The SUM Program for Medical Transcription Training Career Development Series: Interpreting Anatomic Pathology Dictation
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1 The SUM Program for Medical Transcription Training Career Development Series: Interpreting Anatomic Pathology Dictation Table of Contents INTRODUCTION Anatomic Pathology by John H. Dirckx, M.D. Exercises for Anatomic Pathology by Ellen A. Drake, CMT, AHDI-F Answers to Anatomic Pathology Exercises by Ellen A. Drake, CMT, AHDI-F Procedures and Practices in Anatomic Pathology by John H. Dirckx, M.D. Exercises for Procedures and Practices in Anatomic Pathology by Ellen A. Drake, CMT, AHDI-F Answers to Exercises for Procedures and Practices in Anatomic Pathology by Ellen A. Drake, CMT, AHDI-F Autopsy: And the Dead Shall Teach the Living by Sidney K. Moormeister, Ph.D. Careers in Death Investigation Is One Right for You? by Sidney K. Moormeister, Ph.D. What I Learned in the Valley of the Shadow of Death by Sidney K. Moormeister, Ph.D. Guidelines for Transcribing Anatomic Pathology Dictation by Ellen A. Drake, CMT, AHDI-F Sample Pathology Reports Online Resources for Pathology Pathology Glossary Laboratory/Pathology Words and Phrases
2 TRANSCRIPT KEYS Autopsy (13 minutes 46 seconds) 1. Gross Autopsy (6 minutes 51 seconds) 2. Gross Autopsy (6 minutes 55 seconds) Cardiology (1 minute 34 seconds) 1. Gross Description: Plaque, left femoral artery. Occlusion, iliac artery. (1 minute 4 seconds) 2. Microscopic Description: Right iliac plaque: atheromatous plaque. (30 seconds) Dermatology (19 minutes 26 seconds) 1. Gross Description: Mole, back biopsy. Left side of back. (27 seconds) 2. Gross Description: Back lesion. (49 seconds) 3. Gross Description: Seborrheic keratosis of right eyebrow. (34 seconds) 4. Gross Description: Face lesion biopsy. (40 seconds) 5. Gross Description: Left upper helix lesion. Left lower helix lesion. (47 seconds) 6. Gross Description: Intramuscular biceps tumor. (1 minute 24 seconds) 7. Microscopic Description: Lesion from jaw, biopsy. (1 minute 36 seconds) 8. Microscopic Description: Right back cyst, biopsy. (1 minute 3 seconds) 9. Microscopic Description: Lesion from left arm, punch biopsy. (2 minutes 46 seconds) 10. Microscopic Description: Skin lesion from side of right breast, shave biopsy. (58 seconds) 11. Microscopic Description: Skin lesion, left back region, biopsy. (1 minute 24 seconds) 12. Microscopic Description: Skin lesion from left ear canal, biopsy. (2 minutes) 13. Microscopic Description: Skin lesion from left cheek region, biopsy. Skin lesion from forehead region, biopsy. (2 minutes 56 seconds) 14. Microscopic Description: Skin lesion from perineal region, biopsy. (2 minutes 2 seconds) Gastrointestinal (30 minutes 38 seconds) 1. Gross Description: Colon polyps at descending and rectal colon. Colon biopsy, ascending colon. (59 seconds) 2. Microscopic Description: Random colon biopsies. (1 minute 52 seconds) 3. Microscopic Description: Colon polyps, biopsies. (1 minute 24 seconds) 4. Microscopic Description: Sigmoid colon polyp, biopsy. (1 minute 16 seconds) 5. Microscopic Description: Terminal ileum, biopsies. Colon biopsies from cecum to hepatic flexure. Colon biopsies from hepatic flexure to rectum. Rectosigmoid colon biopsies. (4 minutes 6 seconds) 6. Microscopic Description: Ascending and descending colon polyps. (44 seconds) 7. Microscopic Description: Random colon biopsies. Sigmoid colon polyp, biopsy. (1 minute 42 seconds) 8. Microscopic Description: Duodenal polyp, removal. (3 minutes 29 seconds) 9. Microscopic Description: Esophageal biopsies. (1 minute 13 seconds)
