Neville C. W. Smith M.D. Memorial Learning Resource Center: Diagnostic Medical Sonography

Abdomen Clinical Information 

Sonography is used to examine: 

• Size, texture, vascularity and structure of the anatomy 
• Exam may supply information on the morphology (function and structure) of malfunctioning organs which seem normal on the regular physical pelvic examination.  
• Size of the organs/structures 
• Color and spectral Doppler play an important role in assessing normal and pathologic blood flow, as well as identifying a fluid filled structure versus a vessel 
• 3D Ultrasound may be useful in further examination of abnormalities  
• Magnetic Resonance Imaging (MRI/no radiation) and Computed Tomography (CT/radiation) are adjunct modalities and are useful in the staging of malignant diseases or benign masses.  

Your role as a sonographer: 

• Gather the clinical history 
• Identify the referring physician’s (or practitioner, such as a PA, NP or FNP) indication for the exam (working diagnosis). Remember, a physician can be an M.D. (Medical Doctor) or a D.O. (Osteopathic Doctor). Both are physicians, have passed medical boards and are qualified to practice medicine. 
• Review any previous images and reports 
• Critical thinking by the sonographer supplies reliable, valid and reproducible results which are the basis of an effective DMS practice 
• A complete history is critical to tailor the ultrasound exam. Often, a routine questionnaire is used with information such as:  

                                Onset of disease (H/O cirrhosis x 10 yrs, HCV +, Cholecystectomy  x 6 mths) 

• Note any medications being used 
• Note any surgeries, specifically abdominal surgeries 
• Note any family history of cancer, or disease processes 
• Review the previous exam (if available) for size comparison of prior cyst, stone, mass, dilation, etc. for comparison to this current exam you will be performing 
• Note if the patient has had a h/o irregular labs results, positive for H-Pylori bacteria, GERD, abnormal LFT, etc. 
• Note on exam if pt has large body habitus, pt is obese, extremely tall, etc. 
• After taking the history, explain the exam and let them know results are with their doctor in 3-5 days (or whatever your clinic policy is) and that you cannot give out any information today. 
• Gloves go on in the room and are taken off in the room; this helps to avoid spread of infection 
• Do not wear strong perfumes or perfumed body lotions 
• It is important to introduce yourself, confirm the type of exam the patient is having, and ALWAYS confirm the patient name and DOB prior to starting the exam.  
• *By taking a thorough clinical history, by talking with and listening to the patient, you will gain a perspective as to what information the exam needs to answer and can tailor the exam to accomplish this goal and care for your patient. 
• Any incidental findings should be noted. For example, a mass in the urinary bladder, inability to hold the urine with only a small bladder volume (could be a chronic cystitis or interstitial cystitis), debris or sludge in the urinary bladder (possible UTI), inability to empty the bladder (outlet obstruction), large amounts of bowel within the area of complaint, etc. If the urinary bladder is greatly enlarged and the patient cannot fully void, you would need to document this and bring it to the radiologist’s attention. 
• With bladder issues, knowing how to calculate the volume is extremely useful. Take a Sag and Trv image of the UB, measure with calipers. L x H x W x 0.523 = vol in cc or cm3 (multiplying by 0.52 is fine, if you want to be extra detailed about it, use 0.523, both are very similar in results). 

Two Kinds of Physicians Practicing in the United States: Allopathic and Osteopathic Doctors 

There are two kinds of practicing physicians in the United States: allopathic physicians (MD's) and osteopathic physicians (DO's). Both are fully licensed physicians, trained in diagnosing and treating illnesses and disorders, and in providing preventive care. 

MD’s practice allopathic medicine, the classical form of medicine, focused on the diagnosis and treatment of human diseases. Osteopathic medicine began as a nineteenth century health reform movement that emphasized preventive care and allowing the body to heal without overuse of medications.  In the post-Civil War period in the United States many popular medicines were being used that were toxic. An MD named A.T. Still was concerned about overuse of these medications, and founded a new school of medicine that emphasized preventive care and the integration of the body's systems. 

While many of the osteopathic schools still emphasize these principles in their training, in many respects M.D.’s and D.O.’s practice medicine in identical ways today. Like allopathic physicians, osteopathic physicians prescribe medication, perform surgery, and practice in specialty areas. However, osteopathic physicians are trained in some special areas in which allopathic physicians do not receive training. Students at osteopathic medical colleges receive training in Osteopathic Manipulative Treatment (OMT) that MD's do not receive. OMT involves using the hands to diagnose and treat illness. Osteopathic medicine also emphasizes the integration of the entire body's systems, and many of the osteopathic schools place special emphasis on preventive medicine. DO's fill critical needs in our healthcare system, particularly as primary care providers in rural and underserved areas. 

