Example dictation

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:
- No.

Specimen procedure:
- Right hemicolectomy

Specimen length
- 275mm

Anatomical components included and size:
- Caecum and ascending colon = 200mm, appendix=78mm x 5mm, terminal ileum= 75mm X 38mm, Mesocolic fat= 180mm x 60mm.

Tumour perforation:
- No

Maximum tumour diameter:
- 30mm

Tumour site:
- Caecum

Peritoneum:
- 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

Polyps:
- Not seen

Lymph nodes:
- See lymph node blocking below.

Other relevant macroscopic information:
- None.

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
-Two

Specimen dimensions:
A. 5x5x5mm
B. 2x2x2mm

Colour
-White

BLOCKS: A, peritoneal biopsy, larger (1). B, peritoneal biopsy, smaller (1). All tissue submitted. MP. BMS 13.09.13

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