liver or skeletal muscle. Excessive storage of glycogen occurs within the hepatocytes. It is associated with hepatomegaly, increased echogenicity similar to fatty liver and hepatic adenoma formation.

Answer 231

D Because giant cell tumors are soft tissue masses, they will not demonstrate posterior enhancement. Ganglion cysts have the classic signs of a simple cyst on US, including enhancement. Giant cell tumors do not move with the adjacent tendon but neither do ganglion cysts.

Answer 232

C The ureters join the posterior inferior aspect of the bladder. The urine usually flows into the bladder at an angle toward the anterior wall. Color Doppler can be used to evaluate ureter patency and visualize the urinary jet into the bladder. If urine flows into the bladder from both jets at the same time, the jets can form an “X” pattern on color Doppler.

Answer 233

B The right and left lobes are divided by the branches of the main portal vein; right and left portal veins, right and left lobes. These lobes are further divided according to portal branches; right anterior and posterior, left medial and lateral.

Answer 234

B Primary GB carcinoma most commonly presents as diffusely thickened GB wall with cholelithiasis. Increased levels of direct bilirubin, alkaline phosphatase and prothrombin time along with normal WBC count indicates no inflammation.

Answer 235

D Calcitonin is produced by the thyroid and the parathyroid produces parathyroid hormone. Hyperparathyroidism usually leads to increased PTH production which decreases the calcitonin production. This decrease in calcitonin and related calcium metabolism increases the calcium resorption in the intestines and decreases renal filtration of calcium from the blood.

Answer 236

D The debris and dirty shadowing correlate with an infection causing pus accumulation (pyonephrosis). The gas produced by the bacteria in the infection causes dirty shadowing. A staghorn calculus would be highly reflective and exhibit clean shadowing. Hydronephrosis is defined as a backup of urine into the renal pelvis and calyces which would appear anechoic.

Answer 237

A Pulmonary embolism is a vascular abnormality that occurs with thrombus formation in the IVC or its tributaries. Chronic renal hydronephrosis can result in renal failure. The kidney function will decrease and the BP will rise to try to increase the filtration rate. A chronic obstruction usually leads to infection and can develop into sepsis.

Answer 238

B Yolk sac tumor is the most common testicular tumor in pts <2yrs old. They produce AFP (alpha fetoprotein). Sonographically they usually have areas of hemorrhage or necrosis in the mass causing a complex appearance.

Answer 239

A Hyperechoic lesion- metastasis from GI tract Hyperechoic lesions with hypervascularity-metastasis from RCC Hypoechoic lesions- metastasis from lymphoma Cystic lesions-metastasis from sarcoma Bull’s eye (target) lesions- metastasis from lungs

Answer 240

B | The levator ani is one of the muscles of the pelvic floor.

Answer 241

C Seminomatous tumors are the most common “pure” germ cell tumor of the testes. Most common in white males age 40-50yrs. It has been associated with cryptorchidism, trisomy 21 (down syndrome), klinefelter syndrome, and smoking. When it metastasizes, it spreads to the retroperitoneal lymph nodes first. They have the best prognosis of all germ cell tumors because they are very responsive to radiation and chemotherapy.

Answer 242

C Ulcerative colitis allows bacteria to invade the blood stream through the portal venous system. This bacteria enters the liver where it produces gas that is identified within the portal system. An ERCP (endoscopic cholangiopancreatogram) is used to evaluate the head of the pancreas and ampulla of Vater. The procedure may allow a small amount of air to enter the ductal system through the ampulla of Vater.

Answer 243

C Hydatid infection is common in countries with lots of cows and sheep. The parasite infests the liver parenchyma and a cyst with numerous septations forms.

Answer 244

C Flow in the hepatic artery is normally low resistance with an RI of 0.55-0.8. Flow resistance increases to RI >0.8 and portal HTN, hepatic congestion, transplant rejection or chronic HCC is suspected.

Answer 245

B Renal papillary necrosis refers to ischemic necrosis of the renal papilla. The necrosis leads to the presence of sloughed papilla in the urine. It is most commonly caused by analgesic abuse.

Answer 246

C | Why not “A” since the aorta is located in the anterior pararenal space?????

Answer 247

A Biliary hamartomas AKA Meyenburg complexes. They are focal developmental lesions of the liver that are composed of groups of dilated intrahepatic ducts within dense stroma. US appearance includes multiple well defined hypoechoic solid nodules <1cm. numerous echoegenic foci with ringdown may also be identified throughout the liver. Biliary hamartomas have been associated with congenital hepatic fibrosis, autosomal dominant polycystic disease and cholangiocarcinoma.

Answer 248

C If the vessel is occluded there will be no flow detected! Celiac artery occlusion will cause a reversal flow of its branches.

Answer 249

C CHF indicates poor cardiac function. Blood flow returns to the heart from the lower extremities via the IVC. If the heart is not ejecting enough blood during systole, the venous return will backlog in the VIC. The IVC should normally collapse with respiration and demonstrate triphasic, pulsatile waveform on PW Doppler.

Answer 250

B In a properly functioning shunt, portal flow should move easily into the hepatic venous system with hepatopetal flow direction. Flow in the intrahepatic portal branches will be diminished as the main portal flow is shunted directly into the hepatic veins. Signs of portal HTN should diminish, reduced spleen size, reduced appearance of gastric and portal varicosities, resolution of ascites.

Answer 251

B | The right and left hepatic ducts follow the course of the portal veins to merge into the common hepatic duct.