SEER Training Modules
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Home » Cancer Registration & Surveillance Modules » Abstracting a Cancer Case » Abstracting Diagnostic Procedures » Pathological Examinations » Histologic Examination » Autopsy Report » Practical Examples » Example 2 (Page 6)
- 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
Autopsy Example 2 (Page 6)
View the suggested abstraction.
Department Of Pathology - Autopsy Report
Microscopic Description
Gall bladder
Adenocarcinoma extending to liver and hepatic flexure of (R) colon
Kidney
Infiltration with PMN and plasma cells
Hyalinization of arteriae
Fibrosis of glomeruli
Spleen/pancreas
Microscopically unremarkable
Lung
Atelectasis with RBC congestion and edema
Heart
Occasional areas of fibrosis
Final Diagnosis
- Carcinoma of the gallbladder with extension into liver
- Metastatic to hepatic flexure of colon with colonic obstruction
- Obstructive jaundice
- Passive congestion of liver with bile stasis
- Cholelithiasis
- Aspiration pneumonitis with pulmonary edema and acute tracheobronchitis
- Benign nephrosclerosis
- Acute pyelonephritis
