Screening mammogram

Dear Collegue,
Technique : Bilateral Screening mammogram
Views: Bilateral CC and MLO
Comparison :

Breast Composition: (choose 1 of the following statements based on appearance)

-Almost entirely fat
-Scattered fibro glandular densities
-Heterogeneously dense which may obscure detection of small masses
-Extremely dense which may lower the sensitivity of mammography

Findings:
Right breast has no evidence of mass, architectural distortion, suspicious micro calcification, skin
thickening or nipple retraction.
Left breast has no evidence of mass, architectural distortion, suspicious micro calcification, skin
thickening or nipple retraction.

Impression: (choose 1 of the following classifications)

BIRAD 0 incomplete, need additional imaging evaluation, recommend ________.
BIRAD 1 negative, recommend annual screening mammograms.
BIRAD 2 benign findings, recommend annual screening mammograms.
BIRAD 3 probably benign findings, short interval follow up is suggested, Recommend ________. (6
month f/u diagnostic/ US/ etc.)
BIRAD 4 suspicious abnormality, biopsy should be considered. Recommend ________. (Stereotactic/
ultrasound guided/ etc.)
BIRAD 5 Highly suggestive of malignancy. Appropriate action should be taken. Recommend ________.
(Surgical consultation)
BIRAD 6 Known and biopsy proven malignancy.

Regards,
Dr. Yustie Amelia, Sp.Rad
Radiologist

Dear Collegue,

US - Mammae Bilateral
Technique: Bilateral breast and axilla were scanned with a high frequency transducer.

Findings:
Breast Composition :
Symmetric/asymmetric. Entirely fat / scattered fibro glandular tissue / heterogeneous / implant present.

Right Breast :
SKIN THICKENING :
NIPPLE RETRACTION :
MASS: nil
Shape- round / oval / lobular / irregular
Margins- circumscribed / microlobulated / indistinct / spiculated
Echogenicity- solid / cystic / fatty
Size-
Position- Quadrant-wise –
CALCIFICATIONS: nil
DILATED DUCTS: nil
INTRA-MAMMARY NODE: nil
AXILLARY LYMPH NODE : Normal size and shape

Left Breast :
SKIN THICKENING :
NIPPLE RETRACTION :
MASS: nil
Shape- round / oval / lobular / irregular
Margins- circumscribed / microlobulated / indistinct / spiculated
Echogenicity- solid / cystic / fatty
Size-
Position- Quadrant-wise –
CALCIFICATIONS: nil
DILATED DUCTS: nil
INTRA-MAMMARY NODE: nil
AXILLARY LYMPH NODE : Normal size and shape

Impression:

ACR BIRADS assessment category:

[Choose one]
0 - NEEDS ADDITIONAL IMAGING (after mammogram category will change from 0 to 1 / 2 / 3 / 4 / 5).
1 – NEGATIVE: NO DOMINANT MASSES / SUSPICIOUS CALCIFICATION / ARCHITECTURAL DISTORTION.
2 - BENIGN: TYPICAL BENIGN FINDING:
3 - PROBABLY BENIGN: INTERVAL FOLLOW-UP RECOMMENDED FOR 2 – 3 YEARS.
4 - SUSPICIOUS ABNORMALITY – BIOPSY SHOULD BE CONSIDERED.
5 - HIGHLY SUGGESTIVE OF MALIGNANCY.

Regards,
Dr. Yustie Amelia, Sp.Rad
Radiologist

Dear Collegue,
US - THYROID
Technique : The thyroid and adjacent structures were scanned with a high frequency transducer

Clinical Information :
Comparison : None

Findings :
Thyroid : The thyroid is homogeneous without evidence for focal mass. No abnormal soft tissues masses
or fluid collections are seen around the thyroid.
The right lobe measures: Cm
The left lobe measures : cm
Isthmus : The isthmus is normal in size and configuration.
Lymph nodes : Sweep images of the neck bilaterally adjacent to the thyroid demonstrate no abnormal
lymph nodes.
Additional findings : nil

Impression :
Normal
Tirads 1 : Benign: No FNA
Tirads 2 : Not Suspicious: No FNA
Tirads 3 : Mildly Suspicious: FNA if ≥ 2.5 cm; Follow if ≥ 1.5 cm at 1, 3, and 5 y
Tirads 4 : Moderately Suspicious: FNA if ≥ 1.5 cm; Follow if ≥ 1 cm at 1, 2, 3, and 5 y

