SEER Training Modules
11/27/12 - The NCI is working on updating materials.
- 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
Radiologic Example 4
View the suggested abstraction.
Name: Sonya Heare
Hospital No.: 000004
Age: 56
Sex: Female
Race: White
12/31/91
Examination Desired: Ultrasound of Abdomen
Reason for Exam: Retroperitoneal Mass
Report:
Ultrasound of Abdomen:
Examination of the left kidney was performed ion both supine and prone positions. There is evidence of a mass lesion in the superior pole causing a bulbous superior pole of the kidney which is fairly homogenous in consistency but is not cystic. The mass is mainly in the superior pole but also seems to be somewhat more posteriorly placed, displacing the normal midportion of the kidney slightly anteriorly.
An examination of the right kidney is within normal limits.
Impression:
Mass lesion, superior portion and posterior portion of the left kidney, not cystic.
Radiologist: B. Echo, MD
