Normalized 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 yr old G0P0 with h/o FCBD. Approx 3-4cm upper outer quadrant R mobile breast mass. Routine retirement physical.

</REASON_FOR_EXAM>

<INTERPRETATION>

CLINICAL HISTORY: 42-year-old with history of fibrocystic changes, rt 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, suspicious calcification or 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, BILAT (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>