Docstoc

AUTOPSY PROTOCOL

Document Sample
AUTOPSY PROTOCOL Powered By Docstoc
					                                                                                                                                                                                                                                            ~
                                                   FARO        OF MEDICOl~C1AL                     INVE~        1._                  5                                                                           OF~I~E        I'~E     ON\)n
                                        OFFICE                OF TdE             CHIEF          MEDICAL               EXAMINER                                                                          Re.-----co·aLiJL

                                                                                                                           Eastern Division                                                           I here-by certi'\J that this is a true
                   Central Office                                                                                                                                                                     and c(),rec t copy of the original
                                                                                                                           P.O. Box 9666                                                              d()cLlrne nL       V.allid only     when copy
                   P.O. Box 26901
                                                                                                                           2422 West 41 st Street                                                     I:>ea impr in.
                                                                                                                                                                                                           rs              ()If the office      seal.
                   800 N.E. 13th Street, 4-B
                                                                                                                           Tulsa, Oklahoma 74107                                                      A. JAY          CHAPIMAN.         M.D,
                   Oklahoma City, Oklahoma                     73190
                                                                                                                           (918) 446-1581                                                             Chie1      M ed iccal Examiner
                   (405) 239-7141
                                                                                                                                                                                                      By                                                _

                          REPORT OF INVESTIGATION                                                  BY MEDICAL                      EXAMINER                                                           Date


                                                                                                                               Age               Birth      Date                    Race             Sex                   Marital      Status
DECEDENT-First-Middle-Last                        Names (Please avoid use of initials)


                SYRL                  C.        ,...~~.~n
                                                                                                                                C{7                                                       WHITE                             mRRIED
                                                                                                                               Occupation
HOME    ADDRESS-No.           Street,         City,   State
  ,        '




       2200 N. W':56th                      STREET, OKLA. CITYOKLA.                                                        I        RETIRED.
TYPE OF DEATH:                (Check one only)                                                Unattended during fatal illness  0                                                                                Ii m010r ·v·ehicle accident,
                                                                                                                                                                                                                check onlE of the following
                                                                                              Found dead without obvious cause 0
      While in penal incarceration                                         0                 *Under suspicious circumstances   0                                                                                DR IVER               0
      After unexplained coma                                               0                 *Violent, unusual or unnatural   :xm                                                                               CVCLI S   r           0
      During therapeutic procedure                                         0                 *Means: KNIFE                                                                                                      PASSE~GER             0
      Death possible threat to public health                               0                                                                                                                                    PEDE STRlIAN          0
      Unattended stillbirth or by midwife only                             0
                                                                                                                                                                                                     DATE                       I TIME
EXAMINER        NOTIFIED          Bj"-NAME.'-TITLEIAGENC~,                            II')ISTI,T\1TION,    OR ADDRESS)                               'J



       OCPD
                                                                                                                                                                                                        01JmB2                   I      1630
                                                                                                         CITY       OR COUr-iTY                            TYPE         OF PREMISES
INJURED        OR BECAME              ILL    AT(ADDRESS)


       2200 N.W.56th                         ST.                                                          )\ OKLA. CITY                     ..    ,;.I          DWELLING
LOCATION        OF DEATH          (ADDRES,S            OR N,AME      OF, INSTITUTION)I                   CITY       OR COUNTY
                                                                                                                                                           TYPE         OF PREM ISES                 DATE        e*,Fo0rh5~
       2200 N.W.55th'
                                              l
                                             ST. \ ... , J\,,-J.}                ,                  '\(6KLA.CITY                                     'I
                                                                                                                                                                DWELLING                                01JUI132                 I      1530

BODY      VIEWED   B~ M,EDICAL                 EX/'IMINER       AT     IADDRESS)                   \1    CITY       OR COUNTY
                                                                                                                                                           TYPE         OF PREMISES                  DATE                            TIME

