Q.2.3 Example 3: Diagnostic Mammogram - Unilateral
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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