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 [ ]


COMPARISON: [ ]


FINDINGS:


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.


IMPRESSION:

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


RECOMMENDATION:

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]