In general, I like to use what I’ve heard referred to by some as the “WashU” style, where you start by listing the organ, then the more specific location (if given, with further sub-specifications separated by commas), and finally the procedure. Speaking broadly, the procedure can often be characterized as a resection (often removing an entire or large portion of an organ), excision (a removal of a portion of tissue), or a biopsy (a representative sampling of a lesion or organ). Sometimes, the resection or biopsy will have a more specific name, such as a “pancreaticoduodenectomy” or “fine needle aspiration.”
ORGAN, SITE, PROCEDURE
Here are some examples:
STOMACH, ANTRUM, BIOPSY
THYROID, LEFT SUPERIOR LOBE, NODULE, FINE NEEDLE ASPIRATION
LUNG, LEFT UPPER LOBE, NODULE, WEDGE RESECTION
COLON, LEFT, HEMICOLECTOMY
PANCREAS AND DUODENUM, PANCREATICODUODENECTOMY
I list the diagnosis on a new line, after a hyphen. Stylistically, I try to keep my diagnoses as brief as reasonable for simplicity sake. Any additional information I try to save for a comment. If something is “normal,” I personally use the diagnostic line “No significant abnormality” (of which there are many institutional and/or personal permutations).
Here are some examples:
– No significant abnormality
– Mild chronic gastritis
– Gastrointestinal stromal tumor (see comment)
– Basaloid salivary gland neoplasm (see comment)
Also, I tend to not give “pertinent negatives” in the diagnostic line. To me, listing absent findings on the diagnostic line seems like a confusing slippery slope that could lead to a virtually unending cluttered list of increasingly irrelevant possible (but not present) diagnoses. Instead, if I don’t specifically list it as present, assume it isn’t there. There are, of course, noteworthy exceptions that I may mention in a comment. For example, if a biopsy is intended to be of a lung mass but looks like normal lung, I might have as the diagnostic line “Lung parenchyma with no significant abnormality” and in a comment reinforce that “there are no histologic findings to explain the clinical impression of a lung mass.” Likewise, I try to mention in an IBD comment that I don’t see any viral inclusions or dysplasia or in a transplant liver biopsy that there is no evidence of rejection.
Disclaimers: These comments and diagnoses are based on the standardized comments I learned during my training at Stanford, with some of my own additions and modifications. As such, I must give credit to my teachers and co-trainees for helping in their development. They are meant to be used as examples, and seldom can they be just put in a case without modification and customization.
As Dr. Bob Rouse would say: “Ein Buch ist ein Spiegel, aus dem kein Apostel herausgucken kann, wenn ein Affe hineinguckt.”
Also, this is a work in progress, so please let me know if you have any suggestions!
Last updated: Aug 5, 2019