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Home » Cancer Registration & Surveillance Modules » Abstracting a Cancer Case » Abstracting Diagnostic Procedures » Clinical Examinations » Hematologic Examination » Practical Examples » Example 4
- Abstracting a Cancer Case
- Abstracting the Medical Records
- Composition of a Medical Record
- Abstracting Diagnostic Procedures
- Clinical Examinations
- Manipulative Procedures
- Operative Procedures
- Pathological Examinations
- Additional Information
Hematologic Example 4
View the suggested abstraction.
- Name: Bo Comeaway
- Hospital No.: 000018
- Age: 24
- Sex: Male
- Race: White
Examination Desired: Bone Marrow Aspiration
Aspirate Section:
- Normocellular
- Megakaryocytes, normal
- Stainable iron is normal
Smear:
- 59% erythroid
- 35% granulocytes
- 01% lymphoblasts
- 02% immature lymphocytes
- 03% small lymphocytes moderately megaloblastic erythroid hyperplasia
Diagnosis:
Previously diagnosed acute lymphocytic leukemia
Moderately megaloblastic erythroid hyperplasia
Comment:
Acute lymphocytic leukemia in remission
Spiro Bonne, MD
Pathologist
Date: 06/05/91
Exam: Bone Marrow Aspiration
