Autopsy - patholines.org (original) (raw)

Author: Mikael Häggström [note 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:

• Fetopsy in third trimester and stillbirth

Contents

• 1 Comprehensiveness
• 2 Checklist for non-forensic autopsy
  • 2.1 Preparations
  • 2.2 External inspection
  • 2.3 In situ inspection
  • 2.4 Evisceration
  • 2.5 Organ packages
  • 2.6 Heart
  • 2.7 Other thorax
  • 2.8 Retroperitoneal
  • 2.9 Peritoneal
  • 2.10 Brain
  • 2.11 Demonstration
  • 2.12 Weighing
  • 2.13 Tissue sampling
  • 2.14 Microbiology
  • 2.15 Toxicology
• 3 Reporting of non-forensic autopsy
  • 3.1 Data
  • 3.2 Final autopsy diagnosis / Preliminary diagnoses
  • 3.3 External inspection
  • 3.4 Internal examination
  • 3.5 Histopathology
  • 3.6 ((Clinicopathologic correlation))
  • 3.7 Microscopy report
• 4 Licensing
• 5 External applications
• 6 Notes
• 7 Main page
• 8 References
• 9 Image sources

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

• 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).

• Read the autopsy referral (if separate from the consent form)( 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.)

• 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).[note 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

• 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.)

• ((History of smoking

• Medications, especially anticoagulant ones.

• Family history))

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.
• Confirm the identity of the body, generally from attached identity tag.

External inspection

• Measure the size of <<clinically significant / ( all)>> scars, marks, bruises or wounds. Estimate the depth of wounds, either by number or presumed anatomic layer.
• Note any therapeutic tubes or lines
• Inspect the lower legs for swelling (and compare their circumferences taken 10 cm above the ankle. If swelling is suspected, later press the legs while observing the femoral veins emptying into the pelvic cavity to discern if there is free flow.
• Discern the race, gender, nutritional status, and apparent versus stated age
• Inspect the external ears, eyes, nostrils 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.)

Evisceration

Y-incision

• The standard Y-incision is from each acromion process to the xyphoid process. For larger breasted patients, the incision is done under the breast, making it easier to manage later.
• From here the incision extends down the central abdomen, to the patient’s left of the umbilicus, ending at the pubis. Care is taken not to cut too deeply into the abdomen, to avoid puncturing the peritoneal cavity and/or bowel.
• The skin is reflected back over the face and along the sides. Always cut perpendicular to bone.
• Take measurement of the chest and abdominal pannus at this time.

Chest plate

• Using rib cutters or Stryker saw, cut laterally along the ribs, ending at the sterno-clavicular junction.
• Remove chest plate by detaching it from the diaphragm and pulling upward toward the head.
• Inspect the ribs for fractures
• Also, squeeze out bone marrow on a piece of wrapping tissue and submit.
• Perform in situ examination as per checklist.

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

• Pull up stomach and find the ligament of Treitz (pictured).
• At the ligament of Treitz, place two hemostats & cut through the bowel between the clamps.
• 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.

Supra-pelvic organ blocks

• Cut the diaphragm free from the body wall on both sides extending down to the spinal column.
• From here pull all the organs to the left and make an incision along the right side of the spinal column to free the organs
• Do the same along the left side.
• Tease the soft tissue of the neck to expose the carotid arteries.
• Tie off both sides leaving long stumps, which are marked with strings for embalming purposes.
• Dissect the tissue of the neck to expose the thyroid cartilage.
• Transect immediately above the thyroid cartilage, freeing the trachea and esophagus.
• Start to dissect away the tissue around and behind the thyroid cartilage & esophagus.
• Continue this dissection down, following the spinal column to the bifurcation of the abdominal aorta.
• At this point, remove the organ block from the body.

Pelvic organs

• Bluntly dissect the urinary bladder away from the wall of the true pelvis
• Continue this blunt dissection down into the pelvis to include the vagina (if female) & rectum
• Pull directly anterior to free these structures
• You will hear a loud suction noise when done correctly
• At this point, cut straight down to remove the pelvic organs
• If male, insert the scissors into the pelvis toward the feet as far as possible & then down to include the prostate
• To remove the testis, bluntly dissect along the inguinal canal, exposing the spermatic cord
• Pull up on the cord until the testis pulls through the canal & out of the scrotum
• Transect the spermatic cord.

