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

EXAMPLE
Ell
Name:
Emma Bronchilli
Hospital No.: 000011
Age: 48 Sex: Female Race: Chinese
EXAMINATION DESIRED: CT scan of chest
REASON FOR EXAMINATION: Possible metastatic disease
REPORT:
CT BODY SCAN (No contrast material administered)
Axial tomograms of the superior mediastinum were performed at 2 cm distances.
The mediastinum was included from the thoracic inlet to the level of the carina.
The examination showed normal mediastinal structures with no evidence of a
mediastinal mass. Several abnormal densities were recognized, however, in both
upper lungs (at least 6 in the left lung and at least 7 in the right lung) which
probably represent nodular infiltration of the lung parenchyma of metastatic origin.
No evidence of pleural lesions was demonstrated, however.
The esophagus is visualized on this scan by a minimal amount of air in its lumen and
does not appear to be displaced.
IMPRESSION: No evidence of superior mediastinal mass
demonstrated. Multiple nodular infiltrations in both
upper lobes representing probable metastatic lesions.
B. D. Scanner, MD
Radiologist
Date: 6/6/91 Exam: CT scan of chest
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