                     ,":j,).,),
                                  I
                                                      ,J'j,       )/\~                 \:
                                                                                            ~..... \'
                                                                                                 !          .~
                                                                                                             "-,       \                                                    '       f\)                                                 0830
                                              r
                                                                                                                                                     :~I
                                                                                                                                                                MORGUE                                  02JUL82
       Q01 N. STONEWAlL                                                                                         OKLA. CITY
DESCRIPTION          OF      B~;DY                    RI~tR)           I               ~    UVOR    ".    ~~",.I               EXTERNAL              OBSERVAT'IONS                   ')
                                                                                                                                                                                                                 NOSE      I    MOUTH            I EARS




EXTERNAL
PHYSICAL
EXAMINATION
                                  r"
                                  Jaw



                                  Arms

                                      Legs
                                              0

                                              a
                                              0
                                              0
                                                   Complete



                                                   ""0'
                                                   Passed

                                                   Decomposed
                                                                  0

                                                                  a
                                                                  0
                                                                  0
                                                                           Color

                                                                           Anterior
                                                                           \
                                                                           Posterior
                                                                            ~!   ,\

                                                                           Lateral
                                                                                       ~
                                                                                            0
                                                                                            0
                                                                                            0
                                                                                                                      Clo,l",t1

                                                                                                                      Parlly

                                                                                                                      Beard

                                                                                                                      Circumcised
                                                                                                                      E~~S:
                                                                                                                                     0
                                                                                                                                  Clothed




                                                                                                                                   Color'
                                                                                                                                             0
                                                                                                                                                 0
                                                                                                                                                  Unclothed

                                                                                                                                                            Hair

                                                                                                                                                          Mustache

                                                                                                                                                            \
                                                                                                                                                                   '-
                                                                                                                                                                        0
                                                                                                                                                                        """'4111)




                                                                                                                                                                          -----
                                                                                                                                                                                             BLOOD
                                                                                                                                                                                               FROTH
                                                                                                                                                                                            t-:--::-
                                                                                                                                                                                             OIHER
                                                                                                                                                                                             (Sand,dirt,
                                                                                                                                                                                            \/\Iater,etc.


                                                                                                                                                                                               Icm)
                                                                                                                                                                                                            )


                                                                                                                                                                                                                                 (kg)
                                                                           R~gional                             _     Pupils'       Opacities,       Etc.                                    U:NGTH\li\JEIGHT                                               _
 Significant .observations        and injury
 documentation    -(Please        use space below)                .-.,.'\l~\                                               R                L          _                                     BODY      HEA T:


                                                                                 \
 _---~S[£                                                                                  PROTOCOL
                                                                                      ,AUTOPSY
 Probable cause of death:                                                                                 Manner of death:                        (Check one only)                          Ca.f! disp or; lion:

                                                                                                           Natural             0                          Accident              0           Autopsy:              Yesct     roJ DO
                                                                                                                                                                                                                         -"FIBJ
      HEAD AND NECK TRAUMA                                                                                 Suicide             0                          HomicidelX
                                                                                                                                                                                            Authori2oo
                                                                                                                                                                                             Pathologi;t
                                                                                                                                                                                                                  b
                                                                                                                                                                                                                   FBJ33&082
                                                                                                                                                                                                                       "_----'---
                                                                                                           Unknown             0                          Pending               0            Not a medi c3I1 e><a-T1inercase 0
 MEDICAL   EXAMINER
 Name, Address and Telephone                   No,

                                                                                                                I hereby state that, after receiving notice of the death des::riilJed
       FRED B.JORDAN M.D.                                                                                 herein, I conducted an investigation as to the cause an~ man nn of
       901 N. STONEWALL                                                                                   death, as required by law, and that the facts contained hereill r8!!fjard-
       OKLA. CITY ,OKLA.                                                                                  ing such death are true and correct to the best of mv k llowlEn!j1l! and
                         73117                                                                            belief.

