Which structure is indicated by the arrow in this image?
Correct Answer: D
The structure indicated by the arrow in the ultrasound image is the adrenal gland. On ultrasound, the adrenal gland in neonates and infants is relatively large and has a distinctive "Y" or "V" shape in the transverse view. It is located superior and slightly medial to the upper pole of the kidney. In this image, the arrow is pointing to a hypoechoic, curved structure with a thin echogenic central stripe, representing the fetal adrenal gland. This echogenic stripe corresponds to the adrenal medulla, while the surrounding hypoechoic area represents the cortex. Differential features: * A. Kidney: While the kidney is visualized posterior to the adrenal gland and shows a reniform shape with a central echogenic sinus and peripheral cortex, it is not the structure being directly pointed to by the arrow. * B. Bowel loop: Bowel has variable echogenicity with peristalsis and shadowing from air. It does not have the consistent morphology or location seen in the image. * C. Diaphragm: Appears as a thin, hyperechoic linear structure separating the thoracic cavity from the abdomen. It is seen more superiorly than the indicated structure and lacks the "Y" or "V" adrenal configuration. Key Anatomical Landmarks: * The adrenal glands are located in the retroperitoneum, superior to the kidneys, and appear prominent on ultrasound in neonates. * In transverse view, the right adrenal gland is anterior to the crus of the diaphragm and posterior to the inferior vena cava (IVC). References: Rumack CM, Wilson SR, Charboneau JW, Levine D. Diagnostic Ultrasound. 5th Edition. Elsevier, 2018. Chapter: Adrenal Glands and Retroperitoneum, pp. 291-295. American Institute of Ultrasound in Medicine (AIUM) Practice Parameter for the Performance of an Ultrasound Examination of the Abdomen and/or Retroperitoneum. 2020.
Question 22
Which condition is demonstrated in this image of a febrile patient with breast redness and tenderness?
Correct Answer: B
The ultrasound image demonstrates an irregular, complex fluid collection in the subareolar region of the breast with internal echoes, septations, and poorly defined margins. These sonographic findings are classic for a breast abscess, particularly in a patient presenting with clinical signs of infection-fever, redness, and localized tenderness. A breast abscess is typically seen as: * A hypoechoic or anechoic area with thick walls * Presence of internal debris, septations, or floating echoes * Posterior acoustic enhancement * Increased peripheral vascularity on Doppler (surrounding inflammation) * Surrounding hyperechoic fat due to cellulitis This clinical and imaging profile strongly supports the diagnosis of a breast abscess, most commonly seen in lactating women (puerperal mastitis) or in non-lactating women with chronic infection. Comparison of answer choices: * A. Ductal ectasia usually presents with dilated ducts and minimal inflammatory changes, often asymptomatic or causing nipple discharge. * B. Abscess - Correct. The irregular fluid collection with complex echoes and clinical signs of infection supports this. * C. Sebaceous cysts are typically superficial, round, and well-defined with a punctum. * D. Galactocele appears as a well-circumscribed, fat-fluid level-containing lesion in lactating women but lacks surrounding inflammation. References: Mendelson EB, Bohm-Velez M, Berg WA.ACR BI-RADS Atlas: Ultrasound. American College of Radiology; 2013. Rumack CM, Wilson SR, Charboneau JW, Levine D. Diagnostic Ultrasound, 5th ed. Elsevier; 2017. AIUM Practice Parameter for the Performance of Diagnostic and Screening Ultrasound of the Breast (2021).
Question 23
In which position should a patient be placed when internal echoes are seen within a fluid-filled bladder?
Correct Answer: C
Lateral decubitus positioning allows shifting of internal echoes within the bladder, helping differentiate mobile debris (such as blood clots or sediment) from adherent masses like tumors. This technique is helpful in evaluating questionable bladder filling defects. According to Rumack's Diagnostic Ultrasound: "Changing the patient's position, such as turning to the lateral decubitus, can help distinguish mobile debris from attached bladder wall lesions." Reference: Rumack CM, Wilson SR, Charboneau JW, Levine D. Diagnostic Ultrasound. 5th ed. Elsevier, 2017. AIUM Practice Parameter for Bladder Ultrasound, 2020.
Question 24
Which measurement is the upper limit for a normal gallbladder wall?
Correct Answer: A
The normal gallbladder wall measures up to 3 mm. Thickening beyond 3 mm may suggest cholecystitis, heart failure, hepatitis, or hypoalbuminemia. Measurements should be taken with the patient fasting, using the anterior gallbladder wall. According to Rumack's Diagnostic Ultrasound: "The gallbladder wall is considered thickened if it measures greater than 3 mm." Reference: Rumack CM, Wilson SR, Charboneau JW, Levine D. Diagnostic Ultrasound. 5th ed. Elsevier, 2017. AIUM Practice Parameter for the Performance of Gallbladder Ultrasound Examinations, 2020. -
Question 25
Which condition is most consistent with the findings in this image?
Correct Answer: D
The ultrasound image demonstrates a longitudinal view of the right kidney. Within the renal pyramids, there are multiple echogenic foci, some showing posterior acoustic shadowing-findings characteristic of medullary nephrocalcinosis. This sonographic appearance is strongly associated with medullary sponge kidney (MSK). Medullary sponge kidney is a congenital disorder of the renal tubules that results in ectatic (dilated) collecting ducts in the renal medulla. The dilated ducts frequently become calcified, leading to the "paintbrush" or "bouquet of flowers" appearance seen in the renal pyramids on ultrasound. These calcifications are most often bilateral and symmetrical, further aiding the diagnosis. Comparison of answer choices: * A. Fungal balls (mycetomas) typically appear as mobile, non-shadowing echogenic masses within the collecting system, often in immunocompromised patients. * B. Renal cell carcinoma usually presents as a solid mass with irregular borders and variable echogenicity-this image does not show a mass. * C. Acute pyelonephritis may show renal enlargement, decreased echogenicity, or loss of corticomedullary differentiation-but not calcification of the pyramids. * D. Medullary sponge kidney is correct due to the punctate echogenic foci within the medullary pyramids, consistent with nephrocalcinosis. References: Rumack CM, Wilson SR, Charboneau JW, Levine D. Diagnostic Ultrasound, 5th ed. Elsevier; 2017. Hagen-Ansert SL. Textbook of Diagnostic Sonography, 8th ed. Elsevier; 2017. Babcock DS. Sonographic findings in medullary sponge kidney. AJR Am J Roentgenol. 1981;137(6):1239- 1243.
