Ms. MISS KIM TOLIVER is a 54 years old female with a personal history of a new focal asymmetry in the left lower inner breast noted on the screening mammogram 12/30/2015. The patient has a family history of breast cancer in her grandmother. MAMMOGRAM:ML and CC views as well as spot compression views of the left breast were performed digitally and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is heterogeneously dense, which may obscure small masses(BiRads Density Category C), unchanged in pattern and distribution. The previously seen focal asymmetry is again noted, measuring approximately 15 mm in the lower inner quadrant of the left breast. Although the symmetry appeared to persist on the compression views, on the full field ML and CC view this region has the appearance of normal glandular tissue.ULTRASOUND:On physical examination, no palpable lesion was evident.A targeted left ultrasound was performed left breast. There is no solid or cystic mass identified.
No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral screening mammogram is recommended annually. Results and recommendation were discussed with the patient.BIRADS: 1 - Negative.RECOMMENDATION: NS - Screening Mammogram.