Location:	SEND			Medical Record #:		Specimen #:
Name:						Collected:	01/06/06
Date of Birth:						Received:	01/06/06
Age/Gender:						Final:	01/09/06
Submitting Physician:			FAUST,R LOGAN,  MD
Additional Physician:			COOPER,LAWRENCE R  MD

 

 Preoperative Diagnosis

ULCERATIVE COLITIS

 Postoperative Diagnosis:

WITHIN NORMAL LIMITS EXCEPT POLYP AT 75 CM

 Clinical History:

ULCERATIVE COLITIS

 

 

 Specimen Received

	1. Ascending colon - BIOPSY
	2. Colon, NOS - POLYP AT 75 CM
	3. Rectum, NOS - BIOPSY

 

 

Gross Examination

Submitted in formalin in a container labelled with the patientŐs name and "ascending" are three fragments of soft pink/tan tissue measuring 1.0 mm, 1.0 mm, 1.0 mm and 2.0 mm in size.  These are wrapped and totally submitted in cassette "1".

 

 

Submitted in formalin in a container labelled with the patientŐs name and "bx polyp 75 cm" is a single fragment of soft tan tissue measuring 2.0 x 2.0 x 1.5 mm.  This is wrapped and totally submitted in cassette "2".

 

Submitted in formalin in a container labelled with the patientŐs name and "bx rectum" is a single fragment of soft pink/tan tissue measuring 2.0 x 2.0 x 1.5 mm.  This is wrapped and totally submitted in cassette "3"

.

 

Dictated by: JOHN A WOLFE, MD                   Entered: 01/06/06 - 1633 06RNORTON

 

FINAL DIAGNOSIS

 

I.          ASCENDING COLON, BIOPSY:

                        :           ESSENTIALLY UNREMARKABLE COLONIC MUCOSA.

 

II.         COLON, POLYP AT 75 CM:

                        :           TUBULAR ADENOMA.

 

III.        RECTUM, BIOPSY:

                        :           ESSENTIALLY UNREMARKABLE COLONIC MUCOSA.

 

Comment

Examination of the ascending colon and rectal biopsies shows intact colonic mucosa.  Benign crypts are seen with intervening lamina propria showing occasional lymphocytes and plasma cells.  There is no evidence of inflammation or atypia.  The polyp noted at 75 cm shows colonic mucosa with focal adenomatous change.  There is no evidence of in situ or infiltrating malignancy.

 

Entered: 01/09/06 - 0726 06KSATTER

 

 

 

Signed: RICHARD R WILBER, MD 01/09/06                             Original report read and signed