Unilateral Lower Extremity Venous Competency

Student Name: Sarah Craig

Date Written Comp submitted: 4/7/13

Directions: Students are required to complete each area to receive maximum points There are 10 sections, each section is worth a maximum of 5 points Only written competency completed with this EXACT form will be accepted for grading. Failure to comply will result in a zero for the written competency. (Note- there are sections that allow you to add rows) Clinical Site: Baptist Desoto Sonographer Providing Scan Comp Grade: Connie Willis Identify the Sonographers Credentials: RDMS, RVT, RDCS Patient MRN: 0000275139 Exam Ordered on Request: US Doppler Lower Ext Veins Lt Date the Final Scan Competency was Performed: 3/22/2013

Section I: Room and Patient Prep In summary format, complete the following regarding procedures you did as it relates to the examination. Explanation

Examination preparation

Identify the exam room set up The patient was an emergency department patient who was brought and patient setup include into the department by transportation in a wheelchair. The patient reasoning for set up used was asked to remove her pants and laid supine on a stretcher that was placed to the right of the machine after I insured the wheels were locked. I raised the stretcher to the proper height for good body mechanics. The machine was moved close the patient and the keyboard was raised and pulled out for easier access. I stood during the exam. The lighting in the room was dimed and the temperature was cool. After the patient removed her pants I covered her right leg with a sheet while I scanned her left leg. I also tucked a towel into the patients underwear at the groin crease on the left side. I asked the patient to bend her left leg at the knee and roll it out to the side and asked if she was ok laying in that position. She said that she was. The gel was warmed for the patients comfort. Patient identification process The patient answered as I addressed her by name. I checked her wrist band to insure that the MR number matched the request and was correct. I also asked the patient to verbalize her birthdate,

Unilateral Lower Extremity Venous Competency which she did and was checked against the information on the request and machine. The patient verbally conformed that she was not allergic to anything after being asked. I explained to the patient that I was a student and that I was going to perform exam and that the sonographer would be coming in to scan behind me. I told her that I would be looking the veins in her left leg. I told her that pressure would be applied to different areas of the leg to ensure that no blood clot was present but the exam should be relatively painless and that it did not involve and any radiation or needles. I asked if she had any questions and she replied that she did not. Before the exam I used alcohol based hand sanitizer and let it dry before placing gloves on both hands. After ending the exam I wiped the gel off of the patient and then the transducer with a towel, I used santi-wipes to clean the transducer and the cord. I used alcohol based hand sanitizer immediately after taking the gloves off. After helping the patient back in her wheelchair and placing her in the hallway to wait for transportation and before reviewing the images I washed by hands with soap and warm water. Section II: Patient Interview 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 and specifics related to the specific competency. Each required component contains several components, answer each component listed: 1st. Example: Age 35, Race Caucasian, Sex Female, Weight-not available in patient chart Required (Answer each component listed) Age, Race, Sex and Weight 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 Discussion (Must include specifics regarding exam ordered and organs included in the LEV protocol) Age 34, Race Caucasian, Sex Female, Weight-not available in patient chart or on the request form. Reason the exam was ordered: left leg/foot swollen The patient was from the emergency department and had not been admitted to the hospital. The patient had no previous imaging exams that related to the exam ordered. The patient stated that she had never had an ultrasound on her legs.

Identification of allergies Explanation of exam to patient (must include specifics about organs involved in the competency performed)

Universal Precautions utilized at the beginning, throughout, and end of exam (Sterile technique, hand washing, transducer cleaning, etc.)

Grade:

Unilateral Lower Extremity Venous Competency Pertinent lab values At the time the exam was preformed there were no available lab values for review. However, pertinent lab values for this exam include D-dimer which may correlate with the presence or absence of thrombus and possibly hematocrit and white blood cell count. The patient stated that she had never had any medical problems relating to legs or heart. She also stated that the only previous surgery she had was cosmetic. The patient was pregnant and in her third trimester. I asked the patient what brought her for her exam. She said that she was having swelling in her left leg and foot. I asked if the swelling changed with elevation or over time. She said that the swelling went down when she laid down and that it was not as bad on the day of the exam as it had been the previous day. I asked her if she had experienced any pain with the swelling. She said that she had some pain but it was tolerable. I asked how long the swelling had been going on. She said it had gotten bad over the last two days. I asked the patient if she had ever had problems like this before. She said no. I asked the patient if she had been placed on bed rest. She said no. I asked the patient if had ever had a blood clot. She said no. I asked the patient if she had ever had an ultrasound on her legs before. She said no. I asked the patient if she was allergic to anything. She said no. I asked the patient if she had ever had problems with her heart. She said no. I asked the patient if she had hypertension or diabetes with her pregnancy. She said no. I asked the patient if she smoked. She said no. I asked the patient if she has had any surgeries. She said only cosmetic. The fact that the patient was pregnant and in the third trimester is an important factor because it is a risk factor for DVT. Her clinical symptoms of unilateral swelling and pain are associated with DVT as well as other vascular and lower extremity pathologies.

Additional Patient History from chart and interview (surgeries, previous hospital admissions, etc) Current clinical symptoms and pertinent information from chart and interview. (Must include questions asked of the patient including answers given)

What information is most significant in regards to the organs included in the complete abdomen competency and why? Grade:

Section III: Analyze Patient Information

Unilateral Lower Extremity Venous Competency Using information gathered from section II (patient interview) complete this section with an applicable pathology. The identified pathology should be determined in the following order: 1. Current clinical symptoms as it relates to the LEV 2. If clinical symptoms are vague, use clinical history (previous surgery, test, etc) 3. If unable to determine pathology, contact grading instructor for assistance. Detailed directions for the following components Sonographic findings- all sonographic findings must be included, use of proper terminology is required. Where else to look-explain where else you would look sonographically if the pathology is present. Consider other organs that may be affected, other blood flow sources that may be affected, etc. Pitfalls-explain why the diagnosis of the pathology may be incorrect Such as improper technical setting, improper scan technique, a differential that looks similar, etc. Pathology (Must relate to the LEV exam) Name and synonyms for pathology Reason for selecting pathology Definition Acute Deep Vein Thrombosis (DVT) I selected this pathology because the patient was pregnant, which is a significant risk factor for DVT, and her symptoms of unilateral pain and swelling which correlate with this pathology. Acute DVT is the formation of thrombus with in the deep venous system due to development to thrombin. To be considered acute the DVT development is less than four weeks old. Risk factors for DVT include a post operative state, cancer, trauma, pregnancy, hormones, immobility, and thrombophilia. Symptoms include unilateral pain and swelling, which is the most predictive, or could be asymptomatic. Lab values include a positive D-dimer Acute DVT can appear as intraluminal echoes within a dilated vessel that appear faintly echogenic to hypoechoic and may appear attached or poorly attached (floating) to the vessel wall. With the presence of DVT the vessel walls will not compression with transducer pressure. With the use of color Doppler the area of the DVT will demonstrate a color void if the thrombus is partially attached to the vessel wall and/or no flow will be detected if the thrombus is occlusive. With the use of spectral Doppler there will be a loss of spontaneous, phasic forward flow and there will be no response visualized to peripheral augmentation in a partially obstructive DVT. If the thrombus is present within the iliac veins or

Clinical Findings (Symptoms, lab values, etc.) Sonographic Features (main findings)

Unilateral Lower Extremity Venous Competency the inferior vena cava (IVC) the spectral Doppler in peripheral veins may be dampened with a loss of phasicity or cardiac pulsatility. In an obstructive thrombus no flow will be present. DVT can occur anywhere in the deep venous system; therefore the entire deep venous system should be evaluated including veins in the lower extremities, including the calf veins, the upper extremities and the IVC. If DVT is found the superficial venous system in the same leg should also be evaluated. The other leg should also be evaluated when a DVT is found because there is an increased risk to form an additional thrombus. Other modalities can be used to evaluate for a pulmonary embolism in the lungs, especially if the patient presents with shortness of breath. There are many pitfalls in that can occur during a LEV exam. A pitfall is patient body habitus, if the patient is obese visualization and compression of the veins is difficult due to the depth at which the veins are located. Another pitfall is due to the vein being in line with bone or a tendon making compression difficult and possibly resulting in a false positive.

