**EXAMPLE OF GROSS DICTATION**

**EXTERNAL DESCRIPTION:** The body is that of a well-developed,
well-nourished white man appearing about the stated age of 65 years,
measuring 170 cm long and weighing approximately 77 kg. Abundant
grey-brown hair covers the head except for slight frontal balding. The
white sclerae support round, regular, and equal pupils 0.5 cm in
diameter. The ears, nose, and edentulous mouth are unremarkable. The
trachea lies midline, and the neck contains no palpable masses. Multiple
flat dark brown plaques ranging from 0.5 to 1.0 cm in diameter are
scattered over the anterior thorax. The flat breasts contain no palpable
masses. There is livor mortis in the dependent portions of the body and
venipuncture ecchymoses discolor the skin of the forearms. There are no
abdominal scars. The lower extremities are unremarkable.

**PRIMARY INCISION:** The usual Y-shaped trunk incision traverses 2.0 cm
of abdominal panniculus measured at the umbilicus. The pectoralis and
rectus muscles are firm and red-brown. Serially sectioning the breasts
demonstrates no masses. *The scalp is opened by the usual bimastoidal
incision.*

**NECK ORGANS:** Thyroid retains its usual shape, weighs 17 gm and has a
smooth, red-brown external surface. Sectioning demonstrates glossy
parenchyma without nodules. Delicate pink mucosa lines the larynx and
upper trachea. Three yellow-brown 0.4 cm parathyroids are secured from
the neck.

**PERITONEAL CAVITY:** There are no fluid accumulations and all the
serosal surfaces are smooth and glistening, save a few delicate fibrous
adhesions between the region of the cecum and the anterior abdominal
wall. The liver does not extend below the right costal margin or the
xiphoid process. All the organs bear their anatomic relationships to one
another.

**PLEURAL CAVITIES:** Each is devoid of fluid accumulations and is lined
by glistening, smooth parietal pleura.

**HEART:** 310 gm and is surrounded by 25 ml of clear, straw-colored
pericardial fluid. The epicardium is smooth and glistening throughout.
The right predominant coronary arterial system has focal yellow calcific
atheroma producing insignificant stenosis of the lumen. All the
endocardial surfaces are smooth and glistening; valves have thin,
pliable leaflets. The firm, red-brown myocardium contains no focal areas
of fibrosis. The right ventricle has no evidence of dilatation.

Measurements: Tricuspid Valve 10.0 cm

Pulmonic \" 7.0 \"

Mitral \" 8.0 \"

Aortic \" 6.5 \"

Left Ventricle 1.4 \"

Right \" 0.4 \"

**LUNGS:** Left 350 gm; right 375 gm. Glistening, translucent pleura
covers the red-pink parenchyma. Black lymphatics outline the lobules on
the pleural surface. Delicate pink mucosa lines the bronchial tree, and
there is slight hyperemia in the posterior aspect of both lower lobes.
Sectioning demonstrates dry pink parenchyma with normal crepitance.
There are no palpable masses. The pulmonary arteries are pale yellow and
contain no atheromas or thromboemboli.

**SPLEEN:** 150 gm and has an opaque blue-pink capsule with several
firm, white 1.0 cm plaques scattered throughout. Sectioning the firm,
dark red parenchyma demonstrates prominent lymphoid follicles and
fibrous trabeculae.

**PANCREAS:** 100 gm and retains its usual configuration. The pale
yellow-tan lobules are separated by a small quantity of fat. The main
pancreatic duct is not dilated and is patent throughout.

**GASTROINTESTINAL TRACT:** Delicate, longitudinally folded pink mucosa
lines the esophagus. The stomach contains approximately 200 ml of mucoid
green-brown material and has well-preserved rugal folds lined by
pink-tan mucosa. The duodenum and remainder of the small bowel contain
liquid green material and are lined by delicate, velvety pink-tan mucosa
with well-preserved folds. The serosal surface throughout the small
bowel is smooth, glistening, and translucent. The vermiform appendix
measures 8.0 cm and is covered by a smooth serosa. The colon contains
formed green-brown feces and has no mucosal abnormalities.

**LIVER:** 1,500 gm. The glistening, translucent capsule covers firm
red-brown parenchyma, which does not have prominent lobular
architecture.

**BILIARY TRACT:** Viscid green bile distends the gallbladder and shares
the lumen with multiple lobulated black stones ranging up to 1.0 cm in
diameter. The green-brown mucosa is velvety and has no abnormalities.
The common duct measures 1.5 cm in circumference and is patent into the
duodenum.

**ADRENALS:** Left 7.0 gm; right 8.0 gm. A convoluted 0.2 cm bright
yellow cortex surrounds a semitranslucent grey medulla. There are no
nodules present.

