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 - 3

Description: Autopsy - Asphyxia due to ligature strangulation.
(Medical Transcription Sample Report)

EXTERNAL EXAMINATION: The autopsy is begun at 8:30 A.M. on May 24, 2004. The body is presented in a black body bag. The victim is wearing a white sleeveless turtleneck shirt and navy blue sweatpants. Jewelry included two smooth-textured silver hoop pierced earrings, 1-inch diameter, one in each ear, and one 1-inch wide silver expandable wristband on left wrist. A 1.5-inch wide tan belt with green stripes is cinched around the upper neck using the buckle. The opposite end of the belt is tied in a half-hitch knot, which was used to affix it to the crossbar in the closet where the body was found.

The body is that of a normally developed white female measuring 67 inches and weighing 118 pounds, and appearing generally consistent with the stated age of twenty-six years. The body is cold and unembalmed. Lividity is fixed in the distal portions of the limbs. The eyes are open. The irises are brown and corneas are cloudy. Petechial hemorrhaging is present in the conjunctival surfaces of the eyes. The pupils measure 0.3 cm. The hair is dark blonde with lighter blonde highlights, wavy, layered and approximately 11 inches in length at the longest point.

Removal of the belt revealed a ligature mark (known throughout this report as Ligature A) on the neck below the mandible. Ligature A is approximately 1.5 inches wide and encircles the neck in the form of a "V" on the anterior of the neck and an inverted "V" on the posterior of the neck, consistent with hanging. Minor abrasions are present in the area of Ligature A. Lack of hemorrhage surrounding Ligature A indicates this injury to be post-mortem.

Upon removal of the victim's clothing, an odor of bleach was detected. Areas of the body were swabbed and submitted for detection of hypochlorite. Following removal of the shirt, a second ligature mark (known throughout this report as Ligature B) was observed on the victim's neck. The mark is dark red ligature and encircles the neck, crossing the anterior midline of the neck just below the laryngeal prominence. The width of the mark varies between 0.8 and 1cm and is horizontal in orientation. The skin of the anterior neck above and below the ligature mark shows petechial hemorrhaging. Ligature B is not consistent with the belt that caused Ligature A. The absence of abrasions associated with Ligature B, along with the variations in the width of the ligature mark, are consistent with a soft ligature, such as a length of fabric. No trace evidence was recovered from Ligature B that might assist in identification of the ligature used.

The genitalia are that of an adult female and there is no evidence of injury. Pubic hair has been shaved in its entirety within six hours of death. Limbs are equal, symmetrically developed and show no evidence of injury. The fingernails are medium length and fingernail beds are blue. There are no residual scars, markings or tattoos.

INTERNAL EXAMINATION:

HEAD--CENTRAL NERVOUS SYSTEM: Subsequent autopsy shows a broken hyoid bone. Hemorrhaging from Ligature B penetrates the skin and subdermal tissues of the neck. The brain weighs 1,303 grams and within normal limits.

SKELETAL SYSTEM: The hyoid bone is fractured.

RESPIRATORY SYSTEM--THROAT STRUCTURES: The oral cavity shows no lesions. Petechial hemorrhaging is present in the mucosa of the lips and the interior of the mouth. Otherwise, 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 hyoid bone, the thyroid, and the cricoid cartilages are fractured.

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. There is evidence of recent sexual activity but no indications that the sexual contact was forcible. Vaginal fluid samples are removed for analysis.

TOXICOLOGY: Sample of right pleural blood and bile are submitted for toxicologic analysis. Stomach contents are saved.

SEROLOGY: A sample of right pleural blood is submitted in the EDTA tube. Routine toxicologic studies were ordered.

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
Drug Screen Results:

URINE SCREEN {IMMUNOASSAY} WAS NEGATIVE.

Ethanol: 0 gm/dl, Blood (Heart)
Ethanol: 0 gm/dl, Vitreous

EVIDENCE COLLECTED:
1. One (1) white turtleneck sleeveless shirt, size Small.
2. One (1) pair navy blue sweatpants, size Small.
3. Two (2) silver hoop earrings.
4. One (1) silver bracelet.
5. Samples of Blood (type O+), Bile, and Tissue (heart, lung, brain, kidney, liver, spleen).
6. Fifteen (15) swabs from various body locations, to be tested for presence of hypochlorite.
7. Eleven (11) autopsy photographs.
8. One postmortem CT scan.
9. One postmortem MRI.

OPINION
TIME OF DEATH: Body temperature, rigor and livor mortis, and stomach contents approximate the time of death between 7:30 and 9:30 P.M. on 5/22/2004.
IMMEDIATE CAUSE OF DEATH: Asphyxia due to ligature strangulation (Ligature B). Ligature A is made post-mortem.
MANNER OF DEATH: Homicide
REMARKS: Decedent originally presented to this office as suicide victim. Presence of the post-mortem ligature mark suggests that suicide in this case is highly improbable. YCSD detectives were notified of this finding immediately upon conclusion of examination.

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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