This document provides guidance for pathology lab examinations and reports. It outlines that an autopsy examines a body to determine cause of death, while a biopsy examines living tissue to establish a diagnosis. When describing findings, one should be concise, grammatically correct, anatomically precise, and avoid interpretation or comparisons. Key points to describe include tissue, number, distribution, shape, color, size, pattern, consistency, and special features. Descriptions should be based on careful observation and avoid using terms like "lesion." Diagnoses may specify severity, duration, distribution, and nature of any inflammation, degeneration, or neoplasia. Special stains can help identify cell types and intracellular/extracellular materials.

1. Pathology Lab. 1 Introduction

2. Autopsy: Examination of a human body to determine the nature of pathological processes that contributed to death or disease. Biopsy: The removal and examination of tissue from the living body to establish a precise diagnosis.

4. Grammatically correct

6. You Must OBSERVE carefully DESCRIBE completely DIAGNOSE (DEDUCE or INTERPRET) confidently

7. Points you need to describe (not all are applicable in every case). TISSUE ....................... identify the organ or structure. Te NUMBER .................... how many lesions are present? N DISTRIBUTION .......... focal, multifocal, locally-extensive, diffuse. Di SHAPE ....................... spherical, rectangular, symmetrical, etc. S COLOUR .................... please - no unusual color terms. C

8. Points you need to describe (not all are applicable in every case). SIZE ............................ metric length, area, weight, % organ involved. S PATTERN ................... centrolobular, reticulated, mottled cobblestone. Pa CONSISTENCY .......... soft, firm, hard, fluctuant. Ce SPECIAL FEATURES.. polypoid, papillated, pedunculated, etc. S

9. Other odor: significant and distinctive odours, eg: sweet, foul, sulphur-like, etc lumen of tubular organs: patent, dilated, narrowed, obstructed, obliterated, branched, etc surface: smooth, rough, nodular, shiny, dull, ulcerated, elevated, depressed, glistening, etc

10. You must know the NORMAL before you can recognize the ABNORMAL! Avoid using the word "lesion" in the description. The lesion is what you are describing, ieany structural or functional abnormality in an organ, tissue or cell.

11. Morphologic Diagnoses: may include the following modifiers/qualifiers. Severity - mild, moderate, marked (severe) Duration - peracute, acute, subacute, chronic, chronic-active Distribution - focal, multifocal, coalescing, locally-extensive, diffuse, bilateral/unilateral, etc

12. Nature of the lesion - if inflammatory, type of exudate (eg purulent, fibrinous, necrotizing, etc) - if degeneration, type of degeneration (eghydropic, fatty, etc). - if neoplasia, type of neoplasia (eg carcinoma, adenocarcinoma, sarcoma, etc)

13. Organ +/- anatomic modifiers - eg, nephritis, interstitial nephritis, glomerulonephritis, pyelonephritis.

15. PRACTICAL INFORMATION ABOUT HISTOLOGIC STAINS 1. Classes of biologic stains: a. General tissue stains these differentially stain the nucleus and the cytoplasm of cells and permit differentiation between the different tissue types, eg’s 2.Hematoxylin and Eosin - nucleus stains blue and the cytoplasm stains red. Polychromatic stains, egWright's and Giemsa - provide good color range to differentiate between the blood leucocytes.

16. Special staining procedures for more refined identification of cell types, intracellular components and extracellular materials (most of the stains described below fall in this category).