Advances in the Science of Pathology

The Autopsy Lexicon

Suggested Headings for the Autopsy Report
Randy L. Hanzlick, MD, for the Members of the Autopsy Committee, College of American Pathologists

● Context.—Although standard autopsy texts and other topsy report formats, identifying specific categories of in-
publications discuss the general content of autopsy reports, formation usually contained in such reports, and develop-
and some provide examples of autopsy report formats, no ing wording for various sections of the autopsy report that
publication to date has recommended specific headings for would contain specific information. A draft was submitted
autopsy report organization. The College of American Pa- to 45 members (including 12 forensic pathologists) of the
thologists Autopsy Committee decided it would be helpful College of American Pathologists for review, comment, and
to provide suggestions for autopsy report headings to foster reality testing. Reviewers included pathologists from both
more standardized autopsy reporting, to facilitate review community and academic settings. Comments of reviewers
of reports by third parties, and to facilitate searches of were incorporated to the extent possible.
electronically stored autopsy reports. Results.—The Autopsy Lexicon was prepared and is a
Objectives.—To create a model document (named the
model document for autopsy pathologists who wish to de-
Autopsy Lexicon), which defines standard categories of in-
formation that are useful to include in autopsy reports; to fine an autopsy template of headings for consistent orga-
offer specific wording for the headings of various sections nization of autopsy reports.
of the report; and to explain the rationale for including the Conclusions.—The Autopsy Lexicon is available to foster
various items of information and headings. more uniform reporting of autopsy information, which may
Participants and Methods.—The members of the Autopsy facilitate review of autopsy reports and retrieval of infor-
Committee of the College of American Pathologists pre- mation from electronically stored autopsy reports.
pared the document by reviewing various examples of au- (Arch Pathol Lab Med. 2000;124:594–603)

A utopsy guidelines, handbooks, and textbooks often

contain suggestions for autopsy report content, in-
cluding suggested content for the details of gross and mi-
tended to provide suggestions and options for autopsy re-
port organization and should not be construed as a stan-
dard for professional performance.
croscopic descriptions, but few have offered suggested Although the Autopsy Committee encourages the ap-
headings for autopsy report organization.1–10 Consistently plication of electronic word-processing systems for pro-
used headings may be helpful for 4 reasons: duction of autopsy reports, including consistently used
1. A consistent sequence of autopsy reporting, through headings, the Committee does not recommend or encour-
repetition, would reduce the likelihood of omissions. age the use of complete autopsy report templates with
2. When the pathologist must review a report at some ‘‘canned’’ descriptive findings.
time following its original completion, the ability to find LIST OF STANDARDIZED FIRST-LEVEL HEADINGS
a selected type of information would be facilitated.
The autopsy report may contain the following first-level
3. A consistent reporting sequence would facilitate au-
headings, indicated in boldface capital letters if possible.
topsy report review by third parties, such as other pa-
First-level headings may be set centered or left-justified.
thologists and physicians.
4. The widespread application of electronic word pro-
cessing and document storage increases the potential use- ● Autopsy Face Sheet
fulness of autopsy reports for electronic data analysis, and ● Historical Summary
consistently used headings would facilitate the process of ● Examination Type, Date, Time, Place, Assistants, Atten-
analyzing specific categories of information within autop- dees
sy reports. ● Presentation, Clothing, Personal Effects, Associated
The headings presented here are applicable to both hos- Items
pital-based and forensic autopsies. This document is in- ● Evidence of Medical Intervention
● Postmortem Changes
● Postmortem Imaging Studies
Accepted for publication November 30, 1999. ● Features of Identification
From Fulton County Medical Examiner, Atlanta, Ga.
Development supported by the College of American Pathologists,
● External Examination
Northfield, Ill. ● Internal Examination
Reprints: College of American Pathologists Autopsy Committee, 325 ● Summary of Injuries
Waukegan Rd, Northfield, IL 60093-2750. ● Ancillary Procedures, Laboratory Tests, and Results
594 Arch Pathol Lab Med—Vol 124, April 2000 Autopsy Lexicon—Hanzlick
● Block Listing and Histologic Description son the body was stored face down, documentation of that
● Findings and Diagnoses fact might be useful in explaining to an angered family
● Summary and Comments why the face was ‘‘purple and swollen,’’ and would doc-
● Cause-of-Death Statement ument that the findings were not related to the autopsy
● Amendments procedure.
The headings are organized so findings can be dictated Evidence of Medical Intervention
as the various phases of the investigation are performed.
This section is designed for documenting all tubes,
Each heading can be included in each autopsy report, and
bandages, devices, and markings, such as venipunctures,
‘‘none,’’ ‘‘not applicable,’’ or other wording, such as ‘‘see
that are known to have been iatrogenic in origin. This en-
radiology report, filed separately,’’ may be used if specific
ables such findings to be separated from other autopsy
information is not included under the heading. It is not
findings conceptually, as well as in the text of the report.
necessary that the headings appear in the order listed.
