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Wednesday, April 1, 2020

Ultrasound - Pelvis (IUP Identified)



Ultrasound: Pelvic

A focused [transabdominal/transvaginal] ultrasound of the pelvis was performed by [myself/Dr. Resident under my supervision/independently with images reviewed by myself] in the evaluation of patient with [describe complaint]. 

Long and short views of the uterus were obtained including the pouch of Douglas.  The right and left adnexa [were/were not] visualized [and were normal/notable for a right-/left-sided cyst].  There was [no evidence/a small amount] of free fluid present.  

A definitive intrauterine pregnancy (IUP) was identified based on evidence of [a gestational sac (GS)/yolk sac (YS)/fetal pole].  Fetal heart rate [was/was not] measured [at ### beats per minute].  Gestational age was estimated at [##] weeks and [##] days [by crown-rump length (CRL)/biparietal diameter (BPD)].

IMPRESSION:
IUP measuring consistent with a gestational age of [##] weeks and [##] days. No evidence of free fluid noted.

https://www.wikem.org/wiki/Ultrasound:_Pelvic

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