Answer: Manipulative Procedures Example 4

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Esophagogastroscopy:

Mucosa in distal esophagus erythematous; obstruction of distal esophagus. Imp: Prob. Carcinoma of fundus of stomach. Two Bx's taken.

Comments:

  1. To conserve space, it is permissible to combine portions of description with impression.
    It is not necessary to record full statement on report—"scope was passed with ease to gastroesophageal (GE) junction. At that point lumen narrowed and prevented entrance of scope into the stomach."
  2. Lumen means channel.
  3. The report describes the mucosa (mucous membrane or lining) of the esophagus.

The general instructions for abstracting this report are as follows:

  1. Record date and type of procedure.
  2. Record pertinent findings.
  3. Record impressions of cancer, if given.
  4. Record that biopsies were taken, locate the pathology report, and record the pertinent findings.
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