Pathology Gross Dictation Templates
. Determine the reason for the amputation (e.g. Gangrene, trauma, infection), the level of amputation (e.g. Transmetatarsal/ transmetacarpal, below knee/elbow, above knee/elbow), and the parts of the extremity present (e.g. Digits with/without nails, foot/hand, distal leg/arm, knee/elbow, proximal leg/arm). Measure the lengths of each part. Measure the greatest circumferences of the lower leg/arm and upper leg/arm.
Examine the resection margins of skin, soft tissue and bone for necrosis or other abnormalities. Check the vascular resection margins for occlusion. If a traumatic amputation, note whether the amputation site is smooth and even or jagged and irregular.
Open the knee joint and determine whether it is artificial (prosthetic). Describe the joint fluid.
Identify lesions (e.g. Scar of prior surgery, ulcer, hard and black toe, laceration, necrosis) and the extent (e.g. Involving underlying bone). Measure discrete lesions and dictate where each is located. Note the presence of foreign material (e.g. Glass shards, motor oil, dirt) in traumatic amputations. For non-traumatic legs: Dissect the neurovascular bundles of femoral, popliteal, tibial, and peroneal vessels, so as to expose them along their entire course.
Inspect vessels for atheromatous plaque, calcification, and thrombus, and estimate the degree of luminal stenosis as a percentage. Identify and examine the dorsalis pedis vessels by cross-sectioning the dorsal surface of the foot. If vascular graft or stent is identified, dissect en block and photograph. Gangrene and infection:.
Representative skin and soft tissues from areas of ulceration, necrosis, infection, and other abnormalities. Cross sections of major arteries and veins from segments with greatest stenosis: 1 block for each. You may submit heavily calcified arteries for light decalcification. Skin, soft tissue, and vascular margins of amputation: 1 section of anterior and 1 section of posterior. Bone and joint if clinical suspicion of osteomyelitis (you may need to check x-rays or radiology reports to determine exact location) or if grossly involved by necrosis/infection.
Traumatic amputation:. Skin and soft tissues from areas of laceration and hemorrhage. Skin and soft tissue margins of amputation. Any other abnormalities. Received wrapped in a biohazard bag without fixative/in formalin, labeled and “” is a (e.g. Below knee) amputation of the (left or right) (e.g. It measures cm from distal toe tip to heelcm from heel to knee joint, and cm from knee joint to soft tissue margin.
cm of (e.g. Femoral) bone extends beyond the soft tissue margin. The skin, soft tissue, and bone at the margin appear viable. The (e.g. Femoral) artery at the margin is approximately % stenosed by yellow plaque. The knee joint is native/artificial and contains clear fluid.
There are (number) toes/fingers, all with intact (e.g. Thickened, yellow) nails/except for the (e.g. Third toe), which is missing its nail. The (e.g.
Pathology Gross Specimens
Fifth) toe is black, hard, and dry. There is a x cm ulcer in the skin of the (location) which does not/does extend to bone which is soft and easy to cut. The skin over the (location) is (e.g.
Hairless) and has (e.g. Numerous pinpoint areas of hypopigmentation, a cm healed linear scar). The subcutaneous tissue/muscle of the (location) is (e.g. Edematous, diffusely necrotic).
The artery is - % stenosed by calcified yellow plaque throughout its length but most significantly at its (e.g. Upper third).
Appendix Grossing
Repeat for all arteries. No venous thrombi are identified.