LaVerne Stiles Autopsy and Death Cert

MEDICAL EXAMINER DISTRICT 5 Citrus, Hernando, Lake, Marion Sumter Counties 809 Pine Street Leesburg, Florida 34748 Phone: 326-5961 Fax: (352) 365-6438 AUTOPSY REPORT NAME: Stiles, Laverne CASE NUMBER: 2012-0213 DATE OF DEATH: February 24, 2012 AGE: 71 SEX: Female RACE: White COUNTY: Citrus DATE AND TIME OF AUTOPSY: February 25, 2012 9:00 AM CAUSE OF DEATH: Complications of surgical procedure for blunt neck trauma due to motor vehicle collision CONTRIBUTING CONDITION: Atherosclerotic cardiovascular disease MANNER OF DEATH: Accident Wendy A. L?y?ezzi, MD. Deputy Chief Medical Examiner Date: April 6, 2012 NAME: STILES, Laverne CASE NUMBER: 2012-0213 AUTOPSY FINDINGS: 1. 7th cervical vertebral repair, with postoperative hemorrhage a. Right hemothorax (approximately 300 cc) b. Left hemothorax (approximately 100 cc) c. Laryngeal edema 2. Atherosclerotic cardiovascular disease a. Severe coronary atherosclerosis b. Mild aortic atherosclerosis c. Moderate splenic artery atherosclerosis d. Mild cerebral atherosclerosis Mild pulmonary congestion Nodular goiter Hepatic ?brosis, bordering on cirrhosis of the liver Hepatic steatosis, moderate to severe Hyaline perisplenitis Nephrosclerosis SIP hysterectomy NAME: STILES, Laverne CASE NUMBER: 2012-0213 EXTERNAL EXAMINATION: The body is received clothed in a short-sleeved white blouse, a white bra, tan pants, black panties, white socks, and white shoes. The pants, bra, and blouse have been cut. The body is that of a well-developed, well?nourished, adult white female, weighing 140 pounds, measuring 62 inches in length, and appearing the stated age of 71 years. The body is cold to touch. Rigor mortis is fully present in all joints. Postmortem lividity is faint and patchy on the back. The hair is brown, wavy, and approximately 3 inches in length. The eyes are closed. The corneas are clear. The irides are blue. The skeleton of the nose is intact. The earlobes are creased. Both earlobes are pierced once. The teeth are natural and in good repair. There are patchy irregular scars on the neck and upper chest. There is a 2 inch horizontal scar on the left upper chest. The breasts are normally formed and without masses. The left nipple is inverted. The abdomen is protuberant, with multiple striae. There is a 21/2 inch horizontal scar across the pubis. The external genitalia are normal female and show no evidence of trauma. There are a few 1/1 inch round scars and healing abrasions on the left upper back and mid upper back. A 21/2 inch diagonal linear scar is present on the left side of the back. There are super?cial pressure sores over the sacrum. There are external hemorrhoids. There are no deformities of the upper or lower extremities. The musculature of the forearms is diffusely atrophied. There are numerous haphazardly-oriented small scars on the upper and lower extremities. A 2 inch vertical linear scar is: present on the anterior right forearm. The ?ngernails are short, with Visible dirt beneath them. There is ulnar deviation of the ?ngers. A 3 inch and a 4 inch diagonal linear scar are present on the posterolateral right hip. There is a 1/2 inch round scar on the anterior right leg. A bandage covers a 3% inch round super?cial healing wound on the lateral right leg. There is a bandage covering a 2 1 inch super?cial healing wound on the medial right leg. There is a 1/1 inch. round healing abrasion on the anterior left knee. A bandage covers a 2 V2 inch diagonal super?cial healing wound on the medial left leg. The skin