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 - 5

Description: Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.
(Medical Transcription Sample Report)

MANNER OF DEATH: Homicide.

CAUSE OF DEATH: Exsanguination due to multiple stab and incised wounds (head, Neck, trunk, upper extremities).

FINDINGS:
1. Generalized pallor and evidence of exsanguination.
2. Multiple stab and incised wounds of head, neck, trunk and upper extremities with one (1) stab wound penetrating left skull into brain; three (3) stab wounds penetrating right back into chest cavity and right lung; another stab wound at lateral right chest penetrating into right lung; and multiple wounds of upper extremities consistent with defensive injuries.
3. Left lower lateral chest-wall abrasions and contusions with overlying rib fractures of left ribs #6, #7 and #8.
4. Subarachnoid hemorrhage of right cerebrum underlying one of the large, undermined right scalp incised wounds.
5. A few other minor blunt-force injuries of head and trunk.
6. Moderate emphysematous changes of lungs.

LABORATORY RESULTS:

TOXICOLOGY:

1. Blood:
a. Ethanol: 0.16 gm%.
b. Drugs: Cocaine present at less than 0.1 ug/ml; cocaethylene present at 0.2 ug/ml; quantity not sufficient for further examination.

2. Urine: Positive for cocaine, cocaine metabolite (ecgonine methyl ester),and cocaethylene, with negative EMIT barbiturates screen.

3. Ocular fluid: Ethanol, 0.16 gm%.

INTRODUCTION

GENERAL APPEARANCE: The body is that of a well-developed, well-nourished, adult white man who appears the stated age of 43 years. Body height is 69 inches, and body weight is 169 lb. At autopsy, rigor mortis is generalized to late; livor mortis is posterior and slightly blanching; the body is cool to touch. Artifacts of decomposition are absent, and evidence of medical and postmortem care is absent. There is obvious evidence of multiple sharp-force injury.

IDENTIFICATION: The identity of decedent was established by circumstances of death and discovery of the body.

ROUTINE EXTERNAL EXAMINATION

CLOTHING AND VALUABLES: The body is admitted to the morgue dressed and within a sheet and shroud, and then within a body bag, and with the hands bagged.

Clothing is very bloody and has injuries matching those at the trunk (see below). In addition, prior to removal of clothing, the body was examined concurrently by me and by the crime scene technician from the (edited) Police Department, and trace evidence was collected from the body and clothing. See "TRACE EVIDENCE" section at end of report. The clothing consists of a blue-and-white western-style shirt, a pair of blue jeans, a brown belt, a pair of white socks and a pair of brown cowboy-style boots. Valuables on or with the body include a cigarette lighter, a key ring with five (5) keys, a pocket knife and $16.43 in cash. The valuables are released to the mother of the decedent while the clothing is retained for the law enforcement agency.

Please also see "ARTIFACTS" and "INJURIES" sections below.

HEAD AND NECK: The head is normally shaped. Scalp hair is short, brown and straight with the frontal portion balding. The head, face, neck and upper shoulders show no suffusion. The irides are green; the pupils are equal and round; the sclerae are white; the conjunctivae have no petechiae and the periorbital areas have no ecchymosis. Facial hair is clean shaven. A slight amount of bloody mucus is present inn the nasal and oral cavities. The teeth are natural, and oral hygiene is good. Intraoral petechiae are not present.
The neck has no deformities and has the usual range of motion without crepitus.

TRUNK: The chest is not increased in the anteroposterior dimension but has heavy, dried blood over the xiphoid and lower sternal regions. The breasts are masculine and have no palpable masses or nipple discharge. The abdomen is soft with a modest panniculus adiposus, and there is no venous discoloration of the external wall. The back and buttocks have no natural abnormalities. The anus is moderately dilated with some reddish purple circumferential ecchymosis, but there are no lacerations and no visible scars. The external genitalia are appropriate for age and have no injuries.

EXTREMITIES: The extremities are symmetrical and without natural deformities. The legs have no significant peripheral edema and no skin atrophy. The fingernails are all of medium length except the ring fingers which are short and even. The right ring fingernail appears acutely missing but in a smooth,
bloodless fashion.

SCARS, TATTOOS, NEVI, INCIDENTAL FINDINGS: The low midclavicular left chest has two (2) old scars, possibly skin grafting. An old scar is at the low left paravertebral back. A short scar is at the back of the web space of the left thumb. Old scars are also at the left knee with one (1) being surgical. The back of the left wrist has a tattoo of the letters "JD".

ARTIFACTS OF MEDICAL OR POSTMORTEM CARE

There are no acute or recent medical artifacts. The body has no embalming or other mortician's artifacts.

