Medical Specialty:
Obstetrics / Gynecology

Sample Name: Ultrasound OB - 7


Description: A 27-year-old female with a size and date discrepancy.
(Medical Transcription Sample Report)


This is a 27-year-old female with a size and date discrepancy.

GENERAL EVALUATION:
Fetal Cardiac Activity: Normal at 150BPM. Fetal Lie: Longitudinal. Fetal Presentation: Cephalic. Placenta: Anterior Grade I. Uterus: Normal. Cervix: Closed. Adnexa: Not seen. Amniotic Fluid: Normal.

BIOMETRY:
BPD: 8.4 cm consistent with 33 weeks, 6 days gestation

HC: 29.8 cm consistent with 33 weeks, 0 days gestation

AC: 29.7 cm consistent with 33 weeks, 5 days gestation

FL: 6.2 cm consistent with 32 weeks, 1 day gestation

CI: 83 (70-86)

FL/BPD: 74 (71-87)

FL/HC: 20.8 (19.9-21.5)

FL/AC 21 (20-24)

HC/AC: 1.00 (0.96-1.21)

GESTATIONAL AGE BY CURRENT ULTRASOUND: 33 weeks 1 day + or minus 2 weeks 2 days. FETAL WEIGHT BY CURRENT ULTRASOUND: 2137 grams (4 lbs 11 ozs) = 92nd percentile EDD BY CURRENT ULTRASOUND: 7/10/07

GESTATIONAL AGE BY DATES: 31 weeks 2 days.

L M P: 10/16/06

EDD BY DATES: 7/23/07

FETAL ANATOMY:
Fetal Ventricles: Normal

Fetal Cerebellum: Normal

Fetal Cranium: Normal

Fetal Face: Normal Nose and Mouth

Fetal Heart (4 Chamber View): Normal

Fetal Diaphragm: Normal

Fetal Stomach: Normal

Fetal Cord: Normal three vessel cord

Fetal Abdominal Wall: Normal

Fetal Spine: Normal

Fetal Kidneys: Normal

Fetal Bladder: Normal

Fetal Limbs: Normal

IMPRESSION:
Active intrauterine pregnancy with no gross anatomical abnormality.

Size large for dates but within standard deviation.


Keywords: obstetrics / gynecology, fetal presentation, gestational age, fetal, gestational, edd, ultrasound, gestation,