of both legs shows moderate brawny indurations with small patchy scars, left greater than right. There are compression stockings on the legs. The toenails are short and with chipped red polish. There is a prominent right bunion. NAME: STILES, Laverne CASE NUMBER: 2012-0213 EVIDENCE OF INJURY: - There is a 3 1/2 inch recently sealed incision at the right base of the neck, extending downward. toward the medial right clavicle. A 9 6 inch patchy blue/purple bruise with soft tissue swelling surrounds the wound, extending from the medial left clavicle across the right shoulder, and upward along the sides of the neck and lower face. A 10 4 inch faint dark purple bruise extends across the posterior right shoulder and upward behind the right ear. There is extensive hemorrhage in the underlying soft tissues of both sides of the neck, right greater than left, and up along the sides of the face and posterior neck. The carotid arteries are intact. - There are 1/4 inch lacerations on the mucosal surface of the lateral right upper and lower lips. A 21/2 inch oval purple bruise is present on the anterior left shoulder. There is a 1 inch round blue bruise on the left upper chest. A 2 1 inch yellow/purple bruise is present on the right breast. There is a 2 inch round dark purple bruise on the upper lateral left buttock. A 2% 1 inch patchy purple bruise is present on the anterior right arm. There are a few petechiae on the anterior right forearm. A 2 inch curved vertical skin tear is present on the posterior right forearm. There are a few V2 inch round purple bruises on the anterior and lateral left arm. Diffuse purple bruising and purpura are present on both anterior and posterior forearms. There is a 1/2 in round skin tear on the right knee. A few petechiae are present just below the right knee. There is a 1 inch oval purple bruise on the anterior left thigh. EVIDENCE OF RECENT MEDICAL INTERVENTION: A tracheostomy tube is present within a 1/2. inch defect on the anterior neck and terminates in the trachea. 0 A bandage covers needle punctures on the right upper chest. 0 There are multiple punctate abrasions surrounded by a 2 inch red bruise between the breasts. 0 De?brillator pads are present on the right upper chest and left lateral chest. Multiple electrocardiogram leads are present on both sides of the chest. Five hospital bands encircle the right wrist. A bandage covers needle punctures and bruises in the left antecubital fossa. There is an intraosseous needle in the anterior left leg. The right through 61th ribs and the left through 5th ribs are fractured anterolaterally, consistent with cardiopulmonary resuscitative efforts. NAME: STILES, Laverne CASE NUMBER: 2012-0213 EVIDENCE: An AP view of the neck and chest is examined. Orthopedic hardware is present over the 7th cervical vertebra. INTERNAL EXAMINATION: BODY CAVITIES: The body is entered by a Y--shaped incision. All organs are present in their usual anatomic positions and present their usual anatomic relationships. There is approximately 300 cc of ?uid blood in the right chest cavity and 100 cc of ?uid blood in the left chest cavity. No excess ?uid is present in the abdominal cavity. There are no pleural or peritoneal adhesions. NECK ORGANS: Diffuse hemorrhage in and around the neck muscles is previously described. The cartilages of the larynx and epiglottis are difiusely edematous. The hyoid bone is intact. Examination of the tongue reveals no evidence of injury and no evidence of swelling. The thyroid gland is tan, with focal small