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

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EXAMPLE G2 PATHOLOGY REPORT Path. No. $91-210 Name Sally Sacqueski Reg. No. 000038 Age 66 Sex Female Race White Location Date 2/11/91 Address Occupation HISTORY OF CASE: Multiple TURB for Grade 1I TCC with microinvasion; multiple tumors CLINICAL DIAGNOSIS: Carcinoma of bladder; R/O scalene node metastasis POST-OPERATIVE DIAGNOSIS Carcinoma of bladder Surgeon So Long. MD Operation Bx of bladder & L scalene node GROSS DESCRIPTION: The specimen is received in two parts. They are labeled #1, "biopsy bladder tumor, * and #2, "scalene node, left.* Part #1 consists of multiple fragments of gray-brown tissue which appear slightly hemorrhagic. They are submitted in their entirety for processing. Part #2 consists of multiple fragments of fatty yellow tissue which range in size from 0.2 to 1.0 cm in diameter. They are submitted in their entirety for processing. MICROSCOPIC: Section of bladder contains areas of transitional cell carcinoma. No area of invasion can be identified. A marked acute and chronic inflammatory reaction with eosinophils is noted together with some necrosis. Sections are examined at six levels. Section of lymph node contains normal node with reactive germinal centers. DIAGNOSIS: 1. Papillary transitional cell carcinoma, grade II, bladder, biopsy. 2. Acute and chronic inflammation, most consistent with recent biopsy procedure. 3. Scalene lymph node, left, no pathologic diagnosis. Mike O'Seen, MD 203
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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
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PRACTICAL EXERCISE ANSWERS Example
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Bone Marrow Studies. Examination of
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EXAMPLE E20 Name: Bo Comeaway Hospi
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Example E20 can be abstracted as fo
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Blood Serum Studies Automation and
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Other Laboratory Studies Marrow Aci
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Totalprotein. This test measures th
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SECTION F MANIPULATIVE AND OPERATIV
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SECTION F MANIPULATIVE AND OPERATIV
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EXAMPLE FI Rec. No. 000019 Name Iv_
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The manner in which the findings in
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EXAMPLE F2 LARYNGOSCOPY REPORT Hosp
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The illustrated report can be abstr
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I EXAMPLE F3 REPORT OF CYSTOSCOPY N
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Example F3 is abstracted as follows
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EXAMPLE F4 GASTROINTESTINAL DIAGNOS
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The information described in Exampl
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EXAMPLE F5 SIGMOIDOSCOPY REPORT Rec
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EXAMPLE F6 PROCTOSCOPY REPORT Rec.
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EXAMPLE F7 GASTROSCOPIC REPORT Hosp
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EXAMPLE F8 GASTROSCOPIC REPORT Hosp
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EXAMPLE F9 BRONCHOSCOPY REPORT Hosp
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EXAMPLE FIO BRONCHOSCOPY REPORT Hos
Page 158 and 159: EXAMPLE Fll BRONCHOSCOPY REPORT Hos
Page 160 and 161: EXAMPLE F12 BRONCHOSCOPY REPORT Hos
Page 162 and 163: PRACTICAL EXERCISE ANSWERS These en
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 210 and 211: EXAMPLE G3 PATHOLOGICAL SPECIMEN RE
Page 214 and 215: EXAMPLE (34 (continued) DIAGNOSIS:
Page 218 and 219: The information which should be abs
Page 220 and 221: PRACTICAL EXERCISE In the following
Page 222 and 223: EXAMPLE G6 PATHOLOGY REPORT Name Be
Page 230 and 231: PRACTICAL EXERCISE ANSWERS Example
Page 232 and 233: EXAMPLE G10 AUTOPSY REPORT IDENTIFI
Page 234 and 235: EXAMPLE G10 (continued) CLINICOPATH
Page 236 and 237: Example G10 can be abstracted as fo
Page 238 and 239: EXAMPLE Gll DEPARTMENT OF PATHOLOGY
Page 240 and 241: EXAMPLE G11 (Continued) DEPARTMENT
Page 242 and 243: EXAMPLE Gll (Continued) DEPARTMENT
Page 244 and 245: Example G11 can be abstracted as fo
Page 246 and 247: CYTOLOGIC EXAMINATION The study of
Page 248 and 249: A cytology report recorded as suspi
Page 250 and 251: PRACTICAL EXERCISE Summarize the fi
Page 252 and 253: EXAMPLE G13 i ! PATIENT NO. DATE 10
Page 254 and 255: EXAMPLE G14 Patient No. 000050 DATE
Page 256 and 257: 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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