HOW TO WRITE POST MORTEM REPORT

Pashu Sandesh, 16^th January 2018

Dr Rajesh Kumar Singh

Necropsy of animal carcasses is an important tool in the diagnosis of diseases and ultimately their control. It also becomes extremely relevant in addressing vetero-legal cases. Therefore, a veterinarian must have the basic knowledge of the post-mortem techniques, recording of lesions, their interpretation, a collection of proper sample for laboratory examination, and writing of the report. Here is presented the standard format laid down by VCI.

Post-mortem report consists of two parts- A. Post-mortem record, and B. Post-mortem examination

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

A. POST-MORTEM RECORD

1. Species: Here one should write the species of animal such as bovine, porcine, equine, poultry, etc.
2. Date: Date of the post-mortem examination.
3. Case no.: The serial number of your post-mortem book.

4. Breed: Mention the breed of animal, such as Murrah buffalo, Jersey cattle, etc.
5. Age/Born: Age of animal or its date of birth. In case the exact age is not known then mention young, adult or chick, grower, adult in case of poultry.
6. Sex: male or female.
7. Identification number/mark: It must be filled with utmost care; the number (tattoo number or brand number) should be the same as on animal. If the identification number is not available/illegible then write the characteristic mark of the animal.
8. Owner: Here, the name of the owner with complete address must be filled clearly.
9. Referred by: In this column, the name of Veterinary Officer/any other officer who referred the case for post-mortem examination should be written. Sometimes owner himself/herself is interested in post-mortem examination of the animal; in such case, the name of the owner should be written.

10. History of the case: This includes the clinical illness of animal, duration of illness, epidemiological data, tentative diagnosis, therapeutic and preventive measures adopted.
11. Reported date and time of death: It should have the exact date and time of the death of the animal. Sometimes, it is difficult to note the exact time then one can write morning, noon, evening, midnight etc. to approximate the timings of the death of the animal. In some large farms, it is very difficult to record information with regard to each inpidual animal/bird so here one can write “previous night” as a time of death.
12. Date and time of post-mortem examination: 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 any conclusive diagnosis. Some points might be looking like insignificant but one should not overlook them and write as correct as information he/she can gather from the owner’s request letter/form.

B. POST-MORTEM EXAMINATION

It includes the observations made by the pathologist while conducting postmortem examination. This part of the report should be filled in 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 postmortem examination and fill them in report after the conduct of postmortem examination.
1. External appearance: Record the lesions observed in the intact animal before its opening. One should place on record the side of an animal lying down, lesions on the skin, external parasites, trauma etc.
2. Subcutaneous tissue and musculature: The observations made after removal of skin, on subcutaneous tissue and muscle should be included in this column.
3. General observations after opening the carcass: It contains the general information or lesions present in the abdominal and thoracic cavity such as accumulation of fluid, pus, blood, clot of blood, post-mortem changes such as pseudomelanosis, etc.
4. Respiratory system: Record the lesions observed in the respiratory system right from external nares, nasal passage, trachea, bronchi, and lungs along with mediastinal lymph nodes.
5. Cardiovascular system: Record the lesions present in heart, aorta, arteries, veins, and lymphatics.
6. Digestive system: Record the lesions observed in the digestive tract from mouth cavity, esophagus, crop, proventriculus, gizzard (poultry), rumen, reticulum, omasum abomasum (ruminants), stomach, intestines, rectum, anus, cloaca, vent (poultry), liver, pancreas, gallbladder etc.
7. Urinary system: Place on record the lesions present on kidneys, ureter, and urethra.
8. Genital system: Record the lesions present in ovaries, uterus, oviduct, cervix and vagina in females and testes, penis etc. in males.
9. Immune system: Record the lesions present in spleen, bursa, thymus, lymph nodes, respiratory associated lymphoid tissue (RALT), gut-associated lymphoid tissue (GALT) etc.

10. Nervous system: Place on record the lesions present in the brain, spinal cord, and nerves.

11. Miscellaneous observations: Here one can record any missing observation which has not been covered above.
12. Post-mortem diagnosis: Based on the history and lesions present in different systems, pathologists by using his experience and conscience conclude the diagnosis.

13. Signature of the officer conducting post-mortem: Each and every report must be signed by the officer doing post-mortem examination. Without signature of the competent officer, it has no validity.
14. Place and date: The person signing the post-mortem report must also write date and place of a post-mortem examination.

POST-MORTEM REPORT STANDARD FORMATE

POST-MORTEM RECORD

1.Species:
2. Date:
3. Case No.:
4. Breed:
5. Age/Born:
6. Sex:
7. Identification No.:
8. Owner with address:
9. Referred by:
10. History of the case:
11. Reported Date & Time of  Death:
12. Date and Time of post-mortem examination:

POST-MORTEM EXAMINATION (SECOND PAGE)

1.External appearance
2. Subcutaneous tissue and musculature
3. General observations after opening the carcass
4. Respiratory system 5. Cardiovascular system
6. Digestive system
7. Urinary system
8. Genital system
9. Immune system
10. Nervous system
11. Miscellaneous observations
12. Post-mortem diagnosis

Date:
Place:
Signature of officer conducting PM

DR RAJESH KUMAR SINGH,

JAMSHEDPUR,

9431309542,

rajeshsinghvet@gmail.com