**KIDNEYS:** Each weighs approximately 160 gm. The capsule strips with
ease, revealing a finely granular, red cortical surface without coarse
scars. Sectioning demonstrates a sharp cortico-medullary junction with
red-brown cortex separated from dark red medullae. The papillary tips
are white and surrounded by delicate pink calyceal mucosa. The
pelvo-calyceal system is not dilated.

**URETERS:** Each measures approximately 0.8 cm in circumference, is
lined by delicate pink mucosa, and is patent into the urinary bladder.

**BLADDER:** Contains 200 ml of clear, straw-colored urine and has a
folded pink mucosa with hyperemia near the region of the trigone. The
urethral orifice is widely patent.

**GENITALIA:** Each testicle weighs 15 gm with the epididymis removed
and has a glistening tunica albuginea. The seminiferous tubules string
out with ease from the yellow-tan sectioned surface. Vas deferens and
seminal vesicles are grossly unremarkable. Prostate weighs 30 gm and has
a lobulated sectioned surface with scattered 0.5 cm rubbery, pale tan
nodules. There is no constriction of the urethral lumen.

**LYMPH NODES**: Nodes from the para-aortic and celiac region range from
0.5 to 1.0 cm in diameter and are pink-tan and soft. The anthracotic
hilar nodes range up to 1.0 cm in diameter.

**VEINS:** Compression of the thighs produces good return of blood from
both common iliac veins. The inferior vena cava and portal veins are
widely patent.

**ARTERIES:** The aorta contains scattered yellow and white plaques,
some of which are calcified and ulcerated. The process is accentuated
distal to the renal arteries. The orifices of all the major arteries are
widely patent.

**BONE:** A longitudinal section of the vertebral column demonstrates
abundant red-brown marrow and bone of the usual texture.

**PERIPHERAL NERVOUS SYSTEM:** No gross abnormalities. One section of
femoral nerve retained for sectioning.

**SKULL:** No fractures present.

**BRAIN:** See attached.

**SPINAL CORD:** See attached.

**GROSS BRAIN DESCRIPTION: CHECKLIST**

**WEIGHT**

**DURA**

epidural surface

subdural surface

superior sagittal sinus

**EXTERNAL**

**Hemispheres Brainstem/cerebellum**

leptomeninges leptomeninges

discoloration/softening discoloration/softening

gyral pattern cranial nerves

cingulate herniation tonsillar herniation

circle of Willis pineal region

uncal herniation

**SECTIONS**

coronal vs. CT plane aqueduct and IV ventricle

cortex tegmentum

white matter base

deep gray foliar pattern

ventricles dentate nucleus

**SPINAL CORD**

length

dura

leptomeninges

cauda equina

vessels

sections

## SAMPLE GROSS DESCRIPTION AND CODE OF SECTIONS

## BRAIN AND SPINAL CORD

## *Brief Neurologic History: (without dementia)*

## *Brain Gross Examination:*

The brain is removed in its entirety. The brain weighs \_\_\_\_\_\_\_\_
gm fresh. The dura and dural sinuses are unremarkable. The leptomeninges
are smooth and transparent. The cerebral and cerebellar hemispheres are
symmetrical. The surfaces of the cerebrum, cerebellum and brain stem
show no softening, atrophy or masses. There is no evidence of herniation
of the cingulate gyri, unci or cerebellar tonsils. Examination of the
arteries of the circle of Willis and their major branches reveal that
they have no-minimal-moderate-severe atherosclerosis. The \_\_\_\_\_\_\_
artery shows \>50% narrowing. There are no thrombosis nor aneurysm. The
circle of Willis shows no malformation. The superficial veins are
unremarkable. The cranial nerves are normal. After coronal sectioning
the cerebral hemispheres reveal a cortex of normal thickness. The
ventricles are normal size and symmetric. The centrum ovale is
unremarkable. The central nuclei of the cerebrum are unremarkable.
Internal capsules are normal. Serial transverse sectioning of the brain
stem and cerebellum reveals no abnormalities. The external and internal
surfaces of the spinal dura are unremarkable. The spinal leptomeninges
are this and translucent, and the subarachnoid space is free of exudate.
The spinal arteries and veins are unremarkable. Serial transverse
sections of the cord at 1-1.5 cm intervals show normal central grey
matter and peripheral fiber tracts.

