Incision
Y-shaped thoraco-abdominal
Modified Y-shaped incision to include neck
Inverted Y-thorax only incision
Inverted U-abdomen only incision
Other (specify)
Subcutaneous fat
Unremarkable
Decreased
Abundant
Peritoneal cavity
Surfaces smooth and glistening
Surfaces smooth and dull
Surfaces roughened and dull
Diaphragm
Unremarkable, intact hemidiaphragms
Abnormal (specify)
Not evaluated
Abdominal organs
Normally situated, normal bowel rotation
Abnormal (specify)
Not evaluated
Internal genitalia
Male, testes located along pelvic side-walls
Male, testes located in inguinal canal
Male, testes located in scrotum, inguinal rings closed
Female, unremarkable uterus and gonads
Abnormal (specify)
Not evaluated
Pleural cavities
Surfaces smooth and glistening
Surfaces smooth and dull
Surfaces roughened and dull
Not evaluated
Right pleural fluid
Straw colored
Serosanguineous
Bloody
Yellow, purulent
Not evaluated
Right pleural fluid
Straw colored
Serosanguineous
Bloody
Yellow, purulent
Not evaluated
Mediastinum
Unremarkable soft tissues with normally formed thymus
Unremarkable soft tissues with age appropriate thymic remnant
Unremarkable soft tissues with absent thymus
Great vessels
Arise normally in their expected locations
Abnormal (specify)
Not evaluated >
Pericardium
Surfaces smooth and glistening
Surfaces smooth and dull
Surfaces roughened and dull
Not evaluated
Scalp
Unremarkable skin and subcutaneous tissues
Mildly edematous skin and subcutaneous tissues
Markedly edematous skin and subcutaneous tissues
Not evaluated
Cranium/Meninges/Dura
Unremarkable inner cranium, meninges and dural sinuses
Opaque meninges and cloudy CSF; unremarkable inner cranium and dural sinuses
Not evaluated
Microbiology
Blood culture
Snap frozen
Cytogentics
Electron microscopy
Heart size
Normal size and shape
Enlarged, biventricular hypertrophy
Enlarged, global hypertrophy
Abnormal (specify)
Not evaluated
Venous return
Innominate and azygous veins follow usual courses
Innominate and azygous veins follow aberrant courses
Innominate and azygous veins cannot be evaluated
Atrial septum
Intact with probe patent foramen ovale
Intact with probe closed foramen ovale
Abnormal (specify)
Not evaluated
Ventricle septum
Intact and uniform septum without defects
Intact but hypertrophic and curvilinear contour
Ventricular septal defect present, submembranous
Ventricular septal defect present, muscular
Other (specify)
Not evaluated
Ventricles
Uniform and dark brown
Uniform and pale (fatty infiltration)
Asymmetric with left ventricular hypertrophy
Asymmetric with hypoplastic left ventricle
Asymmetric with hypoplastic right ventricle
Other (specify)
Not evaluated
Endocardium
Clear and glistening
Pale with diffuse fibroelastosis
Not evaluated
Coronaries
Unremarkable ostia in normal location
Other (specify)
Not evaluated
Aorta/arch
Left-sided with normal aortic branches
Right-sided with normal aortic branches
Other (specify)
Not evaluated
Pulmonary vein/IVC
Pulmonary veins and IVC drain normally
Other (specify)
Not evaluated
Airways
Larynx and trachea normally formed; unremarkable mucosa
Larynx and trachea normally formed; abundant mucoid debris present
Larynx and trachea normally formed; blood/mucoid contents present
Not evaluated
Right lung
Three lobes, smooth pleural surfaces, unremarkable spongy parenchyma
Three lobes, smooth pleural surfaces, congested parenchyma
Other (specify)
Not evaluated
Left lung
Two lobes, smooth pleural surfaces, unremarkable spongy parenchyma
Two lobes, smooth pleural surfaces, congested parenchyma
Other (specify)
Not evaluated
Parenchymal vessels
Unremarkable; no thrombus seen
Dilated venous channels with hemorrhage
Dilated venous channels with multiple thrombi
Other (specify)
Not evaluated
Stomach contents
Scant, mucoid contents
Mucoid, tan contents
Semi-solid tan contents
Semi-solid reen contents
Semi-digested food particles
Semi-particulate bloody contents
Not evaluated
Pylorus
Unremarkable; patent communication to duodenum
Hypertrophic with stenotic communication to duodenum
Hypertrophic and nearly complete occlusion
Not evaluated
Small intestine contents
Semi-solid tan contents
