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 - 4

Description: Twin pregnancy with threatened preterm labor.
(Medical Transcription Sample Report)

Twin pregnancy with threatened preterm labor.

GENERAL EVALUATION: (Twin A)

Fetal Cardiac Activity: Normal at 166 BPM

Fetal Lie: Twin A lies to the maternal left.

Fetal Presentation: Cephalic

Placenta: Posterior fused placenta Grade I-II

Uterus: Normal

Cervix: Closed

Adnexa: Not seen

Amniotic Fluid: There is a single 3.9cm anterior pocket.

BIOMETRY:
BPD: 8.7cm consistent with 35 weeks, 1 day

HC: 30.3cm consistent with 33 weeks, 5 days.

AC: 28.2cm consistent with 32 weeks, 1 day

FL: 6.2cm consistent with 32 weeks 1 day

CI (BPD/OFD): 85 (70-86)

FL/BPD: 71 (71-87)

FL/HC: 20.5 (19.9-21.5)

FL/AC 22 (20-24)

HC/AC: 1.07 (0.96-1.11).

GESTATIONAL AGE BY CURRENT ULTRASOUND: 33 weeks, 2 days, +/- 2 weeks, 2 days. FETAL WEIGHT BY CURRENT ULTRASOUND: 2008 grams (4 pounds 7 ounces)= < 3rd percentile EDD BY CURRENT ULTRASOUND: 7/28/07

GESTATIONAL AGE BY DATES: 35 weeks, 5 days

L M P: not given

EDD BY DATES: 7/11/07

GESTATIONAL AGE BY PREVIOUS ULTRASOUND: 35 weeks, 2 days DATE OF PREVIOUS ULTRASOUND: 4/20/07 EDD BY PREVIOUS ULTRASOUND: 7/13/07

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, there is a nuchal cord.

Fetal Abdominal Wall: Normal

Fetal Spine: Normal

Fetal Kidneys: Normal

Fetal Bladder: Normal

Fetal Limbs: Normal

IMPRESSION:
Monochorionic diamniotic twin pregnancy.

Twin A is small for gestational age but equal to twin B (size and dates is detailed above).

Nuchal cord.

Low amniotic fluid volume.

ADDENDUM: TWIN B

After further communication with the ultrasound technologist, the small pocket of anterior fluid is only a small portion of the volume of amniotic fluid for the twin. Although AFI could not be determined, the single pocket meets criteria for normal amniotic fluid.

Keywords: obstetrics / gynecology, consistent with weeks, normal fetal, preterm labor, nuchal cord, twin pregnancy, current ultrasound, amniotic fluid, gestational age, fetal, fluid, ultrasound, weeks, twin,
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