Urinary Written Comp

Student Name: Helen McKinney

Date Submitted: 11/23/14

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: The patient was a 74 year old, Caucasian female. The patient was asymptomatic upon the patient
interview but the reason for the exam, stated on the exam order from her primary physician, was unspecified
acute renal failure. The patient was not experiencing flank pain, hematuria, fever, nor did she have a palpable
mass. This patient did not have any pertinent history that was relevant to this exam.

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 and explain what deviations from normal values
indicate.
Answer: The patients labs relevant to this exam were as follows:
High Blood Urea Nitrogen (BUN) measuring 23 mg/dL. An increased BUN can indicate renal failure or renal disease.
Normal Serum Creatinine measuring 1.2 mg/dL.
Normal Uric acid measuring 3.8 mg/dL.
Normal WBC measuring 6.8 billion cells/L.
Low glomerular filtration rate (GFR) non-African American measuring 46.6 mL/min/1.73 m2. A low GFR can
indicate renal failure, glomerular nephritis, and pyelonephritis.

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: There were no previous exams or results available that were relevant to this exam. Another imaging
modality that could be used to evaluate this patients symptoms would be an intravenous pyelogram or IVP. An IVP
is a radiologic examination in which a contrast medium is injected into a vein and x-ray films are taken at specific
intervals to observe kidney function and urinary system anatomy. This modality would be used in conjunction with
sonography to observe kidney function. When a renal pathology is suspected, ultrasound is used to provide a
visual to aid in finding the actual pathology or the cause of the pathology. If a renal pathology, or the cause of the
pathology, is found by ultrasound an IVP can be utilized in assessing how the actual function of the kidneys are
being affected. An IVP to assess renal function would be helpful with this patients diagnosis in that the patients

Urinary Written Comp

lab values indicated a decrease in renal function, but her ultrasound examination revealed her kidneys to be within
normal limits.
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: The patient did not have any pertinent clinical history that was relevant to this exam other than the
reason for the exam being unspecified acute renal failure, as stated by her physician. The patient also did not have
any previous exams and results available that were relevant to this exam. Upon interview of the patient I learned
that she was not diabetic, did not suffer from hypertension, and had never been diagnosed with cancer. The
patient stated that she was asymptomatic. The patient stated that she was not suffering from any abdominal pain,
or flank pain. The patient did not have a palpable mass nor was she experiencing any hematuria or fever. However,
due to the patient being asymptomatic with lab values of increased BUN and decreased GFR, I suspected to
visualize possible hydronephrosis. This pathology can be present in an asymptomatic patient with lab values
indicating a decrease in renal function. Sonographically this would be visualized as a splaying, or spreading of the
central echo complex, resulting in connected anechoic cystic areas. A presence of urinary tract dilatation and
hydronephrosis due to obstruction can be common findings in individuals suffering from acute renal failure, as well
as increased BUN and creatinine levels.
Grade for Section 2
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: I prepared the exam room by applying a clean sheet on the bed. I made sure the bed was set to its lowest
possible setting to ensure an easy transition onto the bed for the patient. The bed wheels were locked. I obtained
two towels from the drawer and placed it on the table closest to the machine. I then obtained a warm gel bottle
from the warmer and placed it in the warmer attached to the machine. After introducing myself and retrieving the
patient from the waiting area, I escorted the patient to her exam room. I then identified the patient by having the
patient state her full name and date of birth. I compared this information with the information provided on the
exam order, as well as the information on the patients wristband. The patient was instructed to lie back on the
bed in the supine position. I chose the correct patient from the work list on the machine and compared the name
and date of birth on the machine to the information on the exam order.
I informed the patient that I would be performing an ultrasound exam of her retroperitoneal structures which
included her aorta, IVC, both kidneys, and bladder. I then interviewed the patient on her current symptoms and
patient history. The patient stated that she was not diabetic, did not suffer from hypertension, and had never been
diagnosed with cancer. The patient was also asymptomatic. The patient stated that she was not suffering from any
abdominal pain, or flank pain. The patient did not have a palpable mass nor was she experiencing any hematuria or
fever. I informed the patient that we would perform the exam with her abdomen exposed and that I would be
applying warm gel to her abdominal area. The bed was then raised to a comfortable position. When the patients
abdomen was exposed I tucked one towel in around her shirt and one around the waistband of her pants so that
gel would not be transferred to her clothing. I informed the patient that during the exam I would be instructing her
to take in deep breaths but that she could exhale at any needed point. I also informed her that she may need to
roll toward her right or left side at some point during the exam while imaging her kidneys. The patient understood
her instructions so I chose the correct transducer and abdomen preset on the machine and began the exam.

