Download pdf - Omaree Autopsy Report

CAUSE OF DEATH

Blunt trauma

MANNER OF DEATH

Homicide

DEATH INVESTIGATION SUMMARYCase Number: 2013-06715

VARELA, OMAREE

Sam Andrews MD FRCPCAssociate Medical Investigator

Odey Ukpo MD Forensic Pathology Fellow

All signatures authenticated electronicallyDate: 3/7/2014 4:50:48 PM

County Pronounced: BernalilloLaw Enforcement: APD Criminalistics

Agent: Chad StuartDate of Birth: 2/3/2004

Central Office Investigator: Daniel WaskoDeputy Field Investigator: Daniel Wasko

Pronounced Date/Time: 12/27/2013 5:32:00 PM

Report Name: Death Investigation Reporting ToolPrinted: 3/25/2014 11:45:49 AM

Death Investigation Report Page 1

DECLARATION

The death of VARELA, OMAREE was investigated by the Office of the Medical Investigator under the statutory authority of the Office of the Medical Investigator.

I, Sam Andrews MD, FRCPC a board certified anatomic, and forensic pathologist licensed to practice pathology in the State of New Mexico, do declare that I personally performed or supervised the tasks described within this Death Investigation Summary document. It is only after careful consideration of all data available to me at the time that this report was finalized that I attest to the diagnoses and opinions stated herein.

Numerous photographs were obtained along the course of the examination. I have personally reviewed those photographs and attest that they are representative of findings reported in this document.

This document is divided into 10 sections with a final Procedural Notes section:

1. Summary and Opinion

2. External Examination

3. Medical Intervention

4. Postmortem Changes

5. Evidence of Injuries

6. Internal Examination

7. Neuropathology

8. Microscopy

9. Radiography

10. Peer Review

Should you have questions after review of this material, please feel free to contact me at the Office of the Medical Investigator (Albuquerque, New Mexico) - 505-272-3053.

Report Name: Death Investigation SummaryPrinted: 3/25/2014 11:45:50 AM


Medical Investigator

Sam Andrews MD

Medical lnvestigator Trainee

Odey Ukpo MD

According to the initial report given to the Office of the Medical Investigator by Detective English of the Albuquerque Police Department, the decedent's mother reports that on December 27, 2013, the decedent was on a toy horse and was pushed from the horse by his 3 year old sibling, striking his head on the floor and losing consciousness. She stated that she called her husband, the decedent's step-father, who was not at home. Apparently, he placed the decedent in the shower to attempt to revive him. His mother then called his pediatrician who advised her to call Emergency Services.

Subsequent conversations with the step-father revealed that he was at home and heard the decedent's mother "beating him". Additionally, the mother told police that she knocked him into a dresser and he fell to the floor. While on the floor she stomped on him twice and kicked him in the abdomen.

The decedent was taken to the University of New Mexico hospital emergency room, where resuscitation was attempted for 30 minutes without success and he was pronounced dead at 17:32 hrs on 12/27/2013.

Review of the decedent's medical records available to us at the time of this report showed that he was born at 34 weeks gestation by Cesarean section at the Cibola General Hospital while his mother was incarcerated at the Grants County Women's Prison. He had been diagnosed with mild developmental delays, attention deficit hyperactivity disorder, and post-traumatic stress disorder. There had been 9 referrals to the Children Youth and Family Department (CYFD) and two were substantiated. One referral came in 2012 when the decedent reported to school personnel that his mother had hit him on the head with either a bat or phone, and had hit him on the leg with a belt. This referral was substantiated for physical abuse by and unknown perpetrator.

At autopsy, there were contusions (bruises) of the chest, arms, legs and tongue; abrasions (skin scrapes) of the face; a healing laceration (skin tear) of the scalp (left parietal scalp); and hemorrhage (bleeding) into the muscles between the ribs (intercostal hemorrhage), into the soft tissues of the back, into the diaphragm (muscle that separates the chest and abdominal organs), into an abdominal wall muscle (right internal oblique muscle), into the abdominal cavity (hemoperitoneum), into the soft tissues around the pancreas and left kidney; and on the outer surface (serosa) of the bowel. On the chest were discreet injuries consistent with thermal injuries (burns).

