Self Instructional Manual for Cancer Registrars - SEER - National ...

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Certain types of disease associated with the abnormality of blood cells are: Anemia - Deficiency in erythrocytes or hemoglobin Aplastic anemia - A form of anemia in which there is a lack of formation of blood cell elements in the bone marrow Leukemia - A progressive, malignant disease of the blood and blood-forming organs characterized by uncontrolled proliferation and development of leukocytes. It is diagnosed by microscopic detection of abnormal cells in the circulating blood and in the bone marrow. Leukocytosis - An increase in the number of leukocytes in the blood Leukopenia - Reduction in the number of leukocytes in the blood Polycythemia - Excessive number of erythrocytes Thrombocytopenia - Decrease in the number of blood platelets Therefore, you can see that the hematology report contains information which the cancer registrar must abstract for leukemias and polycythemia vera. PRACTICAL EXERCISES The examination findings from three routine hematology reports, each using a different format, are demonstrated on the following pages (Examples E17-E19). Example El7 is a routine form using the abbreviations RBC and WBC instead of writing out erythrocytes and leukocytes. You also may not be familiar with the term "lymphoblast" which means an immature lymphocyte. As a check that you have abstracted the correct values, add the various leukocyte percentages to see if they equal 100%. For example, in Example E17 the differential 1 white count is as follows: Leukocytes Percent Neutrophils 69 Lymphoblasts 23 Monocytes 6 Eosinophils 1 Basophils 1__ 100% ldifferential--In performing the blood count, a total of 100 cells are counted. The percent of each type found in these 100 cells is the cell "differential" for each type. 99
Example E18 simply records the workup and the values obtained in/an Abbreviations frequently used are: abbreviated form. CBC = RBC = complete blood count (RBC and WBC) red blood count WBC = white blood count Hct. = hematocrit Hgb. = hemoglobin Plat. = platelets Retic.= reticulocytes PME = polymorphonuclear eosinophils (leukocyte.s) PMN = polymorphonuclear neutrophils (leukocytes) Polymorphonuclear leukocytes usually refer only to neutrophils. Notice in Example E18 that the abbreviations PME and PMN are both used. Promonocytes are immature monocytes. Check that the differential white count adds to 100%. Leukocytes PMN Percent 90 PME 1 Mature lymphocytes 3 Mature monocytes 5 Promonocytes 1 100% Example El9 again is a routine form, but much more detailed and explicit than El7. The leukocytes are subdivided into granulocytes and agranulocytes which are then further subdivided. Check that the differential white count adds to 100%. Leukocytes Percent Granulocytes 59 Neutrophils 57 Eosinophils 1 Basophils 1 Agranulocytes* 41 Monocytes 2 Lymphocytes 39 100% *The term "agranulocyte" will not be found in reports. two different types of leukocytes. We have used it here to differentiate the On the basis of what you know about the diseases associated with abnormal blood cells, abstract what you think is pertinent from the following hematology reports, then check with the abstractions on page 107. 100
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SEER Program Self InstructionalManu
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TABLE OF CONTENTS BOOK 5: ABSTRACTI
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SECTION A OBJECTIVES AND CONTENT OF
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SECTION B THE COMPOSITION AND ORGAN
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Physical Examination General (gener
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FORMS USED TO RECORD INFORMATION IN
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SECTION C ABSTRACTING A MEDICAL REC
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WHEN TO ABSTRACT CASES While it may
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Local Registry Number A patient's r
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Marital Status Select appropriate a
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Abstracting Diagnostic Procedures S
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SECTION D DIAGNOSTIC PROCEDURES: GE
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SECTION E CLINICAL EXAMINATIONS: PH
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EXAMPLE E1 Name: Sarah O. Luckless
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EXAMPLE E2 Name: Hector Breathless
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BODY SECTION RADIOGRAPHY. Body sect
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E. Lower GI Series or Barium Enema:
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Example E3 can be abstracted as fol
Page 54: Example E4 can be abstracted as fol
Page 62: Example E6 might be abstracted as f
Page 70: EXAMPLE E9 Name: Hardy Smooker Hosp
Page 74: Examples E8-E10 can be abstracted a
Page 78: EXAMPLE Ell Name: Emma Bronchilli H
Page 81 and 82: DIAGNOSTIC NUCLEAR MEDICINE EXAMINA
Page 84: EXAMPLE El2 THE DIVISION OF NUCLEAR
Page 88: EXAMPLE E14 Record No.: 000014 Name
Page 92: MAGNETIC RESONANCE IMAGING: Magneti
Page 96: EXAMPLEE16 MRI CONSULTATIONREPORT N
Page 100 and 101: HEMATOLOGIC EXAMINATION A hematolog
Page 102 and 103: Granulocytes or granular leukocytes
Page 106 and 107: EXAMPLE E17 HEMATOLOGY LABORATORY N
Page 108 and 109: EXAMPLEE18 HEMATOLOGY LABORATORY Na
Page 110 and 111: EXAMPLE E19 HEMATOLOGY LABORATORY R
Page 112 and 113: PRACTICAL EXERCISE ANSWERS Example
Page 114 and 115: Bone Marrow Studies. Examination of
Page 116 and 117: EXAMPLE E20 Name: Bo Comeaway Hospi
Page 118 and 119: Example E20 can be abstracted as fo
Page 120 and 121: Blood Serum Studies Automation and
Page 122 and 123: Other Laboratory Studies Marrow Aci
Page 124 and 125: Totalprotein. This test measures th
Page 126 and 127: SECTION F MANIPULATIVE AND OPERATIV
Page 128 and 129: SECTION F MANIPULATIVE AND OPERATIV
Page 130 and 131: EXAMPLE FI Rec. No. 000019 Name Iv_
Page 132 and 133: The manner in which the findings in
Page 134 and 135: EXAMPLE F2 LARYNGOSCOPY REPORT Hosp
Page 136 and 137: The illustrated report can be abstr
Page 138 and 139: I EXAMPLE F3 REPORT OF CYSTOSCOPY N
Page 140 and 141: Example F3 is abstracted as follows
Page 142 and 143: EXAMPLE F4 GASTROINTESTINAL DIAGNOS
Page 144 and 145: The information described in Exampl
Page 146 and 147: EXAMPLE F5 SIGMOIDOSCOPY REPORT Rec
Page 148 and 149: EXAMPLE F6 PROCTOSCOPY REPORT Rec.
