Sample Name: Autopsy - 6
Description: Multiple sharp force injuries, involving chest and abdomen, multiple incised-stab wounds of the neck, and multiple incised or cutting wounds.
(Medical Transcription Sample Report)
1. Sharp force wound of neck, left side, with transection of left internal jugular vein.
2. Multiple stab wounds of chest, abdomen, and left thigh: Penetrating stab wounds of chest and abdomen with right hemothorax and hemoperitoneum.
3. Multiple incised wounds of scalp, face, neck, chest and left hand (defense wound).
4. Multiple abrasions upper extremities and hands (defense wounds).
NOTES AND PROCEDURES
1. The body is described in the Standard Anatomical Position. Reference is to this position only.
2. Where necessary, injuries are numbered for reference. This is arbitrary and does not correspond to any order in which they may have been incurred. All the injuries are antemortem, unless otherwise specified.
3. The term "anatomic" is used as a specification to indicate correspondence with the description as set forth in the textbooks of Gross Anatomy. It denotes freedom from significant, visible or morbid alteration.
EXTERNAL EXAMINATION: The body is that of a well developed, well nourished Caucasian male stated to be 25 years old. The body weighs 171 pounds, measuring 69 inches from crown to sole. The hair on the scalp is brown and straight. The irides appear hazel with the pupils fixed and dilated. The sclerae and conjunctive are unremarkable, with no evidence of petechial hemorrhages on either. Both upper and lower teeth are natural, and there are no injuries of the gums, cheeks, or lips.
There is a picture-type tattoo on the lateral aspect of the left upper arm. There are no deformities, old surgical scars or amputations.
Rigor mortis is fixed.
The body appears to the Examiner as stated above. Identification is by toe tag and the autopsy is not material to identification. The body is not embalmed.
The head is normocephalic, and there is extensive evidence of external traumatic injury, to be described below. Otherwise, the eyes, nose and mouth are not remarkable. The neck shows sharp force injuries to be described below. The front of the chest and abdomen likewise show injuries to be described below. The genitalia are that of an adult male, with the penis circumcised, and no evidence of injury.
Examination of the posterior surface of the trunk reveals no antemortem traumatic injuries.
Refer to available photographs and diagrams and to the specific documentation of the autopsy protocol.
CLOTHING: The clothes were examined both before and after removal from the body.
The decedent was wearing a long-sleeved type of shirt/sweater; it was extensively bloodstained.
On the front, lower right side, there was a 1 1/2 inch long slit-like tear. Also on the lower right sleeve there was a 1 inch slit-like tear. On the back there was a 1/2 inch slit-like tear on the right lower side.
EVIDENCE OF THERAPEUTIC INTERVENTION: None.
EVIDENCE OF INJURY
SHARP FORCE INJURIES OF NECK
1. Sharp force injury of neck, left side, transecting left internal jugular vein. This sharp force injury is complex, and appears to be a combination of a stabbing and cutting wound. It begins on the left side of the neck, at the level of the midlarynx, over the left sternocleidomastoid muscle; it is gaping, measuring 3 inches in length with smooth edges. It tapers superiorly to 1 inch in length cut skin. Dissection discloses that the wound path is through the skin, the subcutaneous tissue, and the sternocleidomastoid muscle with hemorrhage along the wound path and transection of the left internal jugular vein, with dark red-purple hemorrhage in the adjacent subcutaneous tissue and fascia. The direction of the pathway is upward and slightly front to back for a distance of approximately 4 inches where it exits, post-auricular, in a 2 inch in length gaping stab/incised wound which has undulating or wavy borders, but not serrated. Intersecting the wound at right angle superior inferior is a 2 inch in length interrupted superficial, linear incised wound involving only the skin. Also, intervening between the 2 gaping stab-incised wounds is a horizontally oriented 3-1/2 inch in length interrupted superficial, linear incised wound of the skin only. In addition, there is a 1/2 inch long, linear-triangular in size wound of the inferior portion of the left earlobe. The direction of the sharp force injury is upward (rostral), and slightly front to back with no significant angulation or deviation. The total length of the wound path is approximately 4 inches. However, there is a 3/4 inch in length, linear, cutting or incised wound of the top or superior aspect of the pinna of the left ear; a straight metallic probe placed through the major sharp force injury shows that the injury of the superior part of the ear can be aligned with the straight metallic rod, suggesting that the 3 injuries are related; in this instance the total length of the wound path is approximately 6 inches. Also, in the left postauricular region, transversely oriented, extending from the auricular attachment laterally to the scalp is a 1-1/8 inch in length linear superficial incised skin wound.
