Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Obstetrics / Gynecology
Sample Name: Ultrasound OB - 5

Description: This is a 24-year-old pregnant patient to evaluate fetal weight and placental grade.
(Medical Transcription Sample Report)

This is a 24-year-old pregnant patient to evaluate fetal weight and placental grade.

GENERAL EVALUATION:
Fetal Cardiac Activity: Normal with a heart rate of 135BPM

Fetal Presentation: Cephalic.

Placenta: Anterior

Placentral grade: II

Previa: ? None.

Amniotic Fluid: 1.5 + 2.5 + 0.0 + 0.0 = 4cm compatible with oligohydramnios.

BIOMETRY:
BPD: 9.0cm consistent with 36weeks, 4days gestation

HC: 34.6cm which equals 40weeks and 1day gestational age.

FL: 6.9cm which equals 35weeks and 3days gestational age.

AC: 34.6cm which equals 38weeks and 4days gestational age.

CI (BPD/OFD): (70-86) 73

FL/BPD: (71-87) 77

FL/HC: (20.8-22.6) 19.9

FL/AC (20-24) 20

HC/AC: (0.92-1.05) 1.00

GESTATIONAL AGE BY CURRENT ULTRASOUND: 37weeks 4days.

FETAL WEIGHT BY CURRENT ULTRASOUND: 3289grams (7pounds 4ounces).

ESTIMATED FETAL WEIGHT PERCENTILE: 24%.

EDD BY CURRENT ULTRASOUND: 06/04/07.

GESTATIONAL AGE BY DATES: 40weeks 0days.

L M P: Unknown.

EDD BY DATES: 05/18/07.

DATE OF PREVIOUS ULTRASOUND: 03/05/07.

EDD BY PREVIOUS ULTRASOUND: 05/24/07.

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 a sonographic gestational age of 37weeks and 4days.

AFI=4cm compatible with mild oligohydramnios.

Fetal weight equals 3289grams (7pounds 4ounces). EFW percentile is 24%.

Placental grade is II.

No evidence of gross anatomical abnormality, with a biophysical profile total equal to 8 out of 8.



Keywords: obstetrics / gynecology, normal fetal, placental grade, fetal weight, gestational age, oligohydramnios, fetal, pregnant, placental, ultrasound, gestational,
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