ARTIFACTS OF THE POSTMORTEM INTERVAL

See "GENERAL APPEARANCE" above for signs of death. Decomposition is minimal but progressing internally with some autolysis. There is no significant putrefaction.

INJURIES

Multiple incised and stab wounds are present on the head, neck, chest, back and upper extremities. These are entirely too numerous to count and detail. However, in general, there are 30 or more on the head, 15 or more on the chest and back, and about 40 defensive incised wounds at the right and left hands and forearms. Most of the sharp-force injuries present are incised wounds, and most of the stab wound are actually nonpenetrating of the body cavities, except as detailed below, and except for the deeper ones at the upper extremities. There are also some blunt-force injuries and some overlying rib fractures as below.

Many of the head wounds are very irregular and have slightly scalloped or curving borders, as discussed below. The forehead, the right face beside the nose, the right lips, the left side of the head and ear and the right side of the head have multiple incised wounds. At the forehead, the largest is 5 cm long and is irregular and mostly vertical while most of the incised wounds are diagonal, slanting from upper left to lower right, and being about 1.5 cm long each. The longest at the right face is 5.5 cm long. Those at the lips are superficial. At the left side of the head are several marks, mostly diagonal downward and to the front and also passing along the left side of the forehead and the left side of the face. At the frontoparietal area is a V-shaped incision which appears to be two incisions crossing. There are also five (5) short, jab-type incisions at the lateral-most low left forehead. These just penetrate the outer table of the skull beneath this area, the largest being 0.2 x 0.1 cm. Just inferior and posterior to these jab wounds is a definite, penetrating stab wound of the skull. At the skin, this is diagonal with the blunt end 0.1-0.2 cm in thickness, and being at the anteroinferior aspect of the diagonal stab wound, and the acute angle at the superoposterior aspect, the wound being 1.6 cm long. At the skull, this makes a similar triangular- shaped wound, more horizontal over the left sphenoid bone, with a base thickness of 0.1-0.2 cm and length of 1.6 cm. The anterior-most 1.0 cm of this stab is the actual penetration of the skull. It passes 3.5 cm total (approximately) through the skin and brain, passing into the brain about 2.0 cm at the inferolateral left frontal lobe. It creates a 1-cm-wide x 2-cm-deep permanent stab cavity at that area. It just enters the tip of the left lateral ventricle and is accompanied by a slight intraventricular hemorrhage and also by a slight white-matter contusion surrounding the injury.

The inferior border of the left ear has a prominent red band of abrasion and an upside-down V-shape, with a 6-cm-long vertical incision passing through the center of the abrasion and onto the upper lateral left neck. The longest incision of the left face is 5 cm long.

At the right side of the head are multiple stab wounds varying from 1.5 to 5.5 cm long, and including a curving stab, 6.5 cm long, with undermining in the posterior direction. In front of the right ear is a 9.5-cm-long, curving
incision also.

At the top of the head, located mostly on the right front side are another group of incised wounds, the most prominent having slightly scalloped edges, and being 2.2 cm long. At the upper lateral left side of the head are two (2) wounds, 0.9 cm between each other and parallel, each curving slightly and having slightly scalloped edges with the scalloping especially at the left, and with overlying, perpendicular, parallel, pale, reddish purple abrasion and contusion lines over a total area of 2 x 3 cm.

Beginning at the middle of the upper right sternocleidomastoid muscle, the right posterolateral and posterior neck have deep, muscular, incised wounds actually representing about two or three total cuts. The left-most aspect has a 1 cm superficial cut while the major cut passing over to the right posterolateral region is 13.5 cm long. A separate 2-cm-long incision overlies the right posterolateral aspect of this incision and combines with the incision for an additional 9 cm to terminate at the right sternocleidomastoid muscle where this discussion began. More inferiorly, the right sternocleidomastoid muscle also has a smaller incision.

The head also has some blunt-force injuries although these may be ragged incised wounds from a dull object. The back of the head has four (4) parallel, diagonal (upper left to lower right) lacerations with visible tissue bridging. The uppermost two (2) are the most superficial and may actually be incisions, these being 1.5 cm long and 4.0 cm long, respectively. The lowermost two are mostly on the left side and are 2.7 and 1.7 cm long, respectively, and they have prominent abrasion and contusion around the edges. The back of the right ear also has some reddish purple and reddish black abrasion and contusion; the nasal bridge and tip of the nose have some abrasions and contusions; the left scalp above the ear has a linear, vertical abrasion; and the vertex of the head has a 2.3- x 0.6-cm irregular abrasion.

Inside the head, the right parietotemporal region of the cerebrum has a focal area of increased subarachnoid hemorrhage; but, other than the stab wound at the left frontal lobe, the brain has no contusion, lacerations, subdural hematoma or other injuries. This does underlie the larger, curving, 6.5-cm-long incised wound discussed earlier. The spinal cord is not examined.