When appropriate, the position of devices within the body
These headings are consistent with the College of
should be described within the relevant portion of the in-
American Pathologists (CAP) Forensic Pathology Commit-
ternal examination description. Changes related to organ
tee’s Practice Guidelines for Forensic Pathology. 11
or tissue procurement may also be noted here.
RATIONALE FOR HEADINGS
Postmortem Changes
Autopsy Face Sheet
Routine documentation of postmortem changes may be
This section includes information for the autopsy face helpful in establishing or confirming the postmortem in-
sheet in a format consistent with CAP recommendations. terval and in the interpretation of other autopsy findings.
Rigor mortis, livor mortis, degree of corneal clouding and
Historical Summary collapse, presence or absence of skin slippage, discolora-
This section allows the pathologist to include relevant tions, and cutaneous drying are some of the routine pa-
medical history, laboratory data, and other preautopsy in- rameters to be included.
formation that may be relevant to the case. For hospital
autopsies, it is analogous to a review of the medical record Postmortem Imaging Studies
and clinical course. For forensic autopsies, it may also in- This section is used to document the performance and
clude relevant aspects of the background investigation or results of any postmortem imaging studies.
circumstances of the scene investigation. This section need
not be extensive, because investigative reports and medi- Features of Identification
cal records should always be available for review if need- Occasionally, there may be a question of the decedent’s
ed. Some investigators claim that extensive review of med- true identity long after the autopsy was performed. It is
ical records is biased by the reviewer’s own perspective, not uncommon in forensic and some hospital settings for
and it is best to limit the summary of historical informa- people to have an alias or to have multiple medical re-
tion to major information items only.12 This section also cords under different names. Items such as height, weight,
allows for a very brief statement of the context in which and body build; hair color, length, and texture; eye color;
the autopsy was conducted, including the major goals. condition of teeth; presence (and location) or absence of
scars and tattoos; externally missing appendages; circum-
Examination Type, Date, Time, Place, Assistants, Attendees cision status; and other distinctive features (rhinophyma,
This section makes it clear whether the autopsy was cleft in chin, etc) are typically included.
‘‘complete’’ or otherwise, and under what legal authority
the autopsy was performed. Documentation of the date, External Examination
time, and place is needed not only to place autopsy find- The findings noted on external examination may be
ings into temporal perspective, but also to explain any very important in any autopsy, especially forensic ones. It
circumstances (such as lack of, or malfunctioning equip- is the external appearance of the body that often prompts
ment) that might influence the manner in which the au- questions from funeral directors and next-of-kin. Thor-
topsy was performed. Documentation of assistants and at- ough documentation is essential. Details of the types of
tendees may also be helpful for documenting witnesses information to be included in this section are presented in
and to explain why certain aspects of an examination may other CAP publications.5,6,8,9
or may not have been performed or performed in the par-
ticular manner or sequence that occurred. Including the Internal Examination
name of attendees also documents the interest that such The internal examination is obviously a major compo-
people showed by attending the autopsy. nent of the autopsy and deserves thorough reporting. De-
tails of the types of information to be reported are includ-
Presentation, Clothing, Personal Effects, Associated Items ed in other CAP publications.5,6,8,9
This section enables one to describe how the body was
wrapped, protected, prepared, or stored prior to autopsy, Summary of Injuries
as well as to document items present with the body, such This section includes a summary of internal injuries,
as jewelry, clothing, or items of potential evidentiary val- including correlation with evidence of injury noted on ex-
ue. Noting, for example, that the wrists were tied together ternal examination.
with string might allow one to explain to the family why
there were ‘‘marks’’ around the wrists. Documentation of Ancillary Procedures, Laboratory Tests, and Results
personal effects, such as jewelry, might help address This section is used to list the tests, procedures, and
claims that items have been stolen or lost. If for some rea- consultations that are performed or requested in conjunc-
Arch Pathol Lab Med—Vol 124, April 2000 Autopsy Lexicon—Hanzlick 595
tion with the examination. The listing may also include well as the presence or absence of discolorations, peculiar
specimens that were retained. Typical examples are cul- odors, adherent foreign material, and unusual vascular
ture of pulmonary abscess, documentary photographs, pe- markings.
ripheral blood test for drug abuse screening, and the like. Head. This section includes reference to the scalp, au-
Relevant results should also be included. ricles, mastoid regions, auditory meati, forehead, face, na-
sal and facial bones, ocular findings, nasal cavities, and
Block Listing and Histologic Description oral cavity.
This section usually includes a catalog that specifies the Neck. This section includes comment about the pres-
source of each paraffin block (and slide). It also includes ence or absence of symmetry, masses, scars, contusions,
relevant details of the histologic description, as detailed in abrasions, or other markings.
other CAP publications.5,7–9 Torso. This section includes reference to the breasts,
anterior and posterior torso, genitalia, perineum, inguinal
Findings and Diagnoses regions, buttocks, and anus.
