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 - 7

Description: Cause of death - Anoxic Encephalopathy
(Medical Transcription Sample Report)

EXTERNAL EXAMINATION: The body is that of a 62-inch, 112-pound white female who appears the recorded age of 41 years. The body is clad in a pink and white gown. Three pillows and a blanket are also received with the body. The scalp is covered in thick brown hair with flecks of gray. The irides are brown. There is bilateral tache noire. The eyelids are yellow and dry. The eyes have a sunken appearance. The ears and nose are normally developed. The mouth has partial natural dentition. The left upper first bicuspid through the molars are absent. The left lower bicuspid is absent. The right upper second molar is capped. The left lower first molar appears decayed. The teeth are otherwise in good repair. The lips and buccal mucosa have no trauma. The neck is unremarkable except for a 2.5 cm tracheostomy scar just above the suprasternal notch. The posterior portion of the neck is unremarkable and free of scars. An obliquely oriented 6 cm surgical scar is on the anterior left chest with an underlying, implanted, medical device. The breasts are pendulous and otherwise unremarkable. There is white powder underneath the breasts. A round, 8 mm scar is on the upper central abdomen. A horizontally oriented 2.5 cm linear scar is on the central upper abdomen. A faint, approximately 1 cm scar is on the right mid lateral abdomen. There are a few striae on the hips and lower abdomen. The external genitalia are normally developed and white powder covers the perineum. The labia are dry. The urethral meatus is visible and 3.5 mm in diameter. No objects or substances are in the vagina other than a slight amount of yellow-white discharge. The anus is patent and unremarkable. Faint, pink-white, flat, 1-2 cm scars are just above the superior portion of the gluteal cleft. A 2.5 cm, somewhat square shaped, brown macule is on the left buttock. There are no open and active decubitus ulcers. The upper extremities have flexion contractures with striae on the medial portions of the upper arms. The muscles of the extremities are atrophic. The lower extremities are partially shaved. The left fifth toe is absent. The skin on the back is intact. The spine has accentuated thoracic kyphosis and lumbar lordosis. The skin demonstrates tenting

RADIOGRAPHS: Postmortem radiographs show radiopaque shadows extending from the periosteum of the femurs, left tibia, and right ischial tuberosity. Diffuse, severe osteoporosis is present. The 11th thoracic vertebral body has an endplate fracture. Degenerative joint changes are noted in the acromioclavicular joints, hips, right knee, left foot, and pelvis. The left fifth toe is amputated along with the distal portion of the left fifth metatarsal. Radiographs of anterior neck structures and iliac wings are not remarkable. Calculi are seen in the urinary tract. Staples are in the gallbladder bed.

INTERNAL EXAMINATION: The muscles of the chest and abdominal wall are normally developed. The subcutaneous tissues are dry. The panniculus is 2.5-3 cm. In the left chest wall is an implanted medical device with a wire extending through subcutaneous tissues of the left neck and into the left scalp. A flat, four-prong electrical device is in the subgaleal area of the left scalp. A wire then further extends into the cranial cavity. The peritoneal cavity is unremarkable and dry. There are no intraperitoneal adhesions except for an adhesion of the anterior portion of the stomach to the anterior abdominal wall in the area of the previously described round abdominal scar. The organs are in the usual anatomic relations. The pleural cavities are dry. The lungs are well aerated. The pericardial sac is remarkable for a 1 cm focal area of anterior pericardial adhesion to the anterior portion of the right ventricle. There is some lateral adhesion of the right ventricle to the right lateral portion of the pericardial sac. No other adhesions are noted. The pericardial sac is dry. The diaphragm is intact. The sternum is unremarkable. The ribs have no trauma and are normally developed with somewhat prominent costochondral junctions.

CARDIOVASCULAR SYSTEM: The pericardial sac is remarkable as previously described. The epicardial fat of the 255 gram heart is otherwise unremarkable. The root of the aorta has no atherosclerosis. The arch and descending aorta have minimal atherosclerosis (see attached CV pathology report).

