AUTOPSY PROCEDURE - A COMPREHENSIVE OVERVIEW OF PROCEDURES A completed autopsy permission form and the patient's chart are received at the Admitting Office, 9th Floor, University Hospital South. The body is placed in the morgue at University Hospital South, 1st Floor. Basic Science Building. The permit form and the chart are picked up at Admitting. Correct identification of the body and proper completion of the autopsy permission form are confirmed by the prosector. The responsibility for this is solely that of the person performing the autopsy. Any questions must be thoroughly resolved to the satisfaction of the prosecto before the autopsy is begun. The clinical record is reviewed. consultation with pathology staff should be obtained before the autopsy begins. The physicians who were caring for the patient are contacted by telephone so that the prosector may obtain their impressions and inform then when the autopsy will be done. External examination of the body, examination of internal structures in situ, and removal of organs for further examination are done. The body is cleaned, incisions are closed, and the body is wrapped and returned to the morgue Cold Room on the second floor of the Basic Science Building. Admitting is informed that the remains may be taken by the funeral director. Examinations of the organs is completed. Blocks of appropriate dimensions for microscopic examination are put in fixative. A clinical history and description of the gross findings are dictated and submitted for typing. The gross specimens are reviewed with a staff pathologist and provisional anatomic diagnosis is immediately submitted for typing. After adequate fixation, blocks for microscopic examination are placed in cassettes and submitted to the histology lab to be processed, embedded, sectioned, and stained. Microscopic sections are examined by the prosector, and a final diagnosis is prepared. The histology and final diagnosis are reviewed with a staff pathologist. A microscopic description and discussion of the case are dictated. The final diagnosis is submitted in writing for typing. Central nervous system examination is generally done after two week's fixation and a report, including microscopic description, is included in the autopsy report or added subsequently. AUTOPSY TECHNIQUE OUTLINE     The following outline is not meant to be an embellished checklist for performance of a postmortem examination. The suggested particular findings to be noted are meant to be only representative of things to look for. The outline is one method of doing the autopsy which has been satisfactory. Other good methods exist and, to some extent, the method must be tailored to the individual case. This outline has been written with respect to adult cases; different emphasis and methods apply to infants. Prosectors should consider the educational value of autopsies. This implies that they will: 1.    Regard each case as not routine. Prepare to vary the dissection according to the needs. The        history, the clinician or an initial finding after seeing the body or after making incision may        indicate that a particular examination should be performed. (Consider this and act        accordingly.) 2.    Photograph specimens of interest or of uncommon conditions. 3.    Preserve specimens of interest or of uncommon conditions appropriate preservative for        subsequent use at conferences or as mounted specimens for classroom use. (These two        actions may require that prosector interrupt or change the usual method of dissection.) 4.    Encourage visits to the autopsy room to ask and discuss the findings. This includes students,        residents or other physicians who may be interested. OUTLINE OF EXAMINATION OF THE BODY: External examination Examination of abdominal and thoracic organs Removal of abdominal and thoracic organs Examination of abdominal and thoracic parietes Examination of cranial cavity and removal of CNS Closing of body Dissection of the organs (Brain cutting) EXTERNAL EXAMINATION General: Embalmed?, length, estimated weight, phenotypic sex, apparent approximate age, state of nutrition, postmortem changes, tubes, catheters, other medical paraphernalia. Skin: Jaundice, pigmentation and discoloration, petechiae, purpura, angiomata, eruptions, nodules, ulcers, wounds or scars (surgical wounds or scars recorded carefully for location, size and age). Anus: Hemorrhoids, fissures. Head: Scalp (nodules, evidence of trauma, baldness pattern); ears (creased lobe, low set ears, bleeding); eyes (icterus, Kayser-Fleischer rings, size and quality of pupils); nose; mouth and teeth. Extremities: Absent digits, clubbing, splinter hemorrhages, Heberden's nodes, size and shape of joints, edema, calf diameters (if leg vein thrombosis is suspected), toenails, soles, and between toes if malignant tumor or unknown origin has developed. Chest: Breasts, shape of chest. Abdomen: Shape, venous pattern, palpable masses, hernias. Lymph Nodes: Postauricular, submental, cervical, supraclavicular, axillary, epitrochlear, inguinal. External Genitalia EXAMINATION OF ABDOMINAL AND THORACIC CAVITIES     Abdominal cavity: Thickness of anterior abdominal wall fat at umbilicus; peritoneal fluid amount, color, clarity; peritoneal adhesions; greater omentum for masses or other lesions; external inspection of (esophagus), stomach, duodenum, small bowel, and large bowel including appendix; position of spleen; extension of liver below costal margin in right midclavicular line and liver height in right mid clavicular line; pelvic organ locations and adhesions; hernias; peritoneal surfaces (calcifications, pus, fibrin, blood deposition).     Thoracic cavity: Amount and character of pleural fluid on each side; pleural adhesions; remove thymus or fat between thyroid and anterior surface of pericardium (inferior to innominate vein);pericardial fluid (amount, color, character), and adhesions; maximum transverse diameter of heart in situ; pulmonary artery opened and inspected for large thromboemboli; configuration of aortic arch and branches; (heart may be removed at this time by cutting pulmonary veins, and right pulmonary veins. If malformation of the heart is present or suspected, the configuration of the large vessels, especially pulmonary veins, should be carefully determined and often the heart and lungs and even liver left connected for demonstration of the abnormalities. In many cases of congenital heart disease, it is desirable to embalm the block of thoracic organs before dissecting them. Inspect thoracic duct and tie for identification if desired. REMOVAL OF ABDOMINAL AND THORACIC ORGANS     This technique is generally done in cooperation with the autopsy assistant. Long segments of arteries left for the embalmer are important for the funeral director. The tongue may be included in the organ block. The testes may be removed attached to the block by intact spermatic cords by delivering the testes through incisions which enlarge the internal inguinal ring. It is occasionally preferable to remove the mesentery and associated vessels along with the bowel in cases of vascular disease of the intestine. EXAMINATION OF THORACIC AND ABDOMINAL PARIETES     Inspect the cavity lining surfaces. Sample breast tissue. Inspect the breast plate. Collect bone marrow from a rib by compression sample at costochondral junction from allpediatric or fetal subjects. Remove a strip of vertebral bodies. Sample psoas muscle and related peripheral nerve. Sample skin. EXAMINATION OF CRANIAL CAVITY AND REMOVAL OF CENTRAL NERVOUS SYSTEM     After removal of the brain inspect the surface and external configuration. Gently remove any adherent clotted blood before the brain is fixed in formalin. Inspect vessels at the base of the brain. Remove pituitary (care is needed to remove the entire gland without deforming it). Inspect the lining surface of the cranial cavity. Examine the calvarial bone plate for thickness and check for areas of rarefaction by holding the bony plate to the light. If carotid artery disease is suspected test internal carotid arteries for patency by forcing water through them from the neck. Paranasal sinuses and internal ears may be removed by approach through the cranial cavity. CLOSING OF THE BODY Preparation of the body for the funeral director requires attention to the following:     1.    Identification tag on body.     2.    Long ties on carotid and subclavian arteries.     3.    Thorough cleaning of the skin with complete removal of blood. This             is especially important on the scalp, face, neck and hands where             gentle but complete cleansing is required.     4.    Cleaning and drying of the body cavities.     5.    Closing of incisions.     6.    Informing the admitting desk that the body may be picked up by the            funeral director.