Autopsy: Difference between revisions

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*'''[[Fetopsy in third trimester and stillbirth]]'''</noinclude>

*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=notes>Confirmation with a supervisor ought to be done each time until that person tells that it is not necessary.</ref>

:*Latest hospital and/or primary care notes{{Moderate-end}}

*Dissect the '''descending abdominal aorta'''. Cut external iliac artery from a dorsal approach, or after freeing ureters.<ref group="notes">Measures are taken to avoid cutting through the '''ureters'''.</ref>

*Dissect the extrahepatic '''biliary tract''' and '''gallbladder'''.<ref group="notes" 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}}

Cultures for microbiology are indicated in the following cases, if less than 24 hours have passed since the time of death:<ref group=notes>After 24 hours, the likelihood of bacterial contamination and thereby false positive results is high, generally making cultures not indicated.</ref>

{{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}}

<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="notes" name="cut-surfaces/> are unremarkably dark red, with no definable tumors{{Moderate-begin}} or bleeding{{Moderate-end}}.

{{Moderate-begin}}The appendix is non-irritated and of normal size.{{Moderate-end}}<ref group="notes" name="missing"/>

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="notes" 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}}.

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="notes" 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}}

| The '''thyroid''' and '''adrenal glands''' are normal bilaterally / {{Moderate-begin}}are ordinarily configured and with no definable focal changes on cut surfaces<ref group="notes" name="cut-surfaces/>{{Moderate-end}}.  

| 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="notes" name="cut-surfaces/>.{{Comprehensive-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="notes" 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}}

| Uterus and adnexa are unremarkable.<ref group="notes" name="missing"/>

{{Moderate-begin}}After the location identifier, each list item can generally begin as "This section/These sections<ref group=notes>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}}

 

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