OPINION: This sharp force injury of the neck is fatal, associated with transection of the left internal jugular vein.
artery or vein; the direction is front to back and upward for a total wound path length of 2 inches and the wound exits on the right side of the back of the neck, posterior to the right sternocleidomastoid muscle where a 2 inch long gaping incised/stab wound is evident on the skin; both ends are tapered; superiorly there is a 1 inch long superficial incised wounds extension on the skin to the back of the head; inferiorly there is a 2 inch long incised superficial skin extension, extending inferiorly towards the back of the neck. There is fresh hemorrhage and bruising along the wound path; the direction, as stated, is upward and slightly front to back.
OPINION: This is a nonfatal sharp force injury, with no injury or major artery or vein.
3. At the level of the superior border of the larynx there is a transversely oriented, superficial incised wound of the neck, extending from 3 inches to the left of the anterior midline; it is 3 inches in length and involves the skin only; a small amount of cutaneous hemorrhage is evident.
OPINION: This is a nonfatal superficial incised wound.
4. ImmediateLY inferior and adjacent to incised wound #3 is a transversely oriented, superficial incised wound involving the skin and subcutaneous tissue; there is a small amount of dermal hemorrhage.
OPINION: This is a nonfatal superficial incised wound.
1. There is a stab wound, involving the right earlobe; it is vertically oriented, and after approximation of the edges measures 1 inch in length with forked or split ends superiorly and inferiorly approximately 1/16 inch in total width both superior and inferior. Subsequent dissection discloses that the wound path is from right to left, in the horizontal plane for approximately 1-1/4 inches; there is fresh hemorrhage along the wound path; the wound path terminates in the left temporal bone and does not penetrate the cranial cavity.
OPINION: This is a nonfatal stab wound.
2. There is a group of 5 superficial incised or cutting wounds on the right side of the face, involving the right cheek and the right side of the jaw. They are varied in orientation both diagonal and horizontal; the smallest is 1/4 inch in length; the largest 5/8 inch in length. They are superficial, involving the skin only, associated with a small amount of cutaneous hemorrhage.
3. On the back of the neck, right side, posterior to the ear and posterior border of the right sternocleidomastoid muscle there is vertically oriented superficial incised skin wound, measuring 3/4 inch in length.
4. There are numerous superficial incised wounds or cuts, varied in orientation, involving the skin of the right cheek, intersection and mingled with the various superficial incised wounds described above. The longest is a 3 inch long diagonally oriented superficial incised wound extending from the right side of the forehead to the cheek; various other superficial wound vary from 1/2 to 1 inch.
5. On the right side of the cheek, adjacent to the ramus of the mandible, right, there is a 1-1/2 x 3/4 inch superficial nonpatterned red-brown abrasion with irregular border, extending superiorly towards the angle of the jaw where there are poorly defined and circumscribed abrasions adjacent to the superficial cuts or abrasions described above. It should be noted that the 5th superficial incised wound of the right side of the mandible which measures 5/8 inch in length is tapered on the posterior aspect and forked on the anterior aspect where it has a width of 1/32 inch.
6. On the left ear, there is a superficial incised wound measuring 1/4 inch, adjacent to the posterior border of the pinna. Just below this on the inferior pinna, extending to the earlobe, there is an interrupted superficial linear abrasion measuring 1 inch in length.
SHARP FORCE INJURIES OF SCALP
1. The scalp is shaved postmortem for visualization. On the right posterior parietal region of the scalp there is a sharp force wound, diagonally oriented, and after approximation of the edges it measures 5/8 inch in length with a perpendicularly oriented skin cut at the midpoint. Depth of penetration is approximately 1/4 to 3/8 inch into the scalp, with associated deep scalp hemorrhage and a subgaleal hemorrhage beneath the wound measuring 2 x 2 inches in transverse diameter. There is no underlying fracture of the skull or penetration of the cranium.
