A number of the laboratory tests may have been done before the history and physical examination. It is usually preferable to defer the venipuncture for blood specimens until the conclusion of the examination. Abnormalities noted at the time of the doctor's examination may prompt additional blood studies beyond the routine. Thus the need for a second venipuncture may be avoided if one waits until the end of the examination.

Record The Findings

Record the findings noted in the history and upon physical examination. Lesions encountered should be described as to size, (in centimeters or inches), location, character, etc. for future reference and comparison. The forms reproduced on pp. 36 to 43 are self-explanatory in this respect. In the final analysis the physician will record the findings in the manner best suited to his needs and facilities. It should be realized that one is laying the groundwork for a series of examinations over a period of years. Much emphasis will be placed, therefore, on change or lack of change as reflected in the records. The need for precision, clarity, and detail becomes obvious, especially when a lesion is being described.

Record The Diagnosis

At the conclusion of the history and physical examination it is well to record the clinical impression as of that time. Subsequent laboratory or other evaluation may alter or erase these impressions, but they are valuable as a record of the physician's first impression.

It will be noted that the forms reproduced on pp. 39 and 43 attempt to provide answers to the following questions:

1. Any malignant lesions?

2. Any premalignant lesions?

3. Any benign neoplasms?

4. Other major medical diagnoses?

5. Was the condition known to the patient?

6. Is this condition a new diagnosis?

7. Was the patient: (a) Asymptomatic?

(b) Symptomatic but not seeking care?

(c) Symptomatic and seeking care? 8. With regard to each diagnosis:

(a) What was the patient told?

(b) Any further studies advised?

This breakdown is particularly useful for recording large clinic experience where a number of different doctors may be involved and the need for uniformity and precision in data collecting and analysis is great.

The principles involved, however, are pertinent ones, and a number of lessons can be borrowed from this approach for modification and inclusion into private office practice.

Talk To The Patient

A very brief talk with the patient is advisable at this point, informing him or her of the following:

1. The findings thus far

2. Their significance (if known at this time)

3. Any need for further studies or consultation

4. The date of the return visit or teleplione call

This talk with the patient should be as brief as is consistent with the need for immediate reassurance and information.

The follow-up report on another day will tie all the loose ends together.

The interval preceding the return visit can be used by doctor and patient to obtain from other doctors or hospitals any necessary additional information about previous hospitalizations, operations, etc. which may be needed for background.

Laboratory Work

As has already been pointed out, from the cancer detection standpoint the following routine studies are felt to be desirable:

1. Hemoglobin and/or hematocrit

2. White blood count and differential smear

3. Urinalysis (including microscopic examination)

4. Chest x-ray

5. Vaginal and cervical smears

6. Tubeless gastric analysis

7. Test for occult blood in the stool (guaiac preferred)

Other studies may be added for more general medical coverage (e.g., fasting blood sugar, serum cholesterol, electrocardiogram, testing of hearing and eyesight, etc.) according to the desires of the physician and patient.

The details of the tubeless gastric analysis and guaiac test will be described since it is assumed that the physician is familiar with the other commonly employed tests.

The handling of vaginal and cervical smears wall be discussed since they may present special problems.