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 - 3

Description: A 37 year-old female with twin pregnancy with threatened premature labor.
(Medical Transcription Sample Report)

This is a 37 year-old female with twin pregnancy with threatened premature labor.

GENERAL EVALUATION: Twin B

Fetal Cardiac Activity: Normal at 166 BPM

Fetal Lie: Longitudinal, to the maternal right.

Fetal Presentation: Cephalic.

Placenta: Fused, posterior placenta, Grade I to II.

Uterus: Normal

Cervix: Closed.

Adnexa: Not seen

Amniotic Fluid: AFI 5.5cm in a single AP pocket.

BIOMETRY:
BPD: 7.9cm consistent with 31weeks, 5 days gestation

HC: 31.1cm consistent with 33 weeks, 3 days gestation

AC: 30.0cm consistent with 34 weeks, 0 days gestation

FL: 6.4cm consistent with 33 weeks, 1 day gestation

CI (BPD/OFD): 77 (70-86)

FL/BPD: 81 (71-87)

FL/HC: 21.3 (19.9-21.5)

FL/AC 21 (20-24)

HC/AC: 1.00 (0.96-1.11)

GESTATIONAL AGE BY CURRENT ULTRASOUND: 33 weeks, 0 days +/- 2 weeks, 2 days FETAL WEIGHT BY CURRENT ULTRASOUND: 2194 gms (4 lbs 13 oz) = 6th percentile EDD BY CURRENT ULTRASOUND: 07/30/07

GESTATIONAL AGE BY DATES: 35 weeks, 5 days

L M P: Not given.

EDD BY DATES: 07/11/07

GESTATIONAL AGE BY PREVIOUS ULTRASOUND: 35 weeks, 2 days DATE OF PREVIOUS ULTRASOUND: 04/20/07 EDD BY PREVIOUS ULTRASOUND: 07/13/07

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 B is small for gestational age and equivalent to twin A (size and dates as detailed above).

Nuchal cord.

Low amniotic fluid volume.



Keywords: radiology, normal fetal, premature labor, amniotic fluid, nuchal cord, twin pregnancy, gestational age, fetal, pregnancy, gestation, gestational, cord, twin, ultrasound,
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