Medical Pathology Report Form

Basic Report Information

Patient Name

Specimen Number

Age

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Received Date

Date Reported

Nature of Specimen

Report Status

Clinical Data

Gross Description

Microscopic Description

Diagnosis

<ul><li class="ql-align-justify">Endometrium is non-secretory and hyperplastic, it is formed of branching complex glands exhibiting focal crowdness and lined by 1-3 layers of cells. Stroma is cellular. No evidence of atypia or malignancy.</li></ul> <ul><li class="ql-align-justify">Polypoid lesion composed of hyperplastic endocervical mucous glands and covered by extensively ulcerated columnar endocervical epithelium. Stroma is fibrotic and vascular and shows moderate infiltration by inflammatory cells. No evidence of endometrial tissue. No evidence of atypia or malignancy.</li></ul> <ul><li class="ql-align-justify">Smear shows unremarkable squamous cells, satisfactory for evaluation with present endocervical / transformation zone components. There is associated mild inflammatory changes without identified clue cells. No evidence of fungal, viral or trichomonal infection. No evidence of atypical or malignant cells.</li></ul>

D & C Biopsy: <ul><li class="ql-align-justify">Mild adenomatous (complex) endometrial hyperplasia. </li><li class="ql-align-justify">Negative for atypia. </li></ul> Cervical polyp, excision:<ul><li>Inflamed hyperplastic endocervical polyp. </li><li>Negative for malignancy. </li></ul> Pap smear, conventional cytology:<ul><li class="ql-align-justify">Satisfactory for evaluation.</li><li class="ql-align-justify">Negative for intraepithelial lesion or malignancy (NILM).</li><li class="ql-align-justify">Organisms: None.</li><li class="ql-align-justify">Mild neutrophilic infiltrate. </li><li>Clue cells are not identified. </li></ul>

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