OB First Trimester Written Comp

Student Name: Shelley Kraft

Date Submitted: 11/5/2014

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 an African American female, 33 years of age. She was gravida 5, para 2,
with 1 abortion, and 1 ectopic pregnancy on the right side. She was currently experiencing
nausea and vomiting and body cramps (like the flu) for 3 days. The patient denied any
bleeding.
Identify the patients labs relevant to the exam (as high, low, or normal) and explain what
the patients lab values indicate.
If the patient had no labs, identify the labs relevant to the exam (with normal values) and
explain what deviations in these lab values indicate.
Answer:
HCG - 49,631 (normal) within normal limits for 6 8 weeks (15,000 200,000)
Hematocrit 37.6 (normal) no indication of hemorrhage or bleeds
Identify the patients previous exams and results relevant to the 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:
No previous ultrasound exams performed
MRI ABD/PELVIS may be performed in possible emergent cases to evaluate an ectopic
pregnancy. US would still be the greater option due to quicker exam time.
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?

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Answer: The patients lab values were all normal and did not have a clinical history of
bleeding. There were no previous exams/results. The patient knew that she was close to
eight weeks pregnant and I attributed the nausea and vomiting to the pregnancy. With all of
these details in mind I expected to see an eight week old fetus with a normal heart rate.
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 greeted the patient in the hallway and introduced myself and asked to see the patients
armband. I compared it with the printed order. I pushed the stretcher with the patient into
the ultrasound room. I asked the patient if her bladder felt full to allow her to use the
restroom if needed so that the full bladder would not hinder the exam. I then had the
patient lay supine on the stretcher and I placed several folded sheets under her bottom to
ensure she was lifted high enough off of the stretcher for proper mobility of the probe. I
asked the patient if she had ever had a transvaginal ultrasound before, and that it should
not be painful and at any time if she felt extreme discomfort to let me know. Before
beginning the exam I asked the patient to verify her birthdate so I could compare it with the
queried exam on the machine. The proper preset was selected and all equipment was clean
for patient safety. I placed a sterile probe cover on the probe and used sterile get for the tip.
Before taking the first image, I asked the patient how many times she had been pregnant
and how many current children she had. I also asked the patient if she had been given an
estimated due date and if she knew the first day of her last period. I entered all of this data
into the proper location for comparative calculations for the fetal development. I told the
patient that I would be assessing the uterus, adnexal regions, gestational sac, and the fetus
for the radiologist. I also explained that I was a student and the sonographer would be
coming in after me to verify that we had all the appropriate images for the radiologist.
Grade for
Section 3

During the Exam: Sonographic findings of structures, pathologies,

measurements, and instrumentation
Section 4:
Identify the sonographic features of the maternal/fetal structures to include: uterus sagittal
midline, gestational sac transverse mid, and fetal pole crown rump length (CRL)
Answer:
Uterus sagittal midline heterogeneous mid-level gray echoes with echogenic decidua
(doubledecidual sign) around an anechoic gestational sac in the midline.
Gestational sac transverse mid - homogeneous uterus of mid- level gray echoes with
echogenic decidua surrounding the anechoic gestational sac.
Fetal pole crown rump length heterogeneous mid-level gray echoes within the uterus with
an echogenic decidua round the anechoic sac containing an echogenic fetus with an

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anechoic area in the head representing the rhomedoncephlon. There is also an echogenic
circle around the fetus representing the anion.

Grade for
Section 4
Section 5:
Identify all protocol measurements obtained and identify if the measurement is normal or
abnormal. If abnormal, what is indicated?
Answer:
GS SAC SAG MID 3.54 X 2.27 cm (normal)
GS SAC TX MID 3.92 cm
gestational age

(normal) these measurement correlated with the current

YOLK SAC 0.30 cm (normal)

RIGHT OVARY 3.95 x 1.68 x 2.07cm (normal)
LEFT OVARY 4.97 x 2.94 x 2.86cm (slightly enlarged due to possible corpus luteal cyst)
CRL 8 weeks 0 days (normal)
HEART RATE 164 bpm (slightly elevated) the heart rate is normally between 144 159
bpm in the 8th week; still under 200.

