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 - 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: radiology, fetal presentation, gestational age, fetal, gestational, edd, ultrasound, 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