Autopsy

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Author: Mikael Häggström [notes 1]
The extremely minimal autopsy checklist:

  • Check the autopsy referral
  • Cut open and inspect the usually clearly visible organs, as well as the thyroid, pancreas and adrenals.
  • Weigh relevant organs
  • Sample tissues for microscopy and/or microbiology when needed
  • Report at least relevant findings

A separate article is given on:

Comprehensiveness

Factors supporting a relatively more comprehensive autopsy and/or report, particularly in the inclusion of negated findings:

  • Lack of explanation from existing evidence. On the other hand, for example, upon finding an obvious aortic rupture, the rest of the autopsy is less relevant and may be relatively short.
  • Double-reading: If your report is likely to undergo double reading by another pathologist before sign-out, it needs to be more detailed, because the doctor who will do the double-reading then knows that you have looked at those locations.
  • Highly suspected locations, such as given from the referral.

On this resource, the following formatting is used for comprehensiveness:

  • Minimal depth
  • (Moderate depth)
  • ((Comprehensive))
Other legend

<< Decision needed between alternatives separated by / signs >>
{{Common findings / In case of findings}}
[[Comments]]
Organs or important regions are in bold in the report example, but does not need to be in an actual report.

Checklist for non-forensic autopsy

There are many variants, with the following being a suggestion:

Preparations

  • Read the autopsy referral.
  • Confirm that there is a consent from the next of kin to perform the autopsy, and whether it includes any restrictions.
  • Confirm with any supervisor what you may do independently do, and at what stages the supervisor will want to inspect it.[notes 2]
  • (Go through the patient's medical records, at least if necessary aspects are not included in the referral. The most important aspects are:
  • Time of death
  • Surgical history
  • Current diseases
  • Latest hospital and/or primary care notes)
  • ((History of smoking
  • Medications, especially anticoagulant ones.
  • Family history))

In the autopsy room, before starting examination:

  • Bring a camera to document relevant findings.
  • Use protective wear, generally according to local practice. Do any knots before putting on gloves for better dexterity.
  • Confirm the identity of the body, generally from attached identity tag.

External inspection

  • Measure the size of <<clinically significant / ( all)>> scars, marks or wounds. Estimate the depth of wounds, either by number or presumed anatomic layer.
  • Note any therapeutic tubes or lines
  • (Discern the race, gender, nutritional status, and apparent versus stated age
  • Inspect the eyes and mouth.)

In situ inspection

  • Note any atypical organ arrangement
  • Estimate (or measure) excessive amount of fluid in body cavities.
  • (Measure the thickness of subcutaneous fat at the thorax and abdomen.)

Organ packages

Organs are generally initially separated into the following packages:

  • Thorax
  • Gastrointestinal, including liver, spleen and pancreas.
  • Pelvic, including urinary bladder and uterus/prostate.

The kidneys and adrenals may be included in either the gastrointestinal or pelvic package.

Heart

edit

  • Remove the parietal pericardium
  • Separate the heart from the from lungs by cutting through the major vessels. The pulmonary artery should be cut first and the lumen inspected for any pulmonary embolism.
  • Dissect the coronary vesselsFurther information: Arteries
  • On the right side of the heart, dissect in the direction of blood flow: Superior vena cava > right atrium > tricuspid valve > right ventricle. Look for thromboses or patent foramen ovale.[notes 3]
  • Dissect the atrial appendages, to exclude thromboses.
  • Dissect the left ventricle, such as into circumferential slices from the apex to the base.[notes 4] Inspect (and measure) the left ventricular wall thickness.

