Sample Case Study Of Maria's Scan

G4 P3003 (4 Gestations, 3 Full Term, 0 Preterm, 0 Miscarriages, 3 Currently Living); 3 Spontaneous Vaginal Deliveries; Last birth was 7 years ago by SVD, weighed 4000 grams; No previous obstetrical complications or morbidity; No past medical history; No past surgical history; No prior antenatal care

The physical Assessment Findings: The patient’s head, eyes, ears and nose are normal, however there is white patches on the buccal mucosa. The lymph nodes and carotid bruits are absent. Her heart beat at a regular rate and rhythm without murmur. Her lungs sound is diminished to auscultation with end expiratory wheezes, and dull percussion to the right lower lobe. Her anterior-posterior diameter of the chest wall is also increased. Her abdomen is benign. She has strong pedal pulses to all extremities without edema.

Twenty minutes passed and the cat scan was over. They said that my mom and my brother had to wait an hour until they got the results back. So they waited.

Thank you for referring this patient to our office. Please do not hesitate to call us if you have any questions.

On today’s evaluation, she is 13 6/7 weeks and the crown-rump length measurement is concordant. The nuchal translucency measurement fell within the normal range. The nasal bone was identified, and there was normal ductus flow.

Views today demonstrate a viable singleton fetus at 31 weeks 0 days in vertex presentation with an anterior placenta. Fetal biometry appears symmetric and corresponds with stated EDD falling at the 56%ile. Interval growth is noted; however, the growth percentage did trend down from the 80%ile to the 56%ile. Follow-up fetal anatomy visualized as normal or was previously documented as normal. Ductal velocity today measured at 69.2 cm/se, which falls within normal limits. AFI remains reassuring at 12.6 cm. BPP 8/8. Doppler studies are normal in value and wave form.

By dates, the patient is 35 5/7 weeks and the measurements are concordant. The amniotic fluid volume is normal. The fetus is in cephalic presentation. The BPP and Doppler studies are reassuring. A complete fetal anatomical survey was performed and no major malformations were noted at this time within the resolution of the ultrasound equipment other than the fetal abdomen. There is a cystic structure seen in the fetal abdomen that is about 3 cm in diameter with some echolucency surrounding this. It is below the kidney but above the fetal bladder as identified in your office.

Thank you for the opportunity to participate in the care of Ms. Megan Robertson, who as you know is a 20yo female, G2 P0101, currently at 16 weeks 5 days EGA with a pregnancy complicated by a history of prior spontaneous preterm delivery at 35 weeks of gestation and maternal underweight status. She presents today for evaluation of cervical length and fetal growth due to her history of prior preterm delivery and started her course of 17-alpha hydroxyprogesterone caproate injections today and these are weekly injections for her to reduce the risk of preterm birth secondary to her history of prior spontaneous birth.

Thank you for referring this patient to our office. Please do not hesitate to call us if you have any questions.

After her blood work came back clear, the physician ordered an EEG and CT-scan to get an in-depth view

Lynn K. is a 31-year-old Caucasian female G1P0 presents at 25 wga for a prenatal visit. She does not take her prenatal vitamins every day because they make her feel very nauseous and has experienced morning sickness throughout her pregnancy. She states that she feels fatigued very easily and describes feeling short of breath when carrying out simple tasks around the house. She began feeling this way approximately four weeks ago, and attributed it to “normal pregnancy symptoms.” Recently, she began noticing occasional lightheadedness and dizziness. The patient’s history indicates that she has suffered heavy periods prior to her pregnancy.

My prenatal development was normal. There were not any concerns or worries about my development. My mom had a fairly normal pregnancy other than preeclampsia. Preeclampsia is a medical condition in women who have not experienced high blood pressure, and developed in during a pregnancy (Preeclampsia and Eclampsia, 2016). High protein levels in urine and swelling of the hands, legs and feet are other symptoms of preeclampsia. My mom had an ultrasound at fourteen weeks. She did not have any other testing like an amniocentesis or chorionic villus sampling. It was unnecessary.

She is available next Wednesday (3/30) for a lunch so would like to extend the invitation to you all.

Based on this new information, what is your diagnosis for this patient? Has your diagnosis changed? (2 pts.)

By dates, she is 19 1/7 weeks and the fetal measurements overall are concordant at about 3-4 days smaller. The amniotic fluid volume is normal and the cervix is long and closed with no evidence of membrane funneling. The placenta is anterior and is not low-lying. It is possible that the edge of the placenta extends down to where the old cesarean section scar would be located but there is no increased vascularity at this point in time. A complete fetal anatomical survey was performed and no major/minor malformations were noted at this time within the resolution of the ultrasound equipment.