External Examination at Autopsy
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EXTERNAL EXAMINATION - AUTOPSY
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DEFINITIONS
AUTOPSY – seeing for one self i.e. making a personal inspection
Pathological sense – dissection of the dead body to determine, through observation, the cause of death and nature of disease.
EXTERNAL EXAMINATION – ritual full of meaning and common sense.
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On the fabric of the human body
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On the Seats and Causes of Diseases
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PRELIMINARIES
Consent (hospital administrator (RMO/coroner) and relatives)
Identification of body Clinical details
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Should have a statement pertaining to retention of body parts/ organs
Get specific permission for an unusual examination (removal of eyes/limbs) even if signed as NO RESTRICTIONS
Make sure the case is not medicolegal, like delayed accidents, homicides, deaths after abortions, occupational diseases, suspicious cases of poisoning, deaths on table.
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Dictate as follows
Autopsy no, date and time Pathologists Name and designation Patient’s age (look for disparity) and sex State of body (built and nourishment) State any restrictions Final clinical diagnosis Clinical summary Height (crown to heel) Weight
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Dictate as follows
Rigor mortis Livor mortis Algor mortis Post mortem drying Body built Nourishment Edema Cyanosis Skin Nails
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RIGOR MORTIS
Rigor is tested by trying to lift eyelids, trying to depress the jaw and bending the neck and various joints of the body
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RIGOR MORTIS Primary flaccidity (till ATP remains) – rigor –
secondary flaccidity Secondary flaccidity due to onset of
putrefaction Mechanism (4-8 hrs, 24-48hrs) NYSTEN’S rule – doesnot appear in all
muscles simultaneously and both voluntary and involuntary muscles affected
Contraction of erector pilae – cutis anserina/goose flesh
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RIGOR MORTIS Commences in the heart (LV-RV-atria) , in sytole Diaphragm Skeletal musculature – first jaw, neck, face,
arms, lower extremities, last ankle joint Passes off in the same order Contraction of tracheal muscles causes white
dots on mucosa Postmortem intususception Iris – dilatation (postmortem) and then
contraction (rigor) Handling causes loss of rigor – patchy
distribution
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Factors affecting rigor
Age – absent in fetus, early and milder in children and old
Early onset, short duration – wasting diseases, strychnine poisoning
Late onset – asphyxia, hemorrhage, pneumonia, paralytic diseases
Increased duration – CO poisoning Less duration – bacterial infection d/t
early putrefaction Environment – cold – late onset, more
duration, heat – early onset, less duration
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CADAVERIC SPASM / INSTANTANEOUS RIGOR / CATALEPTIC RIGIDITY
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CADAVERIC SPASM
Muscles that were contracted during life become rigid immediately after death without passing into a stage of primary relaxation
Affects single group of voluntary muscles, frequently hands
Sudden death, excitement, severe pain, convulsions, strychnine poisoning
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LIVOR MORTIS
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LIVOR MORTISHypostasis
Mechanism Initially intravascular (can blanch), then
extravascular Begins 30 to 45 mins after death in
dependent parts, max in 6-12 hrs Can enlarge the extent of subcutaneous
hemorrhages, can mimick suboccipital hemorrhage
Initially cut on the area of livor shows delicate hemorrhagic dots showing transected congested vessels.
Not possible to distinguish from antemortem cyanosis
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BLANCHING TEST
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Colour is a shade of blue No livor – hemorrhage, anemia,
wasting diseases Red in bodies kept in moist
refrigeration – higher affininty for O2 Cherry red – cyanide, CO Methemoglobinemia – smoky green,
brown Hydrogen sulfide – black
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Tardieu spots develop in areas of lividity, such as this individual's shoulder area, as decomposing capillaries rupture.
