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How to Update the Autopsy Report to Incorporate the Microscopic Examination and Toxicology Evidence

Dr. Cameron Wood asked you to update particular sections of the draft Autopsy Report to incorporate your findings from the microscopic examination and the toxicology report and to update your conclusions, if needed, regarding the cause of death. First, you should determine the condition of the decedent’s heart and brain based on your examination of tissue from those organs. Then, you should consider the results of the toxicology tests before updating your draft of the Autopsy Report with any new conclusions.

Your goal is to document your microscopic examination, update the diagnoses under consideration, draw appropriate conclusions about the cause of death, and provide detailed evidence to support your findings. This Step-by-Step Guide will help you complete the appropriate sections of the draft Autopsy Report as you make observations about the microscopic tissue slides and the toxicology report.

You are not a medical professional, so you are not expected to use technical medical language when writing your report. Without necessarily using technical terms, 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 for you 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.
   
   To unzip the NHerren_Tissue_Slides.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.


3. Get a sense of where you are headed in this task. Before you begin your analysis, it may be helpful to r eview excerpts from a sample autopsy. Review the Sample Autopsy Report (2nd draft) from the Lawson case which Dr. Wood provided for you. Familiarize yourself with the sample to get a feel for the kind of analysis you need to do as you consider Nick Herren’s cause of death and work on your second draft of the Autopsy Report.
   
   Sections of the sample autopsy report include comments from Dr. Wood to help you in comparing the sample case to the Herren case as you update your draft Autopsy Report.


4. Revisit the Pathologic Diagnoses and Opinion sections of your initial draft of the Autopsy Report. Refresh your memory of your current theories about the decedent’s cause of death.


5. Meet with your team to decide how you will complete your work.


6. Contact your mentor with any questions about your assignment.

 

Evaluate the latest autopsy data (microscopic slides of organ tissue and toxicology report)

Dr. Wood asked you to complete/update the Microscopic Examination, Pathologic Diagnoses, and Opinion sections of your draft Autopsy Report for the Herren case. Examine the decedent’s tissue slides and read the toxicology report so you can later record your observations and conclusions in your updated draft of the Autopsy Report.

1. Review the microscopic tissue slides of the decedent’s heart and brain that Dr. Wood provided in the email. It will be difficult to recognize abnormalities in the tissue slides at first. Refer to your Resources for relevant web sites, photographs, and FAQs (e.g., Conducting Autopsies of the Heart; of the Brain) to help you determine what to look for to confirm or disconfirm the diagnoses in your prioritized differential.


2. Compare each of the decedent’s tissue slides to the corresponding examples of healthy and unhealthy tissue that you can find in the Resources.

   Dr. Wood gave you tissue slides for the decedent’s heart and brain. You can view four different magnifications of the tissue slides – 2x magnification, 4x magnification, 10x magnification, and 20x magnification. The higher the magnification, the closer you “zoom in” and see a close-up view of a specific area of the slide. You can “zoom out” by looking at lower magnifications, such as 2x and 4x, which will give you a wider view of the tissue.

   Be sure to compare slides at the same magnification. For example, you should compare the decedent’s brain tissue at 10x magnification with normal brain tissue at 10x magnification.

   Organize your tissue slide images so you can compare them more easily. One way of viewing examples right beside the decedent’s slides is to view them in the “Slide Sorter” view in PowerPoint. To do this, download the tissue_slides.ppt file in Resources . Open the file in PowerPoint and click “View” in the menu tab at the top, and select “Slide Sorter.” Resize the PowerPoint window by dragging the right lower corner inward, so that it shows only four slides per row.

Each row will be a separate set of slides arranged in order from 2x magnification to 20x magnification. This display should make it easier for you to compare slides. For example, the first row will have four normal heart tissue slides. The second row of slides will be the decedent’s heart tissue slides. To compare the 2x magnifications, compare slide 5 with slide 1 which will be above and below each other in the first column.

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

• What, if anything, do the tissue slides tell you about the decedent’s condition (or possible disease) at the time of death? What similarities and differences do you see when comparing decedent’s tissue slides to examples of healthy and unhealthy tissue slides ? 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?


3. Take notes as you make your comparisons. Note the normal and abnormal characteristics as you evaluate each of the decedent’s tissue slides. 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 complete the Microscopic Examination section and update the Pathologic Diagnoses and Opinion sections of your draft Autopsy Report.

Refer to the Guide to Writing Autopsy Reports in the Resources section, which has general information about the characteristics that medical examiners document in their autopsy reports, and the FAQs on Conducting Autopsies of the Heart and of the Brain for organ-specific details that may also be noteworthy.

The study of tissue slides is called “histology.” Before you can examine the tissue, the lab must process it so that the microscopic details are easier to observe. Lab technicians stain tissue samples with chemicals during the process so that the tissue is easier to study. Hematoxylin and eosin (abbreviated H&E) are the most commonly used stains in histology and histopathology. Hematoxylin colors nuclei blue, eosin colors the cytoplasm pink.

 

Draft the Autopsy Report

Dr. Wood asked you to complete/update the following sections of the Autopsy Report:

• Microscopic Examination
• Pathologic Diagnoses
• Opinion

1. Gather and organize your notes. Review the notes you took when evaluating the tissue slides.


2. Review your Resources to determine what information from your notes is most relevant to include in your draft report. See below for tips on what documents to review.