This section is analogous to the Final Anatomic Diag- Upper Extremities. This section includes reference to
noses. The heading Findings and Diagnoses is preferred, the axillae, arms, elbows, forearms, wrists, and hands.
however, because relevant findings may not constitute true Lower Extremities. This section includes reference to
diagnoses, and reports are always subject to amendment the thighs, knees, legs, ankles, and feet.
and, therefore, are not truly final. Findings and diagnoses Evidence of Injury. This section includes a descrip-
are reported as detailed in other CAP publications and are tion of external evidence of injury or a statement that there
usually organized by organ system, organ, clinical/his- is no external evidence of injury.
torical symptoms and signs, or problem orientation.5–9 The Summary. This section contains a brief capsule sum-
content of this section would usually appear on the au- mary of relevant external findings.
topsy face sheet, as described elsewhere. Prior to case fi-
nalization, this section might contain the provisional find- Caveats
ings and diagnoses, or provisional anatomic diagnoses. Some information items that traditionally have been de-
Relevant date of completion should be included. scribed as part of the external examination may be de-
scribed under other headings as outlined in ‘‘Rationale for
Summary and Comments
Headings.’’ This approach minimizes the tendency to in-
This section may be used to address foreseen questions, advertently omit such information by providing specific
to provide commentary, for clinicopathologic correlations, headings as a prompt to include appropriate and relevant
and to place the examination in perspective. Speculation data.
and lengthy commentary are discouraged. Caveat 1. Information about clothing, jewelry, person-
Cause-of-Death Statement al effects, and other items associated with the body may
be described under the heading Presentation, Clothing,
This section includes a cause-of-death statement written Personal Effects, Associated Items.
in standard format.13 It is included to facilitate linkage be- Example. ‘‘The body is wrapped in a white plastic
tween descriptive autopsy report information and cause- shroud with the wrists tied together with string and rest-
of-death information. The cause-of-death statement can ing on the abdomen. The body is clad in a white and blue
also be included on the autopsy face sheet. hospital gown. No jewelry is present. No other items are
Amendments present with the body.’’
Caveat 2. Information useful for identification purpos-
This section allows for continual updating of findings es may be described under the heading Features of Iden-
or interpretations as needed. It takes into account that tification.
cases remain ‘‘open’’ and may be modified as new infor- Example. ‘‘This is the body of a white male, which
mation becomes available. The date of any amendments weighs 170 pounds and measures 72 inches in height. The
should be included. physique is mesomorphic and muscular. The head hair is
SECOND-LEVEL HEADINGS FOR EXTERNAL brown, wavy, and measures about 2 inches in greatest
EXAMINATION length. There is no balding, no beard, and no moustache.
The irides are blue. The teeth are natural with occlusal
The following second-level headings are used for or- amalgam fillings in teeth 30 and 31. There are no tattoos,
ganizing the report of external examination. These head- no missing body parts, and no visible surgical scars. The
ings are typed in standard text that is left-justified on its penis is circumcised. No other distinctive markings are
own line. visible.’’
● General Caveat 3. Information about diagnostic and therapeu-
● Head tic devices and related bodily findings may be reported
● Neck under the heading Evidence of Medical Intervention.
● Torso Example. ‘‘A nasogastric tube exits the left nares. An
● Upper Extremities endotracheal tube exits the right side of the mouth. An
● Lower Extremities indwelling venous cannula is present in the left cubital
● Evidence of Injury fossa and is surrounded by a 1-inch, circular area of blue-
● Summary green ecchymosis. The cannula is connected to an intra-
venous line and bag of 0.9% sodium chloride solution. A
Rationale and Usage urinary catheter is present. Electrocardiograph conductors
General. This section includes reference to nutritional are adherent to both clavicular regions and to the left lat-
status, body habitus, hydration, and hair distribution, as eral chest wall. Apparent cardioversion markings exist
596 Arch Pathol Lab Med—Vol 124, April 2000 Autopsy Lexicon—Hanzlick
over the sternum, consisting of 2 rectangular superficial ● Cardiovascular System
burns with dimensions of 4 inches by 3 inches.’’ ● Respiratory System
Note. The location of various devices within organs, ● Digestive System
tissues, and lumens may be described under the appro- ● Hepatobiliary System and Pancreas
priate organ system heading in the description of the in- ● Reticuloendothelial System
ternal examination. ● Urogenital Systems
Caveat 4. Postmortem changes may be described un- ● Endocrine Organs
der the heading Postmortem Changes.
Example. ‘‘Rigor mortis is generalized and well-devel- Rationale and Usage
oped. Lividity is distributed dorsally, is the usual viola-
Evisceration/Dissection Method. This section in-
ceous color, and blanches with light pressure. The extrem-
cludes a statement about whether organs were removed
ities and torso are cold to the touch. The corneas show
en masse (Letulle method), piecemeal (Virchow method),
early clouding. The vermilion borders of the lips show
or en bloc (Rokitansky or other).
slight darkening due to drying. No other postmortem
Chest and Abdomen Walls and Cavities. The ap-
changes are visible externally.’’
pearance of the soft tissues and ribs is documented in this
Thus, the External Examination heading is designed to
section, including the presence or absence of hemorrhage,
document the facts of a medically oriented external ex-
masses, fractures, and other relevant findings. Reference
amination of the body in a place separate from the infor-
to breast tissue may also be made here. Statements about
mation presented in caveats 1 through 4.
the presence or absence of fluid collections in body cavi-
Note. If an external finding is unclear as to whether it
ties, abnormal color changes, unusual odors, adhesions of
represents an artifact of diagnosis, therapy, or some other
pleura or peritoneum, the retroperitoneum, and other rel-
cause, it may be described under the appropriate caption
evant findings may also be included.
beneath the External Examination heading (see below).