3 10. Microscopic Description: Gastric antral biopsies. Esophageal biopsies. (1 minute 59 seconds) 11. Microscopic Description: Esophageal gastric junction biopsies. (2 minutes 18 seconds) 12. Microscopic Description: Gastric antral and body biopsies. (1 minute 36 seconds) 13. Gross Description: Small bowel biopsies. Right colon biopsies. Left colon biopsies. (1 minute 22 seconds) 14. Microscopic Description: Small bowel biopsies adjacent to anastomosis. Random colon biopsies. (3 minutes 15 seconds) 15. Microscopic Description: Small bowel biopsies. Gastric biopsies. Esophageal biopsies. (3 minutes 23 seconds) General Surgery (5 minutes 49 seconds) 1. Gross Description: Appendix. (44 seconds) 2. Microscopic Description: Appendix. Appendicitis and periappendicitis. (1 minute 11 seconds) 3. Gross Description: Right breast biopsy. (52 seconds) 4. Microscopic Description: Right breast calcifications at 6 o clock, biopsies. (1 minute 40 seconds) 5. Microscopic Description: Left breast leson at 12 o clock, needle core biopsies. (2 minutes 30 seconds) 6. Microscopic Description: Gallbladder. Gangrenous and calculous cholecystitis. (55 seconds) 7. Microscopic Description: Gallbladder, removal. Appendix, removal. (1 minute 57 seconds) Genitourinary (2 minutes 28 seconds) 1. Gross Description: Left vas deferens. Right vas deferens. (37 seconds) 2. Gross Description: Right base prostate biopsy. Right mid prostate biopsy. Right apex prostate biopsy. Left base prostate biopsy. Left mid prostate biopsy. Left apex prostate biopsy. (1 minute 51 seconds) Obstetrics/Gynecology (31 minutes 52 seconds) 1. Gross Description: Ectocervical biopsy at 12 o clock. ASCUS on Pap smear. (35 seconds) 2. Gross Description: Endocervical curettings. Cervical biopsy. HGSIL. (49 seconds) 3. Gross Description: Endometrial biopsy. Vabra aspirate. Hypermenorrhea; rule out malignancy. (49 seconds) 4. Microscopic Description: Endometrium, dilatation and curettage biopsy. (1 minute 1 second) 5. Microscopic Description: Endometrial biopsy. (2 minutes 31 seconds) 6. Microscopic Description: Endometrial biopsy. (1 minute 18 seconds) 7. Gross Description: Right fallopian tube segment. Left fallopian tube segment. (55 seconds) 8. Gross Description: Bilateral fimbriae. Elective sterilization. (37 seconds) 9. Gross Description: Twin placenta. (2 minutes 40 seconds) 10. Gross Description: Placenta, disk, cord. (2 minutes 33 seconds) 11. Microscopic Description: Singleton placenta. Deciduitis, necrosis, placental infarcts, and 3-vessel cord. (2 minutes 59 seconds) 12. Microscopic Description: Placenta. Chorioamnionitis and acute funisitis. (55 seconds) 13. Gross Description: Products of conception. Incomplete abortion. (42 seconds)
4 14. Microscopic Description: Retained products of conception, removal. (1 minute 56 seconds) 15. Gross Description: Uterus. Left fallopian tube and ovary. Hemorrhoid. (2 minutes 36 seconds) 16. Gross Description: Uterus with bilateral ovaries and left fallopian tube. (2 minutes 1 second) 17. Microscopic Description: Uterus, removal. (1 minute 12 seconds) 18. Microscopic Description: Uterine contents. (1 minute 9 seconds) 19. Microscopic Description: Uterus with separate bilateral tubes and ovaries, removal. (2 minutes 35 seconds) 20. Microscopic Description: Uterine endocervical curetting. Uterine cervical biopsy at 5 o clock. (1 minute 59 seconds) Oncology (16 minutes) 1. Microscopic Description: Right ear sulcus. Punch biopsy. Basosquamous cell carcinoma, right ear sulcus. (55 seconds) 2. Gross Description with Frozen Section: Left upper lobe of lung. Large-cell carcinoma. (33 seconds) 3. Gross Description: Left pelvic nodes. Right pelvic nodes. Prostate. (3 minutes 35 seconds) 4. Microscopic Description: Bone marrow. Myeloproliferative disorder with myelofibrosis. (2 minutes 22 seconds) 5. Microscopic Description: Reexcision of skin graft from left ear. Skin lesion from left ear, reexcision posterior deep margin. (3 minutes 31 seconds) 6. Microscopic Description: Duodenal biopsies. Gastric mass biopsies. (2 minutes 33 seconds) 7. Microscopic Description: Pelvic mass, needle core biopsies. (1 minute 50 seconds) 8. Microscopic Description: Prostate gland resection. Adenocarcinoma. (42 seconds) Orthopedics/Neurology (6 minutes 31 seconds) 1. Microscopic Description: Cartilage, intervertebral disk tissue. (36 seconds) 2. Microscopic Description: Coccygectomy tip. (2 minutes 57 seconds) 3. Microscopic Description: Debridement tissue, left tibia. (1 minute 17 seconds) 4. Microscopic Description: Soft tissue from nuchal/occipital skull region, biopsies. (1 minute 41 seconds) Otorhinolaryngology (Ears, Nose, Throat) (12 minutes) 1. Gross Description: Left buccal mucosa. (28 seconds) 2. Gross Description: Tonsils and adenoids. (32 seconds) 3. Microscopic Description: Right mastoid content, biopsy. (1 minute 26 seconds) 4. Microscopic Description: Left submandibular gland, removal. Left sublingual gland, biopsy. Left sublingual gland, floor of mouth, biopsies. (3 minutes 22 seconds) 5. Microscopic Description: Right and left sinus contents, removal. (2 minutes 15 seconds) 6. Microscopic Description: Thyroid gland tissue, parathyroid gland. (40 seconds) 7. Microscopic Description: Right inferior parathyroid gland, biopsy. Left cervical lymph node, biopsy. (3 minutes 49 seconds)
5 Total number of reports, 81 Total length of dictations, 2-1/2 hours TESTS 1. Dermatology: Microscopic Description: Nasal skin lesion (3 minutes 4 seconds) 2. Gastrointestinal: Gross Description: Colon polyps at cecal, hepatic flexure, ascending and proximal transverse colon. Colon polyps at rectal and sigmoid colon. (59 seconds) 3. Gastrointestinal: Microscopic Description: Mid transverse and proximal transverse colon polyps, biopsies. Cecal colon polyps x2, biopsies. (1 minute 50 seconds) 4. Gastrointestinal: Gross Description: Small bowel biopsies to colon anastomosis. Random colon biopsies. (1 minute 5 seconds) 5. General Surgery: Microscopic Description: Right breast density, biopsies. (1 minute 54 seconds) 6. Gross Description: Gallbladder. Cholelithiasis. (59 seconds) 7. Gross Description: Gallbladder. Cholecystitis, gallstone pancreatitis. (1 minute 9 seconds) 8. Obstetrics/Gynecology: Gross Description: Cervical biopsy at 6 o clock. Cervical biopsy at 12 o clock. Endocervical curettings. (1 minute 7 seconds) 9. Obstetrics/Gynecology: Microscopic Description: Left groin lesion, biopsy. Endometrial curettings including polyp and scar tissue. (2 minutes 41 seconds) 10. Obstetrics/Gynecology: Microscopic Description: Singleton placenta. (3 minutes 17 seconds) 11. Obstetrics/Gynecology: Microscopic Description: Uterine endocervical biopsy. Uterine cervical biopsy at 6 o clock. (1 minute 53 seconds) 12. Genitourinary: Microscopic Description: Urinary bladder tumor, curettings. (3 minutes 8 seconds) 13. Otorhinolaryngology (ENT): Microscopic Description: Cyst behind left ear, biopsy. (1 minute 8 seconds) 14. Otorhinolaryngology (ENT): Microscopic Description: Possible right parathyroid, biopsy. Right paratracheal tissue, biopsy. Right inferior parathyroid, biopsy. (3 minutes 16 seconds) Total number of test reports, 14 Total length of test reports, 23-1/2 minutes
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