Answer: Manipulative Procedures Example 3

01/14/91

Cystoscopy:

Localized sessile lesion in (R) superior lateral portion of bladder. No other overt lesions. Multiple Bx's taken. Dx: Carcinoma of bladder.

Pyelogram:

Prob. cyst in upper pole of (R) kidney. (L) collecting system normal. No ureteral defects.

TURB done.

Bimanual examination: No evidence of induration within bladder wall or other pelvic abnormality.

Comments:

  1. Three examinations are described in this report (cystoscopy, retrograde pyelogram, and bimanual examination) as well as surgical treatment (TURB).
  2. Some reports will indicate the presence or absence of cancer as a "diagnosis". Other reports will contain a statement of the "impression". Do not attempt to distinguish between the two. Simply use whatever term appears on the report.

The general procedures for abstracting a cystoscopy report are as follows:

  1. Record date and type of procedure.
  2. Record pertinent findings.
  3. Record statement of diagnosis,if given.
  4. Record the Bx's and TURB were done, locate pathology reports, and record the pertinent findings.
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