Autopsy report-general (2024)

Autopsy report-general

Author:Terrill L. Tops, M.D.

Last author update: 1 January 2013

Last staff update: 3 June 2024 (update in progress)

Copyright: 2003-2024, PathologyOutlines.com, Inc.

PubMed search: Autopsy lexicon and related articles

Page views in 2023: 1,461

Page views in 2024 to date: 626

Table of Contents

Cite this page: Tops TL. Autopsy report-general. PathologyOutlines.com website. http://www.pathologyoutlines.com/topic/forensicsautopsygeneral.html. Accessed June 16th, 2024.

Definition / general

Completing a forensic autopsy report is an art in itself
Everything, including the decedent's demographics, circ*mstances of death, external examination, clothing / personal effects, medical intervention, radiographic imaging, evidence of injury, internal examination, microscopic examination, specific organ system pathology consultation, final autopsy diagnosis, and opinion sections should complement one another in a cohesive manner
No two autopsy reports are the same; keep an open mind for each case
If using a template, take care to make the appropriate changes to suit each case
Cause of death (COD) is usually straightforward, but the manner of death (MOD) and mechanism of death tend to be more challenging

Differences from nonforensic autopsies

Forensic autopsies emphasize identification of deceased, time of death, proper handling of evidence, recognition of injuries and pathological conditions that may be relevant to the court case
For homicide court cases, an autopsy report is only one piece of the pie
Law enforcement investigators, attorneys, forensic science experts (e.g., trace evidence, fingerprints) and other expert witnesses will fill in the rest
Depending on the jurisdiction, the cover page of a forensic autopsy report includes: demographics of the decedent, circ*mstances of death, identification, cause of death and manner of death

Undetermined cases

Having an autopsy report with an undetermined cause and undetermined manner of death (undetermined / undetermined) is very rare; only if all evidence at autopsy is inconclusive
Frequency of undetermined cases: not more than 1% - 2% of all autopsy cases done by a forensic pathologist in one year

High profile cases

Conduct "VIP" / high profile cases as if you would routinely perform like any other case to avoid unnecessary mistakes
Depending on the case, high profile or difficult autopsies should be checked by another forensic pathologist for accuracy
FP should be board certified in at least anatomic and forensic pathology for competency measures

Demographics of the decedent

Decedent: person who died (a legal term)
Include full name, autopsy number, social security number, age, date of birth, date of death, date of autopsy performed, place of death and date of autopsy report completed

Circ*mstances of death

Events that occurred prior to the person's death, such as when last seen alive, prior hospitalizations, and pertinent positive / negative evidence to support COD / MOD

Identification

Antemortem / postmortem fingerprint, dental, radiographs or DNA comparison is objective evidence and is added to evidence from pictures, driver license or other unique identifiers (e.g., tattoos or amputations)

Cause of death

Drowning, gunshot wound to the chest, acute myocardial infarction, multidrug toxicity (overdose), undetermined, etc.

Manner of death

Accident, homicide, natural, suicide or undetermined

Preliminary investigation

Circ*mstances of death need to be reported by the forensic pathologist (FP) based on information provided by law enforcement personnel who are familiar with the death scene
Depending on the case, the FP can obtain crucial information at the death scene or by a phone call to law enforcement investigators
Asking specific questions related to the case will help provide clues to Cause / Manner of Death (COD / MOD)
Specific questions related to the decedent's past (medical history, recent surgeries, state of mental health, drug / alcohol abuse, etc.) may reduce the need to perform a complete autopsy when only toxicology analysis is required to determine COD / MOD

External examination

Overall: state body weight, height, age, body temperature, rigor and lividity
Head / neck: describe hair color, facial hair, eye color, oral cavity, ear canals, nose, lips and teeth
Torso: describe chest, abdomen, back, anus and genitalia
Extremities: describe upper / lower limbs and fingernails / toenails
Miscellaneous: describe tattoos, ID tags, medical / surgical intervention, etc.
Clothing: describe any defects to support cause of death (COD)
Body surface: state anything to suggest evidence of cause of death, such as gunshot wounds, blunt trauma, sharp force injury, illicit drug residue, anasarca, obesity, emaciation, sexual assault