All premed students should educate themselves about both allopathic and osteopathic medicine. If you become an MD one day you will work alongside DO's in many clinical settings, so you should become informed about their training and practice. If unsure which route to take in becoming a doctor, it is often recommended that premed students arrange opportunities to shadow both allopathic and osteopathic physicians, and decide for themselves about which path towards becoming a licensed physician interests them the most. In fact, many students explore both options by applying to both allopathic and osteopathic medical schools. 

Note: The transverse plane (also called the horizontalplane, axial plane, or transaxial plane) is an imaginary plane that divides the body into superior and inferior parts. It is perpendicular to the coronal and sagittal planes. 

Ultrasound Technologist job duties/prospects 

by Aurelio Locsin, Demand Media 2016 

Because sonograms use relatively benign high-frequency sound waves to image the interior of the human body, they are safe enough to use on pregnant women. Unlike with traditional X-rays, patients are never exposed to radiation. Ultrasound technologists or technicians oversee the device that provides this revelation. 

Basics 

Both “ultrasound technologist” and “*ultrasound technician” refer to the same job, according to the Bureau of Labor Statistics. They are both classified under the category of “diagnostic medical sonographer.” With instructions from doctors and other healthcare workers, ultrasound professionals use ultrasound technology to diagnose medical conditions. They prepare patients by examining medical histories and answering questions. They apply a gel to the targeted area to enhance the imaging ability and operate sonogram machines. Finally, they provide a preliminary analysis of the results, noting any abnormalities, and submit their findings to the physician. 

Types 

Because of the complexity of the human body, ultrasound professionals often specialize in one area. For example, breast sonographers focus on breast tissues, making sonograms important for the early detection of breast cancer. The more commonly known specialty of obstetrics and gynecology tracks the progress of pregnancies. Ultrasound’s ability to reveal the softer structures of the body is particularly useful in neurosonography, which diagnoses conditions of the nervous system and the brain. Abdominal sonographers focus not only on the abdomen but also small parts such as breast, scrotum, thyroid and prostate. 

Training 

Most ultrasound professionals require at least an associate degree in sonography, which includes classroom and clinical training. Students learn how to use ultrasound equipment, anatomy and physiology, and how to image various body parts. Training for specialties requires additional time and awards a certificate. Bachelor’s degrees are also available for those who want in-depth exposure to the field and the broad-based education of a typical undergraduate. 

Careers 

As of May 2019, according to the Bureau of Labor Statistics, ultrasound professionals earned a mean $75,700 per year, or $36.44 per hour. The lowest earning 10 percent made less than $52,770 yearly, or $25.37 hourly, while the best-paid 10 percent received an annual $102,060, or $49.07. Jobs for the profession are expected to jump by 44 percent from 2010 to 2020, which is far greater than the 26 percent expected for all health practitioners and more than the 14 percent predicted for the average worker. Aging baby boomers will drive the demand as they experience more medical conditions that require imaging through sonography.

What to call yourself?  

Sonographer, Ultrasonographer, Ultrasoundtechnologist, *Ultrasound Tech. *Do Not label yourself as an “Ultrasound Tech” on your resume, or they may call you to fix the machine! Your title is that of a Sonographer. 

OB/GYN 

Sonography is used to examine: 

• Size, texture, vascularity and structure of the anatomy 
• Exam may supply information on the morphology (function and structure) of malfunctioning organs which seem normal on the regular physical pelvic examination. Small, nonpalpable myomas, intracavitary fibroids, polyps, etc. may be the cause of abnormal bleeding. 
• Evaluation and location of intrauterine contraception devices (IUD or IUCD) 
• Homogeneity of the myometrium is evaluated 
• Thickness of endometrium (endometrial cavity or EMC) is measured 
• Size of the uterus is measured in three planes (length x height (ant/post) x width in cm) 
• A full pelvic exam uses both transabdominal and transvaginal approaches (trans=across) 
• Transabdominal gives an overall survey of the anatomy (uterus, ovaries, adnexa) 
• Transvaginal imaging provides better characteristics of the internal architecture of the uterus, ovaries and adnexa 
• Color and spectral Doppler play an important role in assessing normal and pathologic blood flow, as well as identifying a fluid filled structure versus a vessel 
• Sonohysterography (hysterosonogram) uses a small catheter which introduces sterile saline into the endometrium to evaluate the endometrial cavity for lesions (fibroid, polyp,) and scarring (synechiae) 
• 3D Ultrasound gives a coronal representation of the uterus and is an additional valuable tool 
• Magnetic Resonance Imaging (MRI/no radiation) and Computed Tomography (CT/radiation) are adjunct modalities and are useful in the staging of malignant diseases, as well as further evaluating uterine conditions such as multiple myomas, adenomyosis, and confirming a septated uterus from a bicornuate uterus. 