Regards,
Dr. Yustie Amelia, Sp.Rad
Radiologist

Dear Collegue
US – Whole Abdomen, Male
Technique : Intraabdominal-pelvis structures were scanned with a low frequency transducer

Clinical Information : MCU

Findings :
LIVER : Normal/ Mild-moderate-marked homogenous increase parenchymal echogenity. Portal Venous
system : Normal.IVC, hepatic veins: Normal.
BILIARY SYSTEM AND GALL BLADDER: Normal.
SPLEEN: Normal.
PANCREAS: Normal.
RIGHT KIDNEY: Normal.
LEFT KIDNEY: Normal.
BLADDER: Normal.
NODES: Nil.
FLUID: Nil.
PROSTATE: Normal.
SEMINAL VESICLES: Normal.

Impression:
- No visualized significant abnormality of intraabdominal organs sonography.
- Mild-moderate-severe fatty liver.
- No visualized significant abnormality of the other intraabdominal organs sonography.

Regards,
Dr. Yustie Amelia, Sp.Rad
Radiologist

Dear Colleague
US – Whole Abdomen, Male/Female
Technique : Intraabdominal-pelvis structures were scanned with a low and high frequency transducer

Clinical Information :

Findings :
The liver is of normal size, shape and echotexture with no intrahepatic duct dilation or focal lesion seen.
The portal vein measures ___ mm with normal flow.

The gallbladder is normal with a wall thickness of ___ mm. No gallstones, polyps or sludge are seen and
the patient is sonographic Murphy’s negative. The CBD measures ___ mm.

The pancreas is well visualised and has a normal size, shape and echotexture, with no duct dilation.

The spleen is of normal size, shape and echotexture with a diameter of ___ cm.

The aorta has a normal appearance with a diameter of ___ cm.

Both kidneys are of normal size and shape with smooth contour and normal cortical echotexture. The
central echogenic complexes have a normal appearance with no hydronephrosis. The right kidney
measures ___ cm, the left ___ cm. No obvius kidney stone/focal lesion.

The bladder has a normal appearance with no wall thickening. Both ureteric jets are seen. The pre-
micturition volume is __mL, post-micturition __mL. No bladder stone/focal lesion.

The prostate is of normal size, shape and echotexture, volume ___ cc.

The uterus and adnexa are of normal size, shape and echotexture.

The appendix is well visualized with a diameter of ___ cm, normal wall thickness and no. mesenterial fat
stranding. No visualized periappendicular abscess/infiltrate. The adjacent bowel is visualized with
normal wall thickness and diameter.

No abnormality of mesenteric lymphnodes.

No ascites.
No pleural effusion.
Impression:
- No visualized significant abnormality of intraabdominal-pelvis organs sonography.
- Mild-moderate-severe fatty liver.
- No visualized significant abnormality of the other intraabdominal-pelvis organs sonography.

Regards,
Dr. Yustie Amelia, Sp.Rad
Radiologist

————————

Dear Collegue

CT Head Examination Without Contrast IV

Clinical Information:

Technique: Fine slice non-contrast CT images were obtained from the skull base to the vertex.
Brain and bone windows were reconstructed.

Comparison:

Findings:

No intra or extra-axial mass lesions or collections are identified.

The ventricles and sulcal spaces are within normal limits

There is no midline shift. The midline structures are normal.

No loss of the grey-white matter junction is seen.

The orbits have a normal appearance and the paranasal sinuses and mastoid air cells are clear.

No bony abnormality is seen.

Conclusion:

Normal CT head.

Regards,
Dr. Yustie Amelia, Sp.Rad
Radiologist
___________
Dear Collegue,
CT Whole Abdomen examination without contrast iv.
Clinical Information:

Technique: fine slice imaging was obtained from the lung bases to the symphysis pubis

Comparison:

Findings:

The liver is of normal size, shape and density with no intrahepatic duct dilation or focal lesion seen. The
portal vein is of normal diameter and density.

The gallbladder is of normal size and shape with no. wall thickening. No hyperdense gallstones, polyps or
sludge are seen. No CBD dilation.

The pancreas is well visualised and has a normal size, shape and density, with no duct dilation.

