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

EXAMPLE
G10
AUTOPSY
REPORT
IDENTIFICATION NO. AUTOPSY NO. A91-21 HOSPITAL NO. 00(1046
NAME Doe, John SERVICE NO. WARD NO.
AGE 70 SEX Male RACE White
Date and hour of death: 12/1/91- 7:25 am Autopsy performed: 12/1/91- 12:30 pm
Check one: Full autopsy [x] Head only [ ] Trunk only [ ]
Prosector Dr. Smith Assistant
CLINICAL
HISTORY
This 70-year-old Caucasian man was admitted to the hospital on November 14, 1991
because of a lesion of the large bowel with partial obstruction. He had a diagnosis of
chronic lymphocytic leukemia many years ago treated with chemotherapy. Apparently he
showed also bilateral pyelonephrosis and metastatic disease to iliac lymph nodes. The
prostate was thought to be benign. His primary problem was in the upper urinary tract.
X-ray examination of the colon showed diverticulosis. No definite nodes or masses. No
gallstones. The esophagus was normal. The distal stomach showed mucosal thickening and
deformity with a certain amount of fixation and rigidity probably due to prepyloric ulcer with
edema and other inflammatory changes. The possibility of carcinoma of stomach with
ulceration raised on x-ray examination of the upper G.I. tract. X-ray examination of urinary
tract showed Stage II - III hydronephrotic changes in both kidneys. The bladder was poorly
defined. The ureters were not seen. The findings were consistent with an obstructive
process in the lower urinary tract.
Laboratory Data: November 16, 1991. SMA-12: Glucose 235, Cholesterol 130, Total
Proteins 5.7, Albumin 6.3, Alkaline Phosphatase 120, all other parameters within normal
range. WBC 3.7, RBC 4.80, Hgb. 15.4, Hot. 45.0, MCV 95, MCH 31.8, MCHC 33.9.
Differential: Segs 72, Lymphs 25, Monos 2, Eosins 1, Platelets adequate, RBC essentially
normochromic with slight anisocytosis. Amylase 127, Glucose 117 mg.% on November 20.
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