Sample Dermatopathology Report

Transcription

Sample Dermatopathology Report
Patient: SAMPLE, REPORT
Age: 62 Sex: F
DOB: 11/28/1952
Clinician: SAMPLE DERM REPORT
123 Main Street
Suite #100
Pleasant Hill, CA 94523
CCP#: 651318
Phone: (925) 111-2222
Fax: 925-222-1111
Case #: SP14-4377
Collected: 03/23/2015
Received: 03/23/2015
DERMATOPATHOLOGY REPORT
MICROSCOPIC DIAGNOSIS:
A. Skin, left cheek, biopsy:
- Melanoma in situ
B. Skin, right shoulder, biopsy:
- Basal cell carcinoma, nodular type
MICROSCOPIC DESCRIPTION:
A. Sections demonstrate skin with a poorly circumscribed proliferation of atypical melanocytes at the dermal-epidermal junction
arranged in a confluent lentiginous fashion with irregular nesting. Occasional pagetoid upward scatter is identified. There is no
evidence of a dermal melanocytic component. There is a background of marked solar elastosis. The proliferation extends to the
peripheral biopsy edges.
B. Sections demonstrate nests of basaloid epithelial cells arranged as nodular aggregates in the dermis. There is peripheral
palisading of nuclei with a myxoid stroma. Stromal retraction from the nests is identified. The proliferation extends to the
peripheral and deep biopsy edges.
MICROSCOPIC IMAGES:
A. Left cheek, melanoma in situ
B. Right shoulder, basal cell carcinoma
GROSS DESCRIPTION:
A. The specimen is received in formalin labeled with the patient's name and "left cheek" and consists of a 0.9 x 0.7 x 0.1 cm shave
biopsy of skin with a flat brown surface. Submitted in toto.
B. The specimen is received in formalin labeled with the patient's name and "right shoulder" and consists of a 0.7 x 0.6 x 0.1 cm
1 of 2 on 03-25-2015 at 15:48 for SP14-4377 SAMPLE, REPORT 651318 1119728 CoCoPath - Contra Costa Pathology Associates
Original
GROSS DESCRIPTION: (continued)
shave biopsy of skin. Submitted in toto.
(CEC/cec)
SPECIMEN:
A. Left cheek
B. Right shoulder
CLINICAL INFORMATION:
A. 1.2 cm irregular tan patch
B. 0.8 cm pearly papule
COPIES TO:
SAMPLE DERM REPORT
ELECTRONICALLY SIGNED:
Christine E Cesca MD
Pathologist
(Case signed 03/25/2015 at 15:48)
The specimen(s) is microscopically examined by a board-certified dermatopathologist at Contra Costa Pathology Associates, 399
Taylor Blvd #200, Pleasant Hill, CA, resulting in the histologic diagnosis.
Any included microscopic images are representative and for purposes of illustration only; they are not suitable for diagnostic use.
2 of 2 on 03-25-2015 at 15:48 for SP14-4377 SAMPLE, REPORT 651318 1119728 CoCoPath - Contra Costa Pathology Associates
Original

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