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Home » Cancer Registration & Surveillance » Abstracting a Cancer Case » Abstracting Diagnostic Procedures » Manipulative Procedures » Practical Examples » Example 7
- Abstracting a Cancer Case
- Introduction
- Composition & Organization of a Medical Record
- Abstracting Diagnostic Procedures
- Clinical Examinations
- Manipulative Procedures
- Operative Procedures
- Pathological Examinations
- Additional Information
Manipulative Procedures Example 7
View the suggested abstraction.
Gastroscopic Report
- Hospital No.: 000025
- Ward/Clinic: E606
- Date: 01/08/91
- Name: Eva Eton
- Age: 62
- Race: White
- Sex: Female
Diagnosis R/O:
- Carcinoma of stomach
- Brief G.I. History: Bloat, loss of appetite and epigastric discomfort
- Pertinent Physical Findings: Loss of weight-10 lbs.
Gastric Analysis: Total_____ Free_______ Histamine_________
Stool Examination_____________ Blood Count_____________
Summary G.I. X-rays:
Two-35 mm pictures taken with esophagoscope camera
Gastroscopic Findings:
The fiberoptic gastroscope was passed into the stomach with ease. There is a fungating mass constricting the antrum. There are hemorrhagic and necrotic areas in the mass. The esophagoscope (flexible fiberoptic scope) was also placed in the stomach and a small Bx of the mass was obtained. A small shallow transverse laceration of the esophagus was incidentally noted.
Impression:
Prob. adenocarcinoma of the stomach
C.A. Pendergast, MD
