ADULT AUTOPSY TEMPLATE - TRAUMA

External Examination

The decedent (length, ____ cm; weight, ____ kg) is a well-developed, well-nourished/poorly nourished/obese/cachectic, phenotypically (race) male/female appearing younger than/older than the recorded age of ____. The unembalmed/embalmed, unclothed/clothed body is identified by a tag attached to the right/left great toe. (In forensic cases, describe the identification on the outside of the body bag and any security precautions preventing unauthorized opening of the bag. Describe the decedent’s clothing, jewelry, pocket contents, and so forth in detail.) There is mild/ moderate/pronounced rigor mortis present in the jaws, neck, back,and extremities. A violaceous posterior/anterior/other lividity pattern is present. The body is cold/warm/other. The decedent is normocephalic/other and without apparent trauma about the face or scalp/other. The scalp hair is (color) and ___cm in average length. (In males, describe facial hair.) The bones of the forehead, nose, cheeks, and jaw are intact/other to palpation. The irides are (color), and the pupils are equal and round measuring ____ cm bilaterally/other. The conjunctivae are pink/other, and the sclerae are lear/icteric/other. The ears are well-formed and symmetrical/other, and the external auditor canals are without/with discharge. The nose is well-formed and symmetrical/other. The external nares are patent/other and without hemorrhage or discharge/other. The lips are intact/other. The mouth contains a small amount of seromucous secretion/other and no obstructing materials or lesions/other. The native teeth are present/absent and in good/poor repair. The buccal mucosa is pink/other and shows no signs of trauma/other. The neck is symmetrical. There is no palpable crepitus or hypermobility. The trachea is palpably straight and in the midline/deviated to the right or left. The chest is symmetrical/other and without palpable crepitus or bony deformity. The breasts are soft/other without palpable masses, skin retraction, or nipple discharge/other. The abdomen appears flat/distended and soft/hard without palpable evidence of organomegaly or external trauma/other. Pubic hair is present in the usual male/female distribution/other. The external genitalia are unremarkable and atraumatic. (For males: The penis appears circumcised/uncircumcised. Both testes are descended and palpable in the scrotum/other.) There is no palpable cervical, axillary, or inguinal lymphadenopathy/other The upper extremities are symmetrical and well developed/other. The fingernails are thin and translucent/other. The nail beds show no cyanosis/other. There is no clubbing/other. The lower extremities are symmetrical and well muscled/other. There is no pedal edema/other. The toenails are thin/thickened/other and translucent/opaque/other. The soles of the feet are soft/callused/other. The posterior trunk shows a symmetrical external contour/other. The spine appears straight/other. The anus is closed and atraumatic/other. The skin color is white/brown/tan/yellow/pale. The skin shows no irregularity/poor turgor and elasticity/eruptions/rashes/other.

Scars and Identifying Marks

Describe scars and identifying marks.

Evidence of Therapeutic Intervention

The following medical paraphernalia are in place: (Describe intravenous or intraarterial lines, Foley catheters, endotracheal tubes, recent surgical incisions, and so forth.)

Evidence of External Trauma

Gunshot Wounds

Entrance. Describe location, dimensions, abrasions, contusions, soot, stippling, or muzzle mark; satellite injuries; bone beveling. This wound is centered _____ cm from the top of the head and _____ cm to the left/right of the anterior/posterior midline.

Exit. Describe location, description, dimensions, abrasions, contusions. This wound is centered cm from the top of the head and cm to the right/left of the anterior/posterior midline.

Path of projectile. Highlight path of projectile through body. Recovery of projectile. A projectile/projectile fragment is recovered from the _____ and is labeled “No. _____.” This fragment is a deformed, copper-colored, lead-cored slug/other. There is no radiographic evidence of metal fragments or retained projectile/other.

—or—

Recovery of projectile. No projectile is recovered (perforating wound). Direction of wound. The projectile traveled from (right to left, front to back, and downward/other).

Summary: In summary, this is a (perforating/penetrating) (gunshot/shotgun) wound _____ of range that entered the body_____, (highlights of path), and exited the body _____. The direction of the wound track is _____. A/No projectile is recovered.

Sharp-Force Injuries

Stab Wound Describe location, dimensions, orientation, wound edges, contusions, abrasions. The wound is centered ___ cm from the top of the head and cm to the left/right of the anterior/posterior midline.

Wound track. This incised wound penetrates at a depth of ___cm (describe internal injuries).

