Gross Description.doc

UO3-FINAL DIAGNOSIS:FINAL NOTE:GROSS DESCRIPTION:The body is that of a _ -year-old (well developed, well nourished, cachectic, thin/obese, male/female). Livor mortis is distributed over the posterior neck, back, and buttocks. Rigor mortis is present in the joints of the upper and lower extremities and in the temporomandibular joint. The body (is/is not) embalmed. The body is identified as that of “_” by identification tags on the (right great toe and left/right wrist). The hair is (color) with normal (male/female) distribution. (No bruises or scars are noted on the skin). There are scars located _. There is no cyanosis or jaundice. The eyes are (color) and the pupils are _ cm in diameter, equal and anicteric. The ears and nose are unremarkable. The oral cavity shows (native teeth with). There are no masses in the neck. The breasts are those of a normal (male/female). The spine and thoracic cage appear unremarkable. There is no fluid wave or protrusion of the abdomen. There is no evidence of deformity, fracture or edema in the extremities. Tubes are located(PEG, Foley catheter, etc.)Thoracic CavityThe right and left pleural cavities contain _ and _ cc (no fluid accumulation) of serous fluid, respectively. There (are/are no) pleural adhesions on the (right and left). The pericardium contains (no fluid accumulation). There (are/are no) pericardial adhesions.Abdominal CavityThe abdominal organs (are/are not) in their usual anatomic positions. There (are/are no) adhesions. The abdominal cavity contains _ cc of serous fluid (no fluid accumulation).Organs of the Thorax and AbdomenHeart: The heart weighs _ gm. The visceral pericardium is smooth and glistening. The ventricles are examined by serial cross-sections from the apex to the mid-papillary muscle level. The ventricular myocardium is uniformly deep brown. The ventricular thicknesses are as follows: left ventricle, _ cm; right ventricle, _ cm; and interventricular septum, _ cm. The base of the heart is opened along the lines of blood flow. The valvular circumferences are as follows: tricuspid, _ cm; mitral, _ cm; pulmonic, _ cm; and aortic, _ cm. The endocardial valves are flexible and free of fibroses and calcifications. The foramen ovale is anatomically sealed. Coronary arteries: The coronary arteries are examined by serial cross-sections every 0.5 cm along the epicardial course. There is atherosclerosis with the following percent luminal narrowing: right coronary artery, _%; left anterior descending, _%; and left circumflex, _%. There (is/is no) focal calcification.Lungs: The right and left lungs weigh _ and _ gm, respectively. The pleural surfaces of the lungs are smooth and glistening. On cut-section, the pulmonary parenchyma (has the usual fine spongy pattern). The large bronchi are empty/contain a moderate amount of mucus, and and are lined by a light-tan mucosal surface. The large pulmonary arteries are empty and lined by pale yellow intimal surfaces. lymph nodesLiver: The liver weighs _ gm. The capsular surface is smooth and glistening. Serial cross-sections reveal uniform brown parenchyma, mild congestion. focal lesions The large intrahepatic veins are empty.Spleen: The spleen weighs _ gm. Serial cross-sections reveal red-brown parenchyma and unremarkable. The white pulp is apparent.Gallbladder: The gallbladder measures _ x _ x _ cm. The mucosal surface is green-tan and velvety with no focal erosions/ pinpoint yellow-tan submucosal nodularities. Within the gallbladder is approximately _ cc of bilious fluid. No stones are present The gallbladder contains multiple ( _), firm, green-brown, faceted gallstones (_ x _ x _ cm in aggregate; largest _ cm) . The wall of the gallbladder measures _ cm in thickness. The bile ducts are patent from the gallbladder to the ampulla of Vater. Pancreas: The pancreas weighs _ gm. Serial cross-sections reveal uniform, lobulated, tan parenchyma and are unremarkable.Esophagus: The light tan mucosal surface is smooth with the usual longitudinal folds. The muscular coat is unremarkable.Stomach: The stomach is moderately distended predominately with air/ and contains approximately _ cc of _. The mucosal surface shows flattened folds with patchy hyperemia of the fundus. The muscular coat and serosa appear unremarkable. The gastric tube is in the proper position.Small intestine: The small intestine contains a small amount of greenish fluid. The tan mucosal surface has the usual folds. The muscular coat and serosa appear unremarkable.Large intestine: The colon contains a small amount of formed fecal material. The muscular coat and serosa are unremarkable. There are multiple diverticuli in the _.Appendix: The appendix measures _ x _ cm and appears unremarkable.Adrenals: The right and left adrenals weigh _ and _ gm, respectively. Cross-sections reveal a pale yellow cortex measuring _ cm in thickness.Kidneys: The right and left kidneys weigh _ and _ gm, respectively. The capsules strip easily revealing finely granular cortical surfaces. On cross-section, the cortex and medulla are well-demarcated over the medullary pyramids. The cortex measures up to _ cm in thickness over the medullary pyramids. The calyces are/are not dilated and are lined by a light tan urothelial surface. Ureters: The ureters are straight. The lumens are of normal caliber. The urothelial surface is light tan and appears unremarkable.Urinary bladder: The bladder shows trabeculations of the mucosal surface. The mucosa and muscular coat appear unremarkable.Reproductive SystemProstate: The prostate measures _ x _ x _ cm. Cross sections reveal tan parenchyma and are unremarkable.Testes: The right and left testes weigh _ and _ gm, respectively. Cross sections reveal homogeneous tan parenchyma with no focal lesions.Ovaries: The right ovary measures _ x _ x _ cm, and the left ovary measures _ x _ x _ cm. Cross sections reveal Uterus: The uterine cavity measures _ x _ x _ cm and is unremarkable. Fallopian tubes: The fallopian tubes are Retroperitoneal SpaceAorta: The aorta has a smooth intimal surface with mild atherosclerosis. The large branches are widely patent. Inferior vena cava: The lumen is empty and lined by a light tan endothelial surface.Abdominal lymph nodes: No enlarged lymph nodes are identified in the abdomen.Organs of the NeckThyroid: The thyroid weighs _ gm. Cross sections reveal firm, tan parenchyma with no