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FACULTY OF MEDICINE AND HEALTH SCIENCES

UNIVERSITY PUTRA MALAYSIA

CASE WRITE-UP

NURSAIDAH BINTI MD SAID


136202
5th YEAR MEDICAL STUDENT
POST-MORTEM POSTING
SPK 3341
REPORT OF POST-MORTEM EXAMINATION

Post-mortem report number : P 47/11


Name of the deceased : Unknown
Identity card number : Unknown
Age : Adult
Sex : Female
Race : Malay or Indonesian
Date and time of death : Brought in dead on 29th January 2011 at 4.10am
Date and time of autopsy : 30th January 2011 @ 1120 hours
Place of autopsy : Mortuary of Hospital Kuala Lumpur
Medical Officer : Dr. Ahmad Hafizam bin Hasmi
MD
Forensic Department
Hospital Kuala Lumpur

History
(from the police)

Deceased body was accidentally knocked down by a car. At that time, she was running naked
along highway Jalan Istana – Seremban (fastlane). She wore a bra and the genitalia was covered
by her hands. She died at the place of accident. She was then brought in dead to Forensic
Department.

Clothing and Personal Effects

1. Middle-aged woman subject


2. Naked with bra on (Calvin Klein – gray colour)
3. Short hair and dun skin colour
External Examination

Height : 156 cm
Estimated weight : 59 kg
Chest : Normal contour with no injury
Build : Medium
Hygiene : Fair
Race : Malay or Indonesian by appearance
Tattoos, etc. : Nil
Hair : Straight black hair until below ear level
Eyes : Colour : Dark brown
Pupils : Fixed and dilated
Conjunctivae : Pale
Face : Normal but smeared with blood, dry leaves and dirt
Right mandible slightly deviated due to fracture
Mouth : Pale lips
Nose : Blood stained
Teeth : Natural dentition, all intact
Ears : Blood stained
Hands : Injury is described in the ‘Marks of Injury’ below
Finger nails : Short and trimmed, appeared pale
Feet : Injury is describe in the ‘Marks of Injury’ below
External genitalia : Normal adult female
Anus : No significant abnormality
Body temperature : Cold
Rigor mortis : Partially established
Postmortem hypostasis : Established
Marks of Injury

1. Laceration wound with comminuted fracture measured 10X4X3cm and brain material is seen
at parietal part of the skull.
2. Laceration wound 3X1cm at the left pinna.
3. Laceration wound 3X1.5cm with surrounding abrasion wound 6X5cm at forehead area.
4. Laceration wound 6X3cm with surrounding abrasion wound 3X6cm lateral to the left eye.
5. Laceration wound 2X1cm at the left cheek.
6. Abrasion wound 4X1cm below left angle of the mouth.
7. Right mandible fracture
8. 2 laceration wounds with measurement 1X0.5cm each at distal phalanx of middle and ring
finger of left hand.
9. Abrasion wound 5X4cm at left dorsal hand.
10. Bruises redness 20X10cm at the medial part of right thigh.
11. Superficial laceration wound at the upper part of anterior left thigh.
12. Bruises redness below the superficial laceration wound at the upper part of anterior left thigh.
13. 3 laceration wounds at lateral side of left thigh with measurement of 6X6cm, 14X5cm, and
7X2cm. The largest wound revealed cutting of the underlying muscles as well.
14. Tram line abrasion 17X10cm posterior part of left thigh
15. Superficial abrasion 4X0.5cm of the left buttock
16. Bruises redness measured 14X8cm at the medial part of left thigh
17. Abrasion wound and linear abrasion below the right knee.
18. Laceration wound with surrounding abrasion wound measured 10X4cm
19. Abrasion wound measured 17X3cm at posterior left thigh.
20. Tear with surrounding redness bruises at 6 o’clock of the vagina
21. Laceration wound at 7 o’clock of the vagina.
Internal Examination
Head:

Skull : Comminuted fracture of the skull base


Meninges : Dura mater severely torn.
Brain : Left lobe severely lacerated and macerated.

Mouth, Throat, and Neck Structures:

Tongue : Intact. No bite mark.


Thyroid : Appeared normal. No lesion or hemorrhage noted.
Larynx : Healthy. No fracture of hyoid bone and thyroid cartilages.
Carotids : Intact.
Cervical muscles : Normal. No contusion.
Cervical spine : Normal. No fracture noted.

Thorax:

Rib cage : All rib bones were intact. No fracture


Pleural cavities : Normal. No blood retained.
Trachea and : Presence of blood clot
air passages
Lungs : Right lung weighed 295g. No injury detected and cut section s
showed leopard skin appearance.
Left lung weighed 190g and injured. Cut section showed leopard
skin appearance.
Thymus : Atrophied.
Pericardium : Intact
Heart : The heart weighed 165g. All valves were normal and all three
major coronary arteries were patent. There was no evidence
of ischaemic changes and no subendocardial hemorrhage.
Aorta : No abnormality seen.
Pulmonary artery : No abnormality seen.
Esophagus : Intact and clean.