Skull cap

• Separate the hair of the scalp, cut from ear to ear (just behind each ear) over the posterior crown of the head.
• Reflect the skin forward over the face & back to the neck, exposing the skull cap (use a towel for better grip).
• Using a scalpel, outline the cut on the anterior & posterior skull cap cutting away the temporalis muscles. The outline should make ~45 degree angle located at the level of the ear.
• Use the Stryker saw to cut along the outline. Be sure to cut through the skull bone but not into the brain tissue.
• Make a V-shaped notch in the anterior midline to help the skull cap stay in place following autopsy
• Pull skull cap off

Brain

• Do an in situ examination before removing.
• Gently insert fingers over frontal lobes and pull backwards.
• Using scalpel/scissors, cut away the exposed cranial nerves.
• Cut away the tentorium, keeping the scalpel close to the bone.
• Free the cerebellum.
• Insert scalpel/scissors as deep as possible to cut the brain stem.
• Pull brain out gently.
• Place a wedge at level of sella turcica and hit it with a hammer to expose pituitary gland.
• Remove the gland gently.
• Weigh the brain.

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.

To separate the thoracic from the abdominal package:

• Turn the packages with the dorsal side up.
• Optionally: Cut the aorta just distally to the exit of the left subclavian vein, and separate the descending thoracic aorta from the rest of the thorax.
• Optionally: Cut the esophagus at its superior attachment to the trachea, and separate it from the thorax.
• Free the basilar aspects of the lungs from the diaphragm.
• Identify the inferior vena cava (IVC) and transect it as close to the diaphragm as possible.
• Detach the pericardium from the diaphragm as close to the line of attachment as possible.

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.
• Weigh the heart.
• Dissect the coronary vessels. Further 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.[note 3]
• Dissect the atrial appendages, to exclude thromboses.
• Dissect the left ventricle, such as into circumferential slices from the apex to the base.[note 4] Inspect (and measure) the left ventricular wall thickness.

Valve circumferences are measured at the basal ring (bottom in image).

• (Measure the circumferences of the four valves. Cutoffs for valve dilatation:[1]

• Mitral valve: circumference greater than 9.9 cm in males and 9.1 cm in females

• Aortic valve: circumference greater than 8.5 cm in males and 7.9 cm in females

• Tricuspid valve: circumference greater than 11.8 cm in males and 11.1 cm in females

• Pulmonic valve: circumference greater than 7.5 cm in males and 7.4 cm in females)

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 blood clots.

Blood clots[2]

Pre-mortem	Post-mortem
Texture	Dull	Shiny
Wall adherence	Yes	No
Color	Grey. Possibly zebraic appearance by lines of Zahn, with mixed red and grey/yellow	Dark-red ("currant jelly") to tan-pink ("chicken-fat")
Pressurized	Yes, can eject from lumen	No, needs to be pulled-out
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.
• Make some additional sections through the lung parenchyma. Squeeze at each side to detect any pus and edema.[3] Further information: Lung autopsy
• Cut each thyroid lobe in horizontal slices and inspect the parenchyma. Further information: Thyroid
• ((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.[note 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.
• In females, bivalve the uterus by cutting along right and left lateral aspects. Measure the ovaries**.**

Peritoneal

• Remove the diaphragm and excess omentum

Wischnewski spots of the stomach are associated with hypothermia.[4]

• 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.[note 6]Further information: Gallbladder
• Make consecutive liver slices, such as in the sagittal or coronal plane. Further information: Liver

"Long" and "short" axis.[5]

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. Note the appearance of the parenchyma (and the size of the duct). Further information: Pancreas
• 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.

For the liver, pancreas and spleen, sectioning preferably goes almost but not fully through each organ, so as to keep the slices together.

