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Autopsy (view source)

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[[Image:Rembrandt Harmensz. van Rijn 007.jpg|thumb|300px|An autopsy.]]
'''Autopsy''' was once a mainstay of [[pathology]].  It is now in decline and uncommonly done.  Fetal autopsy is dealt with in a separate article called ''[[fetal autopsy]]''.
'''Autopsy''' was once a mainstay of [[pathology]].  It is now in decline and uncommonly done.  Fetal autopsy is dealt with in a separate article called ''[[fetal autopsy]]''.


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=Autopsy checklist=
=Autopsy checklist=
===Minimum to proceed===
===Minimum to proceed - hospital autopsy===
*Death certificate complete.
*Death certificate complete.
**Cause of death as per death certificate.
**Cause of death as per death certificate.
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===Who has authority?===
===Who has authority?===
*Consent should be given by the ''executer of the estate''.<ref name=olduhnconsent>URL: [http://www.docstoc.com/docs/51609856/CONSENT-FOR-AUTOPSY http://www.docstoc.com/docs/51609856/CONSENT-FOR-AUTOPSY]. Accessed on: 27 September 2010.</ref>
*Consent should be given by the ''executor of the estate''.<ref name=olduhnconsent>URL: [http://www.docstoc.com/docs/51609856/CONSENT-FOR-AUTOPSY http://www.docstoc.com/docs/51609856/CONSENT-FOR-AUTOPSY]. Accessed on: 27 September 2010.</ref>


====Hierarchy====
====Hierarchy====
If the ''executer of the estate'' is not specified the hierarchy is as follows:<ref name=olduhnconsent/>
If the ''executor of the estate'' is not specified the hierarchy is as follows:<ref name=olduhnconsent/>
#Spouse - by marriage (same sex ''or'' opposite sex) ''or'' by common-law ''or'' by together the parents of a child ''or'' by cohabitation agreement (in law).
#Spouse - by marriage (same sex ''or'' opposite sex) ''or'' by common-law ''or'' by together the parents of a child ''or'' by cohabitation agreement (in law).
#If no spouse, any children 16+ years old,
#If no spouse, any children 16+ years old,
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Notes:
Notes:
*The power a person that is designated as ''power of attorney for health care decisions'' does not have the authority to consent for an autopsy; their power ends with death (unless they are also the ''executer of the estate'').
*Exact hierarchy may vary by jurisdiction.
*The power a person that is designated as ''power of attorney for health care decisions'' does not have the authority to consent for an autopsy; their power ends with death (unless they are also the ''executor of the estate'').
*In clinical medicine, it is allowable to skip down the hierarchy if ''the'' "consent giver" is not reachable, e.g. if a child of the patient is present they can consent in emergency circumstances, if the spouse is ''not'' reachable.  In the context of (non-corner's) autopsies, '''the hierarchy has to be followed strictly''', as there is no such thing as an "emergency autopsy"; it is ''not'' acceptable to ask the child of the decedent 'cause they aren't distraught like the spouse of the decedent.
*In clinical medicine, it is allowable to skip down the hierarchy if ''the'' "consent giver" is not reachable, e.g. if a child of the patient is present they can consent in emergency circumstances, if the spouse is ''not'' reachable.  In the context of (non-corner's) autopsies, '''the hierarchy has to be followed strictly''', as there is no such thing as an "emergency autopsy"; it is ''not'' acceptable to ask the child of the decedent 'cause they aren't distraught like the spouse of the decedent.
*In non-corner's cases, a physician ''cannot'' consent an autopsy.
*In non-corner's cases/non-medical examiner's cases, a physician ''cannot'' give consent for an autopsy.


