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

EXAMPLE
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DEPARTMENT OF PATHOLOGY - AUTOPSY REPORT
Coroner's Case [ ] Yes [x] No
Unit Hospital No. 000047 Necropsy No. N91-2000
Name MarWGallstone Age 78 Race White Sex Male
Admitted: Date 3/3/91 Hour 1:00 pm Ward C400C Service Surgery
Died: Date 3/18/91 Hour 4:15 am Necropsied: Date 3[18/91 Hour 9:30 am
Prosector Harry O'Flexure, MD Reviewer Robert McSplenic, MD
FINAL NOTE
This 78-y/o W M presented with jaundice, anorexia, and wt. loss. The clinical impression
was carcinoma of the head of the pancreas. BE revealed an obstructed area at the
ascending colon - probably due to carcinoma of colon. UGI revealed a hiatal hernia.
Liver scan was abnormal, being compatible with a central lesion. His bilirubin was 22.1;
D/I = 17.3/4.8. His course in the hospital was increasingly downhill with increasing
jaundice and obstruction. He later became unresponsive and died on 3/18/91. At autopsy
he was found to have an adenocarcinoma of the gallbladder extending into the liver and
to the (R) hepatic flexure of the colon with resultant colonic obstruction. No other
metastases were found. His lungs were adenomatous and atelectatic, and several areas of
fibrosis were found in the heart.
PROVISIONAL GROSS NECROPSY FINDINGS:
I
Carcinoma hepatic flexure (R) colon
(micro pending)
a) Obstructive jaundice
b) Extension into liver
II
Cholelithiasis
Biliary cirrhosis
III Aspiration pneumonitis with acute bronchitis pulmonary edema
IV
Benign nephrosclerosis
Chronic pyelonephritis
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