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CDP: Pathology Reports

Terms in this set (50)

What is the purpose of a pathology report?
convey clinically useful diagnostic info relevant to the findings on the slide that can be used for treatment & management of pt
What are the elements of a good pathology report?
-includes critical values & how info was communicated
-easy for the reader to find info
-minimum standards for required
-info med for each report
-disclaimers when required
-documentation for billing
-documentation of consultations
-appropriate formatting of amendments/addenda for clarity
What are the basics of a pathology report?
-clear
-concise
-clinically relevant
-use nomenclature that is understood by the treating physician(s) - intra-institutionally
-use nomenclature that has inter-institutional clarity
_________ template format is recommended
standardized
What is a standardized template format recommended?
-precludes intra-departmental variability in nomenclature
-enhances intra-observer & inter-observer consistency in interpretation
-ensures that treating physicians understand the interpretation that is rendered by all staff b/c the nomenclature in the report is defined & used consistently
-free text is always followed for cases that do not fit the template format
_______ is always allowed for cases that do not fit the template format
free text
What patient identifying info should be included in the report?
-name, age, patient's sex
-medical record number
What identifying info should be included in the report?
-pt identifying info (name, age, sex; medical record number)
-date procedure was performed
-unique number for the specimen (assigned by the lab)
What clinical hx should be included in the report?
-nodule location & size
-functional status of the nodule (hypo vs. hyper-functioning by scan)
Clinical hx is provided by _________ removing the specimen
provider
What information should be included about the specimen in the report?
-specimen number
-specimen type (guided bx vs. non-guided)
-number of passes (optional)
-number of slides & the prep methods (not optional)
What information about the procedure and billing should be included in the report?
-name of physician performing procedure
-rapid interpretations
-ICD-10 code
-Procedure note (note in diagnostic report; separate pt evaluation & management report)
Which codes are used for procedure notes?
CPT
CPT codes
billing codes for medical, surgical and diagnostic services
ICD-10 codes
Diagnosis codes
What would make a specimen's adequacy unsatisfactory?
-improperly labeled/identified specimen
-too few cells & colloid for interpretation
-preparation artifact precludes ability to interpret the specimen
-scant colloid only
What often results in indeterminate/suspicious dx?
scant cellularity but enough for some descriptive interpretation
_________ limits but does not prevent evaluation of specimen
preparation artifact
What makes a specimen satisfactory?
cells are present & interpretable with or without colloid
Recommendation/Comments are optional but are strongly encouraged in reports where a _________________
definitive dx is not rendered
How can a specimen be examined in pathology?
-routine histology (formalin (preserves a wide range of tissues))
-Electron microscopy (buffered glutaraldehyde)
-immunofluorescence testing (snap frozen or special transport)
How is a specimen prepared for processing?
-usually divided in half or smaller sections
-suspicious tissue distinctly separated
_________ is routine fixative of choice
formaldehyde
_________ is a respiratory sensitizer.
Formalin
Need _______ mm thick sections for microscopic exam - requires tissue support for internal cellular structure
1-6
What are the reagents used in pathology examination of a specimen?
-dehydration (alcohol)
-clearing (xylene)
-infiltration (paraffin wax)
-embedding (wax cassette)
Frozen Sectioning
-fresh tissue snap frozen & microtome sectioned
-tissue fixation & staining not utilized
-consistently thin samples difficult
-results available 10-20 min
Un-Decalcified Bone Sectioning
specimen embedded in acrylic or polyester resin
Electron Microscopy
-Ultra-thin sections
-specimen embedded in hard epoxy resins
-determines subcellular features
-helpful for difficult diagnoses (poorly differentiated neoplasms; tumor classification; research)
Which procedure is helpful for difficult diagnoses (such as poorly differentiated neoplasms)?
electron microscopy
Immunofluorescence
-Demonstrates antigen by its binding to an antibody linked to a molecule that can be visualized microscopically
-distinguishes lymphomas, melanomas, CMV, toxoplasma, hormone receptors, oncogene products, etc.
KOH scrapings
-scaly lesions
-use KOH prep to screen for fungi (hyphae)
-implicates fungal infection better than culture
KOH prep is used to screen for __________
fungi (hyphae)
KOH scrapings indicate __________ better than culture
fungal infection
Tzanck Preparation
-confirms herpes lesions (simplex & zoster)
-scraping of contents & base of freshly opened vesicle
-multinucleated giant cells confirms dx
Which prep method is used to confirm herpes lesions (simplex & zoster)?
Tzanck preparation
Scabies Scraping
-#15 blade moistened with oil
-scrape burrow or papule vigorously
-black speck may be adult mite
Darkfield Examination
-immediate dx of syphilis
-curettage scraping of ulcer
-requires darkfield microscopy
-not common in doctor's offices
_________ is used to give an immediate dx of syphilis
darkfield examination
Where is the greatest risk for cervical CA?
cervical transformation zone
Presence of _________ cells confirms cervical transformation zone sample
endocervical
What is the MC type of cervical CA?
squamous cell cancer
CIN
cervical intraepithelial neoplasia
CIN ____ is the most mild; CIN ____ is the worst
1, 3
What does osteosarcoma present as?
generalized bone pain
Who is affected by osteosarcoma most often?
young patients (10-20 yo)
Which bones are most commonly affected by osteosarcoma?
-metadiaphysis of long bones (femur: ~40% (especially distal femur); tibia: ~16% (especially proximal tibia); humerus: ~15%)
Which disorder presents with onion skin periostitis?
Ewing's sarcoma
Ewing's sarcoma typically occurs in children & teens between ______ & ______ years of age.
10, 20
Which bones are most commonly affected by Ewing's Sarcoma?
Femur
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