Practical Skills: Common Bedside Ultrasound Examination

Question 1

Basic set-up

Answer 1

1. Position patient
2. Equipment: Machine + Probe
3. Setting
   - Depth
   - Contrast image
   - Mode: B-mode (for structural assessment) / Colour doppler (for vascular flow)

Question 2

Breast / Thyroid examination

Answer 2

• Supine position
• High frequency probe (8-13 MHz) (∵ superficial organs)

Breast:
- Expose Clavicle —> Abdomen
- Grid pattern / Radial pattern
- Premammary fat layer —> Mammary fat layer —> Retro-mammary layer (Pectoralis muscle + Rib)

Thyroid:
- Expose until below Clavicle
- Identify trachea first (by Palpation) + identify isthmus —> move probe laterally (start with R side (無所謂)) —> from lower pole to upper pole —> laterally to see vessels —> in-between vessels see LN (along jugular chain)

Question 3

Description of Sonographic lesion

Answer 3

1. Location
2. Size (Width, Height, Depth —> 3D measurement)
3. Nature
   - **Echogenicity (Hypo, Iso, Hyper)
   - **Content (Homogenous / Heterogeneous)
   - **Border (Regular, Irregular)
   - **Posterior characteristics (Shadowing / Enhancement) (∵ dense material + microcalcifications)
   - ***Vascularity (Peripheral / Central)

Suspicious features:
- Hypoechoic + Heterogeneous + Irregular + Shadowing + Central

Example:
- Breast: Size + L/R + O’clock + Distance from nipple
- Thyroid: Size + L/R lobe + Upper / Middle / Lower pole

Question 4

Benign breast cyst vs Suspicious breast mass

Answer 4

Benign breast cyst:
- Hypoechoic
- Homogenous (heterogenous if have blood / complex cysts with solid components, papillary projections)
- Regular border
- Posterior enhancement (∵ not much reflection)

Suspicious breast mass:
- Hypoechoic
- Heterogenous (with solid contents)
- Irregular border (lobulated)
- Posterior shadowing
- Increased vascularity
- Invasion to nearby structure (Taller than wide: cross tissue plane rather than along plane)

考試:
- Mass: Non-suspicious / Indeterminate / Suspicious

Question 5

Suspicious thyroid lesion

Answer 5

• Hypoechoic
• Heterogenous (with solid contents)
• Irregular border (lobulated)
• Posterior shadowing (∵ high density + microcalcifications (Psammoma bodies by Papillary cancer))
• Increased vascularity (Central vascularity)
• Invasion to nearby structure (Taller than wide: cross tissue plane rather than along plane)

Question 6

Normal vs Suspicious cervical LN

Answer 6

Normal:
- ***Along carotid artery
—> Central
—> Lateral
- Size <1cm
- Oval shaped
- Presence of fatty hilum (bright spot in central of LN)

Suspicious:
- Size >1cm
- Circular shape (Long / Short ratio <2)
- Punctate calcification
- Peripheral vascularity
- Solid

Question 7

Abdominal examination

Answer 7

• Lower frequency (2.5-5 MHz curvilinear / phased array transducer) (∵ deep seated organs)

HBP examination
- Supine
- Preparation: Fast 4-6 hours before examination (otherwise gallbladder contracted)
- Plane:
1. Subcostal (***Parallel to costal margin)
- Right lobe of liver
- Gallbladder (if cannot find —> Cholecystectomy / Morbid obesity / Contracted gallbladder)
- Morrison pouch (between liver and right kidney)

2. Intercostal
3. Xiphoid to lateral
   - Left lobe of liver

Question 8

Feature of Acute cholecystitis

Answer 8

1. Presence of gallstone (∵ most cholecystitis are calculous cause)
2. Thickened gallbladder wall (>=4mm)
3. Pericholecystic fluid
4. Ultrasonographic Murphy sign
5. Impacted stone (in Hartmann’s pouch)

Question 9

Liver cyst, Liver abscess, Haemangioma, HCC

Answer 9

Liver cyst: Hypoechoic
Liver abscess: Heterogenous (∵ pus inside) (spread by Haematogenous, Local spread (e.g. Biliary tract infection), Portal venous spread (e.g. Diverticulitis))
Haemangioma: Hyperechoic + Increased vascularity
HCC: Large tumour + potentially cirrhosis

Question 10

Urological examination

Answer 10

1. Kidney
   - Supine / Lateral decubitus position
   - Mid-axillary approach (for thin / normal built): Probe longitudinally + MAL + Subcostal region
   - Posterior approach (for obese): Probe longitudinally at Renal angle
   - Hydronephrosis: Dilated pelvicalyceal system
   - Renal calculus: Bright echogenic focus + Acoustic shadowing
   - Renal tumour: Hypoechoic mass, Increased vascularity
2. Bladder
   - Supine with full bladder
   - Axial / Longitudinal
   - Normal: Hypoechoic (urine inside) + Posterior enhancement

(3. Scrotum
- tuck penis up over pubic symphysis)