Microscopically, the chest wounds show features suggestive of a thermal injury, the scalp laceration showed evidence of healing (approximately days old), and there was acute inflammation and hemorrhage into the tongue.

Forensic odontologic (dental) analysis of the bruise on the right forearm was suggestive of a small human bite.

Forensic Neuropathology Consultation showed mild cerebral edema (swelling of the brain).

A skeletal survey showed no osteologic (bone) abnormalities.

Postmortem toxicological testing on the blood was negative for alcohol and drugs of abuse. Postmortem vitreous (eye) fluid electrolytes (a measure of salt-water balcance) was normal.

The decedent was physically an appropriately developed boy with injuries at different stages of healing with no evidence of significant underlying natural disease. This pattern is consistent with a history of abuse. There were impact sites to the trunk associated with bleeding into the soft tissues of the abdomen and into the abdominal cavity. A significant amount of blood was lost, accounting for approximately 25% of his total blood volume. A definitive bleeding source could not be identified and, therefore, likely came from small vessels in abdominal organs or soft connective tissue.After significant blood loss, delivery of oxygenated blood to the brain would decrease resulting in cerebral edema.

SUMMARY AND OPINION

Page 1 Printed: 3/25/2014 11:45:50 AMCause Of Death:

2013-06715 VARELA, OMAREESummary OpinionCase Number:



Sam Andrews MD

Authority for examination:

Body length (cm):Body weight (kgs):

Development:

Stature:

Age:Anasarca:Edema localized:

Dehydration:

Scalp hair color:Scalp hair length:Eyes:

OMI

128.0027.00

Well-developed

ThinAppears to be stated age

NoNo

No

BrownShortBoth eyes present

Irides:Eyes corneae:Eyes sclerae:

BrownTranslucentWhite

Eyes conjunctivae:Eyes petechiae:Palpebral petechiae:Bulbar petechiae:Facial petechiae:Oral mucosal petechiae:

TranslucentNoNoNoNoNo

External exam date time: 12/28/2013 9:13:00 AM

Medical Investigator Trainee

Odey Ukpo MD

Means used to confirm identity:

Other verification means:Location of orange bracelet:

Name on orange bracelet:Other name on orange bracelet:Location of green bracelet:Name on green bracelet:Other name on green bracelet:Hospital ID tags or bracelets?

If yes specify stated name and location:

Visual

Right wristDecedent name

Right wristDecedent name

YesLeft ankleTrauma-Alert, Hurdle C

ID confirmed at time of exam: Yes

Development comments:

Hyperpigmentation of the skin of the chest and back.Skin comments:

Page 1 Printed: 3/25/2014 11:45:50 AMExternal Examination

2013-06715 VARELA, OMAREEExternal ExaminationCase Number:


Nose:Ears:Lips:Facial hair:Facial hair color:Maxillary dentition:Mandibular dentition:Condition of dentition:Neck:Trachea midline:

Normally formedNormally formedNormally formedNoneDoes not applyNaturalNaturalAdequateUnremarkableYes

Chest symmetrical:

Chest diameter:Abdomen:

Back:Spine:External genitalia:

Breast masses:Right hand digits complete:

Left hand digits complete:

Right foot digits complete:

Yes

AppropriateUnremarkable

UnremarkableNormalMale

NoneYesYesYes

Breast development: None

Chest development:

Left foot digits complete: Yes

Muscle group atrophy:

Senile purpura:

Pitting edema:

NoNoNo

Muscle other: NoTattoo(s)

Tattoos present: No

Cosmetic Piercing(s)NoCosmetic piercing present:

Scar(s)YesScar(s) present:YesScar face:YesScar right lateral neck:

Odey Ukpo MDReported by:Reporting Tracking

Extremities: Well-developed and symmetrical

Normal




Verified by: Sam Andrews MD on 3/4/2014 4:08:13 PM

Reviewed and approved by: Sam Andrews MD on 3/7/2014 4:50:48 PM





Sam Andrews MD

Evidence of medical intervention:

If nasogastric tube present, specify course and position:Nasogastric tube:

Nasogastric tube comment:If endotracheal tube present, specify course and position:Tracheostomy site/tube:

Chest tube(s):

If Foley catheter present, specify course and position:

Vascular catheter(s):

Yes

Yes

Passes through the nose and nasopharynx, down the esophagus and terminates in the stomach

No

No

No

No

Yes

Left femoral vein: Yes

Mediastinal tube(s): No

Recent Surgical InterventionEvidence of recent surgical intervention:

No

Indwelling Tubes


Odey Ukpo MD

ECG Monitoring Pads Present?:

ECG Chest Pads:

ECG shoulders pads:ECG shins pads:

Other pads comments:

Defibrillator pads present?:

YesYes

YesYes

No

ECG abdomen pads: Yes

Vascular Catheter(s):

ECG Monitoring Pads

Defibrillator Pads

Odey Ukpo MDReported by:Report Tracking

Medical intervention other:Combitube within the esophagus.

Recent needle puncture within the right antecubital fossa.

Acute needle puncture of the left antecubital fossa.

Pulse oximeter on the right hand.

Page 1 Printed: 3/25/2014 11:45:51 AMMedical Intervention

2013-06715 VARELA, OMAREEMedical InterventionCase Number:


Verified by: Sam Andrews MD on 3/4/2014 4:25:11 PM


Page 2 Printed: 3/25/2014 11:45:51 AMMedical Intervention

2013-06715 VARELA, OMAREEMedical InterventionCase Number:



Sam Andrews MD

Body temperature:

Rigor mortis:Livor mortis - color:Livor mortis - fixation (if applicable):Livor mortis - position (if applicable):State of preservation:

Cool subsequent to refrigerationPartially fixedPurpleFully Fixed

Posterior

No decomposition

External exam date: 12/28/2013 9:16:00 AM


Odey Ukpo MD

Odey Ukpo MDReported by:Verified by: Sam Andrews MD on 12/28/2013 3:18:22 PM


Report Tracking

Page 1 Printed: 3/25/2014 11:45:51 AMPostmortem Changes

2013-06715 VARELA, OMAREEPostmortem ChangesCase Number:



Sam Andrews MD

Autopsy date: 12/28/2013 8:30:00 AMEvidence of Injury:


Odey Ukpo MD

Are there any injuries: Yes

Page 1 Printed: 3/25/2014 11:45:51 AMEvidence of Injury

2013-06715 VARELA, OMAREEEvidence of Injury Case Number:


# Injury Location Injury Description

1 Blunt injury Head On the superior philtrum is a 0.5 x 0.5 cm red abrasion.

On the lateral left supraorbital ridge is a 0.5 x 0.5 cm red/orange, dry abrasion.

On the left parietal scalp is a 1.5 x 0.5 cm red laceration with granulation tissue at the base.

On the anterior tongue is a 0.8 x 0.4 cm blue contusion.2 Blunt injury Chest On the midline superior chest are three distinct, 0.5 x 0.5 cm,

roughly square, orange, waxy abrasions.

On the lateral upper left chest in a 4 x 3.5 cm area, are three distinct, circular, red contusions.

There is hemorrhage within the lateral right 10th and 11thintercostal spaces.

There is hemorrhage within the posterior right 11th intercostal space.

3 Blunt injury Abdomen There is 500 ml of liquid blood within the abdominal cavity.

There is hemorrhage within the peripancreatic and left perirenal fat.

There are irregular hemorrhages of the superior and inferior diaphragmatic surfaces.

There is hemorrhage of the right internal oblique muscle.

On the serosal surfaces of the small and large bowel are multiple patchy small contusions.