Internal examination

General:
- Organs need to be weighed
- All lesions need to be measured in 3 dimensions, if possible
- Evidence of Injury does not need to be repeated in each organ system; a statement such as "see 'evidence of injury' above" will suffice
- Natural causes of death are usually found in this section of the autopsy report: body cavities, head / CNS / neck, cardiovascular system, respiratory system, hepatobiliary system, gastrointestinal system, genitourinary system, lymphorecticular system, endocrine system, and musculoskeletal system
Body cavities: state any abnormal pericardial, thoracic or abdominal fluid acumination
Head / CNS / neck: look for lesions involving the scalp, calvarium, dura mater, falx cerebri, leptomeninges, cerebral hemispheres, gyri / sulci, cut sections of brain, brain stem, cranial nerves, major blood vessels, CSF, cerebellum, atlanto-occipital joint, thyroid cartilage, hyoid bone, larynx, tongue, etc.
Cardiovascular system: epicardial surface, coronary arteries (distribution, patency versus occlusion, and wall thickness), myocardium (LV / RV / septum) thickness, valves, endocardium, aorta, renal vessels, mesenteric vessels, etc.
Respiratory system: upper airway, mucosa, pleural surfaces, pulmonary parenchyma, vasculature, etc.
Hepatobiliary system: hepatic capsule, liver parenchyma / vasculature, gall bladder serosa / mucosa, etc.
Gastrointestinal system: esophagus, gastric mucosa, small bowel, colon, appendix, pancreas, etc.
Genitourinary system: renal capsule(s), cortical surface(s), cortical / medullary parenchyma, bladder, male organs (testes, prostate), female organs (ovaries, uterus), etc.
Lymphorecticular system: splenic capsule, splenic parenchyma, regional lymph nodes, etc.
Endocrine system: pituitary gland, thyroid gland, adrenal glands, etc.
Musculoskeletal system: muscle and bone structures

Evidence of injury (examples)

This section usually contains both external and internal descriptions of injury
Gunshot wounds (GSW): list each GSW trajectory separately, determine how many entry (penetrating) / exit (perforation) wounds, range of fire, soot / stippling, trajectory, recovery of projectile(s), state in proper order of anatomic landmarks injured by each GSW, hemorrhage, etc.
Blunt force injuries from motor vehicle accident (MVA): trace evidence collected on body (e.g., paint chips or glass), pattern contusions / abrasions, fractures, lacerations, avulsions, hemorrhage, etc.
Stab wounds: cuts, incisions, defense wounds, determine the knife's sharp verses blunt end in each skin wound, depth of wound, organs affected, hemorrhage, etc.
Additional injuries: minor lesions that are attributed by the mechanism or cause of death

Microscopic examination

Useful for documenting natural disease or gross lesions histologically (e.g., gunpowder residue)
Describe what is seen microscopically; do not state diagnosis in this section

Additional procedures

This section may include neuropathology or cardiovascular consultation reports, toxicology reports, autopsy attendance roster, etc.

Standard sections (CNS)

Spinal cord (2 - 3 levels), medulla, pons, midbrain, cerebellum, hypothalamus, basal ganglia, hippocampus, thalamus, parietal cortex, occipital cortex, cingulate gyrus, superior temporal gyrus, paracentral cortex and pituitary

Sample gross description (CNS)

The scalp and skull are entered in a standard biparietal, postauricular manner
- The dura is intact and the sagittal sinus is patent
- The prefixation brain weight is __ grams
- The formalin fixed brain weights __ grams
- The cerebral and cerebellar hemispheres are symmetrical with no masses, areas of discoloration or gross lesions identified
- There is no evidence of midline shift
- There is no uncal, subfalcine or tonsillar softening or grooving
- The sulci / gyri are unremarkable, with no atrophy identified
- The leptomeninges are thin, translucent and without hemorrhage
- The circle of Willis is intact, with no atherosclerotic plaque
- Coronal sections of the cerebral hemispheres show well delineated gray and white matter structures
- The ventricles are symmetric and not dilated
- Distal blood vessels are unremarkable
Axial sections of the midbrain, pons and medulla are symmetrical with well delineated gray and white matter structures
- The substantia nigra and locus ceruleus are well pigmented
- The aqueduct and fourth ventricle are unremarkable
- Parasagittal sections of the cerebellum show well delineated white and gray matter structures with prominent folia
The pituitary is removed from the sella and is grossly unremarkable
- The spinal cord is removed by an anterior approach
- Axial sections of the spinal cord are symmetric with well delineated gray and white matter

Sample microscopic description (CNS)

The spinal cord shows...
The midbrain, pons and medulla show mild neuronal loss and gliosis consistent with the patient's age
The cerebellum, basal ganglia and thalamus are unremarkable
The hippocampus shows no senile plaques or neurofibrillary tangles
The cerebral neocortex is unremarkable