Unilateral right mammogram status post left mastectomy sample dictation
CLINICAL HISTORY: [ ] year old woman status post left mastectomy for carcinoma in [ ]. The patient is now referred for follow up right mammogram. [ ]
TECHNIQUE: Unilateral right mammogram dated [ ]
COMPARISON: [ ]
The right 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 suspicious cluster of calcifications are seen in the right breast.
No mammographic evidence of malignancy in the right breast.
Unilateral right 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]