Unilateral right mammogram status post left mastectomy sample dictation

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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: [ ]


FINDINGS:

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.


IMPRESSION:

No mammographic evidence of malignancy in the right breast.


RECOMMENDATION:

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]