RESPIRATORY SYSTEM: The right and left lungs are 260 and 245 grams, respectively. The lungs have a normal number of lobes and have light pink-red outer surfaces. The bronchi are unobstructed. The well-aerated lung parenchyma is pink-red. There are no anthracosis, tumors, cysts, or infarcts. The upper lobe bronchi contain a scant amount pearlescent fluid. The proximal bronchi contain yellow pearlescent fluid. The lower lobe distal bronchi contain some scattered areas of yellow pearlescent fluid. The alveoli otherwise contain foamy, reddish-white fluid. The pulmonary arteries contain no emboli. The lower lobes have firm areas of partial consolidation with yellow-green pearlescent fluid. The firm area of the left lower lobe is
4 x 4 x 3 cm. The right lung has scattered firm areas (<lcm).

HEMOLYMPHATIC SYSTEM: The 215 gram spleen is covered in an intact, gray, somewhat wrinkled capsule. There are two hilar accessory spleens (1.4 and 1 cm in diameter). The splenic parenchyma is dark red-maroon and unremarkable. There is no interstitial fibrosis, tumors, cysts or infarcts. No enlarged lymph nodes are noted. The bone marrow of the lumbar vertebral bodies is red and soft.

GENITOURINARY SYSTEM: The right and left kidneys are 100 and 130 grams, respectively. The right kidney has a central, 2-2.5 cm, obliquely oriented cleft/scar extending from the central renal pelvis to the upper lateral cortex. The brown-tan outer surfaces are otherwise slightly lobular and granular. The pelvis of the right kidney is mildly dilated. A 1 x 0.6 x 0.7 cm, green-brown stone is in the pelvis of the right kidney. The left renal pelvis has an approximately 0.5 x 0.6 x 1 cm, green-brown stone. The corticomedullary ratios are reduced. The pelvic fat is increased. The left ureter contains pearlescent fluid. The urinary bladder contains
6 cc of brown-yellow fluid. A 3.8 x 1.2 x 1 cm, white-yellow, somewhat crescent shaped stone is within the lumen of the bladder. The uterus is present and has a normal shape. The cervix is normally developed. The cervical os is large (coned) and contains mucoid fluid. There are a few minute nabothian cysts (<2 mm). A 2 cm, spherical leiomyoma is in the posterior portion of the uterine corpus. The endometrial cavity contains 3 to 4 mm thick, tan endometrium. The ovaries are present, firm and otherwise grossly unremarkable. The fallopian tubes are unremarkable except for a few adhesions of the fimbriated ends.

GASTROINTESTINAL SYSTEM: The stomach contains 60 cc of green-brown fluid without any solid food fragments. The gastric mucosa is flat, congested, and green-gray. The gastric mucosa is congested. No ulcerations are noted. There are a few congested vessels with minute petechiae around the previously healed ostomy site. An 8 mm blood clot is on the gastric mucosa near the healed/healing gastrostomy site. The wall of the stomach is thin (<3mm). No perforations are noted. The esophagus is not remarkable with gray/pink mucosa. The bowel contains progressively formed feces with the rectum containing hard stool. The appendix is present, but is atrophic/small. The bowel has no perforations. An abundant amount of greenish liquid is in the duodenum. No foreign objects are noted.

HEPATOBILIARY SYSTEM: The outer surface of the 965 gram liver is covered in a transparent intact capsule. There are very few inferior hepatic adhesions associated with an absent gallbladder. Surgical staples are imbedded in the area of the cystic duct. The hepatic parenchyma is brown-green with a slight pattern of congestion. The bile ducts and portal veins appear grossly unremarkable. No fibrosis, cysts or infarcts are noted. A yellow-white, round, 2 mm nodule is in the anterior portion of the right lobe of the liver.

ENDOCRINE SYSTEM: The adrenals and pancreas are present and grossly unremarkable. The thyroid is mildly atrophic without nodules.

MUSCULOSKELETAL SYSTEM: The upper and lower extremities are atrophic as previously described. The trunk musculature is atrophic. A 1 x 1.5 x
1 cm area of induration/calcification extends from the anterior surface of the right femur. The anterior/lateral cortical surface of the distal right femur metaphysis is rough and irregular. The cortical bone of the lumbar and thoracic vertebral bodies is thin and soft. The iliac wings have no trauma or deformity.