 County    of Appointment




 MEDICAL         EXAMINER                   MUST COMPLETE REVERSE SIDE
                                          .;
                                                                 BOARD OF MEDICOLEGAL                     INVESTIGATIONS
                                                             OFFICE     OF THE          CHIEF      MEDICAL          EXAMINER




                                                                              REPORT            OF AUTOPSY
                                                                                                                                                  Fred B.      Jordan,        M.D.
                                                                                                             Authority        for autopsy:                                   Official Title
                            SYRLC.               ORBACH                                                                                           Name
  DECEDENT                                             Middle name                       Last name
                            First   name

                                                                                                                                          Livor              Body Identified by:
                                                                                          0                Rigor
TYPE       OF DEATH                            Unattended by a physician
                                               While in penal incarceration               0                                    Color   Purple                        TAG
Violent or Unnatural    IXJ                                                               0      Jaw     0    Arms       0
                                               During therapeutic procedure
Unusual                 0                                                                                                      Anterior 0
                                               Body to be cremated, buried at sea,               Neck    0    Chest      0
Means.'                                                                                   0                              0     Po~terior I}O
                                                  transported out of state                       Back    0    Abdomen
                                               Death possible threat to public health     0                                    Lateral 0
                                                                                                                                                            Persons Present At Autopsy
                                                                                                 Legs    0
                                               After unexplained coma                     0
                                                                                                                                                              Jim    McCoy
                                               Suspicious                                 0             Complete               Regional

                                                       Length 165cm       Weight56Kg            Eyes 1t .brnpupils:      R.     0.3       Opacities. Etc.
Age 87        Race      W           Sex         M
                                                                                          Body Heat CO' d                L. 0.3
               Beard        No        Mustache         Yes      Circumcised Yes
Hair Gray

                                                                            PATHOLOGICAL                DIAGNOSES


                  1. Acute cutaneous co~tusions of left lateral head, right malar area; right
                     peri-orbital ecchymosis.
                  2. Acute cutaneous lacerations and abrasions of left lateral head, left ear,
                     right malar area and left occiput.
                  3. Incised wound of neck with transection between the hyoid bone and thyroid
                     cartilage, transection of esophagus, transection of left common carotid
                     artery, incised wound of right common carotid artery, tongue hematoma, and
                     incisions~ into the cartilage and bone of the vertebrae.
                  4. Stab wound of left cheek.
                  5. Incised wound of right arm (1), right forearm (2), and back of left hand (1).
                  6. Intrapulmonary aspiration of blood.
                  7. Relative visceral pallor.
                  8. Depressed and linear skull fractures; acute subarachnoid hemorrhage (traumatic).
                  9. Emphysema and bronchiectasis.
                 10. Arteriosclerotic cardiovascular disease.
                 11. Arteriolarnephrosclerosis.
                 12. Benign prostatic hyperplasia.
                 13. Incarcerated inguinal hernia; right hydrocele.
                 14. Scleral petechiae.




   Cause    of death:
                                                                                                                                                                 ML 386-82
                                                 HEAD AND NECK TRAUMA                                                                                               FBJ/bd



                                                                                           The facts       stated    herein     are
   I hereby certify that this document is a true and correct
                                                                                           knowledge          and   belief.
   copy of the original document. Valid only when copy
   bears imprint of the office seal.
                                    A. JAY CHAPMAN.              M.D.
                                    Chief Medical Examiner                               July      2,     1982     (8:30     a.m.)
                                                                                                        Date and time of autopsy                        Place of autopsy
    By                                                   Date
             ,   '
HEAD _ SURFACE AND SKELETAL ANATOMY; LATERAL VIEW




                                    Case No.   ?J2)~
                                _   Date   d   M ¥1.-
           HEAD ~ SURFACE AND SKELETAL ANATOMY, ANTERIOR ANp POSTERIQRVIEWS




Name      4; wrHb.                                   Case No.

                                                     Date
                                                                ~

                                                            .J-M ~
                                                                    ?,sn
CM E-1 B 14 (Series 1978)
       HEAD - SURFACE AND SKELETAL ANATOMY, SUPERIOR VIEW - INFER:IOR VI'EW OF NECK




Name

CME-1B16
           i.      rtM~
           ( enes 1978)
                                                       Case No.