Organ Weights. Organ weights may be included un-
SECOND-LEVEL HEADINGS FOR INTERNAL der the respective organ system description, but a table or
EXAMINATION list of organ weights is convenient and helpful.
This section offers second-level headings for use within Cardiovascular System. A description of the heart
the Internal Examination section of the autopsy report. and major vessels is included in this section. Reference to
the pericardium, epicardium, myocardium, endocardium
● Torso and valves, chordae, ventricular thicknesses, and aorta and
● Head major vessels may be included.
● Pharynx and Neck Respiratory System. Descriptive references to the tra-
● Spinal Column and Cord chea, bronchi, lung, visceral pleura, diaphragm, and pul-
● Additional Dissection monary vessels are reported in this section.
Digestive System. References to the esophagus, stom-
Rationale and Usage
ach, small bowel, colon, rectum, and pancreas are reported
Torso. This section includes descriptions of the thorac- in this section.
ic, abdominal, and pelvic organs and tissues, including the Hepatobiliary System and Pancreas. References to the
thoracoabdominal wall, body cavities, and genitalia, uti- liver, gallbladder, extrahepatic biliary tract, and pancreas
lizing third-level headings as described in ‘‘Third-Level are reported in this section.
Headings for Torso.’’ Reticuloendothelial System. References to mediasti-
Head. Information in this section includes description nal nodes, abdominal nodes, inguinal nodes, axillary
of the scalp, skull (calvarium and base), brain and menin- nodes, other relevant nodes, spleen, bone marrow, and
ges, dura and dural sinuses, air sinuses, atlanto-occipital thymus are included in this section.
junction, and middle or inner ear, as needed. Urogenital Systems. References to the kidneys, renal
Neck and Pharynx. In this section, descriptive infor- vessels, ureters, and bladder are provided in this section,
mation about the tongue, pharynx, larynx, neck vessels, as are references to the vagina, cervix, uterus, fallopian
and prevertebral tissues is described as indicated. tubes, and ovaries in females, or to the testes, vas, seminal
Spinal Column and Cord. This section includes a de- vesicles, and prostate in males.
scription of the spinal column and, if examined, the spinal Endocrine Organs. References to the thyroid, adrenal
cord. glands, and parathyroids are reported here, including a
Additional Dissection. Specialized dissections of statement of whether the parathyroids were located or ex-
nonroutine areas, such as the popliteal fossa; a hip dissec- amined. Relevant findings about paraganglia are also in-
tion; dissection of an extremity, muscle, other soft tissue; cluded in this section.
peripheral nerves; removal of eyes; or placental examina-
tion may be described in this section. SUMMARY
THIRD-LEVEL HEADINGS FOR TORSO Suggested first-level headings, second-level headings,
This section describes third-level headings to be used and third-level headings are as follows:
beneath the second-level heading for the torso. These AUTOPSY FACE SHEET
heads are set in italic type, if possible, and are placed at HISTORICAL SUMMARY
the beginning of the relevant paragraph. EXAMINATION TYPE, DATE, TIME, PLACE, ASSIS-
TANTS, ATTENDEES
● Evisceration/Dissection Method PRESENTATION, CLOTHING, PERSONAL EFFECTS,
● Chest and Abdomen Walls and Cavities ASSOCIATED ITEMS
● Organ Weights EVIDENCE OF MEDICAL INTERVENTION
Arch Pathol Lab Med—Vol 124, April 2000 Autopsy Lexicon—Hanzlick 597
POSTMORTEM CHANGES adhesions, abnormal fluid collections, or unusual color
POSTMORTEM IMAGING STUDIES changes.
FEATURES OF IDENTIFICATION
EXTERNAL EXAMINATION TEMPLATES
General Regarding headings, there is little doubt that electronic
Head templates can facilitate the preparation and quality of au-
Neck topsy reports. For example, in addition to the advantages
Torso cited in the introduction, a transcriptionist may realize
Upper Extremities that nothing has been dictated under the Postmortem
Lower Extremities Changes heading, which may prompt the transcriptionist
Evidence of Injury to ascertain from the pathologist whether the omission
Summary was intentional or an oversight. The Autopsy Committee
INTERNAL EXAMINATION does not, however, recommend or encourage the use of
Torso electronically stored templates of descriptive findings, be-
Evisceration/Dissection Method cause we believe that each autopsy report should docu-
Chest and Abdomen Walls and Cavities ment the unique objective findings observed during a spe-
Organ Weights cific postmortem examination.
Cardiovascular System Members of the Autopsy Committee of the College of Ameri-
Respiratory System can Pathologists are Randy L. Hanzlick, MD; Peter B. Baker, MD;
Digestive System Johannes Bjornsson, MD; Kevin E. Bove, MD; Kim A. Collins,
Hepatobiliary System MD; Gregory J. Davis, MD; Stephen A. Geller, MD; Grover M.