Abdomen

Peritoneum : Intact.
Stomach : Healthy. No significant abnormality detected. The stomach was
empty. No sign of gastritis or peptic ulcer disease.
Intestines : Healthy. No significant abnormality detected.
Colon : Healthy. No significant abnormality detected.
Rectum : Healthy. No significant abnormality detected.
Mesenteric nodes : Intact.
Liver : The liver weighed 730g. Uninjured. There were areas showing
liver discolouration or fatty liver.
Biliary system : Patent. Gall bladder was intact. No stones.
Pancreas : No abnormality detected.
Spleen : Grossly uninjured. It weighed 80g.
Adrenal glands : Right adrenal gland was intact
Left right adrenal gland showed evidence of bleeding.
Kidneys : Right kidney weighed 90g with perinephric hematoma
Left kidney weighed 90g and intact.
Ureters : Healthy and intact.
Bladder : Healthy and intact.
Reproductive : No gravid uterus and ovaries uninjured.
system
Musculoskeletal : Crushed fracture of bilateral pelvic bone and both ischial spines.
system Comminuted fracture of skull.
Laboratory Investigations

Specimen taken:
1. Blood for alcohol and toxicology
2. Urine for drugs screening, alcohol and toxicology

Results are pending.

Specimen taken for rapid test:


1. HIV : negative
2. Hep B : negative
3. Hep C : negative

Histopathology investigation
1. High vaginal swab
2. Low rectal swab
3. High rectal swab
4. Anal swab

Results are pending


Summary and Conclusions

1. The deceased was middle age lady brought in dead naked with the bra put on.
2. Multiple laceration and abrasion wounds found all over the body.
3. Comminuted fracture of cranium and brain material was seen through.
4. Left parietal lobe was lacerated and macerated.
5. Tear with surrounding redness bruises at 6 o’clock of the vagina and laceration wound at 7
o’clock of the vagina.

Cause of Death
Severe head injury
Discussion

An autopsy is defined as an examination and dissection of a dead body by a physician for


the purpose of determining the cause, mechanism, or manner of death, or the seat of disease,
confirming the clinical diagnosis, obtaining specimens for specialized testing, retrieving physical
evidence, identifying the deceased or educating medical professionals and students. 1 In the other
hand, forensic autopsy is defined as an autopsy performed pursuant to statute, by or under the
order of a medical examiner. Performance of a forensic autopsy is the practice of medicine.
Forensic autopsy performance includes the discretion to determine the need for additional
dissection and laboratory tests. A forensic autopsy must be conducted by a licensed physician
who is a forensic pathologist or by a physician who is a forensic pathologist- in-training
(resident/fellow). Responsibility for forensic autopsy quality must rest with the forensic
pathologist, who must directly supervise support staff. Allowing non-forensic pathologists to
conduct forensic autopsy procedures without direct supervision and guidance is fraught with the
potential for serious errors and omission.

Before performing a forensic autopsy, one should know what are the cases that should be
investigate by the forensic physician. The list below lists those cases that need to undergo
forensic autopsy; 1
• the death is known or suspected to have been caused by apparent criminal violence.
• the death is unexpected and unexplained in an infant or child.
• the death is associated with police action.
• the death is apparently nonnatural and in custody of a local, state, or federal institution.
• the death is due to acute workplace injury.
• the death is caused by apparent electrocution.
• the death is by apparent intoxication by alcohol, drugs, or poison.
• the death is caused by unwitnessed or suspected drowning.
• the body is unidentified and the autopsy may aid in identification.
• the body is skeletonized.
• the body is charred.
• the forensic pathologist deems a forensic autopsy is necessary to determine cause or
manner of death or collect evidence.

With regard to this case, the possible reasons that it undergo forensic autopsy are it is
associated with police action, the death is unwitnessed, to exclude possibility that the deceased
death is caused by criminal violence, and last but not least, to aid in identification of the
deceased.

