Nematodes

 How to write a post-mortem report

• What is the post-mortem examination?
• What is the post-mortem report?
• Importance of post-mortem report.
• Writing of post-mortem report.
• Parts of the post-mortem report.

1. Post-mortem record
2. Post-mortem examination  

What is Post-Mortem Examination?

• The term post-mortem is Latin for “After Death”.
• Originally, post-mortem examination or autopsy is an examination of a corpse in order to determine the cause of death.
• It is performed to obtain an accurate cause of death and looking at each individual organ within the body to determine the cause of death.

What is a post mortem report?

• It is what the pathologist writes to give his opinion on how the animal died.
• A good post-mortem report clearly describes problems and opportunities for improvement.
• In many organizations, it is common for post-mortem reports to be widely distributed so that many people have the opportunity to learn from every project.

Importance of post mortem report

• A post-mortem report is a documented form of the results of necropsy examination which is kept as a record for use in the future.
• It helps the investigators to determine the causes of death.
• It helps in resolving the medico-legal issues in the court.
• It is important for the prevention of lethal diseases in the future.

Writing of post mortem report

• The post-mortem report consists of two parts:

1. Post-mortem record
2. Post-mortem examination

• The first part i.e, the post-mortem record have the information related to the animal & is supplied by the owner or person requesting a post-mortem examination.
• Actually, it is a request form of the case for the post-mortem examination. This is necessary for animal identification.
• It should be filled before conducting a post-mortem examination.
• The proper record will be helpful in establishing an accurate diagnosis based on post-mortem examination.

Post-mortem record

1. Species: The species of the animal should be written here such as bovines, porcine, equine,  poultry, etc.
2. Date: The date of the death of the animal & post-mortem examination should be written here.
3. Case No.: The serial no. of postmortem book. It shows cumulatively how many animals have been examined.
4. Breed: The breed of animal is mentioned if known or supplied in the request form such as Murrah buffalo, Jersey cattle, etc.
5. Age/Date of Birth: The age of animal or its date of birth is written here. In case the exact age is not known then mention young, adult in case of animals or chick, grower,  adult in case of poultry.
6. Sex: Sex of animal(male or female).
7. Identification No./Mark: It must be filled with utmost care; the no. (tattoo no or brand no.) should be the same as on the animal.  If identification is not available/illegible then write the characteristic mark of the animal.
8. Owner: The name of the owner with a complete address must be filled clearly.  The address should be complete enough so that the report can reach the owner through post also.
9. Referred by: The name of the veterinary officer/any other officer who referred the case for necropsy examination should be written.  Sometimes the owner himself/herself is interested in the postmortem examination of an animal;  in such cases, the name of the owner should be written.
10. History of the Case:   This includes the clinical illness of animals, duration of illness, epidemiological data, tentative diagnosis, therapeutic and preventive measures adopted.  This is very important and the information of this column has an important role in making the diagnosis.
11. Reported date and time of death: This column should have the exact date and time of death of the animal.   Sometimes, it difficult to note the exact time then one can write morning, noon, evening, midnight, etc. to approximate the timings of death of animal  In some large farms, it is very difficult to record information with regard to each individual animal/bird so here one can write “previous night” as a time of death.
12. Date and time of post-mortem examination: The pathologist conducting post-mortem examination should write here the exact time and date of the post-mortem examination.

• The above information is very important to arrive at any conclusive diagnosis.
• The correct information enhances the specificity of post-mortem diagnosis.

Post-mortem examination

• It includes the observations made by pathologists conducting post-mortem examination.
• This part of the report should be filled as soon as possible after the post-mortem examination.
• It is advisable that one should record some points on a small paper or diary during post-mortem examination & fill them in the report after the conduct of the post-mortem examination.

1. External Appearance: In this column, the lesions observed in intact animals before its opening.  One should place on record the side of the animal lying down, a lesion on the skin, external parasite, trauma, etc.
2. Subcutaneous Tissue & asculature: The observations made after removal of skin, on subcutaneous tissue and muscles should be included in this column.
3. General Observations after Opening the Carcass: This column contains the general information or lesions present in the abdominal or thoracic cavity such as the accumulation of fluid, pus, blood, a clot of blood, or other postmortem changes.
4. Respiratory System: Here write the lesions observed in the respiratory system right from external nares, nasal passage, trachea, bronchi & lungs along with mediastinal lymph nodes.
5. Cardiovascular System: Write about the lesions present in heart,aorta,arteries,veins & lymphatics.
6. Digestive System: In this column, write the lesions observed in the digestive tract from the oral cavity, esophagus, crop, proventriculus, gizzard, rumen, reticulum, omasum, abomasum, stomach, intestines, rectum, anus, cloaca, liver,  pancreas, gall bladder, etc
7. Urinary System: Write about the lesions present on the kidneys, ureter & urethra.
8. Genital System: In this column, write the lesions present in the ovaries, ureter, oviduct, cervix & vagina in females and testes, penis, etc. in males
9. Immune System: Write the lesions present in the spleen, bursa, thymus, lymph nodes, etc. Careful recording of lesions in these organs will be helpful in diagnosis.
10. Nervous System: Here write the lesions present in the brain, spinal cord & nerves.   Most of the pathologists overlook this system and often not taken pain to examine the brain.  It should not be done & every effort should be made to examine & record the lesions present in this system.
11. Miscellaneous Observations: Here one can record any missing observations which have not been covered above.
12. Post-mortem Diagnosis: This is a very important column. Based on the history & lesions present in different systems, the Pathologist, by using his experience & conscience concludes the diagnosis.  He/she may also write suggestions along with diagnosis or some points to suggest the diagnosis of disease in other animals.
13. Signature of Officer conducting Post-mortem: Each & every report must be signed by the officer doing post-mortem examination.   Without the signature of a competent officer, it has no validity.
14. Place & Date: The person signing the post-mortem report must also write the date & place of the post-mortem examination.

Report sample