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.
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
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%.
GESTATIONAL AGE BY DATES: 40weeks 0days.
L M P: Unknown.
EDD BY DATES: 05/18/07.
DATE OF PREVIOUS ULTRASOUND: 03/05/07.
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,