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Breast Written Comp

Student Name: Kristen Cherry

Date Submitted: 06/05/2014


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.
The patient is a 68 year old Caucasian female. She has a history of fibrocystic changes in
both breasts. Currently, the patient reports bilateral breast tenderness on palpation, for six
Identify the patients labs relevant to the exam (as high, low, or normal) and explain what
the patients lab values indicate.
If the patient had no labs, identify the labs relevant to the exam (with normal values) and
explain what deviations in these lab values indicate.
The patient had no labs available. There are several lab values could have been
evaluated in this case. An elevated white blood cell count could indicate an abscess, or
mastitis within the breast tissue. A normal white blood cell count ranges from 4,500 to
10,000 blood cells per microliter. A decrease in hematocrit could indicate a very severe
hematoma within the breast. A normal value for this is between 4.2 and 6.1 million cells per
microliter, depending on gender. In some cases, cancers are fueled by high levels of
estrogen, which can also be measured when there is a need. Normal estrogen levels have a
wide range and lie between 50 and 400 picograms per milliliter. Finally, CA-125 will be
increased in some forms of breast cancer, and can be a very good indicator of a malignancy.
This value should be less than 35 units per milliliter.
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.
A year ago, the patient had a mammogram that was also followed up by ultrasound. The
ultrasound results for that exam showed the same results as the one performed for this
competency. The dense, fibrocystic tissue was present, and does not appear to have
changed within the past year when compared to this exam. The radiologist reported
fibrocystic disease, and gave the patient negative exam results.

Breast Written Comp

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?
Based on the patients clinical history, labs, and previous exams and results, I expected
to find fibrocystic disease during this exam. I expected to see this pathology because
previous mammography images showed dense white areas, which is how fibrocystic tissue
appears in this modality. I also expected to see this, because the fibrocystic breast tissue
had already been documented on previous ultrasound images as well.
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.
I called the patients name in the gallery to let her know we were ready to see her for her
exam. I then checked her name and date of birth on her outpatient arm band, matching it to
the patient request form. I introduced myself, and told her that I am a student sonographer. I
told her that I would be the one performing her exam that day, as long as she had no
Once in the exam room, I instructed the patient to lie down on her back on the exam
table. I then asked her to verbally verify her name and date of birth, and checked this with
the information pulled up on the patient work list. Before beginning the exam, I explained to
the patient that the doctor had ordered a full ultrasound of both breasts. I told her that I
would apply warm gel to her skin, and use a transducer to take a series of images for the
radiologist to review. I told her the exam would take approximately 20-30 minutes, and that
the sonographer would check my images and scan behind me before the doctor came to
discuss the results of the exam with her. I also asked her permission to use the images for a
class grade. Finally, I asked the patient if she had any questions or concerns about the exam
before we began.
In preparation for this exam, the transducer was cleaned with the proper disinfecting
wipes prior to bringing the patient into the exam room. The protective paper on the exam
table was changed out as well. The sonographer and I reviewed the patients chart, past
history, previous breast ultrasounds, and mammogram images that had been taken the
same day. I performed a hand scrub with the proper hand disinfectant, and donned new
gloves before beginning the exam.
The patient was supine on the exam table during this exam. When scanning the right
breast, her right arm was raised above her head to better even out the breast tissue, and
the right side of her robe was opened to expose only the one breast. When scanning the left
breast, the patient was rolled up almost to the right lateral decubitus position. Her left arm
was raised above her head to better even out the breast tissue, and the left side of her robe
was opened to expose only the left breast.