Look for signs of myocardial infarction. Further information: Heart autopsy and Autopsy of myocardial infarction

Other thorax

  • Dissect the aorta, with an anterior dissection of the aortic arch and major branches, and posterior dissection of the descending thoracic aorta. Check for thrombosis and degree of atherosclerosis. Then separate the descending thoracic aorta from the esophagus.
Relations of the aorta, trachea, esophagus and other heart structures
  • Dissect the pulmonary arterial system, from the pulmonary trunk and including at least segmental arteries. To avoid cutting through the left main bronchus (passing anteriorly to the left main pulmonary artery), the initial dissection of the left main pulmonary artery may begin from an anterior perspective but keeping the cuts along the posterior wall, until the dissection can be seen and be continued from a posterior approach. Check the pulmonary arteries for thrombosis.
  • Esophagus: Distinguish from trachea and dissect
Blood clots[1]
Pre-mortem Post-mortem
Tumor embolus in the main pulmonary artery.jpg
Texture Dull Shiny
Wall adherence Yes No
Color Grey. Possibly zebraic appearance by lines of Zahn, with mixed red and grey/yellow Dark purple or bilayered yellow/red (by gravity sedimentation)
Pressurized Yes, can eject from lumen No, needs to be pulled-out
Consistency Firm and brittle Elastic, jellylike
  • Dissect the trachea and the bronchial tree, at least to segmental bronchi. Check for obstructions.
  • Make some additional sections through the lung parenchyma. Squeeze at each side to detect any pus and edema.[2] Further information: Lung autopsy.
  • Cut each thyroid lobe in horizontal slices and inspect the parenchyma. ((Look for parathyroid glands, and if found, inspect for nodules or hypertrophy. Further information: Parathyroid glands ))
  • Look for enlarged lymph nodes in the hilar and paratracheal area.

Retroperitoneal

For orientation, the coeliac trunk and mesenteric arteries exit the aorta from the anterior side.

  • Dissect the descending abdominal aorta. Cut external iliac artery from a dorsal approach, or after freeing ureters.[notes 5]
  • Inspect the renal arteries for patency. ((Dissect them until entry into kidneys.))
  • Make a couple of cuts through the adrenal glands, such as transversal ones, and look mainly for tumors. Further information: Adrenals
  • Cut the kidneys in the coronal planes. Further information: Kidney autopsy
  • Dissect the ureters to the bladder. Look for any increased caliber or abnormal contents.
  • Dissect the prostate in males, and the urinary bladder, by an anterior approach. Dissect the ureteropelvic junctions. Inspect the bladder content and the urothelial surface.
  • Dissect the rectum

Peritoneal

  • Remove the diaphragm and excess omentum
Dark spotting is a normal postmortem change of the stomach.
  • Dissect the stomach along the greater curvature, as well as the duodenum and the esophageal entry into the stomach.
  • Dissect the extrahepatic biliary tract and gallbladder.[notes 6]Further information: Gallbladder
  • Make consecutive liver slices, such as in the sagittal or coronal plane. Further information: Liver
"Long" and "short" axis.[3]

Note its shape, color and consistency.

  • Inspect the pancreas regarding color and consistency. ((Separate it and measure its dimensions.)) Cut it in consecutive short axis slices.[notes 7] Note the appearance of the parenchyma (and the size of the duct).
  • Separate the spleen and make consecutive short axis slices through it. Note its shape, color, texture and consistency.
  • Separate the intestines until the rectum, and dissect them by a longitudinal section, looking for focal and diffuse lesions. Note the presence or absence of the appendix.

Brain

edit

  • Inspect: Grooves indicating herniation? Hemorrhages?
  • Dissect the basilar artery and circle of Willis, either before or after separation from the brain.[notes 8] Look mainly for thromboses.
  • Separate the brainstem, cerebellum and cerebrum, which may be done by first separating the former two together from the cerebrum.
Normal brain versus in Alzheimer's disease.
  • Slice each part, looking for hemorrhages and/or infarcts. At least in people aged over 65-75 years of age {{or with suggestive history}}, look for signs of Alzhemier's disease (see picture).


Further information: Brain autopsy

Demonstration

Consider summoning involved clinicians for a demonstration of any findings.

Weighing

Separate and weigh these organs, either before or after cutting into them, but before tissue sampling.

Tissue sampling

Any tissues where histopathology may aid in establishing the cause of death. If there is no clear cause of death macroscopically after an autopsy, take routine samples:

Generally sample all gross lesions, except uterine fibroids, diverticula and multiple intestinal polyps. One sample is sufficient in case of multiple metastases. Lesion samples should include adjacent normal tissue.

Further information: Gross processing

Microbiology

Indications

Cultures for microbiology are indicated in the following cases, if less than 24 hours have passed since the time of death:[notes 9]

  • Fever of unknown origin
  • At request of the requesting physician
  • (Drug addicts
  • Patients from nursing homes)
Sites
  • Blood cultures from the right ventricle/atrium
  • Any exudates or pus collections
  • (Any organ suspected to have inflammation)
  • {{Cerebrospinal fluid if meningitis is suspected}}
  • {{Body fluids, by individual indication}}

Toxicology

  • {{Toxicology is taken if highly suspected from the history. Up to 2.5 ml can be obtained from each eye, using a red top tube.}}

Reporting of non-forensic autopsy

The order of the sections may vary.[4]

Data

  • Autopsy No.: ________
  • (Hospital No.:000046)
  • Patient name: Bloggs, Joe
  • (Patient No.:)
  • (Ward :_______)
  • Age [[or birthdate]]: _____
  • (Sex: ______)
  • (Race: ______)
  • (Permission: From [[usually close relative of the deceased.]])

((The medical records of the <<patient/deceased>> [[Either denomination works]] were reviewed prior to the commencement of the autopsy.))

  • Date (and time) of death: ______
  • Date (and time) of autopsy: ______
  • (Date of report: _________)
  • Attending physician: _______
  • (Prosector:__________)
  • {{Limitation of the autopsy}} [[such as restriction to thorax only]].

Final autopsy diagnosis / Preliminary diagnoses

[[May be preliminary if histopathology samples are taken.]]

  • [[First, generally the final cause of death, such as:]]
  • {{Acute circulatory failure with pulmonary edema and congestion of abdominal organs.}}
  • [[Other diagnoses that may have caused the death is listed in causative order:]]
  • {{Acute myocardial infarction.}}
  • {{Severe arteriosclerosis.}}
  • [[Other autopsy diagnoses, including presumably incidental ones:]]
  • {{Hepatic steatosis.}}
  • [[Clinically known diagnoses may be marked as such:]]
  • {{Type 2 diabetes (clinical diagnosis).}}
(Clinical history

_________)

(Laboratory data

_________)

External inspection

((The autopsy is performed approximately __ hours after death.)) The body is a ((well developed,)) << ((well nourished)) / {{underweight / overweight}}>> (__ year old) [[if not already given in data]]) << woman / man >>. ((The body appears as stated age.)) (Lengths is __ cm and weight is __ kg..)

Usual signs of death. (Rigor mortis is << well marked / broken >>. Lividity is seen on the << front / back and/or side >>.)

(On the torso there are no puncture marks or healed surgical scars.)

((The skin is <<pale / icteric / cyanotic>>. The body hair shows a normal <<male / female>> distribution. There is no peripheral edema. The head is not deformed. It is covered by <<scanty / moderate / abundant>> amount of [[color:]] ____ hair. The irides are [[color:]] ___. The pupils are round, regular and equal, measuring _cm in diameter. The corneae and lenses are transparent. The sclerae are clear. The conjunctivae are <<pink / pale>>. The nose and external ears are unremarkable and their passages are clear. The lips and gums show no lesions. {{The lips are pale/cyanotic.}} The mouth is not remarkable {{/edentulous /contains a frothy fluid}}. The neck structures are symmetrical, and there are no unusual masses. {{There is jugular venous distention}}. The thorax has normal contour and symmetry. [[In females:]] breasts and nipples are unremarkable. The abdomen is flat {{/protuberant}}. External abdominal palpation detects no abnormal masses or fluid waves. The extremities show no scars or deformities. The nails are normal {{/cyanotic/clubbed}}. No palpable inguinal masses.))

Internal examination

((Standard thoracic incisions are employed.))
{{Overall severe autolysis, making pathologic assessment difficult.}}
((The subcutaneous fat measures ___ in thickness over the thorax and _cm over the abdomen. The skeletal muscles are red-brown, normally firm and of normal bulk. There is no subcutaneous emphysema. The abdominal organs are in their usual anatomic positions. The diaphragmatic domes reach the <<sixth / seventh>> intercostal space, bilaterally.))

Serous cavities
No increased amount of fluid in the pericardial, pleural or abdominal cavities. Serous surfaces are smooth and lustrous.(No signs of inflammation. No adhesions.) [[These are preferably located by the corresponding system of each cavity:]]
  • ((The pleural surfaces are smooth and the cavities are dry. {{The <<right / left>> pleural cavity contains _cc/ml of <<clear / bloody / straw-colored>> fluid and show <<soft / hard>> adhesions.}}
  • The pericardial cavity contains _cc/ml of straw-colored fluid and shows no adhesions.
  • The peritoneal cavity contains _cc/ml of straw-colored fluid. ))
Circulatory system

edit
The heart << has normal weight / is enlarged [[ > 399 g in women and> 449 g in men]] >>, weighing ___ g. ((The epicardium is transparent. There is a moderate amount of subepicardial fat.

Normal configuration (No atrial or ventricular dilation. No ventricular wall thickening) / {{The left ventricle has {{concentric}} hypertrophy, with a wall thickness of ___ mm.}} ((No atrial or ventricular dilation. The right and left auricular appendage is unremarkable. The left ventricular wall thickness is __ cm and the right is ___. The trabeculae carneae are normal ({[Finding-begin}}/ prominent /flattened}}.))
[[A comprehensive report may describe each atrium, valve and ventricle etc. in order of blood flow.]]

(Foramen ovale is closed.) ((The ductus arteriosus is obliterated))
The coronary arteries ((arise in normal position. The coronary ostia are << patent {{partially occluded by arteriosclerotic calcification}}>>. They)) have << no / mild / moderate / severe >> {{and particually calcified}}
arteriosclerosis. They are traced, ((throughout their length by transverse sections)) {{after fixation and decalcification}} <<without significant constrictions.{{ / The lumina of the left anterior descending, right coronary, and left circumflex coronary arteries are _%, _%, and _% narrowed, respectively.}}>>

No thrombi in the cardiac atria (including auricles), chambers or coronary arteries.

Chordae tendineae, the endocardium and heart valves are unremarkable. (The endocardium is smooth and shiny. Chordae tendineae are unremarkable. The valves are normal in number, and are thin and fine at the openings.) ((The endocardium is smooth, transparent and free of mural thrombi. The valve leaflets and chordae tendinae are overall delicate, pliable and free of lesion or calcification. <<Its leaflets are thin and pliable / No signs of inflammation>>.
  • The tricuspid valve measures _cm in circumference.
  • The pulmonic valve measures _cm in circumference. It is composed of <<two / three>> cusps which are discrete and pliable.
  • The mitral valve measures _cm in circumference. Its leaflets are thin and pliable {{/ redundant / adherent to each other}}.
  • The aortic valve measures _ cm in circumference. It is composed of <<two / three>> cusps which are <<thin and pliable {{ / calcified at their bases / adherent to each other}}.

The epicardium and subepicardium are unremarkable. The papillary muscles are normal {{ / hypertrophied}}))

The myocardium has ((a homogeneous reddish brown color, and)) no signs of <<fresh lesion / ((areas of necrosis or hemorrhage))>> (or scar){{/ streaks of white scar tissue}}. In the aorta (and its major branches) there is {{widespread}} << no / mild / moderate / severe >> arteriosclerosis. No aneurysm. (Renal arteries ((are patent and)) have no significant stenosis.) No thrombus in (vena cava, ) the pulmonary arteries ((or the pulmonary veins)){{The <<right / left>> <<proximal and/or distal pulmonary arteries contain coiled, red-purple thromboemboli with(out) attachment to the intima.}} ((The portal system appears unremarkable. The vena cavae are also unremarkable. There is a free flow of blood from the veins of the lower extremities.))

Respiratory system
The larynx, trachea and bronchi are normally configured, with non-irritated lining. ((Larynx has normal configuration. The vocal cords are smooth and symmetrical. The trachea and the larger bronchi have non-irritated lining. No ulceration. Lumina are patent.)) {{The bronchial lumina contain small amounts of frothy mucoid material.}}

No foreign content((, dilatation or mucosal change)). ((Normal lobar structure. No tumor. No visible signs of inflammation.))
The lungs ((have the usual shape and lobar divisions, are expanded and)) have << normal / increased >> weight, of __ g on the right and ___ g on the left. (The consistency is normal) {{/ abnormally firm. There is <<minimal / moderate / extensive subpleural anthracotic pigment present.}}Cut Surfaces[notes 10] are unremarkably dark red, with no definable tumors( or bleeding).
{{There are firm with patchy areas of tan-grey consolidation of location. Watery and frothy liquid is pressed from the parenchyma, indicating pulmonary edema.}}
(The rib cage is intact) / {{Multiple rib fractures, consistent with CPR.}} ((There are no masses in the mediastinum.))

Digestive system

((The tongue has no bleeding.))

The esophagus, stomach and intestines are ordinarily configured, without tumors or blood in the lumen. ((The esophagus is lined by a smooth, tan-white non-irritated epithelium, and the mucosa has normal thickness. No diverticula, varices, mucosal tears or ulcerations.
The ventricle is of normal size, with normal wall-thickness. There is unremarkable <<partially digested food / fluid in the lumen>>, with no suspicion of blood content. The mucosa has well-formed rugae and shows <<no signs of lesions / {{mild / moderate erosions, but no ulceration}}. The gastric serosal surface is smooth.))

((The duodenum, jejunum and ileum and colon are ordinarily configured with non-irritated lining. Content is normal. The mucosa is intact throughout. No visible tumor. The ileocecal valve is competent.))

(The appendix is non-irritated and of normal size.)[notes 6] {{There are scattered <<colonic / sigmoid>> diverticula without inflammation or perforation.}}

The liver weighs ___g. The liver is << of normal size / {{enlarged}}, at ___g. [[</nowiki>Men: 970-1860 g.[5] Women 600-1770g.[6].<nowiki>]]

The liver surface is <<smooth ((and glistening)) {{/deformed by small and large nodules}}((, and is <<light tan / dark brown>> in color)). << Normal/ {{/ firm}} consistency. Cut surface[notes 10] is normal / << (shows normal homogeneous brown parenchyma) / {{Yellowish color, indicating steatosis}} / {{dark nutmeg similar paths, indicating congestion}}. (No focal changes.)((The liver edge is _cm below the right costal margin.)) The gallbladder has (regular size,) thin walls ((lined by a velvety green mucosa)). It contains {{__ number of gallstones measuring up to __ mm. Otherwise}} normal bile ((of about ___ ml [[or cc]]. No tumor or gallstones.)) {{Mild / Moderate / Severe cholesterolosis.}} ((The gallbladder serosa is smooth.))

Further information: Gallbladder

The (extrahepatic) bile ducts are open(, ordinary and without gallstones in the lumen).
The pancreas has normal size (and shape). Cut surfaces[notes 10] are normal((ly tan and lobulated, without bleeding or definable focal changes. The main pancreatic duct is patent.)).

Lymphoid and endocrine organs

The spleen is of << normal size {{ / Enlarged [[> 230g]]}}>>, at ___ g. Normal consistency / {{ Firm consistency indicating of chronic venous stasis}}. Cut surfaces[notes 10] have normal appearance / ( normal bluish-red color, with no definable focal changes). ((The splenic artery and vein are normal.))

The thyroid and adrenal glands are normal bilaterally / (are ordinarily configured and with no definable focal changes on cut surfaces[notes 10]). [[These are preferably located by the corresponding system of each cavity:]]((
  • The thyroid weighs _ grams and is symmetrical. Its consistency is soft {{/firm}}. Its external surface is brown and smooth {{/nodular / wrinkled}}. On sectioning it presents a homogeneous dark red appearance {{/contains several small nodules / contains a cyst}}. <<One/Two/Three/Four>> parathyroids are identified and appear normal. Further information: Parathyroid glands
  • The adrenals are normal in size, shape and consistency. The cortices are orange with <<normal / increased / decreased>> thickness. The medullas are grey (autolyzed).

))

No abnormal lymph nodes. ( Lymph nodes in para-tracheal, para-aortic and abdominal regions are of normal size, texture and color.)
((No definable focal changes on cut surfaces[notes 10].))
Urogenital

edit The kidneys are equally sized / (of normal size, with a total weight of ___ g)((a weight of ___ g on the right side and ___ g on the right)).

Sex Weight, reference range[notes 11]
Right kidney Left kidney Total
Men[7] 80–160 g (2.8–5.6 oz) 80–175 g (2.8–6.2 oz) 160-335g (5.6-12.8 oz)
Women[8] 40–175 g (1.4–6.2 oz) 35–190 g (1.2–6.7 oz) 75-365g (2.6-12.9 oz)


(No abnormal adhesions between the kidneys and surrounding fibrous capsules.)
The kidneys have smooth surfaces/ {{<<Finely / Coarsely>> granular brown surface, possibly indicating benign nephrosclerosis. There are a few cysts on the surface containing clear fluid}}. Cut surfaces have well-defined medulla, cortex, and papillae. {{The cortices and/or medullas are narrowed and congested. The papillary portions are intact.}}
The renal pelvis and ureters are unremarkable /( Renal pelvis and ureters have normal calibers, with non-irritated mucosal surfaces and open lumens).
The urinary bladder ((lies below the symphysis pubis and)) is unremarkable / ( is of normal size, with normal mucosa, and no tumor.)(( The urinary bladder contains __cc/ml of <<clear {{/ turbid}} urine. The wall is not thickened. The ureteral orifices are patent. The serosal surfaces are smooth and glistening {{and show <<soft / hard>> fibrous adhesions}})).
[[Either:]]

  • [[Male]]: The prostate is of <<normal size (( measures _x _ x _ cm>> and has normal color. The consistency is <<normal elastic)){{/ firm / nodular}}. (No definable focal changes on cut surfaces[notes 10]). The testes are ((descended {{, atrophic}} and)) without abnormal masses.(( The penis and scrotum are unremarkable.))
  • [[Female]]:
Uterus and adnexa are unremarkable.[notes 6] ((The uterus is normal. It measures __ x __ x __cm and weighs __ grams. Its serosal surface is <<smooth {{/ deformed by multiple nodules ranging between __ and _ cm}}>>. The cervix is unremarkable. The endometrial cavity is lined by a smooth atrophic velvety, tan membrane. The ovaries and fallopian tubes are normal.))
Central nervous system

edit

The meninges and venous sinuses are unremarkable. ((The skull is unremarkable. The calvarium is opened in the usual manner. The scalp and overlying fascia are not remarkable. The skull is <<normal in thickness {{/ somewhat thickened in the frontal areas}}. The cerebrospinal fluid is clear. The dura and venous sinuses are unremarkable. The leptomeninges are thin, shiny and non-irritated, with no visible bleeding. The superficial blood vessels are not congested. The sulci and gyri are <<normal {{/ flattened}}.

(No visible thrombi. No epidural, subdural or subarachnoid hematoma.)

The brain is symmetrical and weighs ___g. ( The cerebral and cerebellar hemispheres are of equal size, and have a normal weight of ___g. [[Men: 1.180 to 1.620 g. Women: 1.030 to 1.400 g]][9][10]
No signs of herniation (No grooves on the bases of the cerebrum or cerebellum.)

((The cerebral ventricles are of normal size, with normal linings.)) Cut surfaces ((after fixation)) of the cerebrum, cerebellum and brainstem show (normal gray and white parenchyma, and) no ((encephalomalacia, ))(hemorrhages, tumors or other) focal abnormalities. ((The gyral pattern is preserved.))
The basal cerebral arteries << are ordinary / {{have mild / moderate / severe atherosclerosis}}>> without aneurysms or occlusions.

Skeleton

Scalp and base of skull are ordinary / (without visible lesions or injuries).
((The vertebral column is unremarkable. The musculature is fairly well developed. There are no deformities of the musculoskeletal system. The bone marrow appears red and cellular.))

{{Other organs

if evaluated.}}

Histopathology

No samples taken / {{Tissue samples have been taken from the << heart, lungs, liver and/or kidneys >> for supplementary microscopic and/or bacteriological examination.}}

((Clinicopathologic correlation))

[[Discussion of how findings relate to the probable clinical course.]]

Microscopy report

{{Overall <<moderate / severe>> post-mortem autolysis((, making interpretations on cellular level <<difficult / unfeasible>>)).}} [[The degree of autolysis may be specified for each site individually.]]

(After the location identifier, each list item can generally begin as "This section/These sections[notes 12] << shows / reveals >>...)

  • Breast: No focal changes. {{Non-proliferative fibrocystic changes and microcalcifications.}}
  • Bone marrow from <<rib / __ [[other location]] >>: Trilineage hematopoiesis. There is no evidence of malignancy. Further information: Bone marrow
  • Lymph nodes at __ [[ location]]: __ [[number of]] benign{{, reactive lymph node(s) with anthracotic pigment deposition}}.
  • Heart: Sections of ___ [[location]] show no evidence of infarction.
  • Coronary arteries: Sections of the three main coronary arteries reveal << mild / moderate / severe>> atherosclerosis, with approximately __%, __% and __% stenosis of the left anterior descending, left circumflex coronary artery and right coronary artery, respectively. Further information: Arteries
  • Thyroid gland: Normal follicles with no focal changes.
  • Parathyroid: <<1, 2, 3, 4>> parathyroid gland(s) examined, with no focal changes or signs of hyperplasia. Further information: Parathyroid
  • Pituitary gland: Adenohypophysis and neurohypophysis with no focal changes. Further information: Pituitary
  • Liver: {{Congested}} parenchyma with no focal changes.
  • Adrenal glands: Right and left adrenal glands with no focal changes. (Unremarkable cortices and medullae.)
  • Spleen: Normal distribution and architecture of the red and white pulp.
  • Kidneys: Both kidneys show {{<<mild / moderate / severe >> <<generalized / focal / nodular>> glomerular sclerosis, and <<mild / moderate / severe >> arteriosclerosis.}} No focal changes
  • Gastro-esophageal junction: Squamo-epithelial junction with no metaplasia or dysplasia.
  • Pancreas: (Pancreatic parenchyma with) no focal changes
  • Lungs: {{Sections of all lobes of the lung}} show vascular congestion. (There is no evidence of edema acute bronchopneumonia, malignancy or thromboemboli.)
  • Urinary bladder: <<Normal {{/ autolytically denuded}}>> urothelium.
  • Brain: There is no evidence of hemorrhage, tumor, metastatic disease or vasculitis. Further information: Brain autopsy

Males:

  • Testis: No focal changes.
  • Prostate: No focal changes.

Females:

  • Uterus: No focal changes.
  • Ovary: No focal changes.
See also: General notes on reporting

Licensing

The report examples in this article are Public Domain, and can be copied without any need for author attribution. Rest of content is available under the Attribution 4.0 International license. See Patholines:Copyright for details.

Notes

  1. For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.
  2. Confirmation with a supervisor ought to be done each time until that person tells that it is not necessary.
  3. The right ventricle can alternatively be cut in circumferential slices along with the left ventricle.
  4. An alternative approach is to cut the left ventricle through a cut along the left lateral margin, followed by an anterior cut from the apex to the aortic root, freeing the anterior wall. Then cut through the plane of the myocardium of the anterior and posterior myocardial wall, as well as the septum, for any signs of infarction. (Dissect one or more papillary muscles for infarction.)
  5. Measures are taken to avoid cutting through the ureters.
  6. 6.0 6.1 6.2 An appearance like after extirpation such as cholecystectomy, hysterectomy (with bilateral salpingo-oophorectomy) and/or appendectomy, may be reported as "Appearance like after ___". An attempt should be made to confirm it from available medical records.
  7. The pancreas may also be cut in the longitudinal plane.
  8. The arteries of the skull base are preferably dissected after separation from the brain if there is a need to demonstrate the case.
  9. After 24 hours, the likelihood of bacterial contamination and thereby false positive results is high, generally making cultures not indicated.
  10. 10.0 10.1 10.2 10.3 10.4 10.5 10.6 "Cut surface shows..." may alternatively be expressed as "On sectioning the parenchyma is..."
  11. Renal weight range is the standard reference range, that is, defined as the interval between which 95% of values of a reference population fall into.
  12. This wording distinguishes single from multiple section, and emphasizes that sections are representative, and do not cover the entire volume.

Main page

References

The standard reference range reference is duplicated because of technical reasons by being included in Patholines:Templates.
  1. Michael Bonert. Autopsy. Page was last modified: 6 September 2016
  2. Burton, Julian L.; Rutty, Guy N. (2010). The Hospital Autopsy A Manual of Fundamental Autopsy Practice (3rd ed.). Oxford University Press. ISBN 978-0340965146. 
  3. Pellerito, John; Polak, Joseph F. (2012). Introduction to Vascular Ultrasonography (6th ed.). Elsevier Health Sciences. p. 559. ISBN 978-1-4557-3766-6. 
  4. The report is partially inspired from: . Autopsy Report No. A97-015. State University of New York Health Science Center at Syracuse, Department of pathology (1997-05-26).
  5. Standard reference range: Molina, D. Kimberley; DiMaio, Vincent J.M. (2012). "Normal Organ Weights in Men ". The American Journal of Forensic Medicine and Pathology 33 (4): 368–372. doi:10.1097/PAF.0b013e31823d29ad. ISSN 0195-7910. 
  6. Standard reference range: Molina, D. Kimberley; DiMaio, Vincent J. M. (2015). "Normal Organ Weights in Women ". The American Journal of Forensic Medicine and Pathology 36 (3): 182–187. doi:10.1097/PAF.0000000000000175. ISSN 0195-7910. 
  7. Standard reference range: Molina, D. Kimberley; DiMaio, Vincent J.M. (2012). "Normal Organ Weights in Men ". The American Journal of Forensic Medicine and Pathology 33 (4): 368–372. doi:10.1097/PAF.0b013e31823d29ad. ISSN 0195-7910. 
  8. Standard reference range: Molina, D. Kimberley; DiMaio, Vincent J. M. (2015). "Normal Organ Weights in Women ". The American Journal of Forensic Medicine and Pathology 36 (3): 182–187. doi:10.1097/PAF.0000000000000175. ISSN 0195-7910. 
  9. Standard reference range: Molina, D. Kimberley; DiMaio, Vincent J.M. (2012). "Normal Organ Weights in Men ". The American Journal of Forensic Medicine and Pathology 33 (4): 368–372. doi:10.1097/PAF.0b013e31823d29ad. ISSN 0195-7910. 
  10. Standard reference range: Molina, D. Kimberley; DiMaio, Vincent J. M. (2015). "Normal Organ Weights in Women ". The American Journal of Forensic Medicine and Pathology 36 (3): 182–187. doi:10.1097/PAF.0000000000000175. ISSN 0195-7910.