minsa - protocolo de necropsia

8/6/2019 MINSA - Protocolo de Necropsia

1/12

INFORME PERICIAL DE NECROPSIA MDICO LEGAL N__________________-20____Ministerio Pblico

nstituto de Medicina Legal

Sede : _____________________________

Motivo de Solicitud de Necropsia:

Necropsia de Ley Necropsia Ley Post-exhumacin

Necropsia Clnica

Autoridad que Solicita la Necropsia

Datos Generales:

Nombre de la Autoridad Titular

Datos del Fallecido:

- 1 -

Cadver Feto Restos Humanos Restos seos

Identificado: SI NN

Datos Personales:

Semanas deGestacionHora(s)Da (s)Mes(es)Ao(s)

N Doc.

Documento de Identidad Sexo Raza

Fecha y Hora de Ingreso:

Datos de Interes:

Entidad que realiza el Levantamiento

Fiscala y/o Juzgado PNP IML

NECROPSIA:

Persona que Interna el Cadver:

Nombres y apellidos ________________________________________

Cargo:__________________________ N de C.I._______________

Dependencia :______________________________________________

Practicado Por : Dr(a) ______________________________________________

Colegio Medico N ______________________Y Por: Dr(a) ______________________________________________________

Colegio Medico N ______________________

Autoridades Presentes: Fiscal Juez Otros

Detallar: __________________________________________________________

_________________________________________________________________

Tcnico de Apoyo:

Nombres y Apellidos:

_________________________________________________________________

Otras Autoridades : __________________________________________________________________________________________________________________

Fecha y Hora de Inicio de Necropsia: ___________________________________

Lugar del Hecho

Pas ____________ Departamento ___________________________

Provincia __________________________________________________

Distrito __________________________________________________

Urb./ AAHH./ PPJJ __________________________________________

Tipo/Via: Av. Jr. Mz. Calle

____________________________________________ N_____

Lugar Av. / Calle

Lugar de Fallecimiento

Pas ____________ Departamento ___________________________Provincia __________________________________________________

Distrito __________________________________________________

Urb./ AAHH./ PPJJ __________________________________________

Tipo/Via: Av. Jr. Mz. Calle

_____________________________________________ N_____

Lugar Av. / Calle

Documentos Recibidos al Ingreso

Levantamiento Mdico Legal Historia ClnicaActa Levantamiento Fiscal o Judicial EpicrisisLevantamiento Policial

Procede de Servicio de Salud: SI NO

Institucin

MINSA ESSALUD FF.AA. PNP Privado Otros

Nombre del Establecimiento:_________________________________________________________

Fecha y Hora del Fallecimiento:________________________________

Nombre(s)

Apellido Paterno

Apellido Materno y/o casada

Edad aproximada:

Da Mes Ao

Fec. Nac.

DNILM

PasaportePartida de Nac.Carnet ExtranjeriaSin DocumentoOtros

Detallar:__________________

Masc.Fem.Indeterminado.

BlancaMestiza

NegraAmarillaIndeterm.Indoamericana

OcupacinAma de casaEmpleado prof.Empleado tc.Emp. No prof/tec.EmpresarioTrabaj. SexualTrabaj. Indep.Trab. Del HogarEstudianteObreroTaxistaCambistaJubiladoDesocupadoIgnorado

Estado Civil

SolteroCasadoConvivienteSeparadoDivorciado

ViudoIgnorado

AnalfabetoAlfabetoPrim. IncompletaPrim. CompletaSec. Incompleta

Sec. CompletaSup. Tcnica incompletaSup. Tcnica completaSup. Universitaria incompletaSup. Universitaria completaPostgradoIgnorado

Grado de Instruccin

Antecedentes Patolgicos

SI NO No Sabe

______________________________________

HipertensinDiabetesTuberculosisPat. CardiacaInsf. Renal

VIH/SIDAHepatitisCncerEnf. MentalEnf. respiratoriasOtros


2/12

Descripcin de prendas de vestir y objetos del fallecido:

PRENDAS DE VESTIR: ( Describir Tipo, Color, Material )

________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________

Objetos: ( Describir Tipo, Color, Estado )

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________

Fenmenos Cadavricos :

- 2 -

Tiempo Aprox. De Muerte:

Horas Das Semanas Meses Aos

EXAMEN EXTERNO :

Talla: mt Peso: Kg.