Brain

edit

• Weight the brain. Overall normal range (95% prediction interval) is 1100 to 1700 g,[6] +60g for males and -60g for females.[7]
• Inspect: Grooves indicating herniation? Hemorrhages?
• Dissect the basilar artery and circle of Willis, either before or after separation from the brain. [[If there is likely a need to demonstrate the case to an additional person later, the arteries of the skull base are preferably dissected after first separating them from the brain.]] 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.

• For the cerebrum, cut it into slices about 1 cm thick. It can be done from frontal to occipital, or by starting coronally into two halves at the level of the mammillary bodies and continuing in each direction from there.

• 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

Sample tissues for microscopy from wherever histopathology may aid in establishing the cause of death. Following are routine samples:

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 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:[note 7]

• 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.[8]

((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."))

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..)

(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 back has lividity.) 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

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.

(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 partially 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.}} [[If the degree of stenosis on microscopy sections of coronary arteries only differ slightly from the gross description, preferably write "mild/moderate/severe atherosclerosis consistent with the gross inspection."]] (Gross measurement of coronary artery stenosis is generally more accurate than microscopic measurement, so the former generally has precedence.)

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

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

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[note 8] 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 appendix is non-irritated and of normal size.)[note 6] {{There are scattered <<colonic / sigmoid>> diverticula without inflammation or perforation.}}

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[note 8] 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, measuring __ )[[dimensions or weight]]. Cut surfaces[note 8] 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[note 8] have normal appearance / ( normal bluish-red color, with no definable focal changes). ((The splenic artery and vein are normal.))

Urogenital

editThe 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)).

(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[note 8]). The testes are ((descended {{, atrophic}} and)) without abnormal masses.(( The penis and scrotum are unremarkable.))
• [[Female]]:

Central nervous system

edit

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

((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[note 10] << shows / reveals >>...)

• Breast: ((Section(s) show(s))) no focal changes. {{Non-proliferative fibrocystic changes and microcalcifications.}}
• Bone marrow from <<rib / __ [[other location]] >>: Section shows trilineage hematopoiesis. There is no evidence of malignancy. Further information: Bone marrow
• Lymph nodes at __ [[ location]]: ((Section(s) show(s)))__ [[number of]] benign{{, reactive lymph node(s) with anthracotic pigment deposition}}.
• Heart: Sections of ___ [[location]] show no evidence of infarction. Further information: Heart autopsy
• 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 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: ((Section(s) show(s))) normal follicles with no focal changes.
• Parathyroid: <<1, 2, 3, 4>> parathyroid gland(s) examined; ((Section(s) show(s))) no focal changes or signs of hyperplasia. Further information: Parathyroid
• Pituitary gland: ((Section(s) show(s))) adenohypophysis and neurohypophysis with no focal changes. Further information: Pituitary
• Liver: ((Section(s) show(s))) {{congested}} hepatic parenchyma with no focal changes. Further information: Liver
• Adrenal glands: ((Section(s) show(s))) right and left adrenal glands with no focal changes. (The cortices and medullae are unremarkable.)
• Spleen: ((Section(s) show(s))) normal distribution and architecture of the red and white pulp.
• Kidneys: ((Section(s) show(s))) both kidneys with {{<<mild / moderate / severe >> <<generalized / focal / nodular>> glomerular sclerosis, and <<mild / moderate / severe >> arteriosclerosis.}} There are no focal changes. Further information: Kidney autopsy

Gastroesophageal junction with autolytically denuded gastric mucosa (no further comment needed as metaplasia or dysplasia cannot be negated).

• Gastroesophageal junction: ((Section(s) show(s))) squamo-epithelial junction with no metaplasia or dysplasia. Further information: Gastroesophageal junction
• Pancreas: ((Section(s) show(s))) {{autolytic}} (pancreatic parenchyma with) no focal changes. Further information: Pancreas
• Lungs: {{Sections of all lobes of the lung}} show vascular congestion. (There is no evidence of edema, acute bronchopneumonia, malignancy or thromboemboli.) Further information: Lung autopsy
• Urinary bladder: ((Section(s) show(s))) <<normal {{/ autolytically denuded}}>> urothelium.
• Brain: ((Standard sections of the cerebral cortex, basal ganglia, hippocampus, thalamus/substantia nigra, medulla oblongata and cerebellum show)) intact cytoarchitecture. There is no evidence of hemorrhage, tumor, metastatic disease or vasculitis. Further information: Brain autopsy

Males:

• Testis: ((Section(s) show(s))) no focal changes. (There <<are no / are few / is a normal amount of>> visible mature spermatozoa.)
• Prostate: ((Section(s) show(s))) no focal changes {{/nodular prostatic hyperplasia. There is no evidence of malignancy}}.