4 Blunt injury Back On the midline lower back is a 2 x 2 cm blue contusion with associated subcutaneous hemorrhage.

5 Blunt injury Extremity On the posterior distal right forearm is a 3 cm circular blue contusion.

On the lateral distal left forearm are 2 cm and 1 cm circular purple contusions.

On the posterior mid left forearm is a purple contusion.

On the left knee is a 2 x 1 cm oval blue contusion.

On the mid right shin is a 3 x 1.5 cm oval blue contusion.



Report Tracking

Page 2 Printed: 3/25/2014 11:45:51 AMEvidence of Injury

2013-06715 VARELA, OMAREEEvidence of Injury Case Number:



Sam Andrews MD

Date of Internal Exam:

Chest cavities examined:

See evidence of injury sectionOrgans in normal anatomic positionOther organ position comments

Diaphragm:Serosal surfaces:Body cavity adhesions present:

Fluid accumulation present:

Fluid accumulation right chest cavity:Fluid accumulation left chest cavity

Fluid accumulation pericardial sac:Fluid accumulation abdominal cavity:

Fluid accumulation comments:

Body cavity other comments:

Brain examined:

Spinal cord examined:

See separate forensic neuropathology consultation reportSee evidence of injury section:

See evidence of medical Intervention section:

12/28/2013 10:01:00 AM

Yes

YesYes

Other - see commentsSmooth and glisteningNo

YesNo

NoNoNo

See Evidence of Injury

Yes

No

Yes

NoNo

See postmortem changes section:

Facial skeleton:Calvarium:

Skull base:

No

No palpable fracturesNo fracturesNo fractures

Fluid accumulation pelvis: No

Skull comments:

Date of Autopsy: 12/28/2013 8:30:00 AM


Odey Ukpo MD

BODY CAVITIES

HEAD

Spinal Cord

Brain fresh (g):

Brain fixed (g):1190


Page 1 Printed: 3/25/2014 11:45:52 AMInternal Examination

2013-06715 VARELA, OMAREEInternal ExaminationCase Number:


Middle ears examined: No

Neck examined:See Evidence of Injury section: See Evidence of Medical Intervention sectionSee Postmortem Changes section:Subcutaneous soft tissues:

Strap muscles:Jugular veins:

Carotid arteries:Tongue:Epiglottis:

Hyoid bone:

Larynx:Palatine tonsils:

YesNoNo

NoUnremarkableUnremarkableUnremarkableUnremarkableUnremarkableUnremarkableUnremarkableUnremarkableUnremarkable

Middle Ears

Neck

CARDIOVASCULAR SYSTEM

See separate Cardiovascular Pathology report:See Evidence of Injury section:See Evidence of Medical Intervention section:See Postmortem Changes section:

Right coronary ostium position:Left coronary ostium position:Supply of the posterior myocardium:

Right coronary ostium:Proximal third right coronary artery:Middle third right coronary artery:

Left coronary ostium:Left main coronary artery:

Proximal third left anterior descending coronary artery:Middle third left anterior descending coronary artery:Distal third left anterior descending coronary artery:

No

NoNo

No

NormalNormalRight coronary artery

00

0

000

0

0

Distal third right coronary artery: 0

Heart examined: Yes

Heart

Coronary artery stenosis by atherosclerosis (in percent):

Heart fixed (g):

Heart fresh (g): 135




Great vessels examined:

Aorta examined:

Proximal third left circumflex coronary artery:

Distal third left circumflex coronary artery:

Cardiac chambers:

Tricuspid valve:Pulmonic valve:

Mitral valve:Aortic valve:

Yes

Yes

0

0

UnremarkableUnremarkableUnremarkableUnremarkableUnremarkable

Right ventricular myocardium:

Left ventricular myocardium:

No fibrosis, erythema, pathologic infiltration of adipose tissue or areas of accentuated softening or indurationNo fibrosis, erythema, or areas of accentuated softening or induration

Middle third left circumflex coronary artery:

0

Ventricular septum:

Orifices of the major vascular branches:Coarctation:Vascular dissection:

Aneurysm formation:Complex atherosclerosis:

Other aortic pathology:

Vena cava and major tributaries:

Lungs examined:

See separate Cardiovascular Pathology report:

See Evidence of Medical Intervention section:

See Evidence of Injury section:

Upper and lower airways:

Pulmonary parenchyma color:Pulmonary parenchyma congestion and edema:Pulmonary trunk:

Unremarkable

Patent

NoNoNoNoNo

Patent

YesNo

NoNo

Unobstructed, and the mucosal surfaces are smooth and yellow-tanDark red-purpleSlight amounts of blood and frothy fluid

Free of saddle embolus

See Postmortem Changes section: No

Atrial septum: Unremarkable

Aorta

Vena Cava

RESPIRATORY SYSTEM

Lung right (g):

Lung left (g):130125

Cardiac Chambers and Valves:




Pulmonary artery thrombi: None

Liver examined:See Evidence of Injury section:

See Evidence of Medical Intervention section:See Postmortem Changes section:

Hepatic parenchyma (color):Hepatic parenchyma (texture):Hepatic vasculature:Gallbladder:

Gallstones:Intrahepatic biliary tree:

Extrahepatic biliary tree:

Alimentary tract examined:See Evidence of Injury section:


Course:Mucosa:

Mucosa:

Pylorus:

Luminal contents:

YesNoNo

No

Red-brownUnremarkableUnremarkable and free of thrombusUnremarkableNoneUnremarkableUnremarkable

YesYesNo

No

Normal course without fistulaeGray-white, smooth and without lesions

Usual rugal foldsPatent and without muscular hypertrophy

Partially digested food

Pulmonary artery atherosclerosis: None

HEPATOBILIARY SYSTEM

GASTROINTESINAL SYSTEM

Esophagus

Stomach

Colon

Pancreas

Small Intestine

Caliber and continuity:

Luminal contents:

Mucosa:Caliber and continuity:

Appropriate caliber without interruption of luminal continuity

Formed stoolUnremarkableAppropriate caliber without interruption of luminal continuity

Mucosa: Unremarkable

Liver (g):

Stomach contents vol (mL):

615Bile vol (mL):Gallstones autopsy:Gallstones autopsy desc:

Appendix found:

No

YesStomach contents description:




Form:

Genitourinary system examined:

See Evidence of Injury section:See Evidence of Medical Intervention section:See Postmortem Changes section:

Cortical surfaces:Cortices:

Calyces, pelves and ureters:

Urinary bladder mucosa:

Location:

Size:Consistency:

Other testicle comments:

Size:

Normal tan, lobulated appearance

YesYesNo

No

SmoothNormal thickness and well-delineated from the medullary pyramidsNon-dilated and free of stones and masses

Gray-tan and smooth

Bilaterally intrascrotalUnremarkableHomogenous

Unremarkable

Kidneys capsules: Thin, semitransparent

Male: Yes

GENITOURINARY SYSTEM

Kidneys

Urinary Bladder

Male

Testicles

Prostate Gland

Other prostate gland comments:

Spleen (g):

Kidney right (g):

50

45

Kidney left (g): 55

Consistency: Homogenous

Urine volume (mL):Urine description:

Reticuloendothelial system examined:See Evidence of Injury section:

See Postmortem Changes section:

Color:

0

Yes

No

No

Red-brown, homogeous and ample

See Evidence of Medical Intervention section:

No

RETICULOENDOTHELIAL SYSTEM

Spleen

Bone Marrow

Spleen parenchyma: Moderately firmSpleen capsule: IntactSpleen white pulp: Prominent




Adrenal right (g):Adrenal left (g):

Thymus (g):

Regional adenopathy: No adenopathyLymph Nodes

Endocrine system examined:See Evidence of Injury section:


Size:

Position:Size:

Parenchyma:

Size:

Musculoskeletal system examined:See Evidence of Injury section:See Evidence of Medical Intervention section:See Postmortem Changes section:

Bony framework:

Subcutaneous soft tissues:

