More detailed discussion of suggested standard headings [2] for the autopsy are reviewed in this section.
Autopsy face sheet
The autopsy face sheet or the final anatomic diagnosis (FAD) is the first portion of the report that lists the autopsy diagnoses as well as all of the pertinent patient demographic data. This portion of the report is highly variable and institutionally dependent, but it should contain the autopsy results in an outline form. The College of American Pathologists has developed a recommended autopsy face sheet, which can easily be modified for use in any setting. [5]
Historical summary
The historical summary is used to place the autopsy in context with perhaps a listing of the goals of the examination. A statement of the patient's medical history, laboratory and imaging studies, and historical circ*mstances may be included to give the reader of the report a sense of perspective of the events leading to the individual's death and postmortem examination.
Examination type, date, time, place, assistants, and attendees
This section reports the nature of the examination (complete autopsy, partial autopsy) and under what authority the examination is performed. The date, time, and place of the examination provides the when and where of the performance of the examination. This listing of time and place may give insight to the availability of ancillary studies or other limitations to the examination, which may prove important at a later date. The listing of attendees and assistants provides a manner in which to document the witnesses to the autopsy.
Presentation, clothing, personal effects, and associated items
Documentation of how the body was received and the state of the remains before the examination is highly important. The clothing, jewelry, and personal effects are to be painstakingly documented (and perhaps photographed). These items may have evidentiary value or at least very important emotional value to families, who always require an exacting accounting of such items. In addition, the state of the body upon receipt may help explain findings and artifacts not related to the autopsy examination and which occurred before receipt of the remains. Again, photographic documentation of the body as it was received may prove invaluable in addressing questions posed at a later date.
Evidence of medical intervention
This portion of the report is for a listing of all medical devices, no matter how routine, that were placed in the course of medical therapy. All tubes, catheters, puncture sites, bandages, and other appliances that were placed in the patient are important and help to place iatrogenic artifacts into context. An example is soft-tissue hemorrhage associated with catheter placement within the neck. Without the description of the catheter in this section and yet the description of soft-tissue hemorrhage in the internal portion of the examination raises questions about the origin of the hemorrhage and may bring into question the completeness and accuracy of the autopsy report.
It is also prudent to leave certain medical appliances in situ to check their proper placement during the internal portion of the autopsy examination. Endotracheal tubes, nasogastric tubes, and central vascular catheters may not be properly placed, and these findings may be highly important in the final formulation of the cause of death.
Postmortem changes
Documentation of routine postmortem changes aids in interpretation of other autopsy findings. Rigor mortis, livor mortis, skin slippage, discoloration, malodor, etc, aid in establishing or confirming the postmortem interval as well as aid in the interpretation of autopsy findings. Postmortem changes often complicate autopsy findings, in particular the microscopic examination of organs and tissues obtained at the postmortem examination.
Postmortem imaging studies
This section of the report is for listing any postmortem imaging performed and the results of such studies.
Features of identification
Identification of an individual is seldom questioned in a hospital autopsy. Rarely, questions arise and usually occur long after the body is left the morgue. A listing of identifying marks and scars (including detailed descriptions of tattoos and healed surgical incisions), body weight and length, hair color, condition of dentition, etc, are features that are commonly recorded.
Evidence of injury
All external and or internal injuries found on examination, and their number, precise location, size, shape, depth, appearance, etc, are thoroughly detailed in this section of the report. When internal injuries are correlated with external evidence of injury, these findings are also recorded.
External examination
The external portion of the examination, like all other sections of the report, requires detailed observations organized in a logical manner. This portion of the evaluation is especially important in a forensic examination; however, it can also be highly relevant in a hospital autopsy.
The condition of the body externally is often a major concern of the funeral home personnel and, ultimately, the families. Depending on the nature of the case, pertinent negatives can be included throughout the report. Descriptions to include body height, weight, nutrition, body symmetry, eyes (iridies, sclera, conjunctiva), nose, ears, mouth, teeth, neck, chest, abdomen, genitalia, and extremities give the reader of the report a sense of the condition of the body at the time of the examination, and the quality of the detail gives credence to the overall accuracy and thoroughness of the report.
Fetal and perinatal autopsies should include a detailed gross and microscopic examination of the placenta. In addition, pediatric autopsies require additional measurements to be taken (ie, head circumference, abdominal circumference, etc), which should be tabulated in the report. This information places the autopsy findings within a developmental context. [5]
Internal examination
The internal portion of the examination is the central portion of the evaluation and deserves a thoroughness and attention to detail that justifies the autopsy and the original goals of the examination. Obviously, all internal organs should be inspected, weighed, and described. All positive findings should have qualifiers (measurements, color, or degree [eg, mild, moderate, severe]) to give the reader a sense of the magnitude of the abnormality. Pertinent negatives should also be listed based on the peculiarities of the case. A possible outline for the internal examination section of the report follows.
