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How to Draft an Autopsy Report

Dr. Cameron Wood asked you to complete particular sections of the draft autopsy report for Nick Herren. You should describe the condition of particular organ systems, re-prioritize the diagnoses under consideration, and summarize the circumstances surrounding the death. This Step-by-Step will help you complete the appropriate sections of the draft Autopsy Report as completely as you can at this point in the process.

You are not a medical professional, so you are not expected to use technical medical language beyond what you are able to handle and understand when writing your report. You should provide a thorough analysis that is clear and easy to follow.

 

Get Organized

1. Review the email from Dr. Wood. It may be helpful to print the email and highlight the important points. Make sure you understand what Dr. Wood is expecting you to do to complete this task.


2. Download and review the attachments from the email that Dr. Wood sent. Take time to review them and familiarize yourself with the documents.

   There are several attachments in the email from Dr. Wood and many resources to support you in this task. To help you understand what information is available and how it may be useful, start by referring to the Guide to Documents and Resources.

3. Familiarize yourself with autopsy reports . To get a better feel for the work Dr. Cameron is asking you to do, review the draft Autopsy Report paying particular attention to Dr. Wood’s annotations within the report. It may also be helpful to r eview excerpts from the sample autopsy report that Dr. Wood attached to the email, which can serve as a helpful example of the kind of analysis that is expected in an autopsy report.

   Keep in mind that although the Sample Autopsy Report is for a different case, the structure is the same in all autopsy reports. Read Dr. Wood’s comments (in the sample) to understand how the sample compares to the Herren case at this stage in the autopsy process. Get a sense for the technical language that medical examiners use when writing an autopsy report. Technical medical language is not necessary when completing your draft, but try to incorporate some technical terms (and fully explain their meaning) whenever possible.

   You may also refer to the Resources for the Guide to Writing Autopsy Reports, which has general information about the characteristics that medical examiners document in their autopsy reports, and the FAQs on Conducting Autopsies of the Heart ; of the Lungs; of the Brain for organ-specific details that may also be noteworthy. You may use these resources as you do your analysis and write your draft Autopsy Report.

4. Meet with your team and decide how you will collaborate to complete your work.


5. Contact your mentor with any questions about this task.

 

Evaluate autopsy photos

Dr. Wood has asked you to complete the sections of the draft Autopsy Report for the cardiovascular, respiratory and nervous systems (all of which relate to the differential diagnosis at this stage). Examine the provided images of the decedent’s organs so you can later write thorough descriptions of each organ system as part of your draft Autopsy Report.

1. Review the autopsy photos of the decedent’s heart, lungs, and brain that Dr. Wood attached to the email. Without prior experience doing this work, it will be difficult to recognize abnormalities in the organs at first. Refer to your Resources for relevant web sites, photographs, and FAQs (e.g., Conducting Autopsies of the Heart; of the Lungs; of the Brain) to help you understand what to look for. Also use the Resources to learn how to confirm or disconfirm the diagnoses in your prioritized differential.

   Compare each of the decedent’s autopsy photos to the corresponding photos of healthy and unhealthy organs listed in the Resources and in the FAQs.
   

   To unzip the NHerren_Autopsy_Photos.zip file, make sure you have WinZip software to help you open the file. Then find the zipped folder that you downloaded and double-click it. A window with the zipped files contents will open. You can then click Extract all files or drag the files out of the window to the desired location. If you choose to click extract all files, the files will be extracted (unzipped) in the same location as the original file. Double-click a picture to view it in the image viewing software of your choice.

Clicking a link to a photo in Resources or an FAQ will open a new browser window. Some of the links will take you to an image on an external website, while others will open a pop-up window containing the photo and some notes. If you have a pop-up blocker, make sure that it is either disabled or set to allow pop-ups from the Medical Detective web site.

To compare a photograph of the decedent’s heart to an example of a healthy heart, first open the folder where you saved the downloaded photographs from the decedent’s autopsy and double click the photo of the heart. Then, click the link for the photo of a healthy heart (in Resources or the Heart FAQ). Position the windows so you can compare them side by side. To avoid confusion, try not to open more than three or four windows at a time when comparing photos of organs.

You might find it helpful to save some images to your computer so you can view them when you do not have access to the internet. First, create a folder where you will save images for Task 2.4 Conduct Autopsy. To save an image, click the link to view the image. Then right-click the image and select “save image as”. Select the folder that you created, give the file a descriptive name and click “save.”

