Q.2.3 Example 3: Diagnostic Mammogram

Q.2.3 Example 3: Diagnostic Mammogram - Unilateral (Current)
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Q.2.3 Example 3: Diagnostic Mammogram - Unilateral

A diagnostic mammogram was prompted by a clinical finding. The result is a probably benign finding with a short interval follow-up of the left breast. This report provides the narrative text with more extensive supplementary data.

Example Q.2-3. Report Sample: Narrative Text with More Extensive Supplementary Data

Procedure reported

Film screen mammography, left breast.

Reason for procedure

Non-bloody discharge left breast.

Breast composition

The breast is almost entirely fat.

Findings

Film screen mammograms were performed. There are heterogeneous calcifications regionally distributed in the 1 o'clock upper outer quadrant, anterior region of the left breast. There is an increase in the number of calcifications from the prior exam.

Impressions

BI-RADS® Category 3: Probably Benign Finding. Short interval follow-up of the left breast is recommended in 6 months.

Table Q.2-3. Breast Imaging Report Content for Example 3

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.	TID 4202 CID 6053
1.2.2	Reason for procedure		TID 4202 CID 6052
1.2.2.1	Reason for procedure	Non-bloody discharge left breast.	TID 4202 CID 6053
1.2.3	Breast composition		TID 4202 CID 6052
1.2.3.1	Breast composition	The breast is almost entirely fat.	TID 4202 CID 6053
1.2.4	Findings		TID 4202 CID 6052
1.2.4.1	Finding	Film screen mammograms were performed. There are heterogeneous calcifications regionally distributed in the 1 o'clock upper outer quadrant, anterior region of the left breast. There is an increase in the number of calcifications from the prior exam.	TID 4202 CID 6053
1.2.5	Impressions		TID 4202 CID 6052
1.2.5.1	Impression	BI-RADS® Category 3: Probably Benign Finding. Short interval follow-up of the left breast is recommended in 6 months.	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	Clinical Finding	TID 4201 CID 6051
1.3.1.2.1	Clinical Finding	Non-bloody discharge	TID 4201 CID 6055
1.3.1.2.1.1	Laterality	Left breast	TID 4201 CID 6022
1.3.2	Breast composition		TID 4205
1.3.2.1	Breast composition	Almost entirely fat	TID 4205 CID 6000
1.3.2.1.1	Laterality	Left breast	TID 4205 CID 6022
1.3.3	Findings		TID 4206
1.3.3.1	Finding	Calcification of breast	TID 4206 CID 6054
1.3.3.1.1	Assessment Category	3 - Probably Benign Finding - short interval follow-up	TID 4203 CID 6026
1.3.3.1.2	Recommended Follow-up	Follow-up at short interval (1-11 months)	TID 4203 CID 6028
1.3.3.1.2.1	Laterality	Left breast	TID 4203 CID 6022
1.3.3.1.2.2	Recommended Follow-up Interval	6 months	TID 4203 CID 6046
1.3.3.1.3	Clockface or region	1 o'clock position	TID 4206 CID 6018
1.3.3.1.4	Quadrant location	Upper outer quadrant of breast	TID 4206 CID 6020
1.3.3.1.5	Depth	Anterior	TID 4206 CID 6024
1.3.3.1.6	Calcification Type	Heterogeneous calcification	TID 4206 CID 6010
1.3.3.1.7	Calcification Distribution	Regional calcification distribution	TID 4206 CID 6012
1.3.3.1.8	Change since last mammogram	Increase in number of calcifications	TID 4206 CID 6002

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Q.2.2 Example 2: Screening Mammogram With Negative Findings	Home	Q.2.4 Example 4: Diagnostic Mammogram and Ultrasound - Unilateral