Universidad del Cauca

Facultad Ciencias de la Salud

Departamento de Patologa
TANATOLOGA FORENSE
PROTOCOLO DE AUTOPSIA N: ____________
NOMBRE DE INGRESO: __________________________________________ EDAD: ______ SEXO:______________
NOMBRE DEFINITIVO: ____________________________________________________________________________
FECHA DE MUERTE

DIA:______

MES: _______

AO: _______

FECHA DE INGRESO

DIA:______

MES: _______

AO: _______

No DE ACTA: __________

PROCEDENCIA DEL CADVER: ___________________________________________________________________

FECHA DE NECROPSIA

DIA:______

MES: _______

AO: _______ HORA: ________________

AUTORIDAD SOLICITANTE: _______________________________________________________________________

PROSECTOR:
DISECTOR:

___________________________
___________________________

CADVER ENTREGADO
A: ______________________________________

CC ________________________ PARENTESCO:_______________

DIRECCIN TELFONO: _______________________________________________________________________________________

I INFORMACIN PREVIA DISPONIBLE AL MOMENTO DE LA NECROPSIA

1. RESUMEN DE ACTA DE INSPECCIN:
LUGAR, FECHA Y HORA DE LOS HECHOS: ______________________________________________________________________
____________________________________________________________________________________________________________
HORA Y FECHA DE MUERTE: __________________________________________________________________________________
____________________________________________________________________________________________________________
HIPTESIS DE MANERA Y CAUSA DE MUERTE: _________________________________________________________________
____________________________________________________________________________________________________________
OTROS DATOS IMPORTANTES, HERIDOS, OTROS OCCISOS, SINDICADOS ETC: ______________________________________
_____________________________________________________________________________________________________________
EVIDENCIAS RECOLECTADAS EN LOS HECHOS: __________________________________________________________________
_____________________________________________________________________________________________________________
ESCENA Y POSICIN ENCONTRADA DEL CUERPO; FENMENOS CADAVRICOS EN LA ESCENA:________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
RELATO DE LOS HECHOS: ______________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________

DECLARACIN DE TESTIGOS: __________________________________________________________________________________

_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
EVIDENCIAS ENTREGADAS PARA ESTUDIO: _____________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
PERTENENCIAS ENTREGADAS: _________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
RECIBIDAS POR: ______________________________________________________________________________________________
2. RESUMEN DE HISTORIA CLNICA: _____________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________

II EXAMEN EXTERNO
ASPECTO GENERAL DEL CADVER; (describir sexo, contextura, estado nutricional, apariencia, lesiones por AF,ACP etc, si
ingresa

embalado,

desnudo):_____________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
DESCRIPCIN DE PRENDAS; describir estado de preservacin, bsqueda de evidencias): _______________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
FENMENOS CADAVRICOS:
TEMPERATURA RECTAL: ___________ RIGIDEZ;( describir leve, moderada, severa- localizacin: __________________________
_____________________________________________________________________________________________________________
LIVIDECES: ( describir color, ubicacin, si desaparece o no a la digitopresin):__________________________________________
DESHIDRATACIN (describir mucosa, vulva, glande): _______________________________________________________________
FENMENOS CADAVRICOS TARDOS: (describir putrefaccin: fase cromtica, enfisematoso, licuefaccin, reduccin
esqueltica Presencia de fauna cadavrica): ______________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
PESO:__________ KGR, ESTATURA: ____________ PATRN RACIAL: ______________
CUERO CABELLUDO (describir color, distribucin, cantidad, descripcin de lesiones traumticas): ________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________

PIEL Y FANERAS (describir Textura, pigmentacin, tatuajes y lesiones patrn):_________________________________________

