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Forensic pathology

Forensic autopsy report

Internal examination


Reviewer: Terrill L. Tops, M.D. (see Reviewers page)
Revised: 3 February 2013, last major update January 2013
Copyright: (c) 2003-2013, PathologyOutlines.com, Inc.

General
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● Organs need to be weighed
● All lesions need to be measured in three 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
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● State any abnormal pericardial, thoracic or abdominal fluid acumination

Head/CNS/neck
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● 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
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● 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
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● Upper airway, mucosa, pleural surfaces, pulmonary parenchyma, vasculature, etc.

Hepatobiliary system
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● Hepatic capsule, liver parenchyma/vasculature, gall bladder serosa/mucosa, etc.

Gastrointestinal system
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● Esophagus, gastric mucosa, small bowel, colon, appendix, pancreas, etc.

Genitourinary system
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● Renal capsule(s), cortical surface(s), cortical/medullary parenchyma, bladder, male organs (testes, prostate), female organs (ovaries, uterus), etc.

Lymphorecticular system
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● Splenic capsule, splenic parenchyma, regional lymph nodes, etc.

Endocrine system
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● Pituitary gland, thyroid gland, adrenal glands, etc.

Musculoskeletal system
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● Muscle and bone structures


Microscopic examination

General
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● 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

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

End of Forensic pathology > Forensic autopsy report > Internal examination


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