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:
Corpus Luteal cyst: (normal variant) the corpus luteum cyst secretes progesterone to
support the pregnancy until the placenta can take over its hormonal function.
Left ovary
2.73 x 2.48 x 2.51 cm
Heterogeneous round mass with partial anechoic center (comparative to aging hemorrhage)
The mass was vascular with a ring of fire pattern
Grade for
Section 6
Section 7:

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Identify the ultrasound preset, transducer, and frequency utilized to provide diagnostic
images and why the specific instrumentation was correct.
Answer:
Preset OB1 (programmed for the machine to be calibrated for an optimal exam)
Transducer IC5-9 (transvaginal probe; this probe allows for optimal access for best
visualization of the small gestational sac in the uterus.)
Frequency 8.0 MHz (this frequency allows for penetration to optimally visualize the
gestation sac within the uterus and the ovaries in the adnexal regions without disruption of
resolution for a diagnostic image.)
For your fetal heart and chest documenting heart rate with M-mode, identify depth and focal
zone(s) used and why they were correct.
Answer:
Depth 3.5 (this enabled the fetal heart to be positioned in the screen for optimal
visualization to place the Doppler signal.
Focal zone was at the level of the fetal heart, due to the zoom being used there is not a
specific depth the focal zone was placed.
For your gestational sac sagittal mid, identify depth and focal zone(s) used and why they
were correct.
Answer:
Depth 6 (this allows for the posterior portion of the uterus to be visualized while keeping
the gestational sac in the center of the image for optimal evaluation.
Focal zones 2 and 5; the first focal zone is at the level of the gestational sac for the best
resolution and diagnostic evaluation of the fetus and supporting structures. The second
focal zone was placed just below the gestational sac to continue the optimal resolution to
evaluate for possible subchorionic hemorrhages.
Grade for
Section 7

Exam Findings: Students Preliminary Report and Physicians Interpretation

Section 8:
What did you report to the sonographer and/or physician regarding the exam and describe
your interaction.
Answer:
I reported to the sonographer that the patient was gravida 5, para 2, with 1 abortion, and 1
ectopic pregnancy on the right side. I also reported that her labs were normal and the HCG
was within the right levels in comparison the approximate fetal age.
I reported to the sonographer that I had visualized a gestational sac containing a fetus with

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a heart rate of 164 bpm. I also reported that I visualized the yolk sac and measured the
crown- rump length of the fetus. The CRL measured approximately 8 weeks. I also reported
that I visualized many small follicles on the right ovary and possibly a corpus luteal cyst on
the left ovary. I told her that I measured and documented them appropriately. I also
explained that I did not seen any abnormalities within or around the gestational sac. I also
did not visualize any free fluid or adnexal masses.
She told me I did a great job, and went in and took some more images to verify the CRL and
scan through the uterus to make sure that I had not missed any pathologies.
Grade for
Section 8
Section 9:
What was the physicians interpretation of the exam?
Answer:
Uterus measures 8.8 cm x 5 cm x 6.7 cm. There is a single living intrauterine gestation
identified with an estimated mean fetal heart rate of 164 beats per minute. Gestational sac
measures approximately 3.3 cm and crown-rump length measures 1.6 cm. Yolk sac is
identified. Estimated gestational age by crown-rump length is 8 weeks one day.
Left ovary measures 3.1 cm x 4.9 cm x 2.8 cm and demonstrates an echogenic 2.7 cm mass,
likely corpus luteal cyst. Right ovary measures 3.9 cm x 1.9 cm x 1.7 cm and demonstrates
a small simple follicle. No free fluid.
Impression:
Single living intrauterine pregnancy with estimated gestational age of 8 weeks one day.
Probable corpus luteal cyst left ovary.
Grade for
Section 9
Section 10:
Do you agree or disagree with the physicians interpretation of the exam and why or why
not? (This must be supported by current literature)
Answer:
I agree with the physicians interpretation of the exam due to visualizing a normal
gestational sac, no evidence of hemorrhage, and a viable fetal heart rate. I also documented
the possible corpus luteal cyst on the left ovary with the ring of fire color Doppler display.
Also once the CRL was performed it correlated with a gestational age of 8 weeks one day
along with a few days off of the first day of the last menstrual period provided by the
patient. No adnexal masses were visualized. I also documented the gestational sac in the
mid line of the uterus. I am in complete agreement with the physician.
Grade for
Section 10

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Points

Description

No errors were identified

One error was identified

Errors identified In less than the of the components required

Errors identified In up to s of the components required

Immediate action required

errors identified in more than s of the components required

evidence of an unsafe event (unsafe events may result in

failure of the competency)

required image not included

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