Breast Written Comp

Grade for
Section 3

During the Exam: Sonographic findings of structures, pathologies,

measurements, and instrumentation
Section 4:
Identify the sonographic features of the breast in its entirety. If both breasts were scanned,
describe the sonographic features of both breasts.
Both breasts were scanned for this exam, and the sonographic features were the same in
both. The skin line was thin and echogenic. The glandular tissue appeared homogeneous
with medium to low level echoes. The subcutaneous fat appeared homogeneous and
hypoechoic. The ducts appeared as anechoic tubular structures that converged behind each
nipple, which appeared hypoechoic with many shadows. The fibrous tissue and Coopers
ligaments were echogenic lines through the parenchyma. Muscle in the chest wall appeared
hypoechoic with echogenic striations. The ribs were echogenic with posterior shadowing. The
fibrocystic areas of each breast had a slightly cystic, basket weave appearance, and
increased parenchymal echogenicity.
Grade for
Section 4
Section 5:
Identify any protocol measurements obtained and identify if each measurement is normal or
abnormal. If abnormal, what is indicated? If no measurements were obtained due to the
exam being normal, identify the normal measurement ranges for breast skin, intramammary
ducts, and axillary lymph nodes.
The only measurements obtained in this exam were of a left and right axillary lymph
node. The right axillary node measured 0.55 cm in length, and the left axillary node
measured 0.66 cm in length. These are both under 1.5 cm, which makes them normal
measurements in any scan plane.
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.
Fibrocystic disease was the documented during this exam. It affects the breasts
bilaterally and is diffuse. There can be small or larger areas of fibrocystic densities within the
breast parenchyma. Vascularity is not affected, and remains the same as the normal tissue.
Sonographic features include a cystic, honeycomb appearance, and an increase in

Breast Written Comp

echogenicity in the affected parenchyma.
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.
The breast preset under small parts was utilized for this exam. This is the appropriate
preset, because it is specific and sensitive to superficial structures, such as breasts. The
transducer used was a ML6-15. The rectangular field of view allows for good visualization of
large areas of breast parenchyma. The frequency range allows for good penetration through
dense breast tissue, and also for reaching the chest wall in patients with larger breasts.
Although this transducer has good penetration, it has extremely good resolution for
visualizing tiny structures or pathologies within the breast tissue. The frequency for this
exam was set at 15 MHz, for good penetration with the best possible resolution for the size
of the patients breasts.
For your areola/ nipple image, identify the depth and focal zone(s) used and explain why
they were correct.
For the right nipple image, the depth was at 4.5 cm, and focal zones were set at 1, 2, and
3 cm. For the left nipple image, the depth was at 4 cm, and the focal zones were set at 1,
1.5, and 2.5 cm. The depth for these two images was correct, because it allowed for the
posterior landmark, the chest wall/ pectoralis major, to be included in the image. Including
this posterior landmark ensures that no breast tissue is overlooked during the exam. Focal
zones are correct for these two images, because they allowed for maximum resolution
throughout all breast parenchyma up until the posterior landmark border.
For your axillary tail image, identify the depth and focal zone(s) used and explain why they
were correct.
The depth for the right axillary tail image was 5 cm, and the focal zones were set at 1.5,
2, and 3 cm. The depth for the left axillary tail image was 6 cm, and the focal zones were set
at 2.5, 3, and 5 cm. The depth for these two images was correct, because when imaging
axillary lymph nodes, it is best to have them in the middle of the screen, which this depth
allowed. The focal zones are correct, because they allowed for maximum resolution of the
entire axillary tail of each breast, as well as each lymph node that was measured.
Grade for
Section 7

Breast 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.
After I finished the exam, I reported my findings to both the sonographer and the
physician that was assigned to the patient. I said that the axillary lymph nodes on each side
measured within the normal limits, being 0.55 cm in length on the right, and 0.66 cm in
length on the left. I told them that the breast parenchyma appeared homogeneous with
dense fibrocystic areas that were slightly inhomogeneous with cystic characteristics. I told
them that no masses or other abnormalities were seen. The physician reviewed my images,
while quizzing me on breast anatomy as she did so. She also commented on my images
having the correct gain and focal zone settings. She told me I had done well with the exam,
and asked me to bring the patient to her office so they could discuss the exam results.
Grade for
Section 8
Section 9:
What was the physicians interpretation of the exam?
The physician reported that no solid or cystic masses or other abnormalities were seen in
either breast, specifically at 9:00 on the right, or 3:00 on the left in the patients indicated
areas of tenderness. She gave a negative impression and a BI-RADS 1, which means there is
no evidence of malignancy. She indicated no explanation for the patients bilateral breast
pain. The physician recommended mammography in 12 months or as clinically warranted,
regular physical exam by a health care provider, and monthly self-breast exam.
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)
I agree with the physicians interpretation of the exam. Fibrocystic disease is a very
common pathology, and usually causes few problems other than bilateral tenderness when
estrogen levels are high before a womans menstrual cycle. It is defined as, alterations in
stromal and epithelial tissue, and is often viewed as a normal finding in breast sonography.
The patients breast parenchyma appeared slightly echogenic with cystic areas that
resemble a honeycomb. This is how fibrocystic disease is explained in the literature as
Grade for
Section 10

Breast Written Comp

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

BMH Womens Health Center

Sarah Hooks, RDMS (Ab)



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