_____________________________________________________________________________________________________________
UAS DE MANOS Y PIES, BARBA Y BIGOTE: _____________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
CARA (describir caractersticas de forma: frente, cejas, mentn, ojos, boca-labios, orejas, nariz presencia de lesiones
traumticas):__________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
OJOS: (describir color, pupilas, conjuntivas, escleras, lesiones traumticas): ___________________________________________
_____________________________________________________________________________________________________________
NARIZ: (describir tabique, fosas nasales, lesiones traumticas):_______________________________________________________
_____________________________________________________________________________________________________________
BOCA: (describir mucosas, frenillos: _____________________________________________________________________________
_____________________________________________________________________________________________________________
DENTADURA (describir estado, prtesis, si es N.N elaborar carta dental, lesiones traumticas): ___________________________
_____________________________________________________________________________________________________________
ODOS: (describir pabellones auriculares, lesiones traumticas):______________________________________________________
_____________________________________________________________________________________________________________
CUELLO: (describir Masas, Cicatrices, lesiones traumticas) : ________________________________________________________
_____________________________________________________________________________________________________________
TRAX: describir Configuracin, Lesiones) :______________________________________________________________________
_____________________________________________________________________________________________________________
AXILA: (describir lesiones):_____________________________________________________________________________________
_____________________________________________________________________________________________________________
SENOS :(describir (ndulos-secrecin) lesiones traumticas):________________________________________________________
_____________________________________________________________________________________________________________
ABDOMEN: (describir configuracin, Lesiones traumticas): _________________________________________________________
_____________________________________________________________________________________________________________
GENITALES EXTERNOS: (describir aspecto, lesiones traumticas):____________________________________________________
_____________________________________________________________________________________________________________
DORSO: (describir Lesiones traumticas):_________________________________________________________________________
_____________________________________________________________________________________________________________
GLTEOS: (describir lesiones traumticas):_______________________________________________________________________
_____________________________________________________________________________________________________________
ANO: (describir caractersticas, lesiones traumticas):_______________________________________________________________
_____________________________________________________________________________________________________________
EXTREMIDADES:(describir si hay heridas de defensa vacilantes, edema, cianosis, atrofia )
SUPERIOR DERECHA: _________________________________________________________________________________________

_____________________________________________________________________________________________________________
SUPERIOR IZQUIERDA: _________________________________________________________________________________________
_____________________________________________________________________________________________________________
INFERIOR DERECHA: __________________________________________________________________________________________
_____________________________________________________________________________________________________________
INFERIOR IZQUIERDA: _________________________________________________________________________________________
_____________________________________________________________________________________________________________
PROCEDIMIENTO REALIZADOS EN LAS TCNICAS DE DISECCIN:
Una vez terminado el examen externo se inicia el examen interno, realizando las siguientes disecciones
a-.bimastoidea en crneo para observar cuero cabelludo, bveda craneana y extraer encfalo.
b-Mentopubica por planos sobre lnea media anterior, para observacin, extraccin y anlisis de rganos de la cavidad toraco
abdominal.
c-Diseccin por planos anatmicos en cuello hasta esqueleto laringeo.
d-Diseccin en X en regin dorsal para bsqueda de traumas contusos.

III EXAMEN INTERNO

CABEZA ESPACIO SUBGALEAL:_________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
CRNEO:(describir fracturas, localizacin, tamao:________________________________________________________________
_____________________________________________________________________________________________________________
CEREBRO Y MENINGES: (describir peso, aspecto duramadre, seno longitudinal superior, contusin, laceracin, hemorragias,
ubicacin, edema):_____________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
AL CORTE: (describir Ventrculos, Ganglios Basales describir trayectos hemorrgicos si los hay):__________________________
_____________________________________________________________________________________________________________
TALLO CEREBRAL, CEREBELO, BULBO: (describir lesiones traumticas):______________________________________________
_____________________________________________________________________________________________________________
ARTERIAS DEL POLGONO DE WILLIS: ___________________________________________________________________________
_____________________________________________________________________________________________________________
COLUMNA VERTEBRAL: (describir lesiones traumticas): ___________________________________________________________
_____________________________________________________________________________________________________________
LA MEDULA ESPINAL: (describir se explora en caso de enfermedades que afectan SNP y proyectiles alojados): ______________
_____________________________________________________________________________________________________________
CAVIDAD TORCICA : (describir Pleura y espacios pleurales):________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
APARATO RESPIRATORIO: LARINGE, TRAQUEA, BRONQUIOS: ______________________________________________________
_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________
PULMONES:(describir peso, superficie, color, crepitacin, pigmento antracotico, arterias y venas, lesiones traumticas): ______
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
APARATO CARDIO-VASCULAR
PERICARDIO: (describir lesiones traumticas, contenido): ___________________________________________________________
_____________________________________________________________________________________________________________
CORAZN: (describir peso, epicardio, panculo adiposo, miocardio y endocardio) describir y ubicar las lesiones):____________
_____________________________________________________________________________________________________________
ESPESOR DE VENTRCULOS, MEDIDAS DE VLVULAS, MSCULOS PAPILARES, CUERDAS TENDINOSAS, CORONARIAS:
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
AORTA Y GRANDES VASOS Y VENAS: ___________________________________________________________________________
_____________________________________________________________________________________________________________
CAVIDAD ABDOMINAL
ESPESOR DE PANCULO ADIPOSO: (describir liquido, sangre, adherencias, ausencia quirrgica de rganos):_______________
_____________________________________________________________________________________________________________
____________________________________________________________________________________________________
_________
PERITONEO, MESENTERIO, RETROPERITONEO, DIAFRAGMA: (describir lesiones traumticas): ___________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
APARATO DIGESTIVO
LENGUA, FARINGE, ESFAGO: (describir pared mucosa, lesiones traumticas): ________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
ESTOMAGO: (describir serosa, mucosa y describir contenido gstrico, lesiones traumticas): _____________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
INTESTINO DELGADO, APNDICE, COLON, RECTO: (describir pared, apndice, mucosa, lesiones traumticas):_____________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
HGADO: (describir peso, superficie, color, bordes, consistencia, superficie de corte, parnquima, Va biliar intraheptica,
lesiones traumticas): _________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
PNCREAS: (describir peso, color, consistencia, arquitectura lubiliar, lesiones traumticas): ______________________________

