Gross Lesions!
How to describe a gross lesion:
A complete gross description of a lesion should include all of the following characteristics:
- size - use metric units. Unless a lesion is flat, measure three dimensions (width x length x height). If it is relevant, weigh the “lesion,” eg an enlarged heart or liver.
- shape - of the lesion (eg, wedge shaped, circular, spherical, irregular
- margin - smooth/well demarcated, encapsulated, ill-defined
- consistency - soft, firm, hard
- surface - smooth, rough, granular, glistening, pitted, raised, verrucous
- distribution - focal, focally extensive, regionally extensive, multifocal, coalescing, disseminated, diffuse, bilateral, segmental, random
- location - what organ? what part of that organ? Use left vs right for bilateral organs, and consider using descriptors like lateral/medial, proximal/distal, deep/superficial relative to nearby anatomical landmarks. Also, identify whether a lesion affects the cortex vs medulla (or both) in relevant organs, and identify a particular lobe of the lung/liver if these organs have lesions… if a lesion is only on a particular surface you can localize it with terms like diaphgragmatic, peritoneal, pleural, costal, serosal, mucosal, antimesenteric, etc…
A Morphologic Diagnosis for a gross lesion includes:
- severity (mild, moderate, severe)
- duration (acute, subacute, chronic)
- distribution (focal, multifocal, coalescing, diffuse)
- anatomic site (nephro-, hepato-)
- additional descriptions (suppurative, necrotizing)
- lesion (necrosis, hemorrhage, congestion, ulceration, etc)
* For neoplasias, severity, duration, and additional modifiers are not normally included.