As you look at the photos, consider the following questions:

• What do the photos tell you (or not tell you) about the decedent’s condition (or possible disease) at the time of death? What similarities and differences do you see when comparing the decedent’s autopsy photos to photos of healthy and unhealthy organs? How do you explain any differences?
• Are your conclusions about the condition of the decedent’s organs consistent with your current theory(ies) about (and rankings for) the decedent’s cause of death?
• What conclusions can you make about the diagnoses in your current differential? (i.e., Which can you confirm or disconfirm?)
• What additional tests, if any, do you need to conduct to make a conclusive diagnosis, and why?
  


2. Take notes as you make your comparisons. In particular, note the normal and abnormal characteristics for each organ (heart, lungs, brain) as you evaluate each of the decedent’s autopsy photos. You may choose to organize your findings by diagnosis (e.g., myocarditis) and/or organ type (e.g., heart). Keep track of your notes so you can refer to them later as you write your descriptions of the health of each organ system for the draft Autopsy Report.

You may wish to use the Organ Worksheets for the heart, brain, and lungs that Dr. Wood attached in the email to capture your notes. The worksheets are diagrams of the organs that medical examiners use to document what they see (or don’t see) during an autopsy. You may use them if you like, and later you can incorporate your notes from the worksheets into the descriptions you write for the draft Autopsy Report.

You may refer to your Research Notes from Task 2.3 Prioritize the Differential Diagnosis to help you draw comparisons and make sense of your findings as you take notes and analyze the autopsy photos.

It can be hard to determine the texture of an organ by looking at a photo. For example, a lung may have an “airy” or “spongy” feel or a brain may feel “soft”. Some photos may not provide you with as much detail as you would be able to gather if you could touch and feel the organs for yourself. Do your best to make an educated guess about an organ’s texture by looking at the photos. The images you have to work with do tell you enough about the health of the decedent’s organs to be able to make a diagnosis.

Draft the Autopsy Report

Dr. Wood asked you to draft the following sections of the Autopsy Report:

• Cardiovascular system
• Respiratory system
• Nervous system
• Pathologic Diagnoses
• Opinion

1. Gather and organize your notes. Review the notes you took when evaluating the autopsy photos and organize them according to the sections they relate to in the draft Autopsy Report (noted above).

   Refer to your organ worksheets for specific details you noted about the normal and abnormal characteristics of the decedent’s organs. These details will be particularly helpful as you draft the sections for the cardiovascular, respiratory, and nervous systems in your report.

   Revisit your work from Task 2.3 Prioritize the Differential Diagnosis and note any findings from the Diagnostic Report and Research Notes that you may want to include in your draft autopsy report. For example, your “Prioritized Differential Diagnosis” should align with the Pathologic Diagnoses section of your Autopsy Report (although you may need to update it to reflect your latest research). Your earlier Research Notes may provide relevant data about contributing factors that you may include in your report. Often at this stage of the autopsy process, no pathologic diagnosis (i.e., definitive cause of death) can be determined because not enough information is yet known. In this situation, the Pathologic Diagnoses section serves as an updated differential diagnosis, which may need to be updated (since you submitted the earlier Diagnostic Report) based on findings from the organ examinations.

   The Opinion section is where you will “tell the story” behind the autopsy, so notes related to the circumstances surrounding the death will be useful here. At this stage, the Opinion section should also reflect your evolving rationale about the differential diagnosis/likely cause of death including what additional information you need (e.g., tests) and how you expect that data to inform the case. Clearly communicate your reasoning in detail so that your mentor may provide you with constructive feedback about your work.



2. Review your Resources to determine what information from your notes is most relevant to include in your draft report.

   The Guide to Writing Autopsy Reports in the Resources section provides useful information about the type of content, level of detail and overall description that you are expected to write for each section of the Autopsy Report.

   The FAQs on Conducting Autopsies of the Heart ; of the Lungs; of the Brain provide organ-specific details to include in your report.

3. Fill out thoroughly each required section of the draft Autopsy Report. As you draft your report, remember to document your findings in a way that is clear and easy to understand, and base it on the available information.

At this stage, the Autopsy Report is a working draft that you will share with your mentor so that you may receive feedback, and continue to update as you work through the remaining tasks in the case. The organ system sections should capture as much detail as possible about the conditions of the decedent’s organs as description only. Do not write conclusions about the descriptions until the Pathologic Diagnosis and Opinion sections.

Summarize your findings in the Pathologic Diagnoses and Opinions sections. The Pathologic Diagnoses should reflect either a revised prioritized differential diagnosis (if you are not yet able to confirm the cause of death), or rank the cause(s) of death and contributing factors in order of their significance (if you are able to confirm the cause of death). This section should also note which tests are pending, if any.

