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

EXAMPLE
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Name: Ira Sickmann Rec. No.: 000010
Ward _ Age 70 Sex Male Race White Service Clinic Rad Date 9/22/91
CLINICAL DIAGNOSIS: Carcinoma of Esophagus
Summary of Chief Clinical Symptoms and Findings (Specify Duration):
Operation and date: NA
Type of Patient: Ambulatory ( X ) Wheelchair ( ) Roller ( ) Portable ( )
Previous Radiographs: Yes (X) No ( ) Date 7/15/91
May Dressing Be Removed?
EXAMINATION DESIRED: PA Chest
C. N. Lear, MD
Resident or Staff Signature
9/22/91 PA CHEST: There is scoliosis of the thoracic spine with convexity to the left and
there is uncoiling of the thoracic aorta. The heart is normal in size. The costophrenic
angles are clear and the lungs show a minimal degree of interstitial fibrosis. The bony
thorax is intact.
IMP: Essentially normal heart and lungs for the patient's age. There is slight widening of
the superior mediastinum which is thought to be secondary to innominate artery.
Department
Ray Radmann, MD
of Diagnostic Radiology
DEPARTMENT OF DIAGNOSTIC RADIOLOGY
REQUEST FOR CONSULTATION
67