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 - 8

Description: Pregnant female with nausea, vomiting, and diarrhea. OB ultrasound less than 14 weeks, transvaginal.
(Medical Transcription Sample Report)

REASON FOR EXAM: Pregnant female with nausea, vomiting, and diarrhea.

FINDINGS: The uterus measures 8.6 x 4.4 x 5.4 cm and contains a gestational sac with double decidual sac sign. A yolk sac is visualized. What appears to represent a crown-rump length measures 3.3 mm for an estimated sonographic age of 6 weeks 0 days and estimated date of delivery of 09/28/09.

Please note however that no fetal heart tones are seen. However, fetal heart tones would be expected at this age.

The right ovary measures 3.1 x 1.6 x 2.3 cm. The left ovary measures 3.3 x 1.9 x 3.5 cm. No free fluid is detected.

IMPRESSION: Single intrauterine pregnancy at 6 weeks 0 days with an estimated date of delivery of 09/28/09. A live intrauterine pregnancy, however, could not be confirmed, as a sonographic fetal heart rate would be expected at this time. A close interval followup in correlation with beta-hCG is necessary as findings may represent an inevitable abortion.

Keywords: radiology, intrauterine pregnancy, estimated date of delivery, nausea, vomiting, fetal heart tones, ovary measures, fetal heart, ultrasound, ob, ovary, pregnancy, sac, fetal, intrauterine,
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