Page 150 and 151: EXAMPLE F7 GASTROSCOPIC REPORT Hosp
Page 152 and 153: EXAMPLE F8 GASTROSCOPIC REPORT Hosp
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EXAMPLE F9 BRONCHOSCOPY REPORT Hosp
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EXAMPLE FIO BRONCHOSCOPY REPORT Hos
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EXAMPLE Fll BRONCHOSCOPY REPORT Hos
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EXAMPLE F12 BRONCHOSCOPY REPORT Hos
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PRACTICAL EXERCISE ANSWERS These en
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Example F10: 5/5/91. Bronchoscopy:
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In all of the "oscopies" described
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EXAMPLE F13 OPERATIVE REPORT Name:
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This operative report may be abstra
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OPERATIVE PROCEDURES Exploratory_Su
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EXAMPLE F14 OPERATIVE REPORT Servic
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The operative record used as an ill
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Example F15: 3/11/91. Expl. Lap.: L
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PRACTICAL EXERCISE The following pa
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These operative reports can be abst
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EXAMPLE F18A OPERATIVE REPORT Name
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EXAMPLE F18B OPERATIVE REPORT Name
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Example F18 can be abstracted as fo
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SECTION G PATHOLOGICAL EXAMINATIONS
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SECTION G PATHOLOGICAL EXAMINATIONS
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A. The BiopsyReport The termbiopsy(
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EXAMPLE G1 DEPARTMENT OF PATHOLOGY
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Example G1 can be abstracted as fol
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Abstracting the Pathology Report Le
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EXAMPLE G2 PATHOLOGY REPORT Path. N
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EXAMPLE G3 PATHOLOGICAL SPECIMEN RE
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EXAMPLE (34 (continued) DIAGNOSIS:
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The information which should be abs
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PRACTICAL EXERCISE In the following
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EXAMPLE G6 PATHOLOGY REPORT Name Be
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PRACTICAL EXERCISE ANSWERS Example
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EXAMPLE G10 AUTOPSY REPORT IDENTIFI
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EXAMPLE G10 (continued) CLINICOPATH
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Example G10 can be abstracted as fo
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EXAMPLE Gll DEPARTMENT OF PATHOLOGY
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EXAMPLE G11 (Continued) DEPARTMENT
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EXAMPLE Gll (Continued) DEPARTMENT
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Example G11 can be abstracted as fo
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CYTOLOGIC EXAMINATION The study of
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A cytology report recorded as suspi
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PRACTICAL EXERCISE Summarize the fi
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EXAMPLE G13 i ! PATIENT NO. DATE 10
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EXAMPLE G14 Patient No. 000050 DATE
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EXAMPLE GI_ CLINICAL RECORD - TISSU
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Examples G12-15 may be abstracted a
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COMMON ABBREVIATIONS Abbreviation T
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HEENT Head, _ eara, ame & throat LE
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SARC Sarcoma UMB Navel (umbilicus)
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COMMON ABBREVIATIONS Definition Ind
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Impression IMP Lumbar spine L-SPINE
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Staphylococcus STAPH Within normal
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COMMON SYMBOLS Symbol Index Symbol
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ACRONYMS FOR ORGANIZATIONS CONCERNE
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WORLDWIDE ORGANIZATIONS IACR Intern
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ACRONYMS FOR STUDY GROUPS The follo
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SELECTED BIBLIOGRAPHY Cancer Regist
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INDEX Abstract, 3, 9, 11, 15-17, 21
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Cerebral angiogram, 40 Chemistry (S
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Endoscopic examination (Cont'd) Exa
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Laryngogram, 65, 69 Example E9, 65,
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Papanicolaou classification, 243 Pa
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Special examinations, 8 SPECT, 71 S
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Index of Examples E_mmple E1 29, 31
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