NECK: The strap muscles of the anterior neck have intact musculature with atrophy of the musculature on the right side. The right sternocleidomastoid is moderately atrophic. There are no hemorrhages. The larynx and piriform recesses contain yellow-tan, mucoid fluid. There is yellow-green, mucoid fluid on the base of the tongue and epiglottis. The larynx contains a scant amount of fluid. The thyroid and cricoid cartilages are intact. The hyoid bone is intact. The tongue is atrophic. There is a yellow-green dry crusted material on the surface of the tongue. The posterior pharyngeal musculature appears atrophic. There are no hemorrhages. A healed tracheostomy site is on the anterior trachea. The carotid arteries and jugular veins are not remarkable. The muscles and cervical vertebral bodies of the posterior neck are not remarkable. The spinal cord and column have no trauma. The posterior laminae are soft.

CENTRAL NERVOUS SYSTEM: See neuropathology report

MICROSCOPIC EXAMINATION: (Also see neuropathology and cardiovascular pathology reports)
LUNGS, LOWER LOBES: Widespread bronchopneumonia. Intraalveolar debris and bacteria.
Intraalveolar foamy macrophages. Congestion. Edema.

UTERUS: Late proliferative endometrium leiomyoma.

ACCESSORY SPLEEN: Not remarkable.

COLON: Autolysis. Melanosis.

URINARY BLADDER: Chronic inflammation.

OVARIES: Corpora albicantia. Follicular cyst.

FALLOPIAN TUBES: Paratubal cyst. Congestion.

VAGINA: Vascular congestion.

ADRENAL GLANDS: Mild congestion.

STOMACH, GASTROSTOMY: Clotted blood.

LIVER: Focal nodular hyperplasia (single focus). Centrilobular congestion with steatosis

KIDNEYS: Tubular necrosis. Mild vascular congestion.

THYROID: Not remarkable.

PANCREAS: Early autolysis. Mild interstitial fibrosis.

EPIGLOTTIS: Focal ulceration with acute inflammation.

LARYNX, RIGHT ARYEPIGLOTTIC FOLD: Not remarkable.

TONGUE: No significant histologic abnormalities.

FEMUR, RIGHT: Heterotopic ossification.

FEMUR, THIGH, RIGHT: Heterotopic ossification.

RIBS, COSTOCHONDRAL JUNCTION: No significant histologic abnormalities.

BONE, THORACIC VERTEBRA: Severe osteoporosis. Unremarkable bone marrow.

BREASTS: Not remarkable.

AUTOPSY FINDINGS:
1. Anoxic-ischemic encephalopathy (see attached neuropathology report).
a. Extremity muscle atrophy and contractures.
b. Bilateral bronchopneumonia.
c. Osteoporosis (with Tl 1 endplate fracture).
d. Urolithiasis.
e. Renal scar (right).
f. Heterotopic ossification.
g. Degenerative joint changes.
h. Glossal, pharyngeal, and neck muscle atrophy.
i. Healing gastrostomy.
j. Implanted electrical stimulator.
k. Healed decubitus ulcer (s) and remote left fifth toe amputation.

2. Dehydration
a. Vitreous chemistry: sodium 207 mmol/L, chloride 184 mmol/L, urea nitrogen 133 mg/dL, creatinine 1.3 mg/dL, glucose 57 mg/L.
b. Dry skin and body cavities.
c. Renal tubular necrosis.

3. Toxicology
a. Heart blood: acetaminophen 8.8 mg/L.
b. Urine: acetaminophen detected.

4. Status post cholecystectomy.

5. Hyperostosis frontalis interna.

6. Uterine leiomyoma.

7. Cardiovascular (see attached cardiovascular pathology report).
a. Heart weight 255 grams.
b. Focal pericardial adhesions.
c. Cardiac ion channel mutation screening: Negative.

CAUSE OF DEATH: Complications of Anoxic Encephalopathy.

MANNER OF DEATH: Undetermined.

Keywords: autopsy, encephalopathy, examination, autopsy findings, toxicology, manner of death, gown, body, anoxic encephalopathy, gastric mucosa, pericardial sac, pearlescent fluid, fluid, anoxic, noire,
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