Urinary Written Comp

Grade for Section 3

During the Exam: Sonographic findings of structures, pathologies, measurements, and instrumentation
Section 4:
Identify the sonographic features of both kidneys, as well as the urinary bladder.
Answer: The right kidney appeared sonographically as heterogenous with smooth contour. The renal capsule of
the right kidney appeared as a thin, continuous highly reflective line visualized along the periphery of the kidney.
The renal cortex of the right kidney displayed a homogenous echo texture that was hypoechoic when compared to
the liver parenchyma. The renal sinus of the right kidney was visualized sonographically as a hyperechoic, ovoid
central portion with irregular borders when compared to the renal cortex. The renal pyramids were visualized as
small triangular anechoic areas due to being filled with urine. The right kidney appeared as an oval shaped
structure broken medially by the renal hilum in a sagittal view, and a rounded structure broken medially by the
renal hilum in a transverse view.
The left kidney appeared sonographically as heterogenous with smooth contour. The renal capsule of the left
kidney appeared as a thin, continuous highly reflective line visualized along the periphery of the kidney. The renal
cortex of the left kidney displayed a homogenous echo texture that was hypoechoic when compared to the splenic
parenchyma. The renal sinus of the left kidney was visualized sonographically as a hyperechoic, ovoid central
portion with irregular borders when compared to the renal cortex. The renal pyramids were visualized as small
triangular anechoic areas due to being filled with urine. The left kidney appeared as an oval shaped structure
broken medially by the renal hilum in a sagittal view, and a rounded structure broken medially by the renal hilum
in a transverse view.
The patients distended bladder appeared anechoic with well-defined walls that were smooth, thin, and echogenic.
The transverse view revealed a symmetrical bladder with rounded anterior borders and a square posterior border,
and the sagittal view demonstrated a triangular shape of the bladder.
Grade for Section 4
Section 5:
Identify all protocol measurements obtained and identify if each measurement is normal or abnormal. If
abnormal, what is indicated?
Answer: Protocol measurements obtained for this exam were as follows:
Length measurement of right kidney mid portion from superior pole to inferior pole obtained in a sagittal scan
plane- 10.16 cm/ Normal
Length measurement of left kidney mid portion from superior pole to inferior pole obtained in a sagittal scan
plane- 10.15 cm/ Normal
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 no pathology seen in this exam. A common pathology that is seen with this exam is renal
calculi. Renal calculi are defined as focal concentrations of calcium, uric acid or cysteine in the renal parenchyma or

Urinary Written Comp

collecting system. If a renal calculus was visualized, I would move the focal zone to the level of the calculus to aid
in the demonstration of posterior shadowing. I would modify my protocol by documenting the pathology in gray
scale sagittal and transverse images. I would obtain length, width, and height measurements of the renal calculus
in gray scale sagittal and transverse images. I would obtain a color Doppler image to document the presence of
blood flow, and I would obtain a spectral Doppler image to document the type and velocity of blood flow.
Obtaining these images would help aid in the correct diagnosis for this pathology.
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: For this retroperitoneal exam an abdomen preset was utilized to achieve the best possible diagnostic
images. This was the correct selection because it contains preconfigured control settings of specific parameters,
such as gain, depth, power, and focus that optimizes the image of structures obtained from the abdomen. The
transducer that was utilized in this exam was a C1-5 curved array transducer. This selection was correct because it
allowed me to utilize lower frequencies that resulted in deeper penetration of the patients abdominal organs. The
curved array transducer also allows a larger field of view which allows better visualization of multiple abdominal
organs. In order to achieve desired visualization of retroperitoneal structures such as the aorta, IVC, kidneys, and
urinary bladder, a transducer with frequencies ranging from 2 - 5 megahertz is optimal. This allows for a range of
patients from obese to slender to be examined accurately. The frequency utilized in this exam was 4.0 megahertz.
This selection was correct because my patient was slender and I was able to obtain better resolution and
visualization of the aorta, IVC, both kidneys, and urinary bladder with a little higher frequency.
For your sagittal lateral right kidney image, identify the depth and focal zone(s) used and explain why they were
correct.
Answer: For the sagittal lateral right kidney image the depth was set at 12 cm. The right kidney was visualized
between 3 and 10 cm depth. The depth settings are correct because it allowed complete visualization of the right
kidney ensuring that the lateral portion as well as the superior and inferior poles were being evaluated in their
entirety as well as providing a better diagnostic image. If the depth was decreased it would have resulted in
incomplete visualization of the superior and inferior poles. If the depth was increased it would have resulted in less
focus on the lateral portion of the right kidney and would have added irrelevant space in the far field. One focal
zone was placed at 8 cm depth. This focal zone placement was correct because it provided clearer visualization of
the lateral portion of the right kidney and the superior and inferior poles, as well as an improved lateral resolution
of the right kidney.
For your transverse bladder image, identify the depth and focal zone(s) used and explain why they were correct.
Answer: For the transverse bladder image the depth was set at 10 cm. The bladder was visualized between 3 and 8
cm depth. This depth setting was correct because it allowed complete visualization of the transverse bladder in its
entirety including visualization all the way around the bladder walls. If the depth was decreased it would have
prevented full visualization of the right and left lateral bladder walls, and possibly the posterior bladder wall as
well. One focal zone was placed at 7 cm depth. This focal zone placement was correct because it improved the
lateral resolution of the urinary bladder providing clearer visualization of the posterior echogenic bladder wall, as
well as providing a clearer anechoic appearance of the urinary bladder lumen.
Grade for Section 7