Semi-solid green contents
Semi-digested food particles
Semi-particulate bloody contents
Not evaluated
Appendix
Present, expected position
Present, malpositioned
Absent
Not evaluated
Colo-rectal contents
Semi-solid tan contents
Semi-solid green contents
Semi-digested food particles
Semi-particulate bloody contents
Not evaluated
Liver shape
Unremarkable shape; smooth capsule
Globally enlarged shape; smooth capsule
Surgically altered shape; smooth capsule
Not evaluated
Liver parenchyma
Uniform
Mottled
Congested
Bile stained
firm
fibrotic
soft
semi-liquid
completely autolyzed
Hepatic veins
Unremarkable visible venous branches
Dilated visible venous branches
Compressed visible venous branches
Not evaluated
Gallbladder
Normally formed and located; green bile
Small and normally located; scant green bile
Fibrotic remnant at expected location; no bile
Not evaluated
Extra-hepatic Biliary tree
Bile expressed normally into duodenum
Bile cannot be expressed into duodenum
Not evaluated
Cortical surface
Smooth, slight fetal lobations
Smooth, marked fetal lobations
Smooth, capsule strips with ease
Pebbled, roughened surface
Pebbled, scarred segments
Not evaluated
Kidney parenchyma
Normal corticomedullary architecture
Pale preserved corticomedullary architecture
Obscured corticomedullary junction
Hemorrhagic papillae
Ureters
Unremarkable pelvis; normal caliber ureters
Unilateral dilated pelvis and ureter
Bilateral dilated pelves and megaureters
Not evaluated
Bladder
white
dull
hemorrhagic
ulcerated
Thin walled mucosa, scant urine
Thin walled mucosa, abundant urine
Thick walled mucosa, scant urine
Thick walled mucosa, scant urine
Uterus
Smooth surfaces and juvenile proportions
Not evaluated
Ovaries
Smooth capsular surface, unremarkable parenchyma
Smooth capsular surface, scattered cystic follicles present
Not evaluated
Fallopian tubes
Unremarkable fimbriated ends
Not evaluated
Other reproductive findings
Thymus
Age appropriate size, tan lobulated parenchyma
Small for age, tan fibro-fatty parenchyma
Hyperplastic for age, tan lobulated parenchyma
Absent
Not evaluated
Spleen
Firm parenchyma
Soft parenchyma
Congested parenchyma
Absent
Not evaluated
White pulp visible
White pulp absent
Bone marrow
Dark brown, unremarkable marrow spaces
Red, bloody marrow spaces
Not evaluated
Lymph nodes
Small, soft and unremarkable
Variably prominent, soft
Diffusely enlarged, firm
Not evaluated
Thyroid
Normally formed parenchyma
Hypertrophic parenchyma
Hypoplastic parenchyma
Not evaluated
Parathyroids
Inconspicuous (unidentifiable)
Not evaluated
Adrenals
Normal architecture with dark medulla
Depleted, thin cortex and dark medulla
Hemorrhagic parenchyma with loss of markings
Not evaluated
Pituitary
Unremarkable spongy parenchyma
Not evaluated
Skin
Well keratinized and otherwise unremarkable
Poorly keratinized consistent with prematurity
Not evaluated
Muscle tissue
Unremarkable
Abnormal (specify)
Not evaluated
Bones and cartilage
Normally formed, long bone lengths are appropriate for age
Abnormal (specify)
Not evaluated
Duration of fixation (days)
Development stage
Age appropriate
Asynchronous with gestational age
Not evaluated
Brain surface
Unremarkable smooth immature developing cortex
Unremarkable gyrated developing cortex; operculum open
Unremarkable gyrated developing cortex; operculum closed
Semi-liquid and autolyzed
Abnormal (specify)
Not evaluated
Cranial nerves + basal vessels
Arise normally
Cannot be assessed
Not evaluated
Cerebral cortex
Soft with discrete white-gray matter delineation
Poorly fixed with indistinct white-gray matter
Semi-liquid without clear landmarks
Abnormal (specify)
Not evaluated
Ventricles
Normal size for age; no periventricular lesions
Symmetrically dilated with periventricular hemorrhage
Cannot be evaluated due to autolysis
Not evaluated
Cerebellum
Normally developed and symmetric
Artifactually disrupted during extraction
Abnormal (specify)
Not evaluated
Brainstem
Normal external landmarks without visible lesions
Basilar hemorrhage extending into pons
Extensive autolytic changes
Not evaluated
Spinal cord
Unremarkable cut surfaces with peripheral thin meninges
Not evaluated