An illustration · invented records
Diagnostic mammogram and ultrasound report
Record type: imaging report, as downloaded from the patient portal.
Stand-in for: mammogram-ultrasound-report-2026-08-19.pdf (invented document), page 1 of 2.
Reporting clinician: breast radiologist, community breast imaging center.
Ordered by: primary care physician, after a screening mammogram callback.
EXAM: Diagnostic bilateral mammogram with tomosynthesis. Targeted right breast ultrasound. Right axillary ultrasound.
DATE OF SERVICE: 08/19/2026
INDICATION: 64-year-old woman recalled from screening mammogram of 08/12/2026 for a focal asymmetry in the right breast, upper outer quadrant. No palpable abnormality reported by the patient. No prior breast biopsy. Postmenopausal.
COMPARISON: Screening mammograms 08/12/2026, 08/2025, 08/2024.
FINDINGS:
Right breast: Breast density category B (scattered fibroglandular densities). In the upper outer quadrant at the 10 o’clock position, 4 cm from the nipple, there is an irregular mass with spiculated margins measuring 1.8 x 1.4 x 1.2 cm. No associated calcifications. Tomosynthesis confirms the mass is real and not summation artifact. No additional masses, architectural distortion, or suspicious calcifications.
Targeted right breast ultrasound: Corresponding to the mammographic finding at 10 o’clock, 4 cm from the nipple, there is an irregular hypoechoic mass with angular margins and posterior acoustic shadowing measuring 1.8 x 1.3 x 1.2 cm. Not parallel in orientation.
Right axilla: Lymph nodes have normal morphology with preserved fatty hila. Maximum cortical thickness 2 mm. No abnormal lymph nodes identified.
Left breast: No mass, architectural distortion, or suspicious calcifications.
IMPRESSION:
- Right breast, 10 o’clock, 4 cm from nipple: 1.8 cm irregular spiculated mass, highly suggestive of malignancy.
- Right axilla: no sonographically suspicious lymph nodes.
- Left breast: no mammographic evidence of malignancy.
BI-RADS CATEGORY: 5 — Highly suggestive of malignancy.
RECOMMENDATION: Ultrasound-guided core needle biopsy of the right breast mass with marker clip placement. Findings and recommendation discussed with the patient at the time of the exam. Results letter to be sent to the patient and the referring physician.
Page 2 of the invented PDF is the results letter to the patient; it is not reproduced.