NegExpanded Mammogram Report

Ad-Hoc Classification of Electronic Clinical Documents

Aronow & Feng

D-Lib Magazine, January 1997

 

 

<DOC>

<DOCNO>BE71</DOCNO>

<TEXT>

<REASON_FOR_EXAM>

NO_BRIEF_COMMENT.

42 year old G0P0 with history of FCBD. Approx 3-4cm upper outer quadrant RIGHT mobile breast mass. Routine retirement physical.

</REASON_FOR_EXAM>

<INTERPRETATION>

CLINICAL HISTORY: 42 year old with history of fibrocystic changes, right breast mobile mass upper outer quadrant.

BILATERAL FILM SCREEN MAMMOGRAM:

FINDINGS: Prior mammograms are not available for comparison. The breasts are heterogeneously dense. There is extremely dense fibrous tissue in the upper outer quadrants of both breasts. This lowers the sensitivity of mammography. B.B. was placed in the region of palpable abnormality and demonstrates dense breast tissue in this region. An occasional benign appearing calcification is present in both breasts. no_discrete_mass, no_suspicious_calcification or no_other_secondary_sign_of_malignancy is demonstrated.

<IMPRESSION>

comparison with patient's previous mammograms is recommended. The decision to biopsy any palpable abnormality should be based on clinical grounds.

</IMPRESSION>

</INTERPRETATION>

</TEXT>

<AGE_AT_EXAM>42</AGE_AT_EXAM>

<RADIOLOGY_PROCEDURE>MAMMOGRAM, BILATERAL (SCREENING) (ACTIVE DUTY ONLY) </RADIOLOGY_PROCEDURE>

<TYPE>SCREENING</TYPE>

<MARITAL_STATUS></MARITAL_STATUS>

<RACE></RACE>

<PREGNANT>UNKNOWN</PREGNANT>

<PATIENT_CATEGORY>OUTPATIENT</PATIENT_CATEGORY>

<DOB>7-7-53</DOB>

<EXAM_DATE>8-28-95</EXAM_DATE>

</DOC>