Next Page Chapter 8. Recommendation , with specific instructions on what should be done next. This section should also document communication with referring physician and patient, as appropriate. 45 Referred by patient's primary physician for evaluation of new left breast lump. Patient notes strong family history of breast carcinoma in her mother, age of diagnosis 57 years.
Patient notes no current hormonal replacement therapy, and denies history of prior breast surgery.
The area of the patient's left breast lump was marked with an external radiopaque marker prior to imaging. Targeted left breast ultrasound was also performed to further assess the left breast lump. This section describes the mammographic views and other studies that were performed. Ultrasound can sometimes see cystic or solid masses within dense tissue that may not be visible on mammogram. The breast tissue is generally moderately dense, corresponding to ACR Category II parenchymal pattern.