BIOPSIES-GENERAL INSTRUCTIONS FOR PROCESSING
ACCESSIONING CASES
Cases our accessioned in our system with a letter S if the biopsy originated from UCLA or JSEI and R if it is outside this facility. Some cases will come from Outreach with R numbers already assigned. The resident must assign the R or S number according to the location. Each specimen is entered in the computer and in the log book by the resident.
BIOPSIES
The work-up of surgical biopsies is only begun when adequate clinical information is available; the work-up contains 3 parts: a narrative gross description, a narrative microscopic description, and a diagnosis. Be sure to obtain adequate clinical information and type everything listed clinically on the requisition form. Abbreviations should be typed out as complete words. Mistyped or mis-spelled words should be corrected and then followed by [sic] to indicate the mistake was corrected.
Microscopic Examination.
Microscopic exam is performed on most surgical specimens (except gross only cases) and some autopsy eyes. The residents will learn to evaluate microscopic sections of most ocular disorders during this rotation.
Microscopic descriptions should be written in a concise and systematic manner to include, sequentially, the architecture of the lesion and the cytologic features. Do not begin your description until you have thoroughly read up on your case. 95% of the diagnoses can be found in the books referenced in this manual. Get these references from the Biomedical Library or the bookstore.
In general, you may begin by "Sections of the specimen labeled ‘x’ show” or Step sections through the block of the specimen labeled ‘x’show or Step sections of the specimen labeled ‘x’ show. Taylor your report to the way the specimen was sectioned. The term "sections show" refer to a simple case where a ribbon was taken of the biopsy at the same level. "Step sections" refer to a case where levels were taken to more thoroughly sample the tissue, e.g. deeper every 50th section x 5). "Step sections through the block" is used when sections were taken at various levels all the way through the paraffin block exhausting all remaining tissue. This is often used when a neoplasm was strongly suspected and needs to be excluded. Include a description of all special stains that were performed in your report. If a case consists of more than one specimen, each specimen may be described separately. While specimens with the same microscopic findings may be described collectively, diagnoses are listed separately at the very end for each specimen (see example). Usually the main feature is detailed first (such as focus of cancer, ulceration, or the like), and then the secondary features are described. Occasionally, one may finish the description with pertinent negative statements (e.g. "granulomatous inflammation is lacking") or special features (e.g. "tumor is present in the lateral surgical margin"). Each specimen requires its own line and separate heading for diagnosis. There are no exceptions. If a case has 23 specimens that all show the same thing, it may require a single microscopic description but there must be 23 diagnoses listed separately with the respective anatomic sites. Be sure to comment on margins of all tumors.
Do not expect to be able to write perfect microscopic descriptions in the beginning of your rotation. Please always check your work to eliminate errors of omission, grammar, and orthography. You may use the descriptions in the work file or glossary as a guide for your gross and microscopic descriptions. You should expect that most of your work-ups will be significantly modified. The microscopic work up will reveal areas of ignorance, and is an excellent way for the pathology faculty to plot your progress through the rotation. Expect that you will be asked to rewrite the descriptions if they contain errors.
Format for Final Diagnosis.
In general the procedure for final diagnosis is the same as that for the specimens requiring the gross. The tissue type is that which you see under the microscope. So if there is keratinized stratified squamous epithelium with hair shafts and adnexal structures the tissue is skin.
Next in quotation one puts either exactly the wording on the specimen label or that which conveys accurately the type of specimen submitted and laterality from the requisition. Next the procedure rendering the speciem is put in parentheses. Finally the diagnoses are given.
FINAL DIAGNOSIS: Tissue type, "specimen label" (surgical procedure)-1st diagnosis
-2nd diagnosis
or e.g.:
FINAL DIAGNOSIS: Skin, "left lower eyelid" (biopsy)- seborrheic keratosis
Cases our accessioned in our system with a letter S if the biopsy originated from UCLA or JSEI and R if it is outside this facility. Some cases will come from Outreach with R numbers already assigned. The resident must assign the R or S number according to the location. Each specimen is entered in the computer and in the log book by the resident.
BIOPSIES
The work-up of surgical biopsies is only begun when adequate clinical information is available; the work-up contains 3 parts: a narrative gross description, a narrative microscopic description, and a diagnosis. Be sure to obtain adequate clinical information and type everything listed clinically on the requisition form. Abbreviations should be typed out as complete words. Mistyped or mis-spelled words should be corrected and then followed by [sic] to indicate the mistake was corrected.
Microscopic Examination.
Microscopic exam is performed on most surgical specimens (except gross only cases) and some autopsy eyes. The residents will learn to evaluate microscopic sections of most ocular disorders during this rotation.
Microscopic descriptions should be written in a concise and systematic manner to include, sequentially, the architecture of the lesion and the cytologic features. Do not begin your description until you have thoroughly read up on your case. 95% of the diagnoses can be found in the books referenced in this manual. Get these references from the Biomedical Library or the bookstore.
In general, you may begin by "Sections of the specimen labeled ‘x’ show” or Step sections through the block of the specimen labeled ‘x’show or Step sections of the specimen labeled ‘x’ show. Taylor your report to the way the specimen was sectioned. The term "sections show" refer to a simple case where a ribbon was taken of the biopsy at the same level. "Step sections" refer to a case where levels were taken to more thoroughly sample the tissue, e.g. deeper every 50th section x 5). "Step sections through the block" is used when sections were taken at various levels all the way through the paraffin block exhausting all remaining tissue. This is often used when a neoplasm was strongly suspected and needs to be excluded. Include a description of all special stains that were performed in your report. If a case consists of more than one specimen, each specimen may be described separately. While specimens with the same microscopic findings may be described collectively, diagnoses are listed separately at the very end for each specimen (see example). Usually the main feature is detailed first (such as focus of cancer, ulceration, or the like), and then the secondary features are described. Occasionally, one may finish the description with pertinent negative statements (e.g. "granulomatous inflammation is lacking") or special features (e.g. "tumor is present in the lateral surgical margin"). Each specimen requires its own line and separate heading for diagnosis. There are no exceptions. If a case has 23 specimens that all show the same thing, it may require a single microscopic description but there must be 23 diagnoses listed separately with the respective anatomic sites. Be sure to comment on margins of all tumors.
Do not expect to be able to write perfect microscopic descriptions in the beginning of your rotation. Please always check your work to eliminate errors of omission, grammar, and orthography. You may use the descriptions in the work file or glossary as a guide for your gross and microscopic descriptions. You should expect that most of your work-ups will be significantly modified. The microscopic work up will reveal areas of ignorance, and is an excellent way for the pathology faculty to plot your progress through the rotation. Expect that you will be asked to rewrite the descriptions if they contain errors.
Format for Final Diagnosis.
In general the procedure for final diagnosis is the same as that for the specimens requiring the gross. The tissue type is that which you see under the microscope. So if there is keratinized stratified squamous epithelium with hair shafts and adnexal structures the tissue is skin.
Next in quotation one puts either exactly the wording on the specimen label or that which conveys accurately the type of specimen submitted and laterality from the requisition. Next the procedure rendering the speciem is put in parentheses. Finally the diagnoses are given.
FINAL DIAGNOSIS: Tissue type, "specimen label" (surgical procedure)-1st diagnosis
-2nd diagnosis
or e.g.:
FINAL DIAGNOSIS: Skin, "left lower eyelid" (biopsy)- seborrheic keratosis
<NEXT>
0 Comments:
Post a Comment
Links to this post:
Create a Link
<< Home