Dictation Template: Appendectomy Specimen for Acute Appendicitis

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Dictation Template: Appendectomy Specimen for Acute Appendicitis

The specimen is received in formalin, labeled with the patient's name, and designated on the requisition as [appendix]. The specimen consists of pink-tan [dusky-red] appendix measuring [ ] cm in length x [range] cm in external diameter. [The resection margin is closed by 1.5 cm staple line and inked blue.] No perforation is noted. [There is a _x_ cm transmural defect consistent with wall perforation in the mid portion of the appendix, located _ cm from the proximal resection margin.] The serosal surface is hyperemic and focally [diffusely] covered by [grey fibrinous and green cloudy exudate, shaggy fibrous adhesions, and mucinous material] [and is inked black]. [The serosa is remarkable for a 0.3 x 0.2 cm superficial/transmural defect located at the tip with surrounding areas of fibrinous exudate.] The specimen is serially sectioned to reveal a wall thickness ranging from [ ] cm to [ ] cm. The lumen ranges from [ ] to [ ] cm in diameter that contains hemorrhagic material. No fecalith is identified within the lumen. [Sectioning reveals edematous cut surfaces remarkable for purulent material within the lumen. No other abnormalities are identified. The mesoappendix is unremarkable.] The specimen is representatively submitted as follows: cassette A - bisected tip and resection margin, cassette B - midsections.
(Grossed by [Prosector’s Name])

Appendectomy specimen. A. Acute appendicitis with perforation.
B. Sections placed into cassettes.