Full Autopsy Report by Harrison Mbohe MBChB Level 4 JKUAT

1. SECTIONS OF A FULL
AUTOPSY REPORT

2. FORM OF THE AUTOPSY REPORT
• A free style “essay”
• Usually adheres to a conventional sequence.
• Leaves the examiner to expound on various aspects of
significance.
• Usually used litigious autopsies as a legal statement or a
deposition for court.
• A printed proforma
• Various sections of the examination and organ systems are
already set out by title, leaving blank spaces for the insertion of
the findings.
• Commonly used for non-litigious autopsies

3. BASIC SECTIONS
• Full personal details of the deceased subject, unless unidentified. This
includes the name, gender, age, occupation and address.
• Declaration statement:
• The name, qualifications and status of the pathologist.
• The authority(s) commissioning the autopsy.
• The place, date and time of the autopsy.
• A record of who identified the body.
• Persons present at the examination & their designations.
• Clothing on the deceased O/E (+/-).
• The history and circumstances of the death
• Justifies the eventual cause of death where the morphological findings are scanty or
even absent.
• In some jurisdictions, it’s forbidden to include this in the report

4. EXTERNAL EXAMINATION: MAJOR FINDINGS
• Body habitus - height, weight, apparent state of nutrition &
physique.
• The presence of natural disease e.g. oedema, abdominal
swelling, cutaneous disease, senile changes, etc.
• Identifying striking features such as skin colour, tattoos, scars,
congenital or acquired deformities, dentures, and hair colour.
• Post-mortem changes - rigor, hypostasis, decomposition and
abnormal skin coloration. Body and ambient temperature should
be recorded where appropriate.
• Signs of medical intervention
• Listing and description of all external injuries, recent and old.

5. INTERNAL EXAMINATION: MAJOR FINDINGS
CVS - Heart weight, any dilatation, ventricular preponderance, congenital defects, and
any other anomalies pericardium, epicardium, endocardium, valves, coronary arteries,
myocardium, aorta, other great vessels and peripheral vessels.
RS - Hyoid bone and Laryngeal cartilages, Larynx, Soft tissues of neck, Trachea and Main
Bronchi, Lungs (weight RL, LL g), Pleural cavities, Hilar Lymph Nodes:
GIS - Tongue, Tonsils, Oesophagus: Peritoneal Cavity, Stomach, Duodenum, Intestines,
Appendix, Rectum, Liver (weight g), Gall Bladder, Bile Ducts, Pancreas (weight-)
Endocrine system - Pituitary, thyroid (weight), and adrenals.
RES - Spleen (weight) thymus and lymph nodes.
GUS - Kidneys (weight), ureters, bladder, prostate, uterus, ovaries and testes, external
genitalia
Musculoskeletal system - Skull, spine, remaining skeleton (Limb Girdles, Long Limb
Bones, Hand and Feet, Ribs, Sternum, General condition of skeleton) and musculature
where necessary
Nervous system - Scalp, skull, meninges, cerebral vessels, brain (weight), middle ears,
venous sinuses and spinal cord (when examined) and peripheral nerves

6. MISCELLANEOUS
• A list of specimens and samples retained for further examination.
• Specimen handed to other agencies should be formally identified by means of
serial numbers and the name of the person to whom they were handed.
• A summary of the lesions displayed by the autopsy.
• Discussion of the findings, if necessary in the light of the known history.
• An opinion as to the definite or most likely sequence of events leading to the
death.
• A formal cause of death, in format recommended by WHO, suitable for the
completion of a death certificate.
• Pathologist’s signature & date.
NB;- The results of further examinations such as histology, microbiology,
toxicology and serology are usually not available in the main report after autopsy
and a supplementary report is provided for such findings.

7. REFERENCES
Knight's Forensic Pathology. (2004). In P. S. Knight.
London: Edward Arnold (Publishers) Ltd, pp 33-35.
Guide for Clinical Clerkship (2021), E.A.R., Department
of Human Pathology & Forensic Medicine, School
of Medicine, JKUAT, Juja, pp 15-21.

8. THE END
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