Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples

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Sample Type / Medical Specialty: Obstetrics / Gynecology
Sample Name: Full-Field Digital Mammogram (FFDM) - 2

Description: Mammogram, bilateral full-field digital mammography FFDM (patient with positive history of breast cancer).
(Medical Transcription Sample Report)

EXAM: Screening full-field digital mammogram.

HISTORY: Screening examination of a 58-year-old female who currently denies complaints. Patient has had diagnosis of right breast cancer in 1984 with subsequent radiation therapy. The patient's sister was also diagnosed with breast cancer at the age of 59.

TECHNIQUE: Standard digital mammographic imaging was performed. The examination was performed with iCAD Second Look Version 7.2.

COMPARISON: Most recently obtained __________.

FINDINGS: The right breast is again smaller than the left. There is a scar marker with underlying skin thickening and retraction along the upper margin of the right breast. The breasts are again composed of a mixture of adipose tissue and a moderate amount of heterogeneously-dense fibroglandular tissue. There is again some coarsening of the right breast parenchyma with architectural distortion which is unchanged and most consistent with postsurgical and postradiation changes. A few benign-appearing microcalcifications are present.

No dominant malignant-appearing mass lesion, developing area of architectural distortion or suspicious-appearing cluster of microcalcifications are identified. The skin is stable. No enlarged axillary lymph node is seen.

1. No significant interval changes are seen. No mammographic evidence of malignancy is identified.
2. Annual screening mammography is recommended or sooner if clinical symptoms warrant.

BIRADS Classification 2 - Benign

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, digital mammography, full-field digital mammogram, ffdm, second look version, field digital mammogram, digital mammogram, breast cancer, mammographic, icad, microcalcifications, mammogram, screening, digital, mammography, breast,
NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports. These transcribed medical transcription sample reports may include some uncommon or unusual formats; this would be due to the preference of the dictating physician. All names and dates have been changed (or removed) to keep confidentiality. Any resemblance of any type of name or date or place or anything else to real world is purely incidental.
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Transcribed Medical Transcription Sample Reports and Examples