Reticuloendothelial System Hutchins, MD; Eun Young Lee, MD; Larry C. Nichols, MD; J.
Urogenital System Thomas Stocker, MD; Nancy A. Young, MD; Dean M. Havlik,
MD; Marcella F. Fierro, MD; Joseph E. Parisi, MD; James A. Benz,
Endocrine Organs
MD; and Mary Ann Sens, MD, PhD.
Head
Neck and Pharynx References
1. Rezek PR, Millard M. Autopsy Pathology: A Guide for Pathologists and Cli-
Spinal Column and Cord nicians. Springfield, Ill: Charles C Thomas; 1963.
Additional Dissection 2. Baker RD. Postmortem Examination: Specific Methods and Procedures. Phil-
SUMMARY OF INJURIES adelphia, Pa: WB Saunders; 1967.
3. Fisher RS, Petty CS. Forensic Pathology: A Handbook for Pathologists. Wash-
ANCILLARY PROCEDURES, LABORATORY TESTS, ington, DC: National Institute of Law Enforcement and Criminal Justice; 1977.
AND RESULTS 4. DiMaio DJ, DiMaio VJM. Forensic Pathology. New York, NY: Elsevier; 1989.
BLOCK LISTING AND HISTOLOGIC DESCRIPTION 5. Hutchins GM, ed. Autopsy Performance and Reporting. Northfield, Ill: Col-
FINDINGS AND DIAGNOSES lege of American Pathologists; 1990.
6. Froede RC, ed. Handbook of Forensic Pathology. Northfield, Ill: College of
SUMMARY AND COMMENTS American Pathologists; 1990.
CAUSE-OF-DEATH STATEMENT 7. Travers H, ed. Quality Improvement Manual in Anatomic Pathology. North-
AMENDMENTS field, Ill: College of American Pathologists; 1993.
8. Hutchins GM, ed. An Introduction to Autopsy Technique. Northfield, Ill:
College of American Pathologists; 1994.
FORMAT 9. Hutchins GM, for the Autopsy Committee of the College of American Pa-
thologists. Practice guidelines for autopsy pathology: autopsy reporting. Arch
First-level headings are placed alone on a line, either Pathol Lab Med. 1994;118:19–25.
centered or left-justified. Second-level headings are placed 10. Powers JM, for the Autopsy Committee of the College of American Pathol-
ogists. Practice guidelines for autopsy pathology: autopsy procedures for brain, spi-
alone on a line, left-justified. Third-level headings are in- nal cord, and neuromuscular system. Arch Pathol Lab Med. 1995;119:777–783.
cluded as the first entry on a line in a paragraph. A sample 11. Randall BB, Fierro MF, Froede RC, for the Members of the Forensic Pa-
of format with first-, second-, and third-level headings fol- thology Committee of the College of American Pathologists. Practice guidelines
for forensic pathology. Arch Pathol Lab Med. 1998;122:1056–1064.
lows. 12. Davis J. More on the autopsy: a distinguished dissent. Lab Accreditation
Newsl. February 1985.
INTERNAL EXAMINATION 13. Hanzlick R, for the Autopsy Committee of the College of American Pa-
thologists. The Medical Cause of Death Manual: Instructions for Writing Cause-
Torso of-Death Statements for Deaths Due to Natural Causes. Northfield, Ill: College of
American Pathologists; 1994.
Evisceration/Dissection Method. A standard Y-shaped in- Bibliography
cision was used and the organs were removed en masse, Bove K, for the Autopsy Committee of the College of American Pathologists. Prac-
including the tongue and rectum. tice guidelines for autopsy pathology: the perinatal and pediatric autopsy. Arch
Chest and Abdomen Walls and Cavities. The soft tissues Pathol Lab Med. 1997;121:368–376.
Placental Pathology Practice Guideline Development Task Force of the College
and ribs appear normal. There are no masses, fractures, of American Pathologists. Practice guideline for examination of the placenta.
or hemorrhages. The breast tissue is normal. There are no Arch Pathol Lab Med. 1997;121:449–476.

APPENDIX
Sample Autopsy Report Using Autopsy Lexicon Headings

The sample autopsy report shown in the ‘‘Appendix’’ is should not necessarily be viewed as exemplary or as a
presented only to show the use of the headings presented recommendation of descriptive terminology. The autopsy
in the Autopsy Lexicon. The content of the report itself face sheet shown in the example is one method of pre-
598 Arch Pathol Lab Med—Vol 124, April 2000 Autopsy Lexicon—Hanzlick
paring a face sheet, but additional guidance is contained may vary, especially if the report is dictated after the ex-
in other publications from the College of American Pa- amination has been completed.
thologists.5,9 In some settings, face sheets are not prepared. Although the example is derived from a forensic autop-
The format shown in the sample report was structured sy case, the same headings may be used for hospital-based
using a scenario in which the report was dictated at the autopsies. A forensic case was selected for the example so
time the examination was performed. Thus, the order in that all headings would have some information beneath
which information appears is the order in which infor- them.
mation was obtained and documented. The order of items

AUTOPSY FACE SHEET

Case Number: 91-234

Name:
Age/Race/Sex: 57-year-old black male
Date and Time of Death: November 5, 1991; 0800 AM
Date of Autopsy: November 5, 1991; 1205 PM
History
The deceased was found in bed at home with an apparent self-inflicted gunshot wound of the head. He had reportedly
been complaining of recent headaches. He was transported to the hospital, where death occurred 30 minutes after
arrival.