At the left midclavicular region of the upper left chest are some small, skip- like abrasions. The midright clavicular region of the upper chest also has a small area of abrasion. At the right parasternal chest is a 5-cm-tall stab wound. The inferior border is slightly rounded or acute and has some slight contusion with slightly undulating edges at the inferior third of the stab wound. The upper edge of the stab wound at the skin is squared off, 0.3 cm wide. The stab passes through the sternum in a roughly diagonal fashion with blunt upper right edge and acute lower left edge, passing into the chest at the right third intercostal space anteriorly. It passes posteriorly, slightly downward and to the right, and it just catches the outer edge of the right lung at the junction of the right upper and right middle lobes. The stab stops in the lung for a total of about 6 cm. Otherwise, the anterior chest has no stab wounds. Laterally, the right upper chest has a 1.6-cm-long stab, roughly horizontally oriented with the posterior aspect acute and the anterior aspect blunt. This passes into the right posterolateral chest via the third right intercostal space with no visible entry into the lung and with a depth of the stab totalling greater than or equal to 6 cm.

The lateral left chest at the lower half has an irregular area of mottled abrasions and contusions without pattern, the largest two (2) areas being 3.0 x 0.3 cm and 1 x 1 cm. These overlie the fractures of the ribs with accompanying slight intercostal-space contusion, mainly at the left lateral sixth rib, the left posterolateral seventh rib, and the left posterolateral eighth rib. The seventh rib has a parietal pleural perforation and the
greatest amount of contusional hemorrhage. These are blunt-force injuries.

At the back, there are multiple shallow stabs and jab-type wounds along with some tiny superficial abrasions or incisions, all less than or equal to 0.3 cm. At the left upper shoulder posteriorly are two (2) of the more
prominent superficial stab wounds not passing into the chest, the upper right lateral one being diagonally oriented and 2.2 cm long, and the more medial one being 1.4 cm long and oriented horizontally. At the midcenter of the back, slightly more on the right side of the spine than the left, are seven (7) parallel, diagonal stabs. These all have roughly the same appearance at the skin, although their upper and lower edges are less distinct than other stab wounds on the body. Three (3) of these are chosen for representative
measurements. The uppermost right stab of this group is 1.8 cm long and appears to have the blunt edge downward with a V-shaped acute edge superiorly. Bringing the two edges of the wound together creates almost a double "V," although the inferior aspect is more of a shallow "V" than the upper "V" is.
The inferior-most right wound in this group is 1.5 cm long and has a prominent inferior "V" with an acute superior edge. Bringing the two sides together creates no "V" at the top at all but makes the inferior "V" more prominent. The uppermost left wound of this group is 1.6 cm long and has a prominent upper blunt edge and an inferior acute edge. This wound, when the edges are brought together, is a simple slit. Three of the four stabs at the right side of this group penetrate the chest, one going through the sixth posterior right intercostal space, one going through the seventh, and one going through the ninth. These go into the right chest cavity with one injury only penetrating the right lung for a total depth of greater than or equal to 5 cm. This is probably wound "B" with the depth into the lower lobe of the right lung of about 1.5 cm with a height of 1 cm giving the total penetration as mentioned above of greater than or equal to 5 cm. The two (2) stab wounds to the left of the spine pass downward, medially and to the front, but they stop at the left lamina and left lateral side of the spinous processes of the back bone with a short overall distance for the stab of about 2 cm without penetration of the chest cavity.

As mentioned earlier, the upper extremities have multiple sharp-force injuries. At the anterior, distal right wrist are several abrasions and lacerations with slight reddish purple contusions, the longest 4.5 x 0.2 cm,
and the most prominent, 0.8 x 1.6 cm. These are less clearly defined as incised wounds, although they may be from an irregular object. At the back of the right triceps area, almost exposing the bone, is a bloodless, 19.5-cm-long gaping, deep, incised wound. The lateral proximal right shoulder and proximal arm have three (3) incisions, the longest more distal and is 1.6 cm long, with an irregular distal border suggestive of an acute angle and with a proximal border squared off and 0.2-0.3 cm wide. The back of the right forearm has some small abrasions and some small incised wounds toward the wrist. The distal right biceps area, just above the antecubital fossa, has one (1) small incised wound.

The left distal forearm has a large, gaping incised wound of 3 x 5 cm surface area, passing through the tendons. Just proximal to this is a 6- x 4-cm area of dried blood with abrasions and superficial incisions. Just proximal to that and more medial are two (2) parallel, linear, thin abrasions.