Where else to look (what other organs could be involved and why)

Pitfalls (Improper technical setting, a differential, improper scans technique, etc.) Grade:

Section IV: Diagnostic Image Quality- Acquired Images Provide details regarding the images taken in the required LEV Competency (all organs required) These are images that the student took as part of the required liver competency If the examination is required to be reviewed, the images should be able to easily be identified and verified. Students are required to image each structure of the required competency, if a situation occurs that this cannot be completed due to clinical site instructions, contact the clinical coordinator immediately. If additional images are taken of structures required for the competency. Add additional rows to the bottom of the table Scan Plane Label Landmarks (Key structures required for the image according to protocol) Left External Iliac Vein Sonographic Features (Identify and describe the sonographic appearance of each structure seen in the image) Dual screen was utilized to show a comparison of the vein with and without compression. Skin layer superficial

Structure

EIV

Transverse Dual Screen

LEFT EIV W/COMP

Unilateral Lower Extremity Venous Competency echogenic layer Muscle layer hypoechoic to the surrounding tissue with echogenic striations Surrounding tissue heterogeneous with areas of increased echogenicity due to the presence of adipose tissue EIV anechoic lumen EIA anechoic lumen with echogenic walls (In this image there was some artifact present in the vessels which could have cleared out with greater use of TGCs.) All vessels appeared round due to the transverse viewing plane. With compression the EIV compressed completely and the EIA was partially compressed appearing oval in shape. The skin, tissue, and muscle layers were still visualized with compression. Skin layer superficial echogenic layer Muscle layer hypoechoic to the surrounding tissue with echogenic striations Surrounding tissue heterogeneous with areas of increased echogenicity due to the presence of adipose tissue Valve leaflet echogenic line extending into the EIV lumen EIV anechoic lumen (In this image there was some artifact present in the vessels not included in the color box which could have cleared out with greater use of TGCs.)

EIV

Sagittal

LEFT EIV

Left External Iliac Vein

Unilateral Lower Extremity Venous Competency The vessel appeared long due to sagittal viewing plane. Color Doppler was utilized and the vein is filled with an even shade of blue, within the steered color box, which demonstrated the flow was traveling away from the transducer, showed the average velocity, as well as the presence of blood cells. The vessel was angled and PRF and color gain were set for optimal detection of the slow venous flow. Skin layer superficial echogenic layer Muscle layer hypoechoic to the surrounding tissue with echogenic striations Surrounding tissue heterogeneous with areas of increased echogenicity due to the presence of adipose tissue Valve leaflet echogenic line extending into the EIV lumen EIV anechoic lumen (In this image there was some artifact present in the vessels not included in the color box which could have cleared out with greater use of TGCs.) The vessel appeared long due to sagittal viewing plane Color Doppler was utilized and the vein is filled with an even shade of blue, within the steered color box, which demonstrated the flow was traveling away from the transducer, showed the average velocity, as well as the presence of blood cells. The vessel was angled and

EIV

Sagittal

LEFT EIV AUGMENT

Left External Iliac Vein

Unilateral Lower Extremity Venous Competency PRF and color gain were set for optimal detection of the slow venous flow. Spectral Doppler was utilized to show the average velocity and the response of the blood flow to peripheral augmentation. The spectral gate was placed in the center of the vessel to detect the highest velocities. The spectral trace was also visualized demonstrating normal flow (spontaneous, phasic, forward slow venous flow), response from peripheral augmentation, and return to normal flow. The baseline and PRF were set so that the augmentation was well visualized with no aliasing. Dual screen was utilized to show a comparison of the veins with and without compression. Skin layer superficial echogenic layer Muscle layer hypoechoic to the surrounding tissue with echogenic striations Surrounding tissue heterogeneous with areas of increased echogenicity due to the presence of adipose tissue CFV anechoic lumen GSV anechoic lumen CFA anechoic lumen with echogenic walls All vessels appeared round due to the transverse viewing plane With compression the CFV and GSV compressed completely and the CFA was

CFV/GSV

Transverse

LEFT CFV GSV W/COMP

Common Femoral Vein (CFV) & Left Greater Saphenous Vein (GSV) Junction

Unilateral Lower Extremity Venous Competency partially compressed appearing oval in shape. The skin, tissue, and muscle layers were still visualized with compression. Skin layer superficial echogenic layer Muscle layer hypoechoic to the surrounding tissue with echogenic striations Surrounding tissue heterogeneous with areas of increased echogenicity due to the presence of adipose tissue CFV and GSV at junction both appear with an anechoic lumen with the GSV branching from the CFV The vessels appear long due to the sagittal viewing plane. Color Doppler was utilized and the veins filled with an even shade of blue, within the steered color box, which demonstrated the flow was traveling away from the transducer, showed the average velocity, as well as the presence of moving blood cells. (Within the color box the CFA was filled with a small amount of red, the vessel was not filled completely because the settings were for the slow venous flow and not the increased velocity of an artery. The color demonstrated that the flow was going toward the transducer and the presence of moving blood cells.) The vessel was angled and PRF and color gain were set for optimal detection of the

CFV/GSV

Sagittal

LEFT CFV GSV

Left Common Femoral Vein & Left Greater Saphenous Vein Junction

Unilateral Lower Extremity Venous Competency slow venous flow. Skin layer superficial echogenic layer Muscle layer hypoechoic to the surrounding tissue with echogenic striations Surrounding tissue heterogeneous with areas of increased echogenicity due to the presence of adipose tissue CFV and GSV at junction both appear with an anechoic lumen with the GSV branching from the CFV The vessels appear long due to the sagittal viewing plane. Color Doppler was utilized and the veins filled with an even shade of blue, within the steered color box, which demonstrated the flow was traveling away from the transducer, showed the average velocity, as well as the presence of moving blood cells. (Within the color box the CFA was filled with a small amount of red, the vessel was not filled completely because the settings were for the slow venous flow and not the increased velocity of an artery. The color demonstrated that the flow was going toward the transducer and the presence of moving blood cells.) The vessel was angled and PRF and color gain were set for optimal detection of the slow venous flow. Spectral Doppler was utilized to show the average velocity and the response of the

