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.
Film screen mammography, left breast.
Reason for procedure
Non-bloody discharge left breast.
The breast is almost entirely fat.
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.
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||4200|
|1.1||Language of Content Item and Descendants||English||1204|
|220.127.116.11||Procedure reported||Film screen mammography, left breast.||4202/6053|
|1.2.2||Reason for procedure||4202/6052|
|18.104.22.168||Reason for procedure||Non-bloody discharge left breast.||4202/6053|
|22.214.171.124||Breast composition||The breast is almost entirely fat.||4202/6053|
|126.96.36.199||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.||4202/6053|
|188.8.131.52||Impression||BI-RADS® Category 3: Probably Benign Finding. Short interval follow-up of the left breast is recommended in 6 months.||4202/6053|
|1.3.1||Procedure reported||Film Screen Mammography||4201/6050|
|184.108.40.206||Reason for procedure||Clinical Finding||4201/6051|
|220.127.116.11.1||Clinical Finding||Non-bloody discharge||4201/6055|
|18.104.22.168||Breast composition||Almost entirely fat||4205/6000|
|22.214.171.124||Finding||Calcification of breast||4206/6054|
|126.96.36.199.1||Assessment Category||3 – Probably Benign Finding – short interval follow-up||4203/6026|
|188.8.131.52.2||Recommended Follow-up||Follow-up at short interval (1-11 months)||4203/6028|
|184.108.40.206.2.2||Recommended Follow-up Interval||6 months||4203/6046|
|220.127.116.11.3||Clockface or region||1 o’clock position||4206/6018|
|18.104.22.168.4||Quadrant location||Upper outer quadrant of breast||4206/6020|
|22.214.171.124.6||Calcification Type||Heterogeneous calcification||4206/6010|
|126.96.36.199.7||Calcification Distribution||Regional calcification distribution||4206/6012|
|188.8.131.52.8||Change since last mammogram||Increase in number of calcifications||4206/6002|