Obstetrics / Gynecology
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: obstetrics / gynecology, intrauterine pregnancy, estimated date of delivery, nausea, vomiting, fetal heart tones, ovary measures, fetal heart, ultrasound, ob, ovary, pregnancy, sac, fetal, intrauterine,