CFV

Sagittal

LEFT CFV AUGMENT

Left Common Femoral Vein & Left Greater Saphenous Vein Junction

Unilateral Lower Extremity Venous Competency blood flow to peripheral augmentation. The spectral gate was placed in the center of the vessel to detect the highest velocities. The spectral trace was also visualized demonstrating normal flow (spontaneous, phasic, slow forward venous flow), response from peripheral augmentation, and return to normal flow. The baseline and PRF were set so that the augmentation was well visualized with no aliasing. Skin layer superficial echogenic layer Muscle layer hypoechoic to the surrounding tissue with echogenic striations Surrounding tissue heterogeneous with areas of increased echogenicity due to the presence of adipose tissue CFV and GSV at junction both appear with an anechoic lumen with the GSV branching from the CFV The vessels appear long due to the sagittal viewing plane. Color Doppler was utilized and the veins filled with an even shade of blue, within the steered color box, which demonstrated the flow was traveling away from the transducer, showed the average velocity, as well as the presence of blood cells. The vessel was angled and PRF and color gain were set for optimal detection of the slow venous flow. Spectral Doppler was utilized

GSV

Sagittal

LEFT GSV AUGMENT

Left Common Femoral Vein & Left Greater Saphenous Vein Junction

Unilateral Lower Extremity Venous Competency to show the average velocity and the response of the blood flow to peripheral augmentation. The spectral gate was placed in the center of the vessel to detect the highest velocities. The spectral trace was also visualized demonstrating normal flow (spontaneous, phasic, slow forward venous flow), response from peripheral augmentation, and return to normal flow. The baseline and PRF were set so that the augmentation was well visualized with no aliasing. Left Femoral Vein Dual screen was utilized to Central & Left Profunda show a comparison of the veins with and without compression. Skin layer superficial echogenic layer Muscle layer hypoechoic to the surrounding tissue with echogenic striations Surrounding tissue heterogeneous with areas of increased echogenicity due to the presence of adipose tissue Fascia echogenic lines FV Central anechoic lumen Profunda anechoic lumen FA Prox anechoic lumen with echogenic walls Profunda femoral artery anechoic lumen with echogenic walls (In this image there was some artifact present in the vessels which could have cleared out with greater use of TGCs.) All vessels appeared round

FV C/Prof

Transverse

LEFT FV CENTRAL PROFUNDA W/COMP

Unilateral Lower Extremity Venous Competency due to the transverse viewing plane. With compression the FV Central and Profunda vein compressed completely and the FA Prox and the Profunda femoral artery were partially compressed appearing oval in shape. The skin, tissue, and muscle layers were still visualized with compression. Left Femoral Vein Skin layer superficial Central & Left Profunda echogenic layer Muscle layer hypoechoic to the surrounding tissue with echogenic striations Surrounding tissue heterogeneous with areas of increased echogenicity due to the presence of adipose tissue CFV anechoic lumen FV Central anechoic lumen Profunda anechoic lumen The CFV is seen bifurcating into FV Central and Profunda (or deep femoral vein) FA Prox anechoic lumen with echogenic walls Profunda femoral artery anechoic lumen with echogenic walls (In this image there was some artifact present, in the vessels not included in the color box, which could have cleared out with greater use of TGCs.) All vessels appear long due to the sagittal viewing plane. Color Doppler was utilized and the veins filled with an even shade of blue, within the steered color box, which demonstrated the flow was

FV C/Prof

Sagittal

LEFT FV CENTRAL PROFUNDA

Unilateral Lower Extremity Venous Competency toward the transducer, showed the average velocity, as well as the presence of blood cells. The vessels were angled and the PRF and color gain were set for optimal detection of the slow venous flow. Left Femoral Vein Skin layer superficial Central & Left Profunda echogenic layer Muscle layer hypoechoic to the surrounding tissue with echogenic striations Surrounding tissue heterogeneous with areas of increased echogenicity due to the presence of adipose tissue CFV anechoic lumen FV Central anechoic lumen Profunda anechoic lumen The CFV is seen bifurcating into FV Central and Profunda (or deep femoral vein) FA Prox anechoic lumen with echogenic walls Profunda femoral artery anechoic lumen with echogenic walls (In this image there was some artifact present in the vessels not included in the color box which could have cleared out with greater use of TGCs.) All vessels appear long due to the sagittal viewing plane. Color Doppler was utilized however, there was no flow seen due to the time at which the FV was sampled, within the steered color box, (Within the color box the FA Prox was filled with a small amount of red, the vessel was not filled completely

FV Central

Sagittal

LEFT FV CENTRAL AUGMENT

Unilateral Lower Extremity Venous Competency because the settings were for the slow venous flow and not the increased velocity of an artery. The color demonstrated that the flow was going toward the transducer and the presence of moving blood cells.) The vessels were angled and the PRF and color gain were set for optimal detection of the slow venous flow. Spectral Doppler was utilized to show the average velocity and the response of the blood flow to peripheral augmentation. The spectral gate was placed in the center of the vessel to detect the highest velocities. The spectral trace was also visualized demonstrating normal flow (spontaneous, phasic, slow forward venous flow), response from peripheral augmentation, and return to normal flow. The baseline, PRF, and spectral gain were set so that the augmentation was well visualized with no aliasing. Left Femoral Vein Skin layer superficial Central & Left Profunda echogenic layer Muscle layer hypoechoic to the surrounding tissue with echogenic striations Surrounding tissue heterogeneous with areas of increased echogenicity due to the presence of adipose tissue CFV anechoic lumen FV Central anechoic lumen Profunda anechoic lumen The CFV is seen bifurcating into FV Central and Profunda

Profunda V

Sagittal

LEFT PROFUNDA AUGMENT

Unilateral Lower Extremity Venous Competency (or deep femoral vein) FA Prox anechoic lumen with echogenic walls Profunda femoral artery anechoic lumen with echogenic walls (In this image there was some artifact present in the vessels not included in the color box which could have cleared out with greater use of TGCs.) All vessels appear long due to the sagittal viewing plane. Color Doppler was utilized and the Profunda vein filled with an even shade of blue, within the steered color box, which demonstrated the flow was going toward the transducer, showed the average velocity, as well as the presence of blood cells. The vessel was angled and PRF and color gain were set for optimal detection of the slow venous flow. Spectral Doppler was utilized to show the average velocity and the response of the blood flow to peripheral augmentation. The spectral gate was placed in the center of the vessel to detect the highest velocities. The spectral trace was also visualized demonstrating normal flow (spontaneous, phasic, slow forward venous flow), response from peripheral augmentation, and return to normal flow. The baseline, PRF, and spectral gain were set so that the augmentation was well visualized with no aliasing.