gelatinous nodules. RESPIRATORY SYSTEM: The right lung weighs 520 grams. The left lung weighs 490 grams. The lungs are blue/red and ?rm, with no anthracotic pigmentation. The trachea and bronchi display no abnormalities and contain no aspirated material. No thromboemboli are present in the pulmonary arteries. On cut section, the pulmonary shows mild diffuse congestion. No nodular or cavitary lesions are identi?ed. CARDIOVASCULAR SYSTEM: The pericardial sac is intact and contains no excess ?uid. The heart weighs 270 grams. The coronary arteries pursue a normal anatomic course and display severe atherosclerosis. There is 80% calci?c narrowing of the proximal left anterior descending coronary artery and 5 0% calci?c narrowing of the proximal left circum?ex and proximal right coronary arteries. The distal arterial branches are patent. The mitral and tricuspid valves show mild myxoid change. There are no abnormalities of the aortic or pulmonic valves. Sections of the myocardium reveal no focal areas of pathologic change. The left ventricle is 1.2 cm in thickness. The interventricular septum is 1.2 cm in thickness. The right ventricle is 0.3 cm in thickness. The aorta shows mild atherosclerosis. There is diffuse calci?c atherosclerosis of the splenic artery, which is approximately 50% narrowed. HEPATOBILIARY SYSTEM: The liver weighs 1190 grams. The liver is yellow/brown, with vaguely nodular surfaces and blunted margins. On cut section, the hepatic is yellow/brown and firm. The gallbladder contains approximately 5 cc of thin yellow bile and has velvety yellow mucosa. NAME: STILES, Laverne CASE NUMBER: 2012-0213 SYSTEM: The spleen weighs 100 grams. The capsule is red/brown, with patchy hyaline deposition. On cut section, the splenic is dark red and ?rm, with prominent white pulp. No is identi?ed. GASTROINTESTINAL SYSTEM: The esophagus displays no abnormalities. The stomach contains 30 cc of thick tan ?uid. The gastric and duodenal mucosa has normal rugal folds. The small and large intestines display no abnormalities along their serosal surfaces and have no palpable masses. The appendix is present. GENITOURINARY SYSTEM: The right kidney weighs 90 grams. The left kidney weighs 110 grams. The kidneys are red/brown, With coarsely granular surfaces. The renal capsules strip with dif?culty. The renal pelves, meters, and urinary bladder display no abnormalities. The bladder contains 20 cc of clear yellow urine. The vaginal mucosa is atraumatic and terminates in an apical vaginal scar. The uterus is surgically absent. The ovaries are atrophic. ENDOCRINE SYSTEM: The pancreas has ?rm, lobulated, tan The adrenals have thin, bright yellow/orange cortical ribbons and dark tan medullae. The pituitary gland is not enlarged. MUSCULOSKELETAL SYSTEM: The musculature of the forearms is atrophic, as previously described. The rest of the muscles are normally developed. Orthopedic hardware covers the anterior 7th cervical vertebra. The hardware is intact. The underlying spinal cord displays no abnormalities. Recent factures due to cardiopulmonary resuscitative efforts are previously described. No other fractures are identi?ed. CENTRAL NERVOUS SYSTEM: Re?ecting the scalp reveals no subscalpular hemorrhages. The skull is intact. On entering the cranial cavity, there is no epidural or subdural hematoma. The leptomeninges are translucent. The brain weighs 1220 grams. The hemispheres are symmetric, with a normal pattern of sulci and gyri. Sections of the brain reveal no focal areas of pathologic change. The arteries at