OPINION: This is a sharp force wound that may represent either a cutting wound of a superficial stab wound; nonfatal.
2. On the posterior parietal region, midline, to the left of the wound described above there is a 1/4 inch superficial incised wound or skin cut measuring 1/4 inch in length; both ends are pointed or tapered; extension is 1/4 inch into the scalp with a small amount of deep scalp hemorrhage but no subgaleal hemorrhage.
3. On the left posterior parietal region there is an injury that is an abrasion, 1/4 x 1/8 inch in maximal diameter and an ovoid in configuration; it is red-brown with a small amount of superficial skin bruising.
OPINION: This is a skin abrasion-bruise, noncharacteristic.
DESCRIPTION OF MULTIPLE STAB WOUNDS
On the right side of the chest adjacent to the stab wound there are multiple, irregular, brown abrasions consistent with ant bites.
1. STAB WOUND OF RIGHT SIDE OF CHEST.
The stab wound is located on the right side of the chest, 22 inches below the top of the head and 5 inches from the back of the body; it is vertically oriented and after approximation of the edges it measures 5/8 inch in length. Inferiorly there is a squared off or dull end approximately 1/32 in length; superiorly the wound is tapered. Subsequent autopsy shows that the pathway is through the skin, the subcutaneous tissue, and through the right 7th rib at the approximately midaxillary line where the rib is totally incised. Thereafter, it enters the right pleural cavity which at the time of autopsy contains approximately 100-200 ml of predominantly liquid blood. The path is through the lateral base of the border of the right lower lobe as the path is through the pleura and the immediately subjacent pulmonary parenchyma which is hemorrhagic; the pleural wounds are approximately 1/2-3/4 inch in length; thereafter the pathway is from right to left and back to front and through the pleural cavity where the wound path terminates on the anterior rib cage where a 3/4 cutting wound is found on the posterior aspect of the right 4th rib anteriorly at the approximate midclavicular line; there is overlying bruising in the adjacent intercostal musculature. Estimated length of the total wound path is 4 inches and as stated the direction is right to left and back to front with no other angulation measurable.
OPINION: This is a fatal wound associated with perforation of the right
lung and a hemothorax.
2. STAB WOUND OF RIGHT SIDE OF CHEST.
This wound is located on the right side of the chest, 21 inches below the top of the head and 2 inches from the back of the body. After approximation of the edges it measures 1-1/2 inches in length and is diagonally oriented; the posterior aspect is dull or flat, measuring 1/32 inch and the anterior aspect is pointed or tapered. Subsequent autopsy shows that the wound is through the skin, the subcutaneous tissue, and the intercostal musculature and it penetrates into the pleural cavity through the 8th right intercostal space without striking rib. Thereafter the pathway is similar to stab wound #1 as it passes obliquely through the pleura and subjacent hemorrhagic parenchyma at the base of the right lower lobe; 1/2 inch and 3/4 inch pleural cuts are evident both posteriorly and anteriorly. No other terminating point is evident. There is fresh hemorrhage and bruising noted along the wound path as well as the hemothorax described above. The direction is right to left with no other angulation or deviation determined because of absence of fixed reference points. Estimated minimum total depth of penetration is 2-3 inches.
OPINION: This is a fatal stab wound associated with perforation of the lung and hemothorax.
3. STAB WOUND OF RIGHT FLANK.
This is a diagonally oriented wound, on the right flank, 29 inches below the top of the head and 3-1/2 inches to the back of the body. It measures 3/8 inch in length and involves the skin and subcutaneous tissue without penetrating the chest wall or abdominal wall. No square or dull edges are evident. Both ends are rounded or tapered.
OPINION: This is a superficial cutting wound, representing either a superficial stab wound or an incised wound.
4. STAB WOUND OF LEFT THIGH.
This is a transversely oriented stab wound on the lateral left thigh, 33 inches above the left heel and 4 inches from the back of the thigh. After approximation of the edges it measures 2-1/8 inches in length and posteriorly there is a dull or flat end 1/32 inch and anteriorly a pointed or tapered end. Subsequent autopsy shows that the wound path is through the skin, the subcutaneous tissue, and the muscle without striking bone. There is fresh hemorrhage along the wound path. The depth of penetration is 3 to 3-1/2 inches from left to right without angulation or deviation.
