Dictation of a macroscopic description may resemble this example.
Commence with identification and clinical details:
“Joe Bloggs date of birth 1/12/1943 lab number 14-135,
clinical history; adenocarcinoma caecum and peritoneal biopsy ?spread”
“Two specimens received.
Specimen 1 labelled Joe Bloggs, date of birth 1/12/1943, designated extended right hemicolectomy”
Then follow the relevant specimen protocol i.e. colorectal for tumour and dictate the relevant data elements:
Fresh tissue received:
- Right hemicolectomy
Anatomical components included and size:
- Caecum and ascending colon = 200mm, appendix=78mm x 5mm, terminal ileum= 75mm X 38mm, Mesocolic fat= 180mm x 60mm.
Maximum tumour diameter:
- Suspicious area of puckering 25mm x 30mm
Distance of tumour to nearer proximal or distal “cut end” margin:
- 170mm to the distal margin and 125mm to the proximal margin
Distance of tumour to the non-peritonealised circumferential margin: >5mm
- Not seen
- See lymph node blocking below.
Other relevant macroscopic information:
BLOCKS: A, colonic and ileal margin (2); B, apical lymph node and vascular margin (2); C, appendix with appendiceal orifice (1); D and E, full face section of tumour with serosal involvement (1 each); F, three probable lymph nodes (3); G-H, one lymph node bisected in each (2 each); I, three lymph nodes (3); J, mesenteric fat (1); K and L, one lymph node bisected in each (2 each). 3 blocks for tumour banking. 1 of normal tissue. MP. BMS 13.09.13
“Specimen 2 labelled Joe Bloggs, date of birth 1/12/1943, designated peritoneal biopsy”.
[Follow a generic small biopsy protocol here]
Number of tissue pieces
BLOCKS: A, peritoneal biopsy, larger (1). B, peritoneal biopsy, smaller (1). All tissue submitted. MP. BMS 13.09.13
Dictation templates are provided throughout the manual and are useful references at the cut-up bench