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ALGOR MORTIS
Rectal temp falls @ 1 deg/hr Also inferior surface of
liver/EAC/nasal passages Time of death = n body tem – rect t / rate of cool Post mortem caloricity – stroke,
convulsions, strychnine poisoning, septicemia
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POST MORTEM DRYING develops when the eyelids are not completely shut, the areas of the sclera exposed to the air dry out, which results in a first yellowish, then brownish-blackish band like discoloration zonecholera, wasting dis
(Tache noire)
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DRYING
Skin is wrinkled and leathery Loosening of hair, apparent
lengthning of finger nails due to shrinkage of finger tips
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Body built and nourishment
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BODY BUILT
Gigantism – Hereditary/endocrine proportioned/dys Endocrine –
Pituitry - d/t excess GH acromegaly, gigantism
Hypogonadism – eunuchoid - klienfelter
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BODY BUILT
DWARFISM – hereditary / endocrine perfect/imperfect Hereditary – pygmies (primordial) sporadic (mutation)
achondroplasia
Endocrine – Hypothyroidism – cretinism Pituitary dwarfism – GH deficiency Gonadal dwarfism – Turner’s syndrome
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AchondroplasiaUpper arms and thigh shorterTrident handFace disproportionately largeSpinal stenosis, kyphosis
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TURNER SYNDROME
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Spinal deformities
Old ageChronic emphysemaRicketsOsteomalaciaAcromegalyTuberculosis
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Spinal deformities
Dislocation of hipsAscitesPregnancyPostural weakness
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Spinal deformities
Weakness/paralysis of muscles on one side – poliomyelitis, shortening of one lower limb
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NOURISHMENT
OBESITY Exogenous – food intake
Double chin and abdominal Endogenous - glandular
Cushing’s – truncal – moon face, buffalo hump, protuberant abdomen, thin extremities
Hypothyroidism – non pitting myxedema – eyelids, hands and tibia – hyaluronic acid infiltrn
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Complications of obesity
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NOURISHMENT
CACHEXIA Cancer TB Thyrotoxicosis Addison’s disease Anorexia nervosa Starvation
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EDEMA
Generalized and localized Pitting and non pitting
(lymphedema/myxedema)
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GENERALISED/ LOCALISED
GENERALISED Congestive heart failure Nephrotic syndrome Hypoproteinemia Cirrhosis
LOCALISED Filariasis Post operative Insect bites Vena caval syndromes
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CYANOSIS
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CYANOSIS
CENTRAL Conjunctive, mouth, nose, lips Pneumonia, chronic bronchitis, fallot’s,
shunts as in cirrhosis Associated with clubbing
PERIPHERAL Extremities, not associated with
clubbing Localised obstruction to blood flow like
raynaud’s, arterial obstruction, varicose veins
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Raynaud’s
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NAILS
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KOILONYCHIA
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FINGERS – MARFAN’S
DUE TO MUTATION IN FIBRILLIN I GENE
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SKIN PIGMENT DISTURBANCES
Hyperpigmentation Generalised
Jaundice, Addison’s, Hemochromatosis, chronic malaria
Localised Chloasma, Acanthosis nigricans
Hypopigmentation Albinism, vitiligo Fungal disease (tinea vericolor, pityriasis
alba), leprosy
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Signs of liver cell failure
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Hemochromatosis
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SKIN
Petechiae, ecchymoses Striae
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HAIR AND FACE
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HAIR
Loss – debilitating illness, malignancy, typhoid, male pattern baldness, alopecia, ringworms, thallium poisoning
Female distribution in male – portal cirrhosis, after castration
Hirsuitism – Male pattern hair in female – Cushing’s, ovarian tumors
Thinning and drying of scalp hair – myxedema
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Cicatrical alopecia male pattern baldness
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FACE
Hippocratic facies - A pinched expression of the face, with sunken eyes, hollow cheeks and temples, and relaxed lips, observed in one dying after an exhausting illness
Moon face – cushing’s Potter facies - oligohydramnios Mask like facies - parkinsonism Leonine facies - lepromatous leprosy
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•Potter's facies. •Parrot-beaked nose. Recessed chin. Epicanthic folds. micrognathia •Low set ears (helices often folded). •Hypertelorism.
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EYES
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EYES – POST MORTEM CHANGES Loss of corneal reflex – not reliable Opacity of cornea – cholera, wasting
diseases Flaccidity of eyeball – sunken Pupils – dilatation then constriction Retina – Kevorkian sign – shunting/tracking
of blood due to fall in bp Steady rise in K+ values of vitreous upto
100 hrs
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EYES
Exophthalmos Hyperthyroidism, myopia
Enophthalmos Cachexia, Horner’s syndrome
Cornea – Ulceration, opacity, Arcus senilis, Kayser-
Fleischer ring Sclera –
Icterus Blue sclera (osteogenesis imperfecta,
marfan’s)
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Horner’s syndrome – due to compression of ipsilateral thoracic /cervical sympathetic chain – miosis, enophthalmos, ptosis and loss of sweating on same side with loss of ciliospinal reflex
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Arcus senilis wilson’s disease
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ORIFICES
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Tongue
Geographic tongue – Vitamin B12 deficiency
Protuberant tongue – cushing’s
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THYROID
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LYMPH NODES – NECK, AXILLA AND INGUINAL
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NECK
Look for neck veins Prominence indicates RVF
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BREAST
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CHEST
Pectus carinatum aka alar chest Prominence of vertebral border of sternum
Pigeon Chest Nasopharyngeal obstruction, respiratory
disease Barrel Chest
Emphysema, chronic bronchitis Pectus excavatum
Occupational deformity, cobblers Rachitic Chest
Pigeon breast, keel breast, Harrison’s sulci, Verical grooves, Rickety rosary
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RIBS
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LIVER AND SPLEEN
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UMBILICUS
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Perinatal autopsy
Weights lung:heart=3:1 Brain : liver = 3:1 Liver:heart = 6:1 Adrenal:thymus:spleen = 1:1:1 OFC=CR Lanugo hair, poorly formed ear
cartilage, absent breast buds, undescended testis, rugose scrotum, palmar and plantar creases
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