General Practitioner Template
Histology Result
A professional General Practitioner template for healthcare professionals.
About this template
Streamline your clinical documentation with our 'Histology Result' template, meticulously designed for General Practitioners and other specialists managing patient pathology. This template simplifies the recording of crucial biopsy and specimen findings, ensuring all essential details from macroscopic descriptions to microscopic analyses and final diagnoses are captured accurately. Ideal for GPs referring patients for biopsies, it helps maintain comprehensive patient records and facilitates informed decision-making. Utilise Heidi's AI medical scribe to automatically populate this template from your consultations, ensuring consistent, detailed, and easily retrievable histology reports without missing vital information like specimen type, pathology lab, or the requesting consultant. Enhance your practice's efficiency and diagnostic workflow with this indispensable tool.
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Date of Procedure: 1 November 2024
Specimen/Specimen Type: Excisional biopsy of skin lesion from left forearm, 0.8 cm diameter.
Pathology Lab: City General Hospital Pathology Department
Requesting Consultant: Dr. Eleanor Vance, GP
Clinical Information: 45-year-old male with a darkly pigmented, irregularly shaped mole on his left forearm, noted to have changed in size and colour over the past 3 months. Suspected melanoma.
Macroscopic/Gross Description:
- Irregularly shaped, dark brown to black skin ellipse measuring 1.2 cm x 0.9 cm x 0.4 cm.
- Central raised area of 0.7 cm diameter with focal ulceration.
- Margins appear clear grossly.
Microscopic Description:
- Histological examination reveals an atypical melanocytic proliferation within the epidermis and dermis.
- Features consistent with superficial spreading melanoma, Breslow thickness 0.9 mm.
- Invasion noted into the papillary dermis.
- No evidence of lymphovascular invasion or perineural invasion.
- Surgical margins are clear; closest margin 0.2 cm at the deep aspect.
- Mitotic rate: 2 mitoses/mm².
Diagnosis:
Superficial Spreading Melanoma, left forearm. (ICD-10: C43.6)
Comments: Further discussion regarding sentinel lymph node biopsy is recommended given Breslow thickness.
Pathologist: Dr. Thomas Kelly, Consultant Histopathologist. IMC Registration: 12345
Date of Report: 1 November 2024
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Specialty
General Practitioner
Used
1 times
Type
Note
Last edited
17/03/2026
Created by
Isabelle Fallon