Unilateral Lower Extremity Venous Competency FV Mid Transverse LEFT FV MID W/COMP Left Femoral Vein Mid Dual screen was utilized to show a comparison of the veins with and without compression. Skin layer superficial echogenic layer Muscle layer hypoechoic to the surrounding tissue with echogenic striations Surrounding tissue heterogeneous with areas of increased echogenicity due to the presence of adipose tissue FV Mid anechoic lumen FA Mid anechoic lumen with echogenic walls (In this image there was some artifact present in the vessels not included in the color box which could have cleared out with greater use of TGCs.) All vessels appeared round due to the transverse viewing plane. With compression the FV Mid compressed completely and the FA mid was partially compressed appearing oval in shape. The skin, tissue, and muscle layers were still visualized with compression. Skin layer superficial echogenic layer Muscle layer hypoechoic to the surrounding tissue with echogenic striations Surrounding tissue heterogeneous with areas of increased echogenicity due to the presence of adipose tissue FV Mid anechoic lumen FA Mid anechoic lumen with echogenic walls

FV Mid

Sagittal

LEFT FV MID

Femoral Vein Mid

Unilateral Lower Extremity Venous Competency (In this image there was some artifact present in the vessels not included in the color box which could have cleared out with greater use of TGCs.) All vessels appear long due to the sagittal viewing plane. Color Doppler was utilized and the vein filled with an even shade of blue, within the steered color box, which demonstrated the flow was going toward the transducer, showed the average velocity, as well as the presence of blood cells. The vessel was angled and PRF and color gain were set for optimal detection of the slow venous flow. Skin layer superficial echogenic layer Muscle layer hypoechoic to the surrounding tissue with echogenic striations Surrounding tissue heterogeneous with areas of increased echogenicity due to the presence of adipose tissue FV Mid anechoic lumen FA Mid anechoic lumen with echogenic walls (In this image there was some artifact present in the vessels not included in the color box which could have cleared out with greater use of TGCs.) All vessels appear long due to the sagittal viewing plane. Color Doppler was utilized and the vein filled with an even shade of blue and with a gap in color due to the time

FV Mid

Sagittal

LEFT FV MID AUGMENT

Femoral Vein Mid

Unilateral Lower Extremity Venous Competency the vessel was sampled, within the steered color box, which demonstrated the flow was going toward the transducer, showed the average velocity, as well as the presence of blood cells. The vessel was angled and PRF and color gain were set for optimal detection of the slow venous flow. Spectral Doppler was utilized to show the average velocity and the response of the blood flow to peripheral augmentation. The spectral gate was placed in the center of the vessel to detect the highest velocities. The spectral trace was also visualized demonstrating normal flow (spontaneous, phasic, slow forward venous flow), response from peripheral augmentation, and return to normal flow. The baseline, PRF, and spectral gain were set so that the augmentation was well visualized with no aliasing. Dual screen was utilized to show a comparison of the veins with and without compression. Muscle layer hypoechoic to the surrounding tissue with echogenic striations Surrounding tissue heterogeneous with areas of increased echogenicity due to the presence of adipose tissue FV Peripheral anechoic lumen FA Distal anechoic lumen with echogenic walls

FV Peripheral

Transverse

LEFT FV Femoral Vein PERIPHERAL Peripheral W/COMP

Unilateral Lower Extremity Venous Competency (In this image there was some artifact present in the vessels which could have cleared out with greater use of TGCs.) All vessels appeared round due to the transverse viewing plane. With compression the FV Peripheral compressed completely and the FA Distal was partially compressed appearing oval in shape. The skin, tissue, and muscle layers were still visualized with compression. Skin layer superficial echogenic layer Muscle layer hypoechoic to the surrounding tissue with echogenic striations Surrounding tissue heterogeneous with areas of increased echogenicity due to the presence of adipose tissue FA Distal anechoic lumen with echogenic walls (In this image there was some artifact present in the vessels not included in the color box which could have cleared out with greater use of TGCs.) All vessels appear long due to the sagittal viewing plane. Color Doppler was utilized and the vein filled with an even shade of blue, within the steered color box, which demonstrated the flow was going toward the transducer, showed the average velocity, as well as the presence of blood cells. The vessel was angled and

FV Peripheral

Sagittal

LEFT FV Femoral Vein PERIPHERAL Peripheral

Unilateral Lower Extremity Venous Competency PRF and color gain were set for optimal detection of the slow venous flow. Skin layer superficial echogenic layer Muscle layer hypoechoic to the surrounding tissue with echogenic striations Surrounding tissue heterogeneous with areas of increased echogenicity due to the presence of adipose tissue FV Peripheral anechoic lumen FA Distal anechoic lumen with echogenic walls (In this image there was some artifact present in the vessels not included in the color box which could have cleared out with greater use of TGCs.) All vessels appear long due to the sagittal viewing plane. Color Doppler was utilized and the vein filled with an even shade of blue, within the steered color box, which demonstrated the flow was going toward the transducer, showed the average velocity, as well as the presence of blood cells. The vessel was angled and PRF and color gain were set for optimal detection of the slow venous flow. Spectral Doppler was utilized to show the average velocity and the response of the blood flow to peripheral augmentation. The spectral gate was placed in the center of the vessel to detect the highest velocities. The

FV Peripheral

Sagittal

LEFT FV Femoral Vein PERIPHERAL Peripheral AUGMENT

Unilateral Lower Extremity Venous Competency spectral trace was also visualized demonstrating normal flow (slow forward venous flow), response from peripheral augmentation, and return to normal flow. The baseline, PRF, and spectral gain were set so that the augmentation was well visualized with no aliasing. Dual screen was utilized to show a comparison of the veins with and without compression. Muscle layer hypoechoic to the surrounding tissue with echogenic striations Surrounding tissue heterogeneous with areas of increased echogenicity due to the presence of adipose tissue Femur echogenic curved line with posterior shadowing Lesser saphenous vein (LSV) anechoic lumen Pop vein anechoic lumen Pop artery anechoic lumen with echogenic walls The Pop Vein was imaged at the Hunters canal, posterior to the knee, which is why the vein appears anterior to the artery. Small superficial vessels were also visualized appearing with anechoic lumens and some with echogenic walls. All vessels appeared round due to the transverse viewing plane. With compression the Pop vein, LSV, and the small superficial vessels compressed completely and

POP V

Transverse

LEFT POPV W/COMP

Popliteal Vein

Unilateral Lower Extremity Venous Competency the Pop artery was partially compressed appearing oval in shape. The skin, tissue, muscle layers, and Femur bone were still visualized with compression. Skin layer superficial echogenic layer Muscle layer hypoechoic to the surrounding tissue with echogenic striations Surrounding tissue heterogeneous with areas of increased echogenicity due to the presence of adipose tissue Femur echogenic curved line with posterior shadowing Lesser saphenous vein (LSV) anechoic lumen Pop vein anechoic lumen Pop artery anechoic lumen with echogenic walls Small superficial vessels were also visualized appearing with anechoic lumens and some with echogenic walls The Pop vein and Pop artery appear long due to the sagittal viewing plane. Color Doppler was utilized and the Pop vein filled with an even shade of blue, within the steered color box, which demonstrated the flow was going toward the transducer, showed the average velocity, as well as the presence of moving blood cells. The vessel was angled and PRF and color gain were set for optimal detection of the slow venous flow. Skin layer superficial echogenic layer

POP V

Sagittal

LEFT POPV

Popliteal Vein

POP V

Sagittal

LEFT POPV AUGMENT

Popliteal Vein

Unilateral Lower Extremity Venous Competency Muscle layer hypoechoic to the surrounding tissue with echogenic striations Surrounding tissue heterogeneous with areas of increased echogenicity due to the presence of adipose tissue Pop vein anechoic lumen Pop artery anechoic lumen with echogenic walls The Pop vein and pop artery appear long due to the sagittal viewing plane. Color Doppler was utilized and the vein filled with an even shade of blue, within the steered color box, which demonstrated the flow was going toward the transducer, showed the average velocity, as well as the presence of moving blood cells. The vessel was angled and PRF and color gain were set for optimal detection of the slow venous flow. Spectral Doppler was utilized to show the average velocity and the response of the blood flow to peripheral augmentation. The spectral gate was placed in the center of the vessel to detect the highest velocities. The spectral trace was also visualized demonstrating normal flow (slow forward venous flow), response from peripheral augmentation, and return to normal flow. The baseline, PRF, and spectral gain were set so that the augmentation was well visualized with no aliasing. Dual screen was utilized to

