Organizing patients into groups such as medical-surgical, obstetric, pediatric, geriatric, or psychiatric is a common medical practice. Sonographic examinations, too, are categorized by clinical area or specialty. Initially, sonographers were expected to be able to perform all specialty examinations. As the field expanded and more sophisticated equipment and techniques were developed, however, this jack-of-all-trades rubric changed. Today most sonographers choose to specialize in one or more of the following clinically identified examinations:

This chapter focuses on the four most widely practiced diagnostic ultrasound specialties: abdominal, obstetric and gynecologic, cardiac, and vascular sonography. Many of these specialty examinations are associated with additional laboratory tests (see Appendix B). For complete descriptions of sonographic competencies and goals, the Sonography Clinical Assessment Notebook (SCAN), developed by the International Foundation for Sonography Education and Research is highly recommended for students, instructors, and working sonographers. It is available at www.ifser.squarespace.com. Regularly updated, the SCAN, and its electronic counterpart, the mSCAN, are valuable compendiums of specialty information. The SCAN and mSCAN contain specialty-specific master proficiency lists and performance objectives, guidelines, clinical evaluation forms, and logbook forms to document satisfactory mastery of specific scanning objectives. A completed SCAN is a record of an individual learner’s clinical competency and professionalism (Figure 6-1).

Patient positioning

An important part of performing sonography examinations is correct positioning of the patient and knowing when a position change can enhance the visualization of an area of interest. Figure 6-2 depicts the patient positions most commonly used in sonography.

Supine

This position also is referred to as the dorsal recumbent position. The patient lies on his or her back with head and upper shoulders slightly elevated to provide comfort and maintain the natural curve of the spine at the neck. A small pillow placed under the knees relieves pressure on the patient’s back. The patient’s arms should be positioned at the side or across the chest.

For examinations of the upper portion of the abdomen, elevating the patient’s right arm expands the rib spaces to their fullest. Opening up the intercostal spaces in this way facilitates the placement of small, narrow-faced transducers and improves transmission and reflection of the sound beam by eliminating rib artifacts.

Lateral

The patient lies on his or her side with arms positioned in front. The dependent arm may be elevated toward the head and the other arm crossed over the chest. The dependent leg should be straight, and the other leg should cross over so that the knee comes to rest on the tabletop, supporting the patient. For pregnant or elderly patients, a pillow between the legs at knee level provides additional comfort and stability.

Prone

The patient lies on his or her abdomen, arms flexed at either side or elevated alongside the head to widen the intercostal spaces. Small pads or pillows placed under the patient’s head, abdomen, and lower legs relieve pressure. The patient’s feet should extend off the scanning table.

Several position variations may be indicated during the course of an examination. These include the upright/erect, modified Fowler, and Trendelenburg positions (Figure 6-3).

Upright/Erect Position

The patient sits on the edge of the scanning table, right arm elevated above the head, left arm and hand providing support. This position is helpful in scanning a gallbladder in an extremely high position under the rib cage. In some studies (e.g., vascular examinations), the patient may have to stand erect for portions of the study.

Modified Fowler Position

The modified Fowler position is useful in advanced pregnancy when elevation of the patient’s head and upper portion of the back is necessary to avoid vena caval hypotension. The head of the patient’s bed or table is elevated 18 to 20 inches above level; the patient’s knees also are elevated.

Trendelenburg Position

In the Trendelenburg position, the head of the patient’s table or bed is tilted downward 30 to 40 degrees, and the table or bed is angled beneath the knees to elevate the patient’s pelvis. A pelvic elevation of 20% to 30% can be achieved by tilting the lower portion of a scanning table or with the use of pillows or foam bolsters. This position is used whenever fetal parts obscure the lower uterine segment or the fetal lie prevents suitable imaging of the fetal head.

Routine duties

Later in the chapter, scanning protocols for the four major specialty areas are presented in detail. However, a number of study-related and non–study-related duties apply to all ultrasound examinations. Regardless of the setting (e.g., hospital, clinic) or the type of examination, these routine duties are necessary to ensure quality and diagnostic patient studies and that the ultrasound laboratory functions smoothly and efficiently and can meet laboratory accreditation requirements (Box 6-1).

Box 6-1   Sonographers’ Duties

The following duties are associated with performing any specialty diagnostic ultrasound examinations.

Study-Related Duties

• Schedule review to obtain copies of any pertinent diagnostic or laboratory reports.

• Confirm that the patient’s preparation (fasting or hydrating stomach or bladder) has been carried out.

• Question the patient regarding his or her medical history.

• List present medications.

