4.1 Medical History, Physical Findings, and Gender Affirmation

Why This History Stop Is Scored

Patient Care on the ARRT Mammography exam (content specifications implemented September 1, 2025) includes documentation of medical history and clinical physical findings. Those items are not paperwork trivia. The radiologist reads what you marked and what you wrote. A mole that is not circled becomes a possible mass. A lumpectomy scar that is not lined becomes architectural distortion. A gender-affirming surgery that is not recorded sends the wrong tissue down a default screening pathway. You are not expected to manage oncology. You are expected to collect the order, the surgery, the findings on the skin, and the anatomy that is actually present, then make those facts visible on the image and in the record.

Imaging Requests Versus What the Patient Says at the Desk

The imaging request (physician order or requisition) is the legal reason the exposure is made. It identifies the patient, laterality when laterality is part of the order, and the indication. In breast imaging that indication is usually screening or diagnostic.

Screening means the patient is asymptomatic and the study is a routine search for occult cancer, typically a two-view exam of each breast. Diagnostic means there is a problem to solve: a lump, focal pain, nipple discharge, a callback from screening, short-interval follow-up, or additional evaluation of an implant or postoperative breast. The indication controls protocol, extra views, whether ultrasound is paired, and how the examination is billed. A mammographer who always takes the same four pictures regardless of the order is not practicing to the blueprint.

The desk interview is a second, independent data source. Patients add facts the order never listed: a lump found in the shower, a scar they forgot to mention, hormones started after the last visit, or films that live at another hospital. Those statements do not silently overwrite the order, and the order does not erase the new lump.

If the order says screening and the patient reports a new lump, document the lump, mark it, and notify the radiologist or ordering pathway so the study can be converted to diagnostic workup. Do not send an asymptomatic screening hanging protocol on a symptomatic breast. If the order is already diagnostic for a six-o'clock mass and the patient says she feels fine, you still perform the diagnostic protocol and still record her statement. Identity, gender, or anxiety does not choose screening versus diagnostic. The order does, amended when new clinical information requires it.

Verify that the order matches the correct patient (name and date of birth) before you mark skin or expose. Wrong-patient history is as dangerous as wrong-site laterality.

Previous Breast Surgery: Lumpectomy and Augmentation

ARRT's history list gives two surgery examples: lumpectomy and augmentation. Ask which breast, what year, and what the patient understands was removed or placed.

Lumpectomy is breast-conserving removal of a tumor with a surrounding margin of tissue. Expect a skin scar, a possible volume defect, and often surgical clips at the lumpectomy bed. Those clips are landmarks, not dirt to wipe off the skin. Tenderness and reduced compressibility near the scar are common. An axillary incision means lymph nodes were sampled or dissected; that scar will fight you on the mediolateral oblique (MLO).

Augmentation means implants (or rarely other material) were placed to enlarge or reshape breasts that are still present. Implants change how you compress, how much dose automatic exposure control delivers, and whether implant-displaced views are part of the protocol. Ask whether the patient knows saline versus silicone and whether either implant has been revised.

Keep reconstruction after mastectomy for the treatment section. Here you only need to know that tissue is missing, an implant or expander is present, or the chest wall is what you have to image. Reduction mammoplasty, excisional biopsy, and chest-contouring surgery also belong in the history even though they are not the two printed examples. ARRT's examples are a starter list, not a ceiling.

Useful prompts:

• Which breast, and is the scar still tight or painful?
• Were lymph nodes taken from the armpit?
• Are there implants, expanders, or both?
• Was the breast irradiated (skin may be thin and fragile)?

Clinical Findings: Radiopaque Markers and Diagrams

ARRT asks you to document clinical findings, with examples lumps, scars, moles, tattoos, and abnormalities. Two methods work together: radiopaque skin markers that photograph onto the mammogram, and a breast diagram (paper or electronic) that records clock-face position, centimeters from the nipple, and size. A marker without a note can be misread. A note without a marker can be missed on a busy workstation. Use both unless your written protocol says otherwise for a specific finding.

Follow the facility shape protocol. A widely taught convention, used so any radiologist can decode the image, is:

Place markers before compression so they do not slide. Use mammography-rated, typically non-metallic markers so they do not bloom into a huge artifact. If you circle a mole, the radiologist can dismiss a skin density. If you skip the circle, you invite a callback. If you put a triangle on a mole, you have labeled a skin finding as a palpable mass. That mismatch is a known source of false interpretation.

Tattoos can be faintly dense or can overlay parenchyma. You still document them. You do not need a marker on every square centimeter of ink if protocol is diagram-only, but you never pretend the tattoo is not in the field.

Gender Affirmation: Surgery and Hormonal Therapy

ARRT lists gender affirmation with examples surgery and hormonal therapy. Record them as medical history because they change remaining breast tissue and the screening pathway the order should follow. They do not change courtesy, name use, or identity checks.

Hormonal therapy may be feminizing (estrogen, often with an anti-androgen) or masculinizing (testosterone). Glandular tissue can increase or decrease over months to years. Duration is clinically relevant. American College of Radiology appropriateness materials commonly treat about five or more years of feminizing hormones, together with usual screening age (often 40 years for average risk), as the setting in which screening mammography may be appropriate for transfeminine patients. Shorter hormone exposure often is not a screening-mammography pathway. You do not independently start a screening program. You document years of hormones, current use, and how much breast tissue you can position so the order and the interpretation match the anatomy in the room.

Surgery may include augmentation with implants, reduction, or chest masculinization (top surgery). Chest masculinization is usually a contouring operation that leaves residual breast tissue; it is not automatically the same as an oncologic mastectomy. After substantial tissue removal, screening mammography is often not feasible. A palpable area is then typically a diagnostic problem, often ultrasound if ordered. Patients who retain breasts generally follow the same screening logic as other patients with intact breasts, according to the order they arrive with. Document nonbinary patients by anatomy and hormones rather than forcing a binary label onto the requisition.

Technologist practice:

• Verify identity with name and date of birth; use the name and pronouns in the record.
• Ask what was operated on and whether breast tissue or implants remain.
• Position the tissue you can pull onto the receptor. Do not insist on a textbook craniocaudal and MLO the chest wall cannot produce.
• Let the order indication decide screening versus diagnostic. A transfeminine patient can still need diagnostic views for a lump. A transmasculine patient with retained breasts can still be a screening examination.

The scored skill is simple: the request says why the patient is here; the interview and your inspection say what anatomy and findings are present; markers and the diagram leave those facts on the study after the patient has gone.