The spleen is of normal size, shape and density with a diameter of ___ cm.

The aorta has a normal appearance with a diameter of ___ cm.

Both adrenal glands are of normal size, shape and density..

Both kidneys are of normal size and shape with smooth contour and normal density. No sign of
hydronephrosis. The right kidney measures ___ cm, the left ___ cm. No hyperdens nephrolithiasis. No
focal lesion. No abnormal perinephric fluid collection.

Both ureters are of normal size. No hyperdens urolithiasis.

The bladder has a normal appearance with no wall thickening. No bladder stone or focal lesion.

The prostate is of normal size, shape and density, volume ___ cc. The uterus and adnexa are of
normal size, shape and echotexture.

The appendix is visualized with a diameter of ___ cm, normal wall thickness and No. mesenterial fat
stranding. No visualized periappendicular abscess/infiltrate. The adjacent bowel is visualized with
normal wall thickness and diameter.

The stomach and other bowel sistema are unremarkable, with normal wall thickness and no faecal
loading or dilation.

No free fluid or gas is seen with the abdomen or pelvis. No lymphadenopathy is identified. The vascular
structures are normal.
The lung bases are clear. No bony abnormality is seen.

Impression:

Normal CT abdomen/pelvis.

Regards,
Dr. Yustie Amelia, Sp.Rad
Radiologist
————————
Dear Collegue,
CT Chest examinatio with contrast iv.
Technique: Pre and post IV contrast fine slice imaging was obtained from the lung apices to the lung
bases

Comparison:

Findings:

Chest:
The heart, great vessels, trachea and oesophagus have a normal appearance. There is no
lymphadenopathy or mediastinal mass.

The pulmonary vessels and bronchi are normal, as is the pulmonary parenchyma. The pleural spaces are
clear.

The upper abdominal solid organs and bowel have a normal appearance within the field of view.
No bony abnormality is identified.

Impression :

Normal CT chest

Regards,
Dr. Yustie Amelia, Sp.Rad
Radiologist

———————-

Dear Collegue,

Clinical Information:

Technique: CT coronary angiogram was performed following intravenous contrast as per CT CA

protocol. Heart rate at the time of acquisition was ___ bpm. DLP was ___ mGy*cm.
Comparison:

Findings:

Calcium Score: ___. There is calcification plaque on LAD. The total calcium score of this patient is 6.28.
This implies that there is minimal calcified atherosclerotic plaques. This places the patient into below the
75 percentile in comparison to a group of asymptomatic patient (normal/ below the 75 percentile)
Grading of coronary artery disease (based on total calcium score) no evidence of CAD: 0 calcium score;
minimal: 1-10
mild: 11-100; moderate: 101-400; severe: 400

Dominance: Right.
Course : normal. No anomalous origin

SEGMENTATION ANALYSIS
LMCA: Normal
LEFT ANTERIOR DESCENDING:
Proximal: Punctate calcified plaque on proximal segment LAD, however no evidence of stenosis (1-24% =
minimal, 25-49% = mild, 50-69%= moderate, 70-99% = severe, Ga keliatan = oklusi)
Mid: Normal
Distal: Normal
Diagonals: Normal
LEFT CIRCUMFLEX: short / normal
Proximal: Normal
Distal: Normal
Obtuse marginals: Normal
RAMUS INTERMEDIUS: Normal/Nil
RIGHT CORONARY:
Proximal: Normal
Mid: Normal
Distal: Normal
Posterior descending: Normal
Posterolateral ventricular branch: Normal

Non-Coronary Cardiac Findings:

The myocardium, valves and pericardium have a normal appearance. No areas of infarction or scar is
seen. EF and stroke volume =

Non-Cardiac Findings:

The visualised mediastinum is normal with no lymphadenopathy. The pulmonary vessels, lungs, pleural
spaces, chest wall, upper abdomen and bones have a normal appearance within the field of view.

Impression:
 - Calcium scoring show minimal calcified atherosclerotic plaque with total calcium score ___.
This places the patient into below the 75 percentile in comparison to a group of asymptomatic
patient (normal/ below the 75 percentile)
- Coronary CT Angiography appear Right dominant, with normal origin
- No evidence of significant stenosis on the LM, LAD, LCX, RCA and Ramus Intermedius

Regards,
Dr. Yustie Amelia, Sp.Rad
Radiologist

____________
Dear Collegue,
CT Whole Abdomen examination with contrast iv.
Clinical Information:

Technique: Pre and Post IV and oral contrast fine slice imaging was obtained from the lung bases to the
symphysis pubis in portal venous phase.

