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

EXAMPLE
E7
Name: Nancy Etta Feather Record No. 000007
Ward Age 79 Sex Female Race White Service Medicine Date 7/15/91
CLINICAL DIAGNOSIS: Carcinoma of esophagus
Summary of Chief Clinical Symptoms and Findings (Specify Duration):
Difficulty swallowing; weight loss 6 mo.
Operation and Date: NA
Previous Radiographs: Yes ( ) No (X) Date
Type of Patient: Ambulatory ( ) Wheelchair (X) Roller ( ) Portable ( )
May Dressing Be Removed? NA
EXAMINATION DESIRED: PA & Lateral Chest
ESOPHAGRAM
Randy First, MD
Resident or Staff Signature
7-15-91 PA and lateral view of the chest: The lung fields are thought to show signs of
senile fibrotic reaction bilaterally with some minimal abnormal elevation of the left
hemidiaphragm. Cardiac silhouette is within normal limits.
Multiple views of the chest with barium swallow show a persistent constricting lesion of the
upper 1/3 of the esophagus just below the supraclavicular notch. This is probably a
neoplastic process.
DEPARTMENT OF DIAGNOSTIC RADIOLOGY
REQUEST FOR CONSULTATION
Juan Seer, MD
Department of Diagnostic Radiology
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