In the process of narrowing down your differential diagnosis and revising your theories about the cause of death, diagnoses that you rule as the cause of death may still play a role as a contributing factor.

The Opinion section should summarize the circumstances surrounding the death and (if you have not yet arrived at a conclusion about the cause of death) explain your rationale for your revised differential diagnosis. Include the reasoning behind any additional tests that you require to complete your diagnosis. If you were able to confirm the cause of death in the Pathologic Diagnoses section, then you should restate the cause of death and explain your rationale in detail along with your analysis of any contributing factors.

For general writing help, refer to the General Skills Resources link in the left menu.

Review your work.

Refer to your completed draft of the Autopsy Report.

1. Did you write a thorough description for each section that Dr. Wood asked you to draft including:
   
   • Cardiovascular system
   • Respiratory system
   • Nervous system
   
   
2. Did you write descriptions of the decedent’s cardiovascular, respiratory, and nervous systems in a way that thoroughly conveys the overall appearance of each organ system? For each section did you capture the appropriate level of detail about:
   
   
   • the outside of each organ, including overall appearance, texture, and any significant abnormalities?
   • the inside of each organ, including overall appearance, texture, and any significant abnormalities?
     
   
   
3. Did you draft as thorough an analysis as possible for each of the following summary sections given what you know at this point in the autopsy process:
   
   
   • Pathologic Diagnoses
   • Opinion
     


4. Does the Pathologic Diagnoses section capture:
   
   
   • If you are not yet able to determine the cause of death:
     1. A prioritized ranking of the most significant autopsy findings (e.g., gunshot wound to the chest)?
     2. An updated, prioritized list of the remaining possible diagnoses (i.e., differential diagnosis), if still relevant?
     
     
   • Or alternatively if you are able to determine the cause of death at this stage):
     1. A prioritized ranking of the cause(s) of death and any factors that may have contributed to the death.
     
     
5. Does the Opinion section capture the:
   
   
   • Current theories regarding the cause of death
   
   
   • Summary of circumstances, explaining the context of the death
   
   
   • (If you have not yet determined the cause of death) a detailed explanation of the current autopsy findings including:
     1. Diagnoses that have been ruled out at this point and why?
     2. Diagnoses that are still under consideration and why (i.e., why they have not yet been ruled out)?
     3. Of the diagnoses that are still in play, an explanation of the specific details you plan to look for (e.g., test results) as the autopsy progresses that will allow the remaining diagnoses to be confirmed or disconfirmed?
     
     
   • Or alternatively (if you are able to determine the cause of death at this stage), a detailed analysis of your conclusions about the cause of death and any contributing factors that may have contributed to the death.

 

Submit your work.

1. Make sure all team members sign off on the draft of the Autopsy Report.
   


2. Review the checklist located in the Submit your work section of this task and submit your work to your mentor.

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When referring to a Wikipedia resource, note that while Wikipedia is a valuable resource, unlike some other websites anyone can contribute to or modify the site (whether they're knowledgeable about the topic or not). As a result, the site is subject to constant change by questionable sources. Be sure to cross-check information on Wikipedia with other reputable sites to ensure accuracy.

Medical Process

Diagnostic Process - Describes the process that health care professionals typically use to determine, or diagnose, the cause of death.

Autopsy FAQ - An overview of the purpose of the autopsy and the specific components of the Autopsy Report. Note: This FAQ contains the same overview and autopsy report information as the Autopsy FAQ from the Linda Lawson case. The details related to gunshot cases have been removed, since they are not relevant to the Herren case.

Guide to Writing Autopsies – Guidelines for the appropriate content to include (or not include) when drafting your Autopsy Report.

Organ Weights and Measurements - Information on standard organ weights and measurements for an adult human male.

Interactive Autopsy – The steps of an autopsy including an interactive autopsy exesrcise.

Autopsy Procedure – A detailed description of autopsy procedures.

FAQ: Conducting an Autopsy of the Cardiovascular System – A description of the procedures to follow when examining the cardiovascular system during an autopsy; includes what to look for and how to confirm or disconfirm a diagnosis.

FAQ: Conducting an Autopsy of the Nervous System – A description of the procedures to follow when examining the brain during an autopsy; includes what to look for and how to confirm or disconfirm a diagnosis.

FAQ: Conducting an Autopsy of the Respiratory System – A description of the procedures to follow when examining the respiratory system during an autopsy; includes what to look for and how to confirm or rule out a diagnosis.

