Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Radiology
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.

BIOMETRIC DATA:
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: radiology, 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,
NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports. These transcribed medical transcription sample reports may include some uncommon or unusual formats; this would be due to the preference of the dictating physician. All names and dates have been changed (or removed) to keep confidentiality. Any resemblance of any type of name or date or place or anything else to real world is purely incidental.
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Transcribed Medical Transcription Sample Reports and Examples