YesNoNo

No

Normal

NormalNormalHomogenous

Normal

YesYesNo

NoUnremarkable


Parenchyma: Yellow cortices and gray medullae with with the expected corticomedullary ratio

Musculature: See Evidence of Injury

Parenchyma: Absent (involution by adipose tissue)

Thymus

ENDOCRINE SYSTEM

Pituitary Gland

Thyroid Gland

MUSCULOSKELETAL SYSTEM

Adrenal Glands

ADDITIONAL COMMENTS



Report Tracking




1/22/2014 4:00:00 PMBrain exam date:

BLUNT HEAD TRAUMA:

1. Scalp laceration at systemic autopsy

2. Cerebral edema without frank herniation

According to reports, Omaree Varela was at home fighting with a sibling when he fell off of a rocking horse. His mother later admitted to kicking him several times, and at one point he struck his head.

A formal extended examination of the brain demonstrated mild cerebral edema only. There were no significant natural diseases, and no injuries.

Summary:

Dura:Brain Dissection Method:Brain fresh:Brain fresh:Brain fixed:

Evidence of Injury

General Description (External):Dura mater:Dural venous sinuses:

YesCerebrum - coronal1190.00

Smooth and without massessPatent

Cortical briding vein:Leptomeninges: Smooth and translucent

SuperficialCorticalVasculature:

Gyral convolution patterns:

Gyral convolutions:

Uncal processes:

Cerebellar ponsils:

Basilar arterial vasculature:

Cranial nerve roots:

General Description (Internal):Cerebral cortex:

Gray-white matter junctions:

No thromboses or vascular malformations

Within normal limits

Slight widening and flatteningNot grooved or herniated

Not grooved or herniated

Normal

Normal

Intact and without contusion

Distinct

Brain: Yes

Internal Capsule: No neoplasm, cyst, abscess or hemorrhageVentricular system: Appropriately configured and not compressed


Sam Andrews MD


Odey Ukpo MD

Page 1Neuropathology Printed: 3/25/2014 11:45:52 AM

2013-06715 VARELA, OMAREENeuropathology ExaminationCase Number:


Cassette Code Tissue Location Stain

B1 Frontal lobe

B2 Hippocampus

B3 Parietal lobe

B4 Anterior basal ganglia

B5 Posterior basal ganglia

B6 Cerebellum

B7 Medulla

B8 Spinal cord

B9 Dura mater

Hippocampi: No neoplasm, cyst, abscess or hemorrhage

Mammillary bodies: No neoplasm, cyst, abscess or hemorrhageSuperior cerebellar vermis: No neoplasm, cyst, abscess or hemorrhageCerebellar parenchyma: No neoplasm, cyst, abscess or hemorrhage

Deep gray nuclei:Other comment(s) about the deep gray nuclei:

No neoplasm, cyst, abscess or hemorrhage

Brainstem structures: No neoplasm, cyst, abscess or hemorrhageProximal cervical spinal cord: No neoplasm, cyst, abscess or hemorrhageSubstantia nigra: Normally pigmentedLocus ceruleus: Normally pigmented

Other Tissues ExaminedSpinal cord: Not examinedEyes: Not examinedCervical ppine: Not examined

No significant histopathologic abnormalities.

*Unless otherwise indicated sections are stained only with hematoxylin and eosin (H&E).

Deirdre Amaro MDReported by:Verified by: Evan Matshes MD on 2/10/2014 2:26:44 PM


Report Tracking

Microscopic Description

Page 2Neuropathology Printed: 3/25/2014 11:45:52 AM

2013-06715 VARELA, OMAREENeuropathology ExaminationCase Number:



Sam Andrews MD

Microscopic description:HEART (left ventricle, interventricular septum, apex)

Sections of the heart show no significant histopathologic abnormality.

LUNGS

Sections of the right and left lungs show no significant histopathologic abnormality.

KIDNEYS

A section of the right shows focal interstitial chronic inflammation. A section of the left kidney shows no significant histopathologic abnormality.

LIVER

A section of the liver shows no significant histopathologic abnormality.

