Lange Review Ultrasonography Examination, 4th Edition

Case Studies

CASE 1

History: 56-year-old man presenting with jaundice. Sagittal gray scale (A) (C) (D) and color Doppler (B) images of liver and common bile duct and pancreatic head.

1-1. Which of the following are true statements concerning this sonogram?

A. there are no dilated intrahepatic or extrahepatic bile ducts.

B. only the extrahepatic bile ducts are dilated.

C. only the intrahepatic bile ducts are dilated.

D. both the intrahepatic and extrahepatic bile ducts are dilated.

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1-2. What is the possible cause of this finding?

A. stenosis at the ampulla of Vater

B. pancreatic head mass

C. stones at the distal common bile duct

D. all of the above

1-3. In this case, what is the most likely cause of dilated ducts?

A. pancreatic cancer

B. stones in the distal common bile duct

C. cannot tell

D. hepatoma

CASE 2

History: 36-year-old woman with chronic hepatitis C. Sagittal gray scale (A), color Doppler (B), and sonograms of liver (C).

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2-1. What is the most correct statement concerning this patient’s sonogram?

A. there is a 2-cm hypoechoic mass with a central vessel.

B. there is an anechoic mass in the liver.

C. there is a vascular mass within the liver.

D. there is a focal area of normal liver surrounded by fatty liver.

2-2. What is the most likely diagnosis?

A. hepatocellular cancer

B. hemangioma

C. focal nodular hyperplasia

D. metastatic lesion

2-3. Which of the following modalities may be helpful to confirm this sonographic impression?

A. computed tomography

B. magnetic resonance

C. angiography

D. nuclear imaging

E. either A or B

CASE 3

History: 51-year-old man with elevated liver function tests. Sagittal and transverse gray scale (A, B, C) sonograms of the liver.

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3-1. Which of the following are true statements concerning this patient’s sonogram?

A. the liver texture is normal.

B. the liver texture is diffusely irregular.

C. the liver is fatty replaced.

D. there are innumerable metastatic lesions.

3-2. What do the calipers measure?

A. the hepatic artery

B. the portal vein

C. the common bile duct

D. the pancreatic duct

3-3. Which of the following can be included in the diagnostic possibilities?

A. normal liver

B. fatty change

C. hepatitis

D. metastatic disease

CASE 4

History: 51-year-old man with elevated liver function tests. Sagittal (B) and transverse gray scale (A) and color Doppler (C) sonography and arterial phase computed tomography (CT) scan (D).

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4-1. Which of the following statements are true concerning this patient’s imaging studies?

A. there is a solid mass in the left lobe.

B. there is a solid mass in the anterior segment of the right lobe.

C. there is a solid mass in the posterior segment of the right lobe.

D. there are no masses within the liver.

4-2. Based on the imaging findings, what is the most likely diagnosis?

A. hepatocellular carcinoma

B. hemangioma

C. metastatic lesion

D. all of the above are possible

4-3. Which of the following are shown in the arterial-phase CT scan?

A. peripheral “cloud-like” enhancement

B. central vascularity

C. nothing

D. diffuse metastatic disease

CASE 5

History: 62-year-old man S/P liver transplant with elevated liver function tests. Transverse gray scale (A) and color Doppler (B, C) images of main and right portal veins.

5-1. Which of the following abnormal findings are shown in the images?

A. reversed flow in the main portal vein

B. abnormal liver texture

C. both A and B

D. none of the above

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5-2. Which of the following are possible causes of this finding?

A. rejection

B. arterial thrombosis

C. diffuse infiltration by tumor

D. faulty anastomosis of portal vein

5-3. What is the most likely diagnosis?

A. portal hypertension

B. liver steatosis

C. both A and B

D. none of the above

CASE 6

History: 53-year-old with history of inflammatory bowel disease. Sagittal gray scale (A) (B) and color Doppler (C) of liver.

6-1. Which of the following abnormal findings are shown in the images?

A. thrombosis of main portal vein

B. multiple liver masses

C. dilated intrahepatic and extrahepatic bile ducts

D. none of the above

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6-2. Which of the following are possible causes of portal vein thrombosis?

A. extension of hepatic tumor into portal vein

B. hematologic disorder

C. gastrointestinal inflammatory disorders

D. all of the above

6-3. What is the clinical importance of portal vein thrombosis?