                                                       Date   a~
                                                                  ~   1-l-i)fL/
                                                                            ~
                        · LEF'T HAND - PALMAR AND DORSAL




Name    04~ , 521                                CaseNo~'iVI

CME-189 ISeries 1978)                            Date   ~~h-=--=~   _
                      HEAD - SURFACE AND SKELETAL ANATOMY; LATERAL\iIEW




Name

CME-1B15
           4 Q.,6!L()..../
           (Series 1978)
                                                         Case No.
                                                         Date
                                                                     «1- zs<87
                                                                    ~->kb~
)~/'5~                                                                         STAB WOUND CHART
~      IT, 1<1'"

                  .. ,   JI1"'T   ~   •
                                               'I              v...........-                                     I   ,.,
                                                                                                                           ,
                                                                                                                           I   dSsa=:"":


                         -0               '7


                                                                                                 WOUND NO.
                                                                       1 /      2    3      4     5     6        7                8         9   10
                                                       Head           V
                                                       Neck

                                                      Chest
       1.    Location
                 of                             Abdomen
             wound:                                    Back

                                                      Right
                                          Arm    <
                                                        Left

                                                      Right
                                           Leg   <
                                                        Left

                                                      Horiz.
       2.      The skin
                                                       Vert.
              wound is:
                                                    Oblique
                                                                     /
                                           Top of head
                                                                   II(, ~
       3.    Centimeters                            Right of
             from wound to:                          midline
                                                     Left of
                                                    midline
                                                                   q
                                                      Width
       4.
             wo~                                     Length
             in                   eters:                            'I/'*"
                                                      Diam.

                                                Backward

                                                    Forward

       5.     Direction                             Upward
             of wound:                         Downward

                                                    Medially

                                                 Later~

                                                V             No
    REMARKS:                                                                     w;JM".   '3 ~        11Y\lY\.


       Examined by:
    CME-2S   (Rev. 7·76)
                                           ~                        $~                                 Date:.;M                            0-
                 THORACIC ABDOMINAL, MALE - ANTERIOR AND POST~H·IOR.VIEWS




                                     -- -=::::::: --
                                                    )
                                                                   == -

                               ~,             ------
                                       <----------------               -



                        -
                       .....




Name         Ji t9r6&tl-.-                              Case No.   ~_"1-_'   S_<n   _
CME-1B7 (Series 1~8)                                    Date   ~   ~f--"')2C-------
                                                                                                CASE FILE NO.
    'AUTOPSY   NO.

     ML 386-82                                                                                   822587

                                              GROSS EXAMINATION

PLEURA:               Intact.

PERICARDIUM:          Intact.

PERITONEUM:           There are a few small adhesions in the right lower part of the abdomen where
                      there is a noncritically incarcerated inguinal hernia containing several loops
                      of small bowel.

HEART:                360gms.   The coronary arteries arise and distribute normally.    The left main i~
                      quite widely patent.    The anterior descending shows multiple distal areas of
                      ca. 50% occlusion and some- proximal areas of 70 to 80% occlusion--;- The right
                      coronary artery shows many areas of 50 to 60% occlusion while a focal area of
                      the circumflex shows up to 95% occlusion.     The orifice of thel~ft   coronary
                      artery is.J small and surrounded by heaped up atherosclerotic plaques.    The
                      myocardium is uniformly rubbery and tan with no evidence of old scarring.      The
                      left ventricle and septum average 1.5cm in thickness, and the right ventricle
                      averages up to 0.3cm.    The arch of the aorta is classically formed with moder-
                      ate atherosclerotic   change.

NECK ORGANS:          There is extensive transection between the hyoid and the thyroid cartilage.
                      The latter itself shows partial incision and separation of a portion of its
                      right side. The hyoid is intact.    There has been complete transection of the
                      esophagus.  The left common carotid artery is completely transected while the
                      right shows an anterior 4mm incision.    The mid posterior cartilage in the
                      vertebral column shows a horizontally situated 3cm incision which extends to
                      a maximum depth of 3mm. Lateral to this and extending slightly and upward to
                      the left there is a similar 3cm incised wound into bone with fracture and an
                      ca. depth of 4mm. The tongue is intact except for one small 4mm intramuscular
                      hematoma on the right.