   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 is expected for each section of the Autopsy Report.

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

   The Sample Autopsy Report (2nd draft), provided by Dr. Wood, serves as a helpful example of the kind of analysis that is expected. This sample is based on the autopsy conducted for the Linda Lawson case.

   Refer to your own draft of the Autopsy Report (i.e., the template that Dr. Wood provided in Task 2.4 Conduct Autopsy that you have already submitted once for review). Review the sections of your template that correspond to the sections you were asked to complete for this task (i.e., Microscopic Examination, Pathologic Diagnoses, and Opinion). Note any comments that Dr. Wood made within the draft report about how to approach those sections. Also get a sense of the technical language that is used by medical examiners by reviewing the sections of the report that were completed by Dr. Wood’s assistants. Technical medical language is not necessary when completing your draft, but you may incorporate some technical terms and explain their meaning. If you try to use the terms you may learn them better.

3. Write thorough descriptions for 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 based on the information that is available.

Remember that the Autopsy Report is a working draft that you will share with your mentor, receive feedback on, and continue to update as you work through the remaining tasks in the case. At this stage, the report should be nearing completion, but is not yet final. For example, you may have reached a conclusion about the cause of death or have narrowed it to a short list of possibilities. While it may not yet be a polished and finished document, this version of your draft should be much closer to that end goal.

The Microscopic Examination section should capture as much detail as possible about the health of the decedent’s organs based on your analysis of the tissue slides. You should update your earlier findings in the Pathologic Diagnoses and Opinions sections based on the new conclusions you made when reviewing the slides.

The Pathologic Diagnoses should reflect the most significant findings (prioritized) about the likely cause of death and note the diagnoses that remain in consideration (in order of likelihood). If you have enough data to draw a definitive conclusion about the cause of death you may do so, prioritizing your conclusions as appropriate. The Opinion section should summarize the circumstances surrounding the death and explain your detailed rationale behind the Pathologic Diagnoses you provided, including the reasoning behind any diagnoses you were able to confirm and disconfirm.

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:
   • Microscopic Examination?
   • Pathologic Diagnoses?
   • Opinion?
   
   
2. Did you complete the Microscopic Examination section in a way that thoroughly describes your observations and conclusions about the tissue slides?


3. Does the Pathologic Diagnoses capture:
   • an updated, prioritized list of the remaining possible diagnoses (if you cannot yet make conclusions about the cause of death) ?
   • the cause of death (listed first), followed by contributing factors in the order of significance or likelihood (if you are able to draw such conclusions at this point)?
   
   
4. Does the Opinion section capture the:
   • Current theories regarding the cause of death?
   • Summary of circumstances explaining the context of the death?
   • Detailed explanation of the latest 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 regarding specific details to look for as the autopsy progresses, that will allow the remaining diagnoses to be confirmed or disconfirmed?
     4. Significant findings from the analysis of the decedent’s microscopic tissue slide(s) when compared to normal and abnormal organs and tissues?

Submit your work.

1. Make sure all team members sign off on the updated 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.

NOTE: You may refer to Resources from earlier tasks as needed to complete your research.

Tissue Slides - Use this PowerPoint file containing Nick Herren's tissue slides and the slides of normal and abnormal tissues to compare images more easily. (See the tip listed under Step 2 of the heading Evaluate the Latest Autopsy Data in the Step by Step Guide for ideas on how to use this tool)

 

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.

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.

Histopathology - Wikipedia overview of histology

Histology - Wikipedia overview of histology

Histology Technique - describes and illustrates the processes involved in making a microscopic glass slide from tissues examined in the pathology laboratory

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.  

Microscopic Tissue Slides

Heart Tissue

Normal

Image of normal heart tissue (2x magnification)

Image of normal heart tissue (4x magnification)

Image of normal heart tissue (10x magnification)

Image of normal heart tissue (20x magnification)

Hypertrophic Cardiomyopathy (HCM)

Image of HCM heart tissue (2x magnification)

Image of HCM heart tissue (4x magnification)

Image of HCM heart tissue (10x magnification)

Image of HCM heart tissue (20x magnification)

Myocarditis

Image of heart tissue with myocarditis (2x magnification)

Image of heart tissue with myocarditis (4x magnification)

Image of heart tissue with myocarditis (10x magnification)

Image of heart tissue with myocarditis (20x magnification)

Brain Tissue

Normal

Image of normal brain tissue (2x magnification)

Image of normal brain tissue (4x magnification)

Image of normal brain tissue (10x magnification)

Image of normal brain tissue (20x magnification)

Arteriovenous Malformation (AVM)

Image of brain tissue with AVM (2x magnification)

Image of brain tissue with AVM (4x magnification)

Image of brain tissue with AVM (10x magnification)

Image of brain tissue with AVM (20x magnification)

Stroke

Image of brain tissue with stroke (4x magnification)

Image of brain tissue with stroke (10x magnification)

Image of brain tissue with stroke (20x magnification)

Tumor

Image of brain tumor (4x magnification)

Image of brain tumor (20x magnification)

Trauma

Image of brain tissue with trauma (4x magnification)

Image of brain tissue with trauma (10x magnification)

Image of brain tissue with trauma (20x magnification)

 

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 Expert

What should I look for when examining microscopic slides?

How long does an autopsy usually take to complete in real life?