Autopsy Walkthrough - A visual step-by-step that explains the overall autopsy process.  It describes the stages a medical examiner follows when conducting an autopsy and documents each step with photographs from an actual autopsy.   Note: While this resource is quite useful, it is *optional*.  The images it contains show a human cadaver and may be too graphic for sensitive viewers.  

Brain

Anatomy and Function

Brain structure and function – An introduction to the brain, its main structures, and its cells.

How your brain works  -  A slideshow from the Mayo Clinic exploring the anatomy of the brain.

Photograph (from above) of a normal brain

 Photograph (from below) of a normal brain

Photograph of a normal brain (Section I)

Photograph of a normal brain (Section II)

Photograph of a normal brain (Section III)

Photograph of anormal brain (Section IV)

Photograph of a normal brain (Section V)

Photograph of a normal brain (Section VI)

Photograph of a normal brain (Section VII)

Photograph of a normal brain (Section VIII)

Intracranial bleeding – an overview of bleeding inside the skull.

Brain membranes (meninges) – An illustrated description of the three membranes that enclose the brain.

 Photograph showing a subdural hematoma with meninges labled. Click on the arrows on the photograph for more information.

Subarachnoid hemorrhage - An illustrated description of subarachnoid hemorrhage including causes, and risk factors. (Note: Though this source presents subarachnoid hemmorhage within a discussion of stroke, it is not typically classified as a type of stroke.)

Photograph (from below) of a brain with a subarachnoid hemorrhage from a ruptured aneurysm

Subdural hematoma – A detailed description of subdural hematoma including causes and symptoms.

A description of subdural hematoma including detailed illustrations of the brain membranes and the injury.

Photograph (from above) of a brain with a subdural hematoma

Photograph of a brain with the dura pulled back to reveal the veins that bridge the cerebral hemispheres

 

Brain-related Diagnoses

Brain Aneurysm - A comprehensive overview of brain aneurisms including causes, symptoms, and diagnosis.

Risk factors increasing chances of aneurysm

Aneurysm overview with illustrations – Answers to common questions about cerebral aneurysms.

Animated description of brain aneurysms – This narrated animation shows you how brain aneurysms develop and rupture.

Photographs (from below) of a ruptured berry aneurysm

Photographs (from below) comparing blood vessels with a ruptured berry aneurism to normal blood vessels in the Circle of Willis.

Illustration (from below) of a normal Circle of Willis  

Arteriovenus malformation (AVM) - A comprehensive overview of AVM including causes, symptoms, and diagnosis.

Risk factors increasing chances of AVM

Illustrated overview of AVM

Photograph of bleeding, abnormal vascular channels, forming a large cluster of vessels extending from the pial surface deep into the brain.

Photograph of an intraventricular and intracerebral hemorrhage due to a ruptured arteriovenous malformation

Photograph of a non-ruptured avm located in the cross-section of the brain shown in section II.

Photograph (from above) of an AVM on the surface of the brain. The yellow and purple coloring are due to the chemical treatment of the brain.

Black and white photograph (closeup) of an AVM on the surface of the brain. See figure 4 on the page.

Stroke - A comprehensive overview of stroke including causes, symptoms, and diagnosis.

Risk factors increasing chances of stroke - A description of the factors that increase your chances of having a stroke.

Illustrations of the brain and how it is affected by stroke.

The blood vessels of the brain and how they are affected by stroke.

Warning Signs of Stroke - includes videos of doctors discussing stroke in depth.

Stroke Statistics – Facts and statistics about strokes in the United States, Canada, and the world.

Photograph of bleeding due to stroke (Section IV)

Photograph of bleeding due to stroke (Section II)

Photograph of bleeding due to stroke (Section I)

Illustration (from below) of a normal Circle of Willis

Subarachnoid hemorrhage - An illustrated description of subarachnoid hemmorhage including causes, and risk factors. (Note: Though this source presents subarachnoid hemmorhage within a discussion of stroke, it is not typically classified as a type of stroke.)

Tumor - A comprehensive overview of brain tumors including causes, symptoms, and diagnosis.

Photograph of a tumor (Section I)

Photograph of a tumor (close up)

Head injuries - An overview of concussions including causes, symptoms, and diagnosis.

Concussion - A comprehensive overview of concussions including causes, symptoms, and diagnosis.

Concussion overview – A brief description of concussion including illustrations of the brain impacting the skull.

Risk factors increasing chances of concussion – A brief description of the conditions that increase the likelihood of concussion.

Photographs of a brain with a bruise and hemorrhage due to blunt head trauma (from below) and a cross-section equivalent to section II in the brain worksheet.