the base of the. brain display mild non-occlusive atherosclerosis. Stripping the dura reveals no fractures. Fluid blood is present in the dural Sinuses. NAME: STILES, Laverne CASE NUMBER: 2012-0213 MICROSCOPIC SECTIONS SUBMITTED: laryngeal cartilage soft tissue, right neck right ventricle, left ventricle, interventricular septum lung lung, spleen liver, kidney cerebellum, cervical spinal cord cerebral hippocampus MICROSCOPIC EXAMINATION: LARYNX: acute hemorrhage; marked submucosal edema, with a few no signi?cant eosinophilic or mast cell component; sparse intraepithelial in?ltrate SOFT TISSUE, right neck: vascular structures and soft tissue with associated acute hemorrhage, acute in?ammation, and focal associated fragments of bone HEART: mild to moderate perivascular and interstitial myocardial ?brosis, most prominent in section of interventricular septum LUNGS: mild congestion; focal changes LIVER: extensive periportal ?brosis, with associated mixed in?ammatory in?ltrate and bile duct proliferation; focal nodular pattern of cirrhosis; moderated to severe macro- and microvesicular steatosis KIDNEY: focal areas of glomerulosclerosis, with associated chronic in?ammation, ?brosis, and tubular atrophy; thickened arteries and arterioles; mild congestion SPLEEN: congestion of red pulp; white pulp inactivity, without germinal center formation; capsular hyaline BRAIN: white matter edema; unremarkable cerebellum; cerebral hippocampus with patchy vacuolation of the neuropil and gliosis, with associated neuronal pyknosis CERVICAL SPINAL CORD: edema; neuronal loss and gliosis within the posterior horns Wuesthoff Reference Laboratory 6800 Court Melbourne, Florida 32940 Julie Bell, Laboratory Director Client Patient ID: 5-12?21 3 MRN10001475043 Acct No: 7134737 Patient: STILES. LAVERNE DOB: Age: 71 Sex: Client: DIST 5 EXAMINER Physician: WENDY LABORATORY Specimen Collected: 03/01/2012 Order No#: 15010716 Status: ROUTINE Reg Date: 02/27/12 Test Name Low Normal High ABN Reference Site Code COMMENTS: Test performed on postmortem specimen. The validity of the test, clinical significance, and criteria for interpretation hava not been estabiished for this sample type. Normal ranges may not apply. Immunoglobulins ICE 1011.2 (lg?130,0 MAR 03 2012 Critical a 5 Printed: 03/08/12 06:35 Lab Key for Results: - New Results Low High ABN Abnormal LAVERNE INSTANT REPORT Form: MM Single Page 1 of 1 . Wuesthoff Reference Laboratory .. 6800 COM . Melbourne, Florida 32940 Julie Bell, M.D., Laboratory Director Patient: STILES, LAVERNE Age: 71 Sex: Client Patient ID: 5-12-213 Account#: 7149477 Physician: LAVEZZI, WENDY Client:I?ST 5 MEDICAL EXAMINER Specimen Collected :02/25/2012 Lab Order No: 14271207 Reg Date: 04/02/12 Test Name Result Units Cutoff/Reporting Limits VOLATILE PANEL VOLP 98245 SPECIMEN TYPE ILIAC BLOOD ETHANOL NONE DETECTED g/dL 0.020 ACETONE NONE DETECTED mg/dL 7.5 METHANOL NONE DETECTED mg/dL 15.0 ISOPROPANOL NONE DETECTED mg/dL 15.0 Analysis by Gas Chromatography (GC) Headspace Injection BLOOD DRUG SCREEN - SPECIMEN TYPE ILIAC BLOOD PROPOFOL, LIDOCAINE, LIDOCAINE METABOLITE, CAFFEINE HYDROCODONE, GABAPENTIN, VENLAFAXINE, FENTANYL, CAFFEINE, CAFFEINE METABOLITE BLOOD IMMUNOASSAY SCREEN SPECIMEN TYPE ILIAC BLOOD AMPHETAMINES NEGATIVE mg/L 0.100 BARBITURATES NEGATIVE mg/L 0.100 BENZODIAZEPINES NEGATIVE mg/L 0.100 BUPRENORPHINE NEGATIVE mg/L 0.001 CANNABINOIDS NEGATIVE mg/L 0.050 COCAINE METABOLITE NEGATIVE mg/L 0.100 FENTANYL mg/L 0.001 Screening result suggests the need for further testing METHADONE NEGATIVE