ExamplePairedRadReport1

  1. 12345678 - MM DIAGNOSTIC DIGITAL BILAT
  2. BILATERAL DIGITAL DIAGNOSTIC MAMMOGRAM POST LUMPECTOMY MAMMOGRAM:

1/1/2009 CLINICAL: 611.72 Lump Or Mass In Breast-611.72 Patient with palpable abnormality in left breast. Post left lumpectomy. Recent MRI demonstrated suspicious lesions in left breast.

Comparison is made to exams dated: 1/1/2007 ultrasound biopsy and 1/1/2008 mammogram - Acme Breast Imaging. There are scattered fibroglandular elements in both breasts. There is an irregular mass with a spiculated margin in the left breast at 9 o'clock. This is seen in additional views. This correlates as palpated and with breast MRI findings. There also is a new 3.1 cm area of grouped fine linear and pleomorphic calcifications in the left breast at 1 o'clock posterior depth. These are seen in additional views. This correlates with breast MRI findings. No other suspicious masses or calcifications are seen in either breast.


NEEDS ADDITIONAL IMAGING EVALUATION The irregular palpable mass in the left breast at 9 o'clock appears indeterminate. An ultrasound is recommended. The 3.1 cm area of grouped linear and pleomorphic calcifications in the left breast at 1 o'clock posterior depth appears highly suggestive of malignancy. An ultrasound is recommended to determine if these would be amenable to ultrasound guided core needle biopsy. The exam was reviewed by a staff physician. The patient has been or will be contacted.

  1. 12345679 - US MAMMOGRAPHY

ULTRASOUND OF THE LEFT BREAST : 1/1/2009 Comparison is made to exams dated: 1/1/2008 ultrasound biopsy and 1/1/2007 mammogram - Acme Breast Imaging. Real-time ultrasound was performed on the area of interest in the left breast. There is a 1.2 cm x 1.3 cm round mass with an indistinct margin in the left breast at 9 o'clock. This round mass is isoechoic. This correlates with mammography findings and is palpable. There is associated skin involvement.

There also is a 8 mm x 8 mm round mass in the left breast at 1 o'clock posterior depth. This round mass is hypoechoic with posterior acoustic shadowing. This correlates with mammography findings. There are related calcifications. As these calcifications are better seen on mammography, a stereotactic core needle biopsy could be performed or an ultrasound guided core needle biopsy could be performed. No abnormalities were seen sonographically in the left axilla. An email was sent to Dr. Smith regarding the findings and recommendations for biopsy x2. The findings and recommendations were also discussed with the patient by Jenny Jones. The patient is scheduled for the biopsies on 1/2/2009 at 9:00 am.


IMPRESSION: SUSPICIOUS OF MALIGNANCY The 1.2 cm x 1.3 cm palpable round mass in the left breast at 9 o'clock appears suspicious of malignancy. An ultrasound guided biopsy is recommended. The 8 mm x 8 mm round mass with associated calcifications in the left breast at 2 o'clock posterior depth appears suspicious of malignancy. A stereotactic or ultrasound guided biopsy is recommended. The patient subsequently went to the North Pavillion building for the biopsies. The exam was reviewed by a staff physician. The patient was notified of the results.


Electronically signed by: Kirk Kenneth M.D. Jenny Jones Electronically signed on: kk,jj/:1/1/2009 13:01:21

Imaging Technologist: Wendy Williams RT(R)(M), Acme Breast Imaging letter sent: Biopsy Required BI-RADS: 0 Incomplete Assessment Ultrasound BI-RADS: 4 Suspicious abnormality



Result ID: 9876543


ATTENDING MD: MICHAELS,MICHAEL ORDERING MD: MICHAELS,MICHAEL ORDER REASON: 611.72 LUMP OR MASS IN BREAST-611.72

Last modified on 24 January 2011, at 17:23