Tipo Constitucional.

Leptosmico Atltico Pcnico Dismrfico Normosmico

Observaciones: _________________________________________________________________________________________________________

Estado de Nutricin : Bueno Malo Regular Caquctico

Estado de Hidratacin: Hidratado Deshidratado

Caractersticas Identificatorias:

Tatuajes Nevos Cicatrices Deformidades

Observaciones : ________________________________________________________________________________________________________

Fenmenos Oculares:

Pupilas: Miosis Midriasis

Corneas: Transparente Opacas

Tensin: Normal Hipertnica Hipotnica

Observaciones ____________________________________________________

Livideces: Modificable Poco Modificable No Modificable

Dorsales

Ventrales

Laterales derecho

Laterales Izquierdo

En pantaln

Observaciones: ___________________________________________________

Putrefaccin:

Fase Cromtica Fase Enfisematoso Colicuativa

Observacines: ___________________________________________________

________________________________________________________________

Presencia de Flora y Fauna: ________________________________________

________________________________________________________________

Rigidez: Instalado Parcial Flacida

Mandbula

Cuello

Miembros sup.

Miembros inf.

Obs :__________________________________________________________________________________________

Temperatura:

Ambiental ... C

Cadavrica Rectal .......................................................... C

CadavricaHeptica C

Obs :___________________________________________

_______________________________________________

Fenmenos de Conservacin Cadavrica:

AdipociraCorificacin

Momificacin

Obs:____________________________________________

________________________________________________


3/12- 3 -

PIEL:Caractersticas: (Color, Elasticidad, Higiene, Pniculo Adiposo, y Observaciones )

______________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________

CABEZA: Lesiones SI NOPermetroCeflico: cm

Forma: Mesocrneo Dolicrneo Braquicrneo

Cabello: Negro puro Castao Rubio Claro Pelirrojo Blanco Castao Oscuro Caf

Negrusco Caf Oscuro Rubio Cenizo Cenizo Pardo Rojizo Pardo Claro

Rubio Oscuro Rubio Entrecano Otros: _______________________________________________

Caractersticas: (Tamao, forma, cantidad y Alteraciones) ______________________________________________________________________

_____________________________________________________________________________________________________________________

CARA

Tipo Facial: Ovalado Recto Triangular Redondo Alargado Pentagonal Anguloso

Romboidal TrapezoidalCaractersticas (Frente, color, simetra y Alteraciones)__________________________________________________________________________

_____________________________________________________________________________________________________________________

Ojos:

Color: Negro Pardos Oscuros Pardos Claros Azules Gris Verdoso Gris

Caf Miel Verdes Otros: _________________________________________________

Nariz: Tamao : Grande Pequea Mediana

Caractersticas: (Forma, Simetra, y alteraciones) _____________________________________________________________________________

_____________________________________________________________________________________________________________________

Boca: Grande Mediana Pequea

Labios: (Forma, Color, Volumen, Hidratacin, y Alteraciones)___________________________________________________________________

_____________________________________________________________________________________________________________________

Dentadura: Completa Incompleta Con Prtesis Edentulo

Orejas: Grandes Medianas Pequeas

Caractersticas (Simetra, Implantacin y Alteraciones) _________________________________________________________________________

CUELLO:

Largo Corto Mediano

Caractersticas: (Simetra, Forma y Alteraciones) _____________________________________________________________________________

_____________________________________________________________________________________________________________________

Lesiones: SI NO

TRAX:Permetro Torxico: cm

En tonel Cifosis Escoliosis Ofoescoliosis Pectum Carinatum

Pectum Excavatum Asimtrico Plano Cilndrico Mediano

Alteraciones : _________________________________________________________________________________________________________

Lesiones: SI NO

MAMAS: Caractersticas (Simetra, tamao, consistencia)_____________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________