===Religious objections===
===Religious objections===
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Body should be examined for ''defensive-type wounds'':
Body should be examined for ''defensive-type wounds'':
*Between the finger, esp. thumb and pointing finger.
*Between the fingers - especially thumb and pointing finger.
*Dorsal aspect of the hand.
*Dorsal aspect of the hand.
*Forearm.
*Forearm.
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===Before the first incision===
===Before the first incision===
If there is suspicion of pneumothorax - one the the three following can be done:<ref name=Ref_HospAuto120-1>{{Ref HospAuto|120-1}}</ref>
If there is suspicion of [[pneumothorax]] - one the the three following can be done:<ref name=Ref_HospAuto120-1>{{Ref HospAuto|120-1}}</ref>
#Create a "pleural window" (between ribs by removing soft tissue... without entering the pleural cavity).
#Create a "pleural window" (between ribs by removing soft tissue... without entering the pleural cavity).
#Open chest underwater and watch for air bubbles.
#Open chest underwater and watch for air bubbles.
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*Y-shaped incision (standard):
*Y-shaped incision (standard):
**Superior "points" of the Y ~ at the deltoid muscle.
**Superior "points" of the Y ~ at the deltoid muscle.
**"Confuence of lines" in the Y ~ inferior to the suprasternal notch.
**"Confluence of lines" in the Y ~ inferior to the suprasternal notch.
*Neck dissection incisions:
*Neck dissection incisions:
**Deltoid to mastoid process.
**Deltoid to mastoid process.
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Notes:
Notes:
*The sterum may have cleft or foramen - as an anatomical variant.<ref name=pmid10803333>{{cite journal |author=Fokin AA |title=Cleft sternum and sternal foramen |journal=Chest Surg. Clin. N. Am. |volume=10 |issue=2 |pages=261–76 |year=2000 |month=May |pmid=10803333 |doi= |url=}}</ref>
*The sternum may have cleft or foramen - as an anatomical variant.<ref name=pmid10803333>{{cite journal |author=Fokin AA |title=Cleft sternum and sternal foramen |journal=Chest Surg. Clin. N. Am. |volume=10 |issue=2 |pages=261–76 |year=2000 |month=May |pmid=10803333 |doi= |url=}}</ref>
*If the decedent has a history of a [[CABG]] removal of the chest plate should be done with care to preserve the grafts.
*If the decedent has a history of a [[CABG]] removal of the chest plate should be done with care to preserve the grafts.


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==Neck organ pluck==
==Neck organ pluck==
===Non-suspicious cases===
#Trim tissue posterior to horns of the thyroid.
#Trim tissue posterior to horns of the thyroid.
#Cut between thyroid horns & hyoid.
#Cut between thyroid horns & hyoid.
#Cut off base of tongue.
#Cut off base of tongue.
===Suspicious cases===
*In Canada, it is convention to do ''layered neck dissection''.
**The strap muscles of the neck are lifted of in layers to look for injuries (mostly contusions).
**Strap muscle hematomas may arise in a number of contexts, e.g. they are reported in drowning.<ref>{{Cite journal  | last1 = Püschel | first1 = K. | last2 = Schulz | first2 = F. | last3 = Darrmann | first3 = I. | last4 = Tsokos | first4 = M. | title = Macromorphology and histology of intramuscular hemorrhages in cases of drowning. | journal = Int J Legal Med | volume = 112 | issue = 2 | pages = 101-6 | month =  | year = 1999 | doi =  | PMID = 10048667 }}</ref>


====Hyoid bone====
====Hyoid bone====
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#*Check renal veins.
#*Check renal veins.
#Separate IVC.
#Separate IVC.
#Transect esophagus (~2 cm) distal to inferior margin of the cricoid cartilage.
#Transect [[esophagus]] (~2 cm) distal to inferior margin of the cricoid cartilage.
#Take down esophagus using blunt dissection (to separate from thorax).
#Take down esophagus using blunt dissection (to separate from thorax).
#Separate thorax and abdomen - by dissecting through the pericardium.
#Separate thorax and abdomen - by dissecting through the [[pericardium]].


