DICTATION OF CLINICAL HISTORY AND GROSS AUTOPSY FINDINGS     At the completion of the dissection a brief clinical history and a description of the gross findings should be submitted for typing. A provisional anatomic diagnosis must be submitted in writing upon completion of the dissection. CLINICAL HISTORY State the Following:     1.    Patient's full name     2.    Unit number     3.    Autopsy number     4.    Patient's sex and age     5.    Service where the patient was cared for     6.    Physician(s) requesting the autopsy     7.    Prosector's name     8.    Staff pathologist's name     9.    Date and time of death     10.  Date and time of autopsy Dictate a brief clinical history. This should not be more than 1/2 page in length, typed and single spaced. Example: The patient was admitted on 7/7/86 to the OHSU with chest pain. Electrocardiographic and serum enzyme studies confirmed the clinical diagnosis of an acute myocardial infarct. The patient was hypotensive for his hospital course of six hours. He dies on 7/8/86. His past medical history included adult onset diabetes mellitus, a transitional cell carcinoma of the urinary bladder treated by transurethral resection five years prior to admission with no known recurrence, and hypertension of several years' duration. More clinical details can then be added, in condensed form, in subsequent paragraphs. The importance of the gross description lies in the fact that it is the one record of the examination that must stand practically unchanged. The diagnosis can be changed by a reinterpretation of the evidence, and the microscopic description can be redone from the original or recut slices from the paraffin blocks, which are kept on file. These then are always subject to revision. There is only one opportunity to have a description of the gross findings--at or shortly after the post itself. If a tissue, area, or organ is normal, it is usually totally sufficient, and much desired, to state that it is simply "normal". In all cases except mature adults, one should always include, along with the weight of each organ, the weight of the same organ adjusted for age or stage of gestation (see subsequent tables). A logical protocol would be similar to the following: External Examination: "The body is that of (a, an) (embalmed, unembalmed) (well, poorly) developed (state of nutrition) (race) (sex) (type of build). Body length is _____ (centimeters of inches), estimated body weight _____pounds." Make a statement about the extent and severity of postmortem decomposition. Here it is necessary only to describe the abnormality of pertinence. One or two sentences can usually cover this in sufficient detail. It is also sufficient to say, "The head is normal, pupils are round and equal, the irises are _____ (color)". If no abnormalities are noted, one may say, "the nose, ears, jaws, neck, chest, abdomen, and extremities are normal". Note should be made of palpable organs and masses. Jewelry should be identified and described. Tags identifying the body as that of _____________should be identified and their location described. Section: Since a Y-shaped incision is routine, do not mention its use without specific indication. "Subcutaneous fat of the abdominal wall measures ____ cm in thickness." Describe the major cavities as to fluid content, adhesions, etc. It is sufficient to say, "The organs are in normal location and have normal relationships". Cardiovascular System: "The heart is _____ cm in maximum transverse diameter (unopened) and weighs _____ gm (opened and free of clots)." When giving organ weights of children always look up (see charts) and include in the dictation the normal organ weights for a child of this age or size. Then give the organ weights for a child of this age or size. Then give the valve circumference measurements in order in centimeters; thickness of right and left ventricular walls should be indicated; the state of the coronary arteries should be indicated in details if need be; and the presence or absence of myocardial infarction after section of the left ventricle should be indicated. following this, if nothing abnormal is noted, state the organ is normal. The condition of the aorta, inferior vena cava, renal arteries and veins should also be indicated under this section. Respiratory System: "The lungs weigh (right _____ gm), (left _____ gm." If the lungs are normal say so. State any pertinent negatives. Thoroughly describe areas of abnormal color, texture or other pathology; include mention of extent and distribution of lesions. Also state the condition of the trachea, bronchi, and pulmonary arteries. Liver and Gallbladder: The liver weighs _____ gm." It has a normal capsule and parenchyma. The gallbladder contains _____cc of type bile and is normal." This is sufficient dictation for liver and gallbladder if normal. Spleen and Lymph Nodes: "The spleen weighs _____ gm." Describe the capsule and parenchyma if abnormal. Lymph nodes: give the size and shape and description of cut surface if abnormal. Location is often pertinent with abnormal lymph nodes. Thymus: Describe as to color, consistency, and weight in pediatric cases. Gastrointestinal System: If it is normal, name and areas described (esophagus, stomach, small and large bowel including appendix) and so state. Pancreas: One need not weigh the pancreas, but merely state whether of normal size