• Document laboratory data. Be aware of and include normal values and the function of any pertinent laboratory tests.

• Review and compare prior ultrasound or other diagnostic tests.

• Record and archive examination images per institutional directions.

• Prepare sonographer’s technical report.

Laboratory-Related Duties

• Quality assurance testing

• Transducer preparation and care

• Cleaning ultrasound equipment and preparing area for the next patient

• Maintaining supplies

Patient Preparation

Before commencing any ultrasound study, the sonographer must carry out several important tasks:

• Review the patient’s chart to verify the physician’s order and evaluate whether the ultrasound examination ordered is appropriate, given the patient’s symptoms and clinical diagnosis.

• Check the results of any prior diagnostic tests.

• Mentally review the sonographic protocols most likely to answer the clinical question(s).

• Inform the patient of the purpose of the ultrasound examination.

• Ascertain whether the patient has followed any required pre-examination preparations.

• Conduct a brief, but pertinent, patient history.

• Question the patient about any possible latex allergies.

• Perform a brief physical examination, if indicated by the ultrasound exam.

• Instruct the patient on disrobing.

• Position the patient on the scanning table.

• Select the appropriate instrumentation for the examination based on the patient’s body habitus and the examination objectives.

Schedule Review

Whenever possible, review the patient schedule so that any charts or previous and pertinent diagnostic or laboratory test results are available before initiating the study.

Image Generation, Recording, Distribution, and Archiving

Performing and reproducing high-quality ultrasound studies requires following current national standards of care guidelines, such as those developed by professional specialty organizations (see Appendix F). Periodically checking the websites of these organizations keeps your proficiencies current, as new procedures, clinical applications, and instrumentation are developed. The goal of most major hospitals and teaching centers is to create a filmless imaging department. That goal has been achieved by most by adopting the use of picture archiving and communication systems (PACS), computer-assisted programs that electronically store, manage, distribute, and allow viewing of images. The ability to share images and data through an institution-wide communication network has a positive impact on clinical and patient outcomes.

Radiology information systems (RIS) are computer-assisted programs designed to streamline scheduling and ordering of appointments, patient registration, work lists, billing, and medical and management reporting. RIS provide an improved turnaround time for the dictation and sending of reports to the referring physicians, patient scheduling, and so on. Among the additional benefits of filmless PACS and RIS are the savings in time and film costs, patient data tracking, improved dictation and transmission of reports, and validation of procedural codes.

Sonographers are responsible for ensuring that their study images and reports are transmitted properly into PACS or RIS as part of completing each case. If a sonographer works in a setting where such systems are unavailable, he or she is responsible for producing the most pertinent and diagnostic hard copy images of each study and submitting them, along with his or her technical impressions of the study, for interpretation.

Technical Reports

In many ultrasound departments, sonographers are required to provide a preliminary report of their findings and observations upon completion of the ultrasound study. To avoid litigation, the preliminary report may be referred to as the technical, or sonographer’s, impression, meaning that, as such, it is subject to reinterpretation. Technical difficulties encountered during the study should be documented and explained. Any report generated by a sonographer should indicate only essential sonographic findings and not attempt to provide a diagnosis (Box 6-2).

Box 6-2   Sonographer’s Technical Report

A sonographer’s report should describe only what has been documented on film. The following information should be included:

• Location of the scan plane*

• Normal or abnormal echogenicity, or both, of the organs studied

• Measurements and their locations*

• Presence of shadowing or acoustic enhancement

• Presence and location of any masses

• Presence and location of abnormal fluid collections^†

• Any technical difficulties encountered during the study

---

^*In some ultrasound practices the humerus, tibia/fibula, ulna, and radius are measured routinely. Also, in some institutions, the practices of transperineal or translabial and transrectal scans may be required.

^†Depending on the amount of fluid and patient body habitus, sagittal or decubitus scans, or both, may be indicated. This should be noted.

Procedural and Diagnostic Coding

In some ultrasound settings an additional sonographer duty is to enter the appropriate current procedural terminology (CPT) coding for each examination (Box 6-3). Initially instituted by the Health Care Financing Administration (HCFA), the task of maintaining and updating the CPT codes has been given to the American Medical Association (AMA). The purpose of the coding system is as follows:

Box 6-3   CPT Codes

Current procedural terminology (CPT) codes are a system of numbers developed by the American Medical Association for standardizing tasks and services that a medical practitioner provides to a patient. They are used by insurers to determine payment amounts. A sample of coding is listed below.

CPT Code 76816. Ultrasound, pregnant uterus, real-time with image documentation, transabdominal; limited follow-up.

