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 4
- 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 4
View the suggested abstraction.
Gastrointestinal Diagnostic Report
- Hospital No.: 000022
- Name: George E. McJoin
- Service:
- Age: 74
- Race: White
- Sex: Male
- Date: 3/4/91
- Medication: None
- Clinical: Elderly male with epigastric distress, wt. loss 50 lb.
- X-Ray: Filling defect fundus - stomach
Esophagogastroscopy Report:
Esophagoscope was passed with ease to the GE junction. At that point the lumen narrowed and prevented entrance of the scope into the stomach. The mucosa in the distal esophagus is erythematous, and white patches measuring 2-3 mm were noted.
Biopsy:
Two mucosal biopsies taken
Impression:
- Obstruction of distal esophagus
- Etiology undetermined
- Prob. carcinoma of fundus of stomach
- R/O benign tumor
Recommendation:
Louis Tewells, MD
