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

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BODY SECTION RADIOGRAPHY. Body section radiography involves taking radiographs of layers of the body, that is, a series of x-rays taken at different depths in order to define images of desired areas. The desired image is brought sharply into focus while blurring out the other areas. These types of radiograms are used to locate lesions accurately in places like the lungs and bones. They are referred to as tomograms, laminograms, and planograms. TOMOGRAPH_Y: A special x-ray technique to show in detail images of structures lying in a predetermined plane of tissue while blurring or eliminating detail in images of structures in other planes (Same as Laminography). LAMINOGRAPHY: X-ray of a selected layer of the body made by laminography (Picker Ultrasonic Laminograph) (See Tomography). In the early 1970's, computerized tomography (CT) was introduced into clinical medicine and revolutionized the field of diagnostic imaging. DIGITAL RADIOGRAPHY: A system which uses computers to convert the lighter and darker areas of the radiographic image into numbers and then translates these numbers into an image on a cathode ray (television) tube. 39
RADIOLOGIC EXAMINATIONS USING CONTRAST MEDIA Certain materials or gases can be injected into veins, arteries, lymphatics, or hollow cavities to obtain contrast with the surrounding tissues. A contrast medium is a radiopaque substance which obstructs the passage of x-rays so that the structures containing it appear white on the x-ray film thus delineating abnormal pouches or growths and defining the contour of body structures on x-ray. Examples of radiopaque materials are Hypaque and Renografin, dyes used in intravenous pyelogram, and barium, the substance used in a gastrointestinal series. Some of the more common radiographic examinations which use contrast media are: A. Angiography: The radiographic study of the vascular system 1. Cerebral angiogram: X-ray of the vessels of the brain 2. Cardiac angiogram: X-ray showing the functions of the heart and large blood vessels 3. Lymphangiogram: X-ray study of the vessels of the lymphatic system 4. Arteriography: X-ray examination of arteries 5. Venography: X-ray examination of veins B. Urography: Radiologic study of the urinary tract 1. Urogram (Pyelogram): X-ray of the kidney and ureter with emphasis on the pelvis of the kidney by intravenous injection of a contrast medium 2. Cystogram: X-ray of the urinary bladder by intravenous injection of a contrast medium 3. IVP (Intravenous Pyelography): A succession of x-ray films of the urinary tract following the injection into a vein of an iodine-containing substance which is collected by the kidneys, passing into the ureters and subsequently the bladder, allowing the study of urinary tract function (also known as Intravenous Urography, IVU). 4. Retrograde Urography: (Retrograde Pyelography): Examination of the ureter and renal collecting structures by means of instillation of contrast material through a ureteral catheter passed through a cystoscope into the bladder and ureter. C. Bronchography: The radiographic study of the bronchi of the lung Bronchogram: An x-ray of the bronchial system D. Upper GI Series or BariumSwallow: X-ray studies, following ingestion of barium, of the pharynx, esophagus, stomach, duodenum, and small intestine 40
Page 2 and 3: SEER Program Self InstructionalManu
Page 4 and 5: TABLE OF CONTENTS BOOK 5: ABSTRACTI
Page 6: SECTION A OBJECTIVES AND CONTENT OF
Page 10: SECTION B THE COMPOSITION AND ORGAN
Page 13 and 14: Physical Examination General (gener
Page 15 and 16: FORMS USED TO RECORD INFORMATION IN
Page 18: SECTION C ABSTRACTING A MEDICAL REC
Page 21 and 22: WHEN TO ABSTRACT CASES While it may
Page 23 and 24: Local Registry Number A patient's r
Page 25 and 26: Marital Status Select appropriate a
Page 27 and 28: Abstracting Diagnostic Procedures S
Page 30 and 31: SECTION D DIAGNOSTIC PROCEDURES: GE
Page 32: SECTION E CLINICAL EXAMINATIONS: PH
Page 36: EXAMPLE E1 Name: Sarah O. Luckless
Page 40: EXAMPLE E2 Name: Hector Breathless
Page 46: E. Lower GI Series or Barium Enema:
Page 50: Example E3 can be abstracted as fol
Page 62: Example E6 might be abstracted as f
Page 70: EXAMPLE E9 Name: Hardy Smooker Hosp
Page 74: Examples E8-E10 can be abstracted a
Page 78: EXAMPLE Ell Name: Emma Bronchilli H
Page 81 and 82: DIAGNOSTIC NUCLEAR MEDICINE EXAMINA
Page 84: EXAMPLE El2 THE DIVISION OF NUCLEAR
Page 88: EXAMPLE E14 Record No.: 000014 Name
Page 92: MAGNETIC RESONANCE IMAGING: Magneti
Page 96:
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
Page 108 and 109:
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
Page 196 and 197:
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
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EXAMPLE (34 (continued) DIAGNOSIS:
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The information which should be abs
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PRACTICAL EXERCISE In the following
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EXAMPLE G6 PATHOLOGY REPORT Name Be
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Page 226 and 227:
Page 228 and 229:
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PRACTICAL EXERCISE ANSWERS Example
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EXAMPLE G10 AUTOPSY REPORT IDENTIFI
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EXAMPLE G10 (continued) CLINICOPATH
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Example G10 can be abstracted as fo
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EXAMPLE Gll DEPARTMENT OF PATHOLOGY
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EXAMPLE G11 (Continued) DEPARTMENT
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EXAMPLE Gll (Continued) DEPARTMENT
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Example G11 can be abstracted as fo
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CYTOLOGIC EXAMINATION The study of
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A cytology report recorded as suspi
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PRACTICAL EXERCISE Summarize the fi
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EXAMPLE G13 i ! PATIENT NO. DATE 10
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EXAMPLE G14 Patient No. 000050 DATE
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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
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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