===Common finding(s)===
===Common finding(s)===
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===Respiratory system===
===Respiratory system===
#Open trachea + bronchus (see ''Note'').
#Open [[trachea]] + bronchus (see ''Note'').
#Examine proximal airway.
#Examine proximal airway.
#Examine proximal pulmonary arteries.  
#Examine proximal pulmonary arteries.  
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*Opened along greater curvature.
*Opened along greater curvature.
**Large carcinomas preferentially involve the lesser curvature.<ref name=pmid2550682>{{Cite journal  | last1 = Yamagawa | first1 = H. | last2 = Onishi | first2 = T. | title = [A clinicopathological study of early gastric cancers with a diameter larger than five centimeters]. | journal = Gan No Rinsho | volume = 35 | issue = 10 | pages = 1114-8 | month = Sep | year = 1989 | doi =  | PMID = 2550682 }}</ref>
**Large carcinomas preferentially involve the lesser curvature.<ref name=pmid2550682>{{Cite journal  | last1 = Yamagawa | first1 = H. | last2 = Onishi | first2 = T. | title = [A clinicopathological study of early gastric cancers with a diameter larger than five centimeters]. | journal = Gan No Rinsho | volume = 35 | issue = 10 | pages = 1114-8 | month = Sep | year = 1989 | doi =  | PMID = 2550682 }}</ref>
*GE junction should not be opened if portal hypertension is suspected (see: ''esophagus'').
*GE junction should not be opened if [[portal hypertension]] is suspected (see: ''esophagus'').


====Findings====
====Findings====
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===Esophagus===
===Esophagus===
*Should be everted, if portal hypertension is suspected, as varices are thus more readily demonstrated.<ref name=Ref_HospAuto140>{{Ref HospAuto|140}}</ref>
{{Main|Esophagus}}
*Should be everted, if [[portal hypertension]] is suspected, as [[esophageal varices]] are thus more readily demonstrated.<ref name=Ref_HospAuto140>{{Ref HospAuto|140}}</ref>
*#Stomach opened (''without opening GE junction'').
*#Stomach opened (''without opening GE junction'').
*#String tied to proximal esophagus.
*#String tied to proximal esophagus.
*#Forceps inserted from stomach to grasp tied end and invert esophagus.
*#Forceps inserted from stomach to grasp tied end and invert [[esophagus]].


===Omentum===
===Omentum===
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**Capsule of the spleen is white - resembles sugar-coating.
**Capsule of the spleen is white - resembles sugar-coating.
**Importance: ''none'' - benign.
**Importance: ''none'' - benign.
*Splenomegaly secondary to portal hypertension.
*[[Splenomegaly]] secondary to [[portal hypertension]].


===Kidney===
===Kidney===
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**''Flea-bitten appearance'' - seen in [[hypertension]].<ref name=pmid9356598>{{Cite journal  | last1 = Ono | first1 = H. | last2 = Ono | first2 = Y. | title = Nephrosclerosis and hypertension. | journal = Med Clin North Am | volume = 81 | issue = 6 | pages = 1273-88 | month = Nov | year = 1997 | doi =  | PMID = 9356598 }}</ref>
**''Flea-bitten appearance'' - seen in [[hypertension]].<ref name=pmid9356598>{{Cite journal  | last1 = Ono | first1 = H. | last2 = Ono | first2 = Y. | title = Nephrosclerosis and hypertension. | journal = Med Clin North Am | volume = 81 | issue = 6 | pages = 1273-88 | month = Nov | year = 1997 | doi =  | PMID = 9356598 }}</ref>
*[[Acute tubular necrosis]] (ATN).
*[[Acute tubular necrosis]] (ATN).
**ATN is difficult (or impossible) to prove on autopsy material.
**ATN is difficult to prove on autopsy material.
**Look for:
**On microscopy, look for:<ref name=pmid19207286>{{Cite journal  | last1 = Kocovski | first1 = L. | last2 = Duflou | first2 = J. | title = Can renal acute tubular necrosis be differentiated from autolysis at autopsy? | journal = J Forensic Sci | volume = 54 | issue = 2 | pages = 439-42 | month = Mar | year = 2009 | doi = 10.1111/j.1556-4029.2008.00956.x | PMID = 19207286 }}</ref>
***Heme-granular casts in the lumen.
***Tubular epithelial whorls.
***Regenerative activity (mitoses).
***Tubulorrhexis.
***Interstitial edema.