PTV/PERON

Transverse

LEFT PTV

Posterior Tibial Veins

Unilateral Lower Extremity Venous Competency PERON W/COMP (PTVs) and Peroneal Veins (Peron) show a comparison of the veins with and without compression. Skin layer superficial echogenic layer Muscle layer hypoechoic to the surrounding tissue with echogenic striations Surrounding tissue heterogeneous with areas of increased echogenicity due to the presence of adipose tissue Fascia echogenic lines Tibia echogenic curved line with posterior shadowing Fibula small echogenic curved line with posterior shadowing PTVs anechoic lumen Peron anechoic lumen Posterior Tibia Artery (PTA) anechoic lumen with echogenic walls Peroneal artery anechoic lumen with echogenic walls Small superficial vessels were also visualized appearing with anechoic lumens and some with echogenic walls. All vessels appeared round due to the transverse viewing plane. With compression the PTVs, Peron, and small superficial vessels compressed completely and the PTA was partially compressed appearing oval in shape. The skin, tissue, muscle layers, and Femur were still visualized with compression. Skin layer superficial echogenic layer Muscle layer hypoechoic to

PTV

Sagittal

LEFT PTV

Posterior Tibial Veins

Unilateral Lower Extremity Venous Competency the surrounding tissue with echogenic striations Surrounding tissue heterogeneous with areas of increased echogenicity due to the presence of adipose tissue PTVs anechoic lumen Peron anechoic lumen PTA anechoic lumen with echogenic walls Peroneal artery anechoic lumen with echogenic walls The vessels appear long due to the sagittal viewing plane. Color Doppler was utilized and the veins filled with an even shade of blue, within the steered color box, which demonstrated the flow was going away from the transducer, showed the average velocity, as well as the presence of moving blood cells. (Within the color box the PTA was filled with a small amount of red, the vessel was not filled completely because the settings were for the slow venous flow and not the increased velocity of an artery. The color demonstrated that the flow was going toward the transducer and the presence of moving blood cells.) Peripheral augmentation aided in demonstrating the vessels filled with color. The vessel was angled and PRF and color gain were set for optimal detection of the slow venous flow. Skin layer superficial echogenic layer

PTV

Sagittal

LEFT PTV AUGMENT

Posterior Tibial Veins

Unilateral Lower Extremity Venous Competency Muscle layer hypoechoic to the surrounding tissue with echogenic striations Surrounding tissue heterogeneous with areas of increased echogenicity due to the presence of adipose tissue PTVs anechoic lumen Peron anechoic lumen PTA anechoic lumen with echogenic walls Peroneal artery anechoic lumen with echogenic walls The vessels appear long due to the sagittal viewing plane. Color Doppler was utilized and the veins filled with a small amount of blue due to the small vessel size, the slow flow, and the time of sampling, within the steered color box, which demonstrated the flow was going toward the transducer, showed the average velocity, as well as the presence of moving blood cells. (Within the color box the PTA was filled with a small amount of red, the vessel was not filled completely because the settings were for the slow venous flow and not the increased velocity of an artery. The color demonstrated that the flow was going toward the transducer and the presence of moving blood cells.) The vessel was angled and PRF and color gain were set for optimal detection of the slow venous flow. Spectral Doppler was utilized to show the average velocity

Unilateral Lower Extremity Venous Competency and the response of the blood flow to peripheral augmentation. The spectral gate was placed in the center of the more anterior PTV to detect the highest velocities. The spectral trace was also visualized demonstrating normal flow (slow forward venous flow), response from peripheral augmentation, and return to normal flow. The baseline, PRF, and spectral gain were set so that the augmentation was well visualized with no aliasing. Skin layer superficial echogenic layer Muscle layer hypoechoic to the surrounding tissue with echogenic striations Surrounding tissue heterogeneous with areas of increased echogenicity due to the presence of adipose tissue PTVs anechoic lumen Peron anechoic lumen PTA anechoic lumen with echogenic walls Peroneal artery anechoic lumen with echogenic walls The vessels appear long due to the sagittal viewing plane. Color Doppler was utilized and the veins filled with a small amount of blue due to the small vessel size, the slow flow, and the time of sampling, within the steered color box, which demonstrated the flow was going toward the transducer, showed the average velocity, as well as the presence of moving blood cells. (Within

PTV

Sagittal

LEFT PTV AUGMENT

Posterior Tibial Veins

Unilateral Lower Extremity Venous Competency the color box the PTA was filled with a small amount of red, the vessel was not filled completely because the settings were for the slow venous flow and not the increased velocity of an artery. The color demonstrated that the flow was going toward the transducer and the presence of moving blood cells.) The vessel was angled and PRF and color gain were set for optimal detection of the slow venous flow. Spectral Doppler was utilized to show the average velocity and the response of the blood flow to peripheral augmentation. The spectral gate was placed in the center of the posterior PTV to detect the highest velocities. The spectral trace was also visualized demonstrating normal flow (slow forward venous flow), response from peripheral augmentation, and return to normal flow. The baseline, PRF, and spectral gain were set so that the augmentation was well visualized with no aliasing. Skin layer superficial echogenic layer Muscle layer hypoechoic to the surrounding tissue with echogenic striations Surrounding tissue heterogeneous with areas of increased echogenicity due to the presence of adipose tissue PTVs anechoic lumen Peron anechoic lumen

Peroneal V

Sagittal

LEFT PERON Peroneal Veins

Unilateral Lower Extremity Venous Competency PTA anechoic lumen with echogenic walls Peroneal artery anechoic lumen with echogenic walls The vessels appear long due to the sagittal viewing plane. Color Doppler was utilized and the veins filled with a small amount of blue due to the small vessel size, the slow flow, and the time of sampling, within the steered color box, which demonstrated the flow was going toward the transducer, showed the average velocity, as well as the presence of moving blood cells. (Within the color box the Peroneal artery was filled with a small amount of red, the vessel was not filled completely because the settings were for the slow venous flow and not the increased velocity of an artery. The color demonstrated that the flow was going toward the transducer and the presence of moving blood cells.) Peripheral augmentation aided in demonstrating the vessels filled with color. The vessel was angled and PRF and color gain were set for optimal detection of the slow venous flow. Skin layer superficial echogenic layer Muscle layer hypoechoic to the surrounding tissue with echogenic striations Surrounding tissue heterogeneous with areas of increased echogenicity due to the presence of adipose

Peroneal V

Sagittal

LEFT PERON Peroneal Veins AUGMENT

Unilateral Lower Extremity Venous Competency tissue PTVs anechoic lumen Peron anechoic lumen PTA anechoic lumen with echogenic walls Peroneal artery anechoic lumen with echogenic walls The vessels appear long due to the sagittal viewing plane. Color Doppler was utilized and the veins filled with a small amount of blue due to the small vessel size, the slow flow, and the time of sampling, within the steered color box, which demonstrated the flow was going toward the transducer, showed the average velocity, as well as the presence of moving blood cells. The vessel was angled and PRF and color gain were set for optimal detection of the slow venous flow. Spectral Doppler was utilized to show the average velocity and the response of the blood flow to peripheral augmentation. The spectral gate was placed in the center of the anterior Peron to detect the highest velocities. The spectral trace was also visualized demonstrating normal flow (slow forward venous flow), response from peripheral augmentation, and return to normal flow. The baseline, PRF, and spectral gain were set so that the augmentation was well visualized with no aliasing. Skin layer superficial echogenic layer Muscle layer hypoechoic to

