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    Borang Pemeriksaan-Mammografi 1

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    hsentosaosh
    The document is a breast imaging survey form used at a hospital. It collects clinical information about a patient such as risk factors, symptoms, and previous imaging. Radiographer findings and the radiologist report are also included, with notes on breast composition, findings, and impressions.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Borang Pemeriksaan-Mammografi 1

    Uploaded by

    hsentosaosh
    18 views2 pages
    The document is a breast imaging survey form used at a hospital. It collects clinical information about a patient such as risk factors, symptoms, and previous imaging. Radiographer findings and the radiologist report are also included, with notes on breast composition, findings, and impressions.

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    © © All Rights Reserved

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    PDF, TXT or read online from Scribd

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    The document is a breast imaging survey form used at a hospital. It collects clinical information about a patient such as risk factors, symptoms, and previous imaging. Radiographer findings and the radiologist report are also included, with notes on breast composition, findings, and impressions.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    18 views2 pages

    Borang Pemeriksaan-Mammografi 1

    Uploaded by

    hsentosaosh
    The document is a breast imaging survey form used at a hospital. It collects clinical information about a patient such as risk factors, symptoms, and previous imaging. Radiographer findings and the radiologist report are also included, with notes on breast composition, findings, and impressions.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    Lampiran 2

    JABATAN RADIOLOGI
    HOSPITAL Sentosa
    Tel: 082-612 321 Ext: 130 / or NGCS

    BREAST IMAGING SURVEY FORM ( Please fill in into two copies )

    RN : IC / Passport No : 701111135322

    Name : YAM ANAK NORIS

    Request : Screening Diagnostic Additional Views

    Previous imaging & date : NIL

    Menarche 11 y/o Menopause - y/o LMP 1 7 / 2 / 2 0 2 3


    Day Month Year
    nulliparous
    Parity Number of children 0 Breastfed (In months)

    Risk Factors Remarks


    Family History of Cancer ( Relationship & age of onset ) Late father had colorectal cancer, unsure onset
    Personal History of Cancer ( Breast, Ovarian and others ) Nil
    Hormonal history ( HRT/OCP and others ) Nil
    Genetic testing ( BRCA 1, BRCA 2 and others ) Nil
    Right Left
    Clinical Data Remarks
    Yes No Yes No
    Breast pain / tenderness None
    Lump in breast 3x3cm, soft, smooth, immobile
    Nipple discharge None
    Skin & nipple changes None
    Nipple retraction / Inversion None
    Axillary nodes swelling None
    Biopsy history & HPE None
    Previous surgical intervention
    None
    ( Surgery / Implant / RT / ChemoTx )

    Impression : Left Brest Lump TRO cause

    Signature & stamp of the Medical Officer/ Specialist

    1/2
    RADIOGRAPHER FINDINGS :-

    Please note any:


    Scar
    Mole
    Lump
    Nipple changes
    Skin Folds

    Projection kVp mAs Thickness Dose No of images PGMI score


    Right CC
    MLO
    Left CC
    MLO
    Additional views
    Repeat projections

    (Signature of Radiographer)
    BIRADS Breast composition : a b c d e

    RADIOLOGIST REPORT :- Please tick ( √ ) where appropriate

    Findings RT LT
    Mass

    Architectural
    Distortion
    Asymmetrical
    density
    Calcifications :
    (i) Macro
    (ii) Micro
    Axillary
    nodes
    Others

    Impression :-

    BIRADS Category :- 0 1 2 3 4 5 6
    Recommendation :-

    Signature & stamp of the Medical Officer/ Specialist

    2/2

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