Urinary Written Comp

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: Upon completion of my patients retroperitoneal examination, I reported my findings to the overseeing
sonographer. I informed the sonographer that the patient was asymptomatic, but that her exam order stated she
was suffering from unspecified acute renal failure and her labs seemed to correlate with that possible pathology. I
informed her that all of the retroperitoneal organs appeared sonographically to be within normal limits, as well as
all of the obtained measurements. The sonographer reviewed my images in PACS, confirmed that I completed the
retroperitoneal exam in its entirety, and agreed that the measurements along with the sonographic appearances
of the retroperitoneal organs appeared to be within normal limits. The sonographer and I then proceeded to the
patients room together. The sonographer scanned through all of the patients retroperitoneal organs and was
pleased with all of my images. She then proceeded to acquire a measurement of both kidneys and confirmed that
my original measurements were correct. Upon completion of the exam, I proceeded to fill out the jot pad in PACS. I
documented in the jot pad that the patients reason for the exam was unspecified acute renal failure and that the
patient had elevated BUN and a low GFR. It was also documented that all retroperitoneal organs appeared to be
within normal limits. The sonographer approved the jot pad and the exam was closed to be reviewed by the
physician.
Grade for Section 8
Section 9:
What was the physicians interpretation of the exam?
Answer: The physicians interpretation of the exam was negative retroperitoneal sonography. The physician stated
that no solid mass, stone, disease, or obstructive uropathy is present. He also stated that the echogenicity of the
kidneys are considered within normal limits and the urinary bladder is unremarkable in appearance.
Grade for Section 9
Section 10:
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. According to Sonography Introduction to Normal
Structure and Function, by Curry and Tempkin and the Baptist College of Health Sciences protocol, the normal
adult kidney length measurement from superior pole to inferior pole through the mid portion of the kidney in a
sagittal scan plane is 10 to 12cm. My patients renal examination measurements both fell within these normal
limits. The retroperitoneal exam that was performed revealed normal sonographic appearances of both of the
patients kidneys, which as stated by Curry and Tempkin, includes sonographic appearances of both kidneys to
have heterogenous echo textures with smooth contours, including the renal cortexes to be visualized with
homogenous echo textures that are hypoechoic when compared to the liver and spleen parenchyma, and the renal
sinuses of the kidneys to be visualized sonographically as hyperechoic ovoid central portions with irregular
borders when compared to their renal cortexes. The exam also revealed a normal sonographic appearance of the
distended urinary bladder which as stated by Curry and Tempkin, includes a sonographic appearance of an
anechoic structure with well-defined walls that are smooth, thin, and echogenic. My patient did have increased

Urinary Written Comp

BUN and a decreased GFR; however my patient did not exhibit any symptoms. Other than unspecified acute renal
failure as stated by her primary physician, my patient did not have any pertinent history that would indicate a
specific renal pathology. My findings were consistent with current literature in that both of this patients kidneys
as well as her urinary bladder all fell within normal limits.
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?
Points

50=100
40=88
30=75

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

49=98
39=86
29=74

20=60
19=57
10 or less = 0
Section
1
2
3
4
5
6

Description

Point Value Conversion Chart

48=97 47=96 46=95 45=93 44=92
38=85 37=84 36=82 35=80 34=79
28=73 27=72 26=71 25=70 24=68

43=91
33=78
23=66

42=90
32=77
22=64

41=89
31=76
21=61

18=55 17=45

13=30

12=25

11=20

16=40

Points Received

15=45

14=35

Urinary Written Comp

7
8
9
10
Total/Final score
Instructor:
Comments: