Autopsy: Difference between revisions
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{{Top | <noinclude>{{Top | ||
|author1=[[User:Mikael Häggström|Mikael Häggström]] | |author1=[[User:Mikael Häggström|Mikael Häggström]] | ||
|author2= | |author2= | ||
}} | }}</noinclude> | ||
The extremely minimal autopsy checklist: | The extremely minimal autopsy checklist: | ||
*Check the autopsy '''referral''' | *Check the autopsy '''referral''' | ||
| Line 10: | Line 10: | ||
*'''Report''' at least relevant findings | *'''Report''' at least relevant findings | ||
A separate article is given on: | <noinclude>A separate article is given on: | ||
*'''[[Fetopsy in third trimester and stillbirth]]''' | *'''[[Fetopsy in third trimester and stillbirth]]''' | ||
{{Autopsy - comprehensiveness|otherlegend=yes}} | {{Autopsy - comprehensiveness|otherlegend=yes}} | ||
</noinclude> | |||
==Checklist for non-forensic autopsy== | ==Checklist for non-forensic autopsy== | ||
There are many variants, with the following being a suggestion: | There are many variants, with the following being a suggestion: | ||
===Preparations=== | ===Preparations=== | ||
*Confirm that there is a '''consent''' from the next of kin to perform the autopsy, and whether it includes any restrictions (such as only examining the thorax). | |||
*Confirm that there is a '''consent''' from the next of kin to perform the autopsy, and whether it includes any restrictions. | *Read the autopsy '''referral''' (if separate from the consent form){{Moderate-begin}} and talk with the referring person and/or family why they want the autopsy and what they want to be investigated in particular, if not already evident from the referral. Surprisingly often, the main reason for performing an autopsy is not the cause of death in itself, but for some other question by the clinician or relative, such as a cause of a dementia. This information helps you focus on the most pertinent locations and possible findings to answer the question.{{Moderate-end}} | ||
*Confirm with any '''supervisor''' what you may do independently | *Confirm with any '''supervisor''' what you may do independently, and at what stages the supervisor will want to inspect the body and/or organs (for example before evisceration and/or after all pertinent organs have been opened).<ref group=note>Confirmation with a supervisor ought to be done each time until that person tells that it is not necessary.</ref> | ||
*{{Moderate-begin}}Go through the patient's '''medical records''', at least if necessary aspects are not included in the referral. The most important aspects are: | *{{Moderate-begin}}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 | :*Time of death | ||
:*Surgical history | :*Surgical history | ||
:*Current diseases | :*Current diseases | ||
:*Latest hospital and/or primary care notes{{Moderate-end}} | :*Latest hospital and/or primary care notes | ||
:*Presence of any pacemaker or implantable cardioverter-defibrillator (ICD). If present, make sure it is deactivated before cutting open the chest. Generally remove it during autopsy as they may explode if the body is cremated.{{Moderate-end}} | |||
:*{{Comprehensive-begin}}History of smoking | :*{{Comprehensive-begin}}History of smoking | ||
:*Medications, especially anticoagulant ones. | :*Medications, especially anticoagulant ones. | ||
| Line 31: | Line 33: | ||
In the autopsy room, before starting examination: | In the autopsy room, before starting examination: | ||
* | *Charge and bring a '''camera''' to document relevant findings. | ||
*Use '''protective wear''', generally according to local practice. Tie any knots before putting on gloves for better dexterity. | *Use '''protective wear''', generally according to local practice. Tie any knots before putting on gloves for better dexterity. | ||
*Confirm the '''identity''' of the body, generally from attached identity tag. | *Confirm the '''identity''' of the body, generally from attached identity tag. | ||
| Line 60: | Line 62: | ||
*Also, squeeze out bone marrow on a piece of wrapping tissue and submit. | *Also, squeeze out bone marrow on a piece of wrapping tissue and submit. | ||
*Perform in situ examination as per checklist. | *Perform in situ examination as per checklist. | ||
[[File:Gross pathology of a peritoneal loose body.jpg|thumb|180px|'''Peritoneal loose bodies''' may be found in the peritoneal cavity, and are generally caused by torsion and autoamputation of an epiploic appendage, which eventually becomes embedded in a fibrous capsule.]] | |||
;Bowel removal: | ;Bowel removal: | ||
*Pull up stomach and find the ligament of Treitz (pictured). | *Pull up stomach and find the ligament of Treitz (pictured). | ||
| Line 66: | Line 68: | ||
*Cut the mesenteric adipose close to the bowel, without perforating it. | *Cut the mesenteric adipose close to the bowel, without perforating it. | ||
*When you reach the rectum, place two hemostats and cut through the bowel between the clamps as before. | *When you reach the rectum, place two hemostats and cut through the bowel between the clamps as before. | ||
;Supra-pelvic organ blocks | ;Supra-pelvic organ blocks | ||
*Cut the diaphragm free from the body wall on both sides extending down to the spinal column. | *Cut the diaphragm free from the body wall on both sides extending down to the spinal column. | ||
| Line 130: | Line 132: | ||
===Other thorax=== | ===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. | *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. | ||
[[File:Relations of the aorta, trachea, esophagus and other heart structures.png|thumb|Relations of the aorta, trachea, esophagus and other heart structures]] | [[File:Relations of the aorta, trachea, esophagus and other heart structures.png|thumb|300px|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 | *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 blood clots. | ||
{|class="wikitable" align="center" | |||
{|class="wikitable" align=" | |||
|+Blood clots<ref>{{cite web|url=https://librepathology.org/wiki/Autopsy|title=Autopsy|author=Michael Bonert}} Page was last modified: 6 September 2016</ref> | |+Blood clots<ref>{{cite web|url=https://librepathology.org/wiki/Autopsy|title=Autopsy|author=Michael Bonert}} Page was last modified: 6 September 2016</ref> | ||
! !! Pre-mortem !! Post-mortem | ! !! Pre-mortem !! Post-mortem | ||
|- | |- | ||
| || [[File:Tumor embolus in the main pulmonary artery.jpg| | | || [[File:Tumor embolus in the main pulmonary artery.jpg|200px]] || [[File:Gross pathology of a postmortem blood clot.jpg|200px]] | ||
|- | |- | ||
| Texture || Dull || Shiny | | Texture || Dull || Shiny | ||
| Line 145: | Line 146: | ||
| Color | | Color | ||
| Grey. Possibly zebraic appearance by lines of Zahn, with mixed red and grey/yellow | | Grey. Possibly zebraic appearance by lines of Zahn, with mixed red and grey/yellow | ||
| Dark | | Dark-red ("currant jelly") to tan-pink ("chicken-fat") | ||
|- | |- | ||
|Pressurized | |Pressurized | ||
| Line 153: | Line 154: | ||
|Consistency || Firm and brittle || Elastic, jellylike | |Consistency || Firm and brittle || Elastic, jellylike | ||
|} | |} | ||
*'''Esophagus''': Separate it from the trachea and dissect it. | |||
*Dissect the '''trachea''' and the '''bronchial tree''', at least to segmental bronchi. Check for obstructions. | *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.<ref>{{cite book |author=Burton, Julian L.; Rutty, Guy N. |title=The Hospital Autopsy A Manual of Fundamental Autopsy Practice |publisher=Oxford University Press |location= |year=2010 |pages= {{{1|}}} |edition=3rd |isbn=978-0340965146 |oclc= |doi= |accessdate=}}</ref> {{Further|Lung autopsy}} | *Make some additional sections through the '''lung parenchyma'''. Squeeze at each side to detect any pus and edema.<ref>{{cite book |author=Burton, Julian L.; Rutty, Guy N. |title=The Hospital Autopsy A Manual of Fundamental Autopsy Practice |publisher=Oxford University Press |location= |year=2010 |pages= {{{1|}}} |edition=3rd |isbn=978-0340965146 |oclc= |doi= |accessdate=}}</ref> {{Further|Lung autopsy}} | ||
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===Retroperitoneal=== | ===Retroperitoneal=== | ||
For orientation, the coeliac trunk and mesenteric arteries exit the aorta from the anterior side. | 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.<ref group= | *Dissect the '''descending abdominal aorta'''. Cut external iliac artery from a dorsal approach, or after freeing ureters.<ref group=note>Measures are taken to avoid cutting through the '''ureters'''.</ref> | ||
*Inspect the '''renal arteries''' for patency. {{Comprehensive-begin}}Dissect them until entry into kidneys.{{Comprehensive-end}} | *Inspect the '''renal arteries''' for patency. {{Comprehensive-begin}}Dissect them until entry into kidneys.{{Comprehensive-end}} | ||
*Make a couple of cuts through the '''adrenal glands''', such as transversal ones, and look mainly for tumors. {{Further|Adrenals|linebreak=no}} | *Make a couple of cuts through the '''adrenal glands''', such as transversal ones, and look mainly for tumors. {{Further|Adrenals|linebreak=no}} | ||
| Line 172: | Line 174: | ||
===Peritoneal=== | ===Peritoneal=== | ||
*Remove the '''diaphragm''' and excess omentum | *Remove the '''diaphragm''' and excess omentum | ||
[[File:Gross pathology of | [[File:Gross pathology of Wischnewski spots of the stomach - crop.jpg|thumb|200px|Wischnewski spots of the stomach are associated with hypothermia.<ref>{{cite journal| author=Çetýn S, Ýnanir NT, Eren F, Eren B, Dokgöz H| title=Wischnewsky Spots in Fatal Hypothermia: Case Report. | journal=Maedica (Bucur) | year= 2015 | volume= 10 | issue= 3 | pages= 280-282 | pmid=28261368 | doi= | pmc=5327835 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28261368 }}</ref>]] | ||
*Dissect the '''stomach''' along the greater curvature, as well as the '''duodenum''' and the esophageal entry into 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'''.<ref group= | *Dissect the extrahepatic '''biliary tract''' and '''gallbladder'''.<ref group=note name=missing>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.</ref>{{Further|Gallbladder|linebreak=no}} | ||
*Make consecutive '''liver slices''', such as in the sagittal or coronal plane. {{Further|Liver|linebreak=no}} | *Make consecutive '''liver slices''', such as in the sagittal or coronal plane. {{Further|Liver|linebreak=no}} | ||
[[File:Long and short axis.png|thumb|130px|"Long" and "short" axis.<ref>{{cite book|title=Introduction to Vascular Ultrasonography|first1=John |last1=Pellerito |first2=Joseph F. |last2=Polak|edition=6th|publisher=Elsevier Health Sciences|year=2012|isbn=978-1-4557-3766-6 |page=[https://books.google.com/books?id=safNmcP3lakC&pg=PA559 559]}}</ref>]] Note its shape, color and consistency. | [[File:Long and short axis.png|thumb|130px|"Long" and "short" axis.<ref>{{cite book|title=Introduction to Vascular Ultrasonography|first1=John |last1=Pellerito |first2=Joseph F. |last2=Polak|edition=6th|publisher=Elsevier Health Sciences|year=2012|isbn=978-1-4557-3766-6 |page=[https://books.google.com/books?id=safNmcP3lakC&pg=PA559 559]}}</ref>]] Note its shape, color and consistency. | ||
| Line 209: | Line 211: | ||
===Tissue sampling=== | ===Tissue sampling=== | ||
Sample tissues for microscopy from wherever histopathology may aid in establishing the cause of death. Following are routine samples: | |||
{{col-begin}} | {{col-begin}} | ||
{{col-2}} | {{col-2}} | ||
| Line 221: | Line 223: | ||
*'''Liver''', away from the capsule. | *'''Liver''', away from the capsule. | ||
*Each '''kidney''', including cortex, medulla{{Moderate-begin}}, papilla and calyx{{Moderate-end}} | *Each '''kidney''', including cortex, medulla{{Moderate-begin}}, papilla and calyx{{Moderate-end}} | ||
*'''Adrenal glands'''. If grossly unremarkable, a slice of the right adrenal gland may be submitted together with a slice of the right kidney, and the same for the left side. | |||
*{{Moderate-begin}}'''Bone marrow''' (such as from squeezing at the edge of a rib) | *{{Moderate-begin}}'''Bone marrow''' (such as from squeezing at the edge of a rib) | ||
*Each '''breast''' in females | *Each '''breast''' in females | ||
*'''Pituitary''' | *'''Pituitary''' | ||
*'''Thyroid'''{{Moderate-end}} | *'''Thyroid'''{{Moderate-end}} | ||
{{col-2}} | {{col-2}} | ||
| Line 248: | Line 250: | ||
*'''Skeletal muscle'''{{Comprehensive-end}} | *'''Skeletal muscle'''{{Comprehensive-end}} | ||
{{col-end}} | {{col-end}} | ||
In addition, 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. | |||
Furthermore, generally '''save''' a piece of tissue in formalin from at least all sampled locations, in case the sample gets lost or gets processed incorrectly. | |||
{{Further|Gross processing}} | {{Further|Gross processing}} | ||
===Microbiology=== | ===Microbiology=== | ||
;Indications | ;Indications | ||
Cultures for microbiology are indicated in the following cases, if less than 24 hours have passed since the time of death:<ref group= | Cultures for microbiology are indicated in the following cases, if less than 24 hours have passed since the time of death:<ref group=note>After 24 hours, the likelihood of bacterial contamination and thereby false positive results is high, generally making cultures not indicated.</ref> | ||
*Fever of unknown origin | *Fever of unknown origin | ||
*At request of the requesting physician | *At request of the requesting physician | ||
| Line 271: | Line 275: | ||
==Reporting of non-forensic autopsy== | ==Reporting of non-forensic autopsy== | ||
;The order of the sections may vary.<ref>The report is partially inspired from: {{cite web|url=https://www.cdc.gov/niosh/docket/archive/pdfs/niosh-099c/0099C-041210-Satterley_Exhibit13.pdf|title=Autopsy Report No. A97-015|website=State University of New York Health Science Center at Syracuse, Department of pathology|date=1997-05-26}}</ref> | ;The order of the sections may vary.<ref>The report is partially inspired from: {{cite web|url=https://www.cdc.gov/niosh/docket/archive/pdfs/niosh-099c/0099C-041210-Satterley_Exhibit13.pdf|title=Autopsy Report No. A97-015|website=State University of New York Health Science Center at Syracuse, Department of pathology|date=1997-05-26}}</ref> | ||
{{Comprehensive-begin}}Where findings are made, still negate additional findings in the region, such as: ''"There is a 18.0 cm curvilinear well-healed thin scar in the left thorax. Otherwise, there are no puncture marks or healed surgical scars on the torso."''{{Comprehensive-end}} | |||
===Data=== | ===Data=== | ||
| Line 318: | Line 324: | ||
{{Moderate-begin}}On the '''torso''' there are no puncture marks or healed surgical scars.{{Moderate-end}} | {{Moderate-begin}}On the '''torso''' there are no puncture marks or healed surgical scars.{{Moderate-end}} | ||
{{Comprehensive-begin}}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 {{Comment-begin}}color:{{Comment-end}} ____ '''hair'''. The irides are {{Comment-begin}}color:{{Comment-end}} ___. 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. {{Finding-begin}}The lips are pale/cyanotic.{{Finding-end}} The '''mouth''' is not remarkable {{Finding-begin}}/edentulous /contains a frothy fluid{{Finding-end}}. The '''neck''' structures are symmetrical, and there are no unusual masses. {{Finding-begin}}There is jugular venous distention{{Finding-end}}. The '''thorax''' has normal contour and symmetry. {{Comment-begin}}In females:{{Comment-end}} breasts and nipples are unremarkable. The abdomen is flat {{Finding-begin}}/protuberant{{Finding-end}}. External abdominal palpation detects no abnormal masses or fluid waves. The '''extremities''' show no scars or deformities. The '''nails''' are normal {{Finding-begin}}/cyanotic/clubbed{{Finding-end}}. No palpable '''inguinal''' masses.{{Comprehensive-end}} | {{Comprehensive-begin}}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 {{Comment-begin}}color:{{Comment-end}} ____ '''hair'''. The irides are {{Comment-begin}}color:{{Comment-end}} ___. 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. {{Finding-begin}}The lips are pale/cyanotic.{{Finding-end}} The '''mouth''' is not remarkable {{Finding-begin}}/edentulous /contains a frothy fluid{{Finding-end}}. The '''neck''' structures are symmetrical, and there are no unusual masses. {{Finding-begin}}There is jugular venous distention{{Finding-end}}. The '''thorax''' has normal contour and symmetry. {{Comment-begin}}In females:{{Comment-end}} breasts and nipples are unremarkable. {{Moderate-begin}}The '''back''' has lividity.{{Moderate-end}} The abdomen is flat {{Finding-begin}}/protuberant{{Finding-end}}. External abdominal palpation detects no abnormal masses or fluid waves. The '''extremities''' show no scars or deformities. The '''nails''' are normal {{Finding-begin}}/cyanotic/clubbed{{Finding-end}}. No palpable '''inguinal''' masses.{{Comprehensive-end}} | ||
===Internal examination=== | ===Internal examination=== | ||
| Line 347: | Line 353: | ||
No foreign content{{Comprehensive-begin}}, dilatation or mucosal change{{Comprehensive-end}}. | No foreign content{{Comprehensive-begin}}, dilatation or mucosal change{{Comprehensive-end}}. | ||
{{Comprehensive-begin}}Normal lobar structure. No tumor. No visible signs of inflammation.{{Comprehensive-end}} | {{Comprehensive-begin}}Normal lobar structure. No tumor. No visible signs of inflammation.{{Comprehensive-end}} | ||
<br>The '''lungs''' {{Comprehensive-begin}}have the usual shape and lobar divisions, are expanded and{{Comprehensive-end}} have << normal / increased >> weight, of __ g on the right and ___ g on the left. {{Moderate-begin}}The consistency is normal{{Moderate-end}} {{Finding-begin}}/ abnormally firm. There is <<minimal / moderate / extensive subpleural anthracotic pigment present.{{Finding-end}}Cut Surfaces<ref group= | <br>The '''lungs''' {{Comprehensive-begin}}have the usual shape and lobar divisions, are expanded and{{Comprehensive-end}} have << normal / increased >> weight, of __ g on the right and ___ g on the left. {{Moderate-begin}}The consistency is normal{{Moderate-end}} {{Finding-begin}}/ abnormally firm. There is <<minimal / moderate / extensive subpleural anthracotic pigment present.{{Finding-end}}Cut Surfaces<ref group=note name=cut-surfaces/> are unremarkably dark red, with no definable tumors{{Moderate-begin}} or bleeding{{Moderate-end}}. | ||
<br>{{Finding-begin}}There are firm with patchy areas of tan-grey consolidation of [[location]]. Watery and frothy liquid is pressed from the parenchyma, indicating pulmonary edema.{{Finding-end}} | <br>{{Finding-begin}}There are firm with patchy areas of tan-grey consolidation of [[location]]. Watery and frothy liquid is pressed from the parenchyma, indicating pulmonary edema.{{Finding-end}} | ||
<br>{{Moderate-begin}}The rib cage is intact{{Moderate-end}} / {{Finding-begin}}Multiple rib fractures, consistent with CPR.{{Finding-end}} {{Comprehensive-begin}}There are no masses in the mediastinum.{{Comprehensive-end}} | <br>{{Moderate-begin}}The rib cage is intact{{Moderate-end}} / {{Finding-begin}}Multiple rib fractures, consistent with CPR.{{Finding-end}} {{Comprehensive-begin}}There are no masses in the mediastinum.{{Comprehensive-end}} | ||
| Line 357: | Line 363: | ||
| {{Comprehensive-begin}}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.<br>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 / {{Finding-begin}}mild / moderate erosions, but no ulceration{{Finding-end}}. The gastric serosal surface is smooth.{{Comprehensive-end}}<br>{{Comprehensive-begin}}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.{{Comprehensive-end}} | | {{Comprehensive-begin}}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.<br>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 / {{Finding-begin}}mild / moderate erosions, but no ulceration{{Finding-end}}. The gastric serosal surface is smooth.{{Comprehensive-end}}<br>{{Comprehensive-begin}}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.{{Comprehensive-end}} | ||
|} | |} | ||
{{Moderate-begin}}The appendix is non-irritated and of normal size.{{Moderate-end}}<ref group= | {{Moderate-begin}}The appendix is non-irritated and of normal size.{{Moderate-end}}<ref group=note name=missing/> | ||
{{Finding-begin}}There are scattered <<colonic / sigmoid>> diverticula without inflammation or perforation.{{Finding-end}} | {{Finding-begin}}There are scattered <<colonic / sigmoid>> diverticula without inflammation or perforation.{{Finding-end}} | ||
{{Autopsy report of liver}} | |||
The '''gallbladder''' has {{Moderate-begin}}regular size,{{Moderate-end}} thin walls {{Comprehensive-begin}}lined by a velvety green mucosa{{Comprehensive-end}}. It contains {{Finding-begin}}__ [[number of]] gallstones measuring up to __ mm. Otherwise{{Finding-end}} normal bile {{Comprehensive-begin}}of about ___ ml {{Comment-begin}}or cc{{Comment-end}}. No tumor or gallstones.{{Comprehensive-end}} {{Finding-begin}}Mild / Moderate / Severe cholesterolosis.{{Finding-end}} {{Comprehensive-begin}}The gallbladder serosa is smooth.{{Comprehensive-end}} {{Further|Gallbladder}} | The '''gallbladder''' has {{Moderate-begin}}regular size,{{Moderate-end}} thin walls {{Comprehensive-begin}}lined by a velvety green mucosa{{Comprehensive-end}}. It contains {{Finding-begin}}__ [[number of]] gallstones measuring up to __ mm. Otherwise{{Finding-end}} normal bile {{Comprehensive-begin}}of about ___ ml {{Comment-begin}}or cc{{Comment-end}}. No tumor or gallstones.{{Comprehensive-end}} {{Finding-begin}}Mild / Moderate / Severe cholesterolosis.{{Finding-end}} {{Comprehensive-begin}}The gallbladder serosa is smooth.{{Comprehensive-end}} {{Further|Gallbladder}} | ||
The {{Moderate-begin}}extrahepatic{{Moderate-end}} '''bile ducts''' are open{{Moderate-begin}}, ordinary and without gallstones in the lumen{{Moderate-end}}.<br>The '''[[pancreas]]''' has normal size {{Moderate-begin}}and shape, measuring __ {{Moderate-end}}{{Comment-begin}}dimensions or weight{{Comment-end}}. Cut surfaces<ref group= | The {{Moderate-begin}}extrahepatic{{Moderate-end}} '''bile ducts''' are open{{Moderate-begin}}, ordinary and without gallstones in the lumen{{Moderate-end}}.<br>The '''[[pancreas]]''' has normal size {{Moderate-begin}}and shape, measuring __ {{Moderate-end}}{{Comment-begin}}dimensions or weight{{Comment-end}}. Cut surfaces<ref group=note name=cut-surfaces>"Cut surface shows..." may alternatively be expressed as "On sectioning, the parenchyma is..."</ref> are normal{{Comprehensive-begin}}ly tan and lobulated, without bleeding or definable focal changes. The main pancreatic duct is patent.{{Comprehensive-end}}. | ||
;Lymphoid and endocrine organs | ;Lymphoid and endocrine organs | ||
The '''spleen''' is of << normal size {{Finding-begin}} / Enlarged {{Comment-begin}}> 230g{{Comment-end}}{{Finding-end}}>>, at ___ g. Normal consistency / {{Finding-begin}} Firm consistency indicating of chronic venous stasis{{Finding-end}}. Cut surfaces<ref group= | The '''spleen''' is of << normal size {{Finding-begin}} / Enlarged {{Comment-begin}}> 230g{{Comment-end}}{{Finding-end}}>>, at ___ g. Normal consistency / {{Finding-begin}} Firm consistency indicating of chronic venous stasis{{Finding-end}}. Cut surfaces<ref group=note name=cut-surfaces/> have normal appearance / {{Moderate-begin}} normal bluish-red color, with no definable focal changes{{Moderate-end}}. {{Comprehensive-begin}}The splenic artery and vein are normal.{{Comprehensive-end}} | ||
{|class="wikitable" | {|class="wikitable" | ||
| The '''thyroid''' and '''adrenal glands''' are normal bilaterally / {{Moderate-begin}}are ordinarily configured and with no definable focal changes on cut surfaces<ref group= | | The '''thyroid''' and '''adrenal glands''' are normal bilaterally / {{Moderate-begin}}are ordinarily configured and with no definable focal changes on cut surfaces<ref group=note name=cut-surfaces/>{{Moderate-end}}. | ||
| {{Comment-begin}}These are preferably located by the corresponding system of each cavity:{{Comment-end}}{{Comprehensive-begin}} | | {{Comment-begin}}These are preferably located by the corresponding system of each cavity:{{Comment-end}}{{Comprehensive-begin}} | ||
*The thyroid weighs _ grams {{Comment-begin}}Up to 30 g versus over 30 g grams is an accepted cutoff between normal and increased weight of the thyroid gland<ref name="ShamimMonira1970">{{cite journal|last1=Shamim|first1=A|last2=Monira|first2=K|last3=Manowara|first3=B|last4=Sabiha|first4=M|last5=Alim|first5=A|last6=Nurunnabi|first6=ASM|title=Weight of the Human Thyroid Gland A Postmortem Study|journal=Bangladesh Journal of Medical Science|volume=9|issue=1|year=1970|pages=44–48|issn=2076-0299|doi=10.3329/bjms.v9i1.5230}}<br>- In turn citing: Langer P. Discussion about the limit between normal thyroid and goiter: mini review. Endocrine regulations. 1999 March; 33(1): 39-45.</ref>{{Comment-end}} and is symmetrical. Its consistency is soft {{Finding-begin}}/firm{{Finding-end}}. Its external surface is brown and smooth {{Finding-begin}}/nodular / wrinkled{{Finding-end}}. On sectioning it presents a homogeneous dark red appearance {{Finding-begin}}/contains several small nodules / contains a cyst{{Finding-end}}. <<One/Two/Three/Four>> parathyroids are identified and appear normal. {{Further|Parathyroid glands|linebreak=no}} | *The thyroid weighs _ grams {{Comment-begin}}Up to 30 g versus over 30 g grams is an accepted cutoff between normal and increased weight of the thyroid gland<ref name="ShamimMonira1970">{{cite journal|last1=Shamim|first1=A|last2=Monira|first2=K|last3=Manowara|first3=B|last4=Sabiha|first4=M|last5=Alim|first5=A|last6=Nurunnabi|first6=ASM|title=Weight of the Human Thyroid Gland A Postmortem Study|journal=Bangladesh Journal of Medical Science|volume=9|issue=1|year=1970|pages=44–48|issn=2076-0299|doi=10.3329/bjms.v9i1.5230}}<br>- In turn citing: Langer P. Discussion about the limit between normal thyroid and goiter: mini review. Endocrine regulations. 1999 March; 33(1): 39-45.</ref>{{Comment-end}} and is symmetrical. Its consistency is soft {{Finding-begin}}/firm{{Finding-end}}. Its external surface is brown and smooth {{Finding-begin}}/nodular / wrinkled{{Finding-end}}. On sectioning it presents a homogeneous dark red appearance {{Finding-begin}}/contains several small nodules / contains a cyst{{Finding-end}}. <<One/Two/Three/Four>> parathyroids are identified and appear normal. {{Further|Parathyroid glands|linebreak=no}} | ||
| Line 378: | Line 379: | ||
|} | |} | ||
{|class="wikitable" | {|class="wikitable" | ||
| No abnormal lymph nodes. || {{Moderate-begin}} Lymph nodes in para-tracheal, para-aortic and abdominal regions are of normal size, texture and color.{{Moderate-end}}<br>{{Comprehensive-begin}}No definable focal changes on cut surfaces<ref group= | | No abnormal lymph nodes. || {{Moderate-begin}} Lymph nodes in para-tracheal, para-aortic and abdominal regions are of normal size, texture and color.{{Moderate-end}}<br>{{Comprehensive-begin}}No definable focal changes on cut surfaces<ref group=note name=cut-surfaces/>.{{Comprehensive-end}} | ||
|} | |} | ||
| Line 385: | Line 386: | ||
<br>The '''urinary bladder''' {{Comprehensive-begin}}lies below the symphysis pubis and{{Comprehensive-end}} is unremarkable / {{Moderate-begin}} is of normal size, with normal mucosa, and no tumor.{{Moderate-end}}{{Comprehensive-begin}} The urinary bladder contains __cc/ml of <<clear {{Finding-begin}}/ turbid{{Finding-end}} urine. The wall is not thickened. The ureteral orifices are patent. The serosal surfaces are smooth and glistening {{Finding-begin}}and show <<soft / hard>> fibrous adhesions{{Finding-end}}{{Comprehensive-end}}. | <br>The '''urinary bladder''' {{Comprehensive-begin}}lies below the symphysis pubis and{{Comprehensive-end}} is unremarkable / {{Moderate-begin}} is of normal size, with normal mucosa, and no tumor.{{Moderate-end}}{{Comprehensive-begin}} The urinary bladder contains __cc/ml of <<clear {{Finding-begin}}/ turbid{{Finding-end}} urine. The wall is not thickened. The ureteral orifices are patent. The serosal surfaces are smooth and glistening {{Finding-begin}}and show <<soft / hard>> fibrous adhesions{{Finding-end}}{{Comprehensive-end}}. | ||
<br>{{Comment-begin}}Either:{{Comment-end}} | <br>{{Comment-begin}}Either:{{Comment-end}} | ||
*{{Comment-begin}}Male{{Comment-end}}: The prostate is of <<normal size {{Comprehensive-begin}} measures _x _ x _ cm>> and has normal color. The consistency is <<normal elastic{{Comprehensive-end}}{{Finding-begin}}/ firm / nodular{{Finding-end}}. {{Moderate-begin}}No definable focal changes on cut surfaces<ref group= | *{{Comment-begin}}Male{{Comment-end}}: The prostate is of <<normal size {{Comprehensive-begin}} measures _x _ x _ cm>> and has normal color. The consistency is <<normal elastic{{Comprehensive-end}}{{Finding-begin}}/ firm / nodular{{Finding-end}}. {{Moderate-begin}}No definable focal changes on cut surfaces<ref group=note name=cut-surfaces/>{{Moderate-end}}. The '''testes''' are {{Comprehensive-begin}}descended {{Finding-begin}}, atrophic{{Finding-end}} and{{Comprehensive-end}} without abnormal masses.{{Comprehensive-begin}} The penis and scrotum are unremarkable.{{Comprehensive-end}} | ||
*{{Comment-begin}}Female{{Comment-end}}: | *{{Comment-begin}}Female{{Comment-end}}: | ||
{|class="wikitable" | {|class="wikitable" | ||
| Uterus and adnexa are unremarkable.<ref group= | | Uterus and adnexa are unremarkable.<ref group=note name=missing/> | ||
| {{Comprehensive-begin}}The uterus is normal. It measures __ x __ x __cm and weighs __ grams. Its serosal surface is <<smooth {{Finding-begin}}/ deformed by multiple nodules ranging between __ and _ cm{{Finding-end}}>>. The cervix is unremarkable. The endometrial cavity is lined by a smooth atrophic velvety, tan membrane. The ovaries and fallopian tubes are normal.{{Comprehensive-end}} | | {{Comprehensive-begin}}The uterus is normal. It measures __ x __ x __cm and weighs __ grams. Its serosal surface is <<smooth {{Finding-begin}}/ deformed by multiple nodules ranging between __ and _ cm{{Finding-end}}>>. The cervix is unremarkable. The endometrial cavity is lined by a smooth atrophic velvety, tan membrane. The ovaries and fallopian tubes are normal.{{Comprehensive-end}} | ||
|} | |} | ||
| Line 411: | Line 412: | ||
{{Finding-begin}}Overall <<moderate / severe>> post-mortem autolysis{{Comprehensive-begin}}, making interpretations on cellular level <<difficult / unfeasible>>{{Comprehensive-end}}.{{Finding-end}} {{Comment-begin}}The degree of autolysis may be specified for each site individually.{{Comment-end}} | {{Finding-begin}}Overall <<moderate / severe>> post-mortem autolysis{{Comprehensive-begin}}, making interpretations on cellular level <<difficult / unfeasible>>{{Comprehensive-end}}.{{Finding-end}} {{Comment-begin}}The degree of autolysis may be specified for each site individually.{{Comment-end}} | ||
{{Moderate-begin}}After the location identifier, each list item can generally begin as "This section/These sections<ref group= | {{Moderate-begin}}After the location identifier, each list item can generally begin as "This section/These sections<ref group=note>This wording distinguishes single from multiple section, and emphasizes that sections are representative, and do not cover the entire volume.</ref> << shows / reveals >>...{{Moderate-end}} | ||
*'''Breast''': {{Sections show}} no focal changes. {{Finding-begin}}Non-proliferative fibrocystic changes and microcalcifications.{{Finding-end}} | *'''Breast''': {{Sections show}} no focal changes. {{Finding-begin}}Non-proliferative fibrocystic changes and microcalcifications.{{Finding-end}} | ||
*'''Bone marrow''' from <<rib / __ {{Comment-begin}}other location{{Comment-end}} >>: Section shows trilineage hematopoiesis. There is no evidence of malignancy. {{further|Bone marrow|linebreak=no}} | *'''Bone marrow''' from <<rib / __ {{Comment-begin}}other location{{Comment-end}} >>: Section shows trilineage hematopoiesis. There is no evidence of malignancy. {{further|Bone marrow|linebreak=no}} | ||
| Line 417: | Line 418: | ||
*'''Heart''': Sections of ___ {{Comment-begin}}location{{Comment-end}} show no evidence of infarction. {{further|Heart autopsy|linebreak=no}} | *'''Heart''': Sections of ___ {{Comment-begin}}location{{Comment-end}} show no evidence of infarction. {{further|Heart autopsy|linebreak=no}} | ||
*'''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|Arteries|linebreak=no}} | *'''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|Arteries|linebreak=no}} | ||
[[File:Histopathology of thyroid parenchyma with autolytic changes.jpg|thumb|210px|Thyroid parenchyma with autolytic changes, with thyroid follicular cells sloughing off into the follicles. It does not need mentioning in the report (unless severe enough that further evaluation impossible).]] | |||
*'''Thyroid gland''': {{Sections show}} normal follicles with no focal changes. | *'''Thyroid gland''': {{Sections show}} normal follicles with no focal changes. | ||
*'''Parathyroid''': <<1, 2, 3, 4>> parathyroid gland(s) examined; {{Sections show}} no focal changes or signs of hyperplasia. {{Further|Parathyroid|linebreak=no}} | *'''Parathyroid''': <<1, 2, 3, 4>> parathyroid gland(s) examined; {{Sections show}} no focal changes or signs of hyperplasia. {{Further|Parathyroid|linebreak=no}} | ||
*'''Pituitary gland''': {{Sections show}} adenohypophysis and neurohypophysis with no focal changes. {{further|Pituitary|linebreak=no}} | *'''Pituitary gland''': {{Sections show}} adenohypophysis and neurohypophysis with no focal changes. {{further|Pituitary|linebreak=no}} | ||
*'''Liver''': {{Sections show}} {{Finding-begin}}congested{{Finding-end}} parenchyma with no focal changes. {{Further|Liver|linebreak=no}} | *'''Liver''': {{Sections show}} {{Finding-begin}}congested{{Finding-end}} hepatic parenchyma with no focal changes. {{Further|Liver|linebreak=no}} | ||
*'''Adrenal glands''': {{Sections show}} right and left adrenal glands with no focal changes. {{Moderate-begin}} | *'''Adrenal glands''': {{Sections show}} right and left adrenal glands with no focal changes. {{Moderate-begin}}The cortices and medullae are unremarkable.{{Moderate-end}} | ||
*'''Spleen''': {{Sections show}} normal distribution and architecture of the red and white pulp. | *'''Spleen''': {{Sections show}} normal distribution and architecture of the red and white pulp. | ||
*'''Kidneys''': {{Sections show}} both kidneys with {{Finding-begin}}<<mild / moderate / severe >> <<generalized / focal / nodular>> glomerular sclerosis, and <<mild / moderate / severe >> arteriosclerosis.{{Finding-end}} There are no focal changes. {{further|Kidney autopsy|linebreak=no}} | *'''Kidneys''': {{Sections show}} both kidneys with {{Finding-begin}}<<mild / moderate / severe >> <<generalized / focal / nodular>> glomerular sclerosis, and <<mild / moderate / severe >> arteriosclerosis.{{Finding-end}} There are no focal changes. {{further|Kidney autopsy|linebreak=no}} | ||
*''' | [[File:Histopathology of autolytically denuded gastric mucosa at the gastroesophageal junction.jpg|thumb|Gastroesophageal junction with autolytically denuded gastric mucosa (no further comment needed as metaplasia or dysplasia cannot be negated).]] | ||
*'''Pancreas''': {{Sections show}} {{Moderate-begin}}pancreatic parenchyma with{{Moderate-end}} no focal changes. {{Further|Pancreas}} | *'''Gastroesophageal junction''': {{Sections show}} squamo-epithelial junction with no metaplasia or dysplasia. {{Further|Gastroesophageal junction}} | ||
*'''Pancreas''': {{Sections show}} {{Finding-begin}}autolytic{{Finding-end}} {{Moderate-begin}}pancreatic parenchyma with{{Moderate-end}} no focal changes. {{Further|Pancreas}} | |||
*'''Lungs''': {{Finding-begin}}Sections of all lobes of the lung{{Finding-end}} show vascular congestion. {{Moderate-begin}}There is no evidence of edema, acute bronchopneumonia, malignancy or thromboemboli.{{Moderate-end}} {{Further|Lung autopsy|linebreak=no}} | *'''Lungs''': {{Finding-begin}}Sections of all lobes of the lung{{Finding-end}} show vascular congestion. {{Moderate-begin}}There is no evidence of edema, acute bronchopneumonia, malignancy or thromboemboli.{{Moderate-end}} {{Further|Lung autopsy|linebreak=no}} | ||
*'''Urinary bladder''': {{Sections show}} <<normal {{Finding-begin}}/ autolytically denuded{{Finding-end}}>> urothelium. | *'''Urinary bladder''': {{Sections show}} <<normal {{Finding-begin}}/ autolytically denuded{{Finding-end}}>> urothelium. | ||
*'''Brain''': {{Comprehensive-begin}}Standard sections of the cerebral cortex, basal ganglia, hippocampus, thalamus/substantia nigra, medulla oblongata and cerebellum show{{Comprehensive-end}} intact cytoarchitecture. | *'''Brain''': {{Comprehensive-begin}}Standard sections of the cerebral cortex, basal ganglia, hippocampus, thalamus/substantia nigra, medulla oblongata and cerebellum show{{Comprehensive-end}} intact cytoarchitecture. There is no evidence of hemorrhage, tumor, metastatic disease or vasculitis. {{further|Brain autopsy|linebreak=no}} | ||
Males: | Males: | ||
*'''Testis''': {{Sections show}} no focal changes. {{ | *'''Testis''': {{Sections show}} no focal changes. {{Moderate-begin}}There <<are no / are few / is a normal amount of>> visible mature spermatozoa.{{moderate-end}} | ||
*'''Prostate''': {{Sections show}} no focal changes. | *'''Prostate''': {{Sections show}} no focal changes {{Finding-begin}}/nodular prostatic hyperplasia. There is no evidence of malignancy{{Finding-end}}. | ||
Females: | Females: | ||
*'''Uterus''': {{Sections show}} no focal changes. | *'''Uterus''': {{Sections show}} no focal changes. | ||
*'''Ovary''': {{Sections show}} no focal changes bilaterally. | *'''Ovary''': {{Sections show}} no focal changes bilaterally. | ||
<gallery mode=packed heights=170> | |||
File:Histopathology of a blood clot with postmortem bacterial growth.jpg|'''Postmortem bacterial growth''' is often seen in autopsy, generally as basophilic and equally sized tiny granules. The absence of inflammation indicates that it is a postmortem change (such as leukocytes being commensurate with red blood cells as in this image of bacteria within the fibrin of a postmortem blood clot). | |||
File:Histopathology of liver with cocci and granulomatous inflammation.jpg|A true '''bacterial infection''', on the other hand, is expected to have a presence of leukocytes, or as in this case, a monocytic and histiocytic granuloma surrounding the bacteria. | |||
</gallery> | |||
{{Reporting}} | {{Reporting}} | ||
<noinclude> | |||
==Licensing== | ==Licensing== | ||
:The report examples in this article are [https://creativecommons.org/publicdomain/zero/1.0/ Public Domain], and can be copied without any need for author attribution. Rest of content is available under the [https://creativecommons.org/licenses/by/4.0/deed.en Attribution 4.0 International license]. See [[Patholines:Copyright]] for details. | :The report examples in this article are [https://creativecommons.org/publicdomain/zero/1.0/ Public Domain], and can be copied without any need for author attribution. Rest of content is available under the [https://creativecommons.org/licenses/by/4.0/deed.en Attribution 4.0 International license]. See [[Patholines:Copyright]] for details. | ||
</noinclude> | |||
==External applications== | ==External applications== | ||
*[http://mdhero.com/adult-autopsy-standards.php MD Hero reference range generator for autopsy measurements by age and height etc.] | *[http://mdhero.com/adult-autopsy-standards.php MD Hero reference range generator for autopsy measurements by age and height etc.] | ||
{{Bottom}} | <noinclude>{{Bottom}}</noinclude> | ||
The standard reference range reference is duplicated because of technical reasons by being included in [[Patholines:Templates]]. | The standard reference range reference is duplicated because of technical reasons by being included in [[Patholines:Templates]]. | ||