Answer: Manipulative Procedures Example 9

10/01/91

Bronchoscopy:

Encircling neoplastic-appearing tissue involving distal 1/4 of trachea down to carina. Carina massively widened and fixed. Both proximal MSB probably involve.

10/01/91

Esophagoscopy:

Circumferential mass in esophagus at 21 cm. Multiple Bx's taken, tracheal washings.

Comments:

  1. The essential problem in abstracting this report is to properly select and combine the important points in the description. You need a statement describing something about both the esophagus and the trachea. Also, probable involvement of the bronchi should be mentioned. Then, you should try to describe the location of the tumor. The tumor in the trachea involves the distal ¼ trachea. The esophageal lesion is at 21 cm.
  2. V.C. means vocal cords; MSB means main stem bronchus. In the space titled "Procedure" the M.D. has written "Esophagoscopy and Bronchoscopy" to indicate that two procedures were done. You will also frequently encounter abbreviations such as (L) for left and ant. for anterior.
  3. Measurements are routinely made from incisors (upper anterior alveolar ridge). It is not necessary to abstract this information.
  4. "Trachea washings" alerts the abstractor to look for a cytology report.
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