CPT Code 76817. Ultrasound, pelvic (nonobstetric), B-scan and/or real-time with image documentation; complete.

• Provide uniform language that accurately describes medical, surgical, and diagnostic procedures performed by physicians and other health care providers.

• Assist in the assignment of reimbursement amounts to providers by Medicare carriers.

Keeping track of billing and coding compliance rules is a complex task, because the rules and documentation requirements change continuously. Your institution’s accounting and billing staff will issue periodic updates of the CPT codes. You are responsible for keeping them current in your department.

Quality Assurance Testing

Basic tests of the equipment should be performed on a regular basis and the results recorded in an equipment log or notebook. The areas for testing include instrument sensitivity evaluation, image photography uniformity, and vertical/horizontal measurement accuracy (Figure 6-4).

Transducer Preparation and Care

Transducers should be cleaned mechanically with an enzymatic cleanser between every patient study. Whenever a chance of contamination exists, the transducer should be cleaned using either a disinfectant or a sterilization process. When using a disinfecting agent (e.g., alcohol, phenolic solutions), strictly follow the manufacturer’s instructions for dilution, activation, temperature, and contact time. After the disinfecting process, thoroughly rinse the transducer with sterile water and dry it aseptically.

Strong glutaraldehyde solutions often are used to disinfectant transducers, but growing concern exists over the potential adverse effects of being exposed to glutaraldehyde liquids and vapors. The sonographer should check with his or her institution’s infection control supervisor to be sure that any transducer soaking cups or cleansing stations meet current Occupational Safety and Health Administration and Joint Commission requirements. (These requirements may be found at http://www.osha.org and http://www.jointcommission.org.) Guidelines for cleaning and preparing endocavitary ultrasound transducers are available at the American Institute of Ultrasound in Medicine (AIUM) website (http://www.aium.org).

Supplies

In addition to maintaining an adequate supply of linens and coupling gels, each ultrasound room should be equipped with a bedpan, urinal, emesis basin, IV stand, and sterile trays for use in performing paracentesis, thoracentesis, biopsies, aspirations, or amniocentesis procedures.

Specialty ultrasound protocols

The following sections describe the clinical indications and scanning protocols recommended for the four major clinical specialty exams. This material was contributed by nationally recognized registered sonographers working in accredited settings.

Abdominal and retroperitoneal sonography

Contributed by Robert DeJong, RDMS, RDCS, RVT, FSDMS

As an imaging tool, abdominal and retroperitoneal ultrasound is used to examine the abdominal cavity for fluid, abscesses, or lymph adenopathy; to examine the liver, spleen, pancreas, gallbladder, biliary tract, kidneys, and urinary tract; and to examine major abdominal vessels by using 2D, 3D, and Doppler ultrasound techniques.

Clinical indications include the following:

• Pain in the abdomen, flank, and/or back

• Referred pain from the abdominal or retroperitoneal regions

• Presence of palpable masses

• Enlarged organs

• Abnormal laboratory or physical findings

• Evaluation of known or suspected abnormalities

• Exploration for primary or metastatic disease

• Trauma

• Evaluation of known or suspected congenital abnormalities

• Evaluation of pre-transplant and post-transplant patients

• Identification of calculi in the urinary tracts

• Assessment and evaluation of tumors, cysts, abscesses, or fluid

• Evaluation of the abdominal arteries for the presence of an aneurysm

• Evaluation of narrowing of the abdominal arteries

• Guidance during aspiration or biopsy procedures

• Location of a foreign object within the abdominal/retroperitoneal organs or cavities

Because the presence of bowel gas, barium, or other radiology contrast materials in the intestine can block the ultrasonic viewing of internal organs, abdominal sonography should be done before any diagnostic imaging tests that require contrast material. Obesity and dehydration also may make it more difficult to obtain satisfactory images of the abdominal organs. For abdominal or right upper quadrant (RUQ) examinations, patients often are asked to avoid eating for 8 to 12 hours before their examination. To reduce the amount of bowel gas in the upper abdomen, it is best to make the patient NPO (nothing by mouth) after midnight and perform the exam in the morning. Patients also should refrain from smoking or chewing gum, because this can introduce air into the stomach. Patients should take needed medications with sips of water. In some instances, patients may be asked to drink water to fill their stomachs for better visualization of the digestive tract or pancreas. In our radiology departments, patients scheduled for abdominal artery examinations are asked to avoid eating for 8 to 12 hours before the test; alternatively, they may be on a clear liquid diet the day of the test. For urinary tract examinations, patients should drink two to four 8-ounce glasses of liquid 1 hour before the test to fill the urinary bladder.

