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SEER Training Modules

Radiologic Example 7

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Department of Radiology - Division of Thermography

Name: Nancy Etta Feather
Hospital No.: 000007

Ward:___
Age: 79
Sex: Female
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 (_)
  • Date ___________

Type of Patient:

  • Ambulatory (_)
  • Wheelchair ( X )
  • Roller (_)
  • Portable (_)

May Dressing Be Removed? NA

Examination Desired: PA & Lateral Chest Esophogram

Randy First, MD
Resident or Staff Signature:____________________________________


Technical Data:

  • Ambient temp. 70o F
  • Delta T 6o C
  • Oral temp._______

Report:

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 neoplastic process.

Juan Seer, MD
Request for Consultation