and color. The ductal system may be important; if so, describe it. Genitourinary Tract: The kidneys weigh (right _____ gm), (left _____ gm). They are of normal shape and on cut sections have normal cortices and medullae. The cortices measure _____ cm and the capsules peel easily. The pelves and vasculature are normal." One need not describe postmortem artifacts. As elsewhere, thoroughly describe the abnormalities. The prostate, testes, epididymis, vasa deferentia, spermatic cords, and seminal vesicles if normal, are normal. The same applies to the uterus, fallopian tubes, cervix, and ovaries. One need not state that the "prostate gland is slightly firm", "the testes appear slightly granular", or give similar nonpertinent normal description. Endocrine System: "The pituitary, adrenals, parathyroids, and thyroid gland all appear normal." The endocrine glands should be weighed only when there is indication; then the adrenals should be carefully trimmed of fat. Musculoskeletal System: State the nature of the musculature and whether normal: state if the bones cut with normal of abnormal softness, state whether they contain bone marrow which may be pale red, variable, etc. Head: A description of the scalp which is reflected should be made. This can be brief. The meninges should be described. If the brain is sectioned, it is sufficient to say " The cerebral hemispheres, cerebellum, pons, etc. are within normal limits." The blood vessels of the brain should also be described. NOTE: Although this is a markedly abbreviated form of autopsy dictation, if one concentrates on the PATHOLOGY present, the length will be sufficient and the description will be more pertinent, adequate, and much easier both to dictate and read. Photographs: There is much opportunity regarding both surgical and autopsy material to obtain valuable photographs. The specimen must be treated with care in dissection and preservation. In general, the sooner the photographs can be obtained, the better. The next two pages are an abbreviated form of the preceding. It may become useful, after the initial experiences with dictation, to refer to them for each case as a reminder list. Note that one should concentrate one's effort in description on the abnormalities - not the normal. DICTATION OF AUTOPSY FINDINGS Microscopic findings and diagnosis of an autopsy are subject to revision at any time. However, there is only one record of the gross findings, and for most of these findings only a single observation is possible. The following checklist does not mention nearly everything which will be necessary in every case. And it does include several details which are not required in many cases. The list may be used in order to remind one's self, when dictating, of things which are generally or routinely to be considered. They may be omitted, or described in far greater detail, as fits the case. Necessary Information: PROSECTOR: STAFF: IDENTIFICATION OF PATIENT: Name, accession number, unit number. CLINICAL SERVICE: PERMIT: Signed by (relationship). DATE AND TIME: of death; of autopsy DESCRIPTION External: Height, weight (infant; head circumference, crown-heel, crown-rump; placenta weight and dimensions; cord). Race, sex habitus, development and nutrition. Asymmetry. Lesions, distribution and number. Incisions; dimensions, state of healing. Tubes, in what positions. Genitalia. Primary Incision: Thickness of abdominal wall fat; musculature. Abdominal fluid (volume, type, color, opacity); positions and relations of organs; serosa (adhesions, exudate). Height of diaphragmatic domes (in relation to ribs in the midclavicular line). Thoracic cavity: air, fluid (in three cavities; volume, type, color, opacity); positions of organs, adhesions, exudate. Thymus. Lymph nodes. Cardiovascular System: Heart weight, transverse diameter, relative chamber sizes. Epi-, myocardium (discoloration, type and distribution, texture, thickness of walls); endocardial thickening, deformity, tear fusion; chordae. Coronary arteries; distribution of narrowing and/or occlusions; description of occlusive or intramural material (hemorrhage, thrombus, calcification, pale, dark, firm, soft, friable). Aorta and Major Branches: (aneurysms, tortuousity, occlusion, tear) veins. Respiratory System: Larynx, trachea, and main bronchi. Lungs (weights), pleura, parenchyma (consolidation, cavities); bronchi (content, distortion); vessels, including main pulmonary artery. Gastrointestinal System: Esophagus, stomach (content, erosions), small intestine, colon, appendix (autolysis extent and degree). Liver: Weight, color, texture, external and cut surfaces. Lobular markings, intra- and extrahepatic biliary, arterial and two venous systems. Gallbladder. Bile ducts. Pancreas: Texture, color, lobules, ducts. Ampulla. Urinary System: Kidneys: weight, surfaces, cortical thickness, medulla, calices, pelvis, vessels, perirenal fat and capsule. Female Genital System: Ovaries; follicles, cysts, corpora lutea. Tubes. Uterus; size, shape; myometrium, endometrium. Cervix. Male Genital System: Testes; size, position, cut surface, masses. Epididymis. Seminal vesicles and prostate; size, nodules, consistency. Endocrine System: Pituitary. Thyroid. Parathyroids. Adrenals (cortex, medulla). Head: Scalp, cranium, dura, leptomeninges. Brain; weight, symmetry, lesions. Vessels. Skeletal System: Bone (texture, osteoporosis). Marrow.