SECTIONS OF A FULL AUTOPSY REPORT.pptx

Full Autopsy Report by Harrison Mbohe MBChB Level 4 JKUAT

1. SECTIONS OF A FULL AUTOPSY REPORT

2. FORM OF THE AUTOPSY REPORT A free style “essay” Usually adheres to a conventional sequence. Leaves the examiner to expound on various aspects of significance. Usually used litigious autopsies as a legal statement or a deposition for court. A printed proforma Various sections of the examination and organ systems are already set out by title, leaving blank spaces for the insertion of the findings. Commonly used for non-litigious autopsies

3. BASIC SECTIONS Full personal details of the deceased subject, unless unidentified . This includes the name, gender, age, occupation and address. Declaration statement: The name, qualifications and status of the pathologist. The authority(s) commissioning the autopsy. The place, date and time of the autopsy. A record of who identified the body. Persons present at the examination & their designations. Clothing on the deceased O/E (+/-). The history and circumstances of the death Justifies the eventual cause of death where the morphological findings are scanty or even absent. In some jurisdictions, it’s forbidden to include this in the report

4. EXTERNAL EXAMINATION: MAJOR FINDINGS Body habitus - height, weight, apparent state of nutrition & physique. The presence of natural disease e.g. oedema, abdominal swelling, cutaneous disease, senile changes, etc. Identifying striking features such as skin colour, tattoos, scars, congenital or acquired deformities, dentures, and hair colour. Post-mortem changes - rigor, hypostasis, decomposition and abnormal skin coloration. Body and ambient temperature should be recorded where appropriate. Signs of medical intervention Listing and description of all external injuries , recent and old.

5. INTERNAL EXAMINATION: MAJOR FINDINGS CVS - Heart weight, any dilatation, ventricular preponderance, congenital defects, and any other anomalies pericardium, epicardium, endocardium, valves, coronary arteries, myocardium, aorta, other great vessels and peripheral vessels. RS - Hyoid bone and Laryngeal cartilages, Larynx, Soft tissues of neck, Trachea and Main Bronchi, Lungs (weight RL, LL g), Pleural cavities, Hilar Lymph Nodes: GIS - Tongue, Tonsils, Oesophagus: Peritoneal Cavity, Stomach, Duodenum, Intestines, Appendix, Rectum, Liver (weight g), Gall Bladder, Bile Ducts, Pancreas (weight-) Endocrine system - Pituitary, thyroid (weight), and adrenals. RES - Spleen (weight) thymus and lymph nodes. GUS - Kidneys (weight), ureters, bladder, prostate, uterus, ovaries and testes, external genitalia Musculoskeletal system - Skull, spine, remaining skeleton (Limb Girdles, Long Limb Bones, Hand and Feet, Ribs, Sternum, General condition of skeleton) and musculature where necessary Nervous system - Scalp, skull, meninges, cerebral vessels, brain (weight), middle ears, venous sinuses and spinal cord (when examined) and peripheral nerves

6. MISCELLANEOUS A list of specimens and samples retained for further examination. Specimen handed to other agencies should be formally identified by means of serial numbers and the name of the person to whom they were handed. A summary of the lesions displayed by the autopsy. Discussion of the findings, if necessary in the light of the known history. An opinion as to the definite or most likely sequence of events leading to the death. A formal cause of death, in format recommended by WHO, suitable for the completion of a death certificate. Pathologist’s signature & date. NB; - The results of further examinations such as histology, microbiology, toxicology and serology are usually not available in the main report after autopsy and a supplementary report is provided for such findings.

7. REFERENCES Knight's Forensic Pathology. (2004). In P. S. Knight. London: Edward Arnold (Publishers) Ltd, pp 33-35. Guide for Clinical Clerkship (2021), E.A.R., Department of Human Pathology & Forensic Medicine, School of Medicine, JKUAT, Juja, pp 15-21.

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