UTC Patient Assessment & Documentation 2 — Questions and Answers
Question 1: A patient reports taking warfarin daily. How should this information be documented before an abdominal ultrasound?
- Note it only if the patient is having a biopsy
- Record it in the clinical history section with dosage if known (Correct answer)
- Disregard it as irrelevant to diagnostic ultrasound
- Ask the patient to stop the medication before the exam
Correct answer: Record it in the clinical history section with dosage if known
Anticoagulant use must be documented in the clinical history because it is relevant to any interventional procedures and informs the interpreting physician.
Question 2: Which vital sign finding would most warrant immediate notification of the supervising physician before proceeding with a routine pelvic ultrasound?
- Blood pressure of 118/76 mmHg
- Pulse of 72 bpm
- Blood pressure of 80/50 mmHg (Correct answer)
- Temperature of 98.6°F
Correct answer: Blood pressure of 80/50 mmHg
A blood pressure of 80/50 mmHg indicates hypotension, which is a potentially critical finding requiring physician notification before continuing.
Question 3: When documenting a patient's last menstrual period (LMP) for a pelvic ultrasound, what is the primary clinical reason this information is needed?
- To schedule the next appointment appropriately
- To estimate gestational age and assess cycle phase (Correct answer)
- To determine contrast media dosage
- To choose the correct transducer frequency
Correct answer: To estimate gestational age and assess cycle phase
LMP is used to estimate gestational age in potential pregnancy and to understand the phase of the menstrual cycle, which affects uterine and ovarian appearance.
Question 4: A patient arrives for a renal ultrasound and states she is allergic to iodine. What is the most appropriate sonographer action?
- Cancel the exam immediately
- Document the allergy and proceed, as ultrasound does not use iodinated contrast (Correct answer)
- Administer an antihistamine before the exam
- Switch to a CT scan instead
Correct answer: Document the allergy and proceed, as ultrasound does not use iodinated contrast
Standard diagnostic ultrasound does not use iodinated contrast agents, so an iodine allergy does not affect the procedure, but it should still be documented.
Question 5: Which element is essential when documenting image labeling on a sonographic study?
- The sonographer's personal opinion of the findings
- Patient name, date of exam, and anatomical orientation markers (Correct answer)
- The type of ultrasound machine used
- The patient's insurance information
Correct answer: Patient name, date of exam, and anatomical orientation markers
Proper image labeling must include patient identification, exam date, and orientation markers to ensure images are legally and clinically identifiable.
Question 6: During patient assessment, a patient describes pain that worsens with deep inspiration in the right upper quadrant. Which organ should be the primary focus?
- Left kidney
- Gallbladder and liver (Correct answer)
- Urinary bladder
- Pancreatic tail
Correct answer: Gallbladder and liver
Right upper quadrant pain that worsens with inspiration is a classic sign of gallbladder or hepatic pathology, such as cholecystitis (Murphy's sign).
Question 7: A patient's referral order lists 'rule out DVT.' What assessment information is most critical to gather before beginning the venous duplex exam?
- Patient's dietary habits
- Location of symptoms, onset, and any recent surgery or immobilization (Correct answer)
- Whether the patient has had a previous ultrasound
- The patient's employment history
Correct answer: Location of symptoms, onset, and any recent surgery or immobilization
Symptom location, duration, and DVT risk factors such as recent surgery or immobility are essential to focus the exam and interpret findings accurately.
UTC Patient Assessment & Documentation 2
A patient reports taking warfarin daily.
How should this information be documented before an abdominal ultrasound?