SEER Training Modules
Case #5
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Physical Exam
Intermittent bouts of pain in the epigastric and mid-abdominal areas and unexplained weight loss. No epigastric or abdominal masses palpated. No hepatosplenomegaly. Cervical, axillary, and femoral lymph nodes are all normal.
Imaging
10/12/XX
Chest x-ray: negative
Abdominal CT: No abnormalities seen.
Upper GI: No evidence of disease.
Laboratory
10/13/XX
CEA: 8.0 (within normal limits)
Scopes
10/20/XX
Esophagogastroduodenoscopy (EGD): Irregular 6 mm polyp in the 2nd to 3rd portion of duodenum, polypectomy done.
Pathological Reports
10/20/XX
EGD biopsy: adenocarcinoma arising in a polyp
12/01/XX
Partial duodenal resection: very minute focus of residual adenocarcinoma confined to superficial lamina propria. No invasion into underlying muscle layer is seen.
Treatment
10/20/XX
Surgery: Polypectomy
12/01/XX
Surgery: Partial duodenal resection