Clinical Procedures
1. Emergency treatment including attempted resuscitation, vascular line placement, fluid administration, endotracheal
tube placement
Findings and Diagnoses
1. Contact gunshot wound of right parietal area of head
A. Perforating brain injury
B. Fracture of left parietal bone
C. Diffuse subarachnoid hemorrhage
D. Cerebral edema
E. Recovery of bullet from left parietal bone (no exit wound)
F. Wound track right to left and slightly upward
2. Berry aneurysm, left anterior communicating cerebral artery
3. Resolving subungual hematoma, left thumb
4. External hemorrhoid
5. Concentric left ventricular hypertrophy, heart
6. Benign prostatic hyperplasia
7. Degenerative osteoarthritis, spinal column
8. Remote amputation of distal portion of left fifth finger
9. Surgical scar, left inguinal area; probable remote hernia repair
Cause-of-Death Statement
Perforating brain injury
due to: Contact gunshot wound of head
Pathologist: John Smith, MD Date of Report: November 10, 1991

Arch Pathol Lab Med—Vol 124, April 2000 Autopsy Lexicon—Hanzlick 599
HISTORICAL SUMMARY
This 57-year-old black male was reportedly found in his bed with a gunshot wound of the head and a handwritten
suicide note on the bedstand. He was transported to the hospital by emergency medical services but died in the emer-
gency room at Hometown Hospital. He had a history of recent headaches. Additional details are contained in the
investigator’s report contained in the medical examiner case file.
EXAMINATION TYPE, DATE, TIME, PLACE, ASSISTANTS, ATTENDEES
Under the provisions of the Death Investigation Act, a complete autopsy is performed in the County Morgue on
Tuesday, November 5, 1991, beginning at 1205 PM with the assistance of Angela Harden. Also in attendance is Major
Gleet of the Hometown Police Bureau.
PRESENTATION, CLOTHING, PERSONAL EFFECTS, ASSOCIATED ITEMS
The body is contained in a white plastic body bag bearing a tag with the deceased’s name on it and an identification
number of 91-234. The hands are covered with paper bags secured at the wrists with rubber bands. A pair of white
briefs are present in the pelvic area and are stained with a small amount of yellow fluid with an odor of urine. A gold-
colored ring is present on the left ring finger. The briefs are discarded and the ring is removed and forwarded with the
body. No other items are present with the body.
EVIDENCE OF MEDICAL INTERVENTION
An endotracheal tube exits from the right side of the mouth. Multiple perimortem needle-puncture wounds are present
in each subclavian region. An intravascular cannula is inserted in the right cubital fossa. A small needle mark with
underlying hematoma is present in the left radial fossa. Electrocardiographic conductor pads are located over each
shoulder anteriorly and in the left lateral midthoracic area. A gauze pad is taped to the right side of the forehead and
covers a wound that will be described in further detail below.
POSTMORTEM CHANGES
Rigor mortis is generalized and well developed. Livor mortis is well developed, dorsal, the usual violet color, and
blanches with light pressure. The eyes show early corneal clouding. The vermilion borders of the lips are slightly dry.
Other postmortem changes are absent.
POSTMORTEM IMAGING STUDIES
Postmortem radiographs of the head show a density beneath the inner table of the left parietal bone, consistent with
a medium-caliber bullet.
FEATURES OF IDENTIFICATION
A hospital band on the right wrist bears the deceased’s name. The body is unembalmed and that of a black male
appearing slightly older than the stated age. Height measures 68 inches, and weight is 160 lb. The physique is meso-
morphic.
The head hair is black, coarse, measures about 1 inch in greatest length, and shows frontoparietal balding. The irides
are brown. The teeth are natural with some amalgam restorations. An oblique, well-healed, 4-inch scar with cross-
hatched suture marks is located in the left inguinal area. The penis is uncircumcised. No tattoos are noted. The distal
phalanx of the left fifth finger has been previously amputated and is well-healed. No other distinctive external markings
are present.
EXTERNAL EXAMINATION
General
Body habitus and hair distribution are normal for age and gender. There is no evidence of malnutrition or dehydration.
No peculiar odors or color changes are noted. There is no visible or palpable lymphadenopathy.
Head
A penetrating wound, consistent with a gunshot entry wound, is present on the right side of the head, just above the
top of the right ear, 2 inches above the external auditory meatus. The wound is located 64 inches above the heel and 6
inches to the right of the anterior midline. The wound consists of a ⅜-inch circular hole from which extend radial tears
measuring up to ½ inch in length. A ¼-inch concentric rim of purple contusion surrounds the hole. Within the superficial
wound track, prominent deposits of soot and gunshot residue are visible. No soot or stippling is present on the skin
surface surrounding the wound. Dry blood streaks are present posterior to the wound and within the hair. The ear
canals are free of blood.
