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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
Death Investigation Report Page 2
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:
Death Investigation Report Page 3
Medical Investigator
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:
Death Investigation Report Page 4
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
Page 2 Printed: 3/25/2014 11:45:50 AMExternal Examination
2013-06715 VARELA, OMAREEExternal ExaminationCase Number:
Death Investigation Report Page 5
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
Page 3 Printed: 3/25/2014 11:45:50 AMExternal Examination
2013-06715 VARELA, OMAREEExternal ExaminationCase Number:
Death Investigation Report Page 6
Medical Investigator
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
Medical Investigator Trainee
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:
Death Investigation Report Page 7
Verified by: Sam Andrews MD on 3/4/2014 4:25:11 PM
Reviewed and approved by: Sam Andrews MD on 3/7/2014 4:50:48 PM
Page 2 Printed: 3/25/2014 11:45:51 AMMedical Intervention
2013-06715 VARELA, OMAREEMedical InterventionCase Number:
Death Investigation Report Page 8
Medical Investigator
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
Medical Investigator Trainee
Odey Ukpo MD
Odey Ukpo MDReported by:Verified by: Sam Andrews MD on 12/28/2013 3:18:22 PM
Reviewed and approved by: Sam Andrews MD on 3/7/2014 4:50:48 PM
Report Tracking
Page 1 Printed: 3/25/2014 11:45:51 AMPostmortem Changes
2013-06715 VARELA, OMAREEPostmortem ChangesCase Number:
Death Investigation Report Page 9
Medical Investigator
Sam Andrews MD
Autopsy date: 12/28/2013 8:30:00 AMEvidence of Injury:
Medical lnvestigator Trainee
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:
Death Investigation Report Page 10
# 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.
Odey Ukpo MDReported by:Verified by: Sam Andrews MD on 3/7/2014 4:49:43 PM
Reviewed and approved by: Sam Andrews MD on 3/7/2014 4:50:48 PM
Report Tracking
Page 2 Printed: 3/25/2014 11:45:51 AMEvidence of Injury
2013-06715 VARELA, OMAREEEvidence of Injury Case Number:
Death Investigation Report Page 11
Medical Investigator
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
Medical lnvestigator Trainee
Odey Ukpo MD
BODY CAVITIES
HEAD
Spinal Cord
Brain fresh (g):
Brain fixed (g):1190
See Evidence of Injury
Page 1 Printed: 3/25/2014 11:45:52 AMInternal Examination
2013-06715 VARELA, OMAREEInternal ExaminationCase Number:
Death Investigation Report Page 12
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
Page 2 Printed: 3/25/2014 11:45:52 AMInternal Examination
2013-06715 VARELA, OMAREEInternal ExaminationCase Number:
Death Investigation Report Page 13
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:
Page 3 Printed: 3/25/2014 11:45:52 AMInternal Examination
2013-06715 VARELA, OMAREEInternal ExaminationCase Number:
Death Investigation Report Page 14
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:
See Evidence of Medical Intervention section:See Postmortem Changes 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:
Page 4 Printed: 3/25/2014 11:45:52 AMInternal Examination
2013-06715 VARELA, OMAREEInternal ExaminationCase Number:
Death Investigation Report Page 15
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
Page 5 Printed: 3/25/2014 11:45:52 AMInternal Examination
2013-06715 VARELA, OMAREEInternal ExaminationCase Number:
Death Investigation Report Page 16
Adrenal right (g):Adrenal left (g):
Thymus (g):
Regional adenopathy: No adenopathyLymph Nodes
Endocrine system examined:See Evidence of Injury section:
See Evidence of Medical Intervention section:See Postmortem Changes 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
See Evidence of Injury
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
Odey Ukpo MDReported by:Verified by: Sam Andrews MD on 3/7/2014 4:49:46 PM
Reviewed and approved by: Sam Andrews MD on 3/7/2014 4:50:48 PM
Report Tracking
Page 6 Printed: 3/25/2014 11:45:52 AMInternal Examination
2013-06715 VARELA, OMAREEInternal ExaminationCase Number:
Death Investigation Report Page 17
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
Medical Investigator
Sam Andrews MD
Medical lnvestigator Trainee
Odey Ukpo MD
Page 1Neuropathology Printed: 3/25/2014 11:45:52 AM
2013-06715 VARELA, OMAREENeuropathology ExaminationCase Number:
Death Investigation Report Page 18
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
Reviewed and approved by: Sam Andrews MD on 3/7/2014 4:50:48 PM
Report Tracking
Microscopic Description
Page 2Neuropathology Printed: 3/25/2014 11:45:52 AM
2013-06715 VARELA, OMAREENeuropathology ExaminationCase Number:
Death Investigation Report Page 19
Medical Investigator
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.
Medical lnvestigator Trainee
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:
Death Investigation Report Page 20
Odey Ukpo MDReported by:Verified by: Sam Andrews MD on 3/7/2014 4:49:50 PM
Reviewed and approved by: Sam Andrews MD on 3/7/2014 4:50:48 PM
Report Tracking
Page 2 Printed: 3/25/2014 11:45:53 AMMicroscopy:
2013-06715 VARELA, OMAREEMicroscopyCase Number:
Death Investigation Report Page 21
Medical Investigator
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
Medical lnvestigator Trainee
Odey Ukpo MD
Odey Ukpo MDReported by:Verified by: Sam Andrews MD on 3/4/2014 2:37:49 PM
Reviewed and approved by: Sam Andrews MD on 3/7/2014 4:50:48 PM
Report Tracking
Page 1 Printed: 3/25/2014 11:45:53 AMRadiography
2013-06715 VARELA, OMAREERadiographyCase Number:
Death Investigation Report Page 22
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:
Death Investigation Report Page 23
Reviewed and approved by: Sam Andrews MD on 3/7/2014 4:50:48 PM
Page 2 Printed: 3/25/2014 11:45:53 AMPeer Review Report
2013-06715 VARELA, OMAREEPeer Review ReportCase Number:
Death Investigation Report Page 24
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
Toxicology 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
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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
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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
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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
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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
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