EXTERNAL EXAMINATION AUTOPSY

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.

On the fabric of the human body

On the Seats and Causes of Diseases

PRELIMINARIES

Consent (hospital administrator (RMO/coroner) and relatives) Identification of body Clinical details

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.

Dictate as follows

Autopsy no, date and time Pathologists Name and designation Patients 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

Dictate as follows

Rigor mortis Livor mortis Algor mortis Post mortem drying Body built Nourishment Edema Cyanosis Skin Nails

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

RIGOR MORTIS

Primary flaccidity (till ATP remains) rigor secondary flaccidity Secondary flaccidity due to onset of putrefaction Mechanism (4-8 hrs, 24-48hrs) NYSTENS rule doesnot appear in all muscles simultaneously and both voluntary and involuntary muscles affected Contraction of erector pilae cutis anserina/goose flesh

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

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

CADAVERIC SPASM / INSTANTANEOUS RIGOR / CATALEPTIC RIGIDITY

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

LIVOR MORTIS

LIVOR MORTIS Hypostasis

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

BLANCHING TEST

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

Tardieu spots develop in areas of lividity, such as this

individual's shoulder area, as decomposing capillaries rupture.

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

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 brownishblackish band like discoloration zone cholera, wasting dis

(Tache noire)

DRYING

Skin is wrinkled and leathery Loosening of hair, apparent lengthning of finger nails due to shrinkage of finger tips

Body built and nourishment

BODY BUILT

Gigantism Hereditary/endocrine proportioned/dys Endocrine

Pituitry - d/t excess GH acromegaly, gigantism Hypogonadism eunuchoid - klienfelter

BODY BUILT

DWARFISM hereditary / endocrine perfect/imperfect Hereditary pygmies (primordial) sporadic (mutation)

achondroplasia

Endocrine

Hypothyroidism cretinism Pituitary dwarfism GH deficiency Gonadal dwarfism Turners syndrome

Achondroplasia Upper arms and thigh shorter Trident hand Face disproportionately large Spinal stenosis, kyphosis

TURNER SYNDROME

Spinal deformities

Old age Chronic emphysema Rickets Osteomalacia Acromegaly Tuberculosis

Spinal deformities

Dislocation of hips Ascites Pregnancy Postural weakness

Spinal deformities

Weakness/paralysis of muscles on one side poliomyelitis, shortening of one lower limb

NOURISHMENT

OBESITY Exogenous food intake

Double chin and abdominal Cushings truncal moon face, buffalo hump, protuberant abdomen, thin extremities Hypothyroidism non pitting myxedema eyelids, hands and tibia hyaluronic acid infiltrn

Endogenous - glandular

Complications of obesity

NOURISHMENT

CACHEXIA

Cancer TB Thyrotoxicosis Addisons disease Anorexia nervosa Starvation

EDEMA

Generalized and localized Pitting and non pitting (lymphedema/myxedema)

GENERALISED/ LOCALISED

GENERALISED

Congestive heart failure Nephrotic syndrome Hypoproteinemia Cirrhosis Filariasis Post operative Insect bites Vena caval syndromes

LOCALISED

CYANOSIS

CYANOSIS

CENTRAL

Conjunctive, mouth, nose, lips Pneumonia, chronic bronchitis, fallots, shunts as in cirrhosis Associated with clubbing
Extremities, not associated with clubbing Localised obstruction to blood flow like raynauds, arterial obstruction, varicose veins

PERIPHERAL

Raynauds

NAILS

KOILONYCHIA

FINGERS MARFANS

DUE TO MUTATION IN FIBRILLIN I GENE

SKIN PIGMENT DISTURBANCES

Hyperpigmentation

Generalised

Jaundice, Addisons, Hemochromatosis, chronic malaria Chloasma, Acanthosis nigricans

Localised

Hypopigmentation

Albinism, vitiligo Fungal disease (tinea vericolor, pityriasis alba), leprosy

Signs of liver cell failure

Hemochromatosis

SKIN

Petechiae, ecchymoses Striae

HAIR AND FACE

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 Cushings, ovarian tumors Thinning and drying of scalp hair myxedema

Cicatrical alopecia

male pattern baldness

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 cushings Potter facies - oligohydramnios Mask like facies - parkinsonism Leonine facies - lepromatous leprosy

Potter's facies. Parrot-beaked nose. Recessed chin. Epicanthic folds. micrognathia Low set ears (helices often folded). Hypertelorism.

EYES

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

EYES

Exophthalmos

Enophthalmos

Hyperthyroidism, myopia Cachexia, Horners syndrome Ulceration, opacity, Arcus senilis, KayserFleischer ring Icterus Blue sclera (osteogenesis imperfecta, marfans)

Cornea

Sclera

Horners 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

Arcus senilis

wilsons disease

ORIFICES

Tongue

Geographic tongue Vitamin B12 deficiency Protuberant tongue cushings

THYROID

LYMPH NODES NECK, AXILLA AND INGUINAL

NECK

Look for neck veins Prominence indicates RVF

BREAST

CHEST

Pectus carinatum aka alar chest

Prominence of vertebral border of sternum Nasopharyngeal obstruction, respiratory disease Emphysema, chronic bronchitis Occupational deformity, cobblers Pigeon breast, keel breast, Harrisons sulci, Verical grooves, Rickety rosary

Pigeon Chest

Barrel Chest

Pectus excavatum

Rachitic Chest

RIBS

LIVER AND SPLEEN

UMBILICUS

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