Medical Specialty:
Radiology

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.

FL: 6.9cm which equals 35weeks and 3days 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

FL/AC (20-24) 20

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%.

EDD BY CURRENT ULTRASOUND: 06/04/07.

GESTATIONAL AGE BY DATES: 40weeks 0days.

L M P: Unknown.

EDD BY DATES: 05/18/07.

DATE OF PREVIOUS ULTRASOUND: 03/05/07.

EDD BY PREVIOUS ULTRASOUND: 05/24/07.

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: radiology, normal fetal, placental grade, fetal weight, gestational age, oligohydramnios, fetal, pregnant, placental, ultrasound, gestational,