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

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EXAMPLE Gll 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 Continued on next page 233
EXAMPLE Gll (Continued) DEPARTMENT OF PATHOLOGY - AUTOPSY REPORT EXTERNAL EXAMINATION Height 180 cm Weight 143 lb. State of nutrition emaciated Brain examined Subcutaneous [ ] Yes [x] No fat, abdominal 2 cm __=.,__icteric sclerae -- jaundiced 1 _ li i _ldappa_ ndectOmy [x] Indicates no significant abnormality [ ] Skin jaundiced Ix] Hair [x] Extremities Ix] Lymph nodes Ix] External genitalia [x] Breasts [xI Eyes Ix] Ears [x] Nose [x] Mouth [x] Tongue [x] Teeth Continued on next pa_e 234
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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
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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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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
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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
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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
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
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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
Page 258 and 259: Examples G12-15 may be abstracted a
Page 260 and 261: COMMON ABBREVIATIONS Abbreviation T
Page 262 and 263: HEENT Head, _ eara, ame & throat LE
Page 264 and 265: SARC Sarcoma UMB Navel (umbilicus)
Page 266 and 267: COMMON ABBREVIATIONS Definition Ind
Page 268 and 269: Impression IMP Lumbar spine L-SPINE
Page 270 and 271: Staphylococcus STAPH Within normal
Page 272 and 273: COMMON SYMBOLS Symbol Index Symbol
Page 274 and 275: ACRONYMS FOR ORGANIZATIONS CONCERNE
Page 276 and 277: WORLDWIDE ORGANIZATIONS IACR Intern
Page 278 and 279: ACRONYMS FOR STUDY GROUPS The follo
Page 280 and 281: SELECTED BIBLIOGRAPHY Cancer Regist
Page 282 and 283: INDEX Abstract, 3, 9, 11, 15-17, 21
Page 284 and 285: Cerebral angiogram, 40 Chemistry (S
Page 286 and 287: 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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