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Name: Cortney R Ellis | DOB: 12/2/1995 | MRN: E130248997 | PCP:

US OB TRANSVAGINAL - Details

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Study Result
Narrative & Impression
CLINIC 1ST TRIMESTER
TV/TA
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Pat. Name: ELLIS, CORTNEY Study Date:


03/28/2022 8:21am
Pat. NO: E130248997
Referring MD: SARA LARUE, MD
Site: Clinic-10012 Kennerly Ste 405
Sonographer: Moore, Rachel A
DOB: 12/02/1995 Age:
26
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INDICATION
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Encounter for Fetal Viability CONFIRMATION


CODING
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Diagnoses O36.80X1: Encounter for Fetal Viability


Procedures 76817: Ultrasound, pregnant uterus, real time
with image documentation

HISTORY
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OB History Gravida 1. Para 0

MATERNAL ASSESSMENT
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Physical Exam Weight 48 kg. BMI 19.39 kg/m²

METHOD
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Transvaginal ultrasound examination. View: Good view

PREGNANCY
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Singleton pregnancy. Number of fetuses: 1

DATING
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Method of dating: based on the LMP
LMP on: 1/28/2022
GA by LMP 8 w + 3 d
EDD by LMP: 11/4/2022

Ultrasound examination on: 3/28/2022


GA by U/S based upon: CRL
GA by U/S 8 w + 6 d
EDD by U/S: 11/1/2022

Assigned: based on the LMP, selected on 03/28/2022


Assigned GA 8 w + 3 d
Assigned EDD: 11/4/2022

ASSESSMENT
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Gestational sac: visualized. Location: intrauterine


Yolk sac: visualized
Embryo: visualized
Cardiac activity: present
YS 2.8 mm <1%
Grisolia
CRL 22.2 mm 8w 6d
Hadlock
FHR 171 bpm

MATERNAL STRUCTURES
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Uterus Visualized
Long 88 mm x ap 69 mm x tr 98 mm. Vol 309.7 cm³
Position: retroverted, retroflexed
Malformations: none
Right Ovary Visualized
:
Size 31 mm x 18 mm x 27 mm. Vol 8.0 cm³
Left Ovary Visualized
Size 18 mm x 11 mm x 11 mm. Vol 1.2 cm³

IMPRESSION
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Single living fetus with a gestational age of 8w 3d based on sonographic


measurement
Consistent with menstrual dating.
No gross and overt fetal abnormalities noted
The Uterus appears retroverted, retroflexed
The right and left ovary appear unremarkable

Final EDC: 11/4/2022 consistent with stated LMP

Recommendation: Fetal anatomic survey at 20 weeks

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