Body cavities
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Organ arrangement
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Presence or absence of fluids and adhesions
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General appearance of viscera (degree of decomposition, color, malodor)
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Adipose layer of anterior abdominal body wall
Central nervous system
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Weight
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Configuration
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Meninges
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Abnormalities evident externally (hemorrhage, herniations, infection, etc)
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Blood vessels
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Internal abnormalities
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Ventricular system
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Pituitary
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Scalp and skull
Neck
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General appearance
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Thyroid gland
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Lymph nodes
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Airway
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Blood vessels
Cardiovascular system
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Weight
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Configuration
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Coronary arteries
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Valves (including circumferences, if abnormal)
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Myocardium (including left and right ventricular wall thickness)
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Aorta and vena cava
Respiratory system
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Lung weights
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General appearance
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Tracheobronchial tree
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Parenchyma appearance, with details of diffuse or focal lesions
Liver and biliary system
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Weight
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Color
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Consistency
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Gall bladder and contents
Gastrointestinal tract
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Esophagus
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Stomach
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Pancreas
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Small intestine
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Large intestine
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Rectum
Genitourinary tract
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Kidney weights
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Kidney appearance
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Ureters
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Bladder
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Male pelvic organs
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Female pelvic organs
Reticuloendothelial system
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Spleen weight
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Appearance of lymph nodes
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Thymus (if present)
Musculoskeletal system
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General appearance of bones, musculature, and soft tissues
Histology cassette listing and microscopic descriptions
Any number of tissues may be submitted for examination, which is dictated by the nature of the case. In addition, at the discretion of the autopsy pathologists, tissues may be retained and preserved in formalin to serve as a source of additional tissue for microscopic examination. Tissues may also be retained and fixed in formalin, resulting in a firmer consistency, which aids in the ability to obtain quality sections.
Toxicology, laboratory, and ancillary procedure results
The results for all tests (including toxicology, microbiology, chemistry, etc) should be listed in a logical sequence. Occasionally, such testing provides important information that is highly important to the final formulation of the cause of death. Listing these results in the autopsy report allow the report to "stand alone," without the addition of pages of supporting documents that can be lost or difficult to place into context.
Pathologic diagnosis
In this section, the final anatomic diagnoses are listed in an organized and systematic manner. This can be done in one of several manners, but in general, the diagnoses should be listed in a hierarchical manner, starting with the most relevant pathologic processes that culminated in the patient's death, and then those of lesser importance and, finally, those of incidental consequence.
One organizational scheme lists the diagnoses by major pathologic entities, followed by subheadings that list the related pathologies or consequences of the major pathologic entity. An example would be the following:
I. Pericardial tamponade.
A. Rupture of acute myocardial infarction of the anterior left ventricular myocardium.
B. Atherosclerotic coronary vascular disease.
C. Thrombosis of the left anterior descending coronary artery.
This manner of listing the autopsy diagnoses connects multiple consequences of the major pathologic entity and provides a series of cause-and-effect relationships for the reader of the report. A drawback of this method is that there may be some redundancy in the listing of diagnoses, as some interrelationship exists between closely related pathologic entities. An example of this would be hypertensive heart disease and atherosclerotic coronary vascular disease, both of which may result in myocardial ischemia and arteriolonephrosclerosis.
A second utilized method lists all diagnoses by organ system, either in a prescribed order or by importance in the overall context of the death. However, this approach does not readily link associated disease processes, particularly processes that involve more than one organ system, such as sepsis or lupus erythematosus. Thus, the various causes and effects can end up linked by long connecting phrases, such as "due to" or "as a consequence of," which may be satisfactory but awkward.
A third approach is to list the cause of death, followed by a list of the "Intervening Cause(s) of Death," a listing of "Other Significant Contributing Conditions to the Death," and finally "Miscellaneous Findings."
Pediatric autopsy reports are often best written in the context of development. Wherever organ weights are listed, normal ranges for the gestational age are also given. Body heights and weights are listed along with the "Percentile for Age."
Summary and comment
This section of the autopsy report is for summarizing the gross and microscopic autopsy findings, along with history and pertinent imaging and laboratory test results. This summary relates the clinical findings with the autopsy findings in a concise fashion and attempts to answers the major questions that were hopefully well defined at the beginning of the examination.
Cause of death statement
The cause of death statement, which is also included on the face sheet, correlates the autopsy report to the cause of death in a standard format.
The summary and comment, along with the cause of death statement, are often combined in a section often called "Opinion." In this section, the cause of death statement is the first or last sentence, with the remainder of the paragraph(s) supporting or leading up to the cause of death.