Females:

• Uterus: ((Section(s) show(s))) no focal changes.
• Ovary: ((Section(s) show(s))) no focal changes bilaterally.
• 
  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).
• 
  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.

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.

External applications

• MD Hero reference range generator for autopsy measurements by age and height etc.

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. ↑ After 24 hours, the likelihood of bacterial contamination and thereby false positive results is high, generally making cultures not indicated.
8. ↑ 8.0 8.1 8.2 8.3 8.4 8.5 8.6 "Cut surface shows..." may alternatively be expressed as "On sectioning, the parenchyma is..."
9. ↑ 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.
10. ↑ This wording distinguishes single from multiple section, and emphasizes that sections are representative, and do not cover the entire volume.

Main page

• Main page of Patholines

References

1. ↑ Kitzman, Dalane W.; Scholz, David G.; Hagen, Philip T.; Ilstrup, Duane M.; Edwards, William D. (1988). "Age-Related Changes in Normal Human Hearts During the First 10 Decades of Life. Part II (Maturity): A Quantitative Anatomic Study of 765 Specimens From Subjects 20 to 99 Years Old ". Mayo Clinic Proceedings 63 (2): 137–146. doi:10.1016/S0025-6196(12)64946-5. ISSN 00256196.
   • Griffith, Christopher C.; Raval, Jay S.; Nichols, Larry (2012). "Intravascular Talcosis due to Intravenous Drug Use Is an Underrecognized Cause of Pulmonary Hypertension
     ". Pulmonary Medicine 2012: 1–6. doi:10.1155/2012/617531. ISSN 2090-1836.
2. ↑ Michael Bonert. Autopsy. Page was last modified: 6 September 2016
3. ↑ Burton, Julian L.; Rutty, Guy N. (2010). The Hospital Autopsy A Manual of Fundamental Autopsy Practice (3rd ed.). Oxford University Press. ISBN 978-0340965146.
4. ↑ Çetýn S, Ýnanir NT, Eren F, Eren B, Dokgöz H (2015). "Wischnewsky Spots in Fatal Hypothermia: Case Report.". Maedica (Bucur) 10 (3): 280-282. PMID 28261368. PMC: 5327835. Archived from the original. .
5. ↑ Pellerito, John; Polak, Joseph F. (2012). Introduction to Vascular Ultrasonography (6th ed.). Elsevier Health Sciences. p. 559. ISBN 978-1-4557-3766-6.
6. ↑ Govender, S; Lazarus, L; De-Gama, B. Z; Satyapal, K. S (2018). "Post-Mortem Brain Weight Reference Range for a Select South African Population ". International Journal of Morphology 36 (3): 915–920. doi:10.4067/S0717-95022018000300915. ISSN 0717-9502.
7. ↑ Kelley Hays; David S. (1998). Reader in Gender archaeology . Routlegde. ISBN 9780415173605. Retrieved on 2014-09-21.
8. ↑ 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).
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.
11. ↑ Shamim, A; Monira, K; Manowara, B; Sabiha, M; Alim, A; Nurunnabi, ASM (1970). "Weight of the Human Thyroid Gland – A Postmortem Study ". Bangladesh Journal of Medical Science 9 (1): 44–48. doi:10.3329/bjms.v9i1.5230. ISSN 2076-0299.
    - In turn citing: Langer P. Discussion about the limit between normal thyroid and goiter: mini review. Endocrine regulations. 1999 March; 33(1): 39-45.
12. ↑ 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.
13. ↑ 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.
14. ↑ 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.
15. ↑ 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.

Image sources

The standard reference range reference is duplicated because of technical reasons by being included in Patholines:Templates.