===Liver===
===Liver===
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=Histology=
=Histology=
===General===
===General===
It's the at the pathologists discretion.  In ''decomp'' cases it is reasonable to submit nothing.
It's the at the pathologists discretion.  In ''[[decomp]]'' cases it is reasonable to submit nothing.


===Forensic context===
===Forensic context===
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*[[Sudden infant death syndrome]].
*[[Sudden infant death syndrome]].


===Histology checklist===
==Histology checklist==
{| class="wikitable sortable"  
{| class="wikitable sortable"  
! Section/organ
! Section/organ
! Elements
! Expected finding(s)/common finding(s)
! Findings to consider
|-
|-
| Bone marrow
| [[Bone marrow]]
|  
|  
*trilineage hematopoiesis
*trilineage hematopoiesis
|
*infection
*infection
*tumour
*tumour
|-
|-
| Coronary arteries
| [[Coronary arteries]]
|  
|  
*percent stenosis for major arteries (LMCA, LAD, LCx, RCA)
*[[atherosclerosis]] - should give percent stenosis for major arteries (LMCA, LAD, LCx, RCA)
*plaque rupture
|
*atherosclerotic plaque rupture
*thrombi
*thrombi
*inflammation
*inflammation
|-
|-
| Heart muscle
| [[Heart]] muscle
|  
|  
*fibrosis - esp. post. LV (old [[myocardial infarction|MI]])
*nuclear enlargement, arteriolosclerosis, periarteriolar fibrosis ([[hypertensive heart disease]])
|
*hemorrhage
*hemorrhage
*necrosis (coagulative/contraction band)
*wavy fibres (early ischemic change)
*inflammatory infiltrate (necrosis versus not)
*[[necrosis]] - coagulative/contraction band (recent MI)
*nuclear enlargement
*inflammatory infiltrate - not associated with necrosis
*hyaline material (amyloid)
*hyaline material ([[cardiac amyloidosis]])
*fibre disarray ([[hypertrophic cardiomyopathy]])
*fatty replacement ([[ARVC]])
|-
|-
| Adrenal gland
| [[Adrenal gland]]
|  
|  
*tumour  
*no pathology
**primary (cortex/medulla)
|
*tumour
**primary (cortex, medulla)
**metastatic
**metastatic
*hemorrhage
*hemorrhage
*fat
*fat
|-
|-
| Kidney
| [[Kidney]]
|  
|  
*vessels (atherosclerosis, [[arterial hyaline|arteriolar hyalinization]])
|
*tumour
*tumour
*glomeruli (enlargement, cresents, mesangial expansion, inflammation - esp. PMNs)
*glomeruli (enlargement, crescents, [[mesangial expansion]], inflammation - esp. [[PMN]]s)
*vessels (atherosclerosis, arteriolar hyalinization, thrombi)
*vessels - thrombi ([[thrombotic microangiopathy]])
*interstitial (fibrosis, inflammation)
*interstitial (fibrosis, inflammation, edema)
*tubules (regeneration, casts, inflammation)  
*tubules (inflammation, tubular epithelial whorls, tubulorrhexis)  
|-  
|-  
| Liver
| [[Liver]]
|
|
*tumour
*steatosis - should give severity (mild, mederate, severe), location & type (macrovesicular vs. microvesicular)
*fibrosis (septa, rounded contours, cirrhosis), inflammation (cell type, location (portal, interface, lobular))
|
*steatosis (local/type)
*fibrosis (septa, rounded contours, [[cirrhosis]]), inflammation (cell type, location (portal, interface, lobular))
*tumour - esp. metastatic
*bile ducts
*bile ducts
*ballooning cells (steatohepatitis)/feathery degeneration (cholestasis)  
*[[ballooning degeneration]] ([[steatohepatitis]])/feathery degeneration ([[cholestasis]])
*necrosis (location important)
|-
|-
| Spleen
| [[Spleen]]
|  
|  
*white pulp
*normal white pulp/red pulp
*red pulp
|
*tumour
*surface abnormalities
*surface abnormalities
