This
is Your name dictating some cases on
__/__/__ (state today’s date).
The
first case is ___-01-___ on patient _____________________.
History is: (read history of present illness written on request
form)
(Announce sections as follows:)
First
section
(NOTE:
italicized or underlined places below are areas which
can be changed accordingly)
lPeripheral
blood:
Examination of the Peripheral blood reveals mild/moderate/no
anisocytosis and poikilocytosis with no significant
red cell morphologic abnormalities (or, with). The
cells are normochromic and normocytic..(hypochromic,
macrocytic etc.) with occasional/no
polychromatic forms seen. No nucleated red cells are
seen. There is no evidence of red cell agglutination or
rouleaux formation. Examination of the circulating white
blood cells reveals ____ The estimated platelet count is
approximately _____ A peripheral blood differential cell count
by percentage reveals the following: (you may just say, “please fill
in diff count here” as long as there are numbers filled in on the
request form under laboratory data differential section.)
lBone
marrow aspirate:
The
bone marrow aspirate is cellular and adequate for evaluation. Both
the myeloid and erythroid series contain cells which progress
through the full maturation sequence with no morphologic
abnormalities. The M:E ratio is approximately _:_. Megakaryocytes
are present in adequate numbers and also show no morphologic
abnormalities. (“Please fill in diff count here”- no need to dictate
numbers as long as there are numbers filled in on the attached
differential worksheet).
lSpecial
stains:(if
any)
lBone
marrow biopsy:
(Note:
if bilateral, please state “bilateral biopsies are obtained” at
beginning of biopsy dictation, then dictate “Left side......Right
side...”)
The
bone marrow biopsy is approximately ___% cellular and has an M:E
ratio of ___:___. The myeloid and erythroid series progress through
the full maturation sequence. Megakaryocytes are present in
adequate numbers. (Add any pertinent negatives or positives
i.e. no evidence of recurrent disease or there
is no evidence of necrosis, fibrosis, granulomatous inflammation,
lymphoma, leukemia, or cells extrinsic to the marrow).
The bony trabeculae are unremarkable.
lDiagnosis:
Peripheral blood:
