Having a standardised method for performing and reporting on an ultrasound scan will improve competencies and therefore confidence. All structures (normal or otherwise) should be assessed and considered using the same principles and this will ensure there is no uncertainty or ambiguity when reports are reviewed.
Having both images and a report which corroborate each other is good practice from both a ‘care of the patient’ and medico-legal perspective.
A comprehensive description of findings will support patient care pathways when repeat/follow up examinations and treatments are necessary
Any organ or structure should be considered using the same criteria which will then serve to determine if it is within normal limits or abnormal.
At Aspire, we try to make everything easy to remember so that all our focus when performing a scan is on the patient and what we are seeing and doing.
For that reason, we use LEMONS when assessing any organ, structure or abnormality demonstrated on our ultrasound scan:
- Location
- Echotexture
- Measurements
- Outline
- Number
- Shape
Location:
The location of an organ does not need to be stated unless it is sited in an unusual place or is enlarged for example ‘the liver extends to the margins of the left kidney’.
The location of pathology should, wherever possible be described e.g., ‘focal mass present in the head of the spleen’ or ‘focal lesion identified in the cranial pole of the right kidney’’.
Where there are enlarged lymph nodes, it is good practice to describe their location in relation to other structures as demonstrating the efficacy of treatment often relies on the clinician knowing exactly which nodes are being commented upon in subsequent examinations.
Echotexture:
It is important to recognise normal echotexture and how it compares to other structures, for example, the spleen in dogs is generally considered to be more hyperechoic than that of the renal cortices and the liver but in cats, the spleen is often iso-echoic or only mildly hyperechoic to the renal cortex.
The difference in echotexture of a lesion or abnormal structure can guide the operator towards diagnoses. Whilst we acknowledge that ultrasound alone cannot diagnose certain conditions, appreciating the difference in the appearance of parenchyma can point towards certain differentials.
Measurements:
It is always useful to measure structures such as the kidneys to confirm they are within normal parameters for breed and conformity. The size of the walls of the GI tract are often indicators of disease process and whilst in advanced disease, it might be obvious that the walls are thickened, in early stages, the changes may be subtle and not properly appreciated without measurements. Where image quality is good it can often seem that a structure is abnormal (because we are just not used to seeing anatomy with such optimum resolution) but measurements reassure the operator that it is in fact within normal limits.
Any abnormality demonstrated whether it looks benign or malignant should be measured, ideally in 3 planes. It is impossible to confirm if something has increased or decreased in size if there are no actual measurements to compare.
Outline:
The outline of a structure can help in determining its normality. For example, kidneys have a nice smooth outline but the presence of renal lobulations could be due to a mass for example distorting the normal renal architecture or cortical scarring where there may be depletion in the normal capsular outline. Another example where outline can support diagnoses is rounding or blunting of the liver margins as an indicator of a degree of hepatomegaly. Ill-defined margins can also indicate possible infiltration of disease to adjacent structures.
Number:
With pathology, it is always a good idea to give an indication of the number of lesions as this can be useful. ‘Solitary’, ‘multiple’, ‘numerous’ can help when describing liver lesions for example and the size and location (if possible) of the largest should always be given. The subsequent patient management options may well depend on a comprehensive assessment of the number / distribution of lesions.
Shape:
Describing findings by their shape can often help to determine their nature and shows that you have assessed it in multiple planes to aid your description e.g., rounded, tubular, fusiform.
Again, this is important when describing an abnormality.
Lymph nodes for example vary in size and shape between breed, species and in juveniles so often the shape can serve as a more useful descriptor.
Consistency is key to a successful examination and ensuring that everyone who performs ultrasound examinations works to the same protocol will improve the care given to patients
Remember your ‘LEMONS’!