Peroneal V

Sagittal

LEFT PERON Peroneal Veins AUGMENT

Unilateral Lower Extremity Venous Competency the surrounding tissue with echogenic striations Surrounding tissue heterogeneous with areas of increased echogenicity due to the presence of adipose tissue PTVs anechoic lumen Peron anechoic lumen PTA anechoic lumen with echogenic walls Peroneal artery anechoic lumen with echogenic walls The vessels appear long due to the sagittal viewing plane. Color Doppler was utilized and the veins filled with a small amount of blue due to the small vessel size, the slow flow, and the time of sampling, within the steered color box, which demonstrated the flow was going toward the transducer, showed the average velocity, as well as the presence of moving blood cells. (Within the color box the Peroneal artery was filled with a small amount of red, the vessel was not filled completely because the settings were for the slow venous flow and not the increased velocity of an artery. The color demonstrated that the flow was going toward the transducer and the presence of moving blood cells.) The vessel was angled and PRF and color gain were set for optimal detection of the slow venous flow. Spectral Doppler was utilized to show the average velocity and the response of the

Unilateral Lower Extremity Venous Competency blood flow to peripheral augmentation. The spectral gate was placed in the center of the posterior Peron to detect the highest velocities. The spectral trace was also visualized demonstrating normal flow (slow forward venous flow), response from peripheral augmentation, and return to normal flow. The baseline, PRF, and spectral gain were set so that the augmentation was well visualized with no aliasing. Grade:

Section V: Diagnostic Image Quality Identify the required elements below that are a component of the LEV protocol. Compressed or DNC Explain how you know if the vein compressed or DNC (be specific with your probe technique) Augmented or did not augment Explain your augmentation technique and what this told you specific to the image. (be specific with the location of your hand for the augmentation) If you did not augment, explain why. Augmentation was performed while utilizing color and spectral Doppler. The transducer was placed in the groin crease in the sagittal viewing plane and was held straight up. The vessel was angled for

Required Images

EIV

Compressed

The transducer was placed in the groin crease, and was straight up. The vessel was evaluated in the transverse scanning plane and a

Augmented

Unilateral Lower Extremity Venous Competency compression run to the knee had been performed prior to imaging. Compression was performed by placing transducer pressure straight down at the location of the vessel being evaluated. I scanned from the EIA to the CFV and GSV and back into the EIV to ensure that I was in the proper location. The vessel was compressed along the area I could visualize and then imaged at the area of best visualization. Dual screen was used to show the open vessel without any internal echoes and as well as the completely compressed vessel. The transducer Augmented was placed at the medial aspect of the patients inferior thigh, and was straight up. The vessel was evaluated in the transverse scanning plane and a compression run improved angle of incidence. The baseline was raised to upper third of the spectral display and the scale was set so that the spontaneous, phasic, slow vascular flow and the augmentation would be well visualized without aliasing. The spectral gate was placed in the center of the vessel so that the highest velocities were detected. The transducer was held at the location being evaluated while I used other hand to augment. I placed my left hand on the medial aspect of the patients superior thigh and slowly squeezed to produce a wide augmentation. I ensured that normal, spontaneous, phasic flow was seen before and after the augmentation.

FV Peripheral

Compressed

Augmentation was performed while utilizing color and spectral Doppler. The transducer was placed at the medial aspect of the patients inferior thigh and was held straight up. The vessel was angled for improved angle of incidence. The baseline was raised to upper third

Unilateral Lower Extremity Venous Competency to the knee had been performed prior to imaging. Compression was performed by placing transducer pressure straight down at the location of the vessel being evaluated. I increased the depth and scanned from the FV Mid to where the FV Peripheral dives to ensure that I was in the proper location. The vessel was compressed along the area I could visualize and then imaged at the area of best visualization. Dual screen was used to show the open vessel without any internal echoes as well as the completely compressed vessel. The transducer Augmented was placed at the medial aspect of the patients calf and was straight up. The vessel was evaluated in the transverse scanning plane and a compression run from the knee to of the spectral display and the scale was set so that the slow forward vascular flow and the augmentation would be well visualized without aliasing. The spectral gate was placed in the center of the vessel so that the highest velocities were detected. The transducer was held at the location being evaluated while I used other hand to augment. I placed my left hand on the medial aspect of the patients superior calf and slowly squeezed to produce a wide augmentation. I ensured that normal, forward flow was seen before and after the augmentation.

PTV

Compressed

Augmentation was performed while utilizing color and spectral Doppler. The transducer was placed at the medial aspect of the patients calf and was held straight up. The vessel was angled for improved angle of incidence. The baseline was raised to upper third of the

Unilateral Lower Extremity Venous Competency the ankle had been performed prior to imaging. Compression was performed by placing transducer pressure straight down at the location of the vessel being evaluated. I ensured that there was enough depth so that doth the PTVs and Peron veins were visualized to ensure that I was at the proper vessel. The vessel was compressed along the area I could visualize and then imaged at the area of best visualization. Dual screen was used to show the open vessel without any internal echoes as well as the completely compressed vessel. Grade: spectral display and the scale was set so that the slow forward vascular flow and the augmentation would be well visualized without aliasing. The spectral gate was placed in the center of the vessel so that the highest velocities were detected. The transducer was held at the location being evaluated while I used other hand to augment. I placed my left hand on the medial aspect of the patients inferior calf and slowly squeezed to produce a wide augmentation. Due to the small size of the PTVs normal l, forward flow was not seen before and after the augmentation. Both of the PTVs were visualized and an augment was performed in both using the same technique.

Section VI: Diagnostic Image Quality- Instrumentation Detailed directions for the following: o For Additional Techniques- these are techniques utilized beyond (those listed in the required elements) to provide diagnostic images listed above or other images associated with this comp (focal zone, harmonics, patient position, 3D/4D, filter, etc.)

Unilateral Lower Extremity Venous Competency o Why its correct: The description should include why it was used and what additional diagnostic information or resulted changes were evident from the utilization of the technique Required Elements Probe Name(s) 9L What was used Why its correct I used a 9MHz liner transducer for this exam. This transducer offered a Small footprint and rectangular field of view and a good near field which gave the ability to diagnostically image superficial vessels. The core frequency setting was 9MHz. with differing settings the machine adjusted the frequency in the range of 817MHZ. These frequencies offered good visualization of the superficial veins and the deep veins that appeared within the near field. The LEV vascular preset was chosen because it gave the best general settings for diagnostic imaging of the venous system. For grayscale the baseline settings included one focal zone which offered a focused area of interest while maintain frame rate, a depth of 4cm which was adjusted throughout the exam, and a gain of 28 which gave good visualization of the vessels and surrounding tissue. The LEV preset color Doppler settings included a baseline gain which gave a good base for color detection of the slow flowing vascular system and was adjusted throughout the exam, the scale was in a range of -11 through 11cm/sec which was a good base to detect the average slow velocities of the vascular system and was adjusted throughout the exam. Spectral Doppler settings included the baseline in the upper 1/3 of the spectral display so that venous flow below the baseline and the entirety of the peripheral augmentation is visualized, the sample volume was set at one which is small for venous flow in general but was helpful in the detection of only venous flow in the PTVs and Peron, the PRF was preset for

