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DIAGNOSTICS

HISTOPATHOLOGY REQUISITION FORM

25Y 0 M OD
Female
Patient Name: sarita devi
Age:_ Gender: Male/ Female:

Date: S/22
Refering Doctor Jyoliho MBRSLaO Doctor. Mob. No:

Lab / PCC/ PUP Name:_BeXikaxc City Matihay

Site of Specimen:

Relevant Clinical History

SMALL SPECIMEN / 1 MEDIUMSPECIMEN

Breast lump Ectopic gestation
ZEndometrium Bone Marrow Biopsy Cervical stump Excision
Pilonidal sinus
(D&C Material) Testicular Biopsy Fistula/ Sinus Sebaceous Cyst
Cervical biopsy Cervix Cone Biopsy Lymph Node Muscle Biopsy
Endoscopic biopsies Endobroncheal/
Ovarian Cyst :LiverBiopsy
Trucut biopsies Laryngeal Biopsy
Gall Biladder Kidney Biopsy
Appendix Fallopian tube Hemorrhoids
Skin Biopsy Others:..************ Superficial lumps/
Brain & Spinal DLipoma
Synovial Biopsy ****************************

cord tumors
Granulation tissue
Nasal Polyp * * * * * ********** * * * ' * * * "

TUR Urinary Bladder Others:. **************|

Buccal Mucosal Biopsy Fibroids * * * * * * * * * * * * * * * * * * * * * * *

LARGESPECIMEN EXTRA LARGE

****

CANCER RESECTION SPECIMENS

Prostate Chips (Tur-P)
Uterus with cervix & B r e a s t MRM / Breast S o f t Tissue Tumors
adnexae ovaries/ Fibroids Orchidectomy Specimen
Ovarian tumors (Large Oesophagectomy Conservative Surgery Small Intestinal Resection
cysts) Mediastinal Mass Hemi/ Total Colectomy Penis
POC Lung (Lobectomy) Radial Nephrectomy Amputations- Limb
Placenta Hepatic Resection Head &Neck Resection; Bone Specimen
Gastrectomy Radical Cystectomy Uterus with adnexae with
Uterus and cervix
Whipple's resection appendix
Eyebal Others: .. *************

* ** *********** * * * * *
Radial Prostatectomy Others: . .. ****** **
Lipomas (Large) *********** '*****'**********
Hemmandibulectomy * ************
Thyroidectomy with RND/ MND
Radical Neck Dissection
*******************
************ ** **************

Spleen ****** ***

*********************** *******

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