Unilateral left mammogram status post right mastectomy sample dictation

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CLINICAL HISTORY: [ ] year old woman status post right mastectomy for carcinoma in [ ]. The patient is now referred for follow up left mammogram. [ ].

TECHNIQUE: Unilateral left mammogram dated [ ]



The left breast is [almost entirely fatty.; composed of scattered fibroglandular densities.; heterogeneously dense, which may lower the sensitivity of mammography.; extremely dense, which decreases the sensitivity of mammography. This makes physical examination relatively more important in this patient. ].

No mammographically suspicious mass or suspisious cluster of calcifications are seen in the left breast.


No mammographic evidence of malignancy in the left breast. [ ]


Follow up left mammogram in one year. [ ]

Findings and recommendations were discussed with the patient and she received a written record summarizing this report.

[BIRADS 2: benign findings]