Your role as a sonographer: 

• Gather the clinical history 
• Identify the referring physician’s (or practitioner, such as a PA, NP or FNP or CNM)  indication for the exam (working diagnosis) 
• Review any previous images and reports 
• Critical thinking by the sonographer supply reliable, valid and reproducible results which are the basis of an effective DMS practice 
• A complete history is critical to tailor the ultrasound exam. Often, a routine questionnaire is used with information such as:  

1. date of the first day of the last menstrual period (LMP) 
2. Gravidy/Gravida (the number of pregnancies; complete or incomplete) and Parity/Para (the number of births). Also note the number of abortions and miscarriages. For example: G3 P1 M1 A1 (three pregnancies, one live birth, one miscarriage and one abortion). G3 P4 M0 A0 may seem confusing until you confirm that one birth was with twins! 

• Note any medications being taken (and that includes hormones such as oral birth control/OCP=oral contraceptive pill, NuvaRing, Implanon, hormone replacement therapy/HRT) 
• Note any surgeries, specifically any c-sections, or surgeries involving the uterus, cx, fallopian tubes, ovaries, adnexa, urinary bladder and lower abdomen) 
• Note if there is an IUD and what type (if the pt knows) 
• Note any family history of cancer, irregular pap smears, procedures (like a LEEP procedure, etc.) 
• Review the previous exam (if available) for size comparison of prior cyst, fibroid, etc. for comparison to this current exam you will be performing 
• Note if the patient has had a h/o irregular menses since menarche, if the OCP is used to regulate, if their menstrual history has been normal, etc. 
• Note on exam if it is transabdominal only (due to pt being a virgin, elderly, pt refusing, etc.) 
• Note if pt’s menstrual status is Premenarche (prepuberty, prior to menses) or Perimenopausal (transition stage of 2-10 yrs where the cycle starts to change, but has not ceased), or Menopausal (menses have permanently ceased, generally “official” after one year’s time from LMP) 
• After taking the history, explain the exam. If both TA and TV exam are being given, explain that the exam is in two parts. The TA involves simply placing gel on the lower abdomen (pants lowered to the bikini line) and doing a survey of the pelvic area. The full bladder is used as a window to see the organs. The TV is done after the bladder is emptied and is similar to a doctor’s pelvic exam in position (with stirrups, or a wedge raising the hips up) with a drape covering the patient from the waist down for privacy and comfort.  

Let the patient know that the long transducer is mostly handle and only a small portion goes in the vagina and is adjacent to the cervix. They will feel some pressure as you angle the transducer to the right and left, as well as inferiorly and superiorly. Tell them to let you know if they feel discomfort at any time. 

The probe will be covered with a clean sheath (if your facility generally uses latex probe covers, confirm with the pt that they have no latex allergies…if they do, use a latex free probe cover). Remember, the sound beam cannot penetrate a probe cover unless you have gel to help transmit the beam. Place a small amount of gel in the probe cover, roll that onto the vaginal probe, and then add gel to the top of the probe prior to insertion. Most of the time you will be inserting the probe. If a woman prefers to insert it, she can reach under the drape and take the handle of the probe inserting it herself. 
By taking a thorough clinical history, by talking with and listening to the patient, you will gain a perspective as to what information the exam needs to answer and can tailor the exam to accomplish this goal and care for your patient. 

Any incidental findings should be noted. For example, a mass in the urinary bladder, inability to hold the urine with only a small bladder volume (could be a chronic cystis or interstitial cystitis), debris or sludge in the urinary bladder (possible UTI), inability to empty the bladder (outlet obstruction), large amounts of bowel within the area of complaint, etc. If the urinary bladder is greatly enlarged and the patient cannot fully void, take a couple of quick shots of the kidneys (both right and left in sag and trv and document if the ureter is dilated, if there is hydronephrosis or a mass).  

With bladder issues, knowing how to calculate the volume is extremely useful. Take a sag and trv image of the UB, measure with calipers. L x H x W x 0.5235 = vol in cc or cm3 (multiplying by 0.52 is fine, if you want to be extra detailed about it, use 0.523…both are very similar in results). 

*Also, if a patient is not a candidate for a transvaginal exam, a transperineal or translabial approach may be used. Such patients may include: pregnant patients with suspected rupture of membranes or a patient with uterine prolapse (prolapse is when the uterus slips or sags from its normal position into the vaginal canal due to stretched/weakened muscles and ligaments. Postmenopausal women and women who have had more than one vaginal birth are at risk).* 

Two Kinds of Physicians: Allopathic and Osteopathic 

There are two kinds of practicing physicians in the United States: allopathic physicians (MD's) and osteopathic physicians (DO's). Both are fully licensed physicians, trained in diagnosing and treating illnesses and disorders, and in providing preventive care. 