Direction of wound. This wound tracks from (right to left, front to back, and downward/other). Incised Wound of the head and _ inches to the (left/right) of (anterior/posterior) midline.

Blunt-Force Injuries

Hemorrhages: Describe location, color, size, characteristics.

Lacerations: Describe location, size, characteristics.

Fractures: Describe site, characteristics (focal, crush, penetrating, traction, angulation, rotation, compression, combinations).

Abrasions/contusions: Describe location, color, size, characteristics.

Injuries from Hanging and Strangulation

Ligature marks: Completely/partially encircling the neck is a ligature mark measuring cm in length by cm in width with a furrow depth of cm. The ligature mark is centered across the anterior/posterior/lateral/right/left neck at the level of the _____. One end is located _____cm from the top of the head and _____cm to the right of the anterior/posterior midline; the other is_____ cm from the top of the head and _____cm to the left of anterior/posterior midline. The angulation of the ligature mark _____.Describe any wound patterns, margins, point of suspension and excoriations of the skin above or below the mark.

Ligatures: Accompanying the body is a ligature consisting of (type of material/associated pattern/length of ligature/diameter). Describe knot if present. The pattern/texture of the ligature is compatible with the pattern of the mark on the decedent’s neck/other.

Primary Incision, Neck, and Body Cavities

A standard Y-shaped thoracoabdominal incision reveals a subcutaneous fat thickness of ____ cm at the midabdominal level. There is no evidence of hemorrhage in the anterior muscles and soft tissues of the neck/other. The carotid sheaths are intact/other. The anterior cervical spine is palpably unremarkable/other. No obstructive material or lesions are present in the glottis or larynx/other. The hyoid bone and laryngeal cartilage are normally formed and intact without evidence of fractures or hemorrhage/other. The breast tissue consists of a small amount of white stroma within yellow fat/other. The sternum and ribs of the anterior chest are intact/other. The mediastinum is midline/other. The pericardial sac contains ___mL of serous fluid; its surfaces are glistening and smooth/other. The parietal pleural surfaces are glistening and smooth except for a few easily lysed apical fibrous adhesions/other. There is no pleural fluid/other. There are no pneumothoraces/other. The domes of the diaphragm are at the fifth rib bilaterally/other. Omental and mesenteric fat is abundant/other. The peritoneal surfaces are glistening and smooth/other; there are no unusual fluid collections in the abdominal space/other, and the organs occupy their usual positions/other.

Cardiovascular System

The heart (_____ g) is normally formed/other and located in its usual position in the left chest/other, with its apex pointing to the left/right/midline. There is a minimal/moderate/large amount of epicardial fat. The epicardial surface is glistening and smooth/other. The atrial chambers are not dilated/dilated. The interatrial septum is intact/other. The atrioventricular connections are present/other, and the leaflets of the atrioventricular valves are thin and delicate/other. The chordae tendineae are thin/other. The interventricular septum is intact/other. The myocardium is firm and red-brown/other. The right and left ventricular free walls measure ___cm and ____ cm, respectively. The outflow tracts are widely patent/other, and the semilunar valves each contain three thin and delicate/other cusps. The pulmonary artery is of appropriate caliber and configuration/other; its intimal surface is glistening and intact/other. The coronary arteries course over the surface of the heart in the usual fashion/other. There is balanced/ right dominant/left dominant coronary artery circulation. The coronary arteries are patent/other and free of atherosclerosis/other.The ascending aorta is of the usual caliber and arches left/other before descending along the left/other side of the vertebral column. The major arteries arise from the aortic arch and descending aorta in the usual configuration/other and are patent/other. The intimal surface of the aorta is smooth/other. The venae cavae and other major veins are patent and thin walled/other.

Respiratory System

The trachea is of normal/other caliber and courses in the usual/other fashion. The lungs (right, _____ g; left, _____ g) contain the usual/other lobes and fissures. The lungs collapse completely/ collapse only partially/do not collapse. The visceral pleural surfaces are slightly opaque/other with a small/moderate/large amount of anthracotic pigment. The parenchyma is soft and pale red/other. Air spaces are not enlarged/other. Respiratory mucosa is smooth and pale/other, and the lumen contains a small amount of clear mucus/other. The vessels are patent/other.

