Question Bank – Pediatric Residency Essentials

True or False.  There is minimal evidence that of point of care renal ultrasound in children improves clinical outcomes. 

Point of care renal ultrasound can be used to visualize which of the following renal pathologies in children?  Check all that apply. 

In a 2015 case series of 5 pediatric patients with renal colic published in the Journal of Emergency Medicine, Ng et al demonstrated that renal POCUS in these patients was associated with: 

In an article published in 2020 in the Ultrasound Journal, Sibley et al. evaluated the accuracy of point of care ultrasound in the detection of hydronephrosis by emergency residents and attendings in 413 adults with renal colic. Which of the following statements about the conclusions from this paper are TRUE: 

In an article published in 2020 in the Ultrasound Journal, Sibley et al. evaluated the accuracy of point of care ultrasound in the detection of hydronephrosis by emergency residents and attendings in 413 adults with renal colic. Which of the following statements about the conclusions from this paper are TRUE: 

True or False.  The optimal transducer for pediatric renal scanning is the linear probe because it generates a low frequency sound wave which enables adequate visualization of intra-abdominal organs.  

True or False.  The optimal transducer for pediatric renal scanning is the curvilinear probe because it generates a low frequency sound wave which enables adequate visualization of intra-abdominal organs.  

True or False.  Both Curvilinear and Phased Array probes can be used for pediatric adolescent renal ultrasound.  

What is the optimal position for renal ultrasound scanning?

“Knuckles to the bed” is used to optimally visualize what anatomical structures?

What structure is highlighted as A?

What image is generated by the transmission of sound waves through a medium leading to few returning sound waves to the ultrasound probe?

What structure is highlighted as B?

What structure is highlighted as C?

In the image below, which arrow is pointing to the inferior pole of the kidney? 

By definition, what is considered mild (grade 1) hydronephrosis? 

By definition, what is considered moderate hydronephrosis? 

By definition, what is considered severe hydronephrosis? 

True or False.  Hydration status has no impact on the presence or absence of hydronephrosis therefore the absence of hydronephrosis rules out post-renal obstruction regardless of hydration status. 

Simple cysts have which of the following features?

Simple cysts have which of the following features?

Complex cysts have which of the following features?

True or False. Hydronephrosis must by definition involve dilation of the renal pelvis.

True or False.  Hydronephrosis may begin as a cyst in the renal cortex and progress to involve the renal pelvis.  

What artifact is generated by the finding in A?

What finding is highlighted by A?

What sonographic finding is highlighted by B?

What finding is 

What finding is highlighted by C?

True or False.  A linear probe is useful to visualize the kidneys between the ribs.  

Which probe is best used to visualize the kidneys in children due to its small footprint?

Rib shadows pose a challenge to adequately visualize the kidneys by ultrasound.  Which techniques help to better visualize the kidneys?

Which of the following findings is hyperechoic?

Which findings are hypoechoic or anechoic?  Mark all that apply.

A 15 y/o patient with a history of known kidney stones presents to your clinic with acute flank pain and hematuria.  He reports he has been vomiting throughout the night and is only voiding very small amounts of dark urine.  You perform a bedside ultrasound obtaining longitudinal and transverse views of the kidneys and find no hydronephrosis.  What next step can be used to improve POCUS sensitivity for a suspected obstructing renal stone?

The above image is an example of what grade of hydronephrosis?

True or False.  A transverse view is helpful to visualize the proximal ureter to evaluate for proximal ureteral obstructing stone.  

Which findings are present above?  Mark all that apply

What is the most likely cause of the the finding above on renal ultrasound?

A 15 year old male presents with acute right sided flank pain to a local health clinic.  There are limited lab tests and imaging on site.  You are the pediatrician on call and consulted. You note that the patient has no prior history of known structural renal disease.  The health provider calling you performs a bedside ultrasound as an extension of their physical exam and sees the above finding.

The ultrasound findings above raise clinical suspicion for which of the following diagnoses? 

To appropriately obtain a bladder volume, you must obtain a total of 3 measurements in two separate axis.  True or False.

True or False.  Calculating bladder volume is an estimation because the shape of bladders are variable.  A commonly used formula is length, width x height x .7 = bladder volume.  

To manually calculate approximate bladder volume, what is the generally agreed upon coefficient? [Bladder Volume = (Length x Width x Height ) x Coefficient]

Pediatric ultrasound guided lumbar puncture is difficult for all of the reasons except?

In the retrospective review by Pierce et al. published in 2018 in Pediatric Radiology, what percentage of lumbar punctures success was achieved when performed with ultrasound guidance?

In the randomized controlled trial by Zummer et al., published in the American Journal of Emergency Medicine in 2021, researchers compared ultrasound-assisted lumbar puncture vs. landmark based lumbar puncture. Which of the following statements are true about what they found?

