Document dQgggB3E4mXQvReDVJ3zYY7g0
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CJMCAL RECORD
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brr.ClMEN SUOMITTED BY
_St. Anthony Hospital, Louisville, KY
SPECIMEN
TsSSUZ ZXAiV* i iSlAT SON
DATE OBTAINED
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BRIEF CLINICAL HISTORY {include duration ofittion and rapidity 9f growth, i/o neopiatm)
PREOPERATIVE DIAGNOSIS
OPCRATIVC FINDINGS
POSTOPERATIVE DIAGNOSIS
SIGNATURE AND TITLE
NAME OF LABORATORY
PATHOLOGICAL REPORT
1 ACCESSION NO(S).
_ Surgical Pathology Section!S7L-R7L
{Oroit dficripiion. histologic examination and liiognoseH
Gross;
The specimen consists of two submitted slides bearing the label of St. Anthony Hospital, Louisville, Kentucky and the number S74-0545. Also received is a copy of the surgical pathology report.
Microscopic:
Section of the gallbladder shows hypertrophy of the muscularis with irregular fibrosis of the gallbladder wall and surrounding fatty tissue. There is an irregular inflammatory infiltrate present, chiefly lymphocytes, but with a few polys in the mucosa.
Section of the liver shows slight portal tract fibrosis with a mild inflammatory infiltrate of lymphocytes. A few of the sinusoids are dilated and there is slight enlargement of some of the sinusoidal lining cells. Slight fatty metamorphosis is noted. There is no cholestasis. Focally the hepatocytes show variation in size (megalocytosis). The hepatic capsule is normal.
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XaX>CXaXXX MTMOLOaiST
Hans Popper, M.D.
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1 AGE 1 53
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PATIENT'S IDENTIFICATION (For typed or written entriet five: Nome--lent, firat, middle; 4rede; date; hoapitei or medioel facility)
1 RACE | i REGISTER NO. i 00-00-00
I PATE
4/13/74
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IDENTIFICATION NO.
WARD NO.
TISSUE EXAMINATION
Htunclurti I**orm 616
BFG67422
Diagnoses: 1. Chronic cholecystitis with cholelithiasis.
2. Slight changes in the liver consisting of megalocytosis,
portal tract fibrosis and mild chronic inflammation of portal
tracts.
...
Louis B. Thomas, M.D t
BFG67423