Pigmentacin areolar: SI NO

Secrecin mamaria: SI NO


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5/12- 5 -

Cuero Cabelludo (Cara Interna): ___________________________________________________________________________________________

_______________________________________________________________________________________________________________________

Lesiones: Si No

Base de Crneo: ________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________

Lesiones: Si No

Meninges Duramadre y Aracnoides:________________________________________________________________________________________

_______________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________

Encfalo:

Descripcin (Color, Consistencia, Superficie, Simetra, Ventrculos, Cerebelo y Alteraciones) _____________________________________________

_______________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________

Lesiones : Si No

Vasos: ________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________

Macizo Facial: Lesiones: Si No

CUELLOColumna Cervical: ______________________________________________________________________________________________________

Lesiones: Si No

Faringe: _______________________________________________________________________________________________________________Lesiones: Si No

Esfago: ______________________________________________________________________________________________________________

Lesiones: Si No

Laringe: _______________________________________________________________________________________________________________

Lesiones: Si No

Glotis: ________________________________________________________________________________________________________________

Lesiones: Si No

Epiglotis: ______________________________________________________________________________________________________________

Lesiones: Si No

Hioides: _______________________________________________________________________________________________________________

Lesiones: Si No

Traquea:_______________________________________________________________________________________________________________

Lesiones: Si No

Tiroides:

Caractersticas: (Color, Consistencia, Superficie, Simetra y Alteraciones) ___________________________________________________________

Vasos: ________________________________________________________________________________________________________________

Peso: gr Medidas: cm X cm X cm



6/12- 6 -

TORAX

Columna dorsal y parrilla costal :________________________________________________________________________________________

_____________________________________________________________________________________________________________________

Lesiones: Si No

Pleuras y Cavidades

Descripcin : (Adherencias, Contenido y Alteraciones) : ________________________________________________________________________

_____________________________________________________________________________________________________________________

Mediastino: __________________________________________________________________________________________________________

Timo

Descripcin :_________________________________________________________________________________________________________

Pulmn Derecho:

Pulmn Izquierdo:

Descripcin: (Color, Consistencia, Superficie, Textura y Alteraciones) ____________________________________________________________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

Lesiones: Si No

Pericardio

Contenido: (Detallar)___________________________________________________________________________________________________

Lesiones: Si No

Corazn:Lesiones: Si No

Caractersticas: (Forma, Color, Consistencia, Superficie, Cavidades y Alteraciones) _________________________________________________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

Paredes Ventriculares:________________________________________________________________________________________________

Vlvula Artica Mide: mm. Vlvula Pulmonar Mide: mm.

Vlvula Mitral: Mide: mm. Vlvula Tricspide Mide: mm.

Caractersticas: _______________________________________________________________________________________________________

Arterias Aorta/Pulmonar:______________________________________________________________________________________________

____________________________________________________________________________________________________________________

Arterias Coronarias:__________________________________________________________________________________________________






7/12- 7 -

ABDOMEN PELVIS

Columna Lumbosacra y Esqueleto Plvico:_______________________________________________________________________________

Lesiones: Si No

Pared Peritoneal: _____________________________________________________________________________________________________

Lesiones: Si No

Cavidad Peritoneal: Libre Contenido

Detallar: ___________________________________________________________________________ con volumen de ___________ cm.3 Aprox.

Diafragma: _____________________________________________________________________________________ Lesiones Si No

Epiplones: _____________________________________________________________________________________ Lesiones Si No

Mesenterio: ____________________________________________________________________________________ Lesiones: Si No

Estmago: Caractersticas (Distensin, Serosa, Mucosa y Alteraciones) __________________________________________________________

_____________________________________________________________________________________________________________________

Contiene: _____________________________________________________________________________________________________________

Lesiones: Si No

Intestino Delgado: (Distensin, Serosa, Mucosa y Alteraciones)________________________________________________________________

______________________________________________________________________________________________ Lesiones: Si No

Intestino Grueso: (Distensin, Serosa, Mucosa y Alteraciones)_________________________________________________________________