Comparison:

Findings:

The liver is of normal size, shape and density with no intrahepatic duct dilation or focal lesion seen. The
portal vein is of normal diameter and density.

The gallbladder is of normal size and shape with no. wall thickening. No hyperdens gallstones, polyps or
sludge are seen. No CBD dilation.

The pancreas is well visualised and has a normal size, shape and density, with no duct dilation.

The spleen is of normal size, shape and density with a diameter of ___ cm.

The aorta has a normal appearance with a diameter of ___ cm.

Both adrenal glands are of normal size, shape and density.

Both kidneys are of normal size and shape with smooth contour and normal density. No sign of
hydronephrosis. The right kidney measures ___ cm, the left ___ cm. No kidney stone, filling defect or
focal lesion. No abnormal perinephric fluid collection.

Both ureters are of normal size. No hyperdens urolithiasis.

The bladder has a normal appearance with no wall thickening. No bladder stone or focal lesion.

The prostate is of normal size, shape and density, volume ___ cc. The uterus and adnexa are of
normal size, shape and echotexture.
The appendix is visualized with a diameter of ___ cm, normal wall thickness and No. mesenterial fat
stranding. No visualized periappendicular abscess/infiltrate. The adjacent bowel is visualized with
normal wall thickness and diameter.

The stomach and other bowel sistema are unremarkable, with normal wall thickness and no faecal
loading or dilation.

No free fluid or gas is seen with the abdomen or pelvis. No lymphadenopathy is identified. The vascular
structures are normal.

The lung bases are clear. No bony abnormality is seen.

Impression:

Normal CT abdomen/pelvis.

Regards,
Dr. Yustie Amelia, Sp.Rad
Radiologist

———————-

Dear Collegue,

Clinical Information:

CT Facial bone Examination without contrast iv.

Technique:

Fine slice non-contrast helical CT images were obtained through the facial bones. Soft
tissue and bone windows were reconstructed.

Comparison:

___________

Findings:

No fractures or bony abnormalities are identified in the facial bones.

The zygomatic arch is normal and there is no diastasis of the frontozygomatic suture.
The orbital rim is intact, as are the nasal bones.
The paranasal sinuses are clear with no mucoperiosteal thickening. The nasal septum is
midline with no spur. The osteomeatal complexes are normal.

The orbits have a normal appearance with unremarkable

1. globes
2. optic nerves
3. ocular muscles
4. vascular structures
5. infraorbital canal
6. superior and inferior orbital foramina
7. optic canal
8. lamina papyracea
The pterygoid plates and pterygopalatine fossa are normal.

The inferior alveolar ridge is normal.

The mandible is unremarkable with normal temporomandibular joints.

The visualised nasopharynx has a normal appearance.

No contusion or other soft tissue swelling is seen.

Conclusion:

Normal CT facial bones

Regards,
Dr. Yustie Amelia, Sp.Rad
Radiologist

Dear Collegue,

Clinical Information:

CT Head Examination without contrast iv.

Technique:
Fine slice non-contrast helical CT images were obtained from the skull base to the
vertex. Brain and bone windows were reconstructed.

Comparison:

Findings:

No intra or extra-axial mass lesions or collections are identified. The ventricles and sulcal
spaces are within normal limits and there is no midline shift. The midline structures are
normal.

No loss of the grey-white matter junction is seen. Note is made of minor patchy reduced
density in the corona radiata consistent with minor small vessel ischaemic disease.

The orbits have a normal appearance and the paranasal sinuses and mastoid air cells are
clear.

No bony abnormality is seen.

Conclusion:

Minor small vessel ischaemic disease of the deep white matter is noted. Otherwise
normal CT head.

Regards,
Dr. Yustie Amelia, Sp.Rad
Radiologist

Dear Collegue,

CT Urography Examination with contrast iv.

Technique:

Fine slice non-contrast, aterial phase, portal venous phase and delayed phase imaging
was obtained from the lung bases to the symphysis pubis, with the arterial phase
restricted to the upper abdomen.
Comparison:
___________

Findings:

The kidneys have a normal size and shape, with normal symmetric nephrograms and
prompt excretion into the renal collecting systems.