|-
|-
| Gastrointestinal tract
| Gastrointestinal tract
|
*autolytic changes
|
|
*tumour
*tumour
*vessels
*vessels
*inflammation - esp. PMNs
*inflammation - esp. [[PMN]]s
*fibrosis
*fibrosis
|-
|-
| Thyroid gland
| [[Thyroid gland]]
|
*no pathology
|
*tumour - papillary thyroid carcinoma, goitre
*inflammation
|-
| [[Lung pathology|Lung]]
|
|
*pulmonary edema
*[[emphysema]]
|
*infectious pneumonia
*[[pulmonary hypertension]] (may be focal)
*interstitial fibrosis
*tumour
*tumour
*inflammation
*[[granuloma]]s
*hemorrhage
*hyaline membranes ([[diffuse alveolar damage]])
|}
|}
===List form===
====Bone marrow====
*Trilineage hematopoiesis present.
*Negative for infection and negative for tumour.
====Cardiovascular system====
[[Coronary arteries]]:
*[[Atherosclerosis]] in the:
**Left main coronary artery.
**Left anterior descending coronary artery.
**Left circumflex coronary artery.
**Right coronary artery.
*No identified atherosclerotic plaque rupture.
*No thrombosis.
*No vasculitis.
[[Heart]] muscle:
*Fibrosis - posterior left ventricle.
*Nuclear enlargement, arteriolosclerosis and periarteriolar fibrosis.
*No hemorrhage.
*No wavy fibres.
*No [[necrosis]].
*No inflammatory infiltrate.
*No hyaline material.
====Endocrine organs====
[[Adrenal gland]]:
*No pathology apparent.
*No tumour.
*No hemorrhage.
*No fatty replacement.
Thyroid gland:
*Normal thyroid gland.
*No tumour.
*No inflammation.
====Genitourinary system====
[[Kidney]]:
*Atherosclerosis, mild.
*Arteriolar hyalinization.
*No tumour.
*Normal glomeruli (no enlargement, no crescents, no [[mesangial expansion]], no inflammation).
*No thrombi.
*No interstitial fibrosis, no inflammation, and no edema.
*No tubular inflammation, no whorls, and no fragmentation.
*No apparently pathologic renal casts.
====Gastrointestinal system====
[[Liver]]
*Steatosis - mild, centrilobular, macrovesicular.
*No fibrosis.
*No inflammation.
*No tumour.
*Normal bile ducts.
*No [[ballooning degeneration]] and no feathery degeneration.
*No necrosis.
Luminal GI tract:
*Autolytic changes.
*No tumour
*No vasculitis.
*No siginificant atherosclerosis.
*No inflammation.
*No fibrosis.
====Spleen====
*Normal white pulp/red pulp.
*No tumour.
*No surface abnormalities.
====Lung====
*Pulmonary edema.
*Infectious pneumonia, mild.
*Emphysema, mild.
*No pulmonary hypertension.
*No interstitial fibrosis.
*No tumour,
*No granulomas,
*No significant hemorrhage.
*No hyaline membranes.


==Sign out==
==Sign out==
===Sample clinical history===
===Sample clinical history===
<pre>
<pre>
A 63 year old male with a history of alcohol abuse was admitted on December 13, 2018 for
A 63 year old male with a history of alcohol abuse was admitted on December 13, 2022 for
recurrent alcohol related pancreatitis. On December 21, he was found unresponsive at 0:15.  
recurrent alcohol related pancreatitis. On December 21, he was found unresponsive at 0:15.  
Approximately fifteen minutes earlier, he was on oxygen and in no apparent distress. A code  
Approximately fifteen minutes earlier, he was on oxygen and in no apparent distress. A code  
blue was called; however, the attempted resuscitation was unsuccessful.  Death was declared  
blue was called; however, the attempted resuscitation was unsuccessful.  Death was declared  
at 1:00 on December 21, 2018.
at 1:00 on December 21, 2022.
</pre>
</pre>


Michael
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