Frequency(s) used during examination

The frequency was set at 9MHz

Preset

LEV

Unilateral Lower Extremity Venous Competency general venous flow so that the maximum velocities would be detected and the waveform and augmentation would be well visualized without aliasing, the preset gain was a good baseline for well visualized amplitudes of the blood cells that make up the spectral trace and was adjusted through the exam. Harmonics and an acoustic output of 100% were part of the preset and were used throughout the exam offering good visualization of the vessels. The depth was increased from the previous image to 6cm which allowed for good visualization of the vessels without excess tissue below the vessels. One focal zone was placed at the level of the FV Central and Profunda. The focal zone was used to increase the strength of the wave lengths, minimize divergence and attenuation as well as improving lateral resolution for improved visualization of the vessels. The depth remained at 6cm as I turned sagittal on the vessels. This depth allowed for good visualization of the vessels without excess tissue below the vessels. One focal zone was at the level of the FV Central and the Profunda. The focal zone was used to increase the strength of the wave lengths, minimize divergence and attenuation as well as improving lateral resolution for improved visualization of the vessels. The depth was set at 6cm which allowed for good visualization of the vessel, as it dives deeper into the leg, without excess tissue below the vessels. One focal zone was placed at the level of the FV Peripheral. The focal zone was used to increase the strength of the wave lengths, minimize divergence and attenuation as well as improving lateral

Depth and focal zone (transmit focusing) on FV Central/Profunda TX Gray scale without compression

Depth was set at 6cm

One focal zone was used

Depth and Color Doppler on FV Central/Profunda Sagittal

Depth was set at 6cm

One focal zone was used

Color and spectral Doppler on FV peripheral sagittal

Depth was set at 6cm

One focal zone was used

Unilateral Lower Extremity Venous Competency resolution for improved visualization of the vessels. The depth was set at 6cm which allowed for good visualization of the PTVs as well as the Peroneals without excess tissue below the vessels.

Color and spectral Doppler on PTV sagittal

Depth was set at 6cm

One focal zone was placed just below the PTVs. The focal zone was used to increase the strength of the wave lengths, minimize divergence and attenuation as well as improving lateral resolution for improved visualization of the vessels. Additional Technique (if none I could have lower the I could have lower the patients legs, had used what could have been patients legs, had her ben her ben her leg at the knee and place her used) her leg at the knee and foot flat on the stretcher, or had the patient place her foot flat on the sit up and dangle her legs off of the bed for stretcher, or had the patient better detection of color in the calf veins. sit up and dangle her legs This would have increased the off of the bed for better hemodynamic pressure which would aid in detection of color in the calf the filling of the calf veins. Therefore, the veins. detection of color with the use of Doppler would have been easier because on the increased number of blood cells present in the calf veins. Grade

One focal zone was used

Section VII: Diagnostic Image Quality- Pathology Documentation Describe the sonographic features of all pathology(s) seen in the examination o If no pathology was seen, describe 2 pathologies that could be ruled out in the LEV exam.

Unilateral Lower Extremity Venous Competency

Structure If no pathology was seen, Identify the proper name of the pathology seen or excluded (Indicate if the pathology was seen or excluded) Sonographic Features of Pathology or Excluded Pathology including measurements Technique Used to Identify or Rule out Pathology (This includes techniques such as scan through, Doppler, Spectral Doppler, probe angle, probe placement, etc.) The transducer was placed within the groin crease in the transducer viewing plane and a compression run along the medial aspect of the patients leg was performed to the knee evaluating both the deep veins and the GSV along with other superficial vasculature that was visualized. All of the veins compressed with transducer pressure proving that no superficial thrombus was present. The GSV was further evaluated by utilizing both color and spectral Doppler with the vessel in the sagittal viewing plane at the location of the junction with the CFV. The GSV demonstrated complete color fill in and response to peripheral augmentation. The transducer was then placed on the posterior aspect of the patients slightly bent knee within Hunters canal in the transverse viewing plane and compressions were performed on the Pop Vein as well as the LSV and other superficial veins. All of the veins the posterior aspect of the patients knee

describe 2 pathologies that could be ruled out in the LEV exam

Superficial venous system

Superficial thrombophlebitis, (also known as superficial thrombus or superficial vein thrombus) was excluded.

Sonographically the thrombus will appear as anechoic to hyperechoic intraluminal echoes with in a dilated vein if acute or echogenic intraluminal echoes within a narrowed vein if chronic. If thrombus is present the vein will not compress completely with transducer pressure.

With the use of color Doppler the area of the thrombus will demonstrate a color void if the thrombus is partially attached to the vessel wall and no flow will be detected if the thrombus is occlusive. With the use of spectral Doppler there will be a loss of phasic forward flow and there will be no response visualized to peripheral augmentation in a partially obstructive thrombus. In an obstructive thrombus no flow will be present.

Unilateral Lower Extremity Venous Competency

compressed proving that no superficial thrombus was present. Finally, the transducer was placed at the medial superior aspect of the patients calf and a compression run was performed moving inferiorly to the inferior proportion of the patients calf. Multiple superficial veins were visualized and all of the veins compressed proving that no superficial thrombus was present. While evaluating the Pop Vein a scan through of Hunters canal and the popliteal fossa was performed in both the transverse and sagittal viewing planes. The transducer was placed on the posterior aspect of the patients slightly bent knee. There were no fluid collections visualized within the popliteal fossa.

Popliteal fossa

Popliteal cyst or Bakers cyst was excluded

A bakers cyst appears as a round or oval anechoic fluid collection that may contain internal echoes. It should be compressible and has welldefined borders and posterior enhancement. A bakers cyst is located within Hunters canal inbetween muscle layers (which appear hypoechoic with echogenic striations) and should have an anechoic point of attachment to the joint space. If a backers cyst is present it should be measured in two planes documenting an AP, length, and width measurement. The cyst should be evaluated with color and spectral Doppler. No blood flow will be detected with color, power, or spectral Doppler if it is a bakers cyst.

Grade:

Section VIII: Preliminary Findings to Physician

Unilateral Lower Extremity Venous Competency Describe specifically the sonographic findings of the examination given to the reviewing sonographer and the physician, and how the information was relayed. Detailed directions for the following components o Description of findings reported Must be specific and detailed, all students are required to describe at a minimum sonographic features (correct terms) and measurements. Do not diagnose pathology only describe! The description to the physician must include what is written on the jot pad and verbally if applicable. (Note: if you were not allowed to write on the jot pad or disagreed with what was written identify this in the self reflection section.)

o Self Reflection: o Describe the interaction you had with the sonographer and physician. Include at least one of the following regarding the sonographer and physician. Identify which question you are answering. Did you learn how to better your image or use a new technique from the sonographer or physician regarding images or reporting information, etc.) Did the sonographer or physician teach you a new idea, ask for clarification or challenge your images or patient history, etc? Would you have liked the interaction different? Why or why not Were their images better than yours, same, different? Person of Interest Description of Findings Reported (Specific and detailed) I told the sonographer that all of the vessels (EIV, CFV, Profunda, FV Central, FV Mid, FV Peripheral, Pop Vein, PTVs and Peroneals) compressed throughout the left leg and all responded to peripheral augmentation at sampled locations. No pathology was visualized Method used to Report Findings (verbal, written such as jot pad, report page, etc.) Verbal communication was used to relay my findings to the sonographer. Self-Reflection (must answer one question from above The sonographer talked to me about the use of TGCs with vessels. She said that I needed to make sure that vessels are anechoic. She also told me that different

Sonographer

Unilateral Lower Extremity Venous Competency including DVT, superficial sonographers have different preferences and that I did not have to please everyone, I need to do what I know is right. I would have liked to talk to the physician, or resident, or have gotten some written feedback. I believe that this feedback could be beneficial.

