Autopsy A-***
Name: ***
Hospital #***
ADULT PROTOCOL
UCLA DEPARTMENT OF PATHOLOGY AND LABORATORY MEDICINE
AUTOPSY SERVICE
GROSS DESCRIPTION:
EXTERNAL EXAMINATION:
The body is that of a {LAB AP well-nourished/cachectic:28358}{Desc; male/female:11659} weighing approximately *** kg and appearing {LAB AP younger/older:28368} the stated age of ***years. Body length is
Lividity is {Desc; absent/mild/mod/sev:19437}, on the dependent portions of the body.
Icterus is {Desc; absent/mild/mod/sev:19437}.
Cyanosis is {Desc; absent/mild/mod/sev:19437}.
Edema is {ABSENT/FOCAL/GLOBAL:27723}.
The hair color is *** and the length is *** with (a normal distribution OR the characteristic male frontal balding pattern) OR The scalp is alopecic.
The pupils are {Desc; equal/not:12784} and measure *** mm and *** mm on the left and right sides, respectively.
The sclerae are {Lab AP white/icteric/discolored:27997}.
The ears are normally formed.
The nose is normally formed.
The mouth is unremarkable.
The external genitalia are normally formed for a {Desc; male/female:11659}.
Scars are noted: ***
Vascular lines are {PRESENT/ABSENT:12322780}______.
Tubes are { :19119} (state site).
There are no other findings on external examination OR:
______.
The usual Y-shaped thoracoabdominal incision (and U-shaped biparietal scalp incisions) are made.
PERITONEAL CAVITY:
The peritoneal surfaces are smooth and glistening.
The peritoneal cavity contains ***cc of {Lab AP clear/cloudy/yellow/serosanguineous:27870} OR blood.
The liver is normally configured and is anatomically normally situated.
The spleen is normally configured and is anatomically normally situated.
The appendix is in the {Lab AP quadrant/pelvis:28035}.
The stomach is externally {Lab AP unremarkable/distended:27871}.
The small intestine and large intestine are normally situated.
The mesenteric lymph nodes are {Lab AP inconspicuous/unremarkable/diffusely enlarg:27881}.
PLEURAL CAVITIES:
The pleural surfaces are smooth and shiny.
The right pleural cavity contains *** cc of {Lab AP clear/cloudy/yellow/serosanguineous:27870} OR blood.
The left pleural cavity contains ***cc of {Lab AP clear/cloudy/yellow/serosanguineous:27870} OR blood.
The lungs occupy 95% of their respective pleural cavities.
Each lung has a normal number of lobes.
PERICARDIAL CAVITY:
The pericardial surfaces are smooth and shiny.
The cavity is free from adhesions and contains *** cc of {Lab AP clear/cloudy/yellow/serosanguineous:27870} OR blood.
CARDIOVASCULAR SYSTEM:
HEART:
The heart weighs *** g and has *** pericardial fat. The situs is {solitus; inversus; ambiguus}. The configuration of the great arteries is ***{normal or describe}. There is no; left ventricular; right ventricular; biventricular dilatation and/or hypertrophy. The foramen ovale is patent/closed. The mural endocardium is translucent. There are no mural thrombi.The valves show no fibrosis, calcification, or myxomatous degeneration. There are no vegetations, perforations, or commissural fusion. The chordae tendineae are of normal length and thickness. The myocardium is brown and unremarkable without evidence of myocardial infarction, fibrosis, or fibrofatty infiltration. The coronary ostia are in the normal position. The coronary arteries are left/right dominant and exhibitno/mild/moderate/severe atherosclerotic narrowing.
The heart measurements are:
Tricuspid valve *** cm
Pulmonic valve *** cm
Mitral valve *** cm
Aortic valve *** cm
Right ventricular free wall *** cm
Left ventricular free wall *** cm
Interventricular septum *** cm
The aorta shows tortuosity, diffuse atherosclerosis, calcifications, aneurysmal dilatation OR, no abnormality.
RESPIRATORY SYSTEM:
LUNGS:
The right lung weighs ***g, the left *** g. On section after inflation fixation they are firm/fluid filled/foamy/hemorrhagic. The pulmonary vasculature is free of thrombi. The trachea and major bronchi are lined by shiny/hyperemic mucosa, their lumens contain ***.
HEMATOPOIETIC SYSTEM:
The spleen weighs *** g. The capsule is {Lab AP dusky/shiny:27896}. On section the parenchyma is soft and deep red. The white pulp is visible and unremarkable.
The lymph nodes are tan and soft.