OPINION: This is a stab wound of the soft tissue and muscle of the left thigh, nonfatal.
5. STAB WOUND OF LEFT SIDE OF ABDOMEN
This is a transversely oriented stab wound on the left side of the abdomen, located 45 inches above the left heel. After approximation of the edges it measures 3/4 inch in length with the anterior end pointed or tapered and the posterior end forked or split. Subsequent autopsy shows that the wound passes through the skin, the subcutaneous tissue, and through the retroperitoneal tissue which is hemorrhagic; the pathway is through the left ilio-psoas muscle associated with fresh hemorrhage and bruising. The path is from left to right and slightly back to front; the wound path terminates in the abdominal aorta approximately 1-1/4 inches proximal to the bifurcation. Two perforating 1/2 inch wounds are seen in the wall of the aorta with surrounding para-aortic hemorrhage. In addition to the retroperitoneal hemorrhage, including hemorrhage into the mesocolon, approximately 100 ml of liquid blood is found free within the peritoneal cavity. In addition to the fresh bruising and hemorrhage along the wound path the entire length of the wound path is approximately 5-1/2 inches. The direction is left to right, and a slightly back to front direction with no other angulation or deviation evident.
OPINION: This is a fatal stab wound associated with perforation of the abdominal aorta with retroperitoneal and intra-abdominal hemorrhage.
6. STAB WOUND OF THE RIGHT UPPER CHEST, LATERAL BORDER OF RIGHT CLAVICLE
This vertically oriented superficial stab wound or incised wound is located on the lateral border of the right clavicle, is vertically oriented, and measures 1/2 inch in length; involves the skin and subcutaneous tissue; inferiorly the wound is split or forked and superiorly it is tapered or pointed. It should be noted that all of the split or forked ends of the previously mentioned stab wounds overall measure approximately 1/16 to 1/8 inch in overall width. There is a small amount of fresh cutaneous hemorrhage. No direction can be evident except for front to back, inasmuch as it is superficial.
OPINION: This is a nonfatal superficial stab wound or cutting wound.
SHARP FORCE INJURIES OF HANDS:
1. On the palmar surface of the right hand, at the base of the index finger, there is a cutting or incised wound, 3/4 inch in length and 1/2 inch deep involving the skin and subcutaneous tissue with hemorrhage in the margins. Both ends are rounded or tapered.
OPINION: This is compatible with a defense wound.
2. On the palmar surface of the right hand, just proximal to the web of the thumb, there is a triangular or Y-shaped cutting wound measuring 1/2 inch in length maximally and 1/4 inch deep with hemorrhage at the margins.
OPINION: This is compatible with a defense wound.
3. On the palmar surface of the left hand at the web of the thumb, there is a 3/4 inch in size or cutting wound involving the skin, and subcutaneous tissue; it is approximately 1/4 inch deep with hemorrhage at the margins. Both ends are tapered or pointed with smooth edges similar to the 2 wounds described above.
OPINION: This is compatible with a defense wound.
OTHER INJURIES TO HANDS AND UPPER EXTREMITIES:
1. On the lateral aspect of the right distal forearm, adjacent to the wrist, there is a 3/4 x 1/2 inch abrasion on the ulnar surface, red-brown in color, nonpatterned.
2. On the lateral or outer aspect of the left forearm there are multiple abrasions both linear and one that is approximately triangular measuring 3/4 x 1/2 inch; they are all brown to red-brown in color and antemortem; the longest linear abrasion is 3/4 inch in length.
3. On the dorsal surface of the right hand there are fresh bruises (red-purple in color) and fresh red-brown abrasions. On the proximal knuckle of the right middle finger a 1 x 3/4 inch bruise with no overlying abrasion. On the middle knuckle of the index finger a 1/2 x 1/2 inch bruise surrounding a 1/8 nondescript abrasion; just distal on the middle phalanx of the middle finger a 1/8 nondescript abrasion. On the proximal knuckle of the right index finer there is a 1/2 x 1/2 inch fresh bruise surrounding a linear diagonally oriented 1/2 inch red-brown abrasion. There is a 1/2 x 1/2 inch fresh bruise on the middle of the right ring finger surrounding 2 punctate abrasions approximately 1/8 inch in maximal diameter; on the middle knuckle of the right 5th finger there is a 1/16 inch punctate nondescript abrasion.
