UO3FINAL DIAGNOSIS:
FINAL NOTE:
GROSS DESCRIPTION:
The body is that of a __ -year-old (well developed, well nourished, cachectic, thin/obese, male/female).
Livor mortis is distributed over the posterior neck, back, and buttocks. Rigor mortis is present in the
joints of the upper and lower extremities and in the temporomandibular joint. The body (is/is not)
embalmed. The body is identified as that of “___________” by identification tags on the (right great toe
and left/right wrist). The hair is (color) with normal (male/female) distribution. (No bruises or scars are
noted on the skin). There are scars located _____. There is no cyanosis or jaundice. The eyes are (color)
and the pupils are ___ cm in diameter, equal and anicteric. The ears and nose are unremarkable. The oral
cavity shows (native teeth with). There are no masses in the neck. The breasts are those of a normal
(male/female). The spine and thoracic cage appear unremarkable. There is no fluid wave or protrusion of
the abdomen. There is no evidence of deformity, fracture or edema in the extremities. Tubes are
located…(PEG, Foley catheter, etc.)
Thoracic Cavity
The right and left pleural cavities contain ___ and __ cc (no fluid accumulation) of serous fluid,
respectively. There (are/are no) pleural adhesions on the (right and left). The pericardium contains (no
fluid accumulation). There (are/are no) pericardial adhesions.
Abdominal Cavity
The abdominal organs (are/are not) in their usual anatomic positions. There (are/are no) adhesions. The
abdominal cavity contains ___ cc of serous fluid (no fluid accumulation).
Organs of the Thorax and Abdomen
Heart: The heart weighs ___ gm. The visceral pericardium is smooth and glistening. The ventricles are
examined by serial cross-sections from the apex to the mid-papillary muscle level. The ventricular
myocardium is uniformly deep brown. The ventricular thicknesses are as follows: left ventricle, ___ cm;
right ventricle, ___ cm; and interventricular septum, ___ cm. The base of the heart is opened along the
lines of blood flow. The valvular circumferences are as follows: tricuspid, ___ cm; mitral, ___ cm;
pulmonic, ___ cm; and aortic, ___ cm. The endocardial valves are flexible and free of fibroses and
calcifications. The foramen ovale is anatomically sealed.
Coronary arteries: The coronary arteries are examined by serial cross-sections every 0.5 cm along the
epicardial course. There is atherosclerosis with the following percent luminal narrowing: right coronary
artery, ___%; left anterior descending, ___%; and left circumflex, ___%. There (is/is no) focal
calcification.
Lungs: The right and left lungs weigh ___ and ___ gm, respectively. The pleural surfaces of the lungs are
smooth and glistening. On cut-section, the pulmonary parenchyma (has the usual fine spongy pattern).
The large bronchi are [empty/contain a moderate amount of mucus, and …] and are lined by a [light-tan
mucosal surface]. The large pulmonary arteries are empty and lined by pale yellow intimal surfaces.
[lymph nodes]
Liver: The liver weighs ____ gm. The capsular surface is smooth and glistening. Serial cross-sections
reveal [uniform brown parenchyma, mild congestion]. [focal lesions] The large intrahepatic veins are
empty.
Spleen: The spleen weighs ___ gm. Serial cross-sections reveal red-brown parenchyma and
unremarkable. The white pulp is apparent.
Gallbladder: The gallbladder measures ___ x ___ x ___ cm. The mucosal surface is green-tan and
velvety with [no focal erosions/ pinpoint yellow-tan submucosal nodularities]. Within the gallbladder is
approximately ___ cc of bilious fluid. No stones are present [The gallbladder contains multiple (~ __),
firm, green-brown, faceted gallstones (___ x ___ x ___ cm in aggregate; largest ___ cm) .] The wall of
the gallbladder measures __ cm in thickness. The bile ducts are patent from the gallbladder to the
ampulla of Vater.
Pancreas: The pancreas weighs ___ gm. Serial cross-sections reveal uniform, lobulated, tan parenchyma
and are unremarkable.
Esophagus: The light tan mucosal surface is smooth with the usual longitudinal folds. The muscular coat
is unremarkable.
Stomach: The stomach is moderately distended [predominately with air/ and contains approximately ___
cc of ___]. The mucosal surface shows [flattened] folds [with patchy hyperemia of the fundus]. The
muscular coat and serosa appear unremarkable. [The gastric tube is in the proper position].
Small intestine: The small intestine contains a small amount of [greenish fluid]. The tan mucosal surface
has the usual folds. The muscular coat and serosa appear unremarkable.
Large intestine: The colon contains a small amount of [formed fecal] material. The muscular coat and
serosa are unremarkable. [There are multiple diverticuli in the ___].
Appendix: The appendix measures ___ x ___ cm and [appears unremarkable].
Adrenals: The right and left adrenals weigh ____ and ____ gm, respectively. Cross-sections reveal a pale
yellow cortex measuring ___ cm in thickness.
Kidneys: The right and left kidneys weigh ___ and ___ gm, respectively. The capsules strip easily
revealing finely granular cortical surfaces. On cross-section, the cortex and medulla are well-demarcated
over the medullary pyramids. The cortex measures up to __ cm in thickness over the medullary
pyramids. The calyces [are/are not dilated] and are lined by a light tan urothelial surface.
Ureters: The ureters are straight. The lumens are of normal caliber. The urothelial surface is light tan and
appears unremarkable.
Urinary bladder: The bladder shows trabeculations of the mucosal surface. The mucosa and muscular
coat appear unremarkable.
Reproductive System
Prostate: The prostate measures ___ x ___ x ___ cm. Cross sections reveal tan parenchyma and are
unremarkable.
Testes: The right and left testes weigh ____ and ___ gm, respectively. Cross sections reveal
homogeneous tan parenchyma with no focal lesions.
Ovaries: The right ovary measures __ x __ x __ cm, and the left ovary measures __ x __ x __ cm. Cross
sections reveal …
Uterus: The uterine cavity measures __ x __ x __ cm and is unremarkable.
Fallopian tubes: The fallopian tubes are
Retroperitoneal Space
Aorta: The aorta has a smooth intimal surface with [mild atherosclerosis]. The large branches are widely
patent.
Inferior vena cava: The lumen is empty and lined by a light tan endothelial surface.
Abdominal lymph nodes: No enlarged lymph nodes are identified in the abdomen.
Organs of the Neck
Thyroid: The thyroid weighs ___ gm. Cross sections reveal firm, tan parenchyma with no nodules.
Larynx: The vocal cords appear unremarkable. The mucosal surface is light tan and appears
unremarkable. The lumen is empty.
Trachea: The trachea contains a small amount of mucus. The mucosal surface is unremarkable.
Head
The scalp and skull are unremarkable. The dura is unremarkable. The leptomeninges are thin and
transparent. The brain weighs ___ gm.
MICROSCOPIC DESCRIPTION:
Heart:
Coronary Arteries:
Aorta:
Trachea:
Lungs:
Esophagus:
Stomach:
Small intestine:
Colon:
Appendix:
Liver:
Pancreas:
Spleen:
Lymph nodes:
Bone marrow:
Adrenal glands:
Thyroid:
Kidneys:
Urinary bladder:
Prostate:
Testes:
Ovaries:
Uterus:
Breasts:
Pituitary:
Brain:
ANCILLARY STUDIES:
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