Once pathologists have finished describing lesions, they must interpret what they have found and develop a morphologic diagnosis. A morphologic diagnosis is a short phrase that sums up the important aspects of the lesion and is a way to communicate these aspects to other medical professionals in a precise way.
The components of a morphologic diagnosis are:
These four are the basics, but sometimes other modifiers can be used to refer to Distribution (abbreviated as: d)
- Severity (abbreviated as: s)
- Time (abbreviated as: t)
- Lesion (abbreviated as: l)
- Anatomic site (abbreviated as: a)
For example, if you saw a swollen, dark red spleen that dripped blood when you cut it, the morphologic diagnosis would be:
Severe, acute, diffuse, splenic congestion. s t d a l
Similarly, if you saw a kidney with a small wedge-shaped area in the parenchyma that was firm and white/tan and shrunken below the level of the rest of the normal surface, your morphologic diagnosis would be:
Mild, chronic, focal, renal infarct s t d a l
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