Physician

The patient history included left leg and foot swelling and pain. My impression: All veins compressed and no DVT was visualized.

Written communication using a jot pad in PACs

Grade:

Section IX: Impression/Findings Attach the final report or summarize the impression/findings of the examination (dictated report) in the chart below (add rows as needed). Self-reflection Component: o The summary must include why you agree or disagree with the findings normal or abnormal findings. 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. If the report is attached, Complete the Following There are no findings of deep venous thrombus within the leg.

Overall Impression on the Report (Exact wording found on report) Self-Reflection

(refer to instructions above)

I agree that no DVT was visualized within the leg. This was proven with the fact that no echoes were seen with in the vessels, all of the veins compressed, and all of the vessels responded to peripheral augmentation at the sampled areas.

Grade:

Unilateral Lower Extremity Venous Competency

If no report attached: Complete Table and Provide and Overall Impression below the table Structure All Measurements Reported Normal vs Abnormal (If abnormal, describe the abnormal findings)

Overall Impression on report (Exact wording found on report) Self Reflection (refer to instructions above) Grade: Section X: Diagnosis and Differential Diagnosis 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: o The impression/findings made by the physician, identify and define the report diagnosis and 1 differential diagnosis. o In the event of a normal report, identify and define 2 sonographic LEV exam pathologies that should be considered. o In the event 2 or more pathologies are seen, complete the chart for 2 pathologies and no differentials Detailed directions for the following components Sonographic findings- all sonographic findings must be included, use of proper terminology is required. Where else to look-explain where else you would look sonographically if the pathology is present. Consider other organs that may be affected, other blood flow sources that may be affected, etc. Pitfalls-explain why the diagnosis of the pathology may be incorrect

Unilateral Lower Extremity Venous Competency such as improper technical setting, improper scan technique, a differential that looks similar, etc. . Pathology or Differential If case is normal, pathology must relate to the LEV exam Name and synonyms for pathology Superficial thrombophlebitis, also known as superficial thrombus or superficial vein thrombus. Reason for selecting pathology The patient was a young pregnant woman which puts her at risk to develop a thrombus. I also chose this pathology due to the patients symptoms of unilateral leg and foot pain and swelling that was improved with elevation. Definition Superficial thrombophlebitis the formation of thrombus with in the superficial venous system. This thrombus can be associated with varicose veins. Clinical Findings Symptoms include local erythemia, local tenderness or pain, (Symptoms, lab values, etc.) swelling and a palpable subcutaneous cord. A lab value that may be helpful is D-dimer which can be associated with the presence or absence of a thrombus. Sonographic Features (main findings)
Sonography is used to verify the clinical diagnosis of superficial thrombus, determine extension into deep vein, monitor progression and/or evaluate for silent DVT. However, sonography is not reliable to determine the extent of the thrombus. Sonographically the thrombus will appear as anechoic to hyperechoic intraluminal echoes with in a dilated vein if acute or echogenic intraluminal echoes within a narrowed vein if chronic. If thrombus is present the vein will not compress completely with transducer pressure.

Where else to look (what other organs could be involved and why)

With the use of color Doppler the area of the thrombus will demonstrate a color void if the thrombus is partially attached to the vessel wall and no flow will be detected if the thrombus is occlusive. With the use of spectral Doppler there will be a loss of phasic forward flow and there will be no response visualized to peripheral augmentation in a partially obstructive thrombus. In an obstructive thrombus no flow will be present. It is important to document if the superficial thrombus is located in the GVS or LSV where they connect to the deep venous system because the thrombus can migrate and cause a DVT and in the acute stages poorly attached or a free floating thrombus can break off and form a potentially fatal pulmonary embolism. It is also important to look at the entirety of the deep venous system of the leg when a superficial thrombus is found due to the increased risk of DVT. The superficial and deep venous systems in the upper extremities can also be evaluated because a pervious or current clot increases the risk of thrombus in other areas. Other imaging modalities can be used to evaluate for a pulmonary embolism, especially if the patient presents with shortness of

Unilateral Lower Extremity Venous Competency breath. A pitfall is patient body habitus, if the patient is obese visualization and compression of the veins is difficult due to the depth at which the veins are located. Another pitfall is lack of education of the sonographer. The sonographer does not understand anatomy of the venous system or the importance of evaluating the superficial veins as well as the deep veins a thrombus could go undetected.

Pitfalls (Improper technical setting, a differential, improper scans technique, etc.)

Pathology or Differential If case is normal, pathology must relate to the LEV exam Name and synonyms for pathology Popliteal cyst also known as a bakers cyst Reason for selecting pathology I selected this pathology because the symptoms parallel the patients including pain and swelling. Definition A bakers cyst is a synovial fluid collection located in the popliteal fossa that is located between muscle layers and has a connection or communicates with the joint space. Bakers cysts are associated with trauma and rheumatoid arthritis. Clinical Findings Symptoms mimic a DVT including pain, swelling, and stiffness. (Symptoms, lab values, etc.) A bakers cyst appears as a round or oval anechoic fluid collection that Sonographic Features may contain internal echoes. It should be compressible and has well(main findings)

defined borders and posterior enhancement. A bakers cyst is located within Hunters canal in-between muscle layers (which appear hypoechoic with echogenic striations) and should have an anechoic point of attachment to the joint space. If a backers cyst is present it should be measured in two planes documenting an AP, length, and width measurement. The cyst should be evaluated with color and spectral Doppler. No blood flow will be detected with color, power, or spectral Doppler if it is a bakers cyst.

Where else to look (what other organs could be involved and why) Pitfalls (Improper technical setting, a differential, improper scans technique, etc.)

Synovial fluid collection can be found anywhere along the synovial lining and do not usually cause symptoms unless large. A bakers cyst should be followed in its entirety and can be seen splitting the calf muscles. A pitfall is lack of sonographer knowledge, to be classified a bakers cyst a connection to the joint space must be present and if this connection is not documented an incorrect diagnosis could be made. Another pitfall is not putting color and spectral Doppler to detect the presence of blood flow resulting in a false positive for the diagnosis of a bakers cyst. Without the use of putting color and

Unilateral Lower Extremity Venous Competency spectral Doppler pathologies such as a popliteal artery aneurysm or a sarcoma could be mistaken for a bakers cyst. Grade: Grading Points 5 4 3 2 1 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 or evidence of an unsafe event (unsafe events may result in failure of the competency)

50=100 49=98 40=88 39=86 30=75 29=74 20=60 19=57 10 or less = 0 Section 1 2 3 4 5 6 7 8 9 10 Total/Final score Instructor: Comments:

48=97 38=85 28=73 18=55

Point Value Conversion Chart 47=96 46=95 45=93 44=92 37=84 36=82 35=80 34=79 27=72 26=71 25=70 24=68 17=45 16=40 15=45 14=35

43=91 33=78 23=66 13=30

42=90 32=77 22=64 12=25

41=89 31=76 21=61 11=20

Points Received