SEER Training Modules
11/27/12 - The NCI is working on updating materials.
Home » Cancer Registration & Surveillance Modules » Abstracting a Cancer Case » Abstracting Diagnostic Procedures » Manipulative Procedures » Practical Examples » Example 10
- Abstracting a Cancer Case
- Abstracting the Medical Records
- Composition of a Medical Record
- Abstracting Diagnostic Procedures
- Clinical Examinations
- Manipulative Procedures
- Operative Procedures
- Pathological Examinations
- Additional Information
Manipulative Procedures Example 10
View the suggested abstraction.
Bronchoscopy Report
- Hospital No.: 000028
- Name: Essie Phagus
- Service: ENT
- Sex: Female
- Age: 49
- Race: Black
- Date of Operation: 5/5/91
- Clinical Diagnosis: Carcinoma of the lung
- Procedure: Bronchoscopy
- Anesthetic: General
- Larynx: Vocal cords move normally
- Pharynx: WNL
- Trachea: Normal, Carina also normal
Right Bronchus:
(R) main stem bronchus partially occluded by mucus & heaped up friable tissue. RUL bronchus completely occluded with granular tissue. Right bronchus intermedius almost completely occluded with mucus and tissue.
Left Bronchus:
WNL except for slightly reddened mucosa in left main stem bronchus.
Esophagus:
Diagnosis:
Bronchogenic carcinoma: tumor involving RUL and right bronchus intermedius.
Remarks:
Fiberoptic bronchoscopy performed via transnasal approach. RUL bronchus - Bx taken x 3.
Endoscopist S.C.Opes, MD
Assistant I.C. Tou, MD
