SEER Training Modules
11/27/12 - The NCI is working on updating materials.
Manipulative Procedures Example 1
View the suggested abstraction.
- Rec. No.: 000019
- Name: Ivan Block
- Age: 65
- Sex: Male
- Race: White
- Date: 03/31/91
Chief Complaint Bloody Stools Referred by Everett Hope, MD
- Previous Proctoscopy: Yes
- Date: 03/20/84
- Findings: Negative
- Previous Rectal Surgery: None
History
- Blood per Rectum Occas for 6 mo.
- Abdominal Colic None
- Appetite Recent loss
- Abscess _________
- Itching __________
- Weight Loss 10 lbs.
- Protrusion Intermittent
- Change in bowel habits: Diarrhea
- Draining fistula __________
- Rectal Pain__________
- Fever __________
- Constipation Alt. Const./diarrhea
- Diarrhea ______ Duration _______ Character of Stool-Ribbon-like
Periodic for 6 mo. No of Stools ________ Blood ________
Mucus __________ Cramps ___________ - Laboratory: Frei _____Serology_____ Ova & Parasites ________
Proctoscopy
- Distance Scoped: 8 cm Interference ________________
- Mucosa: Normal Red _____ Edmatous X Friable __________
- Ulcerated ________Vascular Pattern _______Mucua _______
- Pus ______ Blood X Granular ________ Glistering __________
Description of Other Pathology and Remarks:
- Digital-Hemorrhoids. Mass palpable posteriorly; feels fixed to sacrum; impinges on lumen
- Proctoscopy-Obstruction posteriorly @ 8 cm. Multiple Bx's taken. Could not pass either regular size or stricture scope past lesion
Examined by: Sid Procter, MD
