Q.2.4 Example 4: Diagnostic Mammogram and Ultrasound

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

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