A. hepatic transplantation cannot occur

B. increased risk of metastatic spread

C. may be “bland”; not related to tumor

D. must be removed by catheter technique

CASE 7

History: 19-year-old with left-lower-quadrant pain. Sagittal gray scale and color Doppler sonography of (A) left kidney and (B) bladder.

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7-1. Which of the following are true statements concerning this sonogram?

A. there is a nonobstructing stone in the left kidney.

B. there is a stone at the left ureterovesicular junction.

C. both A and B are true.

D. neither A nor B is true.

7-2. Which of the following are true statements concerning the “twinkle” sign?

A. It can overestimate size of stone.

B. It can underestimate size of stone.

C. It is only found with certain stones.

D. It does not occur secondarily to vascular calcification.

7-3. Though not shown here, the presence of a ureteral jet indicates which of the following findings?

A. no ureteric obstruction

B. urinary sediment within the bladder

C. cannot represent urine since all fluids are hypoechoic

D. none of the above

CASE 8

History: 30-year-old woman with right upper quadrant pain. Sagittal (A) and transverse (B) gray scale and (C) color Doppler sonogram of the gallbladder.

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8-1. Which of the following are true statements concerning this sonogram?

A. there is severe edema of the gallbladder wall.

B. there are multiple calculi within the lumen.

C. there is no diffuse cholesterosis of the wall.

D. there is focal thickening of the wall.

8-2. Which of the following are diagnostic possibilities?

A. cardiac causes

B. metastatic involvement

C. hepatitis

D. cirrhosis

E. all of the above

8-3. Which of the following is true if the patient experiences pain when the transducer is over the gallbladder?

A. there must be acute cholecystitis.

B. this is referred to as Murphy’s sign.

C. you must stop with the examination.

D. none of the above are true.

CASE 9

History: 56-year-old man with chronic hepatitis C. Sagittal gray scale (A) and color Doppler (B) sonogram of liver.

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9-1. Which of the following is a false statement concerning this sonogram?

A. there is a focal, well-defined mass.

B. the mass contains echogenic focus.

C. A or B

D. there is a well-defined hypoechoic halo surrounding the mass

9-2. Which of the following are diagnostic possibilities for this study?

A. metastatic lesion

B. hepatocellular carcinoma

C. A or B

D. hemangioma

9-3. Which of the following can be said about sonography-guided biopsy of this lesion?

A. not possible

B. can be performed

C. requires CT scanning follow-up

D. none of the above

CASE 10

History: 64-year-old man S/P TIPS procedure. Multiple color Doppler (A, B) sonograms of the liver with an accompanying hepatic venogram (C).

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10-1. Which of the following statements are true concerning these images?

A. the TIPS is perfect

B. the TIPS is obstructed

C. the main portal vein is occluded

D. the left hepatic vein is occluded

10-2. What is the most likely diagnosis?

A. occlusion of the TIPS

B. main portal vein occlusion

C. hepatic vein occlusion

D. normal TIPS patency

10-3. On spectral Doppler, normal velocities in a TIPS:

A. are between 50 and 150 cm/s

B. are near 0 cm/s

C. cannot be calculated, just due to the power

D. do not vary with respiration

CASE 11

History: 28-year-old pregnant patient with right-lower-quadrant pain. Transverse gray scale (A, C) and color Doppler (B) images of right lower quadrant.

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11-1. Positive findings include which of the following?

A. an abnormal bowel segment

B. an abnormal kidney

C. an ectopic pregnancy

D. renal calculi

11-2. Which of the following are diagnostic possibilities?

A. appendicitis

B. small bowel intussusception

C. A or B

D. none of the above

11-3. The normal thickness of a compressed appendix:

A. cannot be measured accurately

B. less than 3 mm

C. less than 6 mm

D. less than 9 mm

CASE 12

History: Sagittal gray scale (A) and color Doppler (B) sonogram of the right thyroid lobe.

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12-1. Which of the following statements are true concerning this patient?

A. there are multiple nodules throughout the entire right lobe.

B. the right lobe is markedly enlarged.

C. there is diffuse textural inhomogeneity of the right lobe.

D. the gain settings are not properly set.

12-2. Diagnostic consideration includes which of the following?

A. chronic lymphocytic thyroiditis

B. Hashimoto’s thyroiditis

C. cancer

D. both A and B

12-3. You are asked to provide sonographic guidance for a biopsy of this patient. Which of the following should be included in your next steps?

A. question whether a biopsy of this lesion is truly indicated

B. use a needle guide

C. refuse to help with the biopsy

D. ask someone else to do it