True or False. The paper published by Ferre et al. in the American Journal of Emergency Medicine (2007) demonstrated that ED physicians can easily obtain ultrasound images of anatomical landmarks relevant to lumbar puncture. 

An Ultrasound Guided Lumbar Puncture procedure is difficult for all of the the following reasons except?

True or False.  In the Journal of Emergency Medicine, Kim et al.’s study on ultrasound assisted LP in pediatric emergency medicine showed that ultrasound-assisted LP led no significant improvement in provider confidence in the identification of insertion points when compared to traditional landmark technique.  

Which of the following is FALSE about the literature on pediatric ultrasound assisted lumbar puncture?

What is the preferred probe to use for pediatric ultrasound assisted lumbar puncture?

For ultrasound guided lumbar puncture in children, what is the appropriate initial depth to set the machine?

In children, ultrasound guided lumbar puncture is performed using what type of frequency probe?

Ultrasound guided lumbar puncture is performed with what type of guidance?

What probe is being used in the above image?

An ultrasound of the lumbar spine is shown. What anatomical landmark is indicated by the green arrow?

An ultrasound image of the lumbar spine is shown. The green arrow in the image is pointing to what part of the spine? 

The above image is obtained when performing an ultrasound assisted LP. Which axis is shown in the above image?

Ultrasound of the lumbar spine is shown.  What structure is indicated by the green arrow in the image?

What structure is being highlighted above?

What pearls are helpful when performing an US Guided Lumbar Puncture?  Mark all that apply.

Knowledge of spine anatomy is important to identify the spinous process and intervertebral space.  Which of the following is a hyperechoic structure with shadowing that is often mistaken for the spinous process?

You attempt ultrasound guided lumbar puncture in a patient with large body habitus and nonpalpable landmarks, but are unable to visualize the lumbar anatomy as the spinous processes are too deep for the waves of the linear transducer to penetrate. What type of probe is most appropriate to try next? 

A patient presents with erythema, warmth, and severe tenderness in her left thigh with a low grade fever. Here is your POCUS. What is the next best step in her care?

After you have made the diagnosis of abscess, what are the benefits of POCUS for an I&D procedure? Select all that apply. 

A patient presents with erythema, warmth, and tenderness on her left leg. She has a low grade fever. Above is her POCUS of the area in question. What is the best next step in her management?

On history and physical exam, you are unsure if a patient has just cellulitis or actually has an early abscess in their inguinal area. The patient is not excited about the prospect of having an I&D. Your POCUS scan results are above. What is the next best course of action for this patient?

What is the best way to scan infected skin/soft tissue to differentiate cellulitis from abscess?

When measuring a cutaneous abscess on ultrasound, you are able to easily see the superficial aspect of the abscess, but are unable to discern the location of the deeper edge of the abscess cavity, where the image has poorer resolution. Which of the following troubleshooting steps can you take? 

Based on available evidence, how does POCUS compare with traditional landmark-based techniques for diagnosis and treatment of peritonsillar abscess? Select all that apply. 

When faced with a diagnosis of abscess vs cellulitis, what is the risk of missing the diagnosis of abscess? Select all that apply. 

True or False: For the diagnosis of cutaneous abscess, the sensitivity of POCUS is comparable and in some cases superior to that of a CT scan.

In the diagnosis of cutaneous abscess, the sensitivity of the physical exam is ____, and the sensitivity of POCUS is _____.

A patient presents for concern for a splinter on the lateral edge of their foot. Because of the awkward angle you find you are unable to get good images of this narrow area. Which of the following troubleshooting measures would help visualize this patient’s extremity?

A patient comes in with a chief complaint of foot pain after having stepped barefoot on a foreign body and they feel that it is embedded in their foot. The patient is morbidly obese and has significant soft tissue on the plantar surface of their foot, limiting your physical exam. See his POCUS clip here:

Which foreign bodies are NOT typically visible on X-ray but ARE better visualized on ultrasound? Select all that apply. 

A 47 y/o male with a history of peptic ulcer disease presents with worsening pain in the right upper quadrant after meals.  An H2 blocker and PPI provide him with no relief.  His clinician performs the ultrasound below.  Applying pressure to the probe causes him more pain.  What artifact present below confirms the patient’s diagnosis?

The presence of the liver superior to the diaphragm is an example of what type of artifact?

Among the artifacts visible in the image below, which artifact explains why the anterior wall of the gallbladder is measured to determine gallbladder wall thickness?

A 23 year old male is involved in an accident falling forward off of his bicycle hitting his abdomen on the handlebars.  He is in severe abdominal pain and has visible bruising over his left flank and around his umbilicus.  You perform an ultrasound exam which shows free fluid in the left upper quadrant between the diaphragm and the spleen concern for a splenic injury.  How do you describe the appearance of fluid on an ultrasound and what happens to sound waves that create this appearance?

