DICOM PS3.17 2019c - Explanatory Information

Q.2.4 Example 4: Diagnostic Mammogram and Ultrasound - Unilateral

Following a screening mammogram, the patient was asked to return for additional imaging and an ultrasound on the breast, for further evaluation of a mammographic mass. This example demonstrates a report on multiple breast imaging procedures. This report provides the narrative text with some supplementary data.

Example Q.2-4. Report Sample: Multiple Procedures, Narrative Text with Some Supplementary Data

Procedure reported

Film screen mammography, left breast; Ultrasound procedure, left breast.

Reason for procedure

Additional evaluation requested at current screening.

Comparison to previous exams

Comparison was made to exam from 11/14/2001.

Findings

Film Screen Mammography: A lobular mass with obscured margins is present measuring 7mm in the upper outer quadrant.

Findings

Ultrasound demonstrates a simple cyst.

Impressions

BI-RADS® Category 2: Benign, no evidence of malignancy. Normal interval follow-up of both breasts is recommended in 12 months.

Overall Assessment

Benign


Table Q.2-4. Breast Imaging Report Content for Example 4

Node

Code Meaning of Concept Name

Code Meaning or Example Value

TID/CID

1

Breast Imaging Report

TID 4200

1.1

Language of Content Item and Descendants

English

TID 1204

1.2

Narrative Summary

TID 4202

1.2.1

Procedure reported

TID 4202

CID 6052

1.2.1.1

Procedure reported

Film screen mammography, left breast; Ultrasound procedure, left breast.

TID 4202

CID 6053

1.2.2

Reason for procedure

TID 4202

CID 6052

1.2.2.1

Reason for procedure

Additional evaluation requested at current screening.

TID 4202

CID 6053

1.2.3

Comparison to previous exams

TID 4202

CID 6052

1.2.3.1

Comparison to previous exams

Comparison was made to exam from 11/14/2001.

TID 4202

CID 6053

1.2.4

Findings

TID 4202

CID 6052

1.2.4.1

Finding

Film Screen Mammography: A lobular mass with obscured margins is present measuring 7mm in the upper outer quadrant.

TID 4202

CID 6053

1.2.5

Findings

TID 4202

CID 6052

1.2.5.1

Finding

Ultrasound demonstrates a simple cyst.

TID 4202

CID 6053

1.2.6

Impressions

TID 4202

CID 6052

1.2.6.1

Impression

BI-RADS® Category 2: Benign, no evidence of malignancy. Normal interval follow-up of both breasts is recommended in 12 months.

TID 4202

CID 6053

1.2.7

Overall Assessment

TID 4202

CID 6052

1.2.7.1

Overall Assessment

Benign

TID 4202

CID 6053

1.3

Supplementary Data

TID 4208

1.3.1

Procedure reported

Film Screen Mammography

TID 4201

CID 6050

1.3.1.1

Laterality

Left breast

TID 4201

CID 6022

1.3.1.2

Reason for procedure

Additional evaluation requested at current screening

TID 4201

CID 6051

1.3.2

Procedure reported

Ultrasound procedure

TID 4201

CID 6050

1.3.2.1

Laterality

Left breast

TID 4201

CID 6022

1.3.2.2

Reason for procedure

Additional evaluation requested at current screening

TID 4201

CID 6051

1.3.3

Findings

TID 4206

1.3.3.1

Procedure reported

Film Screen Mammography

TID 4201

CID 6050

1.3.3.1.1

Laterality

Left breast

TID 4201

CID 6022

1.3.3.1.2

Reason for procedure

Additional evaluation requested at current screening

TID 4201

CID 6051

1.3.3.2

Finding

Mammographic breast mass

TID 4206

CID 6054

1.3.3.2.1

Quadrant location

Upper outer quadrant of breast

TID 4206

CID 6020

1.3.3.2.2

Diameter

7 mm

TID 1400

CID 7470

1.3.3.2.3

Shape

Lobular

TID 4206

CID 6004

1.3.3.2.4

Margins

Obscured lesion

TID 4206

CID 6006

1.3.4

Findings

TID 4206

1.3.4.1

Procedure reported

Ultrasound procedure

TID 4201

CID 6050

1.3.4.1.1

Laterality

Left breast

TID 4201

CID 6022

1.3.4.1.2

Reason for procedure

Additional evaluation requested at current screening

TID 4201

CID 6051

1.3.4.2

Finding

Simple cyst of breast

TID 4206

CID 6054

1.3.5

Overall Assessment

TID 4208

1.3.5.1

Assessment Category

2 - Benign Finding

TID 4203

CID 6026


DICOM PS3.17 2019c - Explanatory Information