Gastrointestinal System

The oesophagus courses in the usual/other fashion to enter the stomach; its mucosal surface is white and intact/other. The squamocolumnar junction is sharp/indistinct/other. The stomach is empty/other and does not contain residuals of medication/other. An ethanol-like odor is apparent/not apparent. Gastric mucosa is intact with tall rugal folds/other. The wall is pliable/other. The pylorus is contracted/other. The small intestine is of the usual/other caliber, and its walls are pliable/other. The cecum is freely mobile/fixed in the right lower quadrant. The appendix is retrocecal/other and not inflamed/other. The colon contains formed brown stool/other and is of generous caliber/other. No focal mass lesions are identified throughout the gastrointestinal tract/other.

Hepatobiliary System

The liver (____ g) has a sharp/blunt/other anterior margin; its surface is intact, smooth and glistening/other. The parenchyma is red-brown and firm with the usual/accentuated/other lobular pattern. Intrahepatic bile ducts and vessels are patent/other. The gallbladder is present/other and contains approximately ____ mL of viscid dark green bile/other. The wall is thin and pliable/other with reticulated intact/other mucosa. The common bile duct is patent/other into the duodenum.

Pancreas

The pancreas (_____ g) is gray/other and located in its usual position/other within the duodenal sweep. Its parenchyma has a firm/lobular/other architecture with minimal/abundant fat in the tail. The pancreatic ducts are of the usual caliber/other.

Urinary System

The kidneys (right, _____ g; left, _____ g) are located in their usual retroperitoneal position/other and have capsules that strip with the usual ease/less difficulty than usual/greater difficulty than usual to reveal smooth/granular/other surfaces. The parenchyma is red-brown/other with clearly demarcated/ill-defined corticomedullary junctions. A minimal/moderate/large amount of peripelvic fat is present. The collecting systems are not dilated/dilated/other. The pelves and ureter are patent and not dilated/other. Their mucosa is smooth/other. The urinary bladder contains_____ mL of clear/turbid/other urine. The bladder mucosa is intact/other.

Reproductive System (Male)

The prostate (_____ _ _____ _ _____ cm or _____ g) is firm/other with lobular gray-white/other parenchyma. The testes have smooth white/other capsules and tan/other parenchyma. Tubules string out in the usual manner/do not string out

Reproductive System (Female)

The uterus, tubes, and ovaries are in their usual/other relative positions within the pelvis and appear appropriate for age. The cervical os is round/elongated/other. The endometrial cavity

(_____ _ _____ cm) is empty/other. The endometrium is pale/ other and measures _____ cm in thickness. The Fallopian tubes are narrow/other and without/other adhesions. The ovaries (right,_____ _ ______ _____ cm or _____ g; left, _____ _ ______ _____ cm or _____ g) are gray/other and convoluted/smooth/other with firmgray parenchyma containing a few scattered cortical corpora lutea and albicantia/homogeneous parenchyma/other.

Lymphoreticular System

The thymic tissue is ill defined; its parenchyma largely replaced by fat/other. The spleen (____ g) has a smooth, intact/other capsule. Splenic parenchyma is dark red/other. The follicles are small/other, and trabeculae are delicate/other. There is no/other lymphadenopathy. The mediastinal lymph nodes are soft and black/other. Other lymph nodes are small and gray/other. Rib and vertebral marrow is red, moist, and ample/other.

Endocrine System

The pituitary (_____ g) fills the sella turcica/other. The thyroid gland is symmetrical, red-brown, and firm/other. The adrenal glands have uniform yellow cortices/other separated from the medullary gray/other by a thin, red line.

Musculoskeletal System

Cartilage is firm/other. The bone is hard/other. The vertebrae, ribs, pelvis, and long bones are intact without gross evidence of fracture or deformity/other. Skeletal muscles are red-brown, firm and appropriate mass for the decedent’s age and sex/other.

Head and Central Nervous System

Reflection of the scalp reveals no evidence of subgaleal hemorrhage/other. The underlying calvarium is intact and normal in thickness/other. The dura is intact/other and its inner surface smooth and glistening/other. The dural sinuses are patent/other. Cerebrospinal fluid is clear/other. The brain weighs _____ g. The leptomeninges are thin and transparent with no vascular congestion, subarachnoid hemorrhage, or exudate/other. The circle of Willis and other basal vasculature are intact and normally formed/other. The vessels are patent and thin walled/other. The cranial nerves are intact and normally distributed/other. The dorsal convexities of the brain are symmetrical with a well-developed gyral pattern/other. The brainstem and cerebellum show the usual/other external configuration. There is no localized external softening or contusion of the brain. There is no displacement of the cingulate gyrus, medial temporal lobe, or cerebellar tonsils/other.