Preliminary Steps for Abdominal and Retroperitoneal Examinations

1. Verify the order.

2. Identify the patient in accordance with the National Safety Patient Goals (NSPGs) published by The Joint Commission.

3. Confirm that the patient’s preparation for the abdominal sonographic examination has been followed.

4. Take the patient’s history and include the following information:

• Location of any pain, (e.g., right or left upper quadrant, general abdominal, or midabdominal)

• Feeling of fullness, fever, nausea, vomiting, burning, belching, or regurgitation related to certain types of food (e.g., fatty foods, fried foods)

• Flank pain or urinary tract symptoms (e.g., hematuria or cloudy urine)

5. Review the patient’s medical history and look for a history of infectious diseases (e.g., HIV, hepatitis), alcohol intake, drug use, personal or family history of carcinoma, known congenital anomalies, previous surgeries, and other disease processes.

6. Obtain a list of present medications, if required, especially before interventional procedures. (This is a National Safety Patient Goal.)

7. Document the findings of normal and abnormal values of laboratory tests, especially aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase, bilirubin, amylase, lipase, blood urea nitrogen, creatinine, and urinalysis.

8. Review any prior ultrasound or other diagnostic imaging tests, including abdominal radiographs, nuclear medicine, PET scans, CT scans, and MRI. If the images are not available, any reports should be read.

Beginning the Ultrasound Examination

Transducer selection will be based on the patient’s body habitus and the examination objectives. The equipment should be adjusted to operate at the highest appropriate frequency that allows adequate beam penetration. When examining infants or children, keep total ultrasound exposure as low as possible while still providing the necessary information. The most commonly used acoustic scanning medium is gel. On occasion, however, water, EKG gel, or another aqueous solution may be used. The recording modality most commonly used today is digital storage, commonly called PACS. Some departments may use film or videotapes.

Abdominal and retroperitoneal examinations use longitudinal, transverse, coronal, and oblique scanning planes. Depending on the examination objectives, a patient also may be placed in a lateral decubitus, erect, or prone position.

The organs listed below should be visualized. The study should demonstrate size, echo texture, and any pathology. Any suspected or known pathology must be documented in longitudinal and transverse planes. The echogenicity of the liver and right kidney, spleen and left kidney, and the liver and pancreas should be compared.

• Liver

• Gallbladder

• Common duct

• Kidneys

• Pancreas

• Spleen

• Diaphragm

• Aorta

• Inferior vena cava (IVC)

Color Doppler images (with accompanying spectral Doppler) of the major vessels serving the following organs and major vessels also should be performed. For certain accrediting bodies, the portal vein spectral Doppler signal must be angle-corrected.

• Liver

• Kidneys

• Aorta

• Inferior vena cava (IVC)

If any fluid collections—abscess, ascites, or hemorrhage—are found, the following areas should also be investigated:

• Mid quadrants: transverse images at the level of the umbilicus

• Lower quadrants: transverse images at the level of the iliac crests

• Pelvis: sagittal midline image

A standard protocol for a right and left upper quadrant sonogram should include longitudinal (sagittal) views of the following:

• Aorta and distal aorta, if patient is older than 55 years of age

• Right, left, and caudate lobes of the liver

• Inferior vena cava

• Common bile duct

• Main lobar fissure and gallbladder

• Head of the pancreas

• Right and left kidneys

• Lateral aspects of the liver and spleen to view diaphragms and pleural spaces

• Spleen

• Adrenal gland area (Note: On pediatric patients the adrenal glands are seen routinely, whereas on adults they are seen infrequently.)

Transverse views should include the following:

• Levels of the hepatic veins

• Porta hepatis to demonstrate common duct, portal vein, and hepatic artery

• Liver to demonstrate the right, left, and caudate lobes

• Gallbladder to demonstrate the neck, body, and fundus of the gallbladder

• Pancreatic region to demonstrate the head, uncinate process, body, and the tail

• Right and left kidneys to demonstrate the upper, mid, and lower poles

• Spleen

• Adrenal glands

• Aorta to demonstrate the upper, mid, and distal aspects

Color Doppler images, with spectral Doppler, of the splenic vein and artery and renal veins and arteries should be used to demonstrate blood flow direction and patency as requested or required.

Left lateral decubitus (right side up) views should include the following:

• Longitudinal views through the gallbladder

• Longitudinal view through the common duct

• Transverse views of the gallbladder at the level of the neck, body, and fundus

• Additional views as needed. Upright scans may be useful in revealing the presence of gallbladder sludge or stones. Prone scans are helpful in visualizing the kidneys, especially when bowel gas obscures the lower poles.

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