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Cytopathology Report Example 3

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Patient No.: 000050

Date: 02/05/91
Name: Kay Kline
Race: Black

  • [x] Inpatient
  • [ ] Clinic

Specimen No.: 01000
Diagnosis: Post menopausal bleeding

Physician

Source of Specimen

  • [x] Fem. Gen Tract
  • [ ] Esophagus

Type ________________

  • [ ] Bronchoscopy
  • [ ] Oral
  • [ ] Sputum
  • [ ] Stomach
  • [ ] Urine
  • [ ] Breast

Type ________________

  • [ ] Spinal Fluid
  • [ ] Pleural
  • [ ] Peritoneal
  • [ ] Other_____________

Examination Desired

  • [x] Screening for Neoplasm
  • [ ] Endocrine Status
  • [ ] Other (Specify)

Unsatisfactory Reason

Clinical Status (Pertinent History, Physical Findings, Prev. Treatment Surgery, etc.) Post menopausal bleeding, 62 year-old

  • [ ] Irradiation
  • [ ] Hormones

Do Not Write Below This Line


Neoplastic Status

  • [ ] Normoplasia
  • [ ] Dysplasia
  • [ ] Mild

  • [ ] Moderate
  • [ ] Severe
  • [x] Neoplasia

Pap class V, Epid. Ca with atypical glandular elements

Inflammatory Status

  • [ ] Mild
  • [ ] Moderate
  • [ ] Severe

Hormonal Status

  • [ ] Normal for Age & Physiologic State
  • [ ] Abnormal

Recommendation:

  • [ ] Routine Follow-up
  • [ ] Repeat 1-3 Mo.
  • [ ] Tissue Study Rec.

Fees:

  • [ ] Reg
  • [ ] Add
  • [ ] None

Name: Kay Kline

Cytopathology Laboratory: 8900
Date: 02/05/91
P. White