Autopsy – 2

November 9, 2017 History

EXTERNAL EXAMINATION The body is that of an adult white mail. The body has been in bombed. The head is normal cephalic. Their is gray hare distributed oyer the scalp. The ears are without legion. The nose is without legion. The eyes have been capped. The mouth has been sealed. At the right base of the neck their is a sutured embalming wound. The chest is symmetric and stable. The abdomen is rounded. Their is an old healed surgical wound between the umbilicus and the pubis in the midline. The scar expands to as wide as 8 cm and is associated with a ventral hernia that measures approximately 15 cm x 12 cm x 8 cm.

The upper extremities are without legion. Their is a yellow metal ring present on the 4th finger of the left hand. The lower extremities are well formed. The back is without legion. The external genitalia are adult male. The penis is uncircumcised. The testicles are descended into the scrotum and are without masses. Along the left hip their is a 25 cm in length recently healed surgical wound. INTERNAL EXAMINATION The body is opened by the usual Y-shaped incision, revealing approximately 5 cm of subcutaneous fat present at the level of the umbilicus. The ventral hernia sac is filled with yellow, clear, low-viscosity fluid.

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The walls of the hernia sack are shiny and trabeculated. The plural spaces are without abnormal accumulations of fluid. Fibrous adhesions are not present. The peritoneal cavity is smooth and glistening. Their are no abnormal accumulations of fluid. No significant fibrous adhesions are observed. RESPIRATORY SYSTEM The larynx is palpated in situ and is without legion. The trachea is patent and without legion. The major bronchi are well formed. The right and left lungs are heavy. The visceral pleura is smooth and glistening. Bilaterally the posterior aspects of both lungs are congested.

At the lateral base of the right lower lobe their is a 3 cm in diameter white metastatic tumor mass. In the right upper lobe and in the left upper and lower lobes, their are numerous small metastatic white tumors, none exceeding 0. 5 cm in diameter. The carinal lymph nodes are enlarged to approximately 3 cm in diameter and filled with gray tumor. The parenchyma of the lung reveals severe panlobular and centrilobular emphysema with extensive anthracotic pigmentation. CARDIOVASCULAR SYSTEM The pericardium is lightly adhesed to the surface of the heart. The pericardial space is obliterated by fibrinous adhesions.

These are easily broken. The heart appears slightly enlarged with dominance of the left ventricle. The myocardium is red and meaty. No evidence of scarring or past infarction is observed. The right atrium is well formed. The tricuspid valve is well formed and without legion. The sinus and conus of the right ventricle are well formed. The right ventricular free wall measures up to 0. 7 cm in thickness. The pulmonary valve is well formed. The pulmonary arteries fail to reveal blood clots. Their are 4 pulmonary veins which return to the left atrium. The mitral valve is well formed. The left ventricle is well formed.

The left ventricular free wall measures up to 2. 1 cm in thickness. The aortic valve is without legion. The coronary arteries are distributed over the heart in the usual fashion, and their is no significant atherosclerosis observed. The aorta runs the usual coarse and reveals only mild atherosclerosis. The great veins are without blood clot or other abnormality. The lymph nodes, right and left of the aorta, from the pelvic floor to the diaphragm are markedly enlarged, up to 5 cm in diameter, white, and filled with tumor. GASTROINTESTINAL SYSTEM The esophagus runs the usual coarse and is without legion. The stomach is well formed.

The small intestine and large intestine are well formed. The appendix is present and without legion. LIVER The liver is of the expected size, shape, and position. Glisson’s capsule is smooth and glistening. The hepatic parenchyma is slightly buttery in character but shows no evidence of metastatic tumor and no evidence of cirrhosis. The gallbladder is present in the usual position and contains approximately 70 mL of greenish-black viscid bile. No stones are observed. The extrahepatic biliary ducts are of the expected caliber and run the usual coarse. SPLEEN The spleen is enlarged and weighs approximately 400 g. The splenic capsule is intact.

The splenic parenchyma is read, meaty, and uniform. No metastatic tumor masses are observed. PANCREAS The pancreas is of the expected size, shape, and position and is without specific gross abnormality. ADRENAL GLANDS The adrenal glands are of the expected size, shape, and position. Both the cortices and medullae are well formed. THYROID GLAND The thyroid gland is palpated in situ and is without legion. UROGENITAL SYSTEM The kidneys are of the expected size, shape, and position. The capsules are smooth and glistening and strip with ease. The renal parenchyma is well formed. The cortex is greater than 0. 5 cm in thickness.

The pelvises and calices and pyramids are all well formed. The ureters run the usual course and are of the usual caliber. The bladder is contracted and trabeculated. The prostate appears to be about 20 g in wait and is gray and uniform. CENTRAL NERVOUS SYSTEM The central nervous system is not examined in this dissection. PROVISIONAL ANATOMIC DIAGNOSIS 1. Bilateral bronchopneumonia. 2. Malignant tumor of unknown primary, with metastases to: a. Periaortic lymph nodes. b. Left and right lungs. c. Carinal lymph nodes. 3. Passed history of bladder carcinoma. 4. Myocardial hypertrophy with left ventricular thickening. 5. Splenic hypertrophy.


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