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

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HEENT Head, _ eara, ame & throat LE Lower enremity;, Lupm e_ematesm HGB Hemoglobia LFr Liver function test H1V H,,,_,, immaaodef_im_ vires LG Larse HN2 Nitmgea mustard LIF Left lilac Rma l-LzO Water LINAC _ accelerator H/O Hittmy of LIQ Lmv_ inncf quadrant (bremt) HORM Hm_ee Lr,_8) _, kidney, _ HOSP Ho_tal i J_ Left _ extremity H&P I-littmy and phyKal IJ J. l-eft lower lobe (lung) HPF High lmWCrfield LLO LcR lower quadrant (abdomca) HPI Histmy of prcscat _ LMD Local medical doctor HPV Flnmu i_ virus LMP Last memtnml period HR(S) Horn(s) LN(S) Lymph node(s) HTLV-III Human T-lym_ vires type III LOP Lower omex quadrant (breast) HVD _ vascular d_ LP Lumbar puncture HX H_m_y LPF Lowpo_r fiem HYST Hyst_ LPN Lkemed practical nurse LS Lmnbosacral z Iodine LSK, t.KS _,w-,s#een, ICD-O-1 International O.amification of Diseases LSO Left salpingo-oophcm_omy fo¢ Oaeok_, 1st Ed., 1976 L-SPINE Lumbar spine ICD-O-2 lntematkmal Classification of Diseases LT Left Caadd_) fox Oncnllog, 2rid Ed., 1992 LUE Left upper extremity ICM lntenmstal margin LUL Left upper lobe (lung) ICS Intenxmld space LUQ Left upper quadrant (abdomen) ICU Intcmive care unit L&W Living and well IG Immlmoglob_ IM Intrammcalar M Mmmcytes, meter IMA Internal mammm'y_ _ Malignant IMP Imi_essioa MALIG Malignant INCL Inchtdm, indedin_ _[AND Mandible INF lafc_km" MAST Mmtectomy INF Infractkm M-CSF Macmpba_ Colony-Stimulatiag Factef INF Infmi_ MC Milticurie INFILT Infiltrating MCH Mean corpuscular hemoglobin INJ lajectioa MCHC Mean _ bemcy,k_n count INT MED Internal medicine MCL Mid clavicular line IP Inpatieat MCV Mean corpuscular volume IPPB Intetmitteat positive premun: Immthing MD Medical Doctoc IT Intntthecal MD Moderately differentiated IV lntmvemms MET, METS Metastatic, mctm_ IVC lnfcliof veto cava MEV Million electron volts IVP Intravcaom pyciogram MH Marital histo_ MI-I Mental health JVD Jugular venom di_tcntioo MG Milligram MICRO Microscopic K pcam*ium ML Middle lobe KG Kilolpram ML Millilite_r KJ Knee je_ MM Millimeter KK Knee kick MOD Moderate KUB Kidneys, urctc_ bladder MOD DIFF Modecately differentiated KV Kilov_t MRI Magnetic resonance ima#qg MRM Modified radical mastectomy L Left MS Mitral step.is L Liter MS Multiple L Lower MSL Mid sternal line L1-L5 Lumbar vextcbt-_ MX Micrmcopic LAP Laparotomy MX Maxilla0y), maximum LAT Latend LAV Lympl_thy-mm3ciated virus NA Not al_icabic LCM Left costal margin NBS Normal bowelsound, LDH Lactic dehydmg,-amP NEC Net elsewhere clastified 257
NED No evidence of disease POD Postoperative day NEG or - Negative POOR DIFF Poorly differentiated NERD No evidence of recurrent disease POS or + Positive NEURO Neurology POSS Possible NL Normal POST Posterior NOS Not otherwise specified POST Postmortem esamination NR Not recorded POSTOP Postoperative(iy) NR Not reportable PPD Purified protein derivative (Tuberculin skin test) NSF No significant filldinn PPD Packs per day NTP Normal temperature and Wemure PR(A) Progesterone receptor (assay) N&V Nausea and vomiting PREOP Preoperative(ly) NVD Neck vein distention PROB Probable(ly) PT Patient OB Obstetrics PT Physiotherapy OBST Obstructed (ing, ion) PTA Prior to admission OD Right eye (oculm dexter PUO Pyrexia of undetermined origin OH Occupational history PULM Pulmonary OP Operation OP Outpatient Q Quadrant OPD Outpatient clinic; department OPHTH Ophthalmology R Roentgen OR Operating room R Respiration ORTH Orthopedics R Right OS Bone RA Radium OS Left eye (oculus sinister) RAD Radiation OS Mouth RAD Radiation Abso_ Dose OS Opening RAD Radical OSTEO Osteomyelitia RAIU Radioactive iodine (I 131) uptake OT Occupational therapy RBC Red blood cells OTO Otology RCM Right Costal Margin OU Each eye (oculus uterque) RCS Reticulum cell sarcoma OV Office visit REG Radioencephaiogram OZ Ounce RES Reticuloendothelial system RESEC Resection P Pulse RESPIR Respiratory P&A Percussion and atuumltation RH Rhesus (monkey) factor in blood PA Posteroanterior RIA Radioimmunoassay PA Pulmonary artery RIF Right iliac foma PALP Palpable, palpated, palpation RIQ Right inner quadrant (abdomen) PAP Papanicolaou smear RLE Right lower extremity PAP Papillary RLL Right lower lobe (lung) PAR Post anesthesia room RLQ Right lower quadrant PARA Number of pregnancies resulting RML Right middle lobe (lung) in viable infants RN Registered nurse PATH Pathology RNA Ribonucleic acid PCV Packed cell volume RO, R/O Rule out PD Poorly differentiated ROF Review of outside films PDR' Physicians' Desk Reference ROM Range of motion PE Physical examination ROS Review of outside slides PED Pediatrics ROS Review of systems PEG Pneumoencephalography ROQ Right outer quadrant (abdomen) PERC Percutaneous RSO Right salpingo-oophorectomy PET Positron emission tomography R-S cells Rced-Steruberg cells PH Past or personal history RT Radiation therapy PI Present illness RT Right PID Pelvic inflammatorydisease RUE Right upper estremity PLT Platelets RUL Right upper lobe PM Post mortem (after death) RUQ Right upper quadrant PMD Personal (primary) medical doctor R-V Rectovaginal PMH Past medical history RX Treatment PND Postnasal drip PO, POSTOP PostoperatNe(ly) S1-$5 Sacral vertebra 258
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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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These operative reports can be abst
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EXAMPLE F18A OPERATIVE REPORT Name
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EXAMPLE F18B OPERATIVE REPORT Name
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Example F18 can be abstracted as fo
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SECTION G PATHOLOGICAL EXAMINATIONS
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SECTION G PATHOLOGICAL EXAMINATIONS
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A. The BiopsyReport The termbiopsy(
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EXAMPLE G1 DEPARTMENT OF PATHOLOGY
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Example G1 can be abstracted as fol
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Abstracting the Pathology Report Le
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EXAMPLE G2 PATHOLOGY REPORT Path. N
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EXAMPLE G3 PATHOLOGICAL SPECIMEN RE
Page 212 and 213: EXAMPLE G4 DEPARTMENT OF PATHOLOGY
Page 214 and 215: EXAMPLE (34 (continued) DIAGNOSIS:
Page 216 and 217: EXAMPLE G5 PATHOLOGICAL SPECIMEN RE
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 224 and 225: EXAMPLE G7 PATHOLOGICAL SPECIMEN RE
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 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
Page 258 and 259: Examples G12-15 may be abstracted a
Page 260 and 261: COMMON ABBREVIATIONS Abbreviation T
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
Page 288 and 289: Laryngogram, 65, 69 Example E9, 65,
Page 290 and 291: Papanicolaou classification, 243 Pa
Page 292 and 293: Special examinations, 8 SPECT, 71 S
Page 294 and 295: Index of Examples E_mmple E1 29, 31
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