Signed out at gross-microscopic examination. Gross kodachromes pictures
are-are not obtained. The following sections are obtained and labelled
as follows:

Frontal R \_\_ L \_\_

Parietal R \_\_ L \_\_

Temporal R \_\_ L \_\_

Occipital R \_\_ L \_\_

Basal ganglia R \_\_ L \_\_

Thalamus R \_\_ L \_\_

Hippocampus R \_\_ L \_\_

Centrum ovale R \_\_ L \_\_

Cerebellar hemisphere R \_\_ L \_\_

Cerebellar vermis \_\_\_

Midbrain \_\_\_

Pons \_\_\_

Medulla \_\_\_

Spinal cord \_\_\_

Cervical \_\_\_

Thoracic \_\_\_

Lumbar \_\_\_

Sacral \_\_\_

Dura \_\_\_

Pituitary gland \_\_\_

Pineal gland \_\_\_

DRG (\_\_\_) \_\_\_

Nerve: \_\_\_

Muscle: \_\_\_

## *Brief Neurologic History: (with dementia)*

## *Brain Gross Examination:*

The brain is removed in its entirety. The brain weighs \_\_\_\_\_\_\_\_
gm fresh (supratentorial (fixed) \_\_\_\_\_ gm, infratentorial (fixed)
\_\_\_\_\_ gm). The dura and dural sinuses are unremarkable. The
leptomeninges are smooth and transparent. The cerebral and cerebellar
hemispheres are symmetrical. The surfaces of the cerebrum, cerebellum
and brain stem show no softening, atrophy or masses. There is
no-mild-moderate-severe atrophy of the frontal, parietal, occipital,
temporal lobes and cerebellum. The hippocampi and entorhinal cortices
are-are not atrophic. There is no evidence of herniation of the
cingulate gyri, unci or cerebellar tonsils. Examination of the arteries
of the circle of Willis and their major branches reveal that they have
no-minimal-moderate-severe atherosclerosis. The \_\_\_\_\_\_\_ artery
shows \>50% narrowing. There are no thrombosis nor aneurysm. The circle
of Willis shows no malformation. The superficial veins are unremarkable.
The cranial nerves are normal. After coronal sectioning the cerebral
hemispheres reveal a cortex of normal thickness. The ventricles are
moderately enlarged and symmetric. The centrum ovale is unremarkable.
The central nuclei of the cerebrum are unremarkable. Internal capsules
are normal. Serial transverse sectioning of the brain stem and
cerebellum reveals a pale substantia nigra. The external and internal
surfaces of the spinal dura are unremarkable.

The spinal leptomeninges are thin and translucent, and the subarachnoid
space is free of exudate. The spinal arteries and veins are
unremarkable. Serial transverse sections of the cord at 1-1.5 cm
intervals show normal central grey matter and peripheral fiber tracts.

**MICROSCOPIC DESCRIPTION**

[Brain]{.underline}: Routine histologic preparations were made on the
sections as outlined above. Examination of the H&E stain of the
hippocampus showed a moderate loss of neurons and scattered
neurofibrillary tangles. Confirmation of the presence of tangles was
made using tau, ubiquitin and silver and showed a mild-moderated-severe
burden. Immunohistochemical staining for amyloid and silver stains
revealed plaques in the neocortex ((measured at \_\_\_\_\_\_\_\_plaques
per high powered (20x) field in the \_\_\_\_\_\_\_\_\_\_\_lobe)).
Amyloid angiopathy was identified in the occipital lobe and was present
in the leptomeninges-superficial cortex-deep cortex-white matter.

Lewy bodies were-were not identified in the substantia nigra.

**Code of Sections**

[Routine AD sections include]{.underline}: middle gyrus frontal lobe,
superior gyrus temporal lobe, inferior gyrus parietal lobe, visual
cortex, cerebellum with dentate nucleus and folia, hippocampus &
midrain. [Additional sections when AD is questioned]{.underline} are
basal ganglia, pons, medulla, spinal cord (lumbar/sacral), superior
gyrus pariental lobe, cingulate gyrus, as indicated by history.

[Routine stains include]{.underline} silver, tau, amyloid b, ubiquitin.

Frontal R \_\_ L \_\_

Parietal R \_\_ L \_\_

Temporal R \_\_ L \_\_

Occipital R \_\_ L \_\_

Basal ganglia R \_\_ L \_\_

Thalamus R \_\_ L \_\_

Hippocampus R \_\_ L \_\_

Centrum ovale R \_\_ L \_\_

Cerebellar hemisphere R \_\_ L \_\_

Cerebellar vermis \_\_\_

Midbrain \_\_\_

Pons \_\_\_

Medulla \_\_\_

Spinal cord \_\_\_

Cervical \_\_\_

Thoracic \_\_\_

######  Lumbar \_\_\_

Sacral \_\_\_

Dura \_\_\_

Pituitary gland \_\_\_

Pineal gland \_\_\_

DRG (\_\_\_) \_\_\_

###### Nerve: \_\_\_

# Muscle: \_\_\_

######