mg/L 0.050 OPIATES POSITIVE mg/L 0.050 SALICYLATES NEGATIVE mg/L 50.0 003052 012 STILES, LAVERNE Page?lofS Printed: 04/03/12 14:07 1?0? Wuesthoff Referenee Laboratory Melbourne, Florida 32940 Julie Bell, M.D., Laboratory Director Patient: STILES, LAVERNE Age: 71 Sex: Client Patient ID: 5*12-213 Account#: 7149477 LAVEZZI, WENDY .. Physician: Specimen Collected :02/25/2012 Lab Order No: 14271207 Test Name Result Units Reg Date: 04/02/12 Cutoff/Reporting Limits TRICYCLICS FENTANYL PANEL - FENP 20505 SPECIMEN TYPE ILIAC BLOOD FENTANYL 0.45 ng/mL 0.25 Immediately following a single 2 meg/kg I.V. dose: Up to 11 ng/mL, declining to 1 ng/mL after one hour. NEGATIVE mg/L 0.100 Following the application of a 100 meg/hour transdermal patch, serum levels (after an initial lag time of approximately six hours) of 0.8 - 2.6 ng/mL were maintained after application. Peak plasma levels following a single oral transmucosal dose (fentanyl orolet) of 15 meg/kg to children: 2 4 ng/mL at 20 minutes. NORFENTANYL NONE DETECTED ng/mL 0.25 Analysis by FREE OPIATES PANEL - OPPF 98182 SPECIMEN TYPE ILIAC BLOOD CODEINE NONE DETECTED mg/L 0.025 MORPHINE NONE DETECTED mg/L 0.025 HYDROCODONE 0.041 mg/L 0.025 Therapeutic range 5 mg oral dose: Less than 0.011 mg/L Therapeutic range 10 mg oral dose: Less than 0.024 mg/L 6-MONOACETYLMORPHINE NONE DETECTED mg/L 0.005 HYDROMORPHONE NONE DETECTED mg/L 0.025 OXYCODONE NONE DETECTED mg/L 0.025 OXYMORPHONE NONE DETECTED mg/L 0.025 Analysis by Form: MM Single RLIT STILES, LAVERNE Page-32055 Printed: 04/03/12 14:07 ?law Wuesthoff Reference Laboratory 9 ik? . ix? i 6800 Court ?53 may? Melbourne, Florida 32940 Patient: STILES, LAVERNE Age: 71 Sex: Client Patient ID: 5?12?213 Account#: 7149477 Physician: LAVEZZI, WENDY 5 MEDICAL EXAMINER 14271207 Reg Date: 04/02/12 Specimen Collected :02/25/2012 Lab Order No: Test Name Result Units Cutoff/Reporting Limits GABAPENTIN - GANMS 98545 SPECIMEN TYPE ILIAC BLOOD GABAPENTIN 7.0 mcg/mL 0.10 Elevated reporting limit, reporting limit is 0.40 mcg/mL. Target anti-epileptic range in refractory patients: 2.0 - 20 mcg/mL. Testing performed by NMS Labs, 3701 Welsh Rd, Willow Grove, PA 19090~2910 PROPOFOL 98592 SPECIMEN TYPE ILIAC BLOOD PROPOFOL NONE DETECTED mcg/mL 0.050 Patients required a mean blood propofol concentration of 4.05 1.01 mcg/mL for major surgery and 2.97 1.07 mcg/mL for non-major surgery. Blood propofol concentrations at which 50% of patients were awake and oriented after surgery were 1.07 and 0.95 mcg/mL respectively. performance returned to baseline at blood propofol concentrations of 0.38 - 0.43 mcg/mL. Testing performed by NMS Labs, 3701 Welsh Rd, Willow Grove, PA 19090~2910 AND METABOLITE - VENNM 98617 SPECIMEN TYPE ILIAC BLOOD VENLAFAXINE 220 ng/mL 20 peak plasma levels following a daily regimen occur at 2 hours for Venlafaxine: 35 - 79 ng/mL (75 mg/day) 93 - 334 ng/mL (150 mg/day) 68 - 265 ng/mL (225 mg/day) 196 - 597 ng/mL (450 mg/day) trough plasma concentrations following a 150 mg per day regimen: 0 - 141 ng/mL. 660 ng/mL 20 Steady?state peak plasma levels following a daily regimen of Venlafaxine occur STILES, LAVERNE Fol-1mMMSiugleRLlT Page 3 01 5 Printed: 04/03/12 14:07 Wuesthoff Reference Laboratory 6800 Court Melbourne Florida 32940 Julie Bell, M.D., ?Lahoratory Director Patient: STILES, LAVERNE Age: 71 Sex: Client Patient ID: 5?12-213 Account#: 7149477 Physician: LAVEZZI, WENDY Clientd DIST 5 MEDICAL EXAMINER Specimen Collected :02/25/2012 Lab Order No: 14271207 Reg Date: 04/02/12 Test Name Result Units Cutoff/Reporting Limits at approximately 2.5 hours for 94 - 200 ng/mL (75 mg/day) 85 472 ng/mL (150 mg/day) 243 - 515 ng/mL (225 mg/day) 390 - 1096 ng/mL (450 mg/day) Steady?state trough plasma levels following a 150 mg per day regimen: 65 - 300 ng Testing performed by NMS Labs, 3701 Welsh Rd, Willow Grove, PA 19090-2910 14271208 Reg Date Specimen Collected :02/25/2012 Lab Order No. 04/02/12 Test Name Result Units Cutoff/Reporting Limits ELECTROLYTE PANEL ELEPV 98644 SPECIMEN TYPE VITREOUS UREA NITROGEN 15 . 