_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
APARATO GENITO URINARIO
RIONES: (describir peso, superficie, color, son o no decapsulables, corteza, medula, urteres lesiones, traumticas): _______
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
VEJIGA: (describir contenido, pared, mucosa, lesiones traumticas): __________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
GENITALES INTERNOS MASCULINOS:
PRSTATA Y TESTCULOS: (describir Consistencia, Ndulos, testculos, aspecto lesiones traumticas):____________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
GENITALES FEMENINOS
TERO: (describir Miometrio, Endometrio, Ovarios y Trompas, Cervix, lesiones traumticas): ____________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
EN CASO DE ENCONTRAR FETO: (describir Sexo, talle, medida planta de pie, malformaciones, signos de sufrimiento fetal,
vermis caseosa, signos de trauma, placenta (medida y peso), membranas): ____________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
SISTEMA HEMAPOYETICO
BAZO: (describir peso, superficie, color, consistencia, superficie de corte, lesiones traumticas):___________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
GANGLIOS (describir aspecto):__________________________________________________________________________________
_____________________________________________________________________________________________________________
SISTEMA ENDOCRINO: TIROIDES, SUPRARRENAL, HIPFISIS: ______________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
EN ESTA PARTE ELABORAR PROTOCOLO DE HERIDA DE P.A.F. O ARMA CORTO PUNZANTE CUALQUIERA SEA EL CASO

IV DIAGNOSTICO ANATOMOPATOLGICO
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________

V ANLISIS INTEGRAL DEL CASO

_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
MECANISMO DE MUERTE:_______________________________________________________________________________________
_____________________________________________________________________________________________________________
CAUSA DE MUERTE: ___________________________________________________________________________________________
_____________________________________________________________________________________________________________
PROBABLE MANERA DE MUERTE (Homicidio, Suicidio, Accidental, Natural. Indeterminada): _____________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
VI ESTUDIOS COMPLEMENTARIOS
-ORINA (PSICOFRMACOS):

____________________________________

-SANGRE (ALCOHOLEMIA) (HEMOCLASIFICACIN):

____________________________________

-PROYECTILES (BALSTICA) (Nro

____________________________________

-TEJIDOS PARA PATOLOGA Y TOXICOLOGA

____________________________________

-OTROS (bilis, humos vtreos, secrecin vaginal, nasal, rectal, oral)

____________________________________

-NINGUNO

____________________________________

-MUESTRAS RECOLECTADAS, PRESERVADAS, ROTULADAS, ENTREGADAS AL SEOR_________________________________

PARA SER REMITIDA A SUS RESPECTIVOS LABORATORIOS DE LA REGIN SUR OCCIDENTE, MEDIANTE OFICIO Nro _______
DE FECHA: DIA: _____________MES:______________AO:______________

____________________________________________
MEDICO

Esther Mariela Estrada / CPCE