4. On the dorsal side of the left hand there are multiple red-brown abrasions irregular in configuration and border, involving the 3 knuckles of the left index finger; maximal dimension 1/4 x 3/8 inch, all red-brown in color. There is an irregularly configured abrasion on the proximal knuckle of the left middle finger consisting of an apparent 3 linear 1/2 inch abrasions converging at the center having a somewhat configuration of the letter W. These are all superficial skin abrasions. On the dorsal side of the left hand adjacent to the web of the thumb there is a linear, 3/4 inch long skin abrasion terminating in a 1/8 inch nondescript punctate abrasion
near the base of the thumb. There is a fresh bruise, 1-1/4 x 1-1/2 inch on the dorsal surface of the left hand adjacent to the wrist surrounding a punctate abrasion.
5.. There are 2 fresh bruises on the ulnar surface of the left wrist, nonabraded, measuring respectively 3/8 x 3/8 inch and 1/2 x 1/2 inch, with the bruising involving the skin and dermis.
INTERNAL EXAMINATION: The body is opened with the usual Y-shaped thoracoabdominal incision revealing the abdominal adipose tissue to measure 1/2 to 3/4 inch in thickness. The anterior abdominal wall has its normal muscular components and no blunt force injuries are evident. Exposure of the body cavities shows the contained organs in their usual anatomic locations with their usual anatomic relationships. The serosal surfaces are smooth, thin, and glistening and the free blood within the peritoneal cavity due to the stab wound as previously described; this also includes the left retroperitoneal hemorrhage, hemorrhage into the left ilio-psoas muscle, and the mesocolon.
INTERNAL EVIDENCE OF INJURY: Aside from the stab wounds of the chest and abdomen, there are no other internal traumatic injuries involving the thoracic or abdominal viscera.
SYSTEMIC AND ORGAN REVIEW: Autopsy findings, or lack of them, considered apart from those already stated. The following observations pertain to findings other than the injuries and changes that are described above.
MUSCULOSKELETAL SYSTEM--SUBCUTANEOUS TISSUE-SKIN: Anatomic except as otherwise stated or implied.
HEAD--CENTRAL NERVOUS SYSTEM: The brain weighs 1,400 grams. The external indications of injury as well as the deep scalp and subgaleal hemorrhage have been described above. There is no hemorrhage into the temporal muscle or the orbits. There are no tears of the dura mater and no recent epidural, subdural, or subarachnoid hemorrhage. The dura is stripped revealing no fractures of the bones of the calvarium or base of the skull. The pituitary gland is normally situated in the sella turcica and is not enlarged. The cranial nerves are enumerated and they are intact, symmetrical and anatomic in size, location and course. The component vessels of the circle of Willis are identified and they are anatomic in size, course and configuration. The blood vessels are intact, free of aneurysm or other anomaly, are non-occluded, and show no significant atherosclerosis. Multiple coronal sections of the non-formalin-fixed, fresh brain shows: The cerebral hemispheres, cerebellum, brain stem, pons and medulla to show their normal anatomical structures. The cerebellar, the pontine and the medullary surfaces present no lesions. The cerebral cortex, the white matter, the ventricular system and basal ganglia are anatomic. There is no evidence of hemorrhage, cysts or neoplasm involving the brain substance. The spinal chord is not dissected.
ORGANS OF SPECIAL SENSES: Not dissected.
RESPIRATORY SYSTEM--THROAT STRUCTURES:
The oral cavity, viewed from below, is anatomic and no lesions are seen. The mucosa is intact and there are no injuries to the lips, teeth or gums. There is no obstruction of the airway. The injury to the left internal jugular vein has been previously described. 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 intact. No hemorrhage is present in the tissues adjacent to the throat organs nor is there hemorrhage into the substance of the anatomic appearing thyroid gland. The parathyroid glands are not identified.
