M4 Project: Autopsy Documentation Instructions

Penetrating stab wounds to abdomen and side:

The right upper abdomen has an entrance wound measuring 3.81cm X 3.3 cm. It appears the initial penetrating wound was caused by a sharp instrument with a clean entry. The instrument penetrated 11.4 cm into the abdominal and thoracic cavities. The anterior inferior liver is lacerated between the right and left lobes. The right hemidiaphragm is perforated. The gall bladder is lacerated. Tearing of the entrance site and internal organs suggests that once the instrument was inside the body, it was twisted and moved around. It appears that the instrument was partially removed and thrust in at a different angle causing more damage. The thoracic cavity contains approximately 100 ml of blood and the abdominal cavity contains approximately 500 ml of blood.

The right side (along the 10th rib) has an entrance wound measuring 3.81cm X 0.7 cm. It appears the initial penetrating wound was caused by a sharp instrument with a clean entry. The instrument penetrated 8.4 cm into the abdominal cavity. This wound is a single stab that went through the ascending colon below the juncture to the transverse colon and into the transverse colon past the juncture to the ascending colon.

Multiple superficial stab/slash wounds:

The back has a stab wound posterior to the midaxillary line. This stab wound penetrates into the muscle tissue 2.2 cm but failed to penetrate into the abdominal cavity.

The right dorsal forearm has a 7.5 cm slash wound. This is a superficial defensive wound. The right dorsal thigh has a 2 cm slash wound. This is a superficial wound.

Multiple contusions:

The right temple has a small laceration and a contusion. The contusion is semi-circular 5.5 cm. This is blunt-force trauma. The laceration had clotted and stopped bleeding before the fatal stab wound was administered.

The neck/throat area shows several contusions consistent with strangulation. There are also several contusions in various stages of healing (old injuries) that are consistent with prior strangulations. The larynx and trachea are intact.

Both wrists and the right arm above the elbow have contusions consistent with being forcefully grasped. There are also several contusions on both wrists in various stages of healing (old injuries) that are consistent with prior episodes of being forcefully grasped.

Gunshot wound: There is a superficial wound to the right thigh. This appears to have occurred first.

Ligature:

The victim's wrists were tightly secured together by a phone cord. The right wrist had a loop tied to it and then both wrists were looped three times. The ligature was then removed.

INTERAL EXAMINATION

CARDIOVASCULAR SYSTEM: The heart is 260 grams and has a normal distribution of epicardial fat. The coronary arteries are patent. The right coronary artery is dominant. The myocardium is tan­ red, firm, and has no scars. The left ventricle is 1 cm thick and 2 cm in internal diameter. The right ventricle is 0.3 cm thick and 3 cm in internal diameter. The tricuspid, pulmonary, mitral, and aortic valves are thin and pliable. The aorta is elastic and has a smooth intimal lining.

RESPIRATORY SYSTEM: The right lung is 550 grams and the left lung is 510 grams. The pleural surfaces are pink to dark red, firm, and congested. The larynx and trachea are patent and have tan, intact mucosa. The pulmonary vessels are patent.

HEPATOBILIARY SYSTEM: The liver is 1350 grams and has a smooth, tan-brown capsule. The parenchyma is tan-browµ and soft. The gallbladder contains approximately 5 ml =of dark green, viscous bile and no choleliths. The gallbladder mucosa is dark green and velvety.

RETICULOENDOTHELIAL SYSTEM: The spleen is 160 grams and has a purple, finely wrinkled, and intact capsule. The parenchyma is dark red and soft. The cervical, mediastinal, and abdominal lymph nodes are not enlarged.

GASTROINTESTINAL TRACT: The tongue has not bite marks or hemorrhage. The esophagus is line by tan, intact mucosa. The serosa of the stomach is tan-grey and glistening. The external surfaces of the intestines are tan-grey and have no palpable masses.

GENITOURINARY SYSTEM: The right kidney is 90 grams and the left kidney is 90 grams. The capsules are adhered to dark red, smooth cortical surfaces. The parenchyma is dark red and has well­ defined corticomedullary demarcation. The ureters have a normal course and caliber. The urinary bladder is empty and has intact mucosa. The uterus, fallopian tubes, and ovaries are unremarkable.

ENDOCRINE SYSTEM: The adrenal glands have well-demarcated cortices. The pancreas is tan and lobular. The thyroid gland is uniform and not enlarged.

HEAD: The skull has no fractures. The brain is 1210 grams. Epidural and subdural hemorrhage are absent. Coronal sections of the cerebrum and transverse sections of the cerebellum and brainstem reveal no neoplasm, hemorrhage, or necrosis.