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

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PRACTICAL EXERCISE ANSWERS These endoscopic examinations may be abstracted as follows: Example F5: 2/12/91. Sigmoidoscopy: Mass from anal verge to 10 cm on ant, (L) and post rectal wall. Bx's taken. Comment: Length of mass is 10 cm; verge means "edge." The sigmoidoseope was passed to 25 cm. Example F6: 2/8/91. Proctoscopy: Unsatisfactory. Digital rectal reveals 8-10 cm lesion. Carcinoma of rectum, R/O more proximal lesion. Multiple Bx's taken. Comment: Reference made to "digital" to indicate a finger examination was done. Melanotic stool suggests bleeding from a source some place beyond that noted in the report. Example F7: 1/8/91. Gastroscopy: Mass constricting antrum. Bx taken. Probably adenocarcinoma of the stomach. Comment: The information on the hemorrhagic and necrotic areas is not necessary for cancer registry abstracting. 157
Example F8: 2/26/91. Gastroscopy: Antrum constricted by an extrinsic mass lesion. No intrinsic mucosal lesions seen. Imp: Malignant disease involving antrum. Comments: a. Intrinsic means situated entirely within or pertaining exclusively to a part, in this ease the lining of the stomach. b. Extrinsic means situated on the outside; coming from or originating outside; having relation to parts outside the organ in which found. Example F9: 10/1/91. Bronchoscopy: Encircling neoplastic-appearing tissue involving distal 1/4 of trachea down to carina. Carina massively widened and timed. Both proximal MSB probably involved. 10/1/91. Esophagoscopy: Circumferential mass in esophagus at 21 cm. Multiple Bx's, tracheal washings. Imp- Carcinoma of esophagus involving trachea. Comments: a. The essential problem in abstracting this report is to properly select and combine the important points in the description. You need a statement describing something about both the esophagus and the trachea. Also, probable involvement of the bronchi should be mentioned. Then, you should try to describe the lbcation of'the tumor. The tumor in the trachea involves the distal 1/4 of trachea. The esophageal lesion is at 21 cm. b. V.C. means vocal cords; MSB means main stem bronchus. In the space titled "Procedure" the M.D. has written "Esophagoscopy and Bronchoscopy" to indicate that two procedures were done. You will also frequently encounter abbreviations such as (L) for left and ant. for anterior. c. Measurements are routinely made from incisors (upper anterior alveolar ridge). It is not necessary to abstract this information. d. "Tracheal washings" alerts the abstractor to look for a cytology report. 158
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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
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Example E6 might be abstracted as f
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EXAMPLE E9 Name: Hardy Smooker Hosp
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Examples E8-E10 can be abstracted a
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EXAMPLE Ell Name: Emma Bronchilli H
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DIAGNOSTIC NUCLEAR MEDICINE EXAMINA
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EXAMPLE El2 THE DIVISION OF NUCLEAR
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EXAMPLE E14 Record No.: 000014 Name
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MAGNETIC RESONANCE IMAGING: Magneti
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EXAMPLEE16 MRI CONSULTATIONREPORT N
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HEMATOLOGIC EXAMINATION A hematolog
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Granulocytes or granular leukocytes
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Certain types of disease associated
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EXAMPLE E17 HEMATOLOGY LABORATORY N
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EXAMPLEE18 HEMATOLOGY LABORATORY Na
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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
Page 154 and 155: EXAMPLE F9 BRONCHOSCOPY REPORT Hosp
Page 156 and 157: EXAMPLE FIO BRONCHOSCOPY REPORT Hos
Page 158 and 159: EXAMPLE Fll BRONCHOSCOPY REPORT Hos
Page 160 and 161: EXAMPLE F12 BRONCHOSCOPY REPORT Hos
Page 164 and 165: Example F10: 5/5/91. Bronchoscopy:
Page 166 and 167: In all of the "oscopies" described
Page 168 and 169: EXAMPLE F13 OPERATIVE REPORT Name:
Page 170 and 171: This operative report may be abstra
Page 172 and 173: OPERATIVE PROCEDURES Exploratory_Su
Page 174 and 175: EXAMPLE F14 OPERATIVE REPORT Servic
Page 176 and 177: The operative record used as an ill
Page 180 and 181: Example F15: 3/11/91. Expl. Lap.: L
Page 182 and 183: PRACTICAL EXERCISE The following pa
Page 188 and 189: These operative reports can be abst
Page 190 and 191: EXAMPLE F18A OPERATIVE REPORT Name
Page 192 and 193: EXAMPLE F18B OPERATIVE REPORT Name
Page 194 and 195: Example F18 can be abstracted as fo
Page 196 and 197: SECTION G PATHOLOGICAL EXAMINATIONS
Page 198 and 199: SECTION G PATHOLOGICAL EXAMINATIONS
Page 200 and 201: A. The BiopsyReport The termbiopsy(
Page 202 and 203: EXAMPLE G1 DEPARTMENT OF PATHOLOGY
Page 204 and 205: Example G1 can be abstracted as fol
Page 206 and 207: Abstracting the Pathology Report Le
Page 208 and 209: EXAMPLE G2 PATHOLOGY REPORT Path. N
Page 210 and 211: EXAMPLE G3 PATHOLOGICAL SPECIMEN RE
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EXAMPLE G4 DEPARTMENT OF PATHOLOGY
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EXAMPLE (34 (continued) DIAGNOSIS:
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EXAMPLE G5 PATHOLOGICAL SPECIMEN RE
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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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EXAMPLE G7 PATHOLOGICAL SPECIMEN RE
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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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