Pediatric Final Report Template - Ohio State University : Pathology

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GROSS EXAMINATION:
The body is that of (well-preserved, focally macerated, extensively macerated), (well-developed, poorly
developed), (male, female) (infant, fetus) with the following external measurements:
MEASUREMENT
Weight (gm)
Crown-rump length (cm)
Crown-heel length (cm)
Occipito-frontal circumference (cm)
Chest circumference (cm)
Abdominal circumference (cm)
Foot length (cm)
Hand length (cm)
Inner canthal distance (cm)
Outer canthal distance (cm)
ACTUAL
(at delivery)
EXPECTED AT x WKS*
* Mean  1SD at 25 weeks gestation from Wigglesworth and Singer, Textbook of Fetal and Perinatal
Pathology, 2nd Edition, Blackwell Scientific Publications, Boston, 1998.
The head is normocephalic. There are no dysmorphic features. The eyes are normally formed and set; the
eyelids are (fused; not fused). The nares are bilaterally patent. The ears are normally formed and set.
There is no evidence of cleft lip or palate. There is no micrognathia. There is no evidence of cystic
hygroma or webbing of the neck. Each extremity contains five normal digits without syndactyly or
polydactyly. There is a _____ cm segment of (trivascular, bivascular) umbilical cord attached to the
abdominal wall. There is no evidence of omphalocele or gastroschisis. The external genitalia are that of a
normal (male, female). The anus is patent. There is no evidence of neural tube defect.
The organ weights are as follows:
ORGAN
Thymus
Heart
Lungs
Liver
Spleen
Pancreas
Kidneys
Adrenals
WEIGHT (gm)
EXPECTED AT x WKS GESTATION*
*Mean  1SD at 25 weeks gestation from Wigglesworth and Singer, Textbook of Fetal and Perinatal
Pathology, 2nd Edition, Blackwell Scientific Publications, Boston, 1998.
Peritoneal Cavity: The peritoneal surfaces are _____. The peritoneal cavity contains _____. The
diaphragm arches to the level of the _____ rib/intercostal space on the right and to the _____ rib/intercostal
space on the left. The umbilical vein is _____. There are _____ umbilical arteries. The liver extends
_____cm below the costal margin in the midclavicular line. The spleen is _____. The appendix is in the
right lower quadrant. The stomach is _____. The small intestine is _____. The large intestine is _____.
The mesenteric lymph nodes are _____.
Pleural Cavities: The pleural surfaces are _____. The right and left pleural cavities contain _____ and
_____ cc of _____ fluid, respectively. The lungs occupy _____% of their respective pleural cavities. Each
has a normal number of lobes.
Musculoskeletal System: There are _____ pairs of ribs. Other bony abnormalities are/are not present.
1
Organs of the Neck: The thymus weighs _____ grams. The surface is (coarsely lobulated and tan-pink),
and the cut surfaces are _____. The thyroid and larynx have no gross abnormalities. The larynx is lined by
(pink-tan) mucosa and is empty.
Pericardial Cavity: The pericardial surfaces are _____. The cavity is free from adhesions and contains
_____.
Cardiovascular System: The heart weighs _____ grams. The foramen ovale is _____. The ductus
arteriosus is _____. The epicardium is (smooth and unremarkable). The mural endocardium shows
_____, and the myocardium is (red-brown). The coronary ostia and coronary sinuses are in normal
position. The great vessels arising from the heart and those arising from the aortic arch do so in normal
position. The measurements of the heart are as follows: tricuspid valve, _____cm; pulmonic valve, _____
cm; mitral valve, _____ cm; and aortic valve, _____ cm. The right ventricular thickness is _____ mm and
the left ventricular thickness is _____ mm. The thoracic and abdominal aortae are _____.
Respiratory system: The weights of the right and left lungs were _____ and _____ grams, respectively. On
section, the parenchyma was (pink-tan and spongy) with (no) gross lesions. The trachea and major
bronchi are lined by (smooth-tan) mucosa, and their lumens contain _____.
Hematopoietic System: The spleen weighs _____ gm. The capsule is _____. On section, the parenchyma
is _____ and _____.
Gastrointestinal System: The mucosa of the esophagus is (tan and smooth), and its lumen contains _____.
The mucosa of the stomach is (red-brown) and its lumen contains _____. The mucosa of the small
intestine is _____, and its lumen contains _____. The mucosa of the large intestine is _____, and its lumen
contains _____.
Liver: The liver weighs _____ gm. The capsule is (red-brown with a rough texture). On section, the
parenchyma is (red-brown). The ductus venosus is (present and unremarkable). Bile is/is not freely
expressed from the gallbladder into the duodenum.
Pancreas: The pancreas is (tan and coarsely lobulated/smooth). It weighs _____ gm. On section, the
parenchyma is _____.
Adrenals: The weights of the right and left adrenal glands are _____ and _____ gm, respectively. They are
(unremarkable). The cut surfaces have (unremarkable) peripheral and central zones.
Kidneys: The weights of the right and left kidneys are _____ and _____ gm, respectively. The renal
arteries and veins are free of thrombi. On section, the cortex and medulla are _____demarcated. The renal
pelvises and ureters are lined by _____ urothelium. The ureteral lumens are _____.
Urinary Bladder: The mucosa of the urinary bladder is _____. The relations at the trigone are (normal).
Genitalia: The prostate is small, firm, and reveals no gross abnormalities.
OR
The uterus, tubes, and ovaries reveal no gross abnormalities. The uterus and ovaries are of normal size.
Brain: The soft tissues of the scalp show _____. The sutures are open. The anterior fontanelle measures
_____cm. The posterior fontanelle measures _____ cm. The sutures are _____. The brain weighs _____
gm. The brain is fixed (in toto?). The dural sinuses are free from thrombi. The pituitary _____.
Placenta: The umbilical cord is inserted (eccentrically, centrally) _____cm from the closest placental disc
margin. The umbilical cord is _____ and measures _____ cm in length x _____ cm in diameter.
Sectioning reveals _____ umbilical vessels. The membranes are ruptured _____ cm from the free edge of
the body of the placenta. The membrane attachment is (marginal, circummarginate, circumvallate).
They are (slightly opaque). The fetal surface is smooth, shiny and has a _____ array of surface vessels.
2
Subchorionic fibrin is/is not present. The placental disc is (ovoid, circular, irregular, etc . . .) and is
_____ x _____ x _____ cm in greatest dimension. The placenta weighs _____ gm after removal of the
umbilical cord and fetal membranes. The maternal surface is (tan-red with septation). Cut sections
through the central portion of the placenta show (uniform spongy, red parenchyma with no gross
lesions).
MICROSCOPIC DESCRIPTIONS:
Heart:
Trachea:
Lungs:
Esophagus:
Stomach:
Small intestine:
Colon:
Liver:
Pancreas:
Spleen:
Bone marrow:
Adrenal:
Thyroid:
Kidney:
Placenta:
Umbilical Cord:
Brain:
ANCILLARY STUDIES:
SUMMARY OF CASSETTES:
A
B
C
D
E
F
G
H
I
J
K
L
M
BR1
BR2
rib, vertebral body
thymus, thyroid, trachea
right lung, right heart
left lung, left heart
liver, pancreas, spleen
right kidney; right adrenal gland
left kidney; left adrenal gland
stomach, esophagus, small intestine
appendix, large intestine, small intestine
uterus, ovaries
umbilical cord, fetal membranes
placenta - full thickness
placenta - maternal surfaces
3
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