- 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 8
View the suggested abstraction.
Gastroscopic Report
- Hospital No.: 000026
- Ward/Clinic: Surgery
- Date: 02/26/91
- Name: Selden McGlutton
- Age: 56
- Race: Black
- Sex: Female
2/8/91
Diagnosis:
Obstruction due to old ulcer disease or malignancy
Brief G.I. History:
Loss of appetite, bloating and occasional bouts of vomiting of retained food
Pertinent Physical Findings:
Epigastric mass
Gastric Analysis:
Total _____ Free ________ Histamine _________
Stool Examination _______________ Blood Count ______________
Summary G.I. X-rays:
Gastroscopic Findings:
Gastroscope was passed into the stomach without difficulty. The antrum was identified and observed constriction by an extrinsic mass lesion.
No intrinsic mucosal lesions were seen but the entire antrum could not be seen because of the degree of constriction.
There was no peristalsis seen to move into the area of constriction. Because of a large amount of retained secretions, adequate visualization of the remainder of the stomach was not attempted.
Impression:
Malignant disease involving the antrum - constricting the antrum.
Adrian Maison, M.D.



