Answer: Manipulative Procedures Example 3
Localized sessile lesion in (R) superior lateral portion of bladder. No other overt lesions. Multiple Bx's taken. Dx: Carcinoma of bladder.
Prob. cyst in upper pole of (R) kidney. (L) collecting system normal. No ureteral defects.
Bimanual examination: No evidence of induration within bladder wall or other pelvic abnormality.
- Three examinations are described in this report (cystoscopy, retrograde pyelogram, and bimanual examination) as well as surgical treatment (TURB).
- 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:
- Record date and type of procedure.
- Record pertinent findings.
- Record statement of diagnosis,if given.
- Record the Bx's and TURB were done, locate pathology reports, and record the pertinent findings.