MD’s practice allopathic medicine, the classical form of medicine, focused on the diagnosis and treatment of human diseases. Osteopathic medicine began as a nineteenth century health reform movement that emphasized preventive care and allowing the body to heal without overuse of medications.  In the post-Civil War period in the United States many popular medicines were being used that were toxic. An MD named A.T. Still was concerned about overuse of these medications, and founded a new school of medicine that emphasized preventive care and the integration of the body's systems. 

While many of the osteopathic schools still emphasize these principles in their training, in many respects M.D.’s and D.O.’s practice medicine in identical ways today. Like allopathic physicians, osteopathic physicians prescribe medication, perform surgery, and practice in specialty areas. However, osteopathic physicians are trained in some special areas in which allopathic physicians do not receive training. Students at osteopathic medical colleges receive training in Osteopathic Manipulative Treatment (OMT) that MD's do not receive. OMT involves using the hands to diagnose and treat illness. Osteopathic medicine also emphasizes the integration of the entire body's systems, and many of the osteopathic schools place special emphasis on preventive medicine. DO's fill critical needs in our healthcare system, particularly as primary care providers in rural and underserved areas. 

All premed students should educate themselves about both allopathic and osteopathic medicine. If you become an MD one day you will work alongside DO's in many clinical settings, so you should become informed about their training and practice. If unsure which route to take in becoming a doctor, it is often recommended that premed students arrange opportunities to shadow both allopathic and osteopathic physicians, and decide for themselves about which path towards becoming a licensed physician interests them the most. In fact, many students explore both options by applying to both allopathic and osteopathic medical schools. 

Ultrasound Technologist job duties/prospects 

by Aurelio Locsin, Demand Media 2016 

Because sonograms use relatively benign high-frequency sound waves to image the interior of the human body, they are safe enough to use on pregnant women. Unlike with traditional X-rays, patients are never exposed to radiation. Ultrasound technologists or technicians oversee the device that provides this revelation. 

Basics 

Both “ultrasound technologist” and “*ultrasound technician” refer to the same job, according to the Bureau of Labor Statistics. They are both classified under the category of “diagnostic medical sonographer.” With instructions from doctors and other healthcare workers, ultrasound professionals use ultrasound technology to diagnose medical conditions. They prepare patients by examining medical histories and answering questions. They apply a gel to the targeted area to enhance the imaging ability and operate sonogram machines. Finally, they provide a preliminary analysis of the results, noting any abnormalities, and submit their findings to the physician. 

Types 

Because of the complexity of the human body, ultrasound professionals often specialize in one area. For example, breast sonographers focus on breast tissues, making sonograms important for the early detection of breast cancer. The more commonly known specialty of obstetrics and gynecology tracks the progress of pregnancies. Ultrasound’s ability to reveal the softer structures of the body is particularly useful in neurosonography, which diagnoses conditions of the nervous system and the brain. Abdominal sonographers focus not only on the abdomen but also small parts such as breast, scrotum, thyroid and prostate. 

Training 

Most ultrasound professionals require at least an associate degree in sonography, which includes classroom and clinical training. Students learn how to use ultrasound equipment, anatomy and physiology, and how to image various body parts. Training for specialties requires additional time and awards a certificate. Bachelor’s degrees are also available for those who want in-depth exposure to the field and the broad-based education of a typical undergraduate. 

Careers 

As of May 2019, according to the Bureau of Labor Statistics, ultrasound professionals earned a mean $75,700 per year, or $36.44 per hour. The lowest earning 10 percent made less than $52,770 yearly, or $25.37 hourly, while the best-paid 10 percent received an annual $102,060, or $49.07. Jobs for the profession are expected to jump by 44 percent from 2010 to 2020, which is far greater than the 26 percent expected for all health practitioners and more than the 14 percent predicted for the average worker. Aging baby boomers will drive the demand as they experience more medical conditions that require imaging through sonography. 

U.S. Bureau of Labor Statistics,

What to call yourself?  

Sonographer, Ultrasonographer, Ultrasoundtechnologist, *“Ultrasound Tech” (*pejorative= a word or phrase that has negative connotations or that is intended to disparage or belittle), Do Not label yourself as an “Ultrasound Tech” on your resume, or they may call you to fix the machine! Your title is that of a Sonographer. 

The transverse plane (also called the horizontal plane, axial plane, or transaxial plane) is an imaginary plane that divides the body into superior and inferior parts. It is perpendicular to the coronal and sagittal planes. 

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