LEFT PARIETAL SCALP

Sections of the left parietal scalp show a laceration cleft through the scalp to galea filled with mixed cellular debris and fibrin, and a prominent fibroblastic and granulation-like response.

SKIN OF THE CHEST

Sections of the skin from the chest show epithelium with smeared nuclei, karyorrhectic debris, and focal acute inflammation that does not extend to the adnexa. One focus shows epidermal detachment with coagulative necrosis and blue discoloration of the dermal-epidermal junction.

BLADDER

A section of the bladder shows no significant histopathologic abnormality.

TONGUE

A section of the tongue shows denuded and reactive epithelium with near full thickness acute inflammation with focal hemorrhage.


Odey Ukpo MD

Block Tissue Location Description Stain

A1 Heart, right kidney

A2 Right lung, left kidney

A3 Liver, left lung

A4 Left scalp

A5 Chest abrasions at sternal notch

A6 Bladder

A7 Tongue

*Unless otherwise indicated sections are stained only with hematoxylin and eosin (H&E).

Page 1 Printed: 3/25/2014 11:45:53 AMMicroscopy:

2013-06715 VARELA, OMAREEMicroscopyCase Number:




Report Tracking

Page 2 Printed: 3/25/2014 11:45:53 AMMicroscopy:

2013-06715 VARELA, OMAREEMicroscopyCase Number:



Sam Andrews MD

Study date:

Accession number:Exam type:

Technique:Comparison:Comments:

12/28/2013 12:00:00 AM2013-6715Skeletal surveyRadiograph

Review of the postmortem skeletal survey shows no acute or subacute fractures.

Date of examination: 12/28/2013 8:30:00 AM


Odey Ukpo MD



Report Tracking

Page 1 Printed: 3/25/2014 11:45:53 AMRadiography

2013-06715 VARELA, OMAREERadiographyCase Number:


Case Number:

Date of Examination:Pathologist:

Fellow/Resident:Reviewer:

Death investigation report:Photographs:Microscopic slides:Toxicology report:

Other Items (specify):Other Items Comments:

Is the report independently reviewable?:

Is the external description (without injuries) appropriately case specific?:

Are the descriptions of injury, if present, appropriate for the complexity of the case, and consistent with diagrams and photographs?:

Are the descriptions of injury, if present, organized in a logical and understandable sequence?:

Are the descriptions of natural disease, if present, appropriate for the complexity of the case?:

Is the text clear and understandable without significant typographical and/or grammatical errors?:

Is the opinion readily understandable by the nonmedical reader?:

Are all significant issues addressed in the opinion?:

Was appropriate ancillary testing performed?:

Are the opinions reasonable?:

Is the cause of death reasonable?:

Is the manner of death reasonable?:

Report completed in a timely fashion?:

Comments:

2013-0671512/28/2013 8:30:00 AMSam Andrews MDOdey Ukpo MDEvan Matshes MD

YesYesYesYesYes

Radiographs (hands not radiographed)

Full body computed tomography (PMCT) scan

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Are the descriptions of clothing and identifying marks and scars appropriate for the complexity of the case?: Yes

Is the opinion logical and complete?: Yes

Decedent Name: VARELA, OMAREE

Items Reviewed

Technical Audit

Select OptionReported by:Verified by: Evan Matshes MD on 3/7/2014 4:40:44 PM

Report Tracking

Page 1 Printed: 3/25/2014 11:45:53 AMPeer Review Report

2013-06715 VARELA, OMAREEPeer Review ReportCase Number:



Page 2 Printed: 3/25/2014 11:45:53 AMPeer Review Report

2013-06715 VARELA, OMAREEPeer Review ReportCase Number:


Yellow Sheet Morphology TechnicianAutopsy Myranda McGowan

Attendees Myranda McGowan

Identification Myranda McGowan

Evidence Myranda McGowan

Evidence Myranda McGowan

Radiology Myranda McGowan

Retention Myranda McGowan

Toxicology Myranda McGowan



LabOther Myranda McGowan

Case Number:

