Upper Extremity Venous Written Comp

Student Name: Courtney Mashburn

Date Submitted: 4/5/2015

Directions:

Students are required to complete each area based on the scan comp completed to receive maximum
points.
There are 10 sections; each section is worth a maximum of 5 points. Answers provided must relate to
specific information requested. Additional information including non-applicable information will result in
point deduction

Before the exam: Patient Interview, Chart Review, Possible Pathology, Patient Set Up, and Preparation
Section 1:
Identify the patients age, sex, ethnicity, current symptoms and pertinent history relevant to the exam.
Answer: A 53 year old Caucasian male who presented with right upper extremity swelling. The patient was in the
CCU and on a ventilator so no history about how long swelling has occurred could be asked. The patient did have
significant bruising on the underside of the forearm extending into the antecubital fossa also with so significant
swelling noticed and small amounts of edema was seen with ultrasound throughout the arm.

Identify the patients labs relevant to the exam (as high, low, or normal) and explain what the patients lab values
indicate.
If the patient had no labs, identify the labs relevant to the exam (with normal values) and explain what deviations
in these lab values indicate.
Answer: The patients D-dimer was elevated at 3.48 mg/L with normal values supposed to be less than 0.5 mg/L. A
positive D-dimer result may indicate the presence of an abnormally high level of fibrin degradation products. It
indicates that there may be significant thrombus formation and breakdown in the body

Identify the patients previous exams and results relevant to this exam.
If the patient had no previous exams, identify one other imaging modality that could be used to evaluate your
patients symptoms. Explain why this modality would be used in conjunction with sonography.
Answer: The patient had no previous exams relevant to an upper extremity venous ultrasound. A modality that
could be used is venography which is an x-ray test that involves injecting x-ray contrast material into a vein to
show how blood is flowing through the veins.
Grade for Section 1
Section 2:
Based on the patients clinical history, labs, and previous exams and results, what did you expect to find during this
exam and why?
Answer: Before seeing the patient, since they had no history of a previous blood clot or any imaging performed to
rule out one, I did not expect to see one but once seeing the patient on a ventilator and immobile with the swelling
and bruising on the arm, I expected that the patient could possibly have a blood clot based on the situation.
Grade for Section 2

Upper Extremity Venous Written Comp

Section 3:
Describe how you identified the patient and educated the patient on the exam being performed. Identify the
patient set up and exam preparation.
Answer: Since the patient was unconscious and on a ventilator, I verified him by his wristband and also with the
nurse that was in the room when I first walked in. The exam was ordered portable so before leaving the
department, I gathered gel and a couple of towels from the department, queried the machine making sure the
patients name was on there and shut the machine down to go to the floor. I told the patient and the nurse that I
was going to be performing an ultrasound on his arm to check for a blood clot and since I am a student, somebody
would be scanning behind me. I unbuttoned the buttons on the sleeve of the gown and tucked a towel into the
gown to avoid gel spreading to it and also laid a towel across the bed where I was leaning to avoid the spread of
germs.
Grade for Section 3

During the Exam: Sonographic findings of structures, pathologies, measurements, and instrumentation
Section 4:
Identify the gray scale and color Doppler sonographic features of the upper extremity veins included in this
protocol.
Answer: The deep veins found in the arm; the internal jugular, subclavian, brachial, radial, and ulnar veins are all
paired with an artery and sonographically appear with thin echogenic walls that collapse with compression, beside
the subclavian vein and they have anechoic lumen when free of thrombus. The superficial veins; basilic and
cephalic also appear with thin echogenic walls that collapse with compression and anechoic lumen. With color
Doppler, veins should completely fill with blue color without color aliasing or color noise present with the box
angled parallel to the vessel, no angle correct is needed when examining veins.
Grade for Section 4
Section 5:
Describe all venous spectral waveforms obtained and identify if each waveform is normal or abnormal. If
abnormal, what is indicated?
Answer: All venous spectral waveforms obtained were abnormal due to the fact the patient was on a ventilator.
The waveforms did not exhibit respiratory phasicity and cardiac pulsatility in the internal jugular, innominate, and
subclavian veins, instead there was on respiratory phasicity with the ventilator. The spectral waveforms in the
other upper extremity veins were phasic with the ventilator but did not look like normal venous spectral
waveforms seen. Also there was no augmentation performed during the exam because the patient did have a
thrombus in the basilic and cephalic veins.
Grade for Section 5
Section 6:
Identify the pathology documented during the exam including location, size, vascularity, and sonographic features.
If no pathology is seen, identify a common pathology seen with this exam and how you would need to modify your
protocol to document this pathology.
Answer: There was a hyperechoic non-occlusive thrombus seen in the basilic vein peripherally in the arm. The
thrombus found in the basilic vein exhibited color flow through the center of the vein with very little spectral

