Medical record ultrasound reports

5-28-2011

I picked up copies of our ultrasound reports to take with to Vanderbilt. I will transcribe the oldest report first- the one that the spina bifida was first detected on.

4-25-2011
With respect to fetal anatomy:
Abnormalities in the head were noted during this scan; please see the anatomy comments. The fetal face appears normal. Anatomy of the fetal thorax appeared within normal limits. The cardiac size and structures appeared sonographically normal at the four chamber long axis and short views and cardiac rhythm was regular. The abdominal cavity appears normal. The fetal stomach appears normal. Both kidney appear within normal limits. The fetal bladder appears normal. The abdominal wall appears intact. Abnormal spine: please see anatomy comments for further details. Abnormal extremities: please see anatomy comments for further detail. The placenta appears within normal limits. There is a 3 cord vessel with normal insertion site.

Anatomy comments:
The following anomalies were noted:
Meningmyelocele- A fetal neural tube defect was noted in the lower lumbar region. The defect was studied using 3D rendering in the skeletal mode. The defect appeared to arise at L4.

There is an associated Arnold Chiari Malformation. There was also bilateral clubbing of the lower extremities noted. There was movement of the fetal extremities at the level of the pelvis and the knee. There was NO evidence of movement at the fetal ankle. It should be noted the lateral ventricle measure 5.4mm which is within normal limits for this gestational age.

There were NO other abnormalities noted that would suggest a diagnosis of fetal chromosome aneuploidy.

Impression:
Singleton IUP
16 wks 4 days by this Ultrasound (EDC=October 7,2011)
17wks 2 days by dates (EDC=October 1, 2011)
Variable presentation
Posterior placenta
Estimated Fetal weight = 0 lbs 6 oz
Meningomyelocele
Arnold Chiari Malformation
Talipes


Ultrasound from 5-26-2011

With respect to fetal anatomy:
The fetal cranium appeared normal in shape. The choroid plexus was well visualized, the lateral ventricles were not dilated and the midline structures were not deviated. The cerebellum and cisterna magna were visualized. The fetal face appears normal. Anatomy of the fetal thorax appeared within normal limits. The cardiac size and structures appeared sonographically normal at the four chamber long axis and short axis views and cardiac rhythm was regular. The abdominal cavity appears normal. The fetal stomach appears normal. Both kidneys appear within normal limits. The fetal bladder appears normal. The abdominal wall appears intact. Abnormal spine: please see the anatomy comments for further details. Abnormal extremities: please see the anatomy comments for further detail. The placenta appears within normal limits. There is a 3 vessel cord with normal insertion site.

Anatomy comments:
The following anomalies were noted:
Meningocele- a low lumbar neural tube defect was seen. It appears to arise at L4. There was NO associated fetal ventriculomegaly. The lateral ventricle measured 7mm. The cisterna magna measured 4mm. The cerebellum appeared slightly displaced posteriorly. The fetal cranial shape was consistent with "lemon sign".

Talipes- bilateral clubbing of the lower extremities was noted. There was evidence of movement of the lower exptremities at the level of the knee.

The amniotic fluid volume was normal. There was NO apparent adverse effects from the amniocentesis.

Impression:
Singleton IUP
20wks 4 days by this Ultrasound (EDC=October 10,2011)
21wks 5 days by dates (EDC=October 1,2011)
Breech presentation
Posterior placenta
Estimated fetal Weight = 0 lbs 14 oz
Meningocele
Talipes