In the gallbladder the gallstone appears _______ compared to its surrounding due to the _______ number of sound waves returning to the ultrasound probe.

Which of the following descriptions of ultrasound frequency and probe selection is most accurate?

A 45 y/o female is suffering from abdominal pain after meals.  What ultrasound mode is used to scan her gallbladder in the image below?

A 45 y/o with a history of kidney stones presents with acute onset of L flank pain.  A renal ultrasound shows finding consistent with mild hydronephrosis.  To determine whether or not what appears to be hydronephrosis are actually the renal vessels, what machine mode is used below to troubleshoot this potential pitfall?

The following image shows a cross section of the heart in the parasternal long view. Increasing the gain would result in a ____________.

A 45 year old female with obesity is experiencing pain in the right upper quadrant after meals. You decide to do an ultrasound to look for gallstones. What are the characteristics of the probe that will allow you to best visualize the gallbladder?

How much did you learn in this lesson?

The following image of the heart in the apical 4 chamber window is in which mode?

A 23 year old male fell off a bicycle and complains of rib pain, shortness of breath and abdominal pain. A focused assessment of sonography in trauma is performed (FAST exam). Which artifact seen above the diaphragm suggests that the patient does NOT have a hemothorax?

The following image is taken in the sagittal plane in the abdominal right upper quadrant.  In this view, the sonographer is evaluating Morrison’s Pouch, the space between the liver and kidney, to evaluate for free fluid concerning for hemoperitoneum in the setting of trauma.  In which direction, relative to the patient, is the probe marker pointing?

To evaluate for a DVT, the linear probe is used in the popliteal region.  In the following video, what probe movement is used to rule out the presence of a popliteal DVT?

The more sound waves that return to the probe the brighter the image.

Fluid transmits sound waves resulting in a hyperechoic image.

A _____ frequency sound wave results in better penetration to visualize intra-abdominal organs.

By convention, in the Sagittal plane, the probe marker should be pointing towards which direction?

True or False.  With the exception of the cardiac setting, the index marker is located at the top right of the screen.

By convention, in the transverse plane, the probe marker should be pointing towards which direction?

Which of the following scans does not follow the typical convention of scanning with the probe marker pointing towards the head in the long axis and the probe marker pointing to the patients right in the short axis?

True or False.  Time equals distance.  The top of the screen is the near field and the bottom of the screen is the far field.

What ultrasound mode is being used in the image above?

What mode is used to visualize flow above?

Cardiac left ventricular ejection fraction is calculated by using the distance between the anterior leaflet of the mitral valve and the interventricular septum.  What mode is being used above?

What artifact is visualized above?

A patient with unilateral flank pain and hematuria was found to have a ureterovesicular stone visualized on their bedside ultrasound.  What artifact is shown in the image above?

A patient with unilateral flank pain and hematuria was found to have a ureterovesicular stone visualized on their bedside ultrasound.  What causes the artifact shown above?

A patient presenting with pain in the right upper quadrant has the ultrasound finding above.  What artifact visualized above is associated with gallbladder stones?

What artifact is seen in the far field in A?

A patient with unilateral flank pain and hematuria had a bedside ultrasound of the kidney showing the above finding.  The area indicated by arrow B can be described as: 

Measurements for bladder are obtained.  Which axis is demonstrated above?

Measurements for bladder are obtained.  Which axis is demonstrated above?

True or False. The shape of the bladder affects the volume measurement.  

What is a common coefficient to use to calculate bladder volume from length, width, and height?

Which measurements are obtained in the transverse view of the bladder?

In the paper Bedside Echocardiography by Emergency Physicians published in 2001, Mandavia et al. determined that the non cardiologist diagnosed pericardial effusion at a sensitivity of ____ and specificity of ____?

In the paper published in 2015 titled Diagnostic Accuracy of Right Ventricular Dysfunction Markers in Normotensive Emergency Department Patients with Acute Pulmonary Embolism, Weekes, et al. drew what conclusions regarding the sensitivity and specificity of non radiologists to diagnose RV dysfunction?

A 60 year old female with a history of hypertension presents with shortness of breath, orthopnea, bilateral lower extremity edema. She is diagnosed with congestive heart failure. A bedside cardiac echo is performed and shows the following:

You estimate her ejection fraction to be __________.

What sonographic finding is present?

A 45 year old male with a history of shortness of breath and chest pain is found to have a pericardial effusion. His blood pressure is 90/50 and his heart rate is 120. A bedside ultrasound shows the presence of a pericardial effusion. What ultrasound findings are concerning for Pericardial Tamponade?

What pathological finding is depicted below?

A 63 year old female with a history of COPD, hypertension, and diabetes presents to the clinic with cough, subjective fever, and shortness of breath. Her CXR shows a right lower lobe pneumonia.

