Unilateral left mammogram status post right mastectomy sample dictation
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 [ ]
COMPARISON: [ ]
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]