Abstract

Immediately record the findings. A tape recorder would be excellent for this. If none is available, findings should be written down as soon as possible before memory of the examination fades. It is important to record comments on every organ that you examined. Three years from now in a court deposition, it may be difficult for the practitioner to remember if he looked at the adrenal glands or if there was no gross evidence of hyperplasia. When writing a report, it is a good idea to describe the tissue changes rather than just to give an interpretation. An example of the latter would be, "The horse had a severe pneumonia." A better method might be, "The horse's lungs had a bilaterally symmetric pneumonia in the ventral portions of the anterior, middle, and diaphragmatic lung lobes. This pneumonia accounted for roughly 45% of the total lung area. These pneumonic areas were dark red, sunken, and firm with a dull granular pleura. When cut, there was a yellow exudate that exuded from the cut surface." This latter description gives good evidence of why it was believed that the lung was pneumonic and just how severe the change was. Several years from now, the latter description does more to refresh the memory of the case. Carefully label and preserve the specimens for later diagnostic tests. List all the fresh samples collected. Time spent on these details now can save you considerable embarrassment later. Following these suggestions should allow the practitioner to provide the best possible service to all parties involved.

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