Forensic pathology
Forensic autopsy report
Internal examination

Author: Terrill L. Tops, M.D. (see Authors page)

Revised: 11 January 2017, last major update January 2013

Copyright: (c) 2003-2017, PathologyOutlines.com, Inc.

PubMed search: autopsy exam

Table of Contents
Definition / General
Cite this page: Internal examination. PathologyOutlines.com website. http://www.pathologyoutlines.com/topic/forensicsautopsyinternal.html. Accessed March 27th, 2017.
Definition / General
  • 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
  • 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

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