LUNGS: The lungs weight: Right, 420 grams; left 320 grams. The external appearance and that of the sectioned surface of the left lung shows a pink external surface without evidence of injuries. There is minimal congestion, otherwise not remarkable. No foreign substance, infarction or neoplasm is encountered. The right lung shows basilar atelectasis due to the hemothorax caused by the stab wound to the right lower lobe described above. Otherwise the external appearance of the sectioned surface shows no focal lesion; there is no evidence of foreign material, infarction or neoplasm.
CARDIOVASCULAR SYSTEM: The heart weighs 290 grams, and has a normal size and configuration. The chambers, valves, and the myocardium are anatomic. There are no focal endocardial, valvular or myocardial lesion and no congenital anomalies. Multiple transverse sections of the left and right coronary arteries reveal them to be thin-walled and patent throughout with no significant atherosclerosis. The aorta and its branches are anatomic; the perforating stab wound injury of the distal abdominal aorta has been previously described. The portal and caval veins and the major branches are anatomic.
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. There are no focal lesions, no residual medications, and no swallowed blood is present. Approximately 200 ml of partially digested semisolid food is found in the stomach with the presence of fragments of green leafy vegetable material compatible with spinach. The mucosa of the duodenum, jejunum, ileum, colon and rectum are intact. The lumen is patent. There are no mucosal lesions or injuries and no blood is present. The fecal content is usual in appearance. The vermiform appendix is present.
HEPATOBILIARY SYSTEM--PANCREAS: The liver weighs 1,360 grams and is normal size and configuration. The subcapsular and the cut surfaces of the liver are uniformly brown-red in color, free of nodularity, and usual in appearance. The biliary duct system, including the gallbladder, is free of anomaly and no lesions are seen. The mucosa is intact and bile stained. The lumina are patent and no calculi are present. The pancreas is anatomic both externally and on cut surface.
HEMOLYMPHATIC SYSTEM--ADRENAL GLAND: The spleen weighs 210 grams and has an intact capsule. Cut surface shows a normal coloration with a firm red-purple parenchyma and no focal lesions. The blood, the bone marrow and the usually-named aggregates of lymph nodes do not appear to be significantly altered. The thymus gland is not identified. The adrenal glands are usual in size and location and the cut surface presents no lesions or injuries. However, there is a small amount of left periadrenal hemorrhage due to the retro-peritoneal hemorrhage caused by the stab wound.
URINARY SYSTEM: The kidneys weigh: Left, 150 grams; right, 140 grams. The kidneys are anatomic in size, shape and location. The capsules are stripped to show a smooth, pale brown surface. On section the cortex and medulla are anatomic without lesions. The calyces, the pelves, the ureters and urinary-bladder are unaltered in appearance. The mucosa is gray-pink. No calculi are present, and no blood is present. The urinary bladder contains no measurable urine.
MALE GENITAL SYSTEM: The testicles, the penis, the prostate gland are anatomic to dissection.
HISTOLOGY: Representatives portions of the various organs, including the larynx, are preserved in 10% formaldehyde and placed in a single storage container.
TOXICOLOGY: A sample of right pleural blood as well as bile are submitted for toxicologic analysis. Stomach contents are saved.
SEROLOGY: A sample of right pleural blood is submitted in the EDTA tube.
PHOTOGRAPHY: In addition to the routine identification photographs; pertinent photographs are taken of the external injuries.
WITNESSES: Detectives Van Natter and Lange, LAPD, Robbery Homicide Division, were present during the autopsy.
DIAGRAMS USED: Form 42, 16, 20F, 20H, 21 and 24 were utilized during the performance of the autopsy.
OPINION: The decedent sustained multiple sharp force injuries, including multiple stab wounds involving the chest and abdomen; multiple incised-stab wounds of the neck; and multiple incised or cutting wounds. Fatal wounds were identified involving the neck where there was transection of the left internal jugular vein and stab wounds of the chest and abdomen causing intrathoracic and intraabdominal hemorrhage.
Of note the cutting wounds of the left and right hands, compatible with defensive wounds. In addition there were a number of blunt force injuries to the upper extremities and hands, likewise compatible with defensive wounds. The remainder of the autopsy revealed a normal, healthy adult male with no congenital anomalies. Routine toxicologic studies were ordered.
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