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Autopsy Example 2 (Page 1)

Department Of Pathology - Autopsy Report


Coroner's Case [ ] Yes [x] No


Unit Hospital No.: 000047
Necropsy No.: N91-2000

Name: Marty Gallstone
Age: 78
Race: White
Sex: Male

Admitted:

Date: 03/03/91
Hour: 1:00 pm
Ward: C400C
Service: Surgery

Died:

Date: 03/18/91
Hour: 4:15 am
Necropsied:
Date: 03/18/91
Hour: 9:30 am

Prosector: Harry O'Flexure, MD
Reviewer: Robert McSplenic, MD


Final Note:

This 78 y/o W M presented with jaundice, anorexia, and wt. Loss. The clinical impression was carcinoma of the head of the pancreas. BE revealed an obstructed area at the ascending colon - probably due to carcinoma of colon. UGI revealed a hiatal hernia. Liver scan was abnormal, being compatible with a central lesion. His bilirubin was 22.1; D/I = 17.3/4.8. His course in the hospital was increasingly downhill with increasing jaundice and obstruction. He later became unresponsive and died on 03/18/91. At autopsy he was found to have an adenocarcinoma of the gallbladder extending into the liver and to the (R) hepatic flexure of the colon with resultant colonic obstruction. No other metastases were found. His lungs were adenomatous and atelectatic, and several areas of fibrosis were found in the heart.

Provisional Gross Necroscopy Findings:

  1. Carcinoma hepatic flexure(R)colon (micro pending)
    1. Obtrusive jaundice
    2. Extension into liver
  2. Cholelithiasis, Biliary cirrhosis
  3. Aspiration pneumonitis with acute bronchitis, and pulmonary edema
  4. Benign nephrosclerosis, Chronic pyelonephritis

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