AUTOPSY REPORT

Case No. ____________ Decedent’s Name: ______________

Investigator’s Name: __________________ Decedent’s Age: _______________

Date of Autopsy: __________________ Decedent’s Ethnicity: ___________

Time of Autopsy: ___________________Decedent’s Length ______________

Decedent’s Weight ______________

EXTERNAL DESCRIPTION

The body is that of a well-developed, well-nourished male / female. The subject’s general appearance is consistent with the stated age. The decedent is unclothed. The body has been refrigerated and is cool to the touch. Rigor mortis is ______ in the jaws, neck, and upper and lower extremities. Livor mortis is present in the posterior dependent distribution, with relative sparing of the weight-bearing areas, and blanches to palpation. The body is unembalmed. The decedent is identified by a Coroner’s tag affixed tio the left great toe bearing the decedent’s name.

The subject ir normecephalic. There is no visible external trauma to the face or scalp. The scalp hair is ____________. The facial hair consists of __________. The facial features appear symmetrical and normally formed. The corneae are ____________. The irides are _________ . The pupils are __________. The conjunctivae are pink and moist, and there are no conjunctival petechial hemorrhages. There is no scleral icterus. The nose is normally formed and has an intact bony and cartilaginous structure. The nostrils are patent. The ears are symmetrical and show no hemorrhage or discharge. The teeth are __________. The oral mucous membranes are pink and moist and show no evidence of trauma or petechial hemorrhage. No foreign material or blood is present in the mouth. The neck is symmetricalk, normally formed, and atraumatic. There is no palpable crepitance or hypermobility of the neck.

The chest is symmetrical and normally formed. There is no visible external chest trauma. No palpable crepitance or bony deformity is present over the chest wall. The breast are __________. The abdomen is ________. No abdominal trauma is noted externally. No masses are palpated. The external genitalia are those of a normally developed, apparently circumcised adult male. Both testicles are present within the scrotal sac. The pubic hair pattern is normal. The anus is closed and atraumatic.

The upper extremities are symmetrical, normally formed, and free of external trauma. No needle tracks or needle marks are noted. The fingernails are __________.

The lower extremties are symmetrical, normally formed, and atraumatic. The toenails are ________. The soles of the feet are ______________.

The posterior trunk shows a normal symmetrical external contour. No visible trauma is present.

SCARS AND DISTINGUISHING MARKS

EVIDENCE OF THERAPEUTIC INTERVENTION

EVIDENCE OF EXTERNAL TRAUMA

EVIDENCE OF INTERNAL TRAUMA

INTERNAL EXAMINATION

OPENING INCISION AND BODY CAVITIES: The standard Y-shaped thoracoabdominal incision reveals a subcutaneous fat thickness of _______ at midabdominal level. The pleural, pericardial, anf peritoneal cavities are smooth and shiny and reveal no accumulation of excess fluid or blood. The internal organs are normally arranged.

NECK ORGANS: The hyoid bone and laryngeal cartilages are intact and normally formed. No fractures are identified. There is no evidence of hemorrhage in the strap muscles or soft tissues of the neck. The carotid sheaths and anterior cervical spine are without obvious abnormalities.

CARDIOVASCULAR SYSTEM: The heart weighs _______ grams. It is normally formed. The epicardial surface is smooth and shiny. There is a normal distribution of epidcardial fat. The myocardium is firm, red-brown without focal softening, discoloration, or fibrosis. The chambers are not dilated, and the ventricular walls are normal in thickness (left ventricle is ______ centimeters; right ventricle is ______ centimeters). The endocardial surfaces show a typical trabecular pattern and are free of fibrosis or mural thrombus. The vales are normally formed, thin, and pliable. The coronary ostia are patent. The coronary arteries are normal in origin and distribution. The _____ coronary artery is dominant. The coronary arteries show ___________. There is no thrombotic occlusion. The aorta is patent and follows a normal course. There is ________ aortic atherosclerosis.

RESPIRATORY SYSTEM: The right lung weighs ______ grams. The left lung weights _____ grams. The lungs are similar in appearance. The pleural surfaces are smooth, shiny, light pink-tan with scattered anthracotic mottling. Sectioning reveals spongy, crepitant, pink-tan parenchyma. There is no localized consolidation or infarction. No parenchymal mass lesions or abscesses are present. The larynx, trachea, and bronchi are normally formed. The mucosal surfaces of the airways are unremarkable. There is no airway obstruction. The pulmonary arteries are normally formed and free of thromboemboli.

GASTROINTESTINAL SYSTEM: The esophagus is normally formed, patent and shows a smooth, pink-tan mucosa. The stomach is normally formed. It contains _____ grams of _____________ (or no identifiable particulate food matter or pill residue is appreciated. No ethanol-like odor is noted.) The gastric mucosa is pink-tan and shows a typical rugal pattern. No localized erosion, ulceration, or mass lesion is evident. The duodenum, small intestine, appendix, and solon are grossly normal.

PANCREAS: The pancreas is normal in size and configuration. Sectioning reveals a uniform, tan, lobulated parenchyma.

HEPATOBILIARY SYSTEM: The liver weighs _______ grams. It is normally formed., The capsule is thin, smooth and shiny. The cut surface is firm, red-brown and displays a typical lobular pattern. No parenchymal mass lesion is noted. The gallbladder is normally formed. It contains bile. There are no calculi. The gallbladder mucosa shows a typical finely reticulated appearance. The bile ducts are patent and of normal caliber.

GENITOURINARY SYSTEM: The right kidney weighs _____ grams. The left kidney weighs _____ grams. The kidneys are similar in appearance. The capsules strip with ease. The cortical surfaces are smooth, and red-tan. Sectioning reveals a normal pattern of internal architecture. Corticomedullary demarcation is distinct. No cysts or mass lesions are present. The pelves and ureters are patent and are of normal caliber. The bladder contains ______ liters of urine. The bladder mucosa is smooth, and a light pink-tan. The prostate and testes are unremarkable to inspection and palpation. (or The internal genitalia are normally developed, non-pregnant adult female. No localized lesions of the ovaries or uterus are present. The cervix appears nonparous.

LYMPHORETICULAR SYSTEM: The spleen weighs _____ grams. It is normally formed. The capsule is thin, smooth and shiny. The cut surface is firm, red-purple and shows a typical follicular pattern without evidence of fibrous or neoplasia. The thymus is atrophic. Lymph nodes throughout the body are small and inconspicuous.

ENDOCRINE SYSTEM: The thyroid is symmetrical and normally formed. Sectioning reveal a uniform, firm, red-brown, colloid parenchyma. The adrenals are grossly unremarkable. The pituitary is grossly unremarkable.

SKELETAL SYSTEM: There is no gross evidence of skeletal fracture or deformity.

HEAD: Reflection of the scalp reveals no evidence of subgaleal hemorrhage. The skull is intact and normal in thickness. The dura is smooth and shiny. There is no dural neomembrane or sinus thrombosis. No subdural hemorrhage is present. Removal of the dura reveals no evidence of skull fracture.

The brain weighs ______ grams. The leptomeninges are thin and transparent. There is no subarachnoid hemorrhage exudate. The superficial blood vessels are fine and patent. The vessels at the base of the brain are free of atherosclerosis. The circle of Willis is normally formed. The cranial nerves are intact. The dorsal surface of the brain presents a symmetrical appearance with a normal convolutional pattern. There is no evidence of subfalcial herniation. The base of the brain shows no evidence of uncal or tonsillar herniation. The brainstem and cerebellum show the usual external configuration. There is no localized external softening or contusion of the brain.

Multiple coronal sections of the cerebrum and transverse sections of the cerebellum and brainstem show the usual pattern of internal architecture without focal mass lesions or hemorrhages. The ventricular system is of normal configuration and contains clear, colorless cerebrospinal fluid.

ASSISTANTS:

SPECIMENS FOR PATHOLOGY Representative sections of all major organs are retained.

SPECIMENS FOR TOXICOLORY Heart, blood, femoral blood, vitreous, gastric contents, liver, bile, and urine.

POSTMORTEM RADIOGRAPHS (name)

PHOTOGRAPHS & DIAGRAMS

MATERIALS FOR CRIME LAB Head hair, facial hair, pubic hair, pubic combings, oral and rectal swabs and smear, fingernail scrapings from right and left hands, and blood for typing. (also introital, vaginal and cervical swabs and smears.)

POLICE WITNESSES names

MICROSCOPIC DESCRIPTION

Sections of the major organs examined confirm the gross pathologic findings and “smear” lines for homicides.

PATHOLOGIC DIAGNOSES

CAUSE OF DEATH

OTHER SIGNIFICANT CONDITIONS