The backs of the hands have multiple avulsed and oblique incisions and lacerations, mostly incisions, ranging from 1.5-3.2 cm long. In addition, the back of the right hand has a larger, gaping wound, 5.5 x 3.0 cm long, and the right wounds and the left dorsal wrist wounds have superimposed purple contusions. On the medial edge of the right thumb is a 1.3-cm-long incised wound which continues onto the thumb pad itself. At the palmar surface of the left hand are approximately eight (8) oblique incised wounds, one being 2.5 cm long and having scalloped edges, and another being 3 cm long with the others varying. The hands do have clumps of straight, long, possibly blond hairs adherent especially at the left palm. These are collected.

Overall, most of the incised wounds of the trunk suggest a single-edged, thin blade, although a double-edged blade cannot be excluded. Many of the head wounds, and also the hand and forearm injuries, suggest a scalloped edge or scalloped object, and the multiple injuries of the hands and forearms are
consistent with defensive injuries.

Internally, there is almost no blood present in the heart and great vessels and tissues due to exsanguination from all of these multiple wounds. X-rays of the head and neck and also the chest and upper abdomen show no obvious fractures or foreign bodies. The internal structures of the neck, including the carotid arteries, show no injuries except for the large neck injury passing into the muscle only as mentioned above. The heart, liver, etc., have no injuries. See above for stabs of right lung, stab of brain, left rib fractures and right brain subarachnoid hemorrhage.

ROUTINE INTERNAL EXAMINATION

In general, internal artifacts and injuries have been described above and will not be further detailed in this section.

The body cavities are opened in the standard autopsy fashion. The organs are present in their usual anatomic locations and relationships. Little blood is present in the pleural cavities, and there are some slight adhesions at the right upper lobe of the lungs. There is no evidence of empyema, purulent exudate or acute inflammation of the serous cavities. There is no tissue discoloration suggestive for carbon monoxide intoxication or jaundice. There is a slight smell suggestive of alcoholic beverages within the body.

The gallbladder contains the usual bile. The stomach contains 20 ml of grayish mucoid fluid with curdled-like, small, soft, whitish lumps of mostly digested, unrecognizable food; but there is no evidence of drug residue. The vermiform appendix is present. The urinary bladder contains clear urine. In general, atherosclerosis is very mild. The heart has no evidence of infarction or scarring. The lungs have bullous emphysematous changes to a slight degree, mostly at the upper lobes. The right lung also has the two (2) stab wounds mentioned earlier. The liver appears pale but not fatty. The spleen, pancreas, kidneys, heart, adrenals, thyroid, pituitary, prostate and bladder are not otherwise remarkable. The testes show no contusions. The
penis does not appear to be circumcised.

Routine organ weights are as follows: heart, 370 gm; right lung, 530 gm; left lung, 580 gm; liver, 1630 gm; spleen, 80 gm; pancreas, 160 gm; right kidney, 140 gm; left kidney, 170 gm; and brain, 1450 gm.

PROCEDURES AND SPECIMENS

TOXICOLOGY: Blood, bile, urine, ocular fluid, nasal swabs.

PHOTOGRAPHY: Instant print and 35-mm slide identification pictures. Instant-print photos are also taken of the scene and of many of the injuries.

TRACE EVIDENCE: Trace materials on tape from right shoulder/chest; possibly small glass fragment from left upper chest; trace materials on tape from left shoulder/neck/chest; trace materials on tape from chest; glass fragments from back; possible glass fragments from chest; hairs adherent to right and left sleeves of shirt; hairs adherent to left hand; one (1) hair from inside the mouth; right fingernail clippings; left fingernail clippings; and adherent hairs from right hand. Purple- and red-topped tubes of blood are also collected and sent to the lab.

CHEMISTRIES OR CULTURES: None.

FIREARMS EXAMINATION: None.

X-RAYS: See "INJURIES."

MICROSCOPIC EXAMINATION: Representative sections of major organ systems have been obtained and routinely processed onto glass slides for histologic examination. These have been reviewed.

The liver, heart and kidney are not remarkable aside from some moderately advanced autolysis especially at the kidney. The lungs show diffuse, moderate emphysematous changes including septal fibrosis and an increased number of macrophages, along with congestion. The cerebrum shows acute petechial hemorrhages at the directed section from the stab-wound area, but otherwise the cerebrum is not remarkable. The anoderm shows no contusion, but it does have dilated submucosal vessels without significant inflammation or scarring. There are no additional significant findings.

Keywords: autopsy, homicide, exsanguination, multiple stab, wounds, brain, skull, cocaine, cocaine metabolite, cocaethylene, barbiturates, death, autolysis, cerebrum, histologic examination, toxicology, clothing, blunt force injuries, stab wounds, incised wounds, scalloped edges, force injuries, evidence, contusions, abrasions, stab,
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Transcribed Medical Transcription Sample Reports and Examples