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: 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

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,
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