Date of Examination:

Pathologist:

Fellow/Resident:

2013-06715

12/28/2013 8:30:00 AM

Sam Andrews MDOdey Ukpo MD

Decedent Name: VARELA, OMAREE

Morphology technican(s) present

Morphology technican supervisor(s) present

Yellow Sheet Morphology Technician LeadToxicology Erika Cavalier

LabOther Erika Cavalier

Attendees Monica Mondragon

Identification Monica Mondragon

Autopsy Stephen Adams

Evidence Monica Mondragon

Radiology Monica Mondragon

Retention Monica Mondragon

Page 1 Printed: 3/25/2014 11:45:54 AMProcedural Notes Report

2013-06715 VARELA, OMAREEProcedural Notes Case Number:


Autopsy attendees

Specimens obtained for toxicology testing

Other morphology technicians present:Monica Mondragon

Law enforcement officers present:Detective Michelle English with APD

Use antemortem specimens for testing:

No

Femoral blood collected: YesYesHeart blood collected:

NoBlood other collected:

YesPreserved vitreous collected:

YesUn-preserved vitreous collected:

NoBile collected:

NoGastric contents collected:

NoKidney tissue collected:

NoLiver tissue collected:

NoBrain tissue collected:

NoMuscle tissue collected:

NoOther tissue collected:

Urine collected: No




Specimens obtained for laboratory testing

Approach to autopsy dissection

HIV serology: No

HCV/HBV serology :

Influenza serology:

Other serology:

Freezer protocol:

DNA card:

Metabolic screen:

Cytogenetics:

Med-X protocol:

Urine dipstick:

Blood cultures (bacterial):Lung cultures (bacterial):

CSF culture (bacterial):

Spleen culture (bacterial):

Stool culture (bacterial):

Other bacterial culture (specify):

Mycobacterial culture (lung):Mycobacterial culture (other):

NoNoNo

NoYesYesNoNoNoNoNoNo

NoNo

NoNo

Rokitansky evisceration: NoVirchow evisceration: YesModified evisceration: No

Viral Cultures: No

HIV spin and store: Yes




Special autopsy techniques

Tissues retention

Disposition of tissues retained for extended examination

Pericranial membrane removal: NoNeck anterior dissection: YesNeck posterior dissection: NoFacial dissection: NoVertebral artery dissection (in situ): NoCervical spine removal: NoLayered anterior trunk dissection: YesAnterolateral rib arc dissection: NoBack dissection: YesPosterior rib arc dissection: NoExtremity soft tissue dissection: NoEye enucleation: NoInner middle ear evaluation: NoMaxilla or mandible resection: NoSpinal cord removal (anterior): NoSpinal cord removal (posterior): No

Other dissection(s):

Stock jar with standard tissue retention:

Yes

Rib segment: YesPituitary gland: YesBreast tissue (women only): NoBrain retention: YesSpinal cord retention: NoCervical spine retention: NoHeart retention: NoHeart-lung block retention: NoRib cage retention: NoLong bone retention: No

Other retention,specify:

Specimen outcome: Fixation with standard disposal/cremation when examination complete

HIV serology: No




Number of scene photos produced by the OMI

Number of autopsy photos produced by the OMI

Evidence collected

Personal effects

Clothing

Scene Photos: 168

Autopsy Photos: 98

FBI blood tube: NoBlood spot card: NoAPD blood card: NoThumbprint: YesFingerprints: NoPalmprints: NoPrint hold: NoOral swab: NoVaginal swab: NoAnal swab: NoOther swab: YesFingernails: NoScalp hair: NoPubic hair: NoPubic hair combing: NoProjectile(s): NoRetain clothing: YesRetain valuables: YesRetain trace evidence: NoRetain body bag: NoRetain hand bags: NoLigature: NoOther evidence retained:

Property Type Property Description Property DetailSwabs Other Swab- bite mark wet

Swabs Other Swab- bite mark dry

Valuables Other eye ointment

Property Type Property DescriptionClothing Underpants

Clothing Shorts


