Sample Type / Medical Specialty: Obstetrics / Gynecology
Sample Name: Ultrasound OB - 1
Description: OB Ultrasound - A 29-year-old female requests for size and date of pregnancy.
(Medical Transcription Sample Report)
EXAM: OB Ultrasound.
HISTORY: A 29-year-old female requests for size and date of pregnancy.
FINDINGS: A single live intrauterine gestation in the cephalic presentation, fetal heart rate is measured 147 beats per minute. Placenta is located posteriorly, grade 0 without previa. Cervical length is 4.2 cm. There is normal amniotic fluid index of 12.2 cm. There is a 4-chamber heart. There is spontaneous body/limb motion. The stomach, bladder, kidneys, cerebral ventricles, heel, spine, extremities, and umbilical cord are unremarkable.
BPD = 7.77 cm = 31 weeks, 1 day
HC = 28.26 cm = 31 weeks, 1 day
AC = 26.63 cm = 30 weeks, 5 days
FL = 6.06 cm = 31 weeks, 4 days
Composite sonographic age 30 weeks 6 days plus minus 17 days.
ESTIMATED DATE OF DELIVERY: Month DD, YYYY.
Estimated fetal weight is 3 pounds 11 ounces plus or minus 10 ounces.
IMPRESSION: Single live intrauterine gestation without complications as described.
Keywords: obstetrics / gynecology, ultrasound, ac, bpd, cervical length, estimated date of delivery, fl, hc, placenta, single live, amniotic fluid, bladder, cephalic, cephalic presentation, cerebral ventricles, extremities, fetal heart rate, fetal weight, gestation, heel, intrauterine, kidneys, pregnancy, previa, spine, stomach, umbilical cord, live intrauterine, intrauterine gestation,