0 mg/dL CREATININE 0.44 mg/dL SODIUM 147 mEq/L POTASSIUM 9.0 mEq/L CHLORIDE 121 mEq/L GLUCOSE 109.0 mg/dL Glucose results from patients with gammopathies, in particular Waldenstrom?s Macroglobulinemia may result in an abnormal reaction profile. Although the incidence of this occurrence is rare, glucose results from these patients should be interpreted with caution. Printed: 04/03/12 14 :07 STILES LAVERNE Form:MM Single Page 4 0f 5 40 . 1 Wuesthoff Reference Laboratory 1.- 5 .. 1 assesses gyms-Cm Melbourne, Florida 32940 Julie Bell, M.D., Laboratory Director Patient: STILES, LAVERNE Age: 71 Sex: Client Patient ID: 5-12-213 Account#: 7149477 Physician: LAVEZZI, WENDY Clients DIST 5 MEDICAL EXAMINER Specimen Collected :02/25/2012 Lab Order No: 15290770 Reg Date: 04/02/12 Test Name Result Units Cutoff/Reporting Limits - TRIBT 98654 SPECIMEN TYPE ILIAC BLOOD 3 .7 ng/mL Reference range: <11.4 ng/mL The finding of an elevated which subsequently decays to background levels is convincing evidence that the patient experienced a systemic mast cell event. values usually peak in the serum 30?60 minutes after initial reaction and decay with a half-life of 2 hours. Mast cell degranulation from localized allergic reactions do not result in significant serum levels of this enzyme. This test measures both the alpha and beta forms of and is therefore useful in the diagnosis of mastocytosis and anaphylaxis. This test was developed and its performance characteristics determined by Viracor~IBT Laboratories. It has not been cleared or approved by the FDA. Test performed on postmortem blood. The validity of the test, clinical significance, and criteria for interpretation have not been established for this specimen type. Normal ranges may not apply. Testing performed by Viracor-IBT Laboratories, 1001 NW Technology Dr, Lee's Summit, MO 64086 Specimens were intact upon receipt. Chain of custody, specimen security and integrity has been mantained. Testing has been performed as requested Reviewed by: Date: e?c?iw?[QL? FINAL REPORT THIS COMPLETES REPORTING CASE STILES, LAVERNE Form:MMSingleRLlT Page 5 Of 5 Printe?j? 04/03/12 14107 OFFICE of VITAL STATISTICS CERTIFIED CQEV Mum-Hum I <Mm West?igmalf .. Ham at Dmmsa'nerimd' Secretarv to Jo Indicale what damdenr oan?daraa? hi9? I. :11? j? a: k' M?kan Aniarfc'oo' I - Fj?pho M, M. "TLOl??i-Iswdw, usrlu RIcan _JII3uI:aln? #Japa?ose r. . I pumanlanorchamonu .- Smuan .M II . . '(Spechy dacedenl was of Mspanlc or Haitian Origin.) Yes. Specify) 1am; . I - I. I_,_OlherHls ed at [mo of dually.) M13. .?Speofry 1h: decedenl?sI dagnfw $1thle of ?Mae?WIel - M- Uh." I Mrgh' achoo! buEInIi'?jfxa'oms I IX. _lh I. -- buI I150 dogma I (M Co?age . WII. if: a eJoseph :Henke - 7- - -- - - - agngonMArgTs NAME m- Karen Finch . . I ?Dauqhteru . I I gagsmEEmooHESS' M- -- - I h'w'j-IM Mgh'?alcsmelamcmmafom aromarplace) ., -. - I . '51;l NatureIIC0asthrematoxy .II OF DISPOSITION ;Bu?al _EniumbmhiM __Olha{ 28b. IF DONATION on BUFIIAL AT SEA, 275. 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