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Autopsy Example 1 (Page 1)

Autopsy Report


Identification No.: ___________
Autopsy No.: A91-21
Hospital No.:000046

Name: Doe, John
Service No.: ______
Ward No.:_________
Age: 70
Sex: Male
Race: White

Date and hour of death: 12/01/91 - 7:25 am
Autopsy performed: 12/01/91 - 12:30 pm
Check one: Full autopsy [x] Head only [ ] Trunk only [ ]
Prosector: Dr. Smith Assistant _____________


Clinical History

This 70 year-old Caucasian man was admitted to the hospital on November 14, 1991 because of a lesion of the large bowel with partial obstruction. He had a diagnosis of chronic lymphocytic leukemia many years ago treated with chemotherapy. Apparently he showed also bilateral pyelonephrosis and metastatic disease to iliac lymph nodes. The prostate was thought to be benign. His primary problem was in the upper urinary tract. X-ray examination of the colon showed diverticulosis. No definite nodes or masses. No gallstones. The esophagus was normal. The distal stomach showed mucosal thickening and deformity with a certain amount of fixation and rigidity probably due to prepyloric ulcer with ulceration raised on x-ray examination of the upper G.I. tract. X-ray examination of urinary tract showed Stage II-III hydronephrotic changes in both kidneys. The bladder was poorly defined. The ureters were not seen. The findings were consistent with an obstruction process in the lower urinary tract.

Laboratory Data:

November 16, 1991.
SMA-12: Glucose 235
Cholesterol 130
Total Proteins 5.7
Albumin 6.3
Alkaline Phosphatase 120

All other parameters within normal range.

WBC 3.7
RBC 4.80
Hgb. 15.4
Hct. 45.0
MCV 95
MCH 31.8
MCHC 33.9

Differential:

Segs 72
Lymphs 25
Monos 2
Eosins 1
Platelets adequate, RBC essentially normochromic with slight anisocytosis. Amylase 127, Glucose 117 mg% on November 20.

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