As the history of the death is mentioned above, it stated that the deceased was found dead
apparently after being knocked down accidentally by a car.
In this case, there was laceration wound measured 10X4X3cm on the scalp with
comminuted fracture of the left and right parietal bone. Brain material also may be seen through
the wound. Besides, comminuted fracture of the coronal and sagittal sutures was also seen during
further external exploration. Lacerations of the scalp can lead to profuse haemorrhage and indeed
death can occur due to massive blood loss from a 'simple' scalp wound (Hamilton et al 2005),
which means that it is better not to underestimate scalp wounds. Regarding the skull fracture
(including the temporal, parietal, and occipital bones fracture), the presence of it does not,
however, determine survival, as it is the presence or absence of underlying damage to the brain
or its coverings that is important. Anatomically, the normal thickness of the skull is
approximately 4-15 mm (depending upon the site at which it is measured), and the presence of a
skull fracture is an indication that severe force has been applied to the skull. Fractures occur
when the elastic limit of the bone has been exceeded, and the formation of a skull fracture
depends upon the force applied, the point of impact (thickness of the skull), presence of scalp
hair and the direction of impact. Saukko and Knight (2004) reviewed the force required to cause
fractures of the skull. For classification of skull fracture, it can be divided into;
• Linear – straight or curved fracture lines, which may radiate from a depressed region, or
occur at a distance from the impact site, and tend to occur at ‘unsupported’ regions of the
skull (e.g. across the supra-orbital ridges). Linear fractures in children or young adults
may pass through the suture lines (‘diastatic fracture’). ‘Hinge’ fractures occur when the
linear fracture passes across the middle cranial fossa, separating the skull base into 2
halves, and may be caused by a heavy blow to the side of the head (e.g. in motorcycle
accidents).
• Ring – these occur in the posterior fossa around the foramen magnum, particularly
following a fall from a height (with primary ‘feet first’ impact), where the kinetic energy
transfer is transmitted up the cervical spine.
• Pond – this is a shallow depressed fracture, more common in infants.
• Mosaic (‘spider’s web’) – a comminuted depressed fracture with radiating fissures.
• Depressed – a fracture caused by force applied in a ‘focused’ area e.g. by a hammer. The
outer and inner tables of the skull are driven inwards, often causing damage to the brain
or its coverings. The shape of the fracture may indicate the type of weapon used.

In addition, we also encountered subarachnoid hemorrhage in this particular case. Trauma


resulting in cerebral contusion or laceration will also lead to damage of blood vessels beneath the
arachnoid. ‘Traumatic SAH’ is characterised by bleeding around the brainstem and in the
posterior cranial fossa, arising from the (usually) intra-cranial part of a vertebral artery or the
basilar artery.

Complication of skull fracture can be divided either into early or late complications. For early
complications, the most important and lethal is direct brain damage, and in addition, meningeal
hemorrhage. For late complications, it can be infection, post-traumatic epilepsy and post-
traumatic dementia. But, in this case, patient had a direct crushed injury of the left parietal lobe
as it was severely lacerated and macerated. Regarding brain damage, it can be either due to open
or closed head injury. In an ‘open head injury’, brain damage due to head injury may be caused
by direct intrusion into the skull by a weapon, bullet or bone fragment. In this condition, usually
the damage will be lacerated/ macerated in nature. In the other hand, 'closed head injuries' are the
result of a combination of relative movement of the brain within the skull, due to the angular
rotation and/or acceleration/deceleration forces, such as may be encountered in road traffic
collisions, falls or assault. Morphological markers of brain damage include contusions and
lacerations (tearing of the brain substance). For cerebral cortical contusion, it characterized by
area of multi-focal punctate or 'streak' haemorrhages associated with foci of necrosis, which tend
to be distributed along the crests of gyri. Contusions merge over time to form wedge-shaped
haemorrhages with their base at the cortical surface and their apex pointing into the sub-cortical
white matter.

I would like to comment regarding patient’s condition when she was found running on the fast
lane along the highway before be hit by a car. She wore only a bra and her hands covering the
genitalia. In the discussion, we agreed that normal person would not run naked in the public and
if she was having a psychiatry illness at that time, she would not cover her genitalia. So, she
might be sexually assaulted prior to the accident. Internal examination showed that she had
sexual intercourse as there was a tear and laceration wound at 7 o’clock the vagina. But, patient
also may willingly do the intercourse. However, there were bruises at the medial aspect of the
thigh which similar to rape case when someone force the victim to expose her vagina. Applying
much force and pressure towards alive human body will cause the blood vessel to rupture and
resulting in bruises formation.

References:

1. Forensic Autopsy Performance Standards, National Association of Medical Examiners,


N.A.M.E. Annual Meeting, San Antonio, Texas, October 16, 2006.
2. Kay A and Teasdale G (2001), 'Head injury in the United Kingdom', World Journal of
Surgery 25:1210-1220
3. National Institute of Clinical Excellence (NICE) (2003), 'Head injury: triage, assessment,
investigation and early management of head injury in infants, children and adults',
http://guidance.nice.org.uk/CG4/guidance/pdf/English
4. Adelson L (1974), 'The pathology of homicide', Charles C Thomas, Springfield USA
(http://www.ccthomas.com/details.cfm?P_ISBN13=9780398030001)