Bone marrow is red and {Desc; firm/soft:30687}.
GASTROINTESTINAL SYSTEM:
The mucosa of the esophagus is shiny/ulcerated and its lumen contains ***.
The mucosa of the stomach is slightly injected/unremarkable and its lumen contains ***.
The mucosa of the small intestine is unremarkable and its lumen contains clear/green tinged mucosal material.
The mucosa of the large intestine is unremarkable and its lumen contains soft stool.
LIVER:
The liver weighs *** g.
The capsule is shiny.
On section the parenchyma is{tan homogenous soft fibrotic:28390}.
The bile, which is green, is freely expressed from the gallbladder into the duodenum. Nocalculi are noted.
PANCREAS:
The pancreas is tan and coarsely lobulated. On section the duct is unremarkable.
ENDOCRINE SYSTEM:
ADRENALS:
The weight of the adrenals is: right *** g, left *** g. They are normally shaped. The cut surfaces reveal golden yellow peripheral zones and gray central zones.
GENITOURINARY SYSTEM:
KIDNEYS:
The weight of the kidneys is: right *** g, left *** g.
The renal arteries and veins are free from thrombi. The capsules strip {Desc; easily/with difficulty/incompletely:30636}. The renal surfaces are{Lab AP Smooth/Granular/Pitted/Scarred:28392}.
On section the cortical-medullary junction is normal, blurred, accentuated. The renal pelvises and ureters are lined by a shiny mucosa.
BLADDER:
The mucosa of the bladder is shiny and the wall is of normal thickness. The relations at the trigone are normal.
GENITALIA:
The prostate is {DESC; NORMAL/ENLARGED:19674}, rubbery, and reveals dense, pale ({coat color:21681}) whorls on section. The testes are {Lab AP unremarkable/atrophic:28393}.
OR
The vaginal mucosa is unremarkable. The uterus, tubes and ovaries reveal {Lab AP gross abnormality/atrophic:28401}.
ORGANS OF THE NECK:
The thymus is not identified or weighs approximately *** g.
The thyroid is normally shaped externally and is slightly nodular on section.
The larynx is injected but otherwise reveals no gross abnormalities.
*** parathyroids are identified and appear {DESC; NORMAL/ENLARGED:19674}.
BRAIN AT AUTOPSY:
The brain weighs *** grams. A detailed neuropathology evaluation is reported separately.
MUSCULOSKELETAL SYSTEM:
BONES:
The vertebral bodies are normally formed; the joint spaces are unremarkable.
No other bones are examined.
NOTE: See Table I for weights and measurements
MICROSCOPIC BLOCK NUMBERS: ***
SPECIAL STUDIES
***
Table I. Weights and Measurements(normal value dependent on body size, gender, and presence of cachexia or obesity).
Actual Measurement / Normal MeasurementBODY WEIGHT / *** / kg
BODY LENGTH / *** / cm
PUPIL, RIGHT / *** / mm
PUPIL, LEFT / *** / mm
HEART / *** / 1.9 x height – 2 (± 40)[g] (M) OR
1.8 x height – 22 (± 30) [g] (F)
tricuspid valve / *** / 12 cm
pulmonic valve / *** / 8.5 cm
mitral valve / *** / 10 cm
aortic valve / *** / 7.5 cm
left ventricle / *** / < 1.5 cm
right ventricle / *** / 0.3 - 0.4 cm
LUNG, RIGHT / *** / 450 g
LUNG, LEFT / *** / 375 g
SPLEEN / *** / 125 - 195 g or 0.15% BW
LIVER / *** / 1200-1500 g or 2-3% BW
KIDNEY, RIGHT / *** / 125 - 170 (M) 115 - 155 gm (F)
KIDNEY, LEFT / *** / or 0.15% BW
ADRENAL, RIGHT / *** / 7 g (excluding adipose tissue)
ADRENAL, LEFT / *** / 7 g (excluding adipose tissue)
TESTIS, RIGHT / *** / 20 - 25 g
TESTIS, LEFT / *** / 20 - 25 g
THYROID / *** / 10 - 22 g
BRAIN / *** / 1200 - 1400 g
PERITONEAL FLUID / *** cc {Lab AP clear/serous/serosanguineous fluid:27883}
PLEURAL FLUID, RIGHT / *** cc {Lab AP clear/serous/serosanguineous fluid:27883}
PLEURAL FLUID, LEFT / *** cc {Lab AP clear/serous/serosanguineous fluid:27883}
PERICARDIAL FLUID / *** cc {Lab AP clear/serous/serosanguineous fluid:27883}