The face shows no evidence of trauma. The scalp and soft tissues of the head are otherwise normal, except for palpable
lump beneath the skin overlying the left midparietal skull just above the left ear. The nasal and facial bones are without
palpable fracture. The conjunctival vessels are slightly congested, and there are no ocular or facial petechiae. A small
amount of blood-tinged fluid is present in each nasal vestibule. The lips, gums, teeth, tongue, and buccal mucosa are
normal and free of injury. The pinnae and mastoid regions are normal.
Neck
The neck shows no indication of abrasion, contusion, swelling, asymmetry, or other abnormality.
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Torso
The torso is free of injury and is symmetrical. No subcutaneous emphysema or cutaneous lesions are noted. The
abdomen is moderately distended with gas. Two testes are palpable in the scrotum, which is otherwise normal. The
external genitalia, perineum, and anorectal areas are normal except for a small external hemorrhoid at the 2 o’clock
position. The inguinal regions and buttocks are normal.
Upper Extremities
The upper extremities are symmetrical, muscular, and well developed. No pigmented or scarred needle tracks are
seen, and there are no hesitation marks or healed incised wounds. A 0.5-cm, resolving, subungual hematoma is present
beneath the left thumbnail. No soot or gunshot residue is visible on the hands.
Lower Extremities
The lower extremities are well developed and symmetrical. There is slight hair loss bilaterally in a socklike distribution,
and the toenails are somewhat thickened and untrimmed.
Evidence of Injury
External evidence of injury is limited to an apparent gunshot wound of the head, a resolving subungual hematoma
of the left thumb, and evidence of medical intervention as described above.
Summary
External examination shows a well-developed black male with no significant findings except an apparent gunshot
wound of the right side of the head.
INTERNAL EXAMINATION
Torso
Evisceration/Dissection Method. The thoracic and abdominal organs are removed using the Virchow technique (individ-
ually).
Chest and Abdomen Walls and Cavities. The skin of the chest and abdomen is reflected using the usual Y-shaped incision.
Subcutaneous fat and musculature are normal and free of injury. There are no abnormal fluid collections in the chest
or abdomen. The ribs and sternum are intact and without fracture. No unusual odors or color changes are identified.
Examination of the organs in situ shows normal organ morphology and relationships. The viscera are congested. The
diaphragm is normal. The stomach is distended with air.
Organ Weights.
Heart, 485 g
Left lung, 450 g
Right lung, 510 g
Liver, 1650 g
Kidneys, 160 g each
Spleen, 140 g
Cardiovascular System. The left ventricle demonstrates concentric hypertrophy with a left ventricular wall thickness of
2.1 cm. The coronary arteries are normally distributed and are widely patent throughout their lengths, with minimal,
soft, atherosclerotic plaques focally. The epicardium, valve leaflets, chordae, and endocardium appear normal. The my-
ocardium is reddish-tan throughout, and no focal myocardial lesions are observed. The thoracoabdominal aorta and
major branches show moderate, yellow, atherosclerotic streaking without ulceration. There are no vascular perforations.
The carotid arteries are pliable and patent.
Respiratory System. The trachea and bronchi are grossly normal except for focal mucosal contusion adjacent to the
endotracheal tube cuff, which is positioned appropriately. The hilar nodes and structures are normal. The major pul-
monary vessels are normally distributed and free of gross abnormalities. The lungs appear similar, and each lung is
congested and moderately edematous, exuding a pink-white foam on manual compression. There is no aspirated blood.
No consolidation is observed. There is no indication of thrombosis, embolism, infarction, or neoplasia. The visceral and
parietal pleura are free of hemorrhage or perforating defects.
Digestive System. The serosa, wall, and mucosa of the esophagus, stomach, small bowel, colon, and rectum are grossly
normal. The stomach is distended with air and contains approximately 1 cup of partially digested food, primarily
consisting of green vegetable material.
Hepatobiliary System and Pancreas. The liver shows intense congestion. There is no indication of fatty change or cirrhosis.
No focal intrahepatic lesions are noted. The gallbladder contains about 15 cc of viscous green bile, no stones, and is
grossly normal. The extrahepatic biliary ducts are patent. The pancreas shows the usual lobular architecture, mild
autolysis, and is otherwise normal.
Reticuloendothelial System. The spleen has a tense capsule and is acutely congested. The red and white pulp are normal.
Nodes of the axillary, hilar, mediastinal, abdominal, and cervical area appear normal, except to note mild anthracosis
of hilar nodes. The thymus is involuted. Bone marrow of the vertebral bodies appears normal and without focal lesions
or masses.
Urogenital Systems. The kidneys are symmetrical and each shows congestion of the cortex and medulla. The capsules
strip easily and the cortical surfaces are smooth. The corticomedullary ratio and junction are normal, as are the pyramids,
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calyces, pelves, and vessels. The ureters are of normal caliber. The urinary bladder is normal and contains approximately
100 cc of amber urine. The seminal vesicles are normal, and the prostate is firm and nodular with slight enlargement.