Upper Extremity Venous Written Comp

waveforms noted. There was also a hyperechoic occlusive thrombus seen in the cephalic vein that filled the vein
starting about mid upper arm continuing down to the elbow area. There was no color flow or spectral waveform
seen with this thrombus. The vessel diameter was also increased because of the size of the thrombus.
Grade for Section 6
Section 7:
Identify the ultrasound preset, transducer, and frequency utilized to provide diagnostic images and explain why
the specific instrumentation was correct.
Answer: The preset used was the UEV present with a 9L linear probe with a frequency of 9.0 MHz used throughout
the entire exam. This instrumentation was correct to provide optimal imaging of the upper extremity veins.
For your subclavian vein central color and spectral image, identify the color and spectral Doppler settings used and
explain why they were correct.
Answer: Color- this was correct because it demonstrated color flow and antegrade flow in the veins.
Frq 3.6
Gn 17.5
L/A 0/7
PRF 2.8
WF 148
S/P 4/16
AO% 100
Spectral- this was correct because it showed correct direction of flow and correct waveforms for patients on
ventilators.
Frq 4.2
Gn 51
PRF 8.0
WF 80
SV 5
SVD 2.5
AO% 100
For your basilic vein color and spectral image, identify the color and spectral Doppler settings used and explain
why they were correct.
Answer: Color- this was correct because is showed the limited flow in the non-occlusive thrombosed basilic vein
with antegrade flow.
Frq 3.6
Gn 23.5
L/A 0/7

Upper Extremity Venous Written Comp

PRF 0.9
WF 49
S/P 4/16
AO% 100
Spectral- this was correct because it showed that the flow was in the correct direction and also represented the
small amount of flow in the thrombosed portion of the vessel.
Frq 4.2
Gn 27
PRF 1.5
WF 71
SV 1
SVD 2.5
AO% 100
Grade for Section 7

Exam Findings: Students Preliminary Report and Physicians Interpretation

Section 8:
What did you report to the sonographer and/or physician regarding the exam? Describe your interaction.
Answer: I reported to the sonographer that the right basilic vein did not compress more peripherally. The right
basilic vein did demonstrate little flow with color Doppler and spectral Doppler. The right cephalic vein did not
compress and did not demonstrate any flow with color or spectral Doppler. She took a second look and agreed
that the vessels did not compress and that the other vessels looked fine. She also said it was very good that I found
the thrombus in the peripheral portion of the arm because that showed that I followed the vessel all the way down
with compressions instead of taking the compression picture centrally and moving on.
Grade for Section 8
Section 9:
What was the physicians interpretation of the exam?
Answer: The right jugular, subclavian, axillary and brachial veins are patent without evidence of deep vein
thrombosis. There is a nonocclusive superficial thrombophlebitis involving the right basilic vein. There is occlusive
superficial thrombophlebitis involving the right cephalic vein.
Grade for Section 9
Section 10:

Upper Extremity Venous Written Comp

Do you agree or disagree with the physicians interpretation of the exam? Why or why not? (This must be
supported by current literature)
Answer: I agree with the physicians interpretation of the exam because all patent veins were compressible and
anechoic lumen free of thrombus. The basilic vein demonstrated little flow through the middle of the vessel and
was partially compressible. The cephalic vein was completely occluded with thrombus, it did not compress at all,
appeared dilated, and there were no Doppler signals or color flow within the vessel.
Grade for Section 10

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

BMH Desoto
Audrey Galey RDMS (AB)(OB), RVT
1C10614294
Ultrasound Venous Upper Extremity Right
03/23/2015
NO

Points

Description

No errors were identified

One error was identified

Errors identified In less than the of the components required

Errors identified In up to s of the components required

Immediate action required

errors identified in more than s of the components required

evidence of an unsafe event (unsafe events may result in failure of the

competency)

required image not included