Autopsy: Clinical Hx

1. Requisitions = previous specimens that were resected could provide clues to death

2. EMR (electronic medical record) = should contain a complete history of present illness and any previous procedures

3. Medical/dental records

4. Patient’s physician/dentist = can contact treating physician prior to performing the autopsy; ask if there are any particular questions they would like addresses or concerns they had; can also invite them to the autopsy or let them know when the organ showing will be

5. Family interviews = could provide idea of circumstances surrounding the immediate death

6. Scene report/authorities (forensics) = provide information that you wouldn’t know otherwise

   1. Sometimes all the info in the world won’t tell you about freak occurrences or behaviors!!

Identify common routes to obtaining a patient’s clinical history (6)

1. EMR may not be available (e.g. forensic autopsies)

   1. Only as good as what is in it!

2. Patient may not have a medical history

3. Requisitions may be sloppy or have errors

4. Patient may have no known ID at time of autopsy

5. Lack of understanding of medical terms or conditions

Describe potential barriers to PA’s learning about a patient’s clinical history (5)

1. developing a plan → know what to expect

2. QA → correlating chart to real life

3. getting consent → proper next of kin

4. CPS → detailed report/COD

5. writing a death certificate

6. risk assessment → protecting yourself and others

Discuss the importance of correlating clinical history to pathological findings during an autopsy (6)

1. Gives background information and details that could help determine what led the patient to die

2. Know what to look for - “create plan”

3. Previous surgeries and what the patient may have removed

4. Knowing meds for tox report

5. Differentials for COD/manner (depression medications)

6. Protect ourselves (prion disease, hep, hiv)

Recognize the benefits of having a complete clinical history (6)

avoid confirmation bias; fine tooth comb - very thorough examination

Benefits of having no clinical history at autopsy