Photograph of a brain with a bruise and hemorrhage due to blunt head trauma (from above)

Photograph of a bruise, without bleeding, to the right inferior frontal lobe.

 

Heart

Anatomy and Function

Anatomy of the heart – A detailed, illustrated overview of the anatomy of the human heart.

Diagram of the heart – A labled, two-dimensional color illustration detailing the anatomy of the human heart.

Interactive 3-dimensional model of the heart – Use the “Exterior” and “Interior” menus to navigate through a variety of interactive models of the heart.

Heart function - A detailed description of how blood is pumped through the heart, including animations of bloodflow and valve function.

Photograph of a normal heart (front)

Photograph of a normal heart (back)

Photograph 1 of a healthy aortic valve in a normal heart.

Photograph 2 of a healthy aortic valve

Photograph 1 of a healthy tricuspid valve in a normal heart.

Photograph 2 of a healthy tricuspid valve.

Anatomy of the mitral valve with graphics including images of abnormal valves

Video tutorial of the mitral valve - A detailed review of normal mitral valve anatomy by two masters of cardiac morphology and pathology. Note that the heart has been preserved in formaldehyde.

Photograph of cross-sections of a normal heart

Photograph of a healthy pulmonic valve in a normal heart.

Photograph of a healthy mitral valve in a normal heart.

 

Diagnoses Under Consideration

Congenital heart disease - A comprehensive overview of congenital heart disease including causes, symptoms, and diagnosis.

Risk factors increasing chances of congenital heart disease

Heart arrhythmia – supraventricular tachycardia – A comprehensive overview of heart rhythm disorders including causes, symptoms, diagnosis, and risk factors.

Diagnosing arrhythmias – Describes the tests used and the challenges of evaluating heart arrhythmias.

Heart attack due to atherosclerosis - A comprehensive overview of atherosclerosis including causes, symptoms, and diagnosis. (Read all 4 pages.)

Risk factors increasing chances of heart attack - A description of the factors that increase your chances of having a heart attack.

Interactive illustration of the development and dangers of atherosclerosis

Photograph 1 of coronary arteries with atherosclerosis

Photograph 2 of coronary arteries with atherosclerosis

Photograph 3 of coronary arteries with atherosclerosis

Photograph 4 of coronary arteries with atherosclerosis

Photograph of cross-sections of a coronary artery with atherosclerosis

Photograph of normal coronary arteries

Hypertrophic cardiomyopathy (HCM) - A comprehensive overview of hypertrophic cardiomyopathy including causes, symptoms, and diagnosis.

Risk factors increasing chances of hypertrophic cardiomyopathy - A description of the factors that increase your chances of having HCM.

Photograph of a heart with hypertrophic cardiomyopathy

Photograph of a heart with hypertrophic cardiomyopathy compared with a normal heart

Photograph of cross-sections of a heart with hypertrophic cardiomyopathy

Myocarditis - A comprehensive overview of myocarditis including causes, risk factors, symptoms, and diagnosis.

Photograph of cross sections of a heart with myocarditis

Photograph of exterior of a heart with myocarditis

Lungs

Anatomy and Function

The structure and function of the lungs – An overview of the anatomy of the lungs and how breathing works.

Photograph of a normal lung. Small amount of black pigment is normal in industrial societies.

Photograph of normal lungs still in body cavity

Photograph of a normal pulmonary artery

Diagnoses Under Consideration

Pulmonary embolism (blood clot in lung) - A comprehensive overview of deep vein thrombosis and pulmonary embolisms including risk factors, causes, symptoms, and diagnosis.

Risk factors increasing chances of a pulmonary embolism - A list of risk factors mentioned for Pulmonary embolism in various sources.

Photograph of a pulmonary embolism (blood clot in lung)

Emphysema - An overview of emphysema including risk factors, causes, symptoms, and diagnosis.

Photographs of lungs of a light smoker: Image 1, Image 2, Image 3.

Photograph of a lung with emphysema

Drug Use

Abuse of stimulants – An overview of stimulant addiction and abuse including effects on the brain and body.

Energy drinks – Article exploring the effects of highly caffeinated energy drinks.

Teen drug abuse – An overview of teen drug abuse including types of drugs, statistics, risk factors, symptoms, and diagnosis.

Pathology of drug abuse - Describes the conditions and processes of Smoking, Alcoholism, Intravenous Drug Abuse, Oxycodone, Cocaine,Methamphetamine, GHB,Ecstasy, Anabolic-Androgenic Steroids

Ask the Experts

Under what circumstances is an autopsy conducted?

How will I conduct an autopsy in this rotation?

What happens to the body after an autopsy has been performed?