______________________________________________________________________________________________ Lesiones: Si No

Apndice: ____________________________________________________________________________________________________________

Hgado:

Caractersticas: (Color, Consistencia, Superficie, Bordes y Alteraciones) ___________________________________________________________

_____________________________________________________________________________________________________________________

Lesiones: Si No

Vescula y Vas Biliares : (Distensin, Serosa, Mucosa y Alteraciones)_____________________________________________________________________________________________________________________

Litiasis Si No

Bazo:

Caractersticas (Color, Consistencia, Superficie, Bordes y Alteraciones) ____________________________________________________________

_____________________________________________________________________________________________________________________

Lesiones: Si No

Pncreas:

Caractersticas (Color, Consistencia, Superficie, Conducto Pancretico y Alteraciones) ________________________________________________

_____________________________________________________________________________________________________________________

Lesiones: Si No

Rin Derecho:

Rin Izquierdo:

Caracteristicas: (Color, Consistencia, Superficie Capsular y Cortical, Alteraciones) ___________________________________________________

_____________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________

Lesiones: Si No

Suprarrenales: ________________________________________________________________________________________________________







8/12- 8 -

ORGANOS ACOMPAANTES

Vas de Excrecin Renal: (Pelvis Renal, Urteres, Vejiga y Uretra)

_____________________________________________________________________________________________________________________

Lesiones: Si No

Vasos:______________________________________________________________________________________________________________

Lesiones: Si No

APARATO GENITAL

FEMENINO

Utero:

Carctersticas: (Forma, Direccin, Cuello, Orificio externo y Cuerpo) _____________________________________________________________

____________________________________________________________________________________________________________________

Cavidad Endometrial: Ocupada: Si No

Placenta Feto Otros Edad Gestacional: (Semanas)

Descripcin: __________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

Anexos:

Ovario Derecho:

Ovario Izquierdo:

Caractersticas: _______________________________________________________________________________________________________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

Lesiones: Si No

MASCULINO

Prstata:

Caractersticas: (Color, Consistencia, Superficie, y Alteraciones) _________________________________________________________________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

Lesiones: Si No

Placenta Cordn Umbilical

Caractersticas: _______________________________________________________________________________________________________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________





9/12

Descripcin Lesiones Traumticas Externas e Internas

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

- 9 -


10/12

PERENNIZACIN DE EVIDENCIAS (detalle)

EXAMEN ANTOMO PATOLGICO

Muestra(s) Remitida(s): ________________________________________________________________________________________________

Exmen(es) solicitado(s): _______________________________________________________________________________________________

EXAMEN TOXICOLGICO



EXAMEN BIOLOGICO



EXAMEN ESTOMATOLOGICO



EXAMEN ANTROPOLOGICO



DIAGNOSTICO POR IMGENES



- 10 -

Se realiz perennizacin de evidencias Si No

Tipo :

Fotogrfico: Foto-revelado Digital Vdeo: Cinta Disc.compact Memoria digital

Cdigo de las vistas tomadas:

_____________________________________________________________________________________________________________________

Responsable de capturar imagen

Nombres y Apellidos: ___________________________________________________________________________________________________

Se registro en cuadernillo de grficos Si No

Detalle del Registro :____________________________________________________________________________________________________

Observaciones ________________________________________________________________________________________________________

EXAMENES AUXILIARES

DATOS REFERENCIALES (USO INTERNO)

_____________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________


11/12

DIAGNOSTICO PRESUNTIVO DE MUERTE: ETIOLOGA MDICO LEGAL PRESUNTIVO:( Ver anexo y llenar causa probable con fines estadsticos en la ultima cara de formato)

Causa Presuntiva de Muerte:

Causa Final ______________________________________ FORMA _____________________________________________

Causa Intermedia _________________________________ AGENTE ____________________________________________

Causa Bsica ____________________________________ TIPO DE AGENTE ____________________________________

Agente Causante ______________________________________________________________________________________

Datos preliminares:

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

____________________________ ____________________________ FIRMA FIRMA

ETIOLOGA MDICO LEGAL DEFINITIVO( Ver anexo y llenar causa probable con fines estadsticos en la ultima cara de formato)

