Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Autopsy
Sample Name: Autopsy - 1

Description: Autopsy - Homicide - Blunt force cranial trauma
(Medical Transcription Sample Report)

EXTERNAL EXAMINATION - SUMMARY

The body is presented in a black body bag. At the time of examination, the body is clothed in a long-sleeved red cotton thermal shirt, khaki twill cargo pants, and one black shoe.

The body is that of a normally developed, well nourished Caucasian female measuring 63 inches in length, weighing 114 pounds, and appearing generally consistent with the stated age of thirty-five years. The body is cold and unembalmed with declining rigor. Pronounced unblanching lividity is present on the posterior of the body in the regions of the feet; the upper thighs, particularly on the right side; the lower back, particularly on the right side; the right arm; and the neck.

The scalp is covered by long (16 inches) brown hair. The body hair is female and average. The skull is symmetric and evidences extensive trauma in the occipital region. The eyes are open and the irises are blue. Pupils are asymmetrically dilated. The teeth are natural and well maintained. The anterior chest is of normal contour and is intact. The breasts are female and contain no palpable masses. The abdomen is flat and the pelvis is intact. The external genitalia are female and unremarkable. The back is symmetrical and intact. The upper and lower extremities are symmetric, normally developed and intact. The hands and nails are clean and evidence no injury.

There are no residual scars, markings or tattoos.

INTERNAL EXAMINATION - SUMMARY

CENTRAL NERVOUS SYSTEM: The brain weighs 1,303 grams and is within normal limits.
SKELETAL SYSTEM: Subdural hematoma and comminuted fractures of the occipital bone are observed. Numerous bone fragments from the fractures penetrated the brain tissue.
RESPIRATORY SYSTEM--THROAT STRUCTURES: The oral cavity shows no lesions. The mucosa is intact and there are no injuries to the lips, teeth or gums. There is no obstruction of the airway. The mucosa of the epiglottis, glottis, piriform sinuses, trachea and major bronchi are anatomic. No injuries are seen and there are no mucosal lesions. The lungs weigh: right, 355 grams; left 362 grams. The lungs are unremarkable.
CARDIOVASCULAR SYSTEM: The heart weighs 253 grams, and has a normal size and configuration. No evidence of atherosclerosis is present.
GASTROINTESTINAL SYSTEM: The mucosa and wall of the esophagus are intact and gray-pink, without lesions or injuries. The gastric mucosa is intact and pink without injury. Approximately 125 ml of partially digested semisolid food is found in the stomach. The mucosa of the duodenum, jejunum, ileum, colon and rectum are intact.
URINARY SYSTEM: The kidneys weigh: left, 115 grams; right, 113 grams. The kidneys are anatomic in size, shape and location and are without lesions.
FEMALE GENITAL SYSTEM: The structures are within normal limits. Examination of the pelvic area indicates the victim had not given birth and was not pregnant at the time of death. Vaginal fluid samples are removed for analysis.

DESCRIPTION OF INJURIES - SUMMARY

Blunt force traumatic injury with multiple cranial fractures resulting in craniocerebral injury. Wound measures approximately 4 inches high x 5 1/2 inches wide. Subdural hematoma and comminuted fractures of the occipital bone are observed. Numerous bone fragments from the fractures penetrated the brain tissue. Depths of penetration range from 1/2-inch to 3 inches. Injury appears to have resulted from a single blow administered to the posterior of the head, delivered at an approximate 90º angle to the occipital bone.

LABORATORY DATA
CEREBROSPINAL FLUID CULTURE AND SENSITIVITY:
Gram stain: Unremarkable
Culture: No growth after 72 hours

CEREBROSPINAL FLUID BACTERIAL ANTIGENS:
Hemophilus influenza B: Negative
Streptococcus pneumoniae: Negative
N. Meningitidis: Negative
Neiserria meningitidis B/E. Coli K1: Negative

PRELIMINARY TOXICOLOGICAL RESULTS:
BLOOD - ETHANOL - NEG
BLOOD - CANNABINOIDS-ETS - INC
BLOOD - COCAINE-ETS - INC
BLOOD - OPIATES-ETS - INC
BLOOD - AMPHETAMINE-ETS - INC
BLOOD - BARBITURATE -ETS - INC
BLOOD - BENZODIAZEPINE-ETS - INC
BLOOD - METHADONE-ETS - INC
BLOOD - PCP-ETS - INC
BLOOD - CARBON MONOXIDE - NEG

Urine Drugs: Initial test results inconclusive. Further tests pending.

EVIDENCE COLLECTED
1. Samples of Blood (type O+), Urine, Bile, and Tissue (heart, lung, brain, kidney, liver, spleen).
2. Thirteen autopsy photographs.
3. Two postmortem x-rays.
Clothing transferred to ABC Lab for further analysis.

OPINION:

TIME OF DEATH: Body temperature, rigor and livor mortis, stomach contents and witness statements approximate the time of death between 9:30 p.m. on 9/17/05 and 12:00 a.m. on 9/18/05.
CAUSE OF DEATH: Blunt force cranial trauma.
MANNER OF DEATH: Homicide

Keywords: autopsy, black body bag, body bag, long-sleeved, pants, cargo, khaki twill, red cotton, thermal shirt, declining rigor, tattoos, brain weighs, hematoma, occipital bone, oral cavity, mucosa, lungs weigh, heart weighs, kidneys weigh, blunt force, comminuted fractures, gram stain, cerebrospinal fluid, urine drugs, time of death, mucosa is intact, cranial trauma, subdural hematoma, bone fragments,
NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports. These transcribed medical transcription sample reports may include some uncommon or unusual formats; this would be due to the preference of the dictating physician. All names and dates have been changed (or removed) to keep confidentiality. Any resemblance of any type of name or date or place or anything else to real world is purely incidental.
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Transcribed Medical Transcription Sample Reports and Examples