J.D. Goldstein MD and M.C. Fishbein MD (Revised 09 2015, May 2017)
UCLA DEPARTMENT OF PATHOLOGY AND LABORATORY MEDICINE
[PLEASE USE ADDITIONAL SHEETS AS NEEDED TO FULLY DESCRIBE ABNORMAL FINDINGS] The body is that of a small for gestational age/macrosomic/normally developed/dysmorphicmale/female infant weighing g.
The crown-rump length is cm and the crown-heel, cm. The occipito-frontal circumference is cm.
Maceration is absent/mild/moderate/severe with .
Rigor is absent/mild/moderate/severe.
Lividity is absent/mild/moderate/severe (state site)
Edema is absent/focal/global (fetal hydrops).
The skin is .
(Describe any localized skin lesions, generalized discoloration, etc.)
The head is normo/micro/macro cephalic with/without molding or caput succedaneum.
The anterior fontanelle is x cm, the posterior fontanelle is x cm, and the cranial sutures are overriding/mobile/normal.
The eyes are normally spaced/show hypertelorism; the inner canthal distance is cm and the outer canthal distance cm.
The palpebral fissures are normal/upslanted/ downslanted, and the eyelids are fused/separate.
The pupils are equal or unequal and measure and on the left and right sides, respectively. [measure only if unequal]
The sclerae are white/discolored; the corneas are clear/cloudy; and the irides are dark/light/The ears are not low set or posteriorly rotated. The pinna are soft/folded/firm
The nose is normally formed. There is no choanal atresia
The mouth is edentulous.
The lip and palate are intact.
The philtrum measures 0. cm.
The thorax appears symmetric/distorted/narrow/broad. The chest circumference is cm. The internipple distance is cm.
The abdomen is flat/scaphoid/protuberant/markedly distended. The abdominal circumference is cm. There is no/an omphalocele or abdominal wall defect. [Measure if present]
The segment of umbilical cord, measures x cm, and vessels are identified.
The back appears normal. No exposed neural tube defect or abnormal spinal curvature are present.
The anus is patent/imperforate.
The external genitalia are normally formed for a male/female. The testes are undescended. OR Both/right/left testes/ testis are/is in the scrotum.
Inguinal Hernia is absent/present.
Extremities are unremarkable without contractures, syndactyly, polydactyly or clinodactyly. No palmar crease or sandal toe deformity are present. The foot length is cm. .
There are no other findings on external examination or .
A fetal radiograph was obtained which shows .
The usual Y-shaped thoracoabdominal incision and U-shaped biparietal scalp incisions are made.
PERITONEAL CAVITY: The peritoneal surfaces are smooth and dusky/glistening.
The peritoneal cavity contains ml of clear/cloudy/yellow/serosanguineous fluid/or blood.
The liver is normally configured and is anatomically normally situated.
The spleen is normally configured and is anatomically normally situated.
The stomach is externally unremarkable/distended
The bowel is normally rotated without redundant mesentery such that the small intestine and large intestine are normally situated and the appendix is the in the right lower quadrant/pelvis.
The mesenteric lymph nodes are inconspicuous/unremarkable/diffusely enlarged.
PLEURAL CAVITIES: The visceral and parietal pleural surfaces are smooth and dusky/shiny with/without petechiae.
The right pleural cavity contains ml of clear/serous/serosanguineous fluid (or blood).
The left pleural cavity contains ml of clear/serous/serosanguineous fluid (or blood).
The lungs occupy 95% of their respective pleural cavities.
The right lung has ____lobes and the left lung has ___ lobes.
PERICARDIAL CAVITY: The pericardial surfaces are smooth and dusky/shiny.
The cavity is free from adhesions and contains ml of clear/serous/serosanguineous fluid (or blood).
HEART: The heart weighs g.The viscero-atrial situs is solitus/inversus/ambiguous.
There is a D ventricular loop with the cardiac apex and left ventricle to the left and a solitus relationship of the great arteries with the pulmonary artery anterior and to the right of the aorta.
(If other than "solitus", "D", and "solitus", describe more thoroughly the site of the apex, position and relationship of the ventricles, and great arteries).
The epicardium is smooth without/with a scant amount of adipose tissue.
There are/no epicardial petechiae.
The atria are/do not appear distended.
The foramen ovale is patent.
The septum secundum appears sufficient/fenestrated/deficient over the ostium.
There is no atrial septal defect.
The coronary sinus ostium is normal in size and location.
The mural and valvular endocardium is smooth and dusky/translucent/white.
The atrioventricular valves are thin and delicate with normal appearing chordae tendinae.
Both semilunar valves contain three cusps.
The ventricular chambers are not dilated.
The myocardium is brown and unremarkable.
There is no ventriculoseptal defect.
The measurements of the heart in cm are as follows:
Tricuspid Valve cm, Pulmonic Valve cm, Mitral Valve cm, Aortic Valve cm, Right Ventricular Myocardial wall cm, Left Ventricular Myocardial wall cm.
All four pulmonary veins enter the left atrium; there is no anomalous pulmonary venous connection.
The coronary ostia are in normal position.
The coronary arteries have a right/left/dominant or aberrant distribution on the epicardial surface.
The great vessels arise from a left/right sided aortic arch in a normal manner.
The caliber of the ascending aorta is normal, and there is no aortic coarctation.
The ductus arteriosus is patent.
The branch pulmonary arteries arise normally from the pulmonary trunk and are of normal caliber.
The trachea and major bronchi are lined by smooth/tan/purple/ mucosa, their lumens contain fluid. There is no tracheal-esophageal fistula.
LUNGS: The weight of the lungs is: right g; left g. The cut surfaces are airless/hemorrhagic. The intraparenchymal bronchi and vessels appear normal. There are no cysts or localized lesions.
HEMATOPOIETIC AND LYMPHATIC SYSTEM:
THYMUS: The thymus weighs g.
The external surface is ivory/rose colored and lobulated without/with petechiae.