Endocrine System. The thyroid gland is normal size, symmetrical, tan, and free of nodularity, hemorrhage, or cysts.
The parathyroids are not identified grossly. The adrenals are of normal size and are free of nodularity or hemorrhage.
Head
The scalp is reflected with the standard intermastoidal incision. There is no indication of scalp trauma, except for a
4-inch circular area of full-thickness soft tissue hemorrhage around the gunshot wound in the right parietal area and a
2-inch circular area of full-thickness soft tissue hemorrhage in the left midparietal region above the left ear. The right
temporoparietal bone shows a ⅜-inch circular hole with sharply defined margins on the outer table and beveling of the
inner table. The outer table of skull around the hole shows black discoloration from gunshot residue, which is also visible
in the diploic spaces. The left midparietal bone contains a ½-inch circular fracture, which is displaced into the overlying
parietal soft tissues 2.5 inches directly above the left auditory meatus. Adjacent to the inner table of the bone fragment
is a medium-caliber, slightly deformed, fully jacketed, round nose, copper-colored projectile, which is retrieved for
submission to the Crime Laboratory. The bullet shows prominent lands and grooves.
The dura shows ragged, roughly circular, ⅜-inch, perforating defects in both parietal areas in locations corresponding
to overlying defects in the skull. Diffuse subarachnoid hemorrhage is present over the convexities.
Brain weight is 1540 g. There is no evidence of significant herniation or midline shift. Coronal sections demonstrate
a hemorrhagic wound track extending from the right midparietal region transversely through the brain to the left
midparietal cortical surface. The wound track extends through the upper cerebral peduncles. Small cortical contusions
are present on the inferior aspect of the frontal poles bilaterally.
The circle of Willis contains a 0.5-cm berry aneurysm of the anterior communicating artery on the left. No focal or
mass lesions are seen within the brain, and the cortex is normal to palpation. Moderate cerebral edema is noted. The
basilar skull and atlanto-occipital region are intact.
Neck and Pharynx
The skin of the neck is dissected up to the angle of the mandible. There is no evidence of soft tissue trauma to the
major airways or vital structures in the lateral neck compartments. The hyoid bone and thyroid cartilages are free of
fracture. The carotid vessels are pliable and patent. The epiglottis is not inflamed or swollen. There is no airway mucosal
edema. No foreign objects are present in the upper airway except for an endotracheal tube. The anterior cervical spine
is intact. The tongue is normal.
Spinal Column and Cord
The thoracolumbar spinal column shows mild degenerative osteophytic lipping. The spinal cord is not removed or
examined.
Additional Dissection
None.
SUMMARY OF INJURIES
Examination shows an apparent contact gunshot wound of the right parietal area with perforating brain injury and
recovery of a projectile in the left midparietal area. No other acute injuries are present.
ANCILLARY PROCEDURES, LABORATORY TESTS, AND RESULTS
1. Vitreous for chemistries: Na, 135; K, 8.0; Cl, 120
2. Peripheral blood for ethanol quantitation: Negative
3. Urine for drug abuse screen: Negative
4. Documentary photographs are prepared and filed in the case folder
5. Retrieved bullet is forwarded to Crime Lab for firearms examination; results will be reported by the Crime Lab
BLOCK LISTING AND HISTOLOGIC DESCRIPTION
Block 1 Heart and lungs
Block 2 Liver, spleen, pancreas, kidney
Block 3 Adrenal, thyroid, pancreas
Block 4 Routine sections of cerebrum, cerebellum, basal ganglia
Block 5 Routine sections of esophagus, stomach, small and large bowel
Block 6 Prostate
Block 7 Gunshot entry wound
The heart shows mild hypertrophic change; prostate shows benign prostatic hyperplasia. The gunshot wound
shows hemorrhage, extensive gunpowder particles, and thermal changes in the collagen. Other sections are not
contributory.
FINDINGS AND DIAGNOSES
1. Contact gunshot wound of right parietal area of head
A. Perforating brain injury
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 B. Fracture of left parietal bone
C. Diffuse subarachnoid hemorrhage
D. Cerebral edema
E. Recovery of bullet from left parietal bone (no exit wound)
F. Wound track right to left and slightly upward
2. Berry aneurysm, left anterior communicating cerebral artery
3. Resolving subungual hematoma, left thumb
4. External hemorrhoid
5. Concentric left ventricular hypertrophy, heart
6. Benign prostatic hyperplasia
7. Degenerative osteoarthritis, spinal column
8. Remote amputation of distal portion of left fifth finger
9. Surgical scar, left inguinal area; probable remote hernia repair
SUMMARY AND COMMENTS
Investigation and autopsy show that death resulted from a self-inflicted gunshot wound of the head. No other sig-
nificant injuries were observed. The finding of a cerebral artery berry aneurysm is a possible explanation for the history
of recent headaches. Cardiac findings suggest a history of hypertension.
CAUSE-OF-DEATH STATEMENT
Perforating brain injury
due to: Contact gunshot wound of head
Based on the circumstances, the manner of death is classified as suicide.
AMENDMENTS
None as of 11/10/91.

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