LUNGS:                Combined weight of 940gms.   The tracheobronchial  tree contains large amounts
                      of partially to completely occlusive blood.    The blood in the tracheobronchial
                      tree is concentrated on the right. The pleura has a somewhat "cobblestoned"
                      and anthracotic appearance.   The parenchyma is moderately emphysematous and
                      there is minimal bronchiectatis.   The lower lobes show a rather diffuse increa-
                      sed firmness yet float moderately well in formalin.

TESTES:               Remarkable    only in a small right hydrocele.

PROSTATE:             Enlarged,    rubbery,   nodular,   and pink-gray.

U. BLADDER:           Distended    by clear straw colored fluid and shows trabeculation        of its mucosa.

ABD. AORTA:           Intact and shows moderate        atherosclerotic    change throughout.

ADRENALS:             Minimal    nodular   cortical hyperplasia.

SPLEEN:               110gms.  The capsule is slightly thickened, wrinkled, and sections show an
                      intact, rather pale maroon parenchyma with a poorly defined follicular pattern.

LIVER:                1030gms.     Intact, tan, rubbery.

GALL BLADDER:         Not remarkable.       Contains   liquid bile, shows no calculi and unremarkable
                      mucosa.

                                                                                           Over - - - -
  CME-2GE(Rev.8-78)

                                           -----------------------
                                 MICROSCOPIC DESCRIPTION AND FINAL SUMMARY




                      """"   r   ORBACH                                             ML 386-82

Heart:                 Subendocardial fibrosis.     Coronary atherosclerosis.
Lungs:                 Anthracosis. Passive hyperemia. Scant residual edema fluid. Emphysema.
                       Intrabronchiolar erythrocyte accumulation.   The cobblestoned areas noted
                       in gross translate to extensive areas of dilated bronchioles with hyperplastic
                       columnar epithelium and associated extensive adjacent fibrosis, hypervascular-
                       ization, and focal ovoid lymphoid follicle infiltrates.

Adrenal:               Focal nodular cortical hyperplasia.
Kidney:                Arteriolarsclerosis. Minimal arteriolarnephrosclerosis.          Minimal atheroscler-
                       osis. Focal chronic pyelonephritis.
Liver:                 No essential histopathology apart from arteriolarsclerosis.

Thyroid:               No essential histopathology. The adjacent neck musculature shows acute
                       hemorrhage in the form of sheets of intact erythrocytes and blood cellular
                       elements.
Pancreas;              Autolysis.     Focal interstitial fibrosis.
Spleen:                 Relatively bloodless sinusoids.
Prostate:              Autolysis.     A pattern consistent with benign glandular hyperplasia.

CNS:                   Acute subarachnoid hemorrhage.     Focal perivascular cortical extravasations
                       of blood.




July 12, 1982
                                                                     Fred B. Jord




       CME - 2MFS (Rev. 8-78)
                                                   822581                                               .. O~)SE           ON~{)
                                        BOARD OF MEDICOLEGAL INVESTIGATIONS                            'Re.~Co.~
                                    OFFICE OF THE CHIEF MEDICAL EXAMINER
                                                                                                       I hereby certify that this isa true
                                                     901 N. Stonewall                                  and correct copy of the original
                                              Oklahoma City, Oklahoma 73117                            document. Valid only when copy,
                                                                                                       bears imprint of the office seal.
                                                                                                       A. JAY CHAPMAN, M.D.
                                                                                                       Chief Medical Examiner
                                                                                                       By                            _
                                        REPORT OF LABORATORY          ANALYSIS                         Date



NAME:      ORBACH,     Syrl    C.                                             LABORATORY NO.    821525

MATERIAL SUBMITTED:            Blood, Liver and Urine                         DATE RECEIVED:    July    2, 1982



SUBMITTED BY:          Fred B. Jordan, M.D.                                   MEDICAL EXAMINER:     Fred B. Jordan, M.D.
RESULTS:

           BLOOD:


                Ethyl Alcohol - Negative




    July    8, 1982
 Date




        Please Note:    Unless notified in writing to the contrary, the specimen(s) submitted in this case will be
                        discarded at the end of 60 days.

CME-8 (Rev. 5-80)

                              -------          -   -----