The pelvicalyceal systems and ureters are normal. The bladder is unremarkable.

The liver, spleen, pancreas and adrenals have a normal appearance.

The bowel has a normal IV contrast only appearance, with normal wall thickness and no
faecal loading or dilation.

No free fluid or gas is seen with the abdomen or pelvis. No lymphadenopathy is

identified. The vascular structures are normal.

The lung bases are clear. No bony abnormality is seen.

Conclusion:

Normal CT Urography.

Regards,
Dr. Yustie Amelia, Sp.Rad
Radiologist

Dear Collegue,

MRI Head Examination without contrast iv

Clinical Information:

Technique:

Standard T1, T2, T2 me2d, Diffusion/ADC and Flair Fat Sat axial images were acquired on
a 1.5T scanner. T2 coronal and sagittal scans were performed. T1 mpRage sagittal
images were acquired. GRE images were performed. T1 mpRage imaging was
performed.
Comparison:

___________

Findings:

Intracranial:

 Extra-axial spaces: normal

 Ventricular system: normal for age
 Basal Cisterns: normal
 Cerebral parenchyma: normal
 Midline Shift: none
 Cerebellum: normal
 Midbrain: normal
 Brainstem: normal
 Vascular system: normal
 Global cortical atrophy score: 0 – no cortical atrophy
 Mesial Temporal Atrophy: 0 – no atrophy
 Koedam score for parietal atrophy: 0 – no atrophy
 Fazekas score of WM lesions: 0 – no or a single white matter lesion
 Strategic lesions: none
Extracranial:

 Calvarium: normal
 Visualised paranasal sinuses: normal
 Visualised orbits: normal
 Visualised upper C-spine: normal
 Sella and skull base: normal
Conclusion:

Normal study. No evidence of abnormal atrophy to suggest dementia.

. Regards,
Dr. Yustie Amelia, Sp.Rad
Radiologist
Dear Collegue,

MRI Brain Examination without contrast iv

Clinical Information:

Technique:

Multiplane T1, T2 and inversion recovery imaging was obtained. Susceptibility weighted
imaging and DWI/ADC imaging was acquired.

Findings:

No intra or extra-axial mass lesion or collection is identified.

The ventricles and sulcal spaces are within normal limits.

The midline structures are normal with no midline shift.

No abnormal signal on the susceptibility weighted images or diffusion/ADC images is

identified.

The orbits, paranasal sinuses and mastoid air cells are clear.

No bony abnormality is seen.

Conclusion:

Normal MRI Brain

Regards,
Dr. Yustie Amelia, Sp.Rad
Radiologist

Dear Collegue,

MRI Cervical Spine Examination Without Contrast IV

Clinical Information:
Technique:

Sagittal T1, T2 and TIRM weighted imaging was obtained through the cervical spine as
well as axial T1 and T2 images. Oblique T2 weighted images were acquired through the
neural exit foramina bilaterally.

Findings:

The vertebral bodies and discs are of normal height and signal with no malalignment.
The posterior elements are normal.

No disc bulges are identified.

The cranio-cervical junction is unremarkable, as is the spinal canal and cord.

The neural exit foramina are widely patent. The paravertebral soft tissues are normal.

Conclusion:

Normal MRI cervical spine.

Regards,
Dr. Yustie Amelia, Sp.Rad
Radiologist

Normal plain film abdomen

Clinical Information:

Findings:

The bowel gas pattern is unremarkable with no dilation or air-fluid levels.

There is _____ faecal loading of the ______ colon consistent with constipation. The bowel
gas pattern is otherwise unremarkable with no dilation or air-fluid levels.
No organomegaly, free gas or abnormal calcification is seen.

Regards,
Dr. Yustie Amelia, Sp.Rad
Radiologist

Lumbar Spine X Ray

Clinical Information:

Findings:

No fractures or other bony abnormalities are identified in the thoracic spine.

The vertebral bodies and discs are of normal height and there is no mal-alignment.

The pedicles, facet joints, transverse processes and spinous processes have a normal
appearance.

The visualised ribs are normal.

The sacro-iliac joints and sacral neural arches are normal for age.