Medical Specialty:
Obstetrics / Gynecology

Sample Name: Bilateral Mammogram


Description: Bilateral Mammogram, (abnormal) additional views requested
(Medical Transcription Sample Report)


EXAM: Mammographic screening FFDM

HISTORY: 40-year-old female who is on oral contraceptive pills. She has no present symptomatic complaints. No prior history of breast surgery nor family history of breast CA.

TECHNIQUE: Standard CC and MLO views of the breasts.

COMPARISON: This is the patient's baseline study.

FINDINGS: The breasts are composed of moderately to significantly dense fibroglandular tissue. The overlying skin is unremarkable.

There are a tiny cluster of calcifications in the right breast, near the central position associated with 11:30 on a clock.

There are benign-appearing calcifications in both breasts as well as unremarkable axillary lymph nodes.

There are no spiculated masses or architectural distortion.

IMPRESSION: Tiny cluster of calcifications at the 11:30 position of the right breast. Recommend additional views; spot magnification in the MLO and CC views of the right breast.

BIRADS Classification 0 - Incomplete

MAMMOGRAPHY INFORMATION:
1. A certain percentage of cancers, probably 10% to 15%, will not be identified by mammography.
2. Lack of radiographic evidence of malignancy should not delay a biopsy if a clinically suspicious mass is present.
3. These images were obtained with FDA-approved digital mammography equipment, and iCAD Second Look Software Version 7.2 was utilized.


Keywords: obstetrics / gynecology, ffdm, mammographic screening, tiny cluster of calcifications, bilateral mammogram, additional views, bilateral, mammogram, cluster, breasts, calcifications, mammography,