Causa Final ______________________________________ FORMA ____________________________________________

Causa Intermedia _________________________________ AGENTE ___________________________________________

Causa Bsica ____________________________________ TIPO DE AGENTE ____________________________________

Agente Causante _______________________________________________________________________________________

Conclusiones:______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

____________________________ ____________________________ FIRMA FIRMA

Fecha y Hora que se culmina la Necropsia:

Fecha y Hora del cierre del Informe Pericial:

- 11 -

DIAGNOSTICO INTEGRADO: (DIAGNOSTICOPRESUNTIVO + EXMENES DE LABORATORIO)


12/12

ANEXO DE PROBABLE ETIOLOGIA MEDICO LEGALpara llenar con fines estadisticos

I N F E C C I O S O

T B C

N eumo nia

E T S

V IH

Sep sis

Hep at i t i s

O t ro s

D E G E N E R A T I V O

N eo p las ias

IM A

Enf erm ed ad es d el c o lag eno

A r tereo sc lero s is s is t emica

O t ro s

C O N G E N I T O

T O T A L

M E T A B O L IC O

D iab et es M .

Tir o id es

o tro s

I D E O P A T I C O

H E C H O D E T R A N S I T O

C o nd uct o r

Pasajero

Peato n

C ic l i s t a

A S F I X I A S M E C A N I C A

Sum ers io n (A ho g amiento )

So fo cacio n

A ho rcamient o

Est rang u lamiento

Sep u l tamient o

A sf ix ia p o r o b st ruc cio n d e vias

aereas

A g e n t e Q u i m ic o

Or g ano s f o sfo rad o s

C arb amat o s

D ro g as

A lco ho l

S in In fo rm ac io n

A R M A S

A rma B lanca

A rma d e Fu eg o

Exp lo s ivo s

O t ro s

A C C . A E R E O

A C C . M A R I T I M O

I N T O X I C A C I O N P O R

M O N O C ID O D E C A R B O N O

A G E N T E C O N T U N D E N T E

D U R O

A g e n t e F i s ic oElec t r i c id ad -E lec t ro cuc i n ,

Fulg urac i n

Quemad ura

O T R O S

T I P O L O G I A D E

L A M U E R T E

N A T U R A L

M U E R T EA C C I D E N T A L

A g e n t e c a u s a nt e



S u m e r s io n

S o f o c a c io n

A h o r c a m i e n t o

E s t r a n g u la m i e n t o

S e p u l t a m ie n t o

A R M A S

A r m a B l a n c a

A r m a d e F u e g o

E x p l o s iv o s

O T R O S

A g e n t e Q u i m i c o

O r g a n o s f o s f o r a d o s

C a r b a m a t o s

D r o g a s

A l c o h o l

S in In f o r m a c io n

A g e n t e F i s i c o

E le c t r ic id a d

Q u e m a d u r a

A g e n t e c o n t u s o

O T R O S


S u m e r c io n

S o f o c a c io n

E s t r a n g u la m i e n t o

S e p u l t a m ie n t o

A s f ix ia p o r o b s t r u c c io n d e v ia s

a e r e a s

A R M A S

A r m a B l a n c a

A r m a d e F u e g o

E x p l o s iv o s

O t r o s


C o n d u c t o r

P a s a je r o

P e a t o n

C i c l is t a

A g e n t e Q u i m i c o

O r g a n o s f o s f o r a d o s

C a r b a m a t o s

D r o g a s

A l c o h o l

S in In f o r m a c io n

A g e n t e F i s i c o

E le c t r ic i d a d - E le c t r o c u c i n ,

F u lg u r a c i n

Q u e m a d u r a

A G E N T E C O N T U N D E N T E

D U R O

M . S u b . L a c t a n t e

M . S u b . A d u l t o

I m p r e c i s a b l e - P u t r e f a c c i o n

O t r o s

S U I C I D I O

H O M I C I D A

O D E T E R M I N A D A

minsa - protocolo de necropsia

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