Her cardiac echo shows what finding?

Identify the cardiac view obtained in the image below:

Identify the structure highlighted below:

Identify the image highlighted below:

Identify the structure highlighted below:

Identify the structure highlighted in the image below:

Identify the highlighted image below:

Identify the structure highlighted below:

Identify the highlighted structure below:

Identify the structure highlighted below:

Which of the following chambers of the heart is featured in this image?

What structure is highlighted in the image below?

Identify the highlighted image below:

The following images shows which focused cardiac view?

Identify the structure highlighted in the image below:

Identify the structure highlighted in the image below:

Identify the structure highlighted in the image below:

The following image in the _________ view is _______ for the presence of a pericardial effusion.

Which cardiac view is obtained in the image below?

Which movement featured below allows you to obtain the Apical 4 Chamber view?

Which anatomical landmark featured below helps you distinguish between the IVC and the Aorta?

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In the apical 4 chamber view, which probe movement featured above allows you to center your image?

In the Apical 4 Chamber View, what structure is highlighted below?

What structure is highlighted below in the parasternal long view?

In the parasternal short view, what structure(s) is(are) highlighted below?

Which cardiac view is obtained in the image below?

Which cardiac view is obtained in the image below?

The use of ultrasound is useful to distinguish cellulitis from abscess and can minimize the number of dry taps performed.

A 17 year female with a history of diabetes presents to you with fever, pain, swelling, warmth and redness in the right leg.  Her ultrasound is negative for DVT though shows the following image.  What does this finding suggest?

A 15 year old male presents with a bump on his arm, pain, redness and swelling.  He has been on antibiotics for 5 days and but it is not getting any better.  There is no spontaneous drainage.   Your ultrasound exam over the area of swelling suggests the presence of:

Which of the following diagnoses can be detected early by focused cardiac POCUS before physical exam or hemodynamic changes?

When compared with radiology performed echocardiogram, POCUS done in emergency rooms has what sensitivity and specificity for effusion?

Although most literature is extrapolated from adult medicine, cardiac POCUS in pediatrics can currently be used to: (select all that apply)

What best describes the locations of the index marker in the cardiology convention vs. the general convention for point of care ultrasound?  Mark all that apply.  

For the parasternal long axis in the general convention, when holding the trandschere where on the patient should the probe marker pointing?

For the parasternal short axis in the general convention, relative to the patient where is the probe marker pointing?

What body position is useful to improve visualization of the apical 4 chamber view?

Which is not one of the focused cardiac views of the heart?

Which ultrasound finding helps differentiate a pericardial effusion from a pleural effusion in the parasternal long view?

Which views can sometimes be easier to obtain with the hand on top of the probe and the probe at a shallow angle? (Select all that apply)

What view is best for comparing sizes of the heart chambers?

What view is most useful for evaluating for pericardial effusion?

What view is seen in the above cardiac echo?

What cardiac view is seen above?

What focused question is best answered in the cardiac view above?

What ventricle is highlighted above in this Subxiphoid view of the heart?

The structure above is used as a __________ to visualize deeper structures.

What convention is seen above?

What chamber is visualized in the near field?

Which probe is preferred for cardiac ultrasound because of its smaller footprint to avoid rib shadow and capacity to provide good resolution of fast moving images?

For the apical 4 chamber view, how does turning the patient to the left side help obtain better visualization?

Which of the following pulmonary conditions does NOT make obtaining cardiac views more difficult?

A point of care ultrasound is performed. What finding is indicated by the yellow arrow in the image?

What features of the cardiac probe make it better for visualizing cardiac structures? (Select all that apply)

The presence of the descending thoracic aorta in the image above helps differentiate what findings?  (Select all that apply)

What findings differentiate a pericardial fat pad from a pericardial effusion? (Select all that apply)

What are ultrasound findings of reduced LV systolic function?

A cardiac ultrasound is performed. What pathology is shown in the image? 

True or False.   Under normal physiological circumstances, the left ventricle is usually larger, longer, and with thicker walls than the right ventricle.  

When performing a focused cardiac ultrasound in a patient who survived a motor vehicle accident, you notice a pericardial effusion with right ventricular free wall collapse during diastole and right atrium inversion during systole. These findings are suggestive of which of the following diagnoses?

In this parasternal short axis view of the heart using the cardiology convention, what pathological finding is present?

What findings on focused cardiac POCUS can help identify a problem with forward flow to pulmonary vasculature?

Which view seen above was used to diagnose hypoplastic left heart seen above?

A parasternal short view of the heart is shown. What cardiac pathology is being shown in the image?

In a patient presenting with shortness of breath, what is the most likely cause given the cardiac ultrasound above in parasternal short axis?

What characteristics make for more difficult IV access?  (Select all that apply)

The DIVA score (Difficult IV Access) is different from all of the following except?