Q.2.4 Example 4: Diagnostic Mammogram and Ultrasound - Unilateral
Prev | Q.2 Breast Imaging Report Examples | Next

### 